Deprescribing in Clinical Practice: Reducing Polypharmacy in Older Patients

An Expert Interview With Ian A. Scott, MBBS, FRACP, MHA

Linda Brookes, MSc; Ian A. Scott, MBBS, FRACP, MHA


November 26, 2013

In This Article

The Problem of Polypharmacy

Taking multiple drugs simultaneously (polypharmacy) is known to be common among older adults in developed countries worldwide; approximately one third of seniors in the United States[4] and Germany[5,6] and almost two thirds in Canada[7] use 5 or more prescription drugs. This higher rate of polypharmacy in older adults compared with younger age groups is driven primarily by increased numbers of comorbid conditions, newer medications that effectively treat more medical conditions, and practice guidelines that often recommend multidrug regimens.

However, this practice increases the risk for adverse drug reactions (ADRs), adverse drug events (ADEs), falls, hospitalization, institutionalization, mortality, and other adverse health outcomes in these patients.[8,9,10,11] According to a recent study, 13% of seniors taking 5 or more prescription medications experience ADEs that required medical attention, compared with 6% of those taking only 1 or 2 drugs.[12] Evidence from numerous studies shows that many medications prescribed to elderly patients are inappropriate, in that they introduce a significant risk for an ADE when there is evidence that alternative medication may be equally or more effective. In primary care, approximately 1 in 5 prescriptions issued for older adults is inappropriate.[13]

The problem of polypharmacy in older adults is being increasingly recognized and addressed in guidelines specifically targeting elderly persons,[14,15,16] and in studies of interventions to improve the appropriate use of polypharmacy and reduce medication-related problems in older people.[17] Tools have been developed to assess the appropriateness of prescribing in elderly patients; these include the Beers criteria,[18] the Inappropriate Prescribing in the Elderly Tool (IPET),[19] and the Screening Tool of Older Person's Prescriptions/Screening Tool to Alert Doctors to the Right Treatment (STOPP/START).[20] The GerontoNet ADR Risk Score was developed as a simple method to identify elderly hospital inpatients at increased risk for an ADR.[21] However, there is little guidance for the process of tapering, withdrawing, discontinuing, or stopping medications ("deprescribing") in older adults with polypharmacy in general clinical practice.

Evidence is emerging in support of a structured approach to deprescribing. Dr. Scott and his colleagues have proposed an algorithm that comprises 10 sequential decision steps to guide clinicians faced with patients on multiple medications, particularly those at high risk for ADRs, who wish to reduce the number of drugs they are taking.[1] The steps are:

1. Ascertain all current medications.

2. Identify patients at high risk for or experiencing ADRs.

3. Estimate life expectancy in high-risk patients.

4. Define overall care goals in the context of life expectancy.

5. Define and confirm current indications for ongoing treatment.

6. Determine the time until benefit for disease-modifying medications.

7. Estimate the magnitude of benefit vs harm in relation to each medication.

8. Review the relative utility of different drugs.

9. Identify drugs that may be discontinued.

10. Implement and monitor a drug minimization plan, with ongoing reappraisal of drug utility and patient adherence by a single nominated clinician.

To date, this guide has been validated in an unselected group of doctors whose prescribing intentions with respect to a hypothetical case changed significantly after guide application,[2] but it must also be validated in clinical trials, as Dr. Scott and his colleagues noted in their report. They suggest that savings made by eliminating drugs and preventing iatrogenic illness "could be channeled toward reimbursing clinicians for the time and effort spent in applying the [new] framework." In a summary guide to deprescribing, they stress that although the process can be difficult and time-consuming, "prescribers have a responsibility to minimize the potential for harm and waste of resources arising from inappropriate polypharmacy in vulnerable older patients."[3]

In an interview with Linda Brookes, MSc, for Medscape, Dr. Scott discussed the growing problem of overuse in older adults and his recommendations for deprescribing in these patients.


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