The Interview
Medscape: The rate of overprescribing in the elderly in Australia appears to be similar to that in Europe and North America. Recent national studies have reported that 49%-66% of people aged 65 years or older are taking 5 or more prescription or over-the-counter-medicines,[22] and 1 in 4 older persons is hospitalized for medication-related problems.[23]
Dr. Scott: Yes, it is a big problem everywhere that is not really appreciated by the medical profession, and probably not by patients either.
As physicians, we do not appreciate the burden that we impose on people with multiple drugs. It is not just the side effects or the drug/drug interactions, but for older people, it is simply the cognitive burden of trying to remember to take medications on a regular basis and ensuring that they don't miss any medications. They don't appreciate that perhaps some of the symptoms that they experience, which they may attribute to just getting old and their body becoming weaker, may actually be drug side effects.
Also, in Australia as well as in the United States, it is now a financial problem in that people may not be able to afford all of these medications; as a result, they start to pick and choose which ones they think they really need and which ones they think they don't -- and that, of course, is potentially dangerous. That is another element that we are seeing here in Australia, because even though we have universal health insurance, there is still a certain amount of out-of-pocket expense that people have to take on in buying medications, so it is becoming a significant factor.
Medscape: How do you hope to reduce polypharmacy and inappropriate prescribing in the elderly with the introduction of your 10-step algorithm?
Dr. Scott: We developed the algorithm to help clinicians decide first whether the patient is the sort of person who is at high risk for an ADR or for harm from their medications, and whether there is a strong indication for a drug on clinical grounds. Does it really fit in with what patients want in terms of what they think is important for their good health?
For example, many of the drugs we prescribe are for secondary prevention -- trying to prevent strokes or heart attacks -- but many of our patients may not have a particularly long life expectancy, and they are interested most in quality of life and being able to feel well and function as best as they can. So we propose that some medications may not benefit them in their remaining life span, and therefore clinicians should think about stopping them, particularly if they are drugs that are known to be associated with side effects in the elderly (putting them at risk of having falls or becoming confused, or increasing their risk for delirium, and so on).
We are trying to get clinicians to think a little more proactively about these patients on multiple drugs and, rather than starting new ones, to think about stopping some of the drugs that they are already taking, especially where there was no substantiated indication for the drug in the first place. This is not an easy task, because we know from the literature that both patients and physicians, even though they may say in principle that they would like to be on fewer drugs, when it comes to the point of looking at specific medications and stopping them, there is always a bit of reticence about doing that in case the drug may actually be preventing something. The prescribing physicians may feel that if a drug was stopped and then over the next few months some calamitous event happened, then they would feel that perhaps they caused this by stopping the drug. So it is not easy, and certainly in the work that we have done with prescribing physicians, we have found that they do have the concern that we cannot predict with certainty in any individual patient whether stopping a drug may necessarily be a good or a bad thing.
But if we discuss the pros and cons of specific medications, many patients are quite happy to at least have a trial of ceasing the medication to see what happens. As long as we monitor them closely and inform them of the symptoms that they should be looking out for that might suggest they are having a relapse of disease or some sort of withdrawal syndrome from the drug, then they are usually happy to go along with a trial of discontinuation.
This takes time, however, because you cannot stop several drugs at once; you have to take 1 drug at a time and discontinue it over weeks to months, and then move on to the next one. So in the busy setting of clinical practice, many doctors feel that they do not have the time to get into this. That is why we believe that it is important that there be some dedicated remuneration for doctors to undertake this task, so that they are given the financial incentive to actually spend time doing this.
Medscape: Who do you think is in the best position to undertake the medication review? Surely there will not be enough geriatricians in most countries to do this for all eligible patients. Moreover, there is often a range of specialists in different chronic diseases involved in the care of older patients.
Dr. Scott: It is not the role of one person, but a collective task that should be shared by everybody. Certainly specialists need to take the lead, because they are often the ones who started patients on their drugs in the past or give their imprimatur for the drug to be continued. They have to signal to the general practitioner that they are happy to undertake a trial of discontinuation of a particular drug if warranted. So the specialists have to spend some time on this task.
The problem is that many of our patients see multiple specialists. They may have heart disease, lung disease, kidney disease, and diabetes, so they may see 3 or 4 different specialists. You have to get all those physicians talking together, because what one person may think is a good drug for their disease may not be quite as good in relation to another disease. You need to get consensus among specialists as to which drugs we should try to get the patient off and which ones are important in terms of symptomatic benefit. That requires someone taking charge of coordinating that effort, and we would propose that a general specialist, a general physician, a geriatrician, or a clinical pharmacologist, who has had general training and can look at the whole person and is familiar with drugs and diseases across the spectrum of medicine, might be the person to help coordinate and achieve that consensus.
But again, it means you have to find the time and designate this task to specific individuals, and at the moment, the way our practice is structured and the way that the remuneration is structured, it may not be easy to identify someone to play that role.
Medscape: How do you best identify the patients who need this kind of attention?
Dr. Scott: People have tried to develop risk prediction tools in identifying who is most at risk, but no tool is 100% perfect and you will misclassify about 1 in 3 patients with these rules. Physicians are also often reluctant to compute scores and use complicated prediction rules.
You have to provide them with some broad principles that might be just as good, and our broad principles are that if a patient is on 8 or more medications, that puts them into a high-risk group. If they are of an advanced age (over 75 years), that certainly is a risk factor, and the older they are, the more risk they entail. If they are on high-risk medications, which are basically drugs that act on the central nervous system or on the cardiovascular system, they are also at increased risk. So if patients are taking sedatives or hypnotics, digoxin, vasodilators, or anticoagulants (such as warfarin), then they are the people you should sort of be looking at in the first instance.
Medscape: How do you find out about all the medications that patients are taking?
Dr. Scott: At the moment, if we are trying to ascertain what drugs people are on, we use the so-called "brown paper bag test."[24] In other words, patients bring all their medications along with them every time they go to the doctor, and then we know exactly what they are taking and we can reconcile that with our written list.
Medscape: Wouldn't having electronic health records that follow each patient make this much easier?
Dr. Scott: Electronic health records are not yet widely used in hospital practice in Australia. General practitioners are more computerized in that they have software in which they record patients' medications, but you have to keep the list up to date, and if a patient moves around and sees different doctors, unless someone is making sure that that medication list in that particular electronic record is updated on a regular basis, then it will become out of date and could be quite inaccurate. We are having a big debate in our country right now about who should be responsible for making sure that electronic health records are kept up to date, which is delaying their widespread uptake by doctors.
Medscape Internal Medicine © 2013 WebMD, LLC
Cite this: Deprescribing in Clinical Practice: Reducing Polypharmacy in Older Patients - Medscape - Nov 26, 2013.
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