Deprescribing: An Approach to Reducing Polypharmacy in Nursing Home Residents

Linda M. Liu, DNP, GNP-BC

Disclosures

Journal for Nurse Practitioners. 2014;10(2):136-139. 

In This Article

Abstract and Introduction

Abstract

There is an urgent need to address the growing problem of polypharmacy in the elderly. Elderly patients are often prescribed multiple medications, some of which are high risk or no longer necessary, which increases the risk for adverse drug reactions and health care costs. Reducing polypharmacy should be a priority for clinicians working in nursing homes. Clinicians should consider care goals, disease trajectory, and life expectancy when discontinuing medications. This article discusses the challenges associated with deprescribing, the ethical and clinical uncertainty that can exist in the indefinite use of some medications, and the guidelines available to help clinicians.

Introduction

Polypharmacy and inappropriate medication use are growing problems in elderly patients.[1] Up to 24% of community-dwelling patients and 40% of nursing home residents in the United States receive at least 1 potentially inappropriate medication, according to the Beers criteria.[2] Nursing home residents consume an average of 7 medications daily.[3] Elderly patients often have multiple comorbidities for which they are prescribed several drugs. While medications can help alleviate symptoms, improve and extend quality of life, and occasionally cure disease, they also increase the risk of adverse drug reaction.[2,4] Polypharmacy (the use of 5 or more medications)[3] has been associated with increased adverse drug effects, falls, hip fractures, hospitalization, and death.[5] Over a 5-year period, medication-related problems accounted for more than 10% of all hospital admissions, with 30% and 55 % estimated to be preventable.[6] Patients prescribed 7 or more medications have up to 82% risk of adverse drug reaction.[6]

Deprescribing, the process of tapering, withdrawing, discontinuing, or stopping medications, is important in reducing polypharmacy, adverse drug effects, inappropriate or ineffective medication use, and costs.[3] It is imperative that clinicians frequently conduct thorough medication reviews with the focus on decreasing medications that are no longer necessary or pose a high risk in nursing home residents.

Clinicians working in nursing homes are often faced with the challenge of knowing when it might be best to withhold or discontinue medications.[7] Additionally, decision making is hampered by the lack of evidence-based guidelines to support when to stop or reduce medications.[3] While the Beers criteria identify medications that should be avoided in the elderly, they do not address such general considerations as when to discontinue certain medications late in life. Appropriate drug prescribing consists of using medications that are associated with strong evidence of benefit while discontinuing medications with questionable or no evidence of efficacy, unfavorable risk/benefit ratios, or those that the patient desires to avoid.[6]

Clinicians need to consider care goals, disease trajectory, and life expectancy of patients.[7] Estimating a patient's life expectancy is important in determining the goals of care and potential long-term value of many preventive medications. Patients with a limited lifespan (12 months or less) because of marked frailty, advanced dementia, or end-stage organ disease should have more conservative care goals and their preferences may call for reduction in medications.[7] Medications that may take several years to gain benefits, such as biophosphonate therapy to prevent osteoporotic fractures, have limited opportunity to benefit patients whose projected life expectancy is short.[4]

The quality of prescribing in nursing home residents has been criticized for both inappropriate excess and, particularly, overuse of medications that are no longer clinically indicated or required. Medications commonly continued in older adults—though found to be no longer needed in some—include acetaminophen, diuretics, antihypertensives, statins, proton-pump inhibitors, and ferrous sulfate.[8] There is growing evidence to support the conclusion that discontinuing specific medications in certain patient population does not worsen outcomes and can decrease adverse drug events and medication costs.[1,9]

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