COMMENTARY

Which Drugs Should Be Deprescribed in the Elderly?

Tom G. Bartol, NP

Disclosures

July 02, 2015

Viewpoint

Today there are many efforts to help the elderly pay for their medications and to be sure that they are taking their medications as prescribed. Legislators are lobbied to continue or increase medication assistance for the elderly so that the elderly do not have to choose between medications and groceries. Clinicians, hospitals, and accountable care organizations, to name a few, are trying to work with elderly persons to ensure that they are taking all of their medications as prescribed.

The cost and complexity of medications in the elderly is a challenge. This study points us to another tool in the solution to medication complexity in the elderly: deprescribing or stopping some of those medications that no longer have utility. There are many tools and guidelines for starting medications but we have few, if any, guidelines for stopping medications. We give too many medications to older adults—medications that they no longer need, are having no significant beneficial effect, and/or may be unsafe. Is it time to take a different view of medications in the elderly, not simply inquiring whether all are being taken but asking whether they need or want them all?

The senior population (those aged 65 years and older) comprises 13.7% of the US population but uses 40% of all prescription drugs. People aged 65-69 years fill an average of 14 prescriptions per year and adults aged 80-84 years average 18 prescriptions per year.[1] A study in Canada recently showed that in a group of elderly patients (mean age, 81 years), the average number of medications taken was 15 (range, 6-28) with 8.9 drug-related problems occurring per patient. When these problems were analyzed, 2.5 of those 8.9 problems were found to be caused by drugs that were not needed.[2] In the United States, 28% of hospitalizations in seniors are caused by medication-related problems.[1]

The key must be appropriate prescribing as well as considering deprescribing medications as patients get older. A medication that may have offered a benefit at a younger age might have little benefit for, and even harm in, the aging patient. For example, most studies on statin drugs for hyperlipidemia were conducted on people aged 70 years or younger. It is not known whether the benefits extend beyond that age or what the harms might be. Some studies indicate that, after age 65, higher cholesterol levels are associated with lower all-cause mortality.[3,4]

In my own practice, when I see an elderly patient I look at all of the patient's medications and investigate whether all are still needed or wanted. Is the patient still having heartburn? If not, he or she can try reducing the proton pump inhibitor or H2 blocker, taking it every other day. If no heartburn is experienced at that dose, I tell the patient to take the pill every third day and, if symptoms do not recur, to stop it or take it on an as-needed basis. A lack of heartburn while taking heartburn medications does not confirm that the medication is working.

I also find that many elderly patients are taking multiple antihypertensive medications. Stopping one medication at a time can assess the effect of that medication. Stopping one or more antihypertensive medications does not always result in a rise in blood pressure and may reduce some of the adverse effects from the medications.

When stopping or deprescribing medications, it is important to stop them one at a time to monitor the individual effects of the medication, whether positive or negative. With some drugs, such as beta-blockers or selective serotonin reuptake inhibitors, the dose may need to be tapered before stopping. The result may be a patient taking fewer medications, feeling better, more able to afford the medication, and better able to keep track of his or her medications and take them as scheduled.

A process of shared decision-making can be very helpful when discussing deprescribing with patients. Inquire about the patient's goals, values, and needs to find out whether the patient (1) would prefer to take fewer medications and (2) understands the benefits vs risks associated with stopping medications. Often there are behavioral or lifestyle changes that a patient can make that will eliminate the need for many medications. A review of the medication list can be an opportunity to identify these options.

Reconciling medication lists has become a common practice during office visits, but the process must become more than just checking to see whether the medications are being taken. The review of medications must include consideration of the need for each medication and an opportunity to discuss deprescribing where appropriate. Prescribing must focus on doing no harm and improving the quality of life for the elderly patient. Less may be better.

Abstract

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