COMMENTARY

Polypharmacy in Older Adults: Tips for Deprescribing in the Nursing Home

Margaret R. Nolan, DNP, GNP

Disclosures

December 08, 2016

Polypharmacy and Deprescribing

Polypharmacy for the long-term care resident in the nursing home is a significant problem. Deprescribing is the process of reducing the medication burden. Deprescribing principles are intended to improve healthcare for the patient by minimizing harm and costs associated with polypharmacy.

In a recent article, Liu and Campbell[1] address the problem of polypharmacy in long-term care and provide concrete tips on how to go about reducing and eliminating unnecessary medications. Often, these are drugs that the patient has been taking for a long period, but they may be affecting the patient's health negatively or are simply no longer beneficial.

The effort to minimize overprescribing and polypharmacy was first termed "deprescribing" by Woodward,[2] and this term has found a place in the literature. Liu and Campbell review the steps for deprescribing in nursing homes using a tip sheet (found in the body of the article).

Medications are listed by categories that may be considered for discontinuation, such as:

  • Drugs that are no longer indicated;

  • Drugs that pose a risk for untoward side effects in the geriatric population (eg, increasing risk for falls);

  • Common prescribing cascades (such as a drug that causes constipation, requiring a second drug to address constipation, which in turn results in another symptom); and

  • Drugs that are associated with adverse reactions when discontinued abruptly, such as discontinuation of an antihypertensive medication causing rebound hypertension.

The authors describe ways for long-term care facilities to prompt medication reviews during all prescriber visits, and assist in the deprescribing process. This can be accomplished by reviewing medication lists at each visit, asking the prescriber to consider lifespan and age-related appropriateness of the patient's prescriptions, and using a consulting pharmacist to conduct monthly medication regimen reviews.

Deterrents to the deprescribing process are complicated and may make the process difficult. One possible barrier is resistance from patients, families, other medical providers, and nursing staff. Prescribers may experience inertia, worry about making changes, or lack the time necessary to effect changes to long-standing medication regimens.

Viewpoint

Polypharmacy is common among older adults. It is not unusual for elderly patients to be taking as many as nine prescription medications. And the problem is not limited to long-term care facilities and nursing homes. Polypharmacy in community-dwelling older adults has been shown to reduce medication compliance, which in turn is associated with adverse drug-related events and a corresponding increase in emergency department visits and hospitalizations, especially in patients older than 65 years. Most reported adverse reactions are associated with unintentional overdoses, and more than two thirds are related to toxic effects of such drugs as warfarin, insulin, and digoxin.[3]

Issues of geriatric pharmacotherapy in nursing homes are different from those affecting the community-dwelling older adult. In long-term care settings, residents' medications are administered by nurses, and prescribers make regular visits. These healthcare professionals can monitor the clinical effects of medication changes and order and review lab tests (serum drug levels, blood pressure, blood glucose, international normalized ratios, and platelet counts, for example) to avoid unintended harms of deprescribing.

In addition to minimizing adverse drug events, deprescribing can lower costs. However, cost should not be the driving force in deprescribing efforts.

Deprescribing requires good communication among staff, prescribers, pharmacists, patients, and family members. Medication lists must be continuously reviewed for their appropriateness. The dose and the pharmacokinetics of the drug must be considered for effective tapering or discontinuation.[4]

Although the overall goal may be to reduce unnecessary medications, it may not be possible to deprescribe in patients with many comorbid conditions. In that case, dose reduction may be the only reasonable goal. The greatest benefits can be achieved if deprescribing is considered a routine part of medication prescribing and renewal in the long-term care facility.[5]

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