Easy to Start, Hard to Stop: Polypharmacy and Deprescribing

Linda Brookes, MSc

Disclosures

June 01, 2017

Deprescribing in elderly persons has been the focus of research by Barbara Farrell, PharmD, for more than 20 years. Dr Farrell is a clinical scientist at the Bruyère Research Institute and the C.T. Lamont Primary Health Care Research Centre, and assistant professor in the Department of Family Medicine, University of Ottawa, Canada. She is a cofounder of the Canadian Deprescribing Network and codeveloper of deprescribing.org, a website for the dissemination and exchange of information about deprescribing approaches and research. Dr Farrell discussed her work to increase awareness about deprescribing with Medscape for this first article in our new series on the topic.

Chronic Disease and Polypharmacy in the 'Over-65s'

A major challenge in developed countries is the increasing number of patients with multiple (two or more) chronic conditions.[1] Multiple chronic conditions are seen most often in older adults (those aged ≥ 65 years),[2] increase with age,[3] and are likely to present an even greater challenge as the proportion of "over-65s" in the general population increases.[4]

A recent survey[5] among older adults in 11 countries reported the highest rates of multiple conditions, such as hypertension, heart disease, diabetes, lung problems, mental health problems, cancer and/or joint pain and arthritis, in the United States (68%) and Canada (56%) compared with European countries and Australia.[5] Rates of 80% were reported from studies that also included such comorbidities as hyperlipidemia and allergies.[1] As a result, older adults are likely to be prescribed multiple medications (polypharmacy) and utilize more healthcare, at a higher cost, compared with patients with no or fewer chronic conditions.[1,2,3,5,6,7]

The Consequences of Polypharmacy

Polypharmacy and potentially inappropriate medications in older individuals are associated with adverse drug events, death, impaired physical and cognitive function, falls, and hospitalization.[8,9] Approximately 53% of over-65s in the United States and 42% in Canada take four or more prescription drugs.[5] Many over-65s take five or more prescription drugs, and this rate is increasing.[10] Reports indicate that in Canada, seniors with three or more chronic conditions take an average of six prescription medications,[6] and more than 30% of over-65s are believed to be taking at least one medication that is potentially inappropriate.[7].

Dr Farrell notes that at her hospital in Ottawa, it is not unusual to see a patient on 25-30 medications. "Frequently, a medication is started to see whether it will help with certain symptoms—almost like a diagnostic test—but then the medication is never stopped," she explains. "Ten years go by, and the family doctor retires or dies, and the patient sees a new family doctor who doesn't know why the drug was prescribed in the first place but is scared to stop it. I see patients in their 80s and 90s who have been on a medication for 30 years, and no one can remember why they are taking it."

Deprescribing: Sounding the Alarm

Although the term "deprescribing" (defined as reviewing and identifying medications to be stopped, substituted, or reduced) first appeared in the literature in 2003,[11] the problem of polypharmacy in the elderly has been recognized for 30 years, Dr Farrell points out. "People had been trying to raise the alarm all that time, but only in the past 4-5 years have we seen greater awareness of the increasing cost to the system, not just of the medication but also of treating adverse outcomes of medication use, including emergency department visits and hospitalizations caused by drugs," she explains.

Deprescribing has earned widespread attention because it is an active word, rather than a description of the problem (such as "polypharmacy"), Dr Farrell suggests. She stresses that deprescribing must be directed and supervised by a healthcare professional, at the same level of expertise as prescribing, and should not be confused with nonadherence or noncompliance.[8]

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