Potentially Inappropriate Medications in Older Adults: Deprescribing With a Clinical Pharmacist

Catherine A. Ammerman, PharmD; Brent A. Simpkins, PharmD; Nora Warman, APRN; Tara N. Downs, PharmD

Disclosures

J Am Geriatr Soc. 2019;67(1):115-118. 

In This Article

Abstract and Introduction

Abstract

Objectives: To compare the effects of a Geriatric Patient-Aligned Care Team (GeriPACT) on deprescribing of potentially inappropriate medications (PIMs) in individuals aged 80 and older with usual care (UC) in the Veterans Affairs setting.

Design: Retrospective cohort study.

Setting: Veterans Affairs Medical Center in Lexington, Kentucky.

Participants: Individuals aged 80 and older who filled a PIM at least 90 days before a GeriPACT or primary care appointment between January 1, 2015, and September 6, 2017 (N = 568).

Measurements: The primary outcome was to determine whether an interdisciplinary team (IDT) including a clinical pharmacy specialist (CPS) resulted in greater deprescribing of PIMs for older adults than UC.

Results: One hundred twenty-one (26.8%) PIMs were deprescribed in GeriPACT, compared with 73 (16.1%) in UC (p = <.001). Of PIMs not deprescribed, 9.7% (n = 32) were dose reduced in GeriPACT, versus 2.8% (n = 11) in UC (p < .001). Documentation of risk versus benefit discussion between a provider and participant or pharmacist and participant occurred with 65.2% (n = 215) of PIMs not deprescribed in GeriPACT and 0.003% (n = 1) in UC (p < .001).

Conclusion: An IDT that included a CPS led to significantly more deprescribing of PIMs in older veterans. Including a CPS on an IDT for the management of older adults can decrease PIM use in our rapidly growing aging population.

Introduction

Older adults are living longer and taking more medications. Adverse drug reactions (ADRs) have been described as 1 of the top 5 greatest threats to the health of this population.[1] Prescribing medications to older adults with a known risk of ADRs has been linked to greater healthcare use and death.[1–3] It is important to identify and reduce the use of medications associated with more risks than benefits in older adults.

The 2015 American Geriatric Society (AGS) Beers Criteria lists potentially inappropriate medications (PIMs) for use in elderly adults because of the probability that they will cause adverse effects in this population.[4] Mark Beers, the geriatrician who conducted the influential research on medication use in older adults, defined Beers Criteria medications as "medications that pose greater risks than they provide in therapeutic value or those medications for which a safer alternative is available."[4] One potential way to avoid ADRs and inappropriate medication use in older adults is to discontinue or "deprescribe" medications that are unnecessary, ineffective, or inappropriate,[5] but the literature on deprescribing of these medications is limited.

This research was conducted to evaluate the effect an interdisciplinary team (IDT) including a clinical pharmacy specialist (CPS) would have on deprescribing of PIMs in older adults. Veterans aged 85 and older are the fastest growing subpopulation of Veteran Health Administration (VHA) beneficiaries.[6] Demand for geriatric primary care programs first arose in 2009 and transitioned to Geriatric Patient-Aligned Care Teams (GeriPACT) to address limitations to providing care for this population.[6] The Lexington Veterans Affairs Medical Center (VAMC) first established a GeriPACT clinic in 2015.

An IDT that includes a CPS follows individuals who receive care in the GeriPACT clinic. We hypothesized that veterans receiving care in the GeriPACT cohort would have more PIMs\ deprescribed than those receiving UC because of inclusion of a CPS as a core member of the IDT.

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