Practical tips for deprescribing in older adults
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CHICAGO — While there are several challenges to deprescribing, applying a practical algorithm of care may ease some of the anxiety that older patients experience during this process, according to a presentation at the ACP Internal Medicine Meeting.
“The onus for a medication to be continued is either proof or a strong suspicion that it’s actually providing a real and substantial benefit,” Michael A. Steinman, MD, FACP, a professor in the division of geriatrics at the University of California, San Francisco, and the San Francisco VA Medical Center, told Healio. “If you fall short of that, then there is no reason to continue the medication. A neutral impact is not good enough to continue a medication. It needs to be actively helpful.”
There is no universal definition of deprescribing, according to Steinman. However, the process is more proactive than reactive.
Deprescribing should be thought of as “behavior change that is more akin to counseling people about alcohol or tobacco use,” Steinman said. “It’s not just a technical decision. It requires a therapeutic alliance between the doctor and the patient to have that conversation and motivate that behavior.”
Data have shown that deprescribing can significantly reduce the risk for mortality among nursing home residents. Older adults may be hesitant to discontinue a medication they have been taking for years, which is why patients play a large role in the deprescribing process. Discontinuing a medication that a patient may be interested in continuing may do more harm by damaging the patient-physician relationship, according to Steinman.
His practical algorithm for deprescribing includes the following patient-centric actions:
- take a comprehensive medication history;
- identify potentially inappropriate medications;
- determine if medication can be ceased, and prioritize;
- plan and initiate withdrawal; and
- monitor, support and document outcomes.
One of the most common mistakes that physicians make with deprescribing is not regularly reviewing medications and assessing if they are still needed.
“Once medications are prescribed, they are sort of like barnacles; they get very sticky and can be hard to take off,” Steinman said.
Physicians may especially be hesitant to discontinue medications when they are prescribed by different specialists.
Another common mistake is not forging the therapeutic alliance with the patient.
Deprescribing applies to all patients but has special relevance to older adults, according to Steinman.
“Older adults, on average, tend to take many medications and have a disproportionate share of health problems,” he said. “The issue of polypharmacy and medication harms tend to be especially accentuated in the older populations.”
Overall, Steinman emphasized that deprescribing is not just the opposite of prescribing. It is often psychological, so attending to the meaning and emotions patients associate with medications is essential.