Expert warns of need to start ‘deprescribing’ drugs for elderly patients
As demand for medications increases in part due to an aging population, many insurers have turned to drug plan management as a cost-containment strategy. However, one expert has suggested that drug prescriptions for seniors may be going to medically dangerous extremes.
The incidence of multiple chronic conditions among adults older than 65 years old is increasing in developed countries, according to a report published by Medscape.com. This leads to an increase in “polypharmacy,” or prescription of multiple medications, among such senior patients. In Canada, seniors with three or more chronic conditions take an average of six prescription drugs, and more than 30% of those over 65 are believed to be taking at least one potentially inappropriate form of medication.
Polypharmacy and inappropriate medications are associated with serious effects among older individuals, including adverse drug events, impaired physical and cognitive functions, and death. To solve the problem, some experts have pushed for a process called deprescribing, where a patient’s medical prescriptions are reviewed for possible stoppage, substitution, or reduction.
Barbara Farrell, PharmD, is an assistant professor in the Department of Family Medicine at the University of Ottawa. She is also a clinical scientist and a cofounder of the Canadian Deprescribing Network.
“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,” Farrell said. “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.”
According to Farrell, the problem of polypharmacy has been recognized for 30 years, “but only in the past four to five years have we seen greater awareness of the increasing cost to the system.” The costs, she said, include expenses from buying the drugs and from treating adverse outcomes caused by inappropriate medicine — all of which could be mitigated through deprescribing.
Farrell emphasised that deprescribing is different from non-compliance or non-adherence to a medical regimen. It should be done with the same level of expertise as prescribing, under the direction and supervision of a healthcare professional. To guide this process, Farrell has worked with colleagues to develop deprescribing guidelines using evidence-based approaches.
To date, they have developed guidelines and decision-support tools for four drug classes: proton pump inhibitors, benzodiazepine receptor agonists, antipsychotics, and antihyperglycemics. They’re working on deprescribing guidelines for acetylcholinesterase inhibitors in the treatment of dementia, and are hoping to get funding for additional work on statins, bisphosphonates, and antihypertensive agents.
“Ideally, in the next 10 years, I would like to see all prescribing guidelines have deprescribing sections,” Farrell said. But implementation would be difficult: there are currently no guidelines mandating medication reviews in primary care, and education on geriatrics, polypharmacy, and deprescribing among medical professionals is inconsistent.
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The incidence of multiple chronic conditions among adults older than 65 years old is increasing in developed countries, according to a report published by Medscape.com. This leads to an increase in “polypharmacy,” or prescription of multiple medications, among such senior patients. In Canada, seniors with three or more chronic conditions take an average of six prescription drugs, and more than 30% of those over 65 are believed to be taking at least one potentially inappropriate form of medication.
Polypharmacy and inappropriate medications are associated with serious effects among older individuals, including adverse drug events, impaired physical and cognitive functions, and death. To solve the problem, some experts have pushed for a process called deprescribing, where a patient’s medical prescriptions are reviewed for possible stoppage, substitution, or reduction.
Barbara Farrell, PharmD, is an assistant professor in the Department of Family Medicine at the University of Ottawa. She is also a clinical scientist and a cofounder of the Canadian Deprescribing Network.
“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,” Farrell said. “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.”
According to Farrell, the problem of polypharmacy has been recognized for 30 years, “but only in the past four to five years have we seen greater awareness of the increasing cost to the system.” The costs, she said, include expenses from buying the drugs and from treating adverse outcomes caused by inappropriate medicine — all of which could be mitigated through deprescribing.
Farrell emphasised that deprescribing is different from non-compliance or non-adherence to a medical regimen. It should be done with the same level of expertise as prescribing, under the direction and supervision of a healthcare professional. To guide this process, Farrell has worked with colleagues to develop deprescribing guidelines using evidence-based approaches.
To date, they have developed guidelines and decision-support tools for four drug classes: proton pump inhibitors, benzodiazepine receptor agonists, antipsychotics, and antihyperglycemics. They’re working on deprescribing guidelines for acetylcholinesterase inhibitors in the treatment of dementia, and are hoping to get funding for additional work on statins, bisphosphonates, and antihypertensive agents.
“Ideally, in the next 10 years, I would like to see all prescribing guidelines have deprescribing sections,” Farrell said. But implementation would be difficult: there are currently no guidelines mandating medication reviews in primary care, and education on geriatrics, polypharmacy, and deprescribing among medical professionals is inconsistent.
Related stories:
Public plans facing costs pressure
Insurers’ health benefit costs rising faster than inflation, says report
