Elayne Ansara, PharmD, BCPS, BCPP
Polypharmacy is the utilization of more medications than needed, or for which the harm outweighs the benefits. Polypharmacy can increase the risk of adverse drug reactions, falls and fractures, functional and cognitive decline, and ultimately hospitalizations and higher healthcare costs. The elderly are particularly susceptible to these adverse effects of polypharmacy as they are often frail and not represented in the research. At the CPNP 2018 Annual Meeting, Barbara Farrell, PharmD, FCSHP, presented on the risks of polypharmacy and spoke about deprescribing as a potential solution to this epidemic.
While no definition of deprescribing exists globally, it can be thought of as the planned and supervised process of dose reduction or stopping of medication that may be causing harm or no longer be of benefit. The goal of deprescribing is to reduce medication burden and harm, while maintaining or improving quality of life. As Dr. Farrell explained, deprescribing is part of good prescribing. Deprescribing has been shown to be feasible and safe. In addition, reductions in falls, numbers of medications and their associated costs, and mortality are all observed with deprescribing.
Several generic deprescribing guidelines exist to aid health-care providers and patients in this process. In general, a medication history should be compiled and those medications that may be potentially inappropriate or those with less evidence for benefit or those with harm identified. Once medications are assessed for eligibility of deprescribing, prioritization of those medications as well as a plan for tapering and monitoring should be developed. As always, monitoring, supporting and documenting care are key steps in the deprescribing process. Dr. Farrell explained that goals of care related to deprescribing should be to maintain and improve several aspects of the patient’s life. These include physical functioning such as activities of daily living as well as psychological functioning such as cognition and mood. Additionally, social function and overall health and well-being should be preserved or improved through the process of deprescribing.
As with most change, there are certain factors that can be barriers to enacting this change. Dr. Farrell explained that these barriers can not only come from patients but also prescribers. Prescriber barriers include awareness or insight into the need for deprescribing, patient and provider complexity, as well as the general feasibility of deprescribing. Treatment guidelines may assist the provider in moving forward with deprescribing. While some may find that patients can be a barrier to deprescribing, Dr. Farrell presented research that shows most patients are hypothetically willing to attempt deprescribing, but can be limited by their fear of doing so. Influences on the patients can include other providers, family, friends as well as other experiences the patient may have had with deprescribing. Providing education to the patient that deprescribing is a process, something that is done gradually and with careful monitoring, may encourage them to proceed.
To close her session Dr. Farrell presented several evidence-based guidelines that she, in conjunction with a deprescribing network in Canada have created. She explained the rationale behind the creation of these guidelines as well as the process for creation. Guidelines presented covered deprescribing of benzodiazepines and z-drugs, and antipsychotics. These guidelines can be accessed at www.deprescribing.org.
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