When less is more: The role of deprescribing and art of medication management
More prescriptions do not necessarily mean better health outcomes. Deprescribing, which is the planned and supervised process of intentionally stopping a medication or reducing its dose, is a critically important part of delivering safe, effective, patient-centered care, especially for older adults.
I commend AMDA — the Society for Post-Acute and Long-Term Care Medicine — for its Drive to Deprescribe campaign, which draws attention to the polypharmacy risk for older adults and the importance of deprescribing to improve a patient’s overall health and reduce the risk of adverse events. It is not unusual for older adults and others with multiple health conditions to take five or more prescribed medications daily, and the average number of prescriptions administered in post-acute and long-term care continues to increase.
Pharmaceuticals are prescribed because of their benefit in treating disease, curing infections and controlling pain and other symptoms. Unfortunately, older populations often have several physicians managing multiple comorbidities, increasing the risk that providers are unaware of medications prescribed by someone else — and the over-the-counter medications or supplements individuals may take — and serious illness or injury can result. In fact, research shows older adults are more likely than younger adults to be hospitalized for adverse drug interactions that could have been prevented.
Clearly, deprescribing is a worthy goal for all of us working with older adult populations. I’d argue, though, that we should also think bigger. Tackling challenges associated with prescription medications and older adults goes beyond simply reducing the variety of drugs a patient takes.
Comprehensive medication management
It’s important to take a comprehensive approach to medication management to promote our patients’ health and quality of life and reduce the possibility of harm. But there’s more to the pharmacy puzzle than prescribing and deprescribing. It’s also critical to focus on medication reconciliation and formulary adherence through the lens of effectiveness, safety and compliance.
Together, these practices can dramatically improve an older adult’s health and quality of life — not to mention their out-of-pocket costs.
Medication reconciliation is the practice of reviewing all of a patient’s medications against their current health status and concerns to ensure they are taking the right medications at the right time.
When patients take a multitude of medications, reconciliation can provide important information about whether all medications are supporting the individual’s primary health concerns. For example, Alzheimer’s patients are often prescribed cholinesterase inhibitors. Many of the same patients experience incontinence and are prescribed anticholinergics to manage this secondary condition, which can cause memory problems. In addition to this combination potentially undermining the primary health concern of dementia, the latter increases the risk of falls in an already vulnerable population. Patients taking this combination deserve to have their prescriptions reviewed.
Reconciliation should be a continual process, not a once-and-done — and these conversations should not be one-sided. Listening carefully to the patient and the family, and taking the time to talk through medications, supplements, concerns and symptoms pays health dividends. Primary health focuses may shift. The same medication prescribed at one age may not be appropriate as patients become older. What a patient is prescribed during a hospital stay may not be indicated after discharge. Health status and comorbidities change, and so should medications.
Patients may find it difficult to take medications as directed if they have memory challenges, are managing multiple medications with differing schedules or if their drugs are cost-prohibitive. They may also have trouble with the method of taking their medications. For example, consider that a large pill or dry mouth may make some drugs difficult to swallow.
The reconciliation process should help identify when patients are not following instructions, missing important doses or even potentially abusing medications. The provider, patient and family can then work together to make adjustments that support better adherence and ultimately promote the best possible outcomes for the patient. Maybe that difficult-to-swallow pill comes in different formulations that are easier to ingest. If a patient isn’t sticking to their regimen due to costs, perhaps there’s a lower-cost, effective alternative. Promoting adherence requires getting to these root causes and working collaboratively to address them.
Healthcare providers should feel empowered to have conversations about older adults’ medications and suggest changes that improve adherence, reduce risk and lower their medication load. In a survey of older patients, the vast majority indicated they would be amenable to their physician’s recommendation to stop taking at least one medication, and more than two-thirds want to reduce the number of medicines they take overall.
Deprescribing as part of a comprehensive approach to medication management is an essential part of delivering patient-centered care to achieve better outcomes and support individuals’ goals for their lives. And isn’t that the goal we’re all striving for?
Kurt Merkelz, M.D., was recently appointed to the Quality Measures Subcommittee of AMDA – The Society for Post-Acute and Long-Term Care Medicine. Triple board-certified in hospice and palliative care medicine, family practice and geriatrics, he has served as chief medical officer of Compassus since 2017.