The results of a recent study published in JAMA have further shined the spotlight on the risks associated with polypharmacy and the need for increased use of deprescribing. This study, led by Dr. Donovan Maust, an associate professor of psychiatry at the University of Michigan in Ann Arbor, examined the Medicare records for more than a million older adults with dementia. Researchers analyzed prescriptions for antidepressants, antipsychotics, antiepileptics, benzodiazepines, certain sleep aids, and opioids. For the study, polypharmacy was defined as having prescriptions for three or more of these drugs for more than 30 consecutive days.
Among the study's results:
- About 14% of the dementia patients had prescriptions for three or more drugs affecting the nervous system for longer than a month.
- Nearly three-quarters received at least one such prescription.
- Among those prescribed three or more of these drugs, almost 60% had the prescriptions for more than half a year.
In comments to Neurology Today about the findings, Dr. Maust said, "In these patients, central nervous system-active polypharmacy may increase the risk for impaired cognition, fall-related injury, and death." He went on to note that the results were unsurprising, and the publication reported that dementia experts not involved with the study confirmed that the findings reflected what they see in clinical practice.
These dementia patients and many others who are "prescribed and taking multiple medications for multiple conditions" (a definition of polypharmacy) would likely benefit from deprescribing.
What is deprescribing? Let's take a closer look.
Background of Deprescribing
Deprescribing has become one of the most effective ways to safely decrease inappropriate and unnecessary polypharmacy. As one of the leading website's concerning deprescribing — Deprescribing.org — notes, "Deprescribing is the planned and supervised process of dose reduction or stopping of medication that might be causing harm, or no longer be of benefit."
The number of patients taking multiple medications for multiple conditions has surged in recent years. As noted in this article, about 44% of men and 57% of women older than age 65 "take five or more medications" — a common way to more specifically define polypharmacy. Furthermore, it is estimated that 12% of those 65 and older are taking 10 or more medications per week, which is sometimes referred to as "excessive polypharmacy."
These figures are believed to be rising, bringing with them risks such as those noted by Dr. Maust as well as increased potential for adverse drug interactions, medication adherence challenges, and medication reconciliation errors. To help reduce the likelihood of patient harm, more clinicians are turning to deprescribing.
A Psychiatry Services article notes that term deprescribing was initially coined in geriatric medicine. Publications, including this Kaiser Health News (KHN) report, often state that the concept was "pioneered" in Canada and Australia. A Journal of Pharmacy Practice and Research article refers to deprescribing as a "new word for an old activity: the planned cessation of non-beneficial medicines." An article in The Mental Health Clinician states, "Deprescribing is an emerging practice in which healthcare providers work to optimize the medication regimen by reducing unnecessary or redundant medications."
As more is understood about deprescribing and the essential role it can and should play in medication and polypharmacy management, a worldwide movement is forming. The European Journal of Hospital Pharmacy explains why: "Unprecedented levels of polypharmacy, especially in the (older) population, combined with increases in patient harm and adverse drug events due to condition-drug and drug-drug interactions leading to morbidity and mortality are key drivers for a deprescribing movement." The KHN report notes that support for the deprescribing movement in the United States has been has bolstered by physician-led efforts, including the Choosing Wisely campaign.
Ultimately, the growth in clinicians embracing deprescribing is largely fueled by the goals of the process.
There are many noteworthy goals associated with deprescribing. They include the following:
Reducing medication burden
As Pharmacy notes, "The concept of 'medication-related burden' or treatment burden has been well-described in the literature as the overall workload that is imposed on patients resulting from utilizing healthcare, leading to multiple negative effects in their lives." Safely decreasing medication burden can deliver significant benefits, including helping patients better manage their medication regimen, improving medication adherence, reducing the need for patients to adapt and allocate more of their time to taking and managing medications as well as the benefits described below.
Reducing polypharmacy safety risks
This is the goal often motivating the embracing of deprescribing. Safe reductions in the number of a patient's medications are associated with decrease risk of drug-drug interactions, adverse drug events, falls, drug-disease interactions, cognitive impairment, hospital admission, and death. Deprescribing can also help deliver improved health outcomes.
Increasing patient engagement
As Health Affairs notes, "A growing body of evidence demonstrates that patients who are more actively involved in their healthcare experience better health outcomes and incur lower costs." An assured way to discourage patient engagement is to make participation more difficult, such as by making care — including medication management — more complex than necessary. Simplifying a medication regimen by reducing the number of medications can help patients feel more confident in the knowledge of their medications and regimen and be empowered to discuss the role medications play in their care and achieving health objectives.
Deprescribing can positively impact a patient's finances by reducing the number of medications they need to purchase, time they need to spend filling and refilling medications, and the likelihood they will need expensive urgent or emergent care due to one of the safety risks highlighted above. Suboptimal medication management drives $528 billion of unnecessary costs and contributes to 275,000 deaths annually. Much of these costs and outcomes are attributable to unnecessary therapy.
Despite the abundance of benefits, the describing process faces some barriers. As an article in the Journal of Pharmacy Practice and Research notes, "It is obvious that the deprescribing movement, however meritorious, is unfortunately still struggling to find widespread traction, a notion that is difficult to grasp in a context of evidence‐based medicine."
Deprescribing obstacles include the following:
- Patient or caregiver resistance to regimen changes, including reductions in medications
- Hesitation by clinicians to discontinue medications recommended/prescribed by other providers
- Worry about drug-withdrawal side effects and management
- Cultural barriers
- Lack of financial incentive for providers
- Limited time for clinicians to spend on deprescribing
- Concern about harming patient-provider relationship
- Lack of tools to support effective deprescribing decisions
For some patients, like those with dementia included in Dr. Maust's study, providers may face additional deprescribing obstacles. An International Psychogeriatrics article notes, "Deprescribing older people with dementia is made even more difficult by the decrease in decision-making capacity, difficulties in understanding and communicating, increased involvement of caregivers, and difficulties in setting goals."
Meds 360°: A Deprescribing Solution
One of the most significant barriers to deprescribing has been a clinician's inability to access a patient's current, comprehensive medication list that includes drug information from all prescribers and retailers. Without a complete medication picture, clinicians are understandably hesitant to perform the deprescribing process for fear of making a change to a regimen that could have unintended consequences.
Enter Meds 360° from Cureatr. With this industry-leading medication management platform, users can now view the past 12 months of a patients' medication history. Features including alerts to dangerous drug combinations, therapeutic duplications, and dose changes identity threats associated with polypharmacy, help assess medication adherence, and support data-based care decisions, including those concerning deprescribing. To learn more about how Meds 360° is helping clinicians nationwide more easily and efficiently perform deprescribing and do so with confidence, click here and then schedule a demo.