Episode 35: Deprescribing in the Care of Older Patients

November 28th, 2014

When to Stop Medications in the Care of Older Patients

In this episode Dr. David B. Hogan introduces the concept of “deprescribing” which is defined as carefully getting patients off some of the medications. David also explores when and how to discontinue medications. He highlights the importance of engaging the patient (or their agent) in shared decision making. Older patients are often open to discuss their medications and willing to stop one or more medications based on their doctor’s suggestion. Before deprescribing doctors should acknowledge goals of care, treatment targets, life expectancy, and the balance between benefits and risks. They should also consider deprescribing before prescribing a new medication, when there are changes in goals of care, at consultations, transitions points and during annual/semi-annual medication reviews.

Older patients frequently take multiple medications and despite the fact their use may be appropriate, no drug is free of side effects. Even when there are potential benefits from a particular agent, its use may be inappropriate due to a number of factors, such as: limited life expectancy, a lengthy time until the drug produces benefits, or potential contrast with the patient’s goal and treatment target. Taking multiple medications can be burdensome to patients and increases the risk of adverse drug effects, drug-drug disease interactions and/or poor adherence to drug schedules.

Finally, David outlines an approach to withdrawing medications. Whenever it is possible drugs should be stopped one at the time (based on priority). The patient should be informed that the drug is being stopped on a trial basis and it can be re-started if needed. Finally, it is important to monitor the patient as closely as possible during the period of deprescribing and document the presence of withdrawal symptoms.

“Deprescribing is not about denying effective treatment to people who would benefit, it is about ensuring people do not receive unnecessary treatment which is unlikely to be of benefit and may cause harm”.
David P. Alldred – International Journal of Pharmacy Practice 2014, 22, 2-3

After listening to this episode listeners will be able to:
1.  Define the concept of “deprescribing” and evaluate its potential benefits in older patients
2.  Identify opportunities to review a patient’s drug regimen
3.  Consider a prudent approach to withdrawing medications

Dr. David B. Hogan MD, FACP, FRCPC, Brenda Strafford Foundation Chair in Geriatric Medicine 
Contact: dhogan@ucalgary.ca 
He is a physician trained in geriatrics, and a professor in the Departments of Medicine, Clinical Neurosciences, and Community Health Sciences in the Cumming School of Medicine, University of Calgary. In addition to being a member of the AHS Seniors’ Health Strategic Care Network Core Committee and Lead for Seniors’ Health Research for W21C, Dr Hogan also holds the Brenda Strafford Foundation Chair in Geriatric Medicine and is Director of the Brenda Strafford Centre on Aging. He has served in a variety of national leadership roles relevant to his field of practice – Chair of the Royal College of Physicians and Surgeons of Canada (RCPSC) Specialty Committee in Geriatric Medicine, Chief Examiner in Geriatric Medicine for the RCPSC, President of the Canadian Geriatrics Society, President of the C5R (a national network of dementia researchers), and editor of the Canadian Journal of Geriatrics (renamed the Canadian Geriatrics Journal). Dr Hogan has published over 200 peer-reviewed papers, and has earned several prestigious awards in his career including the 2010 CIHR Betty Havens Award for Knowledge Translation in Aging and the Irma M. Parhad Award for Excellence through the Consortium of Canadian Centres for Clinical Cognitive Research. From an educational standpoint, he has been instrumental in the development of an RCPSC-approved training program in geriatric medicine and is also active in undergraduate, postgraduate clinical, graduate sciences, and continuing professional development (CPD) education. Dr Hogan’s primary research interest is in clinical aspects of aging with specific focus in cognitive impairment/dementia. Dr Hogan has a long-standing interest in creating systems of seamless care for seniors across the spectrum of health settings (i.e., home, primary and specialty care, hospitals, community-based care, assisted living/ long-term care facilities). He is also interested in the use of intelligent in-home technologies for vulnerable older patients.

References:

• Holmes’ H.M., Hayley, D.C., Alexander, G.C., Sachs, G.A. (2006). Reconsidering Medication Appropriateness for Patients Late in Life. Arch Intern Med, 166, 605-609. 
• Garfinkel, D., Mangin, D.(2010). Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older Adults. Arch Intern Med, 170(18), 1648-1654.
• Reeve,E., Wiese, M.D., Hendrix, I., Roberts, M.S., Shakib, S. (2013). People’s Attitudes, Beliefs, and Experiences Regarding Polypharmacy and Willingness to Deprescribe. J Am Geriatr Soc, 61,1508-1514.
• Alldred, D.P.( 2014).Deprescribing: a brave new word? International Journal of Pharmacy Practice, 22, 2-3.