Deprescribing an overabundance of drugs

Terri Fried, MD, professor of medicine (geriatrics), who has been treating older patients in New Haven for more than 20 years, poses a case that’s not so hypothetical. A patient presents with dementia and is prescribed a drug that increases the level of the neurotransmitter acetylcholine in the brain. But if the patient also has urinary incontinence, that condition is typically treated with drugs that work against storing acetylcholine. “That makes very little inherent sense,” Fried said. “You’ve got two drugs working against each other.”

Yet making sense of medications for older patients is an all-too-common dilemma. The elderly often have multiple medical issues requiring a myriad of medications or other interventions. For each drug doctors prescribe, they consider side effects, interactions with other drugs, and how a drug for one ailment might affect a different disorder. Then there are the effects of medications on a patient’s overall well-being.

“Polypharmacy has been one of the fundamental geriatric syndromes that has been acknowledged as a problem for older patients,” said Marcia Mecca, MD, FW ’13, assistant professor of medicine (geriatrics). “Lots of studies have looked at the association with decreases in cognition, decreases in function, increases in adverse effects, and increases in hospitalization.”

Both Fried and Mecca have been studying better ways to manage medications in older patients, although from different angles. Fried is looking at how clinicians define the benefits and harms of drugs with an eye toward identifying high-risk medications. Mecca, who treats patients at the VA Connecticut Healthcare System in West Haven, is the medical director of the IMPROVE Clinic. Since it started in 2013, the clinic has tried to determine when to deprescribe; that is, to wean patients over 65 who are taking 10 or more medications off those that no longer provide a benefit or may be doing harm. The clinicians also consider reducing dosages or using such nonpharmaceutical approaches as cognitive behavioral therapy. IMPROVE (Initiative to Minimize Pharmaceutical Risk in Older VEterans) is based in the VA and trains residents in internal medicine, nursing, pharmacy, and psychology in how to assess a patient’s pharmacology profile.

“There are lots of guidelines for many conditions that focus on prescribing medications for that condition, and they are usually based on markers of disease severity. These guidelines don’t always provide clear guidance for when a medication is no longer needed or not indicated,” Mecca said. “There is a lot of acknowledgment of that as a problem.”

One area that calls for a multidisciplinary approach is what’s called medication reconciliation, an inventory of all of a patient’s meds. Ideally, reconciliation should happen at every clinical visit, but that’s not always possible. The gold standard for this conversation is what’s called the “brown bag review,” asking the patients to bring all their meds in their original bottles in a bag to the doctor’s office. Again, this alternative is not always possible.

“The starting point is for the physician and the patient to have the same list of medications,” said Fried. “Our work showed that it was rarely the case that that was true.”

At the VA, said Mecca, doctors may review a patient’s panel of pills with a pharmacist, but that doesn’t account for prescriptions from other doctors or for over-the-counter supplements or vitamins the patients may be taking. Ironically, said Mecca, the COVID-19 pandemic has made pill inventories more reliable because more clinical visits are held over the phone or online. “You ask them to get their meds all together from all over the house. Maybe some are in the bathroom, some are in the kitchen, some are on the nightstand,” she said.

Once doctors have ascertained what a patient’s taking, they have a conversation with the patients about what is most important to them. “Which conditions or symptoms are most bothersome to them or get in the way of them doing what they want to do in their day-to-day life?” asked Mecca. “The key is to think about deprescribing as a highly personalized approach to helping older patients make sense of their medications and optimize them, so they are achieving what matters most to patients and not causing harm.”

Guidelines do exist, but Fried notes that criteria don’t always consider all the evidence about potential risks. “The problem is that the main source [of evidence] about medications comes from large randomized controlled trials,” she said. “Those trials specifically exclude the people who are at highest risk for suffering adverse effects of those medications.”

Even with the guidelines, Fried said, decisions will rely on a doctor’s clinical judgment. “Any time I see an 85-year-old patient on 15 medications, I’m thinking, ‘Less has got to be more here,’ ” she said. “I’m also going to listen very hard to what the patient has to say. For a lot of our patients at that stage in their life, their goal is for us to keep them as functionally independent as possible.”