Older adults often need to manage multiple medications to treat different conditions, but the pharmacological mix can have negative interactions that cause unintentional harm. For this reason, many clinicians who care for older patients engage in the process of deprescribing—identifying and discontinuing medications that cause more harm than benefit.
Deprescribing begins with a conversation between the clinician and patient, but this step has proven to be a daunting obstacle for both sides engaged in the dialogue. That’s because the patient doesn’t always understand the benefit of stopping certain medications, while the clinician may not fully appreciate the patient’s treatment preferences.
To develop a framework to improve the deprescribing conversation across healthcare and community organizations, Terri Fried, MD, Humana Foundation Professor of Medicine at Yale School of Medicine, led a multi-institutional, international Communications Working Group composed of 14 experts in geriatrics, pharmacology, and communication, along with community outreach stakeholders who conducted a literature search of deprescribing articles published over the past two decades. The results, which included recommendations for improvements, were recently published in the Journal of American Geriatrics Society.
“More is not always better,” said Fried. “We have to recognize that when we add on medications to treat multiple chronic conditions, inevitably there is a tipping point where having more is associated with greater risks.”
Prescribing guidelines may not benefit older adults
Currently, clinicians follow clinical practice guidelines, typically written by professional medical organizations, when providing care, but this approach may be counterproductive for older adults. Fried points to high blood pressure medications as an example. The medication can lower a patient’s blood pressure to a target range, but it could also make the individual vulnerable to dizzy spells and falls.
“In many ways, deprescribing is going against years and years of effort to promote appropriate prescribing,” said Fried. “Physicians can follow clinical practice guidelines that make it easy to prescribe the correct medications for, say, diabetes or high blood pressure, but following these guidelines can sometimes cause more harm than good. When older persons with multiple conditions are prescribed all of the individual medications included in the different guidelines, these medications can interact with one another, side effects can begin to accumulate, and a medication prescribed to help one condition may worsen another. Medications need to be prioritized depending upon the outcomes that matter most to the patient.”
A new communication framework for prescribing practices takes form
The working group conducted a review of articles, published over the past two decades, that explored different approaches to deprescribing—a term that was introduced in an article published in 2003 in the Journal of Pharmacy Practice and Research describing the principles and practice of removing unnecessary or inappropriate medications and avoiding polypharmacy.
From the 78 papers identified, the Communications Working Group determined that most interventions consist of a clinician being alerted to a potential problem with the patient’s medication but does not provide guidance to the clinician about how to communicate with the patient. Moreover, these interventions do not consider the larger context in which a patient’s view of medications is shaped.
To improve this effort, the team developed a framework that expands the sphere of influence for this important decision-making process. The framework consists of “nested spheres,” in which the innermost sphere is the traditional doctor–patient office visit. Each additional sphere captures opportunities to initiate and continue the deprescribing conversation across the greater healthcare system as well as at different community interactions. This framework allows for input from additional practitioners, including nurses and other specialists, and community partners, such as pharmacists, faith-based groups, and other community-focused organizations.
“Broadening the spheres in which communication about deprescribing occurs can help to normalize the process, address concerns that deprescribing is somehow related to rationing, and help to counteract the prevailing messaging around medications that ‘more is better,’” said Fried.
The literature review is limited by the content that has been published, which only addresses the patients’ priorities and views concerning the benefits and risks of their current medication regimen. While the proposed framework offers a new approach that incorporates shared decision-making, Fried acknowledges that more studies are needed to explore how the deprescribing conversation unfolds during an office visit. These studies could evaluate communication content and style to advance this conversation, especially addressing sensitivities among a more diverse patient population.
“Our community partners helped us remember the bigger world beyond the individual patient and clinician, and reminded us of the need to build trust in the patient–clinician relationship,” said Fried. “Our insights will benefit the next generation of interventions that will be designed for deprescribing.”
Fried and her team received funding from the National Health and Medical Research Council and the National Institute on Aging.