How Deprescribing Can Mitigate the Problem of Overmedication
When patients are referred to our service, we as palliative care clinicians have a unique opportunity to streamline our patients’ medications—especially if they’re doing more harm than good.
Polypharmacy, which typically describes the use of five or more prescription medications, is far more common than most people realize. In fact, research shows that it is particularly common for older adults. Polypharmacy can be (and often is) a consequence of a person having multiple chronic conditions. While it can be tricky to manage and treat multiple overlapping medical conditions, it’s all too easy and routine for clinicians to just add to the list of medications, rather than subtract from it.
"It’s all too easy and routine for clinicians to just add to the list of medications, rather than subtract from it."
We as palliative care clinicians can intervene. Through conversation, we can find out if our patients are overmedicated and begin the process of deprescribing. By doing so, we may be able to eliminate some medications that are unnecessary, also eliminating side effects that may be detracting from our patients’ quality of life and overall well-being. So, how do we assess for overmedication? Below, I outline some suggestions.
How to assess for overmedication
If a new patient is referred to your palliative care service, take the time to learn more about the medications that they are taking. Before you can begin the process of deprescribing, you need to assess them for overmedication. You can do this by carefully screening them, reviewing medical records, and asking some specific questions (e.g., does the patient still need their proton pump inhibitor [PPI]?).
"If a new patient is referred to your palliative care service, take the time to learn more about the medications that they are taking."
1) Take stock of your patient’s list of medications
Carefully examine the list of medications your patient is taking. How many medications are there in total? If the list exceeds five, know that this is associated with worse outcomes, especially in advanced elderly patients (over 75 years old, often with multiple comorbidities, and with some type of cognitive and/or functional decline). Research tells us that older adults tend to be at greater risk for experiencing adverse drug reactions in general, and the risk of drug-drug interaction goes up as more medications are used.
2) Consider the length of time
Has your patient been taking a particular medication for a long period of time, without a break? And do they still really need to keep taking it? Perhaps you should be asking if the benefit of the medicine has run its course and could possibly be discontinued, knowing the timeline for that can vary.
Sometimes patients keep taking a specific medication because a doctor, who they trust, prescribed it to them and they are compliant. They may not think to ask, “How long have I been taking this medication and should I keep taking it?” That said, you may need to ask this question on their behalf.
3) Determine if the medication is still necessary
Necessity is closely related to the previous point regarding time on medication. Some patients may not even know whether they still need a particular medication. For example, a patient who has been taking bupropion (Wellbutrin) for anxiety or depression for two decades might not know if they need to continue taking it. This gives you the chance to ask whether they’d consider tapering it down or taking a "drug holiday”, safely under the guidance of a prescribing clinician.
"Some patients may not even know whether they still need a particular medication."
Another issue to consider is that a patient may be taking a medication originally prescribed to counter the side effects of another medication (a medication cascade). Are they even still taking the original medication? If not, they may not need the aforementioned medication any longer. The best practice would then be to check with the prescribing clinician who has been managing the medication in question.
4) Look for commonly overprescribed medications and high-risk medications
Determine if any of the specific medications that were prescribed to your patient are “usual suspects” for overprescription. As a 2019 study in the Journal of Clinical Medicine Research found, the most commonly overprescribed drugs tend to fall into four classes: opioids, proton pump inhibitors, hormone replacement medications (e.g., levothyroxine), and antidepressants. However, this depends on the stage of life of your patient, especially older adults, as the list may change and even grow as the patient ages.
"You should be especially alert if your patients are taking any high-risk medications, which pose a higher risk of causing significant harm."
You should be especially alert if your patients are taking any high-risk medications, which pose a higher risk of causing significant harm. One category, in particular, to consider if your patients are older adults is anticholinergics (e.g., amitriptilyne). They are used to block the action of the neurotransmitter acetylcholine, which affects muscle contractions, and they are prescribed for a variety of conditions ranging from Parkinson’s disease to chronic obstructive pulmonary disease (COPD). But they are known for causing dizziness, fatigue, cognitive changes, and other symptoms that can impact a patient’s quality of life. And this category of drugs is associated with a substantial increase in mortality (as well as permanent cognitive damage) for any given year that the patient remains on it, especially for older adults.
5) Consider age-appropriate guidelines for medication
I encourage you to look beyond your patients’ age and consider their specific needs. Our medication needs change as we age, and clinical guidelines change, too. What might be appropriate for a middle-aged adult could be quite different from what’s appropriate for an advanced elderly adult. And even that can vary, too. It might be very ambitious to expect an adult of a certain age to achieve a blood pressure level, for example.
This might be a good time to consider what’s realistic. If you need help, you might consider using the American Geriatrics Society’s Beers Criteria to help determine which medications are potentially inappropriate for older adults, as well as which medications may be better substitutes for medications they’re currently taking. The American Diabetes Association and the American College of Cardiology (ACC) also include guidance in this area, such as potential drug interactions.
The goal of deprescribing is to eliminate unnecessary or inappropriate medications that may be causing your patients harm, which includes harm to their cognitive abilities and their quality of life.
While we’re assessing our patients for overmedication, we can’t ignore the importance of the patient’s cognitive function. A NEJM study showed that seventy-five to ninety percent of patients would forego treatments if there were a significant risk of functional or cognitive decline. But too often, those priorities aren’t routinely discussed when originally prescribed.
Ultimately, polypharmacy has been associated with higher mortality and lower quality of life for older adults. Some medicines will remain necessary but deprescribing is not just about taking fewer medicines; it’s about improving care for older adults, and understanding that the medical evidence for this demographic is not the same as younger and healthier patients.
Edited by Melissa Baron. Clinical review by Andrew Esch, MD, MBA.