To Improve Safety in Older Patients, Consider Deprescribing

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Polypharmacy—the use of multiple medications—in older patients is common. According to data compiled by the Centers for Disease Control and Prevention’s Center for Health Statistics, in 2016 nearly 40% of Americans aged 65 years or older reported taking five or more prescription drugs in a 30-day span.

The risk of adverse drug events and drug-drug interactions rises with each medication added to a patient’s drug regimen, and the risk rises yet more as patients age and their bodies absorb and metabolize drugs differently from before. Many central nervous system (CNS) medications, including psychotropics such as barbiturates, benzodiazepines, “Z drugs” (zolpidem, eszopiclone, zaleplon), and certain antidepressants increase risk so greatly in older patients that the American Geriatrics Society Beers Criteria caution against their use in those aged 65 years and older. The Beers Criteria also caution against the use of antipsychotics in older patients, except in those with schizophrenia or bipolar disorder or as a short-term antiemetic during chemotherapy.

“The top reason most psychotropics are considered potentially inappropriate for older adults is because of their association with the increased risk of fall-related injury,” said Donovan Maust, M.D., M.S., an associate professor of psychiatry at the University of Michigan and a research scientist in the Center for Clinical Management Research at the VA Ann Arbor Healthcare System. “I think most people recognize this as a risk for medications like benzodiazepines. I think there is less recognition of this as a risk for other medications such as antidepressants, including the non-tricyclic antidepressants.”

University of Michigan

Yet many older patients are prescribed medications that can raise their risk of adverse events, often in combinations that could be dangerous even for younger patients. In a study of more than 209,000 patients aged 65 or older published last year in Population Health Management, 28% used opioids and one other CNS medication, and 15% used opioids and two or more additional CNS medications. The most common medications used concomitantly with opioids were benzodiazepines and gabapentinoids, and in 60% of cases, these drugs were prescribed by the same health professional, usually one in primary care.

There is a variety of reasons for prescribing potentially inappropriate medications for older patients, said Danielle Fixen, Pharm.D., B.C.G.P., B.C.P.S., an assistant professor in the Department of Clinical Pharmacy at Skaggs School of Pharmacy and Pharmaceutical Sciences in Aurora, Colo.

“Much of it has to do with older patients seeing multiple specialists in addition to primary care providers because older patients have more comorbid conditions,” said Fixen, who is also a clinical pharmacy specialist at the Seniors Clinic at the University of Colorado Hospital. “As patients get older, they also have an increased risk of depression and anxiety, and trying to find medications that assist with these conditions also plays a role. Some may have been diagnosed with these conditions earlier in their lives and have continued to take these medications without re-evaluation.”

University of Colorado/Patrick Campbell

“A lot of these medications are started by well-intentioned providers who are trying to address something that causes significant distress for the patient,” said Ilse Wiechers, M.D., M.P.P., M.H.S., an associate professor of clinical psychiatry at the University of California, San Francisco. She is also the national program director for the VA’s Psychotropic Drug Safety Initiative, a nationwide program aimed at improving the quality of psychopharmacologic treatments for veterans. “Understanding the risks associated with medications in the geriatric population is something we get lots of training on in geriatric psychiatry fellowships. However, most physicians who don’t specialize in geriatrics get only a handful of hours of formal training on these topics. This is a knowledge gap we should all be working hard to fill.”

This dearth of knowledge may lead to inappropriate prescribing for older patients with dementia as well. A study by Maust and colleagues in JAMA examined the prescription records of more than 737,800 patients aged 65 years and older with dementia and found that more than 13% were prescribed hydrocodone, more than 12% were prescribed tramadol, 12% were prescribed quetiapine, more than 11% were prescribed sertraline or gabapentin, and more than 9% were prescribed lorazepam.

“A problem that is specifically concerning for older adults with dementia is the risk of further cognitive impairment,” Maust said. He noted that in the Clinical Antipsychotic Trials of Intervention Effectiveness–Alzheimer’s Disease, patients treated with antipsychotics experienced a 2.5-point decline on the 30-point Mini-Mental State Examination after 36 weeks of treatment. “I really do not think that this worsening of cognition is on many clinicians’ radars.”

Deprescribing Takes Time

In many cases, deprescribing one or more medications may lower the risk of adverse drug events for older patients. The first step in determining if deprescribing is right for a patient is to get an accurate count of all the medications the patient is taking, either from the patient, the patient’s health care team, or the patient’s family caregivers, said Maust.

University of California, San Francisco

“Hopefully all older adults have one clinician that is the quarterback of their care team; in some cases, realistically, this ends up being a family caregiver who plays the role of information coordinator,” Maust said. “I strongly encourage patients to keep an up-to-date list of their prescription medications with them that they bring to all their appointments. If nothing else, they can take their pill bottles along with them.”

From there, Maust assesses how well patients and their caregivers understand the medications they are taking and why they are taking them.

“I think conversations should start something like this for both patients and their families: ‘Why are you taking this medication? Do you recall why it was originally prescribed? Has it been helpful?’ ” he said. “After I have a good sense for their understanding of the medications that they are on, I want to consider the balance of evidence of risks versus harms for that medication.”

In cases where deprescribing is in order, it should happen slowly, Maust added.

“I think the most important thing is that usually patients arrive at a particular regimen over the course of years, so the process of deprescribing can and should take time. While there may be rare exceptions, it is not an emergency,” he said. “Also, much of the evidence suggests that higher doses are associated with a higher risk of harm, which also means that any dose reduction achieved is a success from a harm-reduction perspective.”

Wiechers said that the harm-reduction approach is particularly helpful when tapering patients off benzodiazepines.

“Insisting on getting to zero with patients is a surefire way to get them to reject your attempts to taper a benzodiazepine,” she said. “It is much better to work together with your patients to identify the least necessary dose to ensure good symptom control while also minimizing their risks.”

Wiechers added that tapers take time: “If someone has been taking a benzodiazepine for decades it will take months, if not a year or longer, to safely taper.”

Starting the conversation may be tricky, however, especially when a patient has been taking a medication for decades and has not had any issues with it.

“I find that motivational interviewing techniques can be immensely helpful for working with patients over time to get them to contemplate and then act on medication changes I am recommending,” said Wiechers.

Fixen suggests offering practical reasons for why it might be beneficial to taper off a medication. “I’ll explain to patients … that some medications may stay in the body longer, cause mental fogginess, and impact their driving ability and that coming off an inappropriate medication will also decrease the number of pills they have to take and cost them less money,” Fixen said.

Wiechers encourages psychiatrists to offer alternatives to the medications they deprescribe.

“Sometimes patients have been taking a medication for decades, and in the intervening time we’ve identified a lot of other evidence-based treatments that work and are safer,” she said. “A great example of this is insomnia and chronic benzodiazepine use. Many of our older patients have never had the opportunity to try things like CBT for insomnia.”

Ideally, psychiatrists and their patients will come to an agreement over deprescribing, said Maust.

“If it is important for safety reasons, I would want to be on the same page with the patient about specific changes needed for their safety,” he said. “Hopefully, if you have built a good relationship with the patient, then with some education and reassurance you can get on the same page about needed changes. If not, the patient might need to find a new clinician willing to continue the regimen.”

The research in the Journal of Population Health Management was funded by the AARP Medicare Supplement Insurance Program. The JAMA study by Maust and colleagues was funded by the National Institute on Aging. ■