Resources

  1. Reeve, E., Wolff, JL., Skehan, M., Bayliss, EA., Hilmer, SN., & Boyd, CM. (2018). Assessment of Attitudes Toward Deprescribing in Older Medicare Beneficiaries in the United States. JAMA Intern Med. 2018 Dec 1;178(12):1673-1680. doi: 10.1001/jamainternmed.2018.4720
  2. https://www.ncbi.nlm.nih.gov/pubmed/30326004
  3. McGrath, K., Hajjar, E., Kumar, C. et al (2017). Deprescribing: A simple method for reducing polypharmacy. The Journal of Family Practice, 66 (7), 436-445.https://www.mdedge.com/jfponline/article/141753/practice-management/deprescribing-simple-method-reducing-polypharmacy
  4. https://www.ncbi.nlm.nih.gov/pubmed/28700758
  5. Gillespie, R., Harrison, L. & Mullan, J. (2018). Deprescribing medications for older adults in the primary care context: A mixed studies review. Health Sci Rep, 10;1(7):e45. doi: 10.1002/hsr2.45. eCollection 2018 Ju  https://www.ncbi.nlm.nih.gov/pubmed/30623083






Transcript

Dr. Frank Domino:

Harry is an active 82-year-old in your practice, and he has a history of hypertension, hyperlipidemia, and osteoarthritis. You note on his med list that he's on two antihypertensives, among his other meds, giving him a total of eight prescribed medications, plus four he uses from the over-the-counter world. During the visit, Harry mentions that his health insurance will be changing, and although he feels well, he's interested in possibly coming off some of the medications he takes all the time.

Hi, this is Frank Domino, professor in Department of Family Medicine and Community Health at the University of Massachusetts Medical School, and joining me today to discuss deprescribing in the senior population is Dr. Jill Terrien. Jill's an associate professor and the Director of the Nurse Practitioner program here at the University of Massachusetts Medical School's Graduate School of Nursing. Welcome, Jill.

Jill Terrien:

Thank you, Frank.

Dr. Domino:

Well, this is a great topic. I think we all worry that we're adding meds and meds and meds to our patients constantly, and never really thinking about how to stop. Can you talk to us a little bit about how primary care providers can incorporate deprescribing with their older patients?

Jill Terrien:

Absolutely. Primary care providers are in... They're really in a great role to give that holistic look at their patients, and so today we're talking about deprescribing. Less can be better, especially for our older patients. And so what I did is I saw an interesting study that was done, it was based on Medicare beneficiaries, and they wanted to know... Really they were seeking what are the attitudes of older adults in actually taking medications away, decreasing the number of medications they're taking. And so that's what this is all kinda based on today.

And so how can we do this? We have Harry coming in today, and he's asking, so the communication is open, so it's an open door into the discussion, but it can come in many different ways. So first of all, it's that critical review of what the patients are on. And I think that one of the strategies that people have used over the time is, "Harry, bring your bag of medications with you." The brown bag method. So if you have your older folks, and they do go to other people besides you, many times they have specialists, and sometimes they are not linked to your system. So the brown bag method of having them bring in everything that they're taking every day is a really great way to find out what they're doing.

So first of all, you asked how do we do this? It's the conversation, the communication with the patient, looking at what they're on and then saying, "Okay, Harry's on two antihypertensives, does he really need two?" First of all, like I said, it's the open communication.

Dr. Domino:

Okay. Great. You mention that he's on two antihypertensives. Can you give me some examples of medications in seniors that we should reconsider, possibly start maybe taking them off, and the rationale for that?

Jill Terrien:

Absolutely. One category, statins, and possibly fibrates. Do they need them after the age of 80? There is data out there that doesn't really show benefit to keeping people on statins. The other side of that though, Frank, is the patient says to you, "Dr. Domino, I've been on this medication for 25 years, and I'm in pretty good health. What's gonna happen if I stop it?" You asked me to give you an example, so let's go along the statin line. We've been looking at the patient's lab values, and Harry is active, and you can say, okay, let's just say Harris on 20 milligrams of atorvastatin. And you say, "Okay, Harry, let's cut that in half, let's taper it, let's watch what happens over the next six months, and then we can possibly take you off of it." So that's one way is to taper and review over time.

Dr. Domino:

Okay. What about his blood pressure meds? We know that one of the common complications of treating hypertension in the elderly is we get them too low and they get syncopal or so forth. Would you consider maybe cutting them down to one and seeing how he does with that?

Jill Terrien:

Absolutely. Talk to him about his 24-hour cycle in a day. We have Harry, our patient, what are the antihypertensives? Is it an ace inhibitor and a diuretic, is he maybe getting up to the bathroom at night and that's a problem. So it's kinda looking at what are his values, what's his blood pressure in the office, does he do any home monitoring, and what does his blood pressure look like? And is he having any symptoms of feeling a little light-headed or things like that. But that's definitely something you could do. Or you could, again, stop one of the meds or cut it in half, and then monitor at the next three-month visit if that's what you decided was important.

Dr. Domino:

So let me ask you a question. I was faced with this with a patient not that long ago, and I thought, gee, if I stop that medicine, what if something bad happens? Am I gonna get sued over it? Any thoughts on our risks by deprescribing? How do we do that safely and effectively?

Jill Terrien:

Great question. There's two thoughts on this. First of all, we have Harry asking you the question, but what if you are looking at the list and you say this is a lot. What can we do differently here? I think you have to look at what is the length of time they were on it, and what's a safe way to stop it? So I think there needs to be consideration in that so that it is safe. There's been no data out that has shown that there are adverse events from deprescribing, and that is in one of the papers we have on the website for this episode by McGrath that addresses that point exactly.

Dr. Domino:

I think you're absolutely right, we can document that the patient brought up the question, you have a concern about drug-drug interactions, and that you're worried that the possible benefit is much smaller than the risk it's posing to their liver or their kidneys or the possibility of a syncopal event. And I think as long as we document that, as well as the patient's willingness, I think we're probably operating in the right world. I am a little concerned that he's taking a variety of over-the-counter agents. What should we be doing about that?

Jill Terrien:

Well, first of all, you have to know what they are. And some patients, they think if they're over-the-counter, they don't have to report that because it's not prescribed so much by you. So it's asking that question, are you taking anything that's over-the-counter that's not prescribed? Are you taking anything, herbs or anything like that? 'Cause that all goes into the profile and helps you make your decision.

There are a couple of different quick points I wanna make. What some of the literature showed was that the patient barriers include a fear of their condition worsening if you change, if you de-prescribe. And the other piece is the hope of the future response, which I really found interesting. And for our patients that are on donepezil, if you stop it, is their condition gonna worsen, their dementia, and that's a fear. So that's a real patient barrier sometimes. And then there's provider barriers, contradicting a specialist's recommendations. So how do you get around that? You might wanna have a conversation with the specialist, and say, "I had Harry in my office today. This is what I'm thinking. What do you think?" So it's a shared decision-making not only with the patient but also with the other providers that they see.

The other big barriers for providers, a lack of time at the visit. We all know that we're under a lot of pressure, and then the worry about discussing life expectancy and what it means to the patient. Again, another very time-consuming, but very important point to take up with your patients.

Dr. Domino:

Absolutely. No, I think it's probably one of the most important points, and I love the fact that I can do a wellness visit with my Medicare beneficiaries and focus exactly on what they want with regard to their future plans. Any final thoughts?

Jill Terrien:

Yeah. One more example, which is a common scenario. So it can be Harry, it can be somebody else, they fall, they're taken to the emergency room, their blood pressure's low. The recommendations when they leave, don't take your blood pressure medicine, and now Harry's been off his blood pressure medicine for five days. He's seeing you at that visit. Do you restart it? And what do you do? So it's a common scenario.

Dr. Domino:

It really is. Jill, this is great. I think deprescribing is something, as our population ages, is gonna be a greater and greater focus for our patients and for ourselves, and I think it's totally worth the time it'll take for us to help patients live longer and better. Thanks so much.

Jill Terrien:

Thank you, Frank.

Dr. Domino:

Practice pointer: Less is better when it comes to prescribing for senior citizens. Take the time at each visit to review their med list, both their prescription and over-the-counter agents, and think about what you could possibly suggest that might be worth stopping. Join us next time when we discuss issues of sexuality and intimacy in our aging population and those with cognitive decline.