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The Importance of Patient-Centered Deprescribing in Assisted Living

Medications can extend lives, relieve symptoms, and reduce the consequences of disease. Yet, medication treatment can be a double-edged sword, and can cause bothersome and dangerous side effects, burden patients and their caregivers, and deplete savings.  

Unfortunately, many older adults are taking one or more medications for which the harms and/or risks outweigh the benefits. Medications that were once advisable may have become problematic, either because the individual has developed adverse effects, or because their clinical conditions, overall health, and/or goals of care may have changed since the medication was first prescribed. 

What are the Risks of Polypharmacy in Older Adults?

Older adults have high rates of polypharmacy and increased risk of medication-related adverse health events. Polypharmacy, defined as regular use of at least five medications, is common in older adults and younger at-risk populations and increases the risk of adverse medical outcomes. Unfortunately, there are many negative consequences associated with polypharmacy. Specifically, the burden of taking multiple medications has been associated with greater health care costs and an increased risk of adverse drug events (ADEs), drug-interactions, medication non-adherence, reduced functional and cognitive capacity, and undue pill burdens (Scott et al, 2015). 

There are several ways that prescribers can prevent or better manage polypharmacy in their patients. 

  1. Be militant about medication reconciliation, or comparing a patient’s new medication to all other medications they’ve been taking.
  2. Ask patients if they are being treated by other physicians and providers.
  3. Verify that there is an actual indication for every medication being taken.
  4. Assess deprescribing opportunities at every visit or care transition. 

Patients who take multiple medications often have complex chronic conditions and rely on prescribers and pharmacists who are practicing at the top of their game to educate patients about medications, help them stay adherent, and reduce the possibility of accidental harm. 

What is Deprescribing?

What is depresribing

Deprescribing is the process of dose reduction or stopping of an inappropriate medication, supervised by a healthcare professional with the goal of managing polypharmacy and improving outcomes. Deprescribing is a systematic, patient-centered process that involves gathering a comprehensive list of medications, identifying potentially inappropriate medications, determining which ones to taper, or stop, creating and implementing a plan for  discontinuation with the patient, and providing necessary follow-up support. (Whittaker et al, 2022)

Deprescribing decisions should take into account patient-specific goals,  preferences, and treatment values. Removing (deprescribing) unnecessary medications can reduce the risk of falls, improve motor and cognitive function, and reduce financial and pill burdens often experienced by the older adult population and their caregivers.  

While some medications may be immediately discontinued (deprescribed), others may require a slow taper, depending on dosages and length of time on a specific treatment. This is especially the case for Benzodiazepines (BZD) and a number of antidepressants. Extreme caution should be taken when an elder is found to have been taking a long-term BZD. Assertive deprescribing is not advised, and any deprescribing must be independently evaluated, with risks and benefits weighed. 

The Benefits of Deprescribing for Older Adults

Memory medications or medications to help with dementia should also be considered for deprescribing. These medications most often have modest benefits, but in some cases may contribute to improved function and possibly decreased challenging behaviors. These possible benefits should be weighed with the risks of frequent side effects including: nausea, vomiting, diarrhea, headaches, dizziness, appetite loss, nightmares and vivid dreams. Serious side effects include bradycardia (slow heart rate), syncope (fainting), hypotension, and significant weight loss.

As always, non-pharmacologic interventions should be prioritized, when possible, with older adults. Several assisted living communities focus on providing a variety of enriching daily programs and activities that offer crucial diversional and social pursuits to promote residents’ independence. It is well known that by engaging older adults with purposeful, meaningful activity choices, prescriptive medications are less relied upon, and deprescribing becomes a more practical option. As polypharmacy decreases, drug interactions and side effects also decrease. Ideally, patients will fall less often, their sleep improves, and they no longer experience a high pill burden from managing multiple medications. Over time, staff begin to see the results of their efforts, and less medication is administered as a result. 

  1. Scott IA, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827-34. 
  2. Whittaker P, et al. Deprescribing in older adults: An overview. Current Psychiatry. 2022; 21(5): 40-3

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