Applied Evidence

Strategies to reduce and prevent polypharmacy in older patients

School of Pharmacy, University of Wyoming, Laramie
tbaher@uwyo.edu

The authors reported no potential conflict of interest relevant to this article.


 

References

Deprescribing protocol. A method developed by Scott and co-workers21 is an additional resource to consider. Appropriate times to consider deprescribing are (1) when new symptoms suggest an adverse drug effect; (2) in the presence of end-stage disease, terminal illness, dementia, extreme frailty, or full dependence on others for all care; (3) upon receipt of high-risk medications or combinations; and (4) upon receipt of preventive medications for which risk outweighs benefit.21

Assess every new symptom as a potential adverse effect of a current therapy to reduce the risk of a prescribing cascade.

This suggested method of deprescribing comprises several steps: (1) collecting all medications that the patient is taking and identifying the indication for each; (2) considering the overall risk of drug-induced harm to determine necessary intensity of deprescribing; (3) assessing each drug for its eligibility to be discontinued, such as no indication, part of a prescribing cascade, or lack of benefit; (4) prioritizing drugs for discontinuation; and (5) implementing and monitoring the drug discontinuation regimen.21

Drug-by-drug elimination trial. Reducing the dosage of, or stopping, only 1 medication at a time has been shown to be paramount to assessing development of medication-associated problems and then identifying a likely cause.14

Reduce the dosage of, or stop, only 1 medication at a time to best assess the development of medication-associated problems.

Good Palliative-Geriatric Practice algorithm. This algorithm22 can be used to guide discontinuation of inappropriate medications and improve drug therapy in community-dwelling older adults. The algorithm has been shown to improve the overall well-being of patients studied; however, it has been tested only in patients in long-term care settings and community-dwelling palliative care ­patients, limiting its generalizability to a larger population. The algorithm is also difficult to apply to patients who have multiple comorbidities.

Risks of discontinuing chronic medication might outweigh benefit. Consider those risks before removing or reducing a medication.

Risk vs. benefit of discontinuing chronic medical therapy. A systematic review of the effects of discontinuing chronic medication reveals that the risk of doing so might outweigh benefit14; this finding is thought to be due to potential relapse in the disease state being treated.11 The risks of discontinuation should be contemplated before removing the medication or reducing the dosage. Medications that can be considered to present a risk when discontinued include, but are not limited to, benzodiazepines, oral corticosteroids, antidepressants, acid suppressants, bisphosphonates, statins, and transdermal opioids.1

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