Deprescribing in Older Adults: Implementing Effective Practices

Improving the use of medications in older adults through deprescribing has strong rationale because polypharmacy (or the use of multiple medications) in older adults is common. Recent data indicate that >36% of adults 65 years and older take ≥5 medications daily.1Young EH Pan S Yap AG Reveles KR Bhakta K. Polypharmacy prevalence in older adults seen in United States physician offices from 2009 to 2016.PLoS One. 2021; 16e0255642Crossref Scopus (29) Google Scholar This is not surprising because older adults are more likely than their younger counterparts to have multiple chronic conditions,2He Z Bian J Carretta HJ Lee J Hogan WR Shenkman E Charness N. Prevalence of multiple chronic conditions among older adults in Florida and the United States: comparative analysis of the OneFlorida Data Trust and National Inpatient Sample.J Med Internet Res. 2018; 20: e137Crossref PubMed Scopus (42) Google Scholar each of which may lead to treatment with a combination of drugs. The medication prescription cycle begins with the initiation of medication, but to optimize medication use, it should also include a recurrent assessment of indication and risk-benefit analysis, together with a shared decision-making process with older adults.3Steinman MA Handler SM Gurwitz JH Schiff GD Covinsky KE. Beyond the prescription: medication monitoring and adverse drug events in older adults.J Am Geriatr Soc. 2011; 59: 1513-1520Crossref PubMed Scopus (111) Google Scholar In practice, however, medications are often added ad hoc over time, making the medication regimen increasingly complex as one ages. Coupled with aging-related changes4Rowe JW Andres R Tobin JD Norris AH Shock NW. The effect of age on creatinine clearance in men: a cross-sectional and longitudinal study.J Gerontol. 1976; 31: 155-163Crossref PubMed Scopus (930) Google Scholar,5Tan JL Eastment JG Poudel A Hubbard RE. Age-related changes in hepatic function: an update on implications for drug therapy.Drugs Aging. 2015; 32: 999-1008Crossref PubMed Scopus (59) Google Scholar that affect absorption, metabolism, distribution, and excretion of drugs, older adults are more exposed to risks of adverse effects resulting from drugs or their metabolites. Polypharmacy is associated with increased use of potentially inappropriate medications,6Zhao M Chen Z Xu T Fan P Tian F. Global prevalence of polypharmacy and potentially inappropriate medication in older patients with dementia: a systematic review and meta-analysis.Front Pharmacol. 2023; 141221069Crossref Scopus (0) Google Scholar potentially causing risks that may exceed benefits in older adults and downstream adverse outcomes, such as risk of falls and injuries, adverse drug events, hospitalizations, and other outcomes.7Wallace E McDowell R Bennett K Fahey T Smith SM. Impact of potentially inappropriate prescribing on adverse drug events, health related quality of life and emergency hospital attendance in older people attending general practice: a prospective cohort study.J Gerontol A Biol Sci Med Sci. 2017; 72: 271-277Crossref PubMed Scopus (104) Google Scholar Deprescribing has gained momentum in geriatric therapeutics research and in clinical practice,8Bayliss EA Albers K Gleason K Pieper LE Boyd CM Campbell NL Ensrud KE Gray SL Linsky AM Mangin D Min L Rich MW Steinman MA Turner J Vasilevskis EE Dublin S. Recommendations for outcome measurement for deprescribing intervention studies.J Am Geriatr Soc. 2022; 70: 2487-2497Crossref Scopus (5) Google Scholar and evidence that deprescribing can improve the use of medications, reduce potential inappropriate medication use, and improve downstream outcomes has been building.9Bloomfield H Linsky A Bolduc J Greer N Naidl T Vardeny O MacDonald R McKenzie L Wilt TJ. Deprescribing for Older Veterans: A Systematic Review [Internet]. Department of Veterans Affairs (US), WashingtonDC2019 DecGoogle Scholar However, important questions remain about how deprescribing is performed across different clinical settings and how effective practices can be delivered consistently across settings in practice so that older adults may yield clinical benefits. This topic update contains several articles that highlight these issues. Wang et al10Wang J Shen JY Yu F Nathan K Caprio TV Conwell Y Moskow MS Brasch JD Simmons SF Mixon AS Norton SA. How to deprescribe potentially inappropriate medications during the hospital-to-home transition: stakeholder perspectives on essential tasks.Clin Ther. 2023 Aug 26; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (0) Google Scholar describe deprescribing during care transitions when older adults are discharged from the inpatient setting and examine the question of tasks that are key to deprescribing in the post–acute care setting and identified from stakeholders’ key tasks that can consistently yield improvements in medication use. Winter et al11Winter SG Sedgwick C Wallace-Lacey A Dickerson K Battar S Hung W. Informatics tools in deprescribing and medication optimization in older adults: development and dissemination of VIONE methodology in a high reliability organization.Clin Ther. 2023 Sep 8; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (0) Google Scholar further described informatics tools that support deprescribing, including tools for prescribers to identify older adults who may benefit and to identify medications as potential targets for deprescribing. Additional tools to demonstrate the implementation and impact of deprescribing in a large health system through the VIONE (Vital, Important, Optional, Not needed, Every medication has an indication) method were also discussed.11Winter SG Sedgwick C Wallace-Lacey A Dickerson K Battar S Hung W. Informatics tools in deprescribing and medication optimization in older adults: development and dissemination of VIONE methodology in a high reliability organization.Clin Ther. 2023 Sep 8; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (0) Google Scholar Two additional articles highlight advances in the use of remote technology at home to support deprescribing, bridging outpatient clinical settings to the home setting where older adults manage their medications. Moreira et al12Moreira PM Aguiar EC Castro PR Almeida KC Dourado JA Paula SM Melo MF Santos PM Oliveira MG. Optimizing hypertension treatment in older patients through home blood pressure monitoring by pharmacists in primary care: the MINOR clinical trial.Clin Ther. 2023 June 24; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (0) Google Scholar describe a clinical trial that combines the use of home-based blood pressure monitoring with collaborative medication management to optimize use of antihypertensive medications, reporting the impact of reducing harms through reducing use of medications while maintaining control of hypertension. Cigolle and Phillips13Cigolle C Phillips K. Telepharmacy model of care.Clin Ther. 2023; ([Epub ahead of print])https://doi.org/10.1016/j.clinthera.2023.08.009Abstract Full Text Full Text PDF Google Scholar describe a telemedicine model of care that optimizes medication use through deprescribing remotely via video visits to home. These advances have the potential to bring medication optimization tasks across care settings so that effective deprescribing practices can be implemented. As effective approaches to deprescribing are identified, it is important to consider how to deliver them in practice. Use of informatics tools that offer synthesized information to prescribers and other stakeholders offers a way to introduce these practices reliably. Additional research is needed in the deprescribing field to further hone in on the settings, populations, and approaches. As evidence builds, comparative effectiveness of different approaches to deprescribing should be further examined. Declarations of interest: none.