Case: You’ve assumed the care of an 84-year-old patient who is on nine different medications. Should you carry on with her current regimen or consider stopping some of her drugs?
Introduction: Older patients frequently take multiple medications. While their use may be appropriate, no drugs are entirely free of side effects and in patients 75 years and older we often have limited data on the relative balance between efficacy and toxicity. Even when there are potential benefits with a particular agent, its use may be inappropriate because of limited life expectancy (assistance in estimating life expectancy can be found at – http://eprognosis.ucsf.edu/), there is a lengthy time until benefit from use of the drug occurs (especially in the setting of limited life expectancy) and the patient’s goals of care and treatment targets.1 Taking multiple medications can be burdensome to patients and increases the risk of adverse drug effects, drug-drug and drug-disease interactions and/or poor adherence. In this brief review we will explore why, when and how you can discontinue medications in an older patient.
Literature Review: Many of the drugs being taken by an older patient can often be stopped. This was shown in an Israeli study that took a systematic approach to discontinuing medications.2 Seventy older, community-dwelling patients taking on average seven-to-eight medications were seen in consultation. The investigators reviewed each drug being taken and determined if there was evidence-based consensus supporting its use for the stated indication in patients at the person’s age and disability level and whether this benefit was greater than any known adverse effects. Based on this assessment, it was felt that 58% of all drugs being consumed by the group should be stopped. In 81% of cases it proved possible to stop the drugs without harm to the patients. Often this was associated with improvements in their perceived health.
While it is often said that older patients are reluctant to stop medications, that doesn’t appear to be the case. An American study of 100 older patients taking an average of 10 medications found that 92 of them would be willing to stop one or more of their medications if their doctor said it was possible.3
Summary: Studies like these show that deprescribing – defined as carefully getting patients off some of the medications that have accrued over time – can be safely done.
Opportunities to review a patient’s drug regimen include:
- when there is a change in their goals of care (e.g., if a terminal illness is diagnosed);
- at the time of consultations;
- during care transitions;
- when annual/semi-annual medication reviews are done;
- whenever a patient presents with a new problem or complaint (always consider whether this could be an adverse drug effect); and,
- before prescribing a new medication.
It is important to involve the patient when considering deprescribing as this should be a shared decision. When deciding about the appropriateness of a medication, consider goals of care, treatment targets and life expectancy. Know all the drugs the patient is on and try to match her/his conditions with the medication she/he is on. Look for prescribing cascades (where the use of one drug leads to side effects that are treated by a second agent) and counter-productive prescribing (concurrent use of agents that have opposing effects). Consider stopping a drug if harm (adverse effects) from continued use outweighs benefit, there is no indication for its continued use or the agent is ineffective in managing the patient’s condition.
When stopping drugs, discontinue them one at a time (based on priority) whenever possible. Remember that discontinuing a drug can lead to a worsening of the underlying indication for its use or withdrawal symptoms. Explain to the patient that the drug is being stopped on a trial basis and it can be re-started if needed. While some drugs can be stopped abruptly, with others you have to slowly and carefully taper them. This is especially true for drugs that the body adapts to over time (e.g., opioids, systemic steroids, beta-blockers, nitrates, psychoactive agents). As a general rule you decrease at the same rate you titrated up. Explain to the patient what can occur and give them clear instructions on what they should do if they encounter problems (e.g., when to call you). It’s important to monitor the patient as closely during a period of deprescribing as you did when you initially prescribed the drug.
- Holmes HM, Hayley DC, Alexander GC, Sachs GA: Reconsidering Medication Appropriateness for Patients Late in Life. Arch Intern Med 2006; 166:605-609.
- Garfinkel D, Mangin D: Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older Adults. Arch Intern Med. 2010; 170(18):1648-1654.
- Reeve E, Wiese MD, Hendrix I, Roberts MS, Shakib S: People’s Attitudes, Beliefs, and Experiences Regarding Polypharmacy and Willingness to Deprescribe. J Am Geriatr Soc 2013, 61:1508-14.
(Note: See also “Choosing Wisely Canada” for Canadian Geriatric Society advice on some medications physicians should question prescribing in this age group: http://www.choosingwiselycanada.org/recommendations/canadian-geriatrics-society-2/)