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Deprescribing

Polypharmacy management in older adults with comorbidities

Diggins, Kristene DNP, MBA, CNE, NEA, FAANP

doi: 10.1097/01.NPR.0000554677.33988.af
Feature: POLYPHARMACY
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Abstract: In today's clinical landscape, the simultaneous use of multiple drugs to treat a single condition has become a major patient safety issue. Recent evidence suggests a need to identify deprescribing opportunities in the management of polypharmacy. NPs, as clinical gatekeepers, are in a key position to spearhead deprescribing best practices, specifically as they relate to older adults with multiple medication regimens.

In today's clinical landscape, the simultaneous use of multiple drugs to treat a single condition has become a major patient safety issue. Recent evidence suggests a need to identify deprescribing opportunities in the management of polypharmacy. NPs, as clinical gatekeepers, are in a key position to spearhead deprescribing best practices, specifically as they relate to older adults with multiple medication regimens.

Kristene Diggins is a Senior Clinician, Doctor of Nursing Practice at MinuteClinic and an adjunct faculty member for University of Phoenix and Chamberlain University.

The author has disclosed no financial relationships related to this article.

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Figure

Clinicians have often struggled independently to implement deprescribing principles in medication management. Recent evidence provides clear clinical best practices for deprescribing in older adult patients with comorbidities, who are often on multiple medication regimens.1

Deprescribing is defined as the approach of reducing or discontinuing medications that are unnecessary or deemed harmful.2 There are numerous health benefits associated with deprescribing, including reduced adverse reactions, improved cognition, reduced falls, improved medication adherence, and improved quality of life.2 These effects are especially prominent in older adult patients because the dynamic health needs of this population may not be addressed in a timely fashion because of limited access to primary care providers.2 Addressing the precipitating factors of polypharmacy can be challenging, but NPs can spearhead this effort by focusing on collaborative patient education during each clinical encounter.

Deprescribing involves much more than identifying inappropriate medication use. Recent research has shed light on the fact that deprescribing requires a regular, meticulous review of the risk/benefit ratio of each medication provided to patients. This type of practice approach requires close monitoring and follow-up to manage outcomes of deprescribing interventions.2

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Polypharmacy challenges

Polypharmacy is prevalent in all clinical settings, but especially in geriatric and psychiatric populations in various environments, such as outpatient, inpatient, assisted-living, and long-term-care facilities.3Multimorbidity, which is defined as the coexistence of two or more chronic health conditions, is the most important contributing factor to polypharmacy. Multimorbidity is associated with overall decreases in quality of life, perception of wellness, and functionality.3 It is especially common in older adult patients, given the high prevalence of conditions such as diabetes mellitus, hypertension, Alzheimer disease, and osteoarthritis in this population. There is a clear correlation between chronic health conditions and the increased risk of drug-drug interactions and complex adverse reactions. NPs must be aware that older adults are at an even higher risk for adverse reactions due to decreased renal and hepatic clearance of drugs, lower lean body mass, and reduced cognition and mobility. Because of the unique needs of older adults, it is important that clinical gatekeepers routinely confirm the appropriateness of all prescribed medications, potential adverse reactions, and negative medication interactions, as well as the patient's level of medication adherence.3

Growing evidence suggests patients are increasingly taking more than four prescribed medications, and numerical definitions of polypharmacy do not seem to ascertain the clinical appropriateness of therapy.3 The recent National Institutes of Health's clinical guidance states that although the number of medications (four or more) should be considered, it is the indication, efficacy, and toxicity profile of patients' medications that should be primary concerns while deciding on deprescription.3 In polypharmacy especially, understanding drug-drug interactions is an empowering first step in medication regimen management. Therapeutic duplication is also a cause of polypharmacy, with inadvertent duplication of prescriptions often contributing to the problem of polypharmacy.2,3

The duration of therapy and healthcare setting also contribute to the complexity of polypharmacy. Communication at the points of care transfer plays a major role in precipitating this problem; inadequate medication history taking and medication reconciliation practices are the main culprits, and they are more pronounced in older adult patients.2 Another reported issue is lack of clarity and consistency of clinical documentation as well as lack of decision support systems, especially in long-term-care settings.2 This can lead to confusion, dose duplication, or misread prescriptions, all of which may result in potentially severe complications. Another clinical challenge is managing the medication regimens of patients who see multiple clinicians. Patients who visit four or more providers were found to have received conflicting medical advice, unnecessary duplication of lab testing procedures, and overprescription.2 To summarize the recent literature findings, general administrative and organizational factors in polypharmacy include multiple healthcare providers, hospital admissions, administrative and technical barriers in healthcare systems, and limited patient resources.2,3

Recent research suggests that single-disease guidelines for initiating treatments are one of the precipitating factors of polypharmacy.4 In general, a lack of availability of deprescribing guidelines provides a real challenge in leading patients toward an individualized medication regimen. NPs have been interviewed in numerous studies on the areas of opportunity for enhanced medication management. A desire to err on the safe side, which focuses on reaching specific target guidelines, often results in overprescription.2 Often, the concern about polypharmacy adverse reactions is overshadowed by a genuine concern of worsening health if medications that are treating a patient's illness are deprescribed.2 All these fears combine to drive inaction toward deprescribing.

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Deprescribing practices

Deprescribing may be successful and effective in patients with complex medication regimens, as professionals collaborate to seek further clinician education to monitor patients' individual needs and discern individual recommendations and treatment goals. Patients undergoing this deprescribing approach should be closely monitored to ensure any signs of complication or disease exacerbation are detected.2,3,5 However, deprescribing may also require additional time-intensive interventions by clinical teams, which sometimes may not lead to expected outcomes, and in fact, may have unexpected adverse outcomes affecting a patient's quality of life.5

Recent findings suggest several initiatives that can help establish and promote deprescribing practices in polypharmacy.5 These initiatives include pharmacist-conducted comprehensive deprescribing reviews to identify wrong/redundant medications; adequate reimbursement for the extra workload of staff for medication reconciliation, especially with older adult patients; better communication between practitioners through digital health interfaces; and education of practitioners to address multimorbidity and polypharmacy issues that arise from the treatment of multimorbidity.2

An interesting finding noted that clinical education curricula integrated into undergraduate, graduate, and continuing medical education could lay the foundation of this culture shift toward deprescribing.6 More-effective partnerships between primary care providers, pharmacists, and specialists would also play a synergistic role in deprescribing efforts.6 In fact, working together with community pharmacists to optimize a patient's medication regimen is an excellent starting point for the discovery of redundancy in treatment plans involving polypharmacy.

Through the increased use of electronic healthcare records (EHRs), the potential for optimizing medication regimens and deprescribing where appropriate is maximized. The use of EHRs equips NPs with a keen approach to recognizing medication duplicity and provides ample opportunity to reach out to pharmacists as indicated. Pharmacists are often able to recognize redundancy in prescriptions from multiple providers and are often the first to indicate potential deprescribing options for patients. EHRs should be used to leverage polypharmacy practices and provide decision support with prescribing advice rendered in real time with multiple provider interoperability for optimal coordination of care.6 More research studies on the methods of deprescribing in polypharmacy should be performed to build on the existing evidence base and study patient-oriented outcomes, best practices, and optimized protocols.6

NPs know the importance of evaluating each patient's prescription plan. Recent evidence suggests that the best way NPs can manage patient care is through review of medications and the duration of treatment plans.1,4 Ensuring that a patient's medication plan is relevant is key to long-term patient care management.

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Deprescribing in older adults with comorbidities

Deprescribing can be best done through an understanding of a patient's medication regimen and thorough review of the best practices in pharmacologic treatment options of common chronic comorbidities such as hypertension, diabetes mellitus, and hyperlipidemia. A relevant example of deprescribing in chronic conditions is evident with proton pump inhibitors (PPIs), as they can often be discontinued when no longer necessary.7 Addressing PPI overuse can often be a starting point in managing other medications appropriately.

Another common area of maximizing medication management and potential deprescribing benefits can be found in older adults with diabetes. As is seen in practice, patients with type 2 diabetes mellitus (T2DM) are often prescribed multiple drugs, such as insulin, metformin, or oral antidiabetic drugs, to maximize critical indicator result guidelines, such as reduced hemoglobin A1C (A1C). At each subsequent clinical visit, another medication may be added to the regimen to treat the patient to help achieve guideline- recommended lab test parameters. Older adults with T2DM also tend to have comorbidities, such as hypertension, coronary artery disease, or osteoarthritis, for which they are prescribed several additional drugs. In short, polypharmacy is a significant problem for many older adults, and the complexity of the medication regimens often confounds long-term medication adherence. With each subsequent medication added, adherence often decreases, and the burden associated with treatment cost increases.

A study involving the residents of a long-term-care (LTC) facility in the UK revealed that up to 90% of this population was given inappropriate medication; upon clinical review, it was thought that 39% of the residents would be suitable for deprescribing of their medications.7 This was particularly true of patients taking medications for T2DM in this population. A large retrospective review done on polypharmacy practices from the 2000s reported that reducing the dose or, in appropriate cases, discontinuing oral antidiabetic medications in older adult patients, seemed to be feasible while still maintaining acceptable glycemic control.8 A large review of 211,667 patients who were over 70 years and were receiving medication for T2DM found that for the patients whose treatment resulted in very low levels of A1C or BP, only up to 27% underwent deintensification, suggesting that deprescription (or, in this case, dose-lowering) practice could cover a larger subset of patients without affecting BP or glucose levels.9 Practice guidelines and performance measures are critically lacking in this area. A literature review conducted by Black and colleagues found that only two controlled studies were performed on deprescribing in patients with diabetes—one of which showed that educating stakeholders decreased glyburide without worsening glucose control, and the other reported that discontinuing antidiabetic medications in older adult patients in LTC facilities did not significantly increase A1C levels.10 Another recent study categorized three high-priority medication classes (HMG-CoA reductase inhibitors [statins], cholinesterase inhibitors, and bisphosphonates) as the most fitting prescriptions for clinical pharmacists to consider deprescribing.11 However, given that the scope and size of these studies was small, there remains a pressing need to perform larger randomized controlled clinical trials. In general, there has been a push for establishing deprescribing guidelines and protocols for clinicians to follow for their older adults with T2DM.

As the medication plan becomes more complex, collaboration between providers becomes more essential. Deprescribing where appropriate can often increase goals obtained according to the patient's unique needs. Polypharmacy is also an issue affecting patients suffering from dementia, such as Alzheimer disease. But there are barriers to practicing deprescription in this specific patient population. Some of these barriers include inadequate guidelines, incomplete medical histories, lack of time, and prescribing medications while ignoring medical evidence suggesting negative consequences.12 In this population, the patient-related factors that make matters worse are declining cognitive abilities, increasing comorbidities, and increasing number of care providers who prescribe more drugs.12

There has been a push for adopting an individualized approach to addressing polypharmacy in older adults.13 The evidence is clear that sometimes the best intervention is to treat older adults individually based on their needs and goals, appropriately removing medications that may no longer be necessary because of individual patient goals. For example, an older adult on an aggressive diabetes medication management plan might opt to allow a higher A1C goal to reduce incidence of falls related to hypoglycemia.

Ultimately, an individualized approach to patient care is essential in the NP practice, specifically as patients' needs may change with age.14 The patient's age, race, gender, socioeconomic status, prognosis, and life goals all work together to provide the NP with the individualized approach to management of medication regimens. This type of open communication is key for addressing the concerns of patients following a polypharmacy regimen. Medication management for each condition can play an essential role in the ultimate prescription choices that are made, but each choice is only one piece of a holistic approach.

The continual collaborative approach of reviewing medications is an important part of medication management and allows the patient and NPs to work collectively toward goals in disease management.14,15 What is clear is that one key way to recognize opportunities for deprescribing is to evaluate older adult patients with multimorbidities who are following a polypharmacy regimen. Reviewing medications at every clinical encounter provides a framework for this intervention, as this allows for screening of new medications, and adverse reactions that may not have been previously noted. This type of screening provides an avenue for the discussion of each medication's appropriateness and allows the patient to be informed on the correlation of health goals with the medication regimen.16

Table

Table

A focused approach to deprescribing recognizes that patients' needs are key in any medication regimen, and that these needs are dynamic based on appropriate measurement of chronic disease outcome indicators.17 For example, treating a patient with diabetes to a guideline A1C target of 6.5%, which assumes the patient has no comorbidities, may no longer be relevant to an older adult at risk for hypoglycemia. By approaching comorbidities with a stepwise approach in polypharmacy management, the NP can subsequently reduce the burden of treatment for each unique patients' needs.17,18 Integrating a stepwise approach to polypharmacy and potential deprescribing needs allows for cost-effectiveness in multimorbidity management, providing cost saving treatment regimens for patients. Cost-effectiveness of treatment plans can be easily overlooked and can often confound management of polypharmacy in multimorbidities.19

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A systematic approach to deprescribing

As NPs seek solutions to polypharmacy management in all patients, clear evidence emerges on a systematic approach for each patient encounter. These key steps will help NPs to appropriately deprescribe when appropriate, leading to improved management of clinical indicators, as this focus provides an integration of the patient's needs. (See Suggested stepwise approach for proper deprescribing.)

Following a comprehensive, individualized approach in collaboration with other clinicians can mitigate the risk of overprescribing and facilitate treatments that are individualized to the patient, not treatments targeted to guidelines that may not apply to the individual patient.20 The most important point in medication management is to remember that the specific patient goals must continually be accounted for in polypharmacy regimens.21 Critical indicator outcome goals (such as A1C or low-density lipoprotein cholesterol levels) in chronic disease can be determined for and monitored in each patient.22 The goal is to provide a case-management system focused on interprofessional collaboration, one that appreciates each professional's input into the medication plan.23 A continuity of care plan based on a primary healthcare provider's input into medication management should integrate principles of deprescribing.24

At the onset of each encounter, NPs can work with the patient and collaborating professionals to optimize outcomes that are directed by the patients' goals. Integrating an individualized approach to each patient's medication plan will mediate appropriate prescribing and deprescribing efforts. An intervention based on the patient's optimal critical indicator results can be a part of the systematic approach to understanding each patient's required medication regimen and play a role in recognizing where opportunities for deprescribing may be most appropriate. Often, asking patients at the time of encounter about their medications and confirming what medications they are on provide an avenue for regimen optimization. At this point of confirmation, a review of medication appropriateness considering the needs of the patient can be validated, reviewed, and discussed with the patient. Involving the collaborating professional team through case review will also enable an efficacious approach to which medications may be discontinued after reviewing the patient's goals.

An understanding of the appropriateness of deprescribing will provide a venue for the individualized approach in chronic, multidisease management. This will involve a proactive approach to medication management that sees both prescribing and deprescribing as opportunities to value each patient's goals. This requires a reevaluation at each encounter. The literature suggests that it will take effort, time, and experience for NPs to confidently intervene and deprescribe when necessary.21-24

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Conclusion

Although polypharmacy is a continual patient safety risk, focused and practical approaches can be implemented to ensure accuracy and relevancy of the medication regimen. Managing patients individually and holistically, rather than treating by strictly following a guideline alone, can promote deprescribing practices in polypharmacy management. NPs find themselves strategically positioned to spearhead this movement. Through implementation of an individualized, stepwise approach, NPs can effectively manage polypharmacy one patient at a time.

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REFERENCES

1. McCarthy D. Reducing Inappropriate Medication Use by Implementing Deprescribing Guidelines. Institute for Healthcare Improvement. http://www.ihi.org/resources/Pages/Publications/Evidence-Based-Medication-Deprescribing-Innovation-Case-Study.aspx. 2017.
2. Ailabouni NJ, Nishtala PS, Mangin D, Tordoff JM. Challenges and enablers of deprescribing: a general practitioner perspective. PLoS One. 2016;11(4):e0151066.
3. Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr. 2017;17(1):230.
4. Moriarty F, Pottie K, Dolovich L, McCarthy L, Rojas-Fernandez C, Farrell B. Deprescribing recommendations: an essential consideration for clinical guideline developers. Res Soc Adm Pharm. 2018. pii: S1551-7411(18)30777–0.
5. Dills H, Shah K, Messinger-Rapport B, Bradford K, Syed Q. Deprescribing medications for chronic diseases management in primary care settings: a systematic review of randomized controlled trials. J Am Med Dir Assoc. 2018;19(11):923–935.e2.
6. Mishori R. What needs to change to make deprescribing doable. Fam Pract Manag. 2018;25(3):5–6.
7. Andreassen LM, Kjome RL, Sølvik UØ, Houghton J, Desborough JA. The potential for deprescribing in care home residents with Type 2 diabetes. Int J Clin Pharm. 2016;38(4):977–984.
8. Abdelhafiz AH, Sinclair AJ. Deintensification of hypoglycaemic medications-use of a systematic review approach to highlight safety concerns in older people with type 2 diabetes. J Diabetes Complications. 2018;32(4):444–450.
9. Sussman JB, Kerr EA, Saini SD, et al Rates of deintensification of blood pressure and glycemic medication treatment based on levels of control and life expectancy in older patients with diabetes mellitus. JAMA Intern Med. 2015;175(12):1942–1949.
10. Black CD, Thompson W, Welch V, et al Lack of evidence to guide deprescribing of antihyperglycemics: a systematic review. Diabetes Ther. 2017;8(1):23–31.
11. Bemben NM. Deprescribing: an application to medication management in older adults. Pharmacotherapy. 2016;36(7):774–780.
12. Reeve E, Bell JS, Hilmer SN. Barriers to optimising prescribing and deprescribing in older adults with dementia: a narrative review. Curr Clin Pharmacol. 2015;10(3):168–177.
13. Page AT, Potter K, Clifford R, Etherton-Beer C. Deprescribing in older people. Maturitas. 2016;91:115–134.
14. Rankin A, Cadogan CA, Patterson SM, et al Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2018;9:CD008165.
15. Kim LD, Koncilja K, Nielsen C. Medication management in older adults. Cleve Clin J Med. 2018;85(2):129–135.
16. Zullo AR, Gray SL, Holmes HM, Marcum ZA. Screening for medication appropriateness in older adults. Clin Geriatr Med. 2018;34(1):39–54.
17. Swinglehurst D, Fudge N. The polypharmacy challenge: time for a new script. Br J Gen Pract. 2017;67(662):388–389.
18. Kim J, Parish AL. Polypharmacy and medication management in older adults. Nurs Clin North Am. 2017;52(3):457–468.
19. Lin HW, Lin CH, Chang CK, et al Economic outcomes of pharmacist-physician medication therapy management for polypharmacy elderly: a prospective, randomized, controlled trial. J Formos Med Assoc. 2018;117(3):235–243.
20. Bain KT, Knowlton CH, Turgeon J. Medication risk mitigation: coordinating and collaborating with health care systems, universities, and researchers to facilitate the design and execution of practice-based research. Clin Geriatr Med. 2017;33(2):257–281.
21. Hernandez J. Medication management in the older adult: a narrative exploration. J Am Assoc Nurse Pract. 2017;29(4):186–194.
22. Beuscart JB, Pont LG, Thevelin S, et al A systematic review of the outcomes reported in trials of medication review in older patients: the need for a core outcome set. Br J Clin Pharmacol. 2017;83(5):942–952.
23. Köberlein-Neu J, Mennemann H, Hamacher S, et al Interprofessional medication management in patients with multiple morbidities. Dtsch Arztebl Int. 2016;113(44):741–748.
24. Maciejewski ML, Hammill BG, Bayliss EA, et al Prescriber continuity and disease control of older adults. Med Care. 2017;55(4):405–410.
Keywords:

chronic disease; comorbidities; deprescribing; diabetes mellitus; medication management; older adults; polypharmacy

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