Pharmacist Impact on Deprescribing in Older Adults
Michelle Tran, Pharm.D., Fairview Pharmacy Services
Background: Caring for geriatric patients requires different approaches to manage common chronic disease states. Physiological changes occur as the body ages, thereby changing the pharmacokinetics of many drugs. This may mean alterations in the metabolism and excretion of medications, resulting in increased sensitivity to medications in older adults. This may also lead to an increase in drug-drug interactions, cognitive impairment, adverse events, and a prescribing cascade. As a patient’s preferences, side effects, and goals of therapy change with age, a focus on deprescribing becomes important.
Many patients over the age of 65 are prescribed potentially inappropriate medications. A study by Patel et al. published in 2018 estimated that 29% of Medicare beneficiaries aged 65 years and older in the United States filled a prescription in 2015 for at least one medication listed on the 2015 American Geriatrics Society Beers Criteria list of drugs. Another study by Perez et al. in 2018 found that prevalence of Beers listed medications ranged from 45.3% in 2012 to 51% in 2015. This can be serious, as these high risk medications in the older adult can be associated with emergent hospital admissions, as demonstrated by Budnitz et al. in 2011. Extra measures to aid in deprescribing these medications in the older adult may prove to be necessary in order to help prevent adverse drug events and hospitalizations. Pharmacist-led interventions may prove to be useful in deprescribing potentially inappropriate prescriptions in older adults.
Evidence: In a recent longitudinal retrospective study of 44 different primary care practices from Perez et al. (2018), hospital admission was associated with a higher rate of potentially inappropriate prescribing in the older adult. Potentially inappropriate prescribing was defined using 45 criteria from the Screening Tool for Older Persons’ Prescription (version 2). Following hospital admission, patients were 72% more likely to have a potentially inappropriate medication prescribed to them than before. This was independent of other patient-related factors. Hospital admission, advancing age, polypharmacy, and multiple comorbidities were all associated with a higher rate of potentially inappropriate prescribing. A recent randomized clinical trial from Martin et al. (2018) compared pharmacist-led educational intervention versus usual care for deprescribing inappropriate medications among community dwelling older adults. There were 248 patients in the intervention group where pharmacists sent patients educational deprescribing brochures and sent their physicians an evidence-based recommendation on deprescribing. Rates of deprescribing were compared to 241 patients in the control group receiving usual care. After 6 months, 42.7% of patients in the intervention group were no longer taking the targeted medication recommended to deprescribe compared to 12% in the control group, risk difference 0.31 [95% CI 0.23-0.38]. When discontinuation rates were studied among specific drug classes, successful discontinuation occurred in 43.2% vs. 9% with risk difference 0.34 [95% CI 0.25-0.43] for sedative-hypnotic drugs, 30.6% vs. 13.8% with risk difference 0.17 [95% CI 0.02-0.31] for glyburide, and 57.6% vs. 21.7% with risk difference 0.36 [95% CI 0.1-0.55] for non-steroidal anti-inflammatory drugs, respectively.
Discussion: Both of the studies demonstrate that inappropriate medication use in the older adult population continues to be a problem in the outpatient and inpatient settings. The evidence supports the idea that pharmacists may have a role in the deprescribing process. Transitions of care programs may be more effective if they utilize pharmacists to help deprescribe potentially harmful drugs from hospital admission and improve patients’ understanding of medications. Along with pharmacist-led interventions and pharmacist to physician communication, directly involving patients in decision-making processes to deprescribe further empowers the patients to be able to make these changes with their healthcare team. Both of the studies discussed took place outside of the United States (Canada and Ireland). The settings in which the interventions took place may not fully be applicable to pharmacy and hospital settings in the United States.
Clinical Impact: In caring for older adults, it is important to carefully evaluate every medication to reduce polypharmacy and avoid patient harm. This is particularly true when using Beers Criteria medications in the older population. In these instances, the risks need to be heavily weighed against the benefits of starting these medications. The decision to deprescribe should be continually reevaluated. Pharmacists can be key players on the healthcare team to aid in effectively deprescribing unnecessary and unsafe medications in the older adult population. Information and decision aid tools on deprescribing can be found on www.deprescribing.org.
Patel R, Zhu L, Sohal D, et al. Use of 2015 Beers Criteria Medications by Older Medicare Beneficiaries. Consult Pharm. 2018;33(1):48-54. doi:10.4140/TCP.n.2018.48.
Perez T, Moriarty F, Wallace E, McDowell R, Redmond P, and Fahey T. Prevalence of potentially inappropriate prescribing in older people in primary care and its association with hospital admission: longitudinal study. BMJ. 2018;363:k4524.
Budnitz DS, Lovegrove MC, Shehab N, and Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365(21):2002-2012. doi:10.1056/NEJMsa1103053
Martin P, Tamblyn R, Benedetti A, Ahmed S, and Tannenbaum C. Effect of a pharmacist-led educational intervention on inappropriate medication prescriptions in older adults. JAMA. 2018;320(18):1889-1898.