Danielle Ní Chróinín is a geriatrician at St. Vincent’s Hospital, Sydney, who has a keen interest in research, education, and anything related to geriatric medicine. Her paper on deprescribing is published in the latest edition of Age and Ageing and can be accessed online now.
Mr. T. is an 85 year-old man who has been attending your Geriatric Clinic for the last couple of years. He has a background of hypertension, ischaemic heart disease, osteoarthitis of his knees, and constipation. He now has moderate dementia, with a progressively worsening Mini-Mental State Examination score, 17/30 today. His wife, with whom he lives, has taken over the shopping and financial duties.
Blood pressure is up, once again, at clinic today. His current medications include aspirin, a statin, a calcium channel blocker, an ACE inhibitor, laxatives, donepezil, paracetamol and tramadol. If you shook him, he just might rattle…
Polypharmacy is ridiculously prevalent- 42% of over-50s in Australia are taking five or more medications; terms such as ‘hyperpolypharmacy’ (≥10 drugs), have been coined, in an attempt to stratify polydrug recipients in the context of a multiple-medications epidemic.
So, would you stop any of Mr. T.’s drugs? Which ones? Why?
Immediately, or when he becomes frailer, more demented, more dependent, or when his life-expectancy has dropped to months? The evidence base for making these types of decisions is limited. And individual doctor (de)prescribing practices vary widely. In a survey of Antipodean physicians specialising in the care of older patients, we sought to explore the factors which influence our decisions to ‘stop the drugs’.
A hundred-and-thirty-four busy physicians kindly lay down their prescribing pens to answer our survey. Given a list of factors which might influence their deprescribing practices, these doctors most commonly rated limited life expectancy (96.2%) and cognitive impairment (84.1%) as very/extremely important to deprescribing practices. Interestingly, the age and gender of the doctor appeared to influence the answers supplied. Older respondents less commonly rated functional dependency and limited life expectancy important when deprescribing. On the other hand, female participants, and trainees, more often rated adherence to evidence-based guidelines important.
Confronted with a series of five case vignettes, physicians were more likely to stop many of the listed medications as the case described a patient with increasing dependency and cognitive impairment.
So we asked: “Why are you stopping these medications?” The answers commonly centred on two central themes- dementia severity and pill burden. So it’s comforting to think that if I ever develop bad Alzheimer’s disease, one of these doctors might take a look at my medication list, and strike off a couple of tablets, so that I can enjoy an ice-cream unencumbered by hidden pills. Or that if I ever end up the victim of half-a-dozen different evidence-based guidelines, a sympathetic medic might kindly prioritise the top six or seven pharmaceuticals I really need.
But the fact is that the ‘right time’, the ‘right medications’ and the ‘right deprescriptions’ for frailer older persons aren’t always so clear. Such patients are most often notable for their absence from randomised trials. But a dramatic red pen-slash, crossing off the whole shebang, may not be appropriate outside of an end-of-life scenario. Our geriatric cohort can be the victims of missed treatment opportunities, and not just over-medication. Studies continue to evolve, assessing the benefit and harms of prescribing- and deprescribing- in such patients. In the interim, I admit I mostly rely on the good habit that my first bosses drummed into me: review the meds list regularly, and look at the whole person and not just the diagnosis list. It’s likely Mr. T. will thank you for it.
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The population with intellectual disabilities is a vulnerable one in healthcare. People with intellectual disabilities experience multiple morbidities and receive multiple medications.
The population with intellectual disabilities and behaviour disorders is particularly vulnerable. Medication use is the major therapeutic intervention in this population. De prescribing should be undertaken with care and caution.
The following Principles of Good De-prescribing during Medication Review in the Population with Intellectual Disabilities and Behaviour Disorders were included in my recent PhD thesis. They are based on the British Pharmacological Society’s Principles for Good Prescribing 2010
Principles of Good De-prescribing during Medication Review in the Population with Intellectual Disabilities and Behaviour Disorders.
1. Be clear about the reasons for de-prescribing.
2. Take into account the patient with intellectual disabilities and behaviour disorders medication history before de-prescribing.
3. Take into account other factors that might alter the benefits and risks of de-prescribing treatment in the patient with intellectual disability and behaviour disorders.
4. Take into account the patient’s/carer’s/families/advocates ideas, concerns, and expectations.
5. Ensure all medicines are effective, safe, cost-effective in appropriate form individualised for the patient with intellectual disability, behaviour disorders and other conditions such as dysphagia, autism.
6. Adhere to national guidelines and local formularies where appropriate. Use caution where the population with intellectual disability have not been considered in the guideline development process.
7. Write unambiguous correct documentation detailing reason for de-prescribing.
8. Monitor the beneficial and adverse effects of de-prescribing medicines and any effects on behaviour.
9. Communicate and document all de-prescribing decisions and the reasons for them such as transferred to appropriate personnel such as GP, pharmacist, psychiatrist, epileptologist, carer and patient.
10. De – prescribe within the limitations of your knowledge, skills and experience of the population with intellectual disabilities and behaviour disorders.