Patients over 65 years disproportionately use medications. While they comprise 14% of the US population, 37% of patients over age 60 use more than 5 prescription medications. (1)
Simply citing the number of medications a patient is taking provides limited actionable information as these medications may be appropriately indicated and/or required as the number of comorbidities increases. Deprescribing is a step-wise process to reduce unnecessary or harmful medications based on patient and provider consideration of the patient’s current comorbidities and functional abilities. Jansen et al (2) cite a shared medication deprescribing process partnering patients and providers in collaborative decision making using four steps:
- Step #1. Discuss options, including medication discontinuation, with the patient, family, and providers
- Step #2. Discuss benefits and harms of identified options.
- Step #3. Discuss and define patient preferences for the identified options.
- Step #4. Make a decision whether or not to deprescribe.
To identify medications that can be targeted for deprescribing, Bergman-Evans (3) urges providers to engage in discussions across multiple visits.
Regularly identify and confirm medications the patient is actively taking (e.g. prescribed and over-the counter (OTC) medications, supplements, and naturopathic regimens) and perform medication reconciliation.
Identify the indication for each medication, whether a non-drug treatment alternative exists, if a different drug would be more appropriate or cost-effective, and if the medication is appropriate in elderly patients.
Review medication side effects, interactions, combinations, and risk for addiction or accumulation.
Optimize the medication regimen to decrease unnecessary dosing, adjust to age related physiologic changes and ensure the patient’s functional ability/care goals.
Educate the patient on the medications and their impact on functioning.
All medications used by patients > 65 should checked against the Beers List, a consensus document that identifies high-risk medications for elderly patients (4). When medications are identified as being used inappropriately it is important to note if they can be stopped immediately, or if they need to be weaned prior to discontinuation. Certain medications, such as beta blockers, antidepressants, benzodiazepines, and opiates, need to be weaned gradually to prevent physiologic withdrawal symptoms.