Deprescribing in older people

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Welcome to the Australian Prescriber podcast. My name is Dr Ashlea Broomfield, and I'm here today with Michelle Liacos, who is a pharmacist at the Alfred Hospital and has written an article in the latest edition of Australian Prescriber on deprescribing. Welcome Michelle.

Thank you for having me.

So Michelle, deprescribing is one of those topics that I really love and really want to do all the time, but it's actually really hard in practice. So I'm really glad that I've got the opportunity to have a bit of a chat to you today about balancing some of the risks and benefits of medications and how to go about deprescribing.

You know, a lot of prescribers worry that by deprescribing a medication, there might be an increase in mortality from events in their patients. Is that necessarily true or not?

That's a great question, Ashlea. I've mentioned in my article a systematic review by one of my co-authors, Dr Amy Page, and she examined the effects of deprescribing on mortality and found that deprescribing had no effect on mortality, which is really reassuring.

We often start medications in order to prevent an event like we might start an anti-hypertensive or a statin to prevent cardiovascular events, and we often treat diabetes with anti-glycaemic medication to prevent macro/micro vascular complications, or we start osteoporosis medications to prevent fractures. Whereas a lot of these medications often started in that way, and the benefit as you say in your article can be limited to a shorter period of time. Can you outline some of those medications that in what circumstances we might be able to look at ceasing those?

Yes, so a lot of those medications are definitely appropriate at one stage in that patient's life, but it's always important to consider that with time the patient's circumstances change. They may become more frail. They may be more susceptible to side effects. Their treatment goals and priorities might change. So it's always appropriate to consider whether each medication is appropriate at that point in the patient's life.

You mentioned the example of anti-hypertensives, which are appropriate to reduce the risk of cardiovascular events, but we also know at the same time, elderly people are at increased risk of the side effects like dizziness and falls. So this may be an appropriate deprescribing target in an older person with a limited life expectancy who may be having issues like orthostatic hypertension.

And you also mentioned in the article in relation to statins and that their benefit is time limited as well.

That's right, so we know that patients will need to use a statin for two to five years to reduce the risk of stroke or heart attack. So this benefit might not be realised in a patient with a shorter life expectancy.

And what might we consider in terms of anti-glycaemics when we're looking at patients with diabetes?

Again, tight glycaemic control is appropriate in patients who have sufficient life expectancy to benefit from the reduced risk of the macro and microvascular complications, but in a frail older person, tight glycaemic control may no longer be appropriate. They'll be at increased risk of hypoglycaemia, but they won't get the long-term mortality benefit.

The ones that often are harder to cease are the ones that it can be linked to more of the side effects in relation to polypharmacy, like psychotropics or benzodiazepines, PPIs, and analgesics. What are some of your recommendations when we're looking at ceasing these medications?

You're right, Ashlea, these are probably the categories of medications that patients may be the most concerned about stopping. We do know that they may be more willing to stop one of these medications if they know it's an option to restart it if they do have withdrawal effects. And we also know that patients may be more confident to trial deprescribing these medicines if they've got a clear plan for how the medicine will be tapered if it needs tapering and how to manage withdrawal effects.

In your article, you outlined a deprescribing algorithm. Can you go through what this might look like for our listeners?

Yes, so this is a really helpful tool to help prescribers review a patient's medication list. So we look at all of the medications a patient takes as well as the indications for each medication. And we run through four criteria, which help us identify targets for deprescribing.

So the first criteria is to ask for each medicine, is this medicine inappropriately prescribed? An example might be a patient's taking a laxative, but they're complaining of diarrhoea. That's an obvious example.

And the second question is, is this medicine having any adverse effects or interactions? So again, the example with the antihypertensives, if the patient is experiencing postural hypotension, that might be a prompt to consider deprescribing or reducing the dose of their antihypertensives.

The third criteria is, is the medicine intended for symptom relief and are their symptoms stable or resolved? So if, for example, a patient might be on an inhaled corticosteroid long term with stable COPD, you may look at if it's appropriate to deprescribe the corticosteroid.

And the fourth question is, is the medicine intended to prevent future events? So that's what we look like we were discussing earlier with the statin, for example, whether the patient has adequate life expectancy to get the mortality benefit for that medication.

You also outlined in the article some of the tools that prescribers can use for deprescribing.

Yeah, I've got some really great resources available online. I particularly like the Primary Health Tasmania resources available on deprescribing commonly used medicines. So for example, there's a leaflet there on deprescribing of benzodiazepines, and it will go through all of the things you should consider, the pros and cons of these medications, how to actually go about the deprescribing process.

Yeah, there's a number of resources there. The New South Wales Therapeutic Advisory Group also has really great deprescribing tools. And they've also got consumer information leaflets available, which actually outline a template you can use to help your patient wean certain medications, which is really helpful. We know from a couple of studies that having written information about the pros and cons of the medication, and also having a weaning plan, increases the chance that a medication will be successfully deprescribed.

Yeah, that's really interesting, isn't it, having those tools to facilitate that level of communication with a patient at about where they may be at in their life's journey and where the risks of continuing a medication actually outweigh the benefits of it. And often that's a really hard conversation to have because it's usually in the context of limited life expectancy, and not everybody is always willing to come to terms with that stage of their lives, so having those extra resources can be really useful.

Do you have any particular other tips for our prescribers out there?

Yeah, so I've listed some prompts for situations where you could consider deprescribing. So if your patient's having a significant event, like they've just had a fall, they've just been admitted to hospital, they've had a decline in their cognitive function, these are all really great prompts to consider deprescribing.

The other thing is really every time a new prescription is reissued for a medication, or in the case of a pharmacist every time a medication is redispensed, we should take that as an opportunity to ask the question would I initiate this medication right now at this point in this patient's life. Are they potentially experiencing side effects? Is there a safer option I could choose? Is their life expectancy long enough to benefit from this preventative medication?

I think there's some great questions for prescribers to ask themselves. And it's much easier to not prescribe the medication in the first place than to stop a medication once somebody is used to taking it. And so I like to think of deprescribing in the realm of rational use and rational prescribing in general because do I need to prescribe this medication, and am I prescribing this medication as part of a prescribing cascade where I'm prescribing a medication to account for another medication's side effects, is a really important thing to consider. Is there any other ways that prescribers can work with each other to deprescribe for patients?

Another tool they can use is referring. So GPs can refer an older person for a home medicine review, or if they're in an aged-care facility, it's a residential medication management review. And these are reviews conducted by an accredited pharmacist in the patient's home.

And this can be a really helpful tool. The pharmacist can help identify targets for deprescribing and help understand the patient's feeling towards medications and experiences with medications. And the pharmacist can also help, for example, come up with a dose-tapering plan for medications that were identified as deprescribing targets.

I think the key thing to highlight once again is that this deprescribing, it's a collaborative process. The patient must be involved or their carer, of course. And it's the only way to do it successfully is to have the patient on board, understanding the process, having enough time to ask questions, understanding how the medications will be ceased and in which order. That's probably the most important consideration when going about the deprescribing process.

That's unfortunately all the time we've got for this episode. Thanks for joining us today, Michelle.

Thank you, Ashlea.

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