is just as effective?Drug timing: Can a once–a‐day regimen be as effective?Drug dosing: What is the lowest effective dose for this patient?Potential side‐effects: How well will this person tolerate this drug? What concerns do I have in starting it?Drug–drug/drug–disease interactions: Do any contraindications exist?
Figure 10.1 The Eight C considerations of appropriate prescribing.
Consider the following example. Mr. Xavier Smith is a 79‐year‐old man brought to your office by his wife with complaints of memory loss. He has a diagnosis of systolic heart failure, urinary incontinence, chronic bronchitis, hyperlipidemia, and a lacunar infarct at age 70. You find that he scores low on a cognitive evaluation, indicating probable early dementia. He has also lost about 25 pounds in the last six months due to a decreased sense of taste and appetite with some nausea related to constipation. He had two witnessed falls when his legs suddenly ‘gave out’. His heart rate is 56, and his blood pressure is 98/50. His wife requests a medication to help his memory, as his goals are to ‘take care of myself and keep driving. I don’t want to be an invalid in a home’. Before you start an acetylcholinesterase inhibitor, you review his current medication list, which includes perindopril (an ACE inhibitor), metoprolol (a beta blocker), oxybutynin (an anticholinergic medication), furosemide (a loop diuretic), a combination beta‐agonist/inhaled corticosteroid inhaler, aspirin, and simvastatin (an HMG‐CoA reductase inhibitor). After discussion with Mr Smith and his wife, you decide to forego starting an acetylcholinesterase inhibitor due to the drug’s risk of worsening bradycardia (falls or heart block), nausea, and anorexia (weight loss). In addition, you stop the anticholinergic agent, which could be worsening his memory, adjust the doses of some of the other medications, and institute aggressive non‐pharmacologic interventions for his memory, falls, and urinary incontinence.
Appropriate prescribing also includes periodic deprescribing. Deprescribing is defined as ‘a patient‐centered, systematic optimization of a person’s medication list through the reduction, tapering, or stopping of medications that are not indicated or are causing real or potential harm’.55 Systematic deprescribing has been associated with reduced falls, improved cognitive and psychomotor function, reduced mortality, and reduced healthcare utilization (ED visits and readmissions), all without an increased risk of adverse outcomes.40,55‐60
Caution must be taken regarding unnecessarily treating conditions that are non‐problematic or largely asymptomatic, have an unlikely progression, or have a low chance to cause concerning symptoms. This is especially true in geriatrics, and some studies that have looked into ways of deprescribing have introduced the idea of ‘un‐diagnosing’ ailments in order to prescribe less. The mnemonic ERASE (Evaluate diagnoses through the consideration of Resolved conditions, Ageing normally, and Selecting appropriate targets to Eliminate unnecessary diagnoses and associated medicines) can be used to prioritize and resolve clinical problem lists.61 On the other hand, underprescribing, or the omission of prescribing potentially beneficial medications, is a hallmark of ageism and another problematic issue. Using the START criteria and applying other mnemonics (Table 10.4) can help avoid unnecessary medications and prescribing inertia.
Table 10.4 Mnemonics for medication management.
| Mnemonic | What each letter stands for | Description and use |
|---|---|---|
| SAIL/TIDE | SAIL: Keep meds as Simple as possible, remember Adverse effects, identify the Indication for each medication, List each drug and dose TIDE: Schedule Time during each visit to discuss medications, have awareness of Individual response to medications, avoid potential Drug/drug/disease interactions, Educate the patient | Useful for creating a standard approach to medication management and for teaching learners on the principles of medication management |
| AVOID TOO MANY | Alternatives available Vague history or symptoms OTC (over‐the‐counter) Interactions (drug–drug, drug–disease) Duration Therapeutic versus preventive Once per day (preferred) Other doctors Money Adverse drug effects Needs still? Yes/no (is the person actually taking the medication?) | Lists important considerations when assessing medication prescribing, compliance, and treatment burden |
| ARMOR (67) | Assess based on number of medications or drug class Review pharmacodynamics and pharmacokinetics Minimize medications Optimize doses Re‐assess – compliance, clinical impacts | Useful as a quality improvement tool in post‐acute and long‐term care Focus is on functional status and quality of life |
| ERASE | Evaluate diagnoses through the consideration of Resolved conditions Ageing normally Selecting appropriate targets to Eliminate unnecessary diagnoses and associated medicines | A process for eliminating diagnoses to help prioritize drug deprescribing |
It is important to remember that deprescribing is both a standardized and individualized process. The deprescribing process should follow the same format for all people and include delineating individualized treatment care goals based on age, functional status, life expectancy, and what matters most to the patient. Outcomes or benefits that are important to older people are usually similar to those of younger people, except that prioritising the outcomes may differ. For example, outcomes related to maintaining or improving physical function, cognitive function, and independence (e.g. prevention of nursing home admission) tend to become more important for people who are frail, have dementia, or are at the end of life. For some people, relief of suffering is the paramount goal, even if it comes with the cost of decreased life span. A recent qualitative analysis found that multimorbid older adults identified maintaining social relationships, a positive frame of mind or resilience, enjoyment of life, and independence as primary priorities of care.62 Clarifying these priorities will help the clinician to choose the right evidence‐based regimen and treatment approaches that follow appropriate guidelines tailored to the person’s personal medical history. Once the prescriber understands the process of deprescribing, the process will in essence be the same for every patient, but the actual treatment and outcome goals will be individualized.
Several deprescribing algorithms have been created, following a stepwise approach to assist the clinician at the point of care. The first is a five‐step deprescribing protocol and algorithm developed by Scott and colleagues.55,63,64 One starts by compiling an accurate and complete medication list and then assessing the overall risk of drug‐induced harm using an algorithm to determine each drug’s discontinuation potential, prioritizing drugs for discontinuation, and finally establishing a monitoring plan following the deprescribing episode. Barnett and colleagues describe another patient‐centred deprescribing process that includes seven steps. The process begins by establishing the patient’s needs and overall goals and then proceeds to compile an accurate medication list; identify potentially inappropriate medications; discuss the risks versus benefits of each; reach an agreement about which to stop, reduce, or start; and finally set up a long‐term plan to communicate
