described Deprescribing Rainbow, depicting a conceptual framework of the clinical, psychological, social, financial, and physical determinants that should be considered when approaching the deprescribing process in an individual patient. In this pictorial depiction, the patient is literally placed at the centre of the rainbow to emphasize the patient’s central importance. The authors of the paper remind us that ‘deprescribing will be more successful if it is respectful of the individual patient context and circumstances’.66 These deprescribing frameworks, combined with a comprehensive geriatric syndrome assessment and the use of one of the previously described prescribing tools, can help clinicians develop a patient‐centred and systematic approach to medication management in older adults that can be used in daily clinical practice.
Conclusion
Polypharmacy may be difficult to define but clearly has significant negative impacts on the health and well‐being of older adults. A variety of tools and algorithms have been developed that can reduce the impact of polypharmacy by applying a systematic, patient‐centred approach to clinical decision‐making and prescribing. Let’s return to the vignette presented in the introduction to apply these principles to a clinical case.
The facts:
An 88‐year‐old woman with cognitive changes related to moderate Alzheimer’s disease presents to the hospital with weakness resulting in a fall.
Complex multimorbidity with seven chronic medical conditions: hypertension, type 2 diabetes mellitus, chronic venous insufficiency, moderate depression, osteoporosis, osteoarthritis of knees, and mild Alzheimer’s dementia.
On 21 routine medications, taken up to three times a day.
Additional information is obtained from the patient to elicit her current functional status, goals of care, and treatment burden experiences. She notes difficulty remembering to take her noon and evening medications and describes feelings of fatigue, lightheadedness, generalized weakness, and aching after taking her medications. She notes worsening constipation as well as urinary frequency and urgency with difficulty getting to the toilet on time due to knee pain and unsteady gait. She denies vertigo, reflux, and diarrhoea. She wants to be able to live independently, care for her small dog, and work in her raised garden beds. She has trouble navigating a walker in her small mobile home. She feels that she has adequate support from her daughter and sees her daily. Working together with her home health nurse and the clinic pharmacist, a complete and accurate medication list is obtained. At a close follow‐up visit, you review each medication against the Beers list and weigh the potential benefits against probable medication burden/side effects, prioritizing drugs for discontinuation. Together with the patient and daughter, you agree on a monitoring plan to watch for any adverse events related to deprescribing.
The following medications are discontinued due to the Beers list strong recommendation to avoid use in older adults and the presence of symptoms that suggest ADR: meclizine, nifedipine, glimepiride, high‐dose aspirin (for primary prevention), and omeprazole. After evaluating for drug–drug and drug–disease interactions, it is decided to also discontinue oxybutynin (anticholinergic effects and possible interaction with donepezil), multivitamin (drug absorption interactions and limited evidence of benefit), spironolactone (drug–drug interaction with ACE inhibitor), nadolol (orthostatic hypotension and bradycardia contributing to fall), calcium (constipation and drug absorption interactions), and cilostazol (lack of indication). Dose optimization to reduce the risk of side effects and simplify the medication regimen to once‐daily dosing in the a.m. is done for the following: furosemide once daily (reduce urinary symptoms), metformin changed to ER formulation once daily, simvastatin 20 mg (reduce muscle aches), ferrous sulfate once daily (constipation), and calcium carbonate once daily (constipation). A plan for gradual dose reduction of trazodone, sertraline, and famotidine is initiated. A review of the START criteria indicates that the patient should be treated with vitamin D3 for her osteoporosis. The patient admits to not taking tramadol, so this medication is also discontinued. Non‐pharmacologic interventions of compression stockings, dietician guidance for optimal calcium and protein intake, and a therapist‐led exercise programme are initiated. A discussion is held on the risks versus benefit of statin therapy in diabetes and donepezil in probable early Alzheimer’s disease, and the decision is made to continue these with close monitoring.
Final medication list: lisinopril 5 mg daily, furosemide 20 mg daily, metformin ER 1000 mg daily, simvastatin 20 mg daily, sertraline 75 mg daily, trazodone gradually tapered off over four weeks, donepezil 10 mg daily, ferrous sulfate 325 mg daily, and vitamin D3 1000 units daily.
Her home health interprofessional team makes frequent visits over the next month. At six months, she and her daughter report that she is living independently and continuing to improve functionally, cognitively, and symptomatically with no additional falls.
In conclusion, the idea of polypharmacy as a plethora of medications should suggest something to be feared. The romantic idea of a Horn of Plenty, a beautifully overflowing cornucopia of health, does not apply to a broad medication regimen. A more concrete mythological allusion to polypharmacy is the image of the Chimera, a fire‐breathing ‘thing of immortal make, not human, lion‐fronted and snake behind, a goat in the middle’71 – a thought‐provoking combination with potential dangers. Much like polypharmacy can be conquered, the Chimera, which was once believed to be nearly invincible, was eventually defeated with a sword by Bellerophon on his winged horse, Pegasus. Appropriate prescribing combines the science of gerontology with the art of patient‐centred care, and it takes commitment and attention to assure a proper treatment balance. Medication review should be considered of utmost importance and should be done frequently and carefully, utilizing multiple members of the interprofessional team. Patients should be judiciously educated on the indications of medications as well as their correct use and dosages.
Key points
Inappropriate medication prescribing is a significant problem in geriatrics and should be evaluated in each and every medical encounter.
The presence of multiple medications in older patients is associated with higher risk for frailty, disability, mortality, and falls.
In the geriatric population, responses to medications can be very variable and not always predictable at the time of medication prescription.
An elderly patient’s protein status must be taken into account when assessing medication efficacy or toxicity.
Prescribers must always consider new symptom complaints in an older patient as a potential medication reaction, even if atypical.
Many resources and tools are available to guide appropriate medication prescribing in the older adult, and prescribers should use them regularly.
References
1 1. Wallis KA. No medicine is sometimes the best medicine. BMJ Case Rep. 2015.
2 2. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011; 365(21):2002–12.
3 3. Guthrie B, Makubate B, Hernandez‐Santiago V, Dreischulte T. The rising tide of polypharmacy and drug‐drug interactions: population database analysis 1995‐2010. BMC Med. 2015; 13:74.
4 4. Haider SI, Johnell K, Thorslund M, Fastbom J. Trends in polypharmacy and potential drug‐drug interactions across educational groups in elderly patients in Sweden for the period 1992–2002. Int J Clin Pharmacol Ther. 2007; 45(12):643–53.
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