Avoid common pitfalls, recognize prescribing cascades, and deprescribe like a champ with tips from Clinical Pharmacist, Dr. Sean M. Jeffery, Clinical Professor of Pharmacy at the University of Connecticut School of Pharmacy, and Chair of the Polypharmacy Special Interest Group for the American Geriatrics society. We discuss how to create better medication lists, tools and tips for deprescribing, how to counsel patients on polypharmacy, and safe use of medication in the elderly.
Special thanks to the American Geriatrics Society for setting up this interview.
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Case from Kashlak Memorial:80 yo F with early (mild) dementia, heart failure, atrial fibrillation, chronic kidney disease, obesity, diabetes, and hypertension who presents with complaint of knee pain. You count a total of 22 total meds and supplements. Fourteen of these are daily “mandatory” meds and and seven are as needed.
Polypharmacy= too many meds that aren’t aligned with patient’s goals of care and/or are inappropriate. No specific numerical cutoff defines polypharmacy.
Prescribing cascade: One medication’s side effects leads to prescription of a new medication to treat those side effects, and on, and on, and on…
Deprescribing = Active removal of inappropriate, harmful, or ineffective medications. Dr. Jeffery recommends one change per visit (ideally).
5 steps of deprescribing: 1. List all drugs a patient takes and reasons for each. 2. Consider overall risk of drug-induced harm for your patient to determine the required intensity of deprescribing. 3. Assess each drug for current/future benefit/harm. 4. Prioritize drugs for discontinuation by benefit-harm ratio and likelihood of adverse from withdrawal. 5. Monitor for improvement in outcomes or onset of adverse effects (Scott et al JAMA Int Med 2015).
Making better medication lists: 1. Make sure you have an accurate list. 2. Give list to the patient. 3. Ask about OTC meds and supplements. 4. Group medications by indication 5. Make sure all meds have an indication 6. Assess effectiveness of each medication.
Anticholinergic side effects: Commonly implicated meds are listed in Beers list. Mnemonic = Blind as a bat, dry as a bone, red as a beet, hot as a hare, mad as a hatter (see image on Sketchy Medicine).
Bladder medications: Lots of advertising, but poor evidence (see episode #53 Urinary incontinence). Decrease frequency and incontinence by about one episode per day.
Questions to ask: Patients and providers differ in perception of which meds are most important. Ask patients: What is the most important medication to you? What medication would you most like to stop?
Living medication list: Accurate med list that is updated in real time and tracks across electronic records/health systems. An aspirational goal that doesn’t yet exist.
Dosing in CKD: Use Cockcroft Gault, then add and subtract 5 to number and use a range (Dr. Jeffery’s expert opinion).
Insomnia: No sleep meds are safe in the elderly. Life hacks: Take a walk in the early morning for circadian rhythm. Avoid meds that cause insomnia.
Goal: Listeners will define, and recognize polypharmacy; recognize steps required for deprescribing; identify culprit medications, and avoid adverse events.
Learning objectives: After listening to this episode listeners will…
Define polypharmacy, deprescribing, and prescribing cascade
Develop better medication lists
Evaluate a patient’s medication list and recognize inappropriate prescribing
Counsel patients on polypharmacy and deprescribing
Identify common drug-drug and drug-disease interactions
Become familiar with tools for safe prescribing
Safely dose medications in chronic kidney disease
Disclosures: Dr. Jeffery reports no relevant financial disclosures.
Time Stamps 00:00 Intro 01:12 Listener feedback 01:56 Picks of the week 06:28 Topic intro and guest bio 07:49 Getting to know our guest 13:05 Defining polypharmacy and related terms 16:30 Clinical Case of polypharmacy 20:34 Making better medication lists 25:01 Clinical Case from Kashlak Memorial 28:40 Beers Criteria 35:41 Statins in frail, elderly patients 38:00 Treating insomnia in the elderly 44:15 Dosing of meds in patients with CKD 45:50 Tool for analysis of drug-drug interactions 48:10 Take home points from Dr. Jeffery 50:00 Outro