46 HOW TO TREAT : DEPRESCRIBING IN THE ELDERLY
46 HOW TO TREAT : DEPRESCRIBING IN THE ELDERLY
4 AUGUST 2023 ausdoc . com . au
Figure 2 . Peripheral oedema .
Table 2 . Barriers to deprescribing Barrier
Strategies to overcome barrier
GP barriers and strategies
Not routinely weighing up the benefits and harms of continuing or stopping medication
Pressure to follow guidelines that endorse prescribing but do not factor in
11 , 13 multimorbidity and polypharmacy
Actively articulating the expected benefits for continuing the medicine against the benefits of ceasing the medication for the individual concerned , particularly those with multiple conditions and medications 8
Access to clear , concise and up-to-date information about the benefits and risks of treatment
Considering a deprescribing trial with monitoring for re-emergence of signs especially when the original condition is likely to have changed or resolved or where tight control is no longer desired ( eg , blood pressure , blood glucose , behaviour ) and symptoms ( eg , pain , dizziness , insomnia ) 8
Prioritising the patient-centred approach and focusing on the patient ’ s preferences , wishes and goals of care 14
Difficultly stopping medications initiated by specialists or other GPs ; this may be associated with respect for professional autonomy , medical hierarchy , concern about criticism or apprehension that they may damage their patient ’ s 8 , 11 , 13 relationship with the other prescriber
Direct and open communication between health professionals and not assuming that they are opposed to deprescribing 8 Remember the GP is the central point of communication and co-ordination for all involved in a patient ’ s care
Specialists may not be aware of the intentions or goals of others , or of changed patient condition and situation , so clarify with the specialist , and the patient ( who ideally should also know ), about the ongoing purpose and need for medications
Communicate the proposal to deprescribe and the rationale
Perception of care withdrawal , despite this not being expressed by patients
14 , 15 or family
Ninety per cent of older adults and caregivers are willing to stop one or more
16 , 18 of their medications if their doctor said it was possible
8 , 11 , 13
Time constraints Not
Ask patients if they think that they are on too much , or if any of their medications should or could be stopped
Engage with patients and caregivers to explain why and how deprescribing can occur , to elicit their preferences and to allay any concerns 8 Acknowledge that the process of deprescribing is reversible if symptoms re-emerge or withdrawal symptoms occur 12 conducting all the deprescribing in one visit , prioritise one medication at a time
Asking patients and carers to assist with thinking about particular medication issues before the next visit , eg , “ Can you start to think about your tablets and if you think any should / could be stopped , if you don ’ t like any in particular , or if you think you may be having side effects ”
Lack of confidence in how to deprescribe : which medications can be stopped abruptly , and which need tapering
Using the knowledge of the patient and expertise and services of other health practitioners , including pharmacists and aged care nurses , to identify targets for deprescribing , recommend tapering schedules , provide counselling for the patient and to assist with ongoing monitoring and review 8
( Tapering schedules and recommendations for dose reductions are listed in the resource section )
Patient and caregiver barriers
Attitudes and beliefs about their medications :
• People feel their medication is more effective and less risky than the evidence suggests and are anxious about how they would be without it
16 , 18
• Reluctant to stop medication as they believe a particular medicine prolongs life or improves function 11
Fear of drug withdrawal , inadequate time to discuss their goals of care and lack of practical guidance on how to cease / taper medication , and what to do if symptoms reappear or withdrawal occurs 11
Engaging in shared , informed decision-making which is central to patient centred care 3 Focus on benefits of deprescribing : side-effect symptom reduction , feeling better , reduced drug burden , reduced spending , quality of life
Reassure the patient that there will be ongoing support and discussion
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PAGE 44 engage the patient in the process .
Start with low-hanging fruit to gain trust , or with medication with the most likely adverse impact .
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NON-ADHERENCE Non-adherence presents an important opportunity to deprescribe . Non-adherence may be because of dissatisfaction with treatment , lack of benefit |
and adverse effects , among other reasons . 8 The more medications a person has been prescribed , the higher the risk of non-adherence . 3 Reducing the overall medication load may lead to |
better adherence because of reduced medication complexity and costs and increased patient engagement . 3 , 8
When a patient is not taking a medication , it is crucial to ask why .
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If it is because adverse effects have occurred or symptoms have resolved , this may mean that the medication is no longer required . If planning to reintroduce a medication not adhered |