Australian Doctor 4th August 2023 AD 4th Aug Issue | Page 49

CF

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Explore sustained release or longer acting agents . This may be as part of reviewing the goals of treatment , for example , where tight blood sugar control is no longer a priority , or no longer safe . Insulin regimes can be simplified in some elderly people by using long-acting agents . Some medications can be used in combination preparations to reduce tablet numbers .

The burden of blood monitoring or difficulty stabilising blood level , for example , with warfarin , can lead to consideration of alternative anticoagulants that do not require blood monitoring . Review doses when drug metabolism is likely to be altered , such as in renal or hepatic disease . Preparations need review , for example , when a patient develops swallowing difficulties . This is also an opportunity to review their goals and preferences . Seek alternatives if a large tablet or thin liquid cannot be swallowed or consider stopping the medication . A pharmacist can advise .

Does the patient still want it ?

This is arguably the most important component of the prescribing process . It involves a conversation covering many of the issues discussed . It ensures that care is patient-focused and -centred and transparent . Individuals assess the pros and cons differently and decide differently ; the patient is the one making the ultimate decision and providing their informed consent . Box 5 suggests a conversation to guide deprescribing .

CASE STUDIES

Case study one

MARGARET , 87 , lives in an RACF . Staff ask the GP who attends the facility for a repeat of her medications . These include perindopril , atorvastatin , cholecalciferol , aspirin , cephalexin

1 . Which THREE are consequences of polypharmacy and PIM ? a Adverse drug reactions . b Falls . c Reduced quality of life . d Decreased hospital admissions .

2 . Which THREE factors may contribute to polypharmacy ? a Pharmaceutical technology and marketing . b Practitioners ’ access to accredited pharmacists . c Practitioners ’ impulse to cure or alleviate . d Routinely rewriting medication charts without review .

3 . Which ONE is not a feature of good deprescribing ? a Ceasing unwanted medications to reduce the number of agents taken by a patient . b Prescriber and pharmacist deciding what medications the patient will have reduced / changed . c Cessation of one drug and substitution of a safer alternative with less overall drug burden index . regularly , with nystatin oral drops and clotrimazole cream prescribed on a prn basis . She is prescribed oxycodone prn but has not taken any in the past three months . Margaret is well and her consultation is for renewed prescriptions .

She has a note on her file of a history of recurrent UTIs and is taking cephalexin at night prophylactically . Closer questioning reveals that Margaret has never been symptomatic with a UTI . A review of her records reveals that past UTIs were diagnosed solely based on a ( routine ) positive urinalysis performed by a nurse . This was followed by a call to a GP , who prescribed antibiotics . After three such incidents , Margaret was prescribed prophylactic antibiotics . This is likely to have been asymptomatic bacteria , which does not need treatment , rather than a UTI , as any signs of infection were absent . Review of this option reveals prophylactic antibiotics are no longer recommended in this setting , except in very specific circumstances , and prophylactic antibiotics both disrupt the normal healthy microbiome and contribute to development

d Performed cautiously and slowly .

4 . Which THREE medications are commonly implicated in causing prescribing cascades ? a Laxatives . b Opioids . c Sedatives . d NSAIDs .

5 . Which THREE are predominantly GP barriers to deprescribing ? a Difficultly stopping medications initiated by specialists or other GPs . b Medication is perceived to be more effective and less risky than the evidence suggests . c Lack of confidence in how to deprescribe . d Negative experiences with drug withdrawal . of multi-resistant organisms . 26 The diagnosis of recurrent UTI is revisited . The GP and Margaret discuss the symptoms of UTI and the difference between a UTI and asymptomatic bacteria . They decide to treat for a UTI only when the diagnosis is definite . Margaret agrees to discontinue the prophylactic antibiotics . The oxycodone is also discontinued as she does not require it , and since she has never had high cholesterol and is now 87 , she decides that the statin is also not something she wishes to continue .

The use of the prophylactic antibiotic could be contributing to her need for nystatin and clotrimazole for oral and vulval thrush , so these prn orders are not continued either .

The GP and Margaret agree to review her conditions and medications at future visits to see what she thinks . She is very pleased at the reduction in her pharmacy bill and has not felt any bad effects from the deprescribing .

Case study two

Frank is 71 and now lives with his sister / carer . He is taking

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6 . Which THREE are high-risk situations where deprescribing may be considered ? a Multiple prescribers . b Transitions of care . c All patients in RACFs . d Multimorbidity .

DEPRESCRIBING IN THE ELDERLY

7 . Which TWO statements regarding non-adherence are correct ? a The fewer medications a person has been prescribed , the higher the risk of non-adherence . b When a patient is not taking a medication , it is crucial to ask why . c Reintroduce a medication at the same dose at which it was ceased to ensure a rapid patient response . d If a patient is not taking a medication , this may indicate withdrawal of their consent to take it .

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• Read this article and take the quiz via ausdoc . com . au / how-to-treat

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Figure 7 . Group of older people participating in tai chi class .

chlorpromazine , lithium , verapamil , thiamine , a buprenorphine patch and two laxatives . He has signs of tardive dyskinesia , is very unsteady on his feet and has begun to fall . He has marked skin discolouration in sun exposed areas . He notes severe problems with constipation despite large doses of laxatives . His carer says that he has ‘ slowed down ’ but is eating regular meals . The GP decides to review medications and notes :

• Frank has a long-term diagnosis of schizophrenia and has not seen any psychiatrist or mental health team for many years . It is likely that his typical antipsychotic is causing adverse effects . More modern antipsychotics may well have a better side-effect profile and specialist psychogeriatric assistance in transferring from one agent to another can reasonably be sought .

• He has never been diagnosed with bipolar disorder or mania and the rationale for lithium is unclear .

• Frank has not had any alcohol for some years and has a good diet so is unlikely to need ongoing

8 . Which ONE is a major barrier to deprescribing in RACFs ? a An absence of clinical history on admission . b Poor understanding of medication harms . c Devolving responsibility . d Resistance from residents and family .

9 . Which THREE classes of drugs may be considered for deprescribing in those nearing the end of life ? a Analgesics . b Statins . c Bisphosphonates . d Antihypertensives .

10 . Which THREE factors should be considered at the point of represcribing ? a To check that the medication is still indicated . b To confirm the dose is still appropriate . c To ensure the patient does not run out of medication . d To check the patient still wants to take the medication .

Box 5 . Conversation guide for deprescribing

• What are your goals of treatment , and have they changed , eg , changed life expectancy , improved symptoms ?

• Do you understand what each one is for ? Do you think the reason still applies ?

• What are your expectations of each medication , do you think it has had the anticipated effect ?

• Do you think you still need all the medications ?

• Do you want to keep taking all these medications ?

• Do you understand the possible harms / side effects , and do you think you have any ?

• Have you considered non-drug alternatives recently ?

• Would you look at a trial of lower dose or ceasing ?

supplemental thiamine .

• There have not been any renal or thyroid function bloods or lithium levels tested for some time .

• The opioid was started when he fractured his wrist two years ago and he has no pain . This might also be contributing to falls and constipation .

• He is in sinus rhythm and has never had palpitations or a diagnosis of AF , and his blood pressure is 100 / 65mmHg . There does not appear to be a clear indication for verapamil , and this may be contributing to hypotensive falls and the severe constipation .

Frank is keen to take fewer tablets and his priority is to stop anything that might make his constipation worse . The GP identifies several targets for deprescribing and starts the process with Frank ’ s support .

CONCLUSION

OLDER people are the highest consumers of medication . There is significant scope for a GP to rationalise medication regimes in many older patients without impacting their quality of life and clinical care . Deprescribing can benefit some people greatly by reducing adverse effects , reducing medication costs , improving adherence and simplifying care . When considering deprescribing it is important to select medications where potential risks of the medication could outweigh potential benefits and that align with the individual ’ s goals of care .

RESOURCES

• NSW Therapeutic Advisory Group : Deprescribing tools bit . ly / 3fMONQx

• Primary Health Tasmania : Medication management – deprescribing bit . ly / 3fI6TmM

• Older Persons Advocacy Network : Medication – it ’ s your choice bit . ly / 3AdSkAW

• Goal-directed Medication review Electronic Decision Support System bit . ly / 3qJqZUd

• Aged Care Quality and Safety Commission : Do you need antibiotics ? bit . ly / 3QOeKj8

References Available on request from howtotreat @ adg . com . au