For many older adults, health care is a mobius strip. They move from setting to setting, specialty to primary care, home to hospital to post-acute rehab, and bring with them polypharmacy, the suitcase that older adults carry with them from place to place. As they move through the mobius strip, their suitcase gets packed with new or adjusted medications until it is too heavy to carry and the patient falters in their move along the mobius strip. We see this clinically as the consequences of polypharmacy, such as falls, injuries, adverse drug events (ADEs), delirium, cognitive impairment, and poor compliance with medication regimens, but the relationship is rarely called out. While treating polypharmacy has been mostly siloed in the ambulatory space and at times in post-acute care, hospitalization can be a key step to address crippling polypharmacy. In treating acute medical conditions in older adults, a common occurrence in hospital care is the addition of multiple new agents and adjustment of existing medications. Often, hospitalization is not seen as an opportunity to deprescribe.

Older patients are often admitted to the hospital with long-established medication regimens and there is a common assumption that “they must be on all these for a good reason.” Sometimes these situations may be looked at as being “not my circus, not my monkeys.” Hospital providers are an important check in the mobius strip to ensure that everything in the polypharmacy suitcase really should be there at that time in the patient’s journey. Physiology changes with age, and chronic medical conditions change with time and pharmacology advances. Medications that were reasonable 5 or 10 years ago, may no longer be appropriate for a patient’s current condition.

Age-related pharmacokinetic and pharmacodynamic changes make certain medications potentially inappropriate for older adults, such as those identified in the American Geriatrics Society Beers Criteria.1 Common examples include medications with anticholinergic activity (first generation antihistamines, muscle relaxants, antispasmodics, tricyclic antidepressants), cardiovascular medications (alpha 1 blockers, central alpha agonists), benzodiazepines, and non-steroidal inflammatory agents. Published tools, such as the STOPP/START criteria, are also very useful in identifying medications that may no longer be suitable or contraindicated, as well as potential prescribing omissions.2 For example, a frail patient with hypertension and recurrent falls may have more risks for adverse effects than benefits if they take an alpha blocker or thiazide diuretic.

Recent deprescribing protocols developed specifically in acute care settings use various tools, including an electronic decision support tool for deprescribing, and an interdisciplinary approach comprised of clinical pharmacists, nurse practitioners, and physicians. These protocols incorporate drug specific factors, such as a drug safety profile, as well as drug-drug and drug-disease interactions. These frameworks result in significantly reduced pill burden and improved cost effectiveness of medications.3-5 Elimination of potentially inappropriate medications for older adults and utilizing this interdisciplinary approach are important in helping to prevent future ADEs.

Many of these interventions, however, have not consistently shown a reduction in adverse drug events. This may be because of the relatively small sample sizes of high-risk patients included in studies, as well as the short duration of studies focusing mainly on short-term adverse drug events. Fortunately, many hospitals already routinely involve clinical pharmacists in the care of all patients, so the potential for ADEs may be mitigated in certain instances. Other beneficial effects of deprescribing, such as improved nutritional intake, may also be more evident several weeks to months after hospitalization.

In considering deprescribing in hospitalized older adults, practical steps would include identifying all high-risk patients with polypharmacy (typically defined as taking five or more medications), with particular attention to frail older adults. Providers should carefully consider indications for medications and assess if the medication is appropriate for the patient’s current clinical condition and consistent with the patient’s goals of clinical care. For instance, statin therapy may no longer be indicated in frail older adults with very limited life expectancy and less likelihood of cardiovascular benefit. Hospital medical providers are in the unique position of observing patients consistently over a short period, which can be an opportune setting to deprescribe; however, ambulatory providers need to navigate deprescribing efforts over potentially long periods between visits across a longer interval of time.

Hospitalization is a powerful opportunity along the mobius strip of health care to be a check on medication safety and intervene early in cases of polypharmacy. SGIM members can lighten the suitcase for these vulnerable patients and make it easier for them to carry as they depart on their next journey.

References

  1. By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019 Apr;67(4):674-694. doi:10.1111/jgs.15767. Epub 2019 Jan 29.
  2. O’Mahony D, Cherubini A, Guiteras AR, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: Version 3. Eur Geriatr Med. 2023. Aug;14(4):625-632. doi:10.1007/s41999-023-00777-y. Epub 2023 May 31.
  3. Petersen AW, Shah AS, Simmons SF, et al. Shed-MEDS: Pilot of a patient-centered deprescribing framework reduces medications in hospitalized older adults being transferred to inpatient post-acute care. Ther Adv Drug Saf. 2018 Jun 15;9(9):523-533. doi:10.1177/2042098618781524. eCollection 2018 Sep.
  4. McDonald EG, Wu PE et al. The MedSafer Study-Electronic Decision Support for Deprescrib-ing in Hospitalized Older Adults: A cluster randomized clinical trial. JAMA Intern Med. 2022 Mar 1;182(3):265-273. doi:10.1001/jamainternmed.2021.7429.
  5. Matsumoto A, Yoshimura Y, Wakabayashi H, et al. Deprescribing leads to improved energy intake among hospitalized older sarcopenic adults with polypharmacy after stroke. Nutrients. 2022 Jan 19;14(3):443. doi:10.3390/nu14030443.

Issue

Topic

Clinical Practice, Geriatrics/Palliative Care, Hospital-based Medicine, SGIM

Author Descriptions

Dr. Drago (drago@ohsu.edu) is an associate professor of medicine at Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, OR. Dr. Balogun (seki-balogun@ouhsc.edu) is a professor of medicine at Donald W. Reynolds Section of Geriatrics and Palliative Medicine, University of Oklahoma Health Science Center, Oklahoma City, OK.

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