July/August 2017

Medication Monitor: Deprescribing Improves Quality of Life
By Mark D. Coggins, PharmD, CGP, FASCP
Today's Geriatric Medicine
Vol. 10 No. 4 P. 8

Deprescribing involves reducing or stopping potentially inappropriate medications (PIMs) that may no longer be of benefit or may be causing harm. The goal is to reduce medication burden or harm while improving a patient's quality of life (QoL). Deprescribing can improve medication appropriateness by reducing polypharmacy, adverse drug events (ADEs), and other medication-related problems (MRPs).1

Evidence-based guidelines improve the treatment for a number of diseases; however, strict adherence to guidelines in frail older adults contributes to medication burden and increased MRPs.2 And while numerous guidelines exist to support prescribers in managing diseases, few guidelines provide deprescribing strategies.

Prescribing requires special knowledge and close monitoring. This includes having the courage to deprescribe and the necessity of avoiding a prescribing cascade where a new medication is prescribed to "treat" side effects of another medication, while believing a new medical condition has developed. Further compounding the danger is "prescribing inertia" or the tendency to automatically renew a medication even if the original indication is no longer present. Individuals with multiple medical problems are at even greater risk for MRPs due to multiple prescribers with different specializations who focus on their own areas of expertise while no one takes an overall responsibility regarding the patient.3

Need for Routine Drug Regimen Reviews
Routine drug regimen reviews (DRRs) play a critical role in combating polypharmacy (see Table 1).

Every patient interaction should be considered an opportunity for deprescribing.4 This is especially true during transitions between care settings and has been shown to reduce MRPs. Deprescribing may require greater medication knowledge and sophistication and may be more challenging than was required to initiate drug therapy.2 For these reasons, pharmacists' role as medication experts should be maximized by prescribers and other health care team members to conduct comprehensive and often time-consuming medication reviews as well as to educate regarding efforts to improve overall deprescribing efforts.

Deprescribing requires communication with patients to reach informed decisions and prioritize medications for continuation or discontinuation, in order to maximize benefit and minimize harm.2 With this mind, DRRs should individualize drug therapy based on patient preferences, life expectancy, QoL goals, comorbidities and functional status, while paying special attention to reducing pill burden, ADEs, and drug interactions.4

Medication Appropriateness Index
Medication Appropriateness Index scores have been shown to help assess for a higher probability of hospitalization. The index takes advantage of clinicians' clinical knowledge and judgment in the evaluation process for medication quality/appropriateness. Totaling the score from each question provides an indication of the appropriateness of medication ordered, with a total score of 0 indicating poor quality, while a maximum score of 18 indicates good quality (see Table 2).

Beers Criteria
The Beers Criteria have been evaluated to determine the impact the use of PIMs may have on outcomes in older adults, including the following:

• increased hospitalization when ≥2 PIMs were used together;
• significantly increased ADEs in older adults with ≥1 PIM; and
• increased fall risk.

The Beers Criteria also provide guidance on avoiding 13 combinations of medications known to cause harmful drug-drug interactions. Also noted is a specific list of 20 potentially problematic medications to avoid or that may require dosage adjustments based on kidney function.5,6 The author has been published extensively on these medications in previous editions of Medication Monitor; the Beers Criteria are accessible on the American Geriatrics Society website (www.americangeriatrics.org).

STOPP
STOPP (Screening Tool of Older Adults' Potentially Inappropriate Prescriptions) identifies five high-risk medication classes: proton-pump inhibitors (PPIs), benzodiazepines (BZDs), NSAIDs, nonselective beta blockers, and tricyclic antidepressants. These medication categories are significantly associated with ADEs and, when stopped, improve medication appropriateness.5-7 When applied within 72 hours of hospital admission, ADEs were significantly reduced, along with reducing the average length of stay by three days in older patients hospitalized with unselected acute illnesses.6

Anticholinergic Burden Scales
Medications with anticholinergic properties are prescribed to at least 20% of the 36 million Americans aged 65 and older.5,7 Anticholinergic meds can increase fall risk and associated injuries, leading to diminished QoL and loss of independence. ADEs include cognitive decline, falls, and behaviors such as hallucinations, delirium, and agitated aggressive behaviors, which may result in hospitalization or admission to long term care facilities.5-9

A number of scales exist to help identify meds with high anticholinergic risk while also accounting for the cumulative risk or burden. The Anticholinergic Burden Scale (ACB), for example, gives meds with possible anticholinergic effects a score of 1, while those with definite anticholinergic effects receive a score of 2 or 3 (see Table 3 for Anticholinergic Burden Scoring).8,9

Each definite anticholinergic may increase the risk of cognitive impairment by 46% over six years. A one-point increase in the ACB total score has been suggested to result in a decline in Mini-Mental State Examination score of 0.33 points over two years.8,9 In addition, each one-point increase in ACB total score has been correlated with a 26% increase in the risk of death.10

Reducing Fall Risk
Older adults who take four or more medications may be at an increased fall risk. Reducing the total number of medications a patient takes, especially medications implicated in increasing fall risks, should be considered for deprescribing.6

Medications with the greatest risk of increasing falls include anticonvulsants, antidepressants, antipsychotics, benzodiazepines (BZDs), opioids, and sedative-hypnotics. Other meds that may contribute to falls include anticholinergics, antihistamines, antihypertensives, antiarrhythmics, and skeletal muscle relaxers.5,6

Appetite Stimulants
Megesterol results in minimal appetite improvement and weight gain, with no improvement in QoL or survival but an increased risk of deep vein thrombosis, fluid retention, and death.11,12 One in 12 patients taking megestrol will experience an increase in weight, while one in 23 will die.11 Also, cyproheptadine should be avoided due to anticholinergic effects.5-8,11

Antianxiety and Insomnia Medications
Prescription and over-the-counter meds routinely used for insomnia include BZDs, "z-drugs" (eg, zolpidem), ramelteon (Rozerem), doxepin, suvorexant (Belsomra), diphenhydramine, and doxylamine. Insomnia guidelines recommend avoiding sedative-hypnotics for insomnia due to insufficient evidence for their use, which has also been linked to increased risk of death, regardless of comorbidities.13,14 Tapering BZDs and "z-drugs" may be needed if they're given routinely for more than several weeks due to withdrawal syndrome.14

BZDs are also used for anxiety and other conditions. These medications are not indicated or recommended long-term for any condition due to dependence, excessive sedation, cognitive decline, and psychomotor impairment. There is a strong correlation between BZD use and falls, which frequently result in hip and other skeletal fractures, head injury, and loss of independence. BZDs increase mortality even when use is limited to only a few doses per year, and 10% of geriatric hospitalizations have been shown to be related to the use of BZDs.13,14

Antipsychotics
Deprescribing antipsychotics in patients with dementia has been shown to have a high success rate in long term care facilities.15 Antipsychotic use in these patients carries significant risk with one more death for every 50 to 100 dementia patients on an atypical antipsychotic over eight to 12 weeks.16

Some prescribers are trying Nuedexta instead; however, it is not approved for agitation or psychosis. Nuedexta has many drug interactions, may increase fall risk, and costs about $750 per month. Avoid medications for agitation or psychosis in patients with dementia.16 Instead, consider behavioral concerns such as agitation as signs of an unmet need and address with more appropriate interventions.15-18

Pain Management
The undertreatment of pain in older adults is known to be a significant issue. However, opioids and other high-risk pain medications (long-term NSAIDs) are generally not the answer. Opioid use should be minimized due to the high potential for harm. Use of opioids with BZDs places patients at risk of possible overdose and even death. Follow a step-wise approach using nonpharmacological measures, acetaminophen, topical NSAIDs, and other adjunct analgesics.19,20

Proton Pump Inhibitors
Proton pump inhibitors are widely overutilized despite known concerns with long-term use (more than two to three months) including rebound hypersecretion, reduced calcium and B12 absorption, osteoporosis, increased fractures, infection risk (pneumonia/Clostridium difficile), and magnesium depletion. Tapering of dose and then duration may be required with high dose and long-term use.21

Steroids
If the expected benefits outweigh the risks, limit steroid use to minimum dose and duration for the specific disease treated. In general, limit to a few days or weeks, as the majority of severe ADEs occur during long-term use (more than three months).22

Diabetes Management
Hypoglycemia may result in altered behavior/mental function and level of consciousness, falls, hallucinations, irritability, seizures, stroke, sweating, weakness, and coma. Severe repeated hypoglycemia requiring hospitalization may increase the risk of developing dementia. Even mild hypoglycemia may lead to significant negative outcomes such as falls/injury with nursing home placement.5,23

In many older adults, higher blood glucose levels are acceptable. The American Geriatrics Society recommends A1c <8 (average glucose between 160 and 170 mg/dL) for frail older adults, those with life expectancy of less than five years, or those at risk of treatment complications. The Veterans Administration recommends A1c of <8 with life expectancy from five to 10 years and mild comorbidities while recommending hemoglobin A1c <9% with life expectancy of less than five years or major comorbidities.5

Deprescribe agents with high hypoglycemia risk, including the use of sliding scale insulin, which results in hypoglycemia without improvement in the management of hyperglycemia.5,23

Diuretic Overuse
Avoid diuretic overuse. Monitor labs routinely for electrolyte imbalances and increased creatinine (possible acute kidney injury). Patients with congestive heart failure should be evaluated every three to six months for the possibility of stepping down from loop to thiazide diuretics. Ensure dosing is reduced to maintenance dose levels. For instance, the dose for a loop diuretic may need to be increased fourfold or more in the hospital, yet the baseline dose is often sufficient once the acute crisis has passed.24

Acute Kidney Injury
Medication-related acute kidney injury incidence in older adults is estimated to be as high as 66%. Meds commonly implicated include antihypertensives, antimicrobials, NSAIDs, and statins. Evaluate for discontinuation, use of lower doses, or change to a safer alternative.25

Lipid-Lowering Agents
Deprescribing statins has been demonstrated to be safe while improving QoL in patients with limited life expectancy, advanced dementia, or poor functional status.26 If the suspected ADEs such as nonspecific muscle pains, cognitive decline, or lethargy are noted, cessation should be considered to clarify whether these are statin related.27

Nonstatins, such as niacin and fibrates, should not be used with statins, as the combination has not been shown to improve cardiovascular outcomes. Also, don't use gemfibrozil or niacin with statins due to increased risk of rhabdomyolysis and possible liver damage.

Antihypertensives
Lower blood pressure goals significantly increase ADEs, including dizziness and falls. Blood pressure goals have been raised for older adults, and achieving a goal systolic blood pressure of 150 mmHg reduces stroke incidence, all-cause mortality, and heart failure.

• Target blood pressure <150/90 for older adults over the age of 60 and especially those 80 and older.

• Target blood pressure <140/90 for older adults at high risk of cardiovascular events, with diabetes or kidney disease, and doing well at lower blood pressures.
Recommend tapering antihypertensives down over one to two weeks.28

Other Medications
A number of other medications are often appropriate for deprescribing, including medications for gout, vitamins, bisphosphonates, iron, and laxatives. Evidence exists that a substantial proportion of older patients can tolerate careful dosage reduction or withdrawal of certain classes of medications without harmful consequences and with possible improvement in QoL.1-4 Failure to responsibly prescribe and deprescribe medications is bad both for older adults and for medicine.

— Mark D. Coggins, PharmD, CGP, FASCP, is vice president of pharmacy services for Diversicare, which operates skilled nursing centers in 10 states. He was nationally recognized by the Commission for Certification in Geriatric Pharmacy with the 2010 Excellence in Geriatric Pharmacy Practice Award.

References
1. Deprescribing.org website. http://deprescribing.org/

2. Frailty, polypharmacy and deprescribing. Drug Ther Bull. 2016;54(6):69-72.

3. Olsson IN, Runnamo R, Engfeldt P. Medication quality and quality of life in the elderly, a cohort study. Health Qual Life Outcomes. 2011;9:95.

4. Frank C, Weir E. Deprescribing for older patients. CMAJ. 2014;186(18):1369-1376.

5. Coggins MD. Focus on adverse drug events. Today's Geriatr Med. 2015;8(6):8-11.

6. Pretorius RW, Gataric G, Swedlund SK, Miller JR. Reducing the risk of adverse drug events in older adults. Am Fam Physician. 2013;87(5):331-336.

7. O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213-218.

8. Coggins MD. Antihistamine risks. Aging Well. 2013;6(2):6-7.

9. Salahudeen MS, Duffull SB, Nishtala PS. Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systematic review. BMC Geriatr. 2015;15:31.

10. IDND developed clinical tools: Anticholinergic burden scale. Indy Discovery Network for Dementia website. http://indydiscoverynetwork.org/resources/idnd-developed-clinical-tools/

11. Choose wisely. American Academy of Family Physicians website. http://www.aafp.org/afp/recommendations/viewRecommendation.htm?recommendationId=183

12. Coggins MD. Unintentional weight loss and appetite stimulants. Today's Geriatr Med. 2013;6(3):10-11.

13. Coggins MD. Insomnia management. Today's Geriatr Med. 2014;7(6):6-8.

14. Coggins MD. Antianxiety medications. Today's Geriatr Med. 2017;10(2):9-11.

15. Lazare J. Reducing use of antipsychotics in nursing home patients with dementia. Today's Geriatric Medicine. January 2016. http://www.todaysgeriatricmedicine.com/enewsletter/enews_0116_01.shtml

16. Have an "exit plan" for antipsychotics in dementia patients. TRC website. https://pharmacist.therapeuticresearch.com/Content/Articles/PL/2017/Jun/Have-an-Exit-Plan-for-Antipsychotics-in-Dementia-Patients. Published June 2017.

17. Coggins MD. Behavioral expressions in dementia patients. Today's Geriatr Med. 2015;8(1):6-9.

18. Coggins MD. Dementia-related behavior management. Aging Well. 2012;5(1):32-33.

19. Coggins MD. Undertreating pain. Today's Geriatr Med. 2014;7(2):8-10.

20. Coggins MD. Tramadol safety concerns. Today's Geriatr Med. 2015;8(4):6-8.

21. Coggins MD. Recognizing proton pump inhibitor risk. Today's Geriatr Med. 2014;7(1):6-8.

22. Coggins MD. Steroid-related risks. Today's Geriatr Med. 2014;7(4):8-9.

23. Coggins MD. Sliding-scale insulin: an ineffective practice. Aging Well. 2012;5(6):8-9.

24. Coggins MD. Evaluating potential diuretic overuse. Today's Geriatr Med. 2013;6(6):5-7.

25. Coggins MD. Medication-related kidney injury. Aging Well. 2013;6(1):8-9.

26. Statin discontinuation may increase quality of life in patients with life-limiting illness. The Clinical Advisor website. http://www.clinicaladvisor.com/evidence-based-medicine/statin-discontinuation-might-increase-quality-of-life-in-patients-with-advanced-life-limiting-illness-without-affecting-median-survival/article/418522/

27. Coggins MD. Weighing the benefits and risk of statins. Today's Geriatr Med. 2013;6(5):5-7.

28. Coggins MD. Treating hypertension. Today's Geriatr Med. 2015;8(2):6-7.