When less is bestSeptember 26, 2016
Seniors (those age 65 and older) in Canada take more than their share of prescription drugs. As reported by the Canadian Institute for Health Information (CIHI), a great many seniors are taking at least five drugs, and more senior seniors (age 80 or over) and those in long-term care facilities tend to take at least ten drugs.1
Often a medication is appropriate at the time it was prescribed but, as a patient’s condition changes, it may no longer be the right dosage, the right kind of drug, or required at all. In the case of older people, some drugs aren’t suitable or are unsafe – the benefits of the drug may no longer outweigh the risks. As well, when a person is taking many different drugs, there’s increased possibility of non-adherence, drug interactions, adverse reactions, and visits to the emergency department.2
What can be done to improve this situation? It’s simple: try deprescribing some of those drugs.
What is deprescribing?
It’s pretty much what it sounds like. Deprescribing is the process of tapering, stopping, discontinuing, or withdrawing drugs, with the goal of managing the patient’s multiple medications and ultimately improving health outcomes.
To learn more about deprescribing and how it works in real life, we spoke to a pharmacist on the front line: Peter Dumo who is a clinical pharmacist and owner of Novacare Pharmacy in Windsor, Ontario. We also met with Ned Pojskic, GSC’s Pharmacy Strategy Leader, to get an overview of the issue and a perspective for our plan sponsors.
Ned explains that “deprescribing is part of a larger movement of ‘de-investing’ in tests and treatments to reduce the burden of therapy. The problem isn’t just drugs; there are many tests, including diagnostic ones, routinely done that don’t necessarily need to be. These are tests and treatments commonly used, but that are not supported by evidence and/or could expose patients to unnecessary harm.”
Five prescription drugs
“Polypharmacy” – or taking multiple medications – is a growing issue in older people as the population of seniors increases. But, while seniors represent the bulk of the problem, there are also younger patients taking a number of drugs who could benefit from deprescribing. In his practice, Peter estimates that two-thirds of his deprescribing patients are age 65 or over and one-third is under 65.
Though it’s difficult to apply a definitive cut-off number for prescriptions, taking five or more medications is an indication that a patient could be a candidate for deprescribing.4 However, it’s the appropriateness of each drug for that particular patient that’s most important.
Why are seniors taking so many drugs they might not need?
Peter finds that older people are frequently prescribed a drug as a result of a visit to the emergency department or a hospital stay. The drug would have been necessary at the time but often the prescription is continued indefinitely – whether it’s needed or not – as many physicians are reluctant to change another doctor’s instructions.5
As well, as Ned describes, drugs are typically a physician’s first-line treatment, so prescribing can look like this:
- A patient tells the doctor about some issue they’re experiencing.
- The doctor treats it with a drug.
- The patient then experiences side-effects from that drug.
- So the doctor prescribes a drug to combat the side-effects (which are sometimes mistaken for a new disease).6
- Then the patient has more side-effects from the second drug… and so on.
Another prescribing trend for older patients is an increase in the use of medications, such as statins, for preventive purposes. Sometimes these are prescribed without considering the other medications already in use or the patient’s prognosis and life expectancy.7
Sometimes it seems no one is looking at the patient in a holistic sense that includes the prescription drugs they are taking and why. This is what has led to the “deprescribing movement” over the last few years.
Deprescribing improves lives
There’s no question about the value of deprescribing as many patients experience better outcomes and a better quality of life – sometimes the drugs are actually harming them – once the number of medications they’re taking is reduced. For instance, their adherence to the remaining medications improves as taking fewer drugs is less complex and easier to follow than taking more drugs, and they are less likely to experience drug interactions or side-effects.8 Peter has observed himself that patients appreciate the care and attention they receive at his pharmacy, and they often feel much better once they’re taking fewer drugs.
There’s also the financial side of this issue to consider as the cost of drugs and the related dispensing fees can quickly add up for both public and private drug plans. And the health care system in general benefits when seniors are healthier, with fewer physician visits and hospital admissions.
Whose job is deprescribing?
As Ned told us, “the key is to regularly conduct a holistic review of the medications a person is taking while keeping in mind the possibility of deprescribing.” So who should be doing the reviewing?
The doctor? As Peter commented, “You’d think it should be part of the normal interaction between a family doctor and patient, but sometimes the medication has been started by another practitioner – these patients are often in transition, so they could be seeing specialists or had a hospital stay. It’s difficult for the average family doctor to know everything that’s happening with a patient. Remember, that doctors often have, at most, 10 to 15 minutes to spend with the patient. And today’s health care system isn’t equipped with a simple means of assessing patients for medication use. Deprescribing is a lot more difficult than prescribing – there’s always some detective work involved.”
Do pharmacists have the time? In Peter’s experience it depends on the pharmacist and the practice. He runs his own practice and has decided to devote the time needed for deprescribing; he’s confident that many independent pharmacies see the need and either are doing it now or would embrace the service if they had the means. But many pharmacists are struggling with allocating the necessary time and resources to implement this practice across the board.
Is this an opportunity to join forces? Peter says, “I’ve had tremendous success in working with the local doctors here in Windsor, I approach them as an ally who is trying to investigate a situation with our common patient. Doctors know that people are taking too many meds – they just don’t have the resources to do anything about it.”
Ultimately the pharmacist and MD need to work together and collaborate as each has their own area of knowledge and expertise, but there is a need for more education and effective processes to make it happen. The deprescribing movement has a champion in the Bruyère Research Institute where experts are developing guidelines and publications on how to deprescribe; their perspective is that there should be both prescribing guidelines and deprescribing guidelines for every drug.
We here at GSC are strong supporters of deprescribing. With seniors being a growing demographic – by 2036, one in four Canadians will be older than 659 – it’s clear there’s an opportunity to provide this much-needed service. We see the potential for positive impacts for plan sponsors and their drug plans and for the health care system overall. Currently GSC is supporting the research work undertaken by the Bruyère Research Institute, and we will be sure to revisit this important topic in a future issue of Follow the Script.
1 Canadian Institute for Health Information, “Most seniors take 5 or more drugs; numbers double in long-term care facilities,” www.cihi.ca/en/types-of-care/pharmaceutical-care-and-utilization/most-seniors-take-5-or-more-drugs-numbers-double. Retrieved: August 10, 2016.
2,5,6,8,9 Debbie Kwan and Barbara Farrell, “Polypharmacy: Optimizing Medication use in Elderly Patients,” Canadian Geriatrics Society Journal of CME, Volume 4, Issue 1, 2014, www.canadiangeriatrics.ca/default/index.cfm/journals/canadian-geriatrics-society-journal-of-cme/cme-journal-vol-4-issue-1-2014/polypharmacy-optimizing-medication-use-in-elderly-patients/. Retrieved: August 12, 2016.
3 Deprescribing Algorithms, deprescribing.org/resources/deprescribing-algorithms. Retrieved: August 10, 2016.
4,7 Christopher Frank, “Deprescribing: a new word to guide medication review,” Canadian Medical Association Journal, April 1, 2014, www.ncbi.nlm.nih.gov/pmc/articles/PMC3971020/. Retrieved: August 12, 2016.