Deprescribing: How to Safely Stop Medications and Avoid Overmedication

The Challenge of Polypharmacy

• 💊 Millions of Americans take multiple prescription medications daily, leading to a higher likelihood of side effects and drug interactions.
• 📈 In Canada, 70% of elders take more than five drugs, with 10% taking over 15, highlighting the complexity of managing numerous prescriptions.
• 🔄 A common scenario involves a cascade of prescriptions, where a drug for one condition or side effect leads to another, creating a vicious cycle of medication.

Understanding Deprescribing

• 🎯 Deprescribing is defined as a systematic process to identify and discontinue medications where the risks outweigh the benefits, considering patient goals, medical problems, functioning, and values.
• ⚠️ It can be approached in two ways: urgent deprescribing for immediate adverse effects and preventive deprescribing to simplify and focus pharmaceutical use.
• 🤝 Deprescribing is a collaborative effort between patient and doctor, not something patients should undertake alone.

Strategies for Safe Deprescribing

• 🔍 The first step in deprescribing involves obtaining accurate documentation of all medications and their perceived indications, often requiring a team approach including loved ones and pharmacists.
• 📚 Tools like the Beers Criteria and STOP START criteria are used by healthcare providers, particularly in geriatric care, to identify potentially inappropriate medications for older adults.
• ⚠️ Certain medications, like benzodiazepines, carry significant risks for older adults, including cognitive problems, sedation, and falls, and require a monitored tapering process to prevent withdrawal symptoms.
• 💡 For drugs like antidepressants (e.g., Cymbalta), tapering can be a long and individualized process, sometimes involving opening capsules and removing pellets gradually over months or even a year.

Navigating Medication Challenges

• 🗣️ Open communication between patients and providers is crucial, with patients encouraged to voice concerns about medications and providers to welcome these discussions.
• 🏥 Electronic health records can aid in identifying drug interactions, but alert fatigue can lead to warnings being overridden by clinicians.
• 🩺 Finding a geriatrician can be beneficial for older adults, as they often have expertise in deprescribing and medication review.
• 🔄 It is acceptable to request an entire appointment dedicated to medication review to discuss potential adverse effects and prioritize medications.

Specific Medication Considerations

• 📉 While hypertension is a risk factor for many conditions, studies suggest that in very old adults (80-90+), higher blood pressure might be associated with a lower risk of dementia.
• ❓ Distinguishing between medication side effects and symptoms of underlying conditions can be challenging, requiring careful monitoring and communication with healthcare providers.
• 🩹 Proton pump inhibitors (PPIs), commonly prescribed for heartburn, can also require a slow tapering process to discontinue, as highlighted by listener experiences.
• ⏳ There is a lack of research evidence on how to best taper and discontinue many medications, making the process more challenging for both prescribers and patients.