Polypharmacy and Deprescribing

Polypharmacy - Pill Overload Perils

• Definition: Concurrent use of ≥5 medications; major polypharmacy ≥10 drugs.
• Prevalence: High in elderly (>65 yrs), affecting 40-50%.
• Risk Factors:
  • Multiple comorbidities.
  • Multiple prescribers.
  • Frequent hospitalizations.
  • "Prescribing cascade" (ADR treated with a new drug).
• Consequences:
  • ↑ Adverse Drug Reactions (ADRs).
  • ↑ Drug-drug & drug-disease interactions.
  • ↓ Medication adherence, ↑ medication errors.
  • ↑ Risk of falls, cognitive impairment, frailty.
  • ↑ Hospitalizations, healthcare costs, & mortality.

⭐ The "prescribing cascade," where an adverse drug effect is misdiagnosed as a new medical condition leading to another (often unnecessary) prescription, is a major contributor to polypharmacy and a frequent exam topic_._

Deprescribing - The Great Unburdening

• Definition: Systematic process of identifying and discontinuing or reducing doses of medications where existing or potential harms outweigh existing or potential benefits, within the context of an individual patient’s care goals, current level of functioning, life expectancy, values, and preferences.
• Goals:
  • Improve quality of life (QoL).
  • Reduce adverse drug events (ADEs) & drug interactions.
  • Decrease pill burden & improve adherence.
  • Reduce healthcare costs.
• Benefits: ↓Polypharmacy, ↓ADEs, ↓Falls, ↑Cognition, ↑Adherence, ↑QoL.
• Triggers for Deprescribing:
  • New symptom or syndrome (potential ADE).
  • Multiple prescribers.
  • Prescribing cascade.
  • Patient/caregiver request.
  • High-risk medications (e.g., Beers criteria).
  • Palliative care transition.
  • Frailty or cognitive impairment.
  • Recent hospitalization.

⭐ The Beers Criteria lists potentially inappropriate medications for older adults, guiding deprescribing efforts to minimize ADEs. Common examples include sedative-hypnotics, anticholinergics, and certain antipsychotics.

• Process: Patient-centered, shared decision-making, regular monitoring, and follow-up are key components for successful deprescribing strategies in geriatric care settings to optimize medication regimens effectively and safely.

Tools of the Trade - Criteria & Guides

• Beers Criteria (AGS):
  • Primary US guide for Potentially Inappropriate Medications (PIMs) in adults ≥65 years.
  • Categorizes PIMs, drugs to avoid with certain conditions, and drugs to use with caution.
  • Regularly updated.
• STOPP/START Criteria (European):
  • STOPP (Screening Tool of Older Persons' Prescriptions): Identifies PIMs, drug-drug/drug-disease interactions.
  • START (Screening Tool to Alert to Right Treatment): Addresses Potential Prescribing Omissions (PPOs).

  ⭐ STOPP criteria are linked to ↓ adverse drug reactions & improved medication appropriateness.

• Medication Appropriateness Index (MAI):
  • Patient-specific, 10-question tool assessing individual drug therapy.
  • Evaluates indication, effectiveness, dosage, safety, cost.
• Others: FORTA (Fit fOR The Aged) classification (German/Austrian).

The Deprescribing Dance - Steps & Strategies

• Goal: ↓ Medication burden & risks (ADRs, falls), ↑ quality of life.
• Systematic Process:
  • 1. Medication Reconciliation: Full list (Rx, OTC, herbals).
  • 2. Identify PIMs: Use Beers Criteria, STOPP/START tools.
  • 3. Assess & Prioritize:
    • Risk (ADRs) vs. benefit for each.
    • Align with patient goals, life expectancy.
    • Target high-risk/low-benefit meds first.
  • 4. Plan Deprescribing:
    • Patient collaboration essential.
    • Tapering schedule vs. abrupt stop.
  • 5. Implement & Monitor:
    • Educate on withdrawal.
    • Track benefits, ADRs, symptom return.
  • 6. Document & Follow-Up: Regular review is crucial.

⭐ Successful deprescribing often involves gradual tapering and can significantly reduce adverse drug events (ADEs) without worsening underlying conditions.

High‑Yield Points - ⚡ Biggest Takeaways

• Polypharmacy: concurrent use of ≥5 medications; ↑ risk in elderly.
• Major risks: Adverse Drug Reactions (ADRs), falls, cognitive impairment, non-adherence.
• Deprescribing: planned process to reduce medication burden and harm, improving outcomes.
• Key tools: Beers Criteria and STOPP/START criteria for identifying PIMs.
• Prioritize deprescribing anticholinergics, benzodiazepines, NSAIDs, and long-term PPIs.
• Regular medication review (e.g., annually) is crucial to optimize therapy and QoL.