With the increasing population of elderly people, the use of multiple medications, commonly referred to as polypharmacy, is also on the rise particularly among elderly people with multiple chronic illnesses. Polypharmacy is the use of multiple drugs at the same time which is associated with higher risk of ADRs, DDIs, low compliance, and poor health. De-prescribing is the process of deprescribing or dose reduction of drugs that may be ineffective or even potentially hazardous in the primary care setting. This article outlines the process of medication reconciliation in patients such as Mrs. P. who is an 80-year old woman suffering from acute bronchitis and other chronic conditions.
Assessing Medication Necessity and Burden
The first step in de-prescribing is the medication review process that involves prescription and over the counter medicines. Clinicians working with such patients should ask the following questions: Are all the current medications required given her current symptoms, goals, and prognosis? For example, her statement that she has not experienced any symptoms of GERD for the past six months may mean that she does not need pantoprazole anymore. Prolonged use of PPIs in the elderly can cause bone fractures, kidney diseases, and some infections such as C. difficile. Since she has no symptoms, it is recommended to reduce or stop using pantoprazole, which may help to decrease her medication load without affecting the quality of treatment.
Likewise, low arthritic pain managed by acetaminophen and daily walking indicates that tramadol, an opioid analgesic, can be safely stopped. Tramadol has the side effects of dizziness, falls and dependence particularly in the elderly patient. As Mrs. P. employs it sparingly and has not reported its use in the last two months, it would be safest to exclude it from her treatment plan.
It is necessary to monitor the changes that occur after an acute illness and its impact on the body of the patient. When a patient has been on a course of medications for an acute condition like bronchitis treated with prednisone, the clinicians have to reconsider the necessity of other medications. Tiotropium is an inhaled anticholinergic agent that is used in the management of COPD, however, Mrs. P does not smoke and has no history of chronic lung disease. If her respiratory symptoms were only because of acute bronchitis and are no longer present, the continuation of tiotropium should be questioned. Inhalation of anticholinergics should be avoided in the long term; its side effects include dry mouth, urinary retention, and confusion in the elderly.
It is safe to stop the tiotropium inhaler after the prednisone taper is done and the patient’s lung function can be maintained without any obstructive lung disease. This also presents the chance to inform the patients and the caregivers on which drugs are for short-term use and which are for the long-term use. This is due to the fact that clear communication can assist in preventing the continuation of a medication beyond the recommended time.
Changing the Maintenance Medications Based on Stability
There is no reason for those with chronic diseases but who are now in their 60s and 70s to continue taking the same dosages as when the diseases were newly diagnosed. Mrs. P. has heart failure, hypertension, and hyperlipidemia as his active medical conditions. This is evidenced by her compliance to low sodium intake diet and the absence of oedema or worsening of heart failure. This stability may allow for adjustment of her diuretic prescription. Furosemide is very useful in controlling fluid retention but when used excessively, can cause dehydration, electrolyte imbalance and weight loss. Since the patient has lost 5 pounds, her BMI has not changed, and she has no edema, it is reasonable to try to taper her furosemide dose gradually. This would also enable reevaluation of her potassium intake since potassium is administered to her due to potassium loss as a side effect of furosemide.
It is also important to consider whether she needs to be on the dose of statin that she is currently taking. Though, atorvastatin 10 mg is a comparatively low dose, deprescribing guidelines for lipid-lowering agents in elderly patients particularly those above the age of 75 years recommend that the risk benefit balance may be unfavourable in elderly patients with stable cardiovascular disease and no recent cardiovascular events. If lipid levels are still within target range and other risks have not developed, discussion of whether to continue on the current dose or taper down can involve the patient in her care.
Therefore, de-prescribing should be patient-specific, gradual, and based on clinical reasoning and patient preferences and monitoring. Such patients as Mrs. P., who have stable chronic diseases and scarce acute manifestations, can be considered as a target population for the deprescribing process and safe aging. Hence, it is possible for primary care providers to enhance the quality of life of elderly patients while at the same time minimizing the risks of harm by adopting the “less is more” approach in medication management.
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