Nurse practitioners working with older populations need to be familiar with the concept of deprescribing. Removing unnecessary and potentially harmful medications from an elderly patient’s med list is an important part of risk management in older patient populations. In this article, we will discuss important deprescribing principles and identify potential pharmaceutical candidates for deprescribing consideration.
Related: Deprescribing in Older Adults: Doing More by Doing Less
What is deprescribing?
Deprescribing is the process of lowering the dosage of a medication or stopping the drug altogether. The steps of deprescribing include:
- Evaluating medications to determine if the patient should continue using them
- Creating a plan for removing unnecessary or harmful medications
- Monitoring the patient during and after a drug is stopped
When do you deprescribe a medication?
Nurse practitioners can deprescribe harmful medications at any time. When meeting a new patient for the first time, evaluate their med list and see if any medications are candidates for deprescribing. Later, if a patient presents with a complaint that could be a side effect of a medication, review the patient’s prescriptions. See if any medications should be evaluated for deprescribing.
Finally, if you were the one who prescribed the medication, monitor its efficacy. Every medication must be evaluated to determine if its potential benefits outweigh its potential risks. Over time, you may find a drug does not have the desired effect or its benefit to the patient starts to wane. When the risks outweigh the drug’s utility, you know it’s time to deprescribe.
How do you deprescribe a medication?
When a medication is no longer beneficial to a patient, you can plan for removing it from their med list. Depending on the medication, it might require a tapered dose to wean off or it might be possible to discontinue the medication immediately. To determine how to properly deprescribe a medication, you can follow flowchart algorithms for some common medications that are candidates for deprescribing.
Why is deprescribing important?
Deprescribing is an essential risk management tool for Nurse Practitioners working with older patient populations. Some patients may be on medications for years and no longer remember why the medication was started. Others may suffer from a prescription cascade, where medications are prescribed to manage the side effects of other medications, and on and on.
While it is common for older adults to take multiple medications for the management of chronic conditions, polypharmacy also comes with some big risks.
What are the risks associated with polypharmacy?
Polypharmacy increases the risk of drug interactions. This is why one of the core principles of deprescribing is to choose the medication with the lowest possible drug-to-drug interaction potential when multiple medication options within the same class are available.
Polypharmacy also increases the risk of adverse side effects. Especially in older populations, side effects such as confusion, muscle weakness, and unsteadiness can be potentially life-threatening complications. A patient’s fall risk must be seriously considered when prescribing new medications with potential side effects. Conversely, this can be a good indication for deprescribing a medication as well.
Finally, because our bodies have a harder time processing and eliminating medications as we age, being on too many medications or at too high doses can cause systemic problems. This is why another principle of deprescribing in older adults is to choose medications with shorter half-lives.
Related: Update in Geriatric Prescribing: Beers Criteria, START/STOPP, and Deprescribing
How do older adults process medications differently?
Older adults have leaner muscle mass, proportionally more fat, lower fluid reserves, decreased albumin levels, lower cardiac output, and decreased kidney volume. These are all essential facts for Nurse Practitioners to remember when prescribing to older adults.
Lower fluid reserves mean that older adults dehydrate more easily. This is relevant for deprescribing diuretics in patients who present with complaints of dry mouth, headaches, or dizziness.
Studies have shown that our liver volumes may decrease by up to 40% as we age. This greatly affects the body’s ability to metabolize medications, as does lower hepatic functioning and decreased cardiac output. This means that even if older patients need to continue certain medications, they may be safer with a lower dosage. Decreasing dosages as patients age is another essential principle of deprescribing.
Proportionally more fat provides the opportunity for fat-soluble compounds to dissolve in fat and remain in “storage” for extended periods of time. A typical medication’s half-life becomes markedly longer in older adults because it stores in fat more readily.
Finally, decreased serum albumin levels mean that Nurse Practitioners must be vigilant about prescribing albumin-bound drugs such as warfarin and other blood thinners. In older adults with increased fall risks, the serious risks of such medications may outweigh their potential benefits.
What medications are candidates for deprescribing in older adults?
Published annually by the American Geriatrics Society, the Beers Criteria is a list of medications that may be inappropriate for older adults. Nurse Practitioners should reference the Beers Criteria before starting a patient on a new medication. The Beers Criteria can also be a helpful resource for Nurse Practitioners to crosscheck an elderly patient’s med list to see which medications may be candidates for deprescribing.
- Anticholinergic medications are typically not recommended in patients over 65 years old. Elderly patients are more sensitive to the side effects of anticholinergics. They’re particularly susceptible to side effects such as confusion, delirium, and other cognitive impairments. These can create serious fall risks in older adults. Avoiding anticholinergic medications is another main principle of deprescribing in older adults.
- Chronic antimicrobial therapies are commonly prescribed to older women as a preventive treatment for recurrent urinary tract infections (UTIs). However, as it increases the risk of antibiotic-resistant pathogens, it is not considered a safe first-choice prescription. Chronic antimicrobial therapies should only be considered after other UTI prevention techniques have failed.
- Sedative-hypnotic sleep aids are common in older adults. However, they cause psychomotor impairment, which translates to fall risks. These medications are great candidates for deprescribing. Patients can be prescribed melatonin instead, which is much safer and proven effective.
Deprescribing is an essential part of responsible pharmacological care in older patient populations. By adhering to the principles of deprescribing, Nurse Practitioners can avoid dangerous drug interactions, side effect prescription cascades, and increased fall risks. Great resources like the Beers Criteria before prescribing and the flowchart algorithms for deprescribing can help Nurse Practitioners make smart decisions in managing geriatric patients’ medication lists.
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