Deprescribing and Polypharmacy in an Aging Population

By Ali Elbeddini

Deprescribing and Polypharmacy in an Aging Population supports healthcare professionals across global healthcare institutions in reducing polypharmacy-related drug replated problems (DRPs) by working with patients, families, interprofessional healthcare professionals, and educational institutions to develop, implement, test, improve upon, and educate on strategies for deprescribing and optimizing patient safety. Polypharmacy, the use of multiple medications at the same time by one person, is very common in various patient populations, including those who lack primary physicians, patients with mental health conditions, patients with multiple chronic conditions, and in the aging population.

• Emphasizes the importance of involving a multidisciplinary team in deprescribing efforts
• Identifies barriers and enablers for the implementation of deprescribing programs
• Develops strategies to address barriers and optimize enablers for deprescribing implementation

• Language: English
• Publisher: Academic Press
• Release date: Aug 22, 2023
• ISBN: 9780323993814

Ali Elbeddini

Dr. Elbeddini is Affiliate Investigator in Epidemiology at Ottawa Hospital Research Institute (OHRI), Canada. He previously an Assistant Professor in Clinical Pharmacy at Skaggs School of Pharmacy, University of Colorado, USA and conducted post-doctorate research at Harvard Medical School (HMS) in Global Clinical Scholars Research Education program.

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Chapter 1: A global overview of the current state of deprescribing

Stephanie Laua; Ali Elbeddinib,c    a Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada

b Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada

c Winchester District Memorial Hospital, Winchester, ON, Canada

Abstract

This chapter will explore the health and financial impact of polypharmacy and deprescribing, the steps required for effective deprescribing, a global overview of deprescribing tools, various deprescribing networks, and finally, deprescribing efforts around the world as well as trends and future initiatives.

Keywords

Polypharmacy; Global perspective; Medication safety

A global overview of the current state of deprescribing

Prevalence of polypharmacy in older patients

Polypharmacy is defined as taking five or more medications [1]. Polypharmacy is becoming increasingly prevalent in various patient populations across the world and studies have shown that polypharmacy is on the rise in most, if not all, countries, ranging from approximately 10% to 90% [1–3]. For example, in the United States, polypharmacy in individuals aged 20 years and older nearly doubled from 8.2% in 1999–2000 to 15% in 2011–2012, which is similar to the increase in polypharmacy seen in the United Kingdom (UK): 11.2% in 1995 to 20.8% in 2010 [2]. In other populations, polypharmacy prevalence is even greater. For instance, in Uttaranchal, North India, the prevalence of polypharmacy is 93.1% among adults aged 65 years and older [3].

Populations that are at particularly high risk of polypharmacy and potentially inappropriate medications (PIMs) include those who lack primary physicians, patients with mental health conditions, patients with multiple chronic conditions, and the aging population [4].

As older age is a risk factor for comorbidities and resulting polypharmacy, it comes as no surprise that the increasing prevalence of polypharmacy is consistent with the global rise in life expectancy [4,5]. According to the World Health Organization (WHO), 8% of the world population were considered elderly (65 years and older) in 2010 and this global proportion is expected to increase 16% by 2050, which will account for half of the total growth of the world population [4,5]. Additionally, the global population older than 85 years is projected to increase by 351% within this timeframe and the global population younger than 65 years is projected to increase by 22% [5].

The correlation between age, polypharmacy, and potential harm can be seen upon examination of global and national statistics [4,6]. In 2016, the Canadian Institute for Health Information (CIHI) reported that seniors (aged 65 years and older) comprise only 17% of the total Canadian population; however, more than half the senior population is on polypharmacy with PIMs [6]. In addition, 65.7% of Canadian seniors were found to be prescribed five or more different drug classes and 26.5% of Canadian seniors were found to be prescribed 10 or more different drug classes [4]. In the United States, nearly 50% of older adults take five or more medications and up to one in five of these medications are potentially inappropriate [7].

Health impact of polypharmacy and deprescribing

Polypharmacy places elderly patients at a higher risk for drug-related problems (DRPs), which may lead to avoidable hospitalizations [7]. Seniors are more likely to have multiple chronic conditions than younger populations and therefore require a greater number of medications to manage these conditions [4–6]. An analysis of 2016 Canadian data from the Discharge Abstract Database (DBD) and Hospital Morbidity Database (HMDB) showed that 0.7% of seniors were hospitalized for an adverse drug reaction (ADR) and patients with 10 or more different drug classes (21.1% of the senior population) experienced more than half of all reported ADR-related hospitalizations (58.6%) [7]. The likelihood of prescribing cascades increases with the number of medications a patient is taking, which can further increase the likelihood of DRPs and ADR-related hospitalizations in these vulnerable populations and cyclically exacerbate poorer health outcomes in patients [7].

The global incidence of adverse drug events (ADEs) ranges from 0.2% to 65%, and it is estimated that 20%–70% of ADEs are potentially preventable, including those arising from drug-drug interactions and PIMs [8]. Annually, 3.5% of hospitalizations are due to ADEs [8].

Deprescribing is an effective way of reducing DRPs and improving patient outcomes [6]. For example, multiple Canadian organizations, such as the Canadian Deprescribing Network (CaDeN), the Canadian Foundation for Healthcare Improvement (CFHI), the Institute for Safe Medication Practices (ISMP), and the Canadian Patient Safety Institute (CPSI), have developed deprescribing educational initiatives, awareness campaigns, and tools to reduce polypharmacy in aging populations [6]. These tools have contributed to a significant reduction of inappropriate chronic drug use in Canada from 33.9% in 2011 to 31.1% in 2016 [6].

Financial impact of polypharmacy and deprescribing

Polypharmacy is known to incur steep and unnecessary costs to healthcare systems across the world [7,8]. In 2019, the WHO found that PIMs contribute to 4% of the world’s total avoidable costs due to suboptimal medicine use, and 0.3% of the global total health expenditure (approximately $18 billion USD) could be avoided by appropriate polypharmacy management [7,9].

This trend is seen not only in developing countries but also in developed countries such as Canada and those in the United Kingdom [7]. In 2013, Canadian seniors spent approximately $419 million on PIMs and $1.4 billion on the treatment of PIM-related side effects [7]. More recent statistics show that Canadian public drug programs spent $250 million on proton pump inhibitors (PPIs), $97 million on antipsychotics, and $135 million on benzodiazepines, which are some of the most common prescribed PIMs [7]. Despite these steep costs, various long-term studies have shown that unnecessary polypharmacy is avoidable and deprescribing is a direct solution to improved health and financial savings. A 5-year UK study (2015–19) on medication reviews and deprescribing in care homes demonstrated that deprescribing by pharmacists alone accounted for 53% of financial drug savings over 5 years, which equates to £431,493 GBP [10].

The implementation of deprescribing practices has shown a consistent trend of improved economic and patient outcomes across various other countries [11,12].

The Stimulating Innovation Management of Polypharmacy and Adherence in the Elderly (SIMPATHY) Project is an economic analysis tool developed by the European Union to perform cost-benefit analysis on polypharmacy reviews, which can be beneficial to improve resource productivity [11]. The SIMPATHY project showed in multiple countries that financial and healthcare outcomes were significantly improved when deprescribing and medication reviews were conducted [11]:

•In Sweden, hospitals saved 200 EUR per patient and reduced medication-related readmissions by 80% when medication reviews were performed by clinical pharmacists [11].

•In Scotland, the Scottish Polypharmacy Management Programme showed that 9.87 GBP was saved per medication stopped in patients with high-risk medicines, and anywhere from 66 to 155 GBP was saved as an estimated value of the medications themselves [11].

In other countries such as China, pharmacist interventions have been shown to promote the rational, appropriate use of PPIs and antibiotics and reduce patient charges. In a 2014 study in a Chinese hospital, it was found that pharmacist interventions reduced costs by 18.79 times the mean cost of the pharmacist’s time required to make the intervention (i.e., the mean cost of the pharmacist’s time was $12.75 USD, but the mean cost reduction was 18-fold higher at $239.64 USD) [12].

How does deprescribing work?

The previous sections examined the health and financial significance of reducing PIMs in polypharmacy through interventions such as deprescribing [6,7,11,12]. This section provides a general overview of the deprescribing process. Typically, deprescribing frameworks provide a stepwise approach that includes the following [4,13]:

1.Gather a medication history

•Encourage active participation from the patient and/or caregivers

•Include a disease history to contextualize the medication history

•Seek out the patient’s opinions on their needs for the medications or if the patient believes the medication is not helpful/necessary

•Determine reasons for not taking any medications

•Determine if there are any medications the patient has already self-deprescribed

2.Determine if any of the medications a patient is currently taking are not indicated and if the potential harms outweigh the potential benefits for any medication

•For instance:

○Medications indicated for a limited duration or specific acute purpose and are no longer required

○PIMs

○Medications that cause ADRs

○Ineffective medications

○Noncompliance

3.Determine the required intensity of the deprescribing intervention by considering the overall risk of drug-induced harm and patient preference

•Discuss the benefits and adverse outcomes of deprescribing with the patient

4.If multiple medications are appropriate for deprescribing, prioritize medications for deprescribing; and

5.Implement and monitor the reduction, withdrawal, or cessation of the medication during and after the process.

Many frameworks have been proposed and emphasize different steps of the preceding framework [4,13].

Global overview of deprescribing tools

To approach deprescribing in a more consistent, structured manner, many countries have developed tools to assist with identifying and/or deprescribing PIMs that commonly cause harm [14]. However, most tools of the mid-to-late 2010s were developed using expert opinion, many tools lacked sufficient descriptions of development methodology, and a limited number of tools were tested in clinical trials. Importantly, the tools that were were clinically tested resulted in low-quality evidence [14].

Deprescribing tools can be grouped into two main categories [14]:

(1)Those with Explicit approaches to medication review, i.e., these tools list medications to be reviewed by name, and

(2)Those with Implicit approaches to medication review, i.e., these tools suggest helpful questions that a clinician should ask to help determine if a medication is still indicated.

Please see Table 1.1 for examples of explicit and implicit deprescribing tools [14,15].

Table 1.1