In this week’s interview, a board-certified geriatric pharmacist explains why taking an older person off a medication might be just as important as putting them on one. In fact, since prescriptions tend to accumulate over time, the delicate art of deprescribing is even more essential. This pharmacist helps physicians determine how to reduce the number of drugs a patient takes.

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A recent perspective in JAMA describes the dilemma doctors face in the title: “Deciding When It’s Better to Deprescribe Medicines Than to Continue Them” (JAMA, Nov. 29, 2023). It quotes geriatrician Eric Lee of Kaiser Permanente as saying, “We’re all taught how to prescribe these medications. We’re not taught how to stop these medications.” The result is prescription inertia, the tendency to keep prescribing a drug even if it is no longer appropriate.

What harm could that do, after all? Well, 750 older individuals are hospitalized in the US daily because of adverse drug reactions. So it is important to remember that every medicine has risks as well as benefits. As we age, the balance between those two may change. If downsides begin to outweigh the advantages, it may be time to think about deprescribing. If a pharmacist helps with that process, so much the better.

Doctors who take care of older adults are the ones who may most commonly have patients who are taking half a dozen or more medicines. They may have been taking these pills for years, and it may no longer be clear that they are necessary. Some prescriptions might have been added primarily to counter side effects from previous medications.

Today’s guest urges health care providers to step back and take a look at the whole picture. How many of the problems being treated could be addressed with changes in lifestyle? Is the patient willing or even interested in making those changes? Unless someone asks the question, the patient may not even realize that could be an option.

Have you had the chance to tell your health care provider about a problem and received a prescription to treat it? Are you quite sure the problem being treated is a new condition–or could it be a side effect of a medication? We sometimes hear from people who eventually learn that their insomnia is a side effect of their blood pressure medicine. But the doctor prescribed a sleeping pill that caused heartburn, so they are now taking an acid suppressing drug in addition to the sleeping pill and blood pressure medicine. This is a relatively short prescribing cascade, but such chains of prescriptions to treat first one side effect and then another are all too common.

One reason that not every healthcare professional embraces deprescribing is the potential for difficulties stopping a medicine. Quitting certain drugs too suddenly can trigger a discontinuation syndrome, the medical term for withdrawal symptoms. While we associate this type of trouble with opioids (and they certainly do cause it), people may also experience discomfort or even intolerable reactions when they stop other medications such as benzodiazepines, antidepressants or even certain blood pressure pills. A professional who recommends dropping a dose or phasing off a medicine altogether should be able to support a patient who has troublesome symptoms as they stop.

Some decades ago, a geriatrician named Mark Beers put together a list of medicines that may be inappropriate for older patients. The list is periodically updated as a guide to healthcare providers. Here is a link to the latest version. This list is not intended to prohibit prescribing certain drugs for elderly individuals. But it should serve as a red flag for the prescriber to evaluate whether an alternative might work equally well with less risk. Such a list can be very useful when a pharmacist helps with this process.

The Beers list is not the only tool a doctor or nurse practitioner might use to check on the safety of a medicine they are considering. There are interaction checkers and other warnings that are often built into the software used for prescribing. But the time pressures experienced in so many health care arenas can make these warnings less effective. If they crop up too often, physicians and pharmacists are likely to experience alert fatigue. This is a bit like the tale by Aesop in which the shepherd boy repeatedly cries wolf when there is no wolf. Consequently, when the wolf comes along to threaten his sheep, the townsfolk refuse to come to his aid, believing his plea to be groundless. Alert fatigue is a serious problem in healthcare. We are not aware of an effective remedy.

DeLon Canterbury, PharmD, BCGP, is the founder, President and CEO of GeriatRx, Inc. He is also a Deprescribing Implementation Strategist. Dr. Canterbury is a Board Certified Geriatric Pharmacist with a passion for reducing harmful medication use in our older adults across the country.

website: www.geriatrx.org

Dr. DeLon Canterbury, the pharmacist helps providers deprescribe unnecessary meds

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