Review of Systems From Physician H & P Care Plan
Polypharmacy: Evaluating Risks and Deprescribing
Am Fam Medico. 2019 Jul 1;100(one):32-38.
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Article Sections
- Abstract
- Risk Factors for Polypharmacy
- Assessment Tools for Polypharmacy
- Approach to Deprescribing
- Challenges to Deprescribing
- References
Polypharmacy, defined as regular employ of at least five medications, is common in older adults and younger at-hazard populations and increases the risk of adverse medical outcomes. At that place are several risk factors that can lead to polypharmacy. Patient-related factors include having multiple medical weather condition managed by multiple subspecialist physicians, having chronic mental health conditions, and residing in a long-term care facility. Systems-level factors include poorly updated medical records, automatic refill services, and prescribing to meet affliction-specific quality metrics. Tools that help identify potentially inappropriate medication use include the Beers, STOPP (screening tool of older people'south prescriptions), and START (screening tool to warning to right treatment) criteria, and the Medication Appropriateness Index. No i tool or strategy has been shown to be superior in improving patient-related outcomes and decreasing polypharmacy risks. Monitoring patients' agile medication lists and deprescribing whatever unnecessary medications are recommended to reduce pill burden, the risks of agin drug events, and financial hardship. Physicians should view deprescribing as a therapeutic intervention similar to initiating clinically appropriate therapy. When deprescribing, physicians should consider patient/caregiver perspectives on goals of therapy, including views on medications and chronic conditions and preferences and priorities regarding prescribing to slow illness progression, prevent health decline, and accost symptoms. Point-of-care tools tin can assist physicians in deprescribing and help patients understand the need to subtract medication brunt to reduce the risks of polypharmacy.
As the size of the older adult population (those older than 62) and the number of younger people with complex health weather have increased in the United states, polypharmacy has become a growing problem.1 Polypharmacy has negative consequences for patients and the health care system (Table i).ii–17 For example, patients taking more than iv medications have an increased risk of injurious falls, and the hazard of falls increases significantly with each boosted medication, regardless of medication type.18
SORT: KEY RECOMMENDATIONS FOR Exercise
| Clinical recommendation | Show rating | Comments |
|---|---|---|
| Physicians should identify and prioritize medications to discontinue and hash out potential deprescribing with the patient.31–34 | C | Expert consensus and narrative review articles |
| When deprescribing, ever develop a specific follow-up plan with the patient.31,33,38,41 | C | Expert opinion from review articles |
| Once a medication reconciliation and deprescribing plan has been put into place, it should exist considered at each visit equally fourth dimension allows and comprehensively reviewed at wellness maintenance visits.19,20,29,32 | B | Cochrane review with inconsistent and limited testify and expert consensus |
| Before starting any new medications, consider underlying causes to treat first, necessity of treatment, alternative nonpharmacologic treatments, and benefits vs. risks of handling.13,26,29,32,40 | C | Survey study, narrative review, and skilful consensus |
| When starting whatever new medication, consider it a trial rather than a permanent improver.13,26,32,twoscore | C | Survey study and narrative review articles |
| When refilling medications, consider the benefits vs. risks of continuation in the brusque term and long term.xiii,26,32,40 | C | Survey written report and narrative review articles |
BEST PRACTICES IN PHARMACOLOGY
Recommendations from the Choosing Wisely Campaign
| Recommendation | Sponsoring organization |
|---|---|
| Do non prescribe medications for patients currently on five or more medications, or continue medications indefinitely, without a comprehensive review of their existing medications, including over-the-counter medications and dietary supplements, to determine whether any of the medications or supplements should or tin exist discontinued. | American Society of Health-Organization Pharmacists |
| Practice not prescribe a medication without conducting a drug regimen review. | American Geriatrics Society |
Tabular array 1.
Negative Consequences of Polypharmacy
| Patientii–15 |
| Decreased quality of life |
| Increased mobility issues |
| Increased bloodshed |
| Increased run a risk of
|
| Increased use of the health care system (clinic visits, emergency department visits, hospitalizations) |
| Health care systemxvi,17 |
| Decreased physician functionality (workflow impairment, decreased quality of care) |
| Decreased doctor productivity |
| Increased burden on the health care arrangement |
| Increased medication errors |
Although in that location is no standard definition for polypharmacy, the definition widely used in the literature is the regular use of at least five medications.19 This threshold does not account for whether the medications are appropriate per the Beers criteria.20 Multiple medications may exist indicated in patients with certain complex medical atmospheric condition, such as heart affliction or diabetes mellitus. In these cases, polypharmacy may exist appropriate. However, prescribing to run across disease-specific quality metrics could increase polypharmacy for patients with multiple medical conditions, which increases the risk of agin consequences and increases the patient's financial burden.21
Risk Factors for Polypharmacy
- Abstruse
- Risk Factors for Polypharmacy
- Assessment Tools for Polypharmacy
- Approach to Deprescribing
- Challenges to Deprescribing
- References
Polypharmacy is most recognized in older adults, because patients with 1 or more chronic conditions take longer medication lists.21,22 Older adults with multiple subspecialist physicians and no primary care md are especially vulnerable to polypharmacy. Adults residing in long-term intendance facilities are also at risk, considering they are more frail than community-abode populations and have multiple medical issues and cognitive impairment that oftentimes warrant pharmacologic treatment. Upwards to 91% of patients in long-term care take at least five medications daily.23
Younger adults with chronic pain, such as fibromyalgia, or with developmental disabilities, especially those with additional chronic medical conditions, may feel polypharmacy because of multiple treatments and modalities.22 Other conditions associated with polypharmacy in younger patients include diabetes, heart disease, stroke, and cancer.24
A population oft overlooked with regard to polypharmacy is patients with mental wellness conditions.22,25 These patients are often prescribed psychotropic medications with adverse effects, and more medications may exist added to mitigate side effect profiles. Although patients with chronic mental health and medical issues may crave multiple medications to accomplish maximal functioning and forbid disease sequelae, this advisable polypharmacy can still increase the gamble of adverse drug events.
Polypharmacy hazard factors can occur at the patient level and at the health care system level (Table ii).21–26 For case, poor medical tape keeping tin can atomic number 82 to polypharmacy if discontinued medications are not removed from the tape and are refilled automatically or if a physician receives an automated refill request for a discontinued medication.
TABLE 2.
Risk Factors for Polypharmacy
| Patient |
| Age older than 62 years |
| Cerebral impairment |
| Developmental inability |
| Frailty |
| Lack of a primary care doctor |
| Mental wellness weather condition |
| Multiple chronic conditions (e.k., pain conditions, diabetes mellitus, coronary avenue disease, cerebrovascular disease, cancer) |
| Residing in a long-term care facility |
| Seeing multiple subspecialists |
| Health care system |
| Poor medical tape keeping |
| Poor transitions of intendance |
| Prescribing to meet disease-specific quality metrics |
| Use of automatic refill systems |
Cess Tools for Polypharmacy
- Abstract
- Run a risk Factors for Polypharmacy
- Cess Tools for Polypharmacy
- Arroyo to Deprescribing
- Challenges to Deprescribing
- References
No validated tool or strategy has been proven superior in improving polypharmacy-related patient outcomes. Likewise, no one validated tool assesses all aspects of potentially inappropriate medication use or polypharmacy.19 Based on a 2018 Cochrane review, information technology is unclear if interventions to reduce inappropriate polypharmacy meliorate patient-oriented outcomes.19 Although interventions may reduce potential prescribing omissions, this needs to be validated in future trials.xix
Assessment tools may be explicit, implicit, or mixed.27 Explicit tools, such as the Beers, STOPP (screening tool of older people's prescriptions), and START (screening tool to alert to correct treatment) criteria, have rigid standards, and articulate criteria help with quick and easy decision-making. However, patient complexity is not considered in the controlling process.20,28 These tools let for comparison of a patient'southward medication list to a set of potentially inappropriate medications and to check for medication duplication; medication and affliction interactions; and medication adjustments required for sure disease states, such as renal impairment. The recently updated Beers criteria listing potentially inappropriate medications by drug form and disease country.twenty The STOPP and First criteria are used together to place medications that may be inappropriate (STOPP) and alternative medications that tin can be started to safely treat a illness (START).28
Implicit tools, such every bit the Medication Ceremoniousness Index, are more time-consuming, because they are based on physician judgment rather than set criteria, but they are more patient-centered and consider patient complication. Implicit tools are inherently express past the doc's cognition, experiences, and attitudes and are less reliable than explicit tools in clinical studies.27,29 The Medication Ceremoniousness Index (https://globalrph.com/medcalcs/medication-appropriateness-index-calculator/) includes 10 questions that accost medication need; optimal therapy for diseases and conditions; medication duplications; appropriateness of dosage, formulation, and elapsing of treatment; medication and disease interactions; and directions for use.30 Although the questions are clear and straightforward, it can have considerable fourth dimension to apply the Medication Ceremoniousness Alphabetize to each medication prescribed.
Arroyo to Deprescribing
- Abstract
- Run a risk Factors for Polypharmacy
- Assessment Tools for Polypharmacy
- Arroyo to Deprescribing
- Challenges to Deprescribing
- References
Physicians should identify and prioritize medications to discontinue and discuss potential deprescribing with the patient.31–34 There are many definitions for deprescribing. One definition is: a systematic process to identify and discontinue medications in instances in which existing or potential harms outweigh potential benefits inside the context of an individual patient's care goals, current level of functioning, life expectancy, values, and preferences.31 Deprescribing discontinues medications, decreases medication dosages, and changes medications to optimize clinical outcomes.31,35–38 Evidence is lacking that a structured approach to decreasing the absolute number of medications, as opposed to discontinuing potentially inappropriate medications, improves patient outcomes.nineteen,20,31,35,39 This is probable because deprescribing efforts are focused, patient-specific interventions with considerable variability in patient characteristics and medications used. Guidelines oftentimes discuss how to initiate therapies but rarely discuss when and how to discontinue them. Judicious prescribing is equally important equally judicious deprescribing (Table 3).thirteen,26,32,twoscore
TABLE three.
Considerations for Judicious Prescribing
| Before starting any new medication ask:
|
| When starting whatever new medications, consider information technology a trial rather than a permanent improver.
|
| When renewing refills, consider the benefits vs. the risks of continuation (long term and short term). |
Physicians should view deprescribing as initiating a "therapeutic intervention" similar to initiating clinically appropriate therapy.31,33,41 When deprescribing, it is imperative to consider patient/caregiver perspectives on goals of therapy, including views on medications and chronic conditions and preferences and priorities regarding prescribing to boring disease progression, prevent health decline, and accost symptoms.38 Only one-third of older adults specifically discuss health care decision-making priorities with their primary care physicians.39 All the same, patients are more probable to consider deprescribing if the physician recommends it.42–44 Physicians should too examine specific therapy goals at every patient visit—illness command (primary/secondary prevention, symptom command/management) vs. acute symptom management.38 A specific follow-upward plan for deprescribing should exist adult with the patient.31,33,38,41 Furthermore, practices and health systems should adopt streamlined approaches to medication reconciliation and tracking, because upward-to-date medication lists might assistance place potential medications for deprescribing and reduce doc, staff, and patient burden. Figure 1 presents an approach to deprescribing.x,13,31,32,34,35,38,40
Figure i.
An approach to deprescribing. (ADME = absorption, distribution, metabolism, and excretion.)
Information from references 10,13,31,32,34,35,38, and 40.
One time a medication reconciliation and deprescribing plan has been put into place, it should be considered at each visit every bit time allows and comprehensively reviewed at health maintenance visits.19,twenty,29,32 There are several resources available that physicians can use at the signal of care to help identify bug with medication prescribing (Tabular array 4).
Tabular array 4.
Point-of-Care Resources for Deprescribing
| Resources | Comments |
|---|---|
| Beers criteria20 | List of medications that pose the highest risk to older adults, as well equally alternatives |
| Bruyère Research Institute and the Canadian Deprescribing Network: https://deprescribing.org | Guidelines, shared determination-making aids, up-to-date research, and algorithms for discontinuing proton pump inhibitors, antihyperglycemics, antipsychotics, benzodiazepines, cholinesterase inhibitors, and memantine (Namenda) |
| Electronic health records, such every bit Epic or NextGen | Autodiscontinuation of expired medications, which may assistance reduce polypharmacy |
| Epocrates: https://www.epocrates.com | Check for drug-drug or drug-herbal interactions |
| MedStopper: http://medstopper.com | Allows users to enter a medication list and receive recommendations regarding which medications might be discontinued or switched |
Challenges to Deprescribing
- Abstruse
- Take a chance Factors for Polypharmacy
- Assessment Tools for Polypharmacy
- Approach to Deprescribing
- Challenges to Deprescribing
- References
The benefits of deprescribing and shortened medication lists are recognized at the patient, physician, and arrangement levels. Withal, time constraints, patient resistance, and lack of systematic support hinder acceptance of deprescribing equally routine medical care. Patients may be reluctant to discontinue medications, even when presented with prove that the medications are not beneficial and may cause physiologic impairment and financial distress. Patients taking chronic medications may worry about conditions worsening and resist discontinuing medications despite new guidelines (eastward.g., concurrent use of opioids and benzodiazepines is now discouraged).45 Patients taking medications prescribed by previous physicians may fearfulness contradicting the original intendance plan by stopping their medications.33 Automated refills of discontinued medications may confuse patients and filibuster deprescribing considering of unclear communication.
Master care physicians may experience pressured to accost multiple issues per visit and may not take adequate fourth dimension to counsel patients on polypharmacy or to deprescribe through shared controlling. Additionally, pressure from patients who desire medications with unclear benefit may cause physicians to prescribe medications to minimize suspension in dispensary workflow.
Patients with multiple prescribers may exist reluctant for ane doc to stop medications prescribed by some other. Such deprescribing must occur with clear interphysician communication to formulate a comprehensive patient care programme.
3 professional organizations in the American Board of Internal Medicine Foundation's Choosing Wisely campaign (American Elderliness Society, American Gild of Wellness-System Pharmacists, and American Psychiatric Association) specifically mention polypharmacy and the need to review medications regularly, question the utility of calculation new medications, and deprescribe when appropriate.32 Such recommendations can persuade physicians to consider deprescribing and can reassure patients that deprescribing medications is bear witness based and beneficial.
Data Sources: A PubMed search was completed using the primal terms polypharmacy, multiple medications, risks, potentially inappropriate medications, and deprescribing. The search included randomized controlled trials, clinical trials, reviews, and meta-analyses, as well as instance reports and bear witness-based guidelines. Searches were likewise performed in the Cochrane Database of Systematic Reviews, UpToDate, the Canadian Task Force on Preventive Wellness Care, the ABIM Foundation's Choosing Wisely website, the Centers for Disease Command and Prevention guideline on prescribing opioids for chronic hurting, and the U.Southward. Preventive Services Task Strength recommendations. Search dates: July and August 2018, and February 2019.
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