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Deprescribing in older adults: An overview

Paige Whittaker, BS, Sarah E. Vordenberg, PharmD, MPH, and Antoinette B. Coe, PharmD, PhD

M
r. J, age 73, has a 25-year history also reports taking ginseng, milk thistle, a
of generalized anxiety disorder multivitamin, and, based on a friend’s recom-
and major depressive disorder. mendation, St John’s Wort (Table 1, page 41).
His medical history includes hypertension,
hyperlipidemia, type 2 diabetes mellitus, Similar to Mr. J, many older adults take mul-
hypothyroidism, osteoarthritis, insomnia, tiple medications to manage chronic health
and allergic rhinitis. His last laboratory test conditions and promote their overall health.
Vicki L. Ellingrod,
results indicate his hemoglobin A1c, thyroid- On average, 30% of older adults take ≥5
PharmD, FCCP
stimulating hormone, low-density lipopro- medications.1 Among commonly prescribed
Department Editor
tein, and blood pressure measurements are medications for these patients, an estimated
at goal. He believes his conditions are well 1 in 5 of may be inappropriate.1 Older adults
controlled but cites concerns about taking have high rates of polypharmacy (often
multiple medications each day and being defined as taking ≥5 medications1), age-
able to afford his medications. related physiological changes, increased
You review the list of Mr. J’s current prescrip- number of comorbidities, and frailty, all of
tion medications, which include alprazolam which can increase the risk of medication-
0.5 mg/d, atorvastatin 40 mg/d, escitalopram related adverse events.2 As a result, older
10 mg/d, levothyroxine 0.125 mg/d, lisino- patients’ medications should be regularly
pril 20 mg/d, and metformin XR 1,000 mg/d.
Mr. J reports taking over-the-counter (OTC) Practice Points
acetaminophen as needed for pain, diphen- • Many older adults take unnecessary
medications that may be both unsafe and
hydramine for insomnia, loratadine as needed
burdensome. It is important to regularly
for allergic rhinitis, and omeprazole for 2 years monitor medication use among older
for indigestion. After further questioning, he adults to ensure that only medications
that provide more benefit than risk are
Ms. Whittaker is a PharmD student, College of Pharmacy, University continued.
of Michigan, Ann Arbor, Michigan. Dr. Vordenberg is Clinical Associate
Professor, College of Pharmacy, Department of Clinical Pharmacy, • Deprescribing is a systematic,
University of Michigan, Ann Arbor, Michigan. Dr. Coe is Assistant patient-centered process that
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Professor, College of Pharmacy, Department of Clinical Pharmacy, involves gathering a comprehensive list
University of Michigan, Ann Arbor, Michigan.
is produced in partnership of medications, identifying potentially
with the College Disclosures inappropriate medications, determining
of Psychiatric Dr. Coe is supported by the National Institute on Aging of the which ones to taper or stop, creating and
and Neurologic National Institutes of Health (NIH) (Award Number K08 AG071856).
Pharmacists Dr. Vordenberg has received support from the U.S. Deprescribing
implementing a plan for discontinuation
cpnp.org Research Network via the Northern California Institute for Research with the patient, and providing necessary
mhc.cpnp.org (journal) and Education through the NIH (Award Number R24 AG064025). follow-up support.
The content is solely the responsibility of the authors and does not
necessarily represent the official views of the NIH. The authors report • Deprescribing decisions should take
no financial relationships with any companies whose products are into account patient-specific goals,
mentioned in this article, or with manufacturers of competing products.
Current Psychiatry preferences, and treatment values.
40 May 2022 doi: 10.12788/cp.0246
 Savvy Psychopharmacology

Table 1

Mr. J’s current medication list

Name Indication Morning Evening As needed
Prescription medications
Alprazolam Difficulty sleeping ✓
Atorvastatin Stroke prevention ✓
Escitalopram Depression ✓
Levothyroxine Low thyroid hormone levels ✓
Lisinopril High blood pressure ✓
Metformin High blood sugar ✓
Over-the-counter medications and dietary supplements
Acetaminophen Pain ✓ Clinical Point
Diphenhydramine Difficulty sleeping ✓
Ginseng Memory ✓
Older adults have
Loratadine Allergies ✓ high rates of
Milk thistle Liver health ✓ ✓ polypharmacy and
Multivitamin General wellness ✓ an increased risk of
Omeprazole Indigestion ✓ ✓
medication-related
St John’s wort Depression ✓
adverse events

evaluated to determine if each medication nutritional supplements the patient is tak-

is appropriate to continue or should be ing. It is important to specifically ask patients
tapered or stopped. about their use of nonprescription products,
Deprescribing, in which medications are because these products are infrequently doc-
tapered or discontinued using a patient- umented in medical records.
centered approach, should be considered The second step is to evaluate the indi-
when a patient is no longer receiving ben- cation, effectiveness, safety, and patient’s
efit from a medication, or when the harm adherence to each medication while begin-
may exceed the benefit.1,3 While both ning to consider opportunities to limit treat-
patients and prescribing clinicians may ment burden and the risk of harm from
have concerns about deprescribing, studies medications. Ideally, this assessment should
suggest that for most older adults, careful involve a patient-centered conversation that
deprescribing of antihypertensives, psycho- considers the patient’s goals, preferences,
tropics, and benzodiazepines can be done and treatment values. Many resources can
without causing harm.4 Removing unneces- be used to evaluate which medications
sary medications can reduce the risk of falls, might be inappropriate for an older adult.
and improve motor function and cognitive Two examples are the American Geriatrics
performance.2,3,5 Society Beers Criteria5 and STOPP/START
Several researchers1,3 and organizations criteria.6 By looking at these resources, you Discuss this article at
have published detailed descriptions of and could identify that (for example) anticholin- www.facebook.com/
MDedgePsychiatry
guidelines for the process of deprescrib- ergic medications should be avoided in older
ing (see Related Resources, page 43). Here patients due to an increased risk of adverse
we provide a brief overview of this pro- effects, change in cognitive status, and falls.5,6
cess (Figure,1,3 page 42). The first step is to These resources can aid in identifying, prior-
assemble a list of all prescription and OTC itizing, and deprescribing potentially harm-
Current Psychiatry
medications, herbal products, vitamins, or ful and/or inappropriate medications. Vol. 21, No. 5 41
continued
Savvy Psychopharmacology

Figure

Processes for successful deprescribing

Review
medication
history

Provide
Identify
monitoring and
inappropriate
support for
Patient- medications
Clinical Point patient
centered
Consider deprescribing
deprescribing when
the patient is no
longer benefiting Make and Decide if
implement a medications
from a medication or plan for can be
discontinuation discontinued
when the harm may
exceed the benefit
Source: Adapted from references 1,3

Table 2

Plan for tapering Mr. J’s alprazolam (number of 0.5 mg tablets

at bedtime)a
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Week 1 1 1 1 1 1 1 1
Week 2 ½ ½ ½ ½ ½ ½ ½
Week 3 ½ 0 ½ 0 ½ 0 ½
Week 4 0 0 0 0 0 0 0
A slower taper may be necessary depending on Mr. J’s response to this plan
a

The next step is to decide whether changes should be individualized based

any medications should be discontinued. on the patient’s preferences as well as the
Whenever possible, include the patient in properties of the medication. For example,
this conversation, as they may have strong some medications can be immediately dis-
feelings about their current medication regi- continued, while others (eg, benzodiaz-
men. When there are multiple medications epines) may need to be slowly tapered. It
that can be discontinued, consider which is important to consider if the patient will
medication to stop first based on potential need to switch to a safer medication, change
harm, patient resistance, and other factors. their behaviors (eg, lifestyle changes), or
Subsequently, work with the patient to engage in alternative treatments (such as
create a plan for stopping or lowering the cognitive-behavioral therapy for insomnia)
Current Psychiatry
42 May 2022 dose or frequency of the medication. These when they stop their current medication.
 Savvy Psychopharmacology

Take an active role in monitoring your

patient during this process, and encourage Related Resources
them to reach out to you or to their primary • Deprescribing.org. Deprescribing guidelines and algorithms.
https://deprescribing.org/resources/deprescribing-guidelines-
clinician if they have concerns.
algorithms/
•
US Deprescribing Research Network. Resources for
CASE CONTINUED Clinicians. https://deprescribingresearch.org/resources-2/
Mr. J is a candidate for deprescribing because resources-for-clinicians/

he has expressed concerns about his current Drug Brand Names

regimen, and because he is taking poten- Alprazolam • Xanax Lisinopril • Zestril
Atorvastatin • Lipitor Metformin XR •
tially unsafe medications. The 2 medications Escitalopram • Lexapro Glucophage XR
he’s taking that may cause the most harm Levothyroxine • Synthroid Trazodone • Desyrel
are diphenhydramine and alprazolam, due
to the risk of cognitive impairment and falls.
Through a patient-centered conversation, Mr. Clinical Point
J says he is willing to stop diphenhydramine
immediately and taper off the alprazolam over that at his next visit with his primary care Before deprescribing
physician, he will bring up the idea of stop-
the next month, with the support of a taper- any medications,
ing chart (Table 2, page 42). You explain to ping omeprazole.
consider the
him that a long tapering of alprazolam may
be necessary. He is willing to try good sleep References patient’s goals,
hygiene practices and will put off starting
1. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate
polypharmacy: the process of deprescribing. JAMA Intern
preferences, and
trazodone as an alternative to diphenhydr- Med. 2015;175(5):827-834.
treatment values
2. Gibson G, Kennedy LH, Barlow G. Polypharmacy in older
amine until he sees if it will be necessary. You adults. Current Psychiatry. 2020;19(4):40-46.
make a note to follow up with him in 1 week 3. Reeve E, Shakib S, Hendrix I, et al. Review of deprescribing
to assess his insomnia and adherence to the processes and development of an evidence-based, patient-
centred deprescribing process. Br J Clin Pharmcol. 2014;
new treatment plan. You also teach Mr. J that 78(4):738-747.
some of his supplements may interact with 4. Iyer S, Naganathan V, McLachlan AJ, et al. Medication
withdrawal trials in people aged 65 years and older: a
his prescription medications, such as St John’s systematic review. Drugs Aging. 2008;25(12):1021-1031.
Wort with escitalopram (ie, risk of serotonin 5. 2019 American Geriatrics Society Beers Criteria®
syndrome) and ginseng with metformin (ie, Update Expert Panel. American Geriatrics Society 2019
updated AGS Beers Criteria® for potentially inappropriate
risk for hypoglycemia). He says he doesn’t take medication use in older adults. J Am Geriatr Soc. 2019;
ginseng, milk thistle, or St John’s Wort regu- 67(4):674-694.
6. O’Mahony D, O’Sullivan D, Byrne S, et al. STOPP/START
larly, and because he feels they do not offer criteria for potentially inappropriate prescribing in older
any benefit, he will stop taking them. He says people: version 2. Age Ageing. 2015;44(2):213-218.

Current Psychiatry
Vol. 21, No. 5 43