Weaning older patients off inappropriate medications which may harm them more than help them should be a priority for all prescribing clinicians, say the authors of two clinical focus articles published in the Medical Journal of Australia.
Deprescribing - the process of reducing or stopping drugs, "with the goal of minimising polypharmacy and improving outcomes" - has the potential to relieve unnecessary medication- related adverse events and disability in vulnerable older people, the authors wrote.
Associate Professor Ian Scott, from the Department of Internal Medicine and Clinical Epidemiology at Princess Alexandra Hospital in Brisbane, and colleagues wrote that one in five prescriptions issued to older adults were "inappropriate".
"One in four community-living older people are hospitalised for medication-related problems over a 5-year period and 15% of older patients attending general practice report an adverse drug event (ADE) over the previous 6 months", the authors wrote.
"At least a quarter of these ADEs are potentially preventable".
"Up to 30% of hospital admissions for patients over 75 years of age are medication-related, and up to three-quarters are potentially preventable."
Research had shown that the single strongest predictor of inappropriate prescribing and increased risk of ADEs was the number of medications a person was taking, the authors said.
"People in residential aged care facilities are prescribed, on average, seven drugs."
Barriers to deprescribing include an underappreciation of the extent of polypharmacy-related harms; increasing intensity of medical care and drug therapy; a too-narrow focus on inappropriate use of drugs whose benefits are mostly outweighed by harm but account for relatively few ADEs, while ignoring the fact that "commonly prescribed drugs with proven benefits in many older people . . . are more frequently implicated"; and resistance of prescribers to discontinue medication, particularly that prescribed by specialists.
Patients were also often reluctant to cease medications that may have helped them stay alive and symptom free.
The second MJA clinical focus article, by Dr Emily Reeve and her coauthors, from the Division of Health Sciences at the University of South Australia in Adelaide, said that although evidence to date suggested deprescribing would produce more benefits than risks, more research was desperately needed.
"More evidence is needed regarding negative, non-reversible effects of ceasing use of certain classes of medication", Dr Reeve wrote.
She cited the example of acetylcholinesterase inhibitors used in Alzheimer disease. Data have shown that after donepezil was discontinued, some patients' cognitive scores dropped below pretreatment levels and did not return to those levels despite reinitiation of donepezil.
Both articles concluded that most of the risks of deprescribing could be minimised with proper planning.
Professor Scott said reframing the issue to one of "affirmation for highest quality care and shared decision making" rather than "abandonment" would help overcome patient reluctance and fears.
Strong lines of communication between doctor and patient, targeting patients at highest risk of ADEs and drugs most likely to be non-beneficial, and consistency of care from one clinician over an extended period of time were also vital to the success of deprescribing.
"Inappropriate polypharmacy and its associated harm is a growing threat among older patients that requires deliberate yet judicious deprescribing using a systematic approach.
"Widespread adoption of this strategy has . . . considerable potential to relieve unnecessary suffering and disability, as embodied in that basic Hippocratic dictum - first do no harm", Professor Scott concluded.