deprescribing a proactive approach geriatric syndromes

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2021 Annual Meeting & ExhibitionNovember 4-7, 2021 | San Diego, California

Deprescribing:A Proactive Approach to

Prevent Geriatric Syndromes

Katie Connolly, PharmD, MS, BCGP, CPE

Ryan J. Connolly, DO, MS, FACOI

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Meet the Speakers: Katie Connolly, PharmD, MS, BCGP

• Clinical Pharmacist, Medical University of South Carolina

• Masters of Science in Medical Education

• Board Certified Geriatric Pharmacist

• Certified Pain Educator

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Meet the Speakers: Ryan J. Connolly, DO, MS, FACOI

• Internal Medicine Physician, Roper St. Francis Health System

• Medical Director, Hospital at Home Program

• Masters of Science in Medical Education

• Fellow of the American College of Osteopathic Internists

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Disclosure

• The speakers have no actual or potentially relevant financial relationship to disclose and no conflict of interest in relation to this activity.

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Pharmacist Learning Objectives

• Describe the relationship between polypharmacy and geriatric syndromes • Identify methods by which pharmacists and physicians can work

together to optimize the medication regimens of older adults• Describe tools that can be used to safely deprescribe medications • Utilize deprescribing to reduce the risk of potential adverse events in

geriatric patients

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Pharmacy Technician Learning Objectives

• Define polypharmacy, geriatric syndromes, and deprescribing• Describe how deprescribing can be utilized to prevent adverse events • Identify medications that may increase the risk of geriatric

syndromes in an older adult

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Background

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Geriatric Patients

Polypharmacy

Geriatric Syndromes

Multi-morbidity

Age Related Changes

Functional & Cognitive Limitations

Limited Evidence

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Polypharmacy

• “The simultaneous use of multiple drugs by a single patient, for one or more conditions”• Can be defined by quantity

• Commonly, five or more medications• Range from two or more to greater than 10 meds

• Associated with multimorbidity and geriatric syndromes• Increases risk of adverse outcomes • Risk factors

• Patient related• Systems related

Lexico.com/en/definition/polypharmacy (from Oxford dictionary)Halli-Tierney A, et al. AAFP. 2019; 100(1):32-38.Masnoon N, et al. BMC Geriatrics (2017) 17:230

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Multimorbidity

• “The coexistence of multiple health conditions”• Often, two or more chronic conditions

• Associated with many challenges• Polypharmacy• Complex visits with multiple clinicians• Lack of clinical data/studies

Johnston MC, et al. EJPH. 2019; 29(1):182-9.

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Geriatric Syndromes

Adapted from: Inouye SK, et al. J Am Geriatric Society. 2007 May; 55(5): 780-791.

RISK

FA

CTO

RS GERIATRIC SYNDROMESPolypharmacyFallsIncontinencePressure UlcersDelirium

FRAI

LTY POOR

OUTCOMESDisabilityNursing HomeDeath

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Age Related Changes

• Physiologic changes • Pharmacokinetic changes

• Absorption• Distribution • Metabolism• Elimination

• Pharmacodynamic changes • Decreases in receptors

Change Result

A↓ Active transport↓ First pass Unpredictable bioavailability

D ↓ Total body water↑ Total body fat

↓ Vd for water soluble drugs↑ Vd for fat soluble drugs

M↓ Phase I metabolism↓ Hepatic blood flow ↓ Metabolism = ↑ t1/2

E ↓ Renal elimination ↑ t1/2

Hämmerlein A, et al. Clinical Pharmacokinetics. 1998; 35(1):49-64.

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Functional and Cognitive Limitations

• Functional changes• Hearing loss• Reduced physical activity• Decreased motor skills

• Cognitive changes• Increased processing time • Decreased attention • Decline in “new” learning abilities• Decline in executive cognitive

function

Limitation and changes can also be related to chronic disease and multimorbidity

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Limited Evidence

• Lack of guidelines • Particularly, to discontinue

medications• Exclusion of older adults with

multimorbidity

• Biases in literature • Recruitment bias • Misclassification bias

Image from: https://pharma.elsevier.com/pharmacovigilance/the-role-of-scientific-literature-in-pharmacovigilance/

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Self-Assessment Question #1

Which of the following contribute to the complexity of caring for geriatric patients?

A. Pharmacokinetic changes B. PolypharmacyC. Limited evidence D. All of the above

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Deprescribing

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Deprescribing

• “Deprescribing is the planned and supervised process of dose reduction or stopping of medication that might be causing harm, or no longer be of benefit.”• Deprescribing.org

• Systematic process to:• Identify medications that may cause harm • Discontinue those medications

• Patient-centered intervention

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Why deprescribe?

Reduce Polypharmacy

Improve Health Outcomes

Prevent Adverse Events

Improve Medication Adherence

Increase Patient Satisfaction

Reduce Healthcare Costs

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Polypharmacy + Geriatric SyndromesMedication Class Geriatric Syndrome

Anticholinergics OpioidsCalcium channel blockers Constipation

Anticholinergics CorticosteroidsBenzodiazepines H2-receptor antagonists Delirium

Anticholinergics SulfonylureasAntihypertensives Dizziness

AntihypertensivesCentrally acting medications Falls

Diuretics Sedative hypnoticsOpioids Urinary Incontinence

Adapted from: McGrath, et al. JFP 2017; 66(7).

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Can Deprescribing Prevent Geriatric Syndromes?

• If, treatment of geriatric syndrome consists of:• Identifying and treating related disease states • Risk assessment and reduction

• And, deprescribing identifies and removes medications that may cause harm • Then, deprescribing can prevent geriatric syndromes

Deprescribing is a Proactive Approach!

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Deprescribing ApproachIdentify

Prioritize

Discuss

Implement

Follow-up

Review

Deprescribing

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Assessing Medication Regimens: Patient Case

Mr. Taylor is a 74 year-old-male with a history of hypertension, hyperlipidemia, GERD, benign prostatic hyperplasia, osteoarthritis of the knee, and insomnia. He presents to the clinic today for a medication review.

Age: 74 yearsHeight: 70 inchesWeight: 182 lbs

Pertinent Labs

Na 140 mmol/L Hgb 14 g/dL

K 4.2 mmol/L Hct 42%

Cl 102 mmol/L WBC 5.2

CO2 20 mmol/L Plt 240

SCr 1.2 mg/dL HgbA1c 6.8%

BUN 12 mmol/L Glucose 138 mg/dL

Vital Signs

HR 66

BP 124/82

Temp 98.2

RR 18

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Patient Case: Mr. Taylor

Past Medical History:• Hypertension• Hyperlipidemia• GERD• BPH • Osteoarthritis• Insomnia

Home Medications:• Amlodipine 10mg PO daily • Lisinopril 20mg PO daily • Rosuvastatin 40mg PO daily • Pantoprazole 40mg PO daily• Tamsulosin 0.4mg PO daily • Oxycodone/Acetaminophen

5/325mg, 1 to 2 tabs PO q6h PRN pain• Amitriptyline 25mg PO HS • Zolpidem 10mg PO HS

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Assess the Medication Regimen

Indication

Duplication

Dosing

Interactions

Risk-Benefit

Patient Factors

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Tools to Evaluate the Medication Regimen

• Potentially inappropriate medications

Beers Criteria & STOPP

• Criteria to determine appropriateness

Medication Appropriateness Index

• Identify medications with a high anticholinergic burden

Anticholinergic Burden Calculator

• Tool to optimize drug therapy management

Fit FOr The Aged (FORTA)

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Tools to Evaluate the Medication Regimen

• Review all medications the patient has at home

Brown Bag Method

• Enter medication list for specific patient

MedStopper.com

• Medication fall risk score and evaluation tools

AHRQ 3I tool & CDC: STEADI tool

• Ten medications older adults should avoid or use with caution

Health in Aging

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After reviewing Mr. Taylor’s medication regimen, can you identify all ofthe medications that may put this patient at risk for developing a geriatric syndrome?

A. Lisinopril, Rosuvastatin, PantoprazoleB. Amlodipine, Lisinopril, Tamsulosin, Oxycodone/APAP, Amitriptyline,

ZolpidemC. Oxycodone/APAP, Zolpidem, AmitriptylineD. Amlodipine, Lisinopril, Rosuvastatin, Tamsulosin, Oxycodone/APAP,

Amitriptyline, Zolpidem

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Patient Case: Mr. TaylorMedication Geriatric Syndrome

Anticholinergics OpioidsCalcium channel blockers Constipation

Anticholinergics CorticosteroidsBenzodiazepines H2-receptor antagonists Delirium

Anticholinergics SulfonylureasAntihypertensives Dizziness

AntihypertensivesCentrally acting medications Falls

Diuretics Sedative hypnoticsOpioids Urinary Incontinence

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Prioritize Medications

1.Medications that have already caused an adverse event

2.Medications most likely to cause the greatest harm

3.One medication that can cause multiple geriatric syndromes

4.Medications with safer alternatives

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Unnecessary medicationsNo indication Duplication of therapy

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After identifying medications that can cause geriatric syndromes in Mr. Taylor’s medication regimen, how would you prioritize deprescribing?

A. Oxycodone/APAP, Zolpidem, AmitriptylineB. Amlodipine, Oxycodone/APAP, ZolpidemC. Lisinopril, Amlodipine, TamsulosinD. Oxycodone/APAP, Amlodipine, Tamsulosin

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Deprescribing Algorithms

• Deprescribing.org• Evidence based guidelines and

algorithms• Antihyperglycemics• Antipsychotics• Benzodiazepines• Cholinesterase Inhibitors and

Memantine • Proton Pump Inhibitors

• Educational tools for patients

Image from: Deprescribing.org

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Deprescribing Algorithms

• Primary Health Tasmania• Evidence based guides

• Consumer resources • https://www.primaryhealthtas.com.au/

resources/deprescribing-resources/

• Allopurinol • Cholinesterase Inhibitors• Antihyperglycemics • Glaucoma eye drops• Antihypertensives • NSAIDs• Antipsychotics • Opioids• Aspirin • Proton Pump Inhibitors• Benzodiazepines • Statins• Bisphosphonates • Vitamin D and Calcium

Image from: Primary Health Tasmania

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Avoiding Withdrawal Events

• Tapering algorithms • Use to avoid adverse drug

withdrawal events • Can stop many drugs without

withdrawal reactions

• If there is concern for adverse withdrawal events, and no guideline exists:• Taper slowly, over 4-6 weeks • Monitor patient closely

Medications That Can be Stopped without Tapering

ACE/ARB (for nephroprotection) 5-⍺ Reductase Inhibitors

Antibiotics (prophylaxis) Memantine

Antihyperglycemics (oral) Multivitamins

Anti-platelets NSAIDs

Bisphosphonates Nutritional Supplements

Calcium + Vitamin D Statins

Estrogen (for menopausal symptoms) Theophylline

Adapted from: Hanlon JT, Tjia J. Sr Care Pharm 2021; 36:136-41.

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Medications that Require TaperingMedication Class Withdrawal Reaction Tapering Duration

Anticholinergics Irritability, anxiety, insomnia 4 – 8 weeks

Antiepileptics Seizure recurrence 3 – 6 months

Antipsychotics Dyskinesias, overactivity 1st generation: 1 – 2 weeks2nd generation: 4 – 8 weeks

Beta Blockers Tachycardia, rebound HTN 3 – 4 months

Benzodiazepines Anxiety, insomnia, tremor 1 – 2 months

Central ⍺-blockers Rebound hypertension 3 – 6 weeks

CorticosteroidsAnorexia, lethargy, arthralgia, postural hypotension Several months

H-2 receptor antagonists (H2RA) Proton Pump Inhibitors (PPI) Rebound gastric hypersecretion 4 weeks

Adapted from: Hanlon JT, Tjia J. Sr Care Pharm 2021; 36:136-41.

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Perspectives

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Pharmacist Perspective

• Understand importance of deprescribing • Interpret data • Communicate across healthcare team

• Medication review and recommendations • Utilize literature• Apply evidence based algorithms • Discuss with physician• Counsel patient

• Goal to collaborate with physician

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Pharmacy Technician Perspective

• Perform medication reconciliation in the inpatient setting• Obtain preadmission medication list • Contact outpatient pharmacies and physician offices • Document complete medication list

• Upon discharge, list sent to:• Primary care physician

• Accurate medication list is key to deprescribing efforts

• Home with patient

• Collaborate with pharmacist when polypharmacy is identified

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Physician Perspective

• View deprescribing as a therapeutic intervention • Practice prudent prescribing• Patients are more likely to consider deprescribing if recommended by a

trusted physician • Importance of a streamlined medication reconciliation process• Challenges

• Time constraints • Multiple prescribers• Multiple pharmacies • Prescribing cascade

• Goal to collaborate with pharmacist

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Pharmacy + Physician Team

• Key role in managing polypharmacy• Areas for collaboration

• Recommendations regarding drug therapy• Over the counter medication selection • Patient counseling • Identification of medication side effects • Improving medication adherence • Advise regarding drug interactions

• Challenges• Community setting• Reimbursement • Experience• Time

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Patient Perspective

• Willingness to deprescribe influenced by:• Perception of medication appropriateness • Fear of adverse outcomes • Involvement of regular primary care physician• Understanding of why deprescribing is important• Previous experiences

• Caregiver perspective• Influenced by complexity

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Communicating with Patients

• Consider goals • Ask the right questions!• Discuss options, introduce choice, make decisions:

• Several medications you are taking have side effects that may be contributing to your dizziness

• If you are open to it, we can reduce the dose or stop one of these medications to see if your dizziness improves

• How do you feel about this? • What questions do you have for me?

Adapted from: Farrell B, Mangin D. AAFP, 2019; 99(1): 7-9

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Patient Case

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Mrs. Brown

Mrs. Brown is a 78-year-old female with a recent fall at home. The fall occurred at night when she was getting up to use the bathroom. This is the first fall she has had. She lives at home with her husband. She presents to the clinic today for a follow up appointment.

Age: 78 yearsHeight: 64 inchesWeight: 144 lbsImaging: normalMicro: UA no growth

Pertinent Labs

Na 138 mmol/L Hgb 12 g/dL

K 4.0 mmol/L Hct 36%

Cl 104 mmol/L WBC 4.6

CO2 22 mmol/L Plt 200

SCr 1.0 mg/dL HgbA1c 7.2%

BUN 10 mmol/L Glucose 144 mg/dL

Vital Signs

HR 58

BP 110/72

Temp 98.4

RR 16

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Mrs. Brown

Past Medical History:• Hypertension • Hyperlipidemia • Depression• Anxiety • Incontinence• Osteoporosis• Recent Fall

Home Medications:• Lisinopril 10mg PO daily• Hydrochlorothiazide 12.5mg PO daily• Atorvastatin 80mg PO daily• Escitalopram 10mg PO daily• Lorazepam 0.5mg PO TID PRN • Oxybutynin ER 10mg PO daily• Calcium/Vitamin D 600mg/400 IU PO

daily

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Which diagnoses does Mrs. Brown have that would be considered geriatric syndromes?

A. HypertensionB. IncontinenceC. FallsD. B and C

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Could any of the medications Mrs. Brown is taking contribute to geriatric syndromes?

A. Hydrochlorothiazide B. OxybutyninC. LorazepamD. All of the above

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Mrs. Brown: Collaboration

• Prior to seeing Mrs. Brown in the office, the physician and pharmacist meet to discuss a plan • Would like to deprescribe one or more medications• Determine that more information is needed to develop a plan

• Key discussion points with Mrs. Brown: • Timing of lorazepam before the fall • Frequency of lorazepam usage• Urinary incontinence history • Symptoms prior to fall

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Mrs. Brown: Additional Information

• How often do you take your lorazepam?• “I only take it when I can’t sleep. On average, I take it two times a month.”

• How long have you been taking lorazepam? • “I first got the prescription 10 or 15 years ago after my neighbor passed away. We were close

friends, and I was was very worried about how I would get on without her. I took the medicine a lot more back then. Now, I just keep it around because I find it useful to help me sleep.”

• What time did you last take your lorazepam before your fall? • “I took it at 8 or 8:30pm.”

• Did you take your lorazepam that evening to help with sleep? • “Yes. Our 14-year-old cat has been sick lately. We had an appointment to take her to the

veterinarian the next morning, and I was worried about the diagnosis. I was thinking too much about it, and couldn’t fall asleep.”

• Did you try anything else to help with your symptoms that night?• “No, I didn’t. Sometimes I take a melatonin pill before I take the lorazepam, but I was out of

them.”

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Mrs. Brown: Additional Information

• How long have you been suffering from urinary incontinence? • “Probably 5 years. When I have to go, I have to go! I figured it’s just part of getting old.”

• Was it before or after you started taking hydrochlorothiazide? • “Well, I started taking it about 7 or 8 years ago. So I think my bladder issues came after I

started the water pill.”

• How often do you get up during the night to use the bathroom? • “At least once every night. Sometimes twice. Usually I am very thirsty, so I have a glass of

water when I get up too. Come to think of it, that probably makes my bladder issues worse.”• Did you feel any different than normal before you fell?

• “Well, I got up to go to the bathroom. I was in the hallway, and I started to feel dizzy. There wasn’t anything to hold on to, so I fell to the floor. I wouldn’t say that it was very different though. I have had quite a few dizzy spells lately. It was something I wanted to talk to you about today.”

• How often do you experience dizziness?• “Oh, I feel dizzy for a minute or two almost every day now. It started about two months ago.”

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Mrs. Brown: Polypharmacy + Geriatric Syndromes

• Taking greater than 5 medications• Evaluate all medications

associated with geriatric syndromes for deprescribing

• By deprescribing now, we can:• Prevent future medication related

adverse events • Increase quality of life

Geriatric Syndrome Associated Medications

Falls/Dizziness

HydrochlorothiazideLisinoprilLorazepamOxybutynin

Urinary Incontinence HydrochlorothiazideOxybutynin

Polypharmacy all

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We have identified that we should consider deprescribing Mrs. Brown’s hydrochlorothiazide, lisinopril, lorazepam and oxybutynin. Based on the information gathered during your discussion with Mrs. Brown, which medication would you prioritize to deprescribe first?

A. Hydrochlorothiazide B. LisinoprilC. LorazepamD. Oxybutynin

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Mrs. Brown: Deprescribing Benzodiazepines

• Mrs. Brown no longer has an appropriate indication for lorazepam• Discussion with Mrs. Brown about

risks and benefits of tapering• She is in agreement

• Implement tapering plan• Dose reduction to 0.25mg• Frequency reduction to HS PRN

• Follow-up phone call in 2 weeks, Follow-up visit in 4 weeks

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Mrs. Brown: 8 Week Follow-up

Identify

Prioritize

Discuss

Implement

Follow-up

Review

• Mrs. Brown is completely tapered off lorazepam• She has not had any falls!

• She is still struggling with urge incontinence• Discuss deprescribing

hydrochlorothiazide • She is in agreement • Follow-up on BP and frequency of

urge incontinence in 4 weeks• If improved, can taper off

oxybutynin

Deprescribing

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Mrs. Brown: Discussion

• Other ideas on how to approach this patient?• Have you used any of these deprescribing techniques in practice? • Thoughts on pharmacist – physician collaboration?

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Summary

• Deprescribing is a proactive approach to prevent geriatric syndromes • Identify• Prioritize• Discuss • Implement• Follow-up• Review

• Collaboration between physician, pharmacy team, and patient are key to successful deprescribing • Key resources:

• Beer’s Criteria, STOPP, Medication Appropriateness Index, FORTA• Deprescribing.org and Primary Health Tasmania

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References • American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older

Adults. J Am Geriatr Soc. January 2019.

• American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. Patient-centered care for older adults with multiple chronic conditions: a stepwise approach from the American Geriatrics Society: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. J Am Geriatr Soc. 2012;60(10):1957-1968.

• Deprescribing.org. What is deprescribing? https://deprescribing.org/what-is-deprescribing/

• Endsley, S. Deprescribing unnecessary medications: a four part process. American Academy of Family Physicians. 2018; 25(3):28-32.

• Fabiili NA, Powers MF. Roles for pharmacy technicians in medication reconciliation during transitions of care. Journal of Pharmacy Technology. 2017 Feb; 33(1): 3–7.

• Farrell B, Mangin D. Deprescribing is an essential part of good prescribing. American Academy of Family Physicians. 2019; 99(1):7-9.

• Farrell B, Pottie K, Thompson W et al. Deprescribing proton pump inhibitors. Canadian Family Physician. 2017; 63:354-64.

• Halli-Tierney A, Scarbrough C, Carroll D. Polypharmacy: evaluating risks and deprescribing. American Family Physician. 2019; 100(1):32-38.

• Hämmerlein A, Derendorf H, Lowenthal DT. Pharmacokinetic and pharmacodynamic changes in the elderly. Clinical implications. Clinical Pharmacokinetics. 1998; 35(1):49-64.

• Hanlon JT, Tjia J. Avoiding adverse drug events when stopping unnecessary medications according to the STOPPFrail criteria. Senior Care Pharmacist. 2021; 36:136-41.

• Inouye SK, et al. Geriatric syndromes: Clinical research and policy implications of a core geriatric concept. J Am Geriatric Society. 2007 May; 55(5): 780-791.

• Johnston MC, Crilly M, Black C, et al. Defining and measuring multimorbidity: a systematic review of systematic reviews. Eur J Public Health. 2019; 29(1):182-9.

• Kelly DV, Bishop L, Young S, et al. Pharmacist and physician views on collaborative practice: findings from the community pharmaceutical care project. Canadian Pharmacists Journal. 2013; 146(4):218-26.

• Krishnaswami A, Steinman MA, Goyal P, et al. Deprescribing in older adults with cardiovascular disease. Journal of the American College of Cardiology. 2019; 73(20):2584-95.

• Kuhn-Thiel AM, Weiß C, Wehling M; FORTA authors/expert panel members. Consensus validation of the FORTA (Fit fOR The Aged) List: a clinical tool for increasing the appropriateness of pharmacotherapy in the elderly. Drugs Aging. 2014 Feb;31(2):131-40.

• Lexico.com/en/definition/polypharmacy (from Oxford dictionary)

• Magnuson A, Sattar S, Nightingale G, et al. A practical guide to geriatric syndromes in older adults with cancer: A focus on falls, cognition, polypharmacy and depression. American Society of Clinical Oncology. 2019; e96-109.

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References• Markota M, Rummans TA, Bostwick JM et al. Benzodiazepine use in older adults: Dangers, management, and alternative therapies. Mayo Clinic Proceedings. 2016; 1632-9.

• Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatrics (2017) 17:230

• Maust DT, Lin LA, Goldstick JE et al. Association of Medicare part D benzodiazepine coverage expansion in fall-related injuries and overdoses among Medicare Advantage beneficiaries. JAMA Network Open. 2020; 3(4): e202051.

• McGrath K, Hajjar ER, Kumar C, et al. Deprescribing: a simple method for reducing polypharmacy. Journal of Family Practice. 2017; 66(7):436-45.

• Murman DL. The impact of age on cognition. Semin. Hear. 2015;36:111–121.

• National Council on Aging. Falls Prevention. https://www.ncoa.org/healthy-aging/falls-prevention/

• O'Mahony, O'Sullivan, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2 Age Ageing (2015) 44 (2): 213-218 doi:10.1093/ageing/afu145

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• Pottie K, Thompson W, Davies S et al. Deprescribing benzodiazepine receptor agonists. Canadian Family Physician. 2018; 64:339-51.

• Primary Health Tasmania. Deprescribing Resources. https://www.primaryhealthtas.com.au/resources/deprescribing-resources/

• Reeve E, Farrell B, Thompson W et al. Deprescribing cholinesterase inhibitors and memantine in dementia: guideline summary. Medical Journal of Australia. 2019; 210(4):174-9.

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• Stevens JA. The STEADI Tool Kit: A fall prevention resource for health care providers. IHS Prim Care Provid. 2013 Sep: 39(9); 162-166.

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• Tool 3I: Medication Fall Risk Score and Evaluation Tools. Content last reviewed January 2013. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk-tool3i.htm

• Turnheim K. When drug therapy gets old: Pharmacokinetics and pharmacodynamics in the elderly. Experimental Gerontology. 2003; 38:843-53.

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deprescribing a proactive approach geriatric syndromes

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