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EDITORIAL
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 61-62

Should I prescribe or deprescribe!


Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission25-Dec-2021
Date of Decision01-Jan-2022
Date of Acceptance03-Jan-2022
Date of Web Publication31-Jan-2022

Correspondence Address:
Dr. Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgmh.jgmh_1_22

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How to cite this article:
Grover S. Should I prescribe or deprescribe!. J Geriatr Ment Health 2021;8:61-2

How to cite this URL:
Grover S. Should I prescribe or deprescribe!. J Geriatr Ment Health [serial online] 2021 [cited 2022 May 24];8:61-2. Available from: https://www.jgmh.org/text.asp?2021/8/2/61/336904



Comorbidity and multimorbidity (i.e. the occurrence of 2 or more chronic medical conditions) among the elderly are common. A household survey from China that evaluated multimorbidity among the elderly estimated the prevalence of multimorbidity to be 43.6%, with a higher prevalence of multimorbidity among women compared to men.[1] Studies from other parts of the world have also estimated multimorbidity with varying ranges, with estimated rates to be as high as 95.9%.[2]

The multimorbidity leads to consultations from multiple physicians, and the elderly are often prescribed numerous medications. The polypharmacy rates among the elderly vary according to the definition, and these have also been relatively high. A study that defined polypharmacy (use of five or more medications) conservatively estimated the prevalence of polypharmacy to be 32% (95% confidence interval [CI]: 29.8–34.3) among the elderly. It was also seen that the rates of polypharmacy were higher among women; increased with increasing age, higher among those who had evaluated their health status negatively and had a medical appointment in the 3 months before assessment. In terms of different classes of medications used, medications used to treat ailments of the cardiovascular system, gastrointestinal system, and nervous system were the most commonly used medications.[3] Evidence also suggests that polypharmacy is associated with increased risk of mortality, with one study estimating that compared to elderly receiving no medications, the hazard ratio (HR) for mortality among persons receiving six or more drugs was 2.78 (95% CI: 2.36–3.27, P < 0.001), and the HR was 1.47 (95% CI: 1.31–1.64, P < 0.001) among those receiving 1–5 drugs.[4] Polypharmacy can also lead to frequent emergency visits and hospitalization, due to either side effects or poor medication adherence.[5] A study from India estimated that 14.4% of admissions to the emergency were medication related, with 6.7% arising due to side effects and 7.6% arising due to nonadherence with medications. The admissions to emergency due to medication side effects were associated with diabetes mellitus or neoplasms and patients receiving multiple medications. The admissions due to poor nonadherence were associated with the poor recall of the medication regimen, consulting numerous physicians, female gender, polypharmacy, medication costs, and switching over to nonconventional forms of treatment.[5]

Due to multimorbidity and polypharmacy, clinicians are often faced with a situation to stop certain medications rather than just prescribing pills. Often in clinical round discussions, the emphasis is on prescribing drugs, and deprescribing is rarely discussed.

Deprescribing is a systematic process of identification, reduction in the doses of medications, or stopping the medications when the current and potential risks of continuing the medications outweigh the current or potential benefits taking into account the patient's medical morbidity, functioning, values, and preferences.[6],[7] The final aim of deprescribing is not necessarily to stop the medications entirely but is judicious use of drugs.[7]

With age, there is a decrease in the body reserve and emergence of multiple comorbidities, which leads to change in the pharmacokinetics and pharmacodynamics of various medications. Further, concomitant use of medications impacts the pharmacokinetics and pharmacodynamics at the initiation of medication or when a medication is withdrawn. All these factors make the elderly more prone to side effects and make it imperative for the clinicians to have a proper understanding of deprescribing and an understanding of judicious prescribing.

The five principles to be followed while considering deprescribing in the elderly include a review of a current prescription, identifying the target medication to be reduced or stopped, developing a plan how to deprescribe, plan deprescribing in collaboration with the patient and their caregivers, and reviewing the patient frequently and providing support to the patient.[8] Other authors suggest additional steps to be considered while deprescribing: selecting the right time to discontinue the medications and discussing the perceived risk and benefits of individual medicine after reviewing the prescription.[7] In selecting the drug to be discontinued first, the medication with high potential risk and most negligible potential benefits should be placed at the top of the list of medicines to be deprescribed.[7]

In India, fragmented care is a rule rather than an exception. Further, the busy clinicians often fail to examine all the ongoing prescriptions, and at times, patients end up getting the same medications from two physicians. Patients usually take over-the-counter medications, receive medicines from other pathies (Homeopathy or Ayurvedic), and take self-prescribed homemade remedies. Accordingly, the principle of prescribing and deprescribing in India should consider all these [Table 1] and [Table 2]. Prescribing among the elderly should not be done casually. Before prescribing, always managing the condition in question with nonpharmacological interventions should be considered as an alternative option. While prescribing, the clinicians should also be aware of the impact of new medication on the medical comorbidities, ongoing patient's patient frailty. The clinicians should also start the new medicines collaborating with the patients and their caregivers. The patients should be closely monitored whenever a new drug is introduced, and any new side effects reported by the patients should be ignored.
Table 1: Principles of prescribing among the elderly

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Table 2: Principles of deprescribing

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The clinicians should follow different tools and frameworks designed to identify inappropriate prescribing while introducing and withdrawing medications among the elderly.[9] Among various available tools and frameworks, Beers criteria are one of the oldest tools which provide a list of potentially inappropriate medications, medications to be used with caution, specific drug–drug interactions, and medications that need to be adjusted with change in the renal functions.[10] Other frameworks include Screening Tool of Older Person's potentially inappropriate Prescriptions,[11] Screening Tool to Alert doctors to the Right Treatment criteria,[12] the Fit fOR The Aged list while prescribing to avoid the use of inappropriate medications.[13]



 
  References Top

1.
Zhang R, Lu Y, Shi L, Zhang S, Chang F. Prevalence and patterns of multimorbidity among the elderly in China: A cross sectional study using national survey data. BMJ Open 2019;9:e024268.  Back to cited text no. 1
    
2.
Gontijo Guerra S, Berbiche D, Vasiliadis HM. Measuring multimorbidity in older adults: Comparing different data sources. BMC Geriatr 2019;19:166.  Back to cited text no. 2
    
3.
Pereira KG, Peres MA, Iop D, Boing AC, Boing AF, Aziz M, et al. Polypharmacy among the elderly: A population-based study. Rev Bras Epidemiol 2017;20:335-44.  Back to cited text no. 3
    
4.
Gómez C, Vega-Quiroga S, Bermejo-Pareja F, Medrano MJ, Louis ED, Benito-León J. Polypharmacy in the elderly: A marker of increased risk of mortality in a population-based prospective study (NEDICES). Gerontology 2015;61:301-9.  Back to cited text no. 4
    
5.
Malhotra S, Karan RS, Pandhi P, Jain S. Drug related medical emergencies in the elderly: Role of adverse drug reactions and non-compliance. Postgrad Med J 2001;77:703-7.  Back to cited text no. 5
    
6.
Scott IA, Hilmer SN, Reeve E, Potter K, Le Couteur D, Rigby D, et al. Reducing inappropriate polypharmacy: The process of deprescribing. JAMA Intern Med 2015;175:827-34.  Back to cited text no. 6
    
7.
Gupta S, Cahill JD. A prescription for “deprescribing” in psychiatry. Psychiatr Serv 2016;67:904-7.  Back to cited text no. 7
    
8.
Woodward MC. Deprescribing: Achieving better health outcomes for older people through reducing medications. J Pharm Pract Res 2003;33:323-8.  Back to cited text no. 8
    
9.
Rochon PA, Petrovic M, Cherubini A, Onder G, O'Mahony D, Sternberg SA, et al. Polypharmacy, inappropriate prescribing, and deprescribing in older people: Through a sex and gender lens. Lancet Healthy Longev 2021;2:e290-300.  Back to cited text no. 9
    
10.
Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine. Arch Intern Med 1991;151:1825-32.  Back to cited text no. 10
    
11.
Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D. STOPP (screening tool of older person's prescriptions) and START (screening tool to alert doctors to right treatment). Consensus validation. Int J Clin Pharmacol Ther 2008;46:72-83.  Back to cited text no. 11
    
12.
Barry PJ, Gallagher P, Ryan C, O'mahony D. START (screening tool to alert doctors to the right treatment) An evidence-based screening tool to detect prescribing omissions in elderly patients. Age Ageing 2007;36:632-8.  Back to cited text no. 12
    
13.
Pazan F, Gercke Y, Weiss C, Wehling M; FORTA Raters. The U.S.-FORTA (Fit fOR the aged) List: Consensus validation of a clinical tool to improve drug therapy in older adults. J Am Med Dir Assoc 2020;21:439.e9-13.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2]



 

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