Strategies to reduce and prevent polypharmacy in older patients

The NO TEARS tool¹¹ can be useful for simplifying the medication review process. Components of this tool are:

• Need and indication: Does the patient still require each of his medications? Was long-term treatment anticipated?
• Open questions: Ask the patient for his views about his medications; for example, “Do you think the drugs you take work?”
• Tests and monitoring: Are any of the patient’s conditions undertreated, based on laboratory and clinical findings?
• Evidence and guidelines: Has the base of evidence been updated for each of the patient’s medications since they were started?
• Adverse events: Is the patient experiencing adverse effects of medication? Have possible adverse drug interactions been noted?
• Risk reduction or prevention: Does the patient face risks of treatment (eg, loss of appetite, urinary incontinence) that can be reduced by optimizing the medication plan?
• Simplification and switches: Can treatment be simplified while maintaining effectiveness?

There are strategies to promote patient advocacy, as well. Encourage patients to use a holistic approach by asking you, their other physicians, and their pharmacist about how their condition is being treated:

• What other treatment options exist, including nonpharmacotherapeutic options?
• What are the possible benefits and harms of medical therapy?
• Under what circumstances would discontinuing a medication be appropriate?¹²

CASE

Medication reconciliation identifies > 20 medications that had been prescribed for the patient to take at home (TABLE 1). A clinical pharmacist then performs a home medication review as part of routine patient care upon transition of care into the hospital.

Identifying polypharmacy

Implementing polypharmacy identification tools is a necessary first step in the process of mitigating the risk of multiple concurrent medications (TABLE 2^2,10,12-18). In addition to tools that are used to identify polypharmacy, there are steps that physicians and pharmacists can take to decrease the risk of polypharmacy.

Get patients to collaborate on deprescribing by having them bring all medications to appointments and hospital admissions—the actual supply, not just a list.

For example, in a longitudinal, time-series cohort study measuring polypharmacy events, a pharmacist intervention was used as the means to decrease polypharmacy.¹⁹ Pharmacists intervened twice (each intervention separated by 1 year) to identify and manage 5 categories of high-risk drugs in patients whose care was provided by a managed care plan.¹⁹ During that time, pharmacists provided drug therapy reviews, education to physicians and patients about drug safety, and information for physicians on ways to correct problems with polypharmacy.¹⁹

Continue to: Over the course of the 2 interventions...