Among our numerous columns on potentially inappropriate medication use in the elderly, we’ve done a few specifically on deprescribing (see our Patient Safety Tips of the Week for March 4, 2014 “Evidence-Based Prescribing and Deprescribing in the Elderly” and September 30, 2014 “More on Deprescribing”).
We always recommend that you do a “brown bag” medication reconciliation at least annually with all your geriatric patients in which you determine all the medications a patient is taking, including OTC drugs and supplements. The same can be done in a Medication Therapeutic Management (MTM) session with a pharmacist or nurse in other settings. You will always be surprised how many drugs are found to be duplicative or no longer necessary or potentially inappropriate and the opportunity to “deprescribe” presents itself.
But a new study from Australia points out that we often miss another ideal opportunity for deprescribing: the inpatient hospitalization (Hubbard 2015). They looked at patients aged 70 years or older admitted to general medical units of 11 acute care hospitals and, not unexpectedly, found that polypharmacy and hyperpolypharmacy were prevalent. However, significantly, they found that despite identification of multiple medications that might be considered potentially inappropriate almost no changes were made in the number or classification of medications.
Hubbard and colleagues note that the optimal setting for deprescribing is not clear. The inpatient setting typically has time constraints and the inpatient physicians may be much less familiar with the whole clinical picture than the outpatient physicians. Nevertheless, an inpatient hospitalization should be considered an opportunity to consider deprescribing.
In a related commentary several Australian healthcare professionals discuss the importance of better communication channels between all parts of the healthcare system (Mitchell 2015).
While it may be time-intensive, we believe that failure to do a thorough medication review with intent to deprescribe while the patient is an inpatient is, indeed, a missed opportunity. The inpatient physicians can arrange for a time to discuss the medications with the primary care physician. The inpatient hospitalization provides another unique opportunity. We’ve mentioned on numerous occasions that physicians almost never discontinue a medication they have prescribed even if it appears on Beers’ list or the STOPP list or equivalent list of potentially inappropriate medications. But here it is possible to say “things are different now” so we are going to take you off this medication.
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
Hubbard RE, Peel NM, Scott IA, et al. Polypharmacy among inpatients aged 70 years or older in Australia. Med J Aust 2015; 202(7): 373-377
Mitchell C. Polypharmacy a shared duty. MJA InSight 2015; Monday, 20 April, 2015
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