We’ve done numerous columns on the use of potentially inappropriate medications (PIM’s) in the elderly and the value of deprescribing (see list at the end of today’s column). Two populations particularly vulnerable to PIM’s are: (1) nursing home residents and (2) patients with dementia. Two recent studies examined PIM’s in these populations.
Dutch researchers looked at the impact of deprescribing in a nursing home population in a randomized trial (Wouters 2017). Potentially inappropriate medications (PIM’s) were identified using several tools we’ve often discussed: START (Screening Tool to Alert Doctors to Right Treatment), STOPP (Screening Tool of Older Persons' Potentially Inappropriate Prescriptions), and the Beers criteria.
Patients were assigned to intervention with their Multidisciplinary Multistep Medication Review (3MR) or to usual care. Components of the 3MR are:
More patients discontinued use of at least 1 PIM in the intervention group than the control group (39.1% vs. 29.5%) and clinical outcomes did not deteriorate between baseline and follow-up.
Another European study (Renom-Guiteras 2017) found that 60% of the patients with dementia had at least one PIM prescription and 26.4% at least two. The PIM therapeutic subgroups most frequently prescribed were psycholeptics (26% of all PIM prescriptions) and ‘drugs for acid-related disorders’ (21%). Prescription of two or more PIM’s was associated with higher chance of suffering from at least one fall-related injury and at least one episode of hospitalization in the time between baseline and follow-up. Risk factors for being prescribed two or more PIM’s were: age 80 years and older, living in institutional long-term care settings, having more comorbidities, and having more functional impairment.
Douglas Paauw, MD (Paauw 2017) recently discussed “11 Drugs You Should Seriously Consider Deprescribing”:
Paauw also co-authored a recent study on polypharmacy in primary care, focusing on medication side effects and drug interactions (Merel 2017). They discussed important side effects of several medications commonly prescribed in older adults (statins, proton pump inhibitors, trimethoprim-sulfamethoxazole and fluoroquinolone antibiotics, zolpidem, nonsteroidal antiinflammatory drugs, selective serotonin reuptake inhibitors, dipeptidyl peptidase 4 inhibitors). They also discussed important drug interactions with four agents or classes (statins, warfarin, factor Xa inhibitors, and calcium channel blockers).
These articles are important practical contributions to our understanding of polypharmacy and our potential to reduce use of PIM’s. Deprescribing, when done properly, can be a very valuable intervention to improve the lives of our elderly patients. We hope you’ll go back and review some of our previous articles on deprescribing.
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
Some of our past columns on deprescribing:
Wouters H, Scheper J, Koning H, et al. Discontinuing Inappropriate Medication Use in Nursing Home Residents: A Cluster Randomized Controlled Trial. Ann Intern Med 2017; published online October 10, 2017
Renom-Guiteras A, Thürmann PA, Miralles TR, et al.Potentially inappropriate medication among people with dementia in eight European countries. Age and Ageing 2017; Published online 01 September 2017
Paauw DS. 11 Drugs You Should Seriously Consider Deprescribing. Medscape 2017; September 5, 2017
Merel SE, Paauw DS. Common Drug Side Effects and Drug-Drug Interactions in Elderly Adults in Primary Care. J Am Geriatr Soc 2017; 65(7): 1578-1585