If your older adult is taking 5 or more medications, are you sure all of them are still needed? Dr. Leslie Kernisan of Better Health While Aging explains why doctors should regularly review all medications and might want to remove or reduce some medications. Learn more about Dr. Kernisan »
Have you ever wondered whether you – or your older relative – might be taking too many medications?
You’re certainly right to ask yourself this. I consider this for all my own patients, and wish every doctor would.
In part, this is because over the years, I’ve had countless older adults express their worries and frustrations, related to their medications.
These include:
The hassle of having so many pills to take
Worries about side-effects
Frustration with medication costs
Wondering whether a given medication is the “right” one for you, or for your condition
The sneaky feeling that some of those medications don’t seem to help much
The hassle of coordinating a long medication list among multiple doctors
Needless to say, all of this is not so good for quality of life while aging.
And unlike some things that people worry about, these concerns are all actually justified, given what geriatricians know about older adults and medications.
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So if you’ve ever experienced the above worries – or if you (or your older relative) are taking more than five medications – then I want to make sure you know about a process that can improve or resolve all those problems that older adults have with their medications.
It’s called deprescribing, and it’s really essential to optimizing the health of an older person.
In this article, I’ll cover what every older adult and family caregiver should know about it:
What is deprescribing?
Why is deprescribing especially important for older adults?
How does deprescribing work?
What medications are most important for older adults to consider deprescribing?
How can older adults and family caregivers get doctors to address deprescribing?
This way, you’ll have a better shot at what everyone wants when it comes to medication:
To only take medications that are more likely to help than to harm
To be taking the minimum amount of medication necessary, to optimize health and well-being
What is deprescribing?
In literal terms, deprescribing means what it sounds like: it’s the opposite of prescribing.
So instead of adding a medication to someone’s care plan, healthcare providers remove – or reduce the dosage – of one or more medications.
The Canadian Deprescribing Network has an especially nice definition here: “Deprescribing means reducing or stopping medications that may not be beneficial or may be causing harm. The goal of deprescribing is to maintain or improve quality of life.”
Of course, there’s a little more to deprescribing. The truth is that it requires a long-needed shift in mindset and approach to health care, for doctors and patients alike.
That’s because deprescribing comes down to doctors and patients regularly asking themselves:
Is this medication still needed?
Does the likely benefit of this medication outweigh any risks or harms that it might cause?
Could we manage without this drug, or could we make do with a lower dose of it?
You might think this would be the default in healthcare, but unfortunately, it isn’t.
For many reasons – the influence of drug companies, the shortage of time during visits, etc. – it tends to be much easier for doctors to prescribe medication, than it is for them to deprescribe.
And once prescribed, medications tend to just…stay. And be refilled almost indefinitely.
The result of all this is that older adults are often on a lot of medications.
But when we take a close look, many of these can and should be deprescribed.
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Why is deprescribing especially important for older adults?
Deprescribing is especially important to address in older adults because:
1) People tend to be prescribed more medications as they get older.
A 2015 study found that almost 40% of older Americans take five or more prescription medications.
2) Many older adults experience “inappropriate prescribing.”
Studies have found that 20% to 79% of older participants were taking a potentially inappropriate medication. Despite recent efforts to educate doctors about safer medication prescribing in aging, it remains common for seniors to be prescribed medications on the “Beer’s List”, which is a regularly updated American Geriatrics Society list of “Medications that Older Adults Should Avoid or Use with Caution.”
3) Many “potentially inappropriate medications” are bad for the brain, or increase the risk of falls.
Falls and declines in mental abilities are two very common problems that most older adults want to avoid. Yet many of them don’t realize that they are often taking medications associated with increased risk for these problems.
4) Older adults are more vulnerable to side-effects and harm from their medications.
The CDC estimates that every year 177,000 older adults visit the emergency room due to medication problems.
5) Most older people would like to be on fewer medications.
Surveys generally find that older adults don’t like being on many medications.
6) It is often possible – and usually safer – to treat many health conditions with non-pharmacological methods, such as therapy and lifestyle changes.
Geriatricians have long known that many of the prescription drugs seniors take are not strictly necessary. Some are even causing harm to those who take them.
So really, deprescribing means doing what geriatricians are very proactive about doing: eliminating medications that aren’t needed, or are more likely to harm than to help.
Fortunately, since the concept of deprescribing is becoming more common in healthcare, it’s becoming easier for seniors and families to get help with this, even if they can’t see a geriatrician in person.
How does the process of deprescribing work?
Deprescribing requires doctors and other clinicians to follow these basic steps:
1) Create an accurate and up-to-date list of all the drugs a person is currently taking.
The best way to do this is to ask a person to bring in all the medications they are taking, and review the bottles.
Clinicians should avoid relying on the medication list they have in the chart or computer. These lists are often inaccurate or out-of-date, especially if the person has been seeing multiple doctors.
2) Review the reason each medication has been prescribed.
Doctors should consider whether this use of the medication is in line with best practice guidelines, or otherwise is likely to benefit the person, based on good clinical evidence.
Clinicians and patients together should consider whether the medication is providing symptom relief, or otherwise seems likely to be providing a meaningful benefit to the person.
It’s important to consider whether the likely benefit is a good fit for someone’s health situation and values. For instance, if the likely benefit is a 1-in-60 chance of avoiding a heart attack over the next 10 years, this may be more worthwhile to someone in their 60s than to someone in their 90s.
3) Consider whether the medication is likely to be risky, or cause harm to the person.
For older adults, clinicians should pay special attention to medications known to be risky in seniors, such as those on the Beers List of “Medications that Older Adults Should Avoid or Use with Caution.”
4) Consider whether any safer alternatives are available, for a given purpose.
It is often possible to treat a given health concern with non-drug alternatives, or with medications that are less risky for older adults.
5) Discontinue or reduce dosages of medication when possible.
Many medications will require a tapering process, in which the dose is lowered over time.
6) Make a plan to follow-up on the deprescribing plan.
It’s essential to follow-up after medication changes, to check on related symptoms or health conditions.
Deprescribing isn’t something that you can do for yourself or a family member; you should always work with a health professional before stopping or reducing any prescription medications.
However, you can certainly get a head-start on the process by doing a little research and preparation before discussing medications with your health providers. I explain how to do this here: How to Review Medications for Safety & Appropriateness.
Which medications are the most important to consider deprescribing in older adults?
Here are some of the medications that are especially important to assess for deprescribing:
1) Medications associated with falls.
These include sedatives such as benzodiazepines and other sleeping pills, antidepressants, antipsychotics, anticholinergics, blood pressure medications, and also medications that lower blood sugar.
For more on these medications, see 10 Types of Medications to Review if You’re Concerned About Falling.
2) Medications associated with diminished brain function and cognitive impairment.
Most of these, such as sedatives and anticholinergics, are also associated with falls.
For more on these, see 4 Types of Brain-Slowing Medication to Avoid if You’re Worried About Memory.
3) Non-steroidal anti-inflammatory drugs (NSAIDs).
These are painkillers in the same class as ibuprofen. They are easily available over-the-counter, but are also prescribed by doctors.
They are usually used to treat arthritis or other conditions related to pain and inflammation.
In older adults, chronic use of NSAIDs can provoke internal bleeding, decreased kidney function, water retention, and other problems.
For more on the risks of NSAIDs and finding better alternatives, see How to Choose the Safest Over-the-Counter Painkiller for Older Adults.
4) Medications that lower blood sugar (for people with diabetes).
Most people with diabetes take medication to keep their blood sugar from getting too high.
It’s important to be careful that such medications don’t overtreat the person and cause too much low blood sugar.
Low blood sugar (known as hypoglycemia) can provoke a fall or otherwise leave a senior feeling weak and unwell. Frequent episodes of hypoglycemia have also been associated with developing dementia and with higher mortality.
Many experts, such as the authors of this 2016 review, recommend “moderate” blood sugar control for older adults, which means aiming for a middle ground in which blood sugar is kept not too high but also not too low.
5) Proton-pump inhibitors (PPIs).
This is a class of anti-acid drugs; they have been widely prescribed to treat gastroesophageal reflux disease, which can cause pain in the stomach area.
They are also used to reduce stomach acid to treat other health problems.
Research suggests that long-term use (e.g. more than 8 weeks) may be linked to an increased risk of problems such as bowel infection, hip fracture, malabsorption of key vitamins, and other problems.
Commonly used PPIs include omeprazole, esomeprazole, lansoprazole, and pantoprazole (US brand names Prilosec, Nexium, Prevacid, and Protonix, respectively).
For more on these, see You May Be At Risk: You are currently taking a proton-pump inhibitor (PPI)
6) Medications used in Alzheimer’s and other dementias to manage difficult behaviors.
Antipsychotics and sedatives are often used in people with Alzheimer’s and other dementias, to try to control difficult behaviors.
But these medications are often prescribed before safer alternatives have been tried, and families are not always aware of the risks.
For more on this, see 5 Types of Medication Used to Treat Difficult Dementia Behaviors.
7) Opioids and other medications prescribed for pain.
Pain is common in older adults, so many are taking opioids or other prescription painkillers.
Although prescription medication for pain is often needed and appropriate, it’s essential to regularly review the use of these medications.
Per this review, it is not yet clear if overdose and misuse are as big a problem among older adults as they are in the general population.
All of these medications are frequently prescribed to older adults. Most of them are commonly – although not always – reduced or discontinued by geriatricians and others who are particularly knowledgeable about medications in older adults.
If you or your older relative are taking any of these medications, remember that this is not necessarily inappropriate. In some situations, there’s no good alternative available to continuing with the medication.
Sometimes after a careful review of the situation and alternative options, we do conclude that the likely benefits of continuing a “risky” medication do outweigh the risks.
What’s most important is that seniors and their doctors regularly discuss any associated risks and available alternatives. This is how you can ensure that you are only taking medication that is truly needed, or otherwise is more likely to help than to harm.
How can older adults and family caregivers get doctors to address deprescribing?
The most important thing to do is to regularly ask your doctors to review your medications with you, and ask for help with deprescribing.
Fortunately, several excellent resources online can make deprescribing easier for you, and for your doctors.
The Canadian Deprescribing Network, in particular, has some of my favorite resources. They include informative brochures to help older adults request deprescribing for several types of risky drugs.
These brochures have been proven, in randomized control trials, to help seniors stop certain medications.
What I especially like about them is that they often include a sample schedule of how the medication can be safely reduced.
Available brochures cover:
Anti-inflammatory medications like ibuprofen – non-steroidal anti-inflammatory drugs or NSAIDs)
Antipsychotic medication – as sleeping pills or for dementia
Medications for allergies and itchiness – first-generation antihistamines
Medication for type-2 diabetes – sulfonylurea diabetes medication
Sleeping pills & anti-anxiety medication – sedative-hypnotic medication, such as Ativan, Ambien, and others
Stomach pills for acid reflux – proton-pump inhibitors
I especially like the suggested questions you can ask, which include:
Why am I taking this medication?
What are the potential benefits, and potential harmful effects?
Can it affect my memory?
Can it cause me to fall?
Can I stop one of my pills? Do I need to reduce the medication slowly?
Who do I follow-up with and when?
Deprescribing algorithms, and other useful resources for healthcare providers:
These provide step-by-step guidance to doctors and other clinicians, which makes it much easier for them to work with you in reassessing the use of risky medications.
Find these here: Tools for Your Doctor, Pharmacist, or Nurse
Remember, it will really help if you can regularly remind your doctors that your goal is to be on the minimum number of medications necessary.
To do this, you and your doctors will have to work together to regularly reassess every medication you are taking.
Again, healthcare providers are supposed to be regularly reassessing all your medications, but they are often too busy to do so unless you remind them.
So if you want to be proactive about maintaining health and well-being in aging, learn more about your medications. And then talk to your doctors about deprescribing!
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Guest contributor: Leslie Kernisan, MD, is a practicing board-certified geriatrician, a Clinical Instructor in the UCSF Division of Geriatrics, and the founder of the popular aging health website Better Health While Aging. She believes that it shouldn’t be so hard for older adults and families to get the right kind of help with health concerns. She is the author of the book “When Your Aging Parent Needs Help,” has been featured in The New York Times and Next Avenue, and provides guidance to families through her Helping Older Parents online courses and programs.
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