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First do no harm: a real need to deprescribe in older patients

Ian A Scott, Kristen Anderson, Christopher R Freeman and Danielle A Stowasser
Med J Aust 2014; 201 (7): 390-392. || doi: 10.5694/mja14.00146

Summary

  • Inappropriate polypharmacy in older patients imposes a significant burden of decreased physical functioning, increased risk of falls, delirium and other geriatric syndromes, hospital admissions and death.
  • The single most important predictor of inappropriate prescribing and risk of adverse drug events in older patients is the number of prescribed medications.
  • Deprescribing is the process of tapering or stopping drugs, with the goal of minimising polypharmacy and improving outcomes.
  • Barriers to deprescribing include underappreciation of the scale of polypharmacy-related harm by both patients and prescribers; multiple incentives to overprescribe; a narrow focus on lists of potentially inappropriate medications; reluctance of prescribers and patients to discontinue medication for fear of unfavourable sequelae; and uncertainty about effectiveness of strategies to reduce polypharmacy.
  • Ways of countering such barriers comprise reframing the issue to one of highest quality patient-centred care; openly discussing benefit–harm trade-offs with patients and assessing their willingness to consider deprescribing; targeting patients according to highest risk of adverse drug events; targeting drugs more likely to be non-beneficial; accessing field-tested discontinuation regimens for specific drugs; fostering shared education and training in deprescribing among all members of the health care team; and undertaking deprescribing over an extended time frame under the supervision of a single generalist clinician.

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  • Ian A Scott1
  • Kristen Anderson2,3
  • Christopher R Freeman3
  • Danielle A Stowasser4

  • 1 Princess Alexandra Hospital, Brisbane, QLD.
  • 2 Centre of Research Excellence in Quality and Safety in Integrated Primary/Secondary Care, University of Queensland, Brisbane, QLD.
  • 3 CHARMING Institute, Brisbane, QLD.
  • 4 University of Queensland, Brisbane, QLD.


Acknowledgements: 

Ian Scott and Kristen Anderson were assisted in this research by a program grant from the National Health and Medical Research Council (grant 1001157).

Competing interests:

No relevant disclosures.

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