Sometimes a patient who takes multiple medications a day wants to reduce that load, but is unsure about which drug can be stopped safely. A pharmacist may want to discuss deprescribing options with patients who are experiencing polypharmacy, but feels unsure about how to start that conversation.
Fortunately, there are ways to demystify these and other deprescribing challenges, an expert noted during the ACCP 2024 Annual Meeting, in Phoenix.
“As patients age, their functional status changes and what matters to them changes,” said Jennifer Pruskowski, PharmD, BCGP, BCPS, the director of geriatric pharmacy research and education at the University of Pittsburgh School of Medicine. “We don’t do a great job of readjusting medications based off those changes.”
Health-system leaders may be interested in deprescribing to save on drug purchasing costs, while a patient may like to reduce out-of-pocket costs in addition to managing adverse effects from multiple medications, noted Dr. Pruskowski, who is also the associate director of education and evaluation at the VA Pittsburgh Geriatric Research Education and Clinical Center. However, simply declaring which drugs should be eliminated, without any conversation, will not inspire trust, she stressed. During the ACCP session, Dr. Pruskowski presented the FRAME map, a method for having successful deprescribing conversations (J Palliat Med 2019;22[3]:335-336).
“The goal is to allow the clinician to have a focused yet flexible conversation with the patient about deprescribing options,” Dr. Pruskowski said, adding that many pharmacists become more primed to have these discussions after a firsthand experience of watching an older patient endure adverse effects from a slew of medications. Once those potential harms of polypharmacy sink in, “they become much more interested in deprescribing,” she said.
That newfound interest in deprescribing should not inspire a rapid stop in every drug a patient takes, or drastic dose reductions across the board. At the ACCP session, Dr. Pruskowski spoke about the value of prudence and monitoring when deprescribing, and of giving patients final decision-making authority over changes to their medications.
“Don’t make more than one or two drug changes at a time; don’t try to take on everything in one shot,” Dr. Pruskowski said, noting that a similar principle applies to performing multiple procedures or imaging scans at the same time. “A lot of things all at once tends not to be good.”
Getting to Know Them
Dr. Pruskowski said she spends the first few appointments with a new patient getting to know them and gaining their trust before launching into discussions about deprescribing options. The trust-building step is an essential element of making the FRAME conversational method a success, she noted.
Although Dr. Pruskowski has honed her skills in deprescribing conversations, she knows that some colleagues are hesitant to discuss the topic. “The goal is to give people at any point in their deprescribing career some quick and easy-to-implement pearls and skills,” she said, so that they are more confident about their abilities to do this.
Owning the Conversation
Kristin Meyer, PharmD, BCGP, FASCP, a professor of pharmacy practice at Drake University College of Pharmacy and Health Sciences, in Des Moines, Iowa, underscored the importance of addressing polypharmacy in older patients—but with an eye toward finding common ground.
“To be successful, it really comes down to finding a shared motivation or goal,” said Dr. Meyer, who was not part of the ACCP session. For example, when she can link a particular medication to a specific complaint that a patient has, that increases the chance the patient will choose to deprescribe. Or when she can show health-system leaders that inappropriate medications boost rehospitalization rates, this also boosts deprescribing adoption.
One cause of excessive medication, in Dr. Meyer’s view, is a profusion of guidelines about treating different ailments. She cited, as an example, someone who has diabetes, hypertension and hyperlipidemia.
“Guideline-directed medical therapy necessitates polypharmacy,” said Dr. Meyer, who added that it is not uncommon for her to work with people who take 20 medications a day. In the elderly population, this is particularly concerning, Dr. Meyer added, because they are more likely to have adverse events due to age-related renal and liver clearance issues.
Pharmacists are the experts in medication regimens on any healthcare team, Dr. Meyer said, and should not be afraid to own that expertise in interdisciplinary meetings. “Stay in your lane but work with others,” she said, adding that it also is important to choose deprescribing targets wisely. “A pharmacist should make deprescribing recommendations to physicians based on patient impact—for example, a patient who slept through lunch—rather than referring to lists of dangerous medications,” she said.
“Nobody wants to hear about the Beers Criteria”—a list of potentially inappropriate medications for older patients that the American Geriatrics Society updates every three years (bit.ly/3XO6Lbg)—“but everyone wants to do what’s right for the patient,” Dr. Meyer said.
Dr. Meyer reported no relevant financial disclosures. Dr. Pruskowski reported that she is a federal employee, and her views do not reflect those of the U.S. government.
This article is from the November 2024 print issue.