One of the present author’s father-in-law, Arthur Reinhard, was an excellent caregiver for his wife, Peggy. While he had no formal training in health care, he always had a keen eye for details and adeptly managed his wife’s many medications. One day, Arthur sat down and started reading through the side effects of Peggy’s medications. This generated a long list of concerns and questions that he took to Peggy’s next provider visit. At Arthur’s urging, the provider initiated a plan, which, eventually, reduced Peggy’s number of prescriptions from 12 to five and dramatically improved her overall health and wellness.
For years, providers and government officials have viewed deprescribing as a part of good prescribing practice and supported the development of tools and interventions to help older adults like my in-laws evaluate their medications and begin the deprescribing process—that is, reducing or eliminating certain drugs that may be causing harm.
Yet despite these efforts and the potential for deprescribing to reduce risks associated with polypharmacy, older adults continue to have high levels of medication burden. Adults ages 65 and older take, on average, 4.6 medications per month. Additionally, polypharmacy rates among older adults remain high with close to one-fifth (18 percent) taking 10 or more drugs per month.
So, what evidence – information and support to motivate action – would help compel more consumers to engage in efforts to develop and maintain an appropriate medication regime? Consider two steps of the deprescribing process.
Step One: Initiating the Process
Too many consumers come to the deprescribing process out of necessity: After some precipitating event such as a fall resulting from a drug-related reaction, a consumer meets with their primary provider to examine their full set of prescriptions and remove any potentially inappropriate medications causing harm. For older adults, these precipitating events are all too common. Adults ages 65 and older made 35 million emergency room visits in the past decade for adverse drug events (ADE), had more than 200,000 annual hospitalizations due to ADEs, and were 50 percent more likely to fall when taking 10 or more drugs. In these situations, consumers are understandably more motivated to engage in deprescribing efforts.
For consumers who aren’t emerging from a major event, however, the evidence may be less clear. Successful deprescribing in the course of routine care may depend on strengthening and elevating the information that is available to consumers. Age-Friendly Health Systems have done this by building deprescribing into a system’s core practices and processes. Before making any prescription decision, staff evaluate a prospective drug alongside a consumer’s other medications and, as part of that process, have conversations with consumers and their caregivers about the value of deprescribing. Providers could also leverage the strong trust that consumers have in them. A 2018 study showed that 92 percent of older adult respondents were willing to stop taking one or more prescriptions upon the advice of their provider. Regular evaluation of a consumer’s medication and repeated communication about the risks and benefits of each prescription can help normalize deprescribing.
Step Two: Managing Change
Deprescribing isn’t a single activity but a process. It typically requires slow changes over a period of time and continual monitoring to ensure that the new medication regime is effective. However, the evidence that compels consumers to initiate the deprescribing process may be different than what spurs them to maintain and complete it. Providers and officials should attend to the evidence most applicable to enabling behavior change, including:
- Shared decision making: Research shows improved outcomes when consumers and their loved ones play an active role in the deprescribing process. Open and regular communication can help consumers navigate their options, allow providers to tailor describing protocols, and enable consumers to become invested in their care.
- Engagement of family caregivers: More than 80 percent of family caregivers report managing their loved one’s medications. Developing materials and dedicating time to train caregivers about the deprescribing protocol can help build confidence and alleviate fear of making a mistake.
- Addressing other factors impacting a consumer’s medication regime: Deprescribing is contextual and should account for the unique circumstances of the consumer. These may include particular clinical, psychological, social, financial, and physical determinants – all of which could impact the ability of a consumer to engage in deprescribing efforts successfully.
- Personalizing the impact of change: Tailored messages about the out-of-pocket savings and changes in health a consumer can expect to see as a result of deprescribing can reinforce the importance of continuing the process.
- Provider follow-up: Hearing from a trusted source throughout and after the deprescribing process can help ensure adherence to the new medication regime. It can also help identify quickly the introduction of new medications and coordinate communication among providers.
Building up the Evidence Base
Evidence that enables more consumers to undertake and adhere to efforts to deprescribe is only one part of the overall deprescribing process. We recognize that effective deprescribing depends on the coordinated efforts of providers, policymakers, and consumers to break down barriers (e.g., appropriate reimbursement). This is especially true when considering how to improve the deprescribing process for certain populations with limited access to providers. Yet, the consumer role remains an important part of the process, and one with potential still not fully tapped. And perhaps renewed attention to developing the necessary evidence can enable consumers to deprescribe and achieve better health—just as Peggy ultimately did.