Deprescribing in Older Adults in PACE

Background

In recent years, there has been an increased focus on deprescribing in the Programs of All-Inclusive Care for the Elderly (PACE) practice setting. Per the PACE manual provided by the Centers for Medication and Medicaid Services (CMS) services for participants should include initial and periodic assessments which include the reviews of medication use, the participant’s preference for their care as well as their current health status and treatment needs. As more programs incorporate clinical pharmacists into their interdisciplinary care teams (IDTs), deprescribing has become a topic of conversation.

The Risks of Polypharmacy

In order to discuss deprescribing, it is important to first discuss polypharmacy. Polypharmacy has different definitions, but overall it is generally agreed that polypharmacy is the regular use of 5 or more medications. Hyperpolypharmacy is the regular use of 10 or more medications. In the last 20 years in the United States, the proportion of older adults prescribed multiple medications has increased by more than 300%.

In a study conducted by Kim, et al. in 2024, it was found that about 37% of the general population is taking 5 or more medications. In those 65 and older, that number increases to 45%. When factoring in frailty, the prevalence of polypharmacy increased further to 59%. In a previous study, 9.1-23.2% of patients 65 or older were taking 10 or more medications.

Polypharmacy may lead to unnecessary drug use, drug contraindications, and inappropriate drug use. It has been associated with a higher fall risk, declining of functional and cognitive status, as well as an increase in all-cause mortality. Due to the use of multiple medications, older adults may be especially susceptible to adverse drug events, hospitalizations, increased length of stay, falls, and cognitive and functional decline. The combination of these risks influences the overall socioeconomic burden.

Drivers of polypharmacy include a culture of prescribing, for example the phrase “a pill for every ill”. In some cases, there are gaps in time, knowledge, and education of both providers and patients. Sometimes patients are kept on medications for longer than needed, taking the “don’t rock the boat” approach, also known as therapeutic inertia. A lot of patients, especially older adults, are seeing multiple specialists which means multiple medications from multiple sources.

What is Deprescribing

In general, the definition of deprescribing is a supervised stopping or decreasing medication doses to the minimum effective dose, especially when the risks outweigh the benefits. Deprescribing is essentially a strategy used to reduce the use of inappropriate or unnecessary medications in an effort to decrease polypharmacy.

One of the most important aspects of deprescribing is that it engages the patient and their caregiver to participate in shared decision making and centers on person-focused care. In every assessment of the patient, what their goals of care are and what they want from their therapy should be considered. Goals of care may change with age, where more focus may be put on comfort and maximizing the quality of life. In addition, previous goals of care may cause more harm than good. For example, older adults may be at higher risk of developing hypoglycemia and therefore tight blood glucose control (e.g. Hgba1c <7%) may increase their risk of side effects from medications.

As patients get older, it is important to discuss several things with them in regard to their medications. First, older bodies respond and process medications differently. This means that medications that were prescribed when the patient was younger may not be working as well, or they may be at higher risk of causing side effects than when they were younger. In addition, there are weaker data for medication effectiveness in older adults, especially those who are frailer with multiple comorbidities. Often, guidelines and clinical studies are designed with exclusion criteria that limit the number of older adults in a study and this under representation may lead to a lack of overall evidence. Often these studies do not take into account the pharmacokinetic and pharmacodynamic changes with age. As patients get older and they have more specialists prescribing medications, they may be experiencing additive side effects from polypharmacy. Finally, the patient’s goals of care may change as they age and are potentially approaching the end of life.

Strategies for Deprescribing

Deprescribing should be performed individually based on the patient’s medical conditions, current medication regimen, prognosis, and goals of care. A general overall process involves identifying potentially inappropriate medications, determine if there are medications that can be discontinued or the dose reduced, a plan for tapering, and documentation of the outcomes.

To start, the patient should be assessed for medication problems. This may include looking at one specific side effect across multiple medications, such as looking at the overall risk of anticholinergic side effects which may increase the risk of falls and cognitive impairment. Routinely assessing if a patient’s problem may be caused by a medication to avoid further medications. Another strategy includes looking for “legacy” medications, or medications started that were meant to be of a shorter duration like proton-pump inhibitors or benzodiazepines.

As mentioned before, it is important to involve the patient and caregiver in the decision making. Therefore, it may be more appropriate to try a “drug holiday” or trial discontinuation before stopping completely. It is also important that if a medication is discontinued or the dose is lowered that the patient and caregiver be informed to look out not only for improvement of side effects, but any worsening of the condition for which the medication was being used to treat.

Addressing Barriers to Deprescribing

Several barriers exist to deprescribing from multiple perspectives. From the patient and caregiver perspective, they may have a fear of stopping a medication, or they may have a belief that the medication will continue to provide a benefit. Patients may also be experiencing a poor coordination of care amongst their multiple healthcare providers which may include poor communication. A healthcare provider may have limited time and workflow resources to implement deprescribing practices. Due to limited guidance and resources related to deprescribing, they may be uncertain of the effects around deprescribing. In addition, due to a fragmented and siloed healthcare system, they may be hesitant to stop a medication that was started by a different provider. Finally, they may also have a fear of the patient’s reaction. In the overall health system, there is a culture of prescribing with a lack of reimbursement structure to support deprescribing.

With so many barriers, what can be done to help facilitate deprescribing, especially in the PACE setting? First, leveraging the support of a clinical pharmacist as part of the IDT team can help with addressing time constraints, gaps in knowledge, and patient communication. The GalenusCare solution involves the use of Precision Pharmacists utilizing a unique and proprietary medication safety analysis tool that helps to target the highest risk medications. Interventions made by the GalenusCare team are backed by science and evidence that can help to provide educational resources to patients and providers on changes recommended. These recommendations can help guide conversations to involve the patient and their caregivers in the decision-making process.

As science advances and experience continues, GalenusCare will be able to track critical outcomes such as the reductions in falls, hospitalizations, and overall medical costs associated with deprescribing. This information will add to the growing data surrounding deprescribing in an effort to enhance outcomes and improve patients’ quality of care.

If you are interested in learning more about the GalenusCare solution, please use our contact form to set up a meeting.

References:

• Centers for Medication & Medicaid Services. Programs of All-Inclusive Care for the Elderly (PACE) Manual. Publication #100-11. Available from: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019036
• Kim, S, Lee, H, Park, J, et al. Global and regional prevalence of polypharmacy and related factors, 1997-2022: an umbrella review. Arch Gerontol Geriatr. 124;105465
• Thompson, W, McDonald, EG. Polypharmacy and deprescribing in older adults. Ann Rev Med. 75:113-27.
• Farrell, B, Mangin, D. Deprescribing is an essential part of good prescribing. Am Fam Physician. 99:7-9.