Maintaining Participant Independence through Consolidation of Therapy

February is National Senior Independence Month, and with the goal of PACE to maintain care at home, it is a good opportunity to discuss one strategy for maintaining independence: consolidation of therapy.

Oftentimes, polypharmacy leads to increased burden of side effects. Of particular concern are medications which add to the risk of sedation and falls as well as those that may negatively impact cognitive ability.

One way to help to mitigate these risks is to identify and recommend opportunities to consolidate therapy. Using one medication to treat multiple conditions helps to reduce exposure to medications and helps to improve participant satisfaction by having less pills to take every day.

To demonstrate how consolidation of therapy can be used to help reduce these risks, let’s look at Stella, an 88-year-old PACE participant. Stella is being treated for chronic neuropathic pain, depression, and anxiety. At the time of her initial review she was taking escitalopram 20 mg daily, gabapentin 300 mg three times daily, and buspirone 15 mg twice daily. Upon review of her medications, I identified risks of sedation and falls as well as some potential opportunity to consolidate her therapy.

Treatment of Anxiety & Depression

As noted, Stella was prescribed escitalopram 20 mg daily as well as buspirone 15 mg for her depression and anxiety. In a previous blog post, I reviewed the risks associated with high doses of escitalopram. Due to the risk of dose accumulation which may be increasing the risk of falls and sedation, I decided it was best to address escitalopram first.

When looking at Stella as a whole-person, a couple factors lead me to recommend that an alternative to escitalopram was preferable to a dose reduction. First, she was co-prescribed buspirone which indicated to me that on a high-dose of escitalopram, her anxiety was unable to be controlled with one medication. Second, she was concomitantly being treated for neuropathy.

At lower doses, escitalopram is a reasonable option for treatment of anxiety and depression. However, given Stella’s current dose and her concomitant conditions, a better option may be available. Specifically, I recommended replacing escitalopram with duloxetine for treatment of anxiety and depression. Duloxetine is indicated for the use of depression and anxiety and utilizes a different mechanism of action than both escitalopram and buspirone. Therefore, duloxetine may be more successful as a single agent. In addition, duloxetine is approved for the treatment of neuropathy. Therefore, the use of duloxetine may benefit Stella from multiple perspectives.

Pain Management

Stella was using gabapentin throughout the day for management of her neuropathic pain. As a pharmacist specializing in older adults, gabapentin is often a “red flag” medication. Gabapentin is associated with a high risk of sedative side effects, hypotension, and falls. In addition, I often speak with participants who believe they are experiencing symptoms of dementia while taking gabapentin. If a participant is on gabapentin and tells me that they are having trouble remembering words in conversations, my inclination is often to target gabapentin for deprescribing.

For older adults, it is often these memory lapses that are most concerning for maintaining their independence. They think they are experiencing cognitive decline, when in actuality it could just be a side effect of a medication. Due to these risks, using an alternative for gabapentin, such as duloxetine, to treat neuropathic pain can help to reduce the risk of side effects in the future. By replacing escitalopram with duloxetine, it may help Stella to no longer need to take gabapentin in the future. 

Consolidation of Therapy

When discussing consolidating therapy, it is important to note that not everything should change at once. In the case of Stella, I recommended doing a cross taper of escitalopram and duloxetine, meaning that duloxetine should be started at a low dose while the dose of escitalopram is lowered. This can help to avoid withdrawal symptoms and unnecessary anxiety for the participant.

When determining the maintenance dose of duloxetine, it is important to keep in mind the participant’s kidney function. Older adults tend to respond to lower doses due to reduced kidney function. Once a maintenance dose of duloxetine is achieved, backing off the dose of gabapentin may be appropriate.

In general, gabapentin should be tapered when being deprescribed, and it is important to maintain a balance between treating the participant’s pain and reducing the risk of side effects. When reducing the dose of gabapentin, I typically target the daytime doses first. The fewer times gabapentin is taken during the day, the lower the risk of daytime sedation and falls.

In addition, Stella may notice improvements in her memory and cognitive function as the dose of gabapentin is lowered. When recommending this consolidation, I advise to lower the dose of gabapentin until it can be discontinued or until the participant is on the lowest effective dose.

While gabapentin is being tapered, I recommended to check in with Stella's anxiety to determine if buspirone is still providing a benefit. If duloxetine is more effective at treating anxiety, Stella may be able to also use a lower dose or stop using buspirone altogether. Utilizing fewer medications, Stella is at a lower risk of sedative side effects and may notice improvement in her cognition. These factors can help to make Stella more comfortable and confident maintaining her independence at home.

Summary

When helping PACE participants maintain their independence, it is important to consider the whole person and not just one medication or one condition in isolation. Using my clinical expertise as a Precision Pharmacist and AI-enabled risk analytics, I was able to make recommendations to streamline Stella’s therapy and to help her feel more confident that her medication regimen works well for her.