More is less and less is more? Breaking the cycle of polypharmacy with deprescribing
Dr Henry J. Woodford is Chair of the BGS Medicine Optimisation SIG and works as a consultant geriatrician for Northumbria Healthcare in northeast England. He originally trained at King's College London. His role at work includes acute frailty assessment and care on a delirium unit. He tweets @woodford_henry
Long-term conditions are diseases that cannot be cured, just controlled with medications. Over our lifetime we accumulate diagnoses, such that many people experience old age as a state of multimorbidity. Each new diagnosis brings with it one or more drugs that can be used to prevent progression or manage symptoms, often linked to a clinical guideline. Multimorbidity thus breeds polypharmacy. In addition, polypharmacy promotes further prescribing. This can be the addition of drugs explicitly to manage side effects (e.g. laxatives and opiates) or when side effects are wrongly interpreted as new conditions through prescription cascades (e.g. furosemide and amlodipine). Multimorbidity, and thus polypharmacy, is linked to frailty. Those with the narrowest shoulders bear the greatest therapeutic burden.
Sometimes the balance between risks and benefits becomes lost and people are exposed to harm. Does adding that eleventh tablet have the same beneficial effect, similar to the other ten, when compared to trials recruiting an idealised, non-frail trial population? Older people are at an increased risk of disease and death. Frailty is a state of increased vulnerability to external stressors. Logic would suggest that this group stand to gain the most from medications. Yet through physiological changes, multiple morbidities and competing causes of death, each medication has only a smaller beneficial effect in this group. Along with this, frail older people are also more susceptible to adverse drug reactions (ADR). This is the drug-ageing paradox – the group who take the most tablets get the least net gain from them.
Polypharmacy is associated with many negative outcomes, which might be explained by the link between having more illnesses and worse prognosis, rather than the effect of medications per se. However, taking multiple drugs does increase the risk of ADR, drug-drug interactions, drug-disease interactions and overall therapeutic burden. Around 10% of hospital admissions are estimated to be directly due to ADR in older people. A greater percentage may be more loosely linked because ADR are not always easy to detect. Just like illnesses, they tend to present atypically in frail older people, for example by provoking immobility, falls or delirium.
So, what becomes of all of these medications when the patient leaves the dispensary or hospital ward? Are they all consumed as prescribed? No, this is true probably less than half of the time on average. We hand our patients a bewildering array of packages with unpronounceable names, or wrap drugs up in a multi-dose dispenser that adds an extra layer of removal from the decision making process. These latter devices may even be mandated by a home care provider even if just for a single tablet. Sometimes they require multiple dispensing trays when combinations cannot be placed together or won’t fit in the provided compartment space, not to mention the effects of liquids, inhaled or non-oral route of administration. Then we ask our patients “why do you take all of these tablets?” and are answered with learned helplessness - “I just take what they give me”. Many people have become disconnected from their treatments and their personal goals have been lost along the way.
Fortunately, polypharmacy can be addressed through deprescribing, which is a term for the discontinuation of medications in a systematic and considered manner. Currently there are few randomised controlled trial data to support its efficacy but this has to be offset against the near complete lack of evidence that continuing medications in people with advanced frailty is beneficial. The evidence base is beginning to emerge in the absence of ‘big pharma’ money to speed it along. To date, no major benefits have been shown regarding reducing mortality or hospital admissions, but if outcomes remain the same whether you take the pill or not then this demonstrates the futility of continuation and an unnecessary therapeutic burden. In addition, some studies suggest that quality of life may be improved. In the future, long term studies will be needed to evaluate slowly emerging adverse effects such as cognitive decline suspected to be caused by anticholinergic drugs. Also longer studies will help to show that most deprescribed medications do not later need to be restarted.
Given the uncertainty of many interventions in frail older people, including deprescribing, it is helpful to adopt a shared decision making approach that respects individual priorities and goals. Personalising care this way takes time and skill. This cannot be replaced a simple list of explicit prescribing criteria or potentially inappropriate medications in isolation. Deprescribing is often not the path of least resistance. It requires a thoughtful explanation to patients and carers. There needs to be some acceptance of the risk of withdrawal effects and disease or symptom recurrence, which necessitates monitoring and follow up. It can be aided by the use of multidisciplinary teams that include pharmacists and nurse specialists. Deprescribing is not about restricting the access of some people to healthcare but instead an acceptance of the limitations of medicines in some situations. Prescribing fewer drugs is not the same as offering less care.