Which drugs to stop in which older patients?
Tischa van der Cammen is a Consultant Geriatrician and Carolyn Sterkeis a public health researcher. Both are based at the Erasmus University Medical Center in Rotterdam, Netherlands and have recently published a paper in Age and Ageing journal.
Drug treatment has brought many benefits for older patients. For example, the treatment of hypertension in patients aged over 80 led to a major reduction in stroke and mortality, as was shown in the HYVET study.
As people age, diseases may accumulate, and hence older patients usually are prescribed several drugs at the same time. It is ‘rule rather than exception’ that patients above age 75 use 4 or more drugs, this is called polypharmacy. There are a variety of definitions for polypharmacy – in the UK it is generally 4 or more prescribed medicines - as specified by Department of health and Rollason.
Inappropriate poly-pharmacy in older patients may lead to negative health impacts in the form of increased side-effects and drug-drug interactions, and can be a contributing factor towards falls or cognitive decline. This has been highlighted in recent Cochrane and King’s Fund publications, these studies can be found in the BJCP and ACCP and in this BBC report.
General opinion is growing that reducing or stopping drugs in complex older patients is justified in certain situations, where drug cessation rather than prescribing might be beneficial. From a clinical viewpoint, drug cessation seems most justified in four situations, i.e., falls, delirium, cognitive impairment, and end-of-life situations.
Stopping drugs in older fallers was the area most well studied. There is evidence that withdrawal of psychotropics is effective in reducing the rate of falls, and that a regular ‘medication review’ by general practitioners reduced risk of falling.
Studies on drugs cessation in delirium were lacking, however withdrawal of psychotropics and a systematic reduction of polypharmacy resulted in an improvement of cognition.
Very little rigorous research has been conducted on reducing inappropriate medications in patients approaching the end of life. At the end of life, careful assessment of medication is recommended in order to avoid inappropriate treatment and potentially serious adverse drug reactions and events.
In summary, available studies seem to suggest a beneficial impact of cessation of psychotropic drugs on falls and cognitive status. There is a clear need for more work on poly-pharmacy and benefits of medication discontinuation in older patients.
The latest BGS Newsletter also features the topic of polypharmacy: ''Policy, medical training and clinical practice must adapt to the significant increase in patients taking multiple prescription drugs''. Read the full article here.
What is meant by psychotropics?
A psychotropic is a chemical substance that crosses the blood–brain barrier and acts primarily upon the central nervous system where it affects brain function, resulting in alterations in perception, mood, consciousness, cognition, and behaviour. The following drug classes belong to the psychotropics: antipsychotics, benzodiazepines (anxiolytics, hypnotics and sedatives) and antidepressants.