or stopping of medications that are not indicated or are causing real or potential harm’.55 Systematic deprescribing has been associated with reduced falls, improved cognitive and psychomotor function, reduced mortality, and reduced healthcare utilization (ED visits and readmissions), all without an increased risk of adverse outcomes.40,55‐60
Caution must be taken regarding unnecessarily treating conditions that are non‐problematic or largely asymptomatic, have an unlikely progression, or have a low chance to cause concerning symptoms. This is especially true in geriatrics, and some studies that have looked into ways of deprescribing have introduced the idea of ‘un‐diagnosing’ ailments in order to prescribe less. The mnemonic ERASE (Evaluate diagnoses through the consideration of Resolved conditions, Ageing normally, and Selecting appropriate targets to Eliminate unnecessary diagnoses and associated medicines) can be used to prioritize and resolve clinical problem lists.61 On the other hand, underprescribing, or the omission of prescribing potentially beneficial medications, is a hallmark of ageism and another problematic issue. Using the START criteria and applying other mnemonics (Table 10.4) can help avoid unnecessary medications and prescribing inertia.
Table 10.4 Mnemonics for medication management.
| Mnemonic | What each letter stands for | Description and use |
|---|---|---|
| SAIL/TIDE | SAIL: Keep meds as Simple as possible, remember Adverse effects, identify the Indication for each medication, List each drug and dose TIDE: Schedule Time during each visit to discuss medications, have awareness of Individual response to medications, avoid potential Drug/drug/disease interactions, Educate the patient | Useful for creating a standard approach to medication management and for teaching learners on the principles of medication management |
| AVOID TOO MANY | Alternatives available Vague history or symptoms OTC (over‐the‐counter) Interactions (drug–drug, drug–disease) Duration Therapeutic versus preventive Once per day (preferred) Other doctors Money Adverse drug effects Needs still? Yes/no (is the person actually taking the medication?) | Lists important considerations when assessing medication prescribing, compliance, and treatment burden |
| ARMOR (67) | Assess based on number of medications or drug class Review pharmacodynamics and pharmacokinetics Minimize medications Optimize doses Re‐assess – compliance, clinical impacts | Useful as a quality improvement tool in post‐acute and long‐term care Focus is on functional status and quality of life |
| ERASE | Evaluate diagnoses through the consideration of Resolved conditions Ageing normally Selecting appropriate targets to Eliminate unnecessary diagnoses and associated medicines | A process for eliminating diagnoses to help prioritize drug deprescribing |
It is important to remember that deprescribing is both a standardized and individualized process. The deprescribing process should follow the same format for all people and include delineating individualized treatment care goals based on age, functional status, life expectancy, and what matters most to the patient. Outcomes or benefits that are important to older people are usually similar to those of younger people, except that prioritising the outcomes may differ. For example, outcomes related to maintaining or improving physical function, cognitive function, and independence (e.g. prevention of nursing home admission) tend to become more important for people who are frail, have dementia, or are at the end of life. For some people, relief of suffering is the paramount goal, even if it comes with the cost of decreased life span. A recent qualitative analysis found that multimorbid older adults identified maintaining social relationships, a positive frame of mind or resilience, enjoyment of life, and independence as primary priorities of care.62 Clarifying these priorities will help the clinician to choose the right evidence‐based regimen and treatment approaches that follow appropriate guidelines tailored to the person’s personal medical history. Once the prescriber understands the process of deprescribing, the process will in essence be the same for every patient, but the actual treatment and outcome goals will be individualized.
Several deprescribing algorithms have been created, following a stepwise approach to assist the clinician at the point of care. The first is a five‐step deprescribing protocol and algorithm developed by Scott and colleagues.55,63,64 One starts by compiling an accurate and complete medication list and then assessing the overall risk of drug‐induced harm using an algorithm to determine each drug’s discontinuation potential, prioritizing drugs for discontinuation, and finally establishing a monitoring plan following the deprescribing episode. Barnett and colleagues describe another patient‐centred deprescribing process that includes seven steps. The process begins by establishing the patient’s needs and overall goals and then proceeds to compile an accurate medication list; identify potentially inappropriate medications; discuss the risks versus benefits of each; reach an agreement about which to stop, reduce, or start; and finally set up a long‐term plan to communicate changes and monitor the patient.65 A third useful resource is the recently described Deprescribing Rainbow, depicting a conceptual framework of the clinical, psychological, social, financial, and physical determinants that should be considered when approaching the deprescribing process in an individual patient. In this pictorial depiction, the patient is literally placed at the centre of the rainbow to emphasize the patient’s central importance. The authors of the paper remind us that ‘deprescribing will be more successful if it is respectful of the individual patient context and circumstances’.66 These deprescribing frameworks, combined with a comprehensive geriatric syndrome assessment and the use of one of the previously described prescribing tools, can help clinicians develop a patient‐centred and systematic approach to medication management in older adults that can be used in daily clinical practice.
Conclusion
Polypharmacy may be difficult to define but clearly has significant negative impacts on the health and well‐being of older adults. A variety of tools and algorithms have been developed that can reduce the impact of polypharmacy by applying a systematic, patient‐centred approach to clinical decision‐making and prescribing. Let’s return to the vignette presented in the introduction to apply these principles to a clinical case.
The facts:
An 88‐year‐old woman with cognitive changes related to moderate Alzheimer’s disease presents to the hospital with weakness resulting in a fall.
Complex multimorbidity with seven chronic medical conditions: hypertension, type 2 diabetes mellitus, chronic venous insufficiency, moderate depression, osteoporosis, osteoarthritis of knees, and mild Alzheimer’s dementia.
On 21 routine medications, taken up to three times a day.
Additional information is obtained from the patient to elicit her current functional status, goals of care, and treatment burden experiences. She notes difficulty remembering to take her noon and evening medications and describes feelings of fatigue, lightheadedness, generalized weakness, and aching after taking her medications. She notes worsening constipation as well as urinary frequency and urgency with difficulty getting to the toilet on time due to knee pain and unsteady gait. She denies