Taking too many medications raises your risk of adverse events. Deprescribing—the thoughtful process of identifying problematic medications and reducing the dose or stopping those medications in a safe, effective manner that helps people maximize their well-being—is often easier said than done, explains Cynthia Boyd, MD, MPH, director of geriatric medicine and gerontology at Johns Hopkins University.
This is especially critical, if you have dementia or multiple chronic conditions. “There is relatively little research about how we actually deprescribe,” she says. “That speaks to the issue of how people end up on a whole bunch of medicines. It often is much easier to just start more medicines than it is to pare them back.”
She and her team recently published a study in JAMA Internal Medicine, showing that providing pamphlets about deprescribing to patients with dementia who were taking more than five prescription medications, along with their caregivers and primary-care physicians, unfortunately, did not lead to a meaningful reduction in prescriptions over the following six months. Still, she says, the study provided meaningful insights and is paving the way for more research on helping patients and doctors safely reduce the use of medication when appropriate. MedShadow spoke with Boyd about what her team learned from the study and about what patients and caregivers should know about deprescribing.
MedShadow: Why do you focus your research on deprescribing?
Boyd: There’s increasing interest in the fact that as we age, there’s an increasing amount of medicines that we may be on. [Our prescriptions] tend to accumulate over time. And there’s recognition that the more medicines you’re on, the greater chances of there being an adverse event resulting from one of those medicines or an interaction between two of them.
I am one of the co-leaders of the US Deprescribing Research Network, [which] is trying to figure out how we approach this, making sure that we’re deprescribing in appropriate ways that make a difference for patients.
MedShadow: What do we know already about deprescribing?
Boyd: Giving information to patients is a key piece in fostering appropriate deprescribing. [Researchers at the Canada Deprescribing Network] have done a fair bit of work where they created patient- and family-friendly educational materials about specific medicines. When these are given to patients who are taking medicines that we know have a greater potential to be harmful or [are] dangerous over the long run, and patients then [can] have a conversation with a healthcare professional, [such as a primary-care physician or pharmacist] that actually leads to meaningful changes in the number of of medicines [they’re prescribed].
MedShadow: How did your team work to build on that knowledge in the JAMA study?
Boyd: For our research, we were interested in the population of older adults who have cognitive impairment or dementia, with at least one other chronic condition, who are on a number of medicines. This is a population that we know experiences a lot of polypharmacy, but also is perhaps at increased risk of some of the harms of medication.
We were really interested in pragmatic interventions that are feasible without requiring a huge alteration to the way care is delivered. We developed a brochure for patients and families that was targeted toward this patient population and their overall medication list, recognizing that many older adults with cognitive impairment or dementia actually have family involved in both their medication management and decision-making about medicines.
We tailored the materials such that whoever was reading it would hopefully be able to come to a primary-care visit ready to have a conversation about any medicines that they had concerns or questions about, or [would be] prepared to ask their physician, “Are all the medicines I’m taking still the right ones for me?”
We also had an educational arm for primary-care physicians. They received monthly tip sheets that gave input or advice about how to think about deprescribing and how to communicate it and specific types of medicines that they might want to consider reducing.
MedShadow: Your study results didn’t show a meaningful reduction in medications for those who had received the pamphlets. What did you find?
Boyd: The findings were not statistically significant for the population of older adults with dementia on five or more medicines, but the findings suggested that there may be value in focusing future studies on the population that’s prescribed even more [than five] medications.
While we obviously would have loved to have seen an effect in this study, we still do feel like we learned a tremendous amount about how to think about deprescribing approaches in pragmatic ways. It also shows that a large-scale patient and clinician education intervention on deprescribing can be safe in primary care.
MedShadow: As your research continues, what advice do you have for caregivers?
Boyd: It is important, reasonable and appropriate to be asking questions about medications. There’s data that shows that medications tend to accumulate and that we don’t always stop certain medicines when we should. An important piece of the conversation is engaging and asking questions over time about a patient’s needs and what’s best for them.
Another piece that we would want family caregivers to take away wasn’t something that we specifically studied in this project. An important basis for having a conversation about “which medicines are the right ones for my loved one” is actually having an accurate representation of what medicines patients are on. Don’t assume that healthcare providers have an accurate representation of what you’re actually doing. [When] coming to a visit, bring the pill bottles. That is a fundamental piece that is so helpful for having a good conversation and identifying the potential drug interactions or the potential symptoms that might actually be side effects of medications.
This conversation has been lightly edited and condensed for clarity.