Care Considerations for Older Adults: The Assessment and Management of Polypharmacy for APRNs Nursing CE Course

mation regarding renal function considerations in prescribing. Increasing levels of unbound or free medication may result from a reduction in serum albumin levels related to malnutrition in a geriatric patient experiencing feeding or eating problems. Decreased cardiac output may lead to inadequate drug distribution (Saljoughian, 2019; Terrery & Nicoteri, 2016). Due to changes in pharmacodynamics in older adults, many patients will also develop a heightened sensitivity to certain drugs. All of this can lead to a lower dosage of most medications required to achieve the same plasma concentration and, therefore, the same therapeutic effects (Rochon, 2020).

Education and communication may help avoid many of the adverse effects of polypharmacy in the older adult population. Patients should be encouraged to maintain an accurate medication list; they should update it regularly, bring it with them to all medical appointments (or keep a digital copy on their phone), and share it with all of their medical providers to ensure accuracy and awareness across disciplines and specialists. This list should include the medication name, dosage, frequency, and the indication/rationale for prescribing. Patient education regarding any new medications should include these basic facts as well as potential side effects, any dietary restrictions, and any look-alike or sound-alike medications. Patients should be encouraged not to stop or change how they take a medication without asking the prescriber first, and patients should be verbally and directly asked at each visit about medication adherence. Education about medication safety can also prevent mishaps, including the importance of not saving or sharing medications and safe medication storage in a secure location. Patients with memory deficits should be encouraged to explore various solutions available, including pill dispensers, color-coded pillboxes, or technology aids offering reminder features, such as smartphone applications. A simple alternative is to consistently link the medication dose with a routine daily activity, such as brushing their teeth, shaving, or drinking coffee. From a system standpoint, providers must ensure that they are consistently and accurately communicating any medication changes to the other members of the interdisciplinary healthcare team, including pharmacists, intensivists, specialists, and primary care providers (Saljoughian, 2019). The Assessing Care of Vulnerable Elders (ACOVE) project endorses many of the above helpful tips when prescribing for older adults. The ACOVE project also encourages prescribers to document any response, either expected and positive or unexpected and adverse, to therapy (Rochon, 2020). 

Deprescribing

Deprescribing is the process of systematically reviewing a patient’s medication list to determine if certain medications are causing more harm than good or are no longer indicated. The ACOVE project recommends that prescribers review the ongoing need for a particular drug annually (Rochon, 2020). The process should involve shared decision-making, planning, and robust communication with the patient and family regarding the underlying rationale. Medications should be tapered safely while the patient and family observe for any resulting effects (Saljoughian, 2019; Steinman & Reeve, 2020). As a process, proponents describe deprescribing as proactive and systematic because it allows the provider to prevent adverse events and side effects before they occur, as opposed to reactively tapering a medication after an adverse drug event has been identified. Reducing medication burden may improve the patient’s adherence to their remaining medications. Deprescribing can also reduce the risk of falls, hospitalization, and death and improve cognitive function. The process may be especially beneficial when targeted for patients with the following characteristics:

• numerous prescribed medications
• the presence of multiple comorbidities/chronic medical conditions
• a history of renal impairment
• the existence of multiple prescribers and transitions of care
• a history of medication nonadherence
• a limited life expectancy
• a history of cognitive impairment
• older, frail patients (Steinman & Reeve, 2020)

The deprescribing process is more impactful if targeted at specific medications or classes of medications, such as potentially inappropriate medications (PIMs) and other high-risk medications. High-risk medications may include insulin (due to risk of hypoglycemia and related sequelae) or aspirin (due to risk of bleeding events). Medications with no known indication, those causing or contributing to an adverse drug reaction, those associated with extreme treatment burden, or ineffective medications are also often targeted for deprescribing. Preventative medications in a patient with a life-limiting condition are also frequently targeted (Steinman & Reeve, 2020). Certain drug classes are known to be associated with an increased risk of adverse reactions, including anticoagulants, nonsteroidal anti-inflammatory drugs (NSAIDs), cardiovascular medications, diuretics, antibiotics, antiepileptic drugs (AEDs), benzodiazepines, and hypoglycemic agents (Saljoughian, 2019). Anticholinergic medications may cause dizziness, memory loss, confusion, hallucinations, or dry mouth and increase cognitive impairment risk (Rochon, 2020). 

Prescriber Tools

Various tools have been developed to help providers screen for PIMs. The American Geriatric Society (AGS) Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (The Beers Criteria, or BC) was last updated in 2019 and includes six categories: PIMs, medications that are potentially inappropriate with certain conditions, medications that should be used with caution, drug-drug interactions that should be avoided, medications that should be avoided or reduced in patients with kidney dysfunction (Table 1), and drugs with strong anticholinergic effects. The list includes 88 medications or classes of medications (AGS Beers Criteria Update Expert Panel, 2019; Fixen, 2019; Nguyen et al., 2020). Critics point out that the BC does not include information on underused or alternative medications (Nguyen et al., 2020). 

Between 2015 and 2019, a handful of changes were made to the BC based on the most updated evidence. Ticlopidine (Ticlid, an antiplatelet) and oral pentazocine (Talwin, a partial opioid agonist) were both removed from the list as they are no longer available in the US market. The first-generation antihistamine pyrilamine (Pamprin, Midol) was added for its anticholinergic effects. A medication used to reduce gastric acid secretion in patients with peptic ulcer disease, methscopolamine (Pamine), was removed for the same reason. Glimepiride (Amaryl) was added to two other common sulfonylureas (chlorpropamide [Diabinese] and glyburide [DiaBeta]) due to the risk of potentially severe and prolonged hypoglycemia in patients over 65 due to an extended half-life (9-10 hours). Glipizide (Glucotrol), which has a half-life of just 2-5 hours, is not included in the 2019 BC list and is considered a safer substitute for older adults. Some modifications were made in hopes of enhancing clarity, such as adding “for the treatment of hypertension” to the warning regarding avoidance of nonselective peripheral alpha-1 blockers (doxazosin [Cardura], prazosin [Minipress], and terazosin [Hytrin]) due to the risk of orthostatic hypotension. The definition of sliding scale insulin was added, clarifying that this phrase refers to “the use of rapid- or short-acting insulin only based on current blood glucose levels without the concurrent use of long-acting or basal insulin” (p. 44). For some medications, such as metoclopramide (Reglan), the recommendation now includes a maximum duration of acceptable use (12 weeks) in older adults with gastroparesis due to the risk of tardive dyskinesia. Meperidine (Demerol) should now be avoided for all older adults due to the risk of neurotoxicity and delirium, not just in those with chronic kidney dysfunction as the 2015 recommendations specified (AGS Beers Criteria Update Expert Panel, 2019; Fixen, 2019).

The second section regarding medications that may affect or negatively impact certain diseases or syndromes is broken down into four groups of medications: cardiovascular, central nervous system, gastrointestinal, and kidney/urinary tract. Of note, H2 blockers were removed from the section on dementia due to weak evidence. This removal of H2 blockers is important for prescribers, as proton pump inhibitors (PPIs), the other medication class commonly used to treat chronic gastroesophageal reflux, remains on BC with caution to avoid this class of medications for longer than 8 weeks duration due to risk of bone loss/fracture and C. difficile infection. For older adult patients with Parkinson’s disease who require an antipsychotic, the list of preferred agents now includes clozapine (Clozaril), quetiapine (Seroquel), and pimavanserin (Nuplazid); aripiprazole (Abilify) is no longer recommended due to safety and efficacy concerns. The 2019 BC includes the following medications that should be avoided in older patients at risk of falls: serotonin-norepinephrine reuptake inhibitors (SNRIs, which were newly added since the 2015 list was released), selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), anticonvulsants (AKA antiepileptic drugs, or AEDs), antipsychotics, benzodiazepines, nonbenzodiazepine receptor agonist hypnotics (Z drugs, such as zolpidem [Ambien], zaleplon [Sonata], and eszopiclone [Lunesta]), and opioids, specifically mu-opioid receptor agonists. The 2019 BC suggests that acetylcholinesterase inhibitors should be avoided in patients at increased risk for falls based on high-quality evidence that they increase the risk of bradycardia and subsequent syncope. Tertiary TCAs and certain antipsychotics (chlorpromazine [Thorazine], thioridazine [Mellaril], and olanzapine [Zyprexa]) should also be avoided in these patients due to the risk of bradycardia or orthostatic hypotension. NSAIDs are mentioned in the BC list multiple times, such as avoiding use in older patients with chronic kidney disease (stage 4+ or CrCl < 30 mL/min) due to the risk of acute kidney injury and worsening renal function. It is also recommended to avoid the use of nonselective NSAID agents in those with a history of gastric ulcers unless safer alternatives are not available. The AGS also suggests concurrently prescribing a gastroprotective agent, such as a PPI, with all NSAIDs in older adults. Prescribers are cautioned against combining NSAIDs with corticosteroids due to the risk of gastrointestinal ulcer development (AGS Beers Criteria Update Expert Panel, 2019; Fixen, 2019).

The 2019 AGS BC includes rivaroxaban (Xarelto) and dabigatran (Pradaxa) on their list of medications to use with caution for the treatment of venous thromboembolism (VTE) or prevention of VTE due to atrial fibrillation (a-fib) in patients over the age of 75. This is due to an increased risk of GI bleeding seen with these two medications. The other newer oral anticoagulants are often referred to as direct oral anticoagulants or DOACs. Apixaban (Eliquis) and edoxaban (Savaysa), along with an older anticoagulant warfarin (Coumadin), are not included in the cautionary BC list, indicating that these may be better treatment options in patients over the age of 75 with these conditions. The patient’s renal function should also be evaluated before initiating edoxaban (Savaysa), rivaroxaban (Xarelto), or dabigatran (Pradaxa) as detailed in Table 1 (AGS Beers Criteria Update Expert Panel, 2019). Of note, research indicates that the benefit of anticoagulant use in older patients with a-fib far outweighs the risk of subdural hematoma related to head trauma suffered during a fall, even in patients at high risk of falling (Kiel, 2020). Evidence suggests that apixaban (Eliquis) may be the safest option amongst oral anticoagulants for use in older adults (Fixen, 2019). Warfarin (Coumadin) appears to be less safe (i.e., a higher rate of major bleeding) and less convenient (i.e., the requirement for therapeutic monitoring) than the DOACs in general, unless contraindicated based on drug-drug interactions or renal function. The only slight disadvantage of apixaban (Eliquis) is its requirement for twice-daily dosing, while edoxaban (Savaysa) and rivaroxaban (Xarelto) can often be dosed once-daily. Patients over the age of 80 with a weight under 60 kg or a serum creatinine > 1.5 mg/dL should have their dose of apixaban (Eliquis) cut in half, from 5 mg twice daily to 2.5 mg twice daily, if being used to prevent VTE due to a-fib. Prescribers should also avoid combining anticoagulants with antiplatelets and NSAIDs (including aspirin), as these compound the bleeding risk unless necessary based on cardiac history. Uncontrolled HTN should also be avoided to reduce the hemorrhagic stroke risk, and patients should be cautioned to limit their alcohol intake (Chan & Eikelboom, 2019).

The BC cautions against combining certain medications in older patients, such as opioids with benzodiazepines due to the risk of overdose, opioids with AEDs (gabapentin [Neurontin] and pregabalin [Lyrica]) due to the risk of sedation-related adverse events, and multiple anticholinergic medications due to the risk of cognitive decline. No more than two CNS-active drugs should be prescribed concurrently due to the risk of falls and fracture. They also explicitly warn against combining loop diuretics with alpha-1 blockers in older patients due to increased risk of incontinence. Toxicity is also a risk with older patients on certain medications. For example, the BC warns that lithium (Lithobid) toxicity can result if combined with an ACE inhibitor or loop diuretic, phenytoin (Dilantin) toxicity may result if combined with TMP-SMX (Bactrim), and theophylline (Theo-24, Uniphyl) toxicity may result if combined with cimetidine (Tagamet) or ciprofloxacin (Cipro). Similarly, warfarin (Coumadin) may lead to an increased risk of bleeding if combined with amiodarone (Cordarone), ciprofloxacin (Cipro), most macrolides (except azithromycin [Zithromax]), TMP-SMX (Bactrim), or NSAIDs (AGS Beers Criteria Update Expert Panel, 2019; Fixen, 2019).

Other prescribing tools include the Screening Tools of Older Persons Potentially Inappropriate Prescriptions (STOPP) and the Screening Tool to Alert Doctors to Right Treatments (START). The STOPP/START tools contain 80 criteria for stopping and 34 for starting a medication organized by organ system, adverse events, and other drug classes. A greater percentage of the identified inappropriate medications contained in the STOPP list were associated with an adverse drug event as compared to the BC, but critics point out that the STOPP/START tools do not suggest alternative medications or renal dosing adjustments. Fit for The Aged (FORTA) was originally developed in Germany. The expanded EURO-FORTA list is organized by organ system, and all 264 medications/drug classes are given a grade of A (indispensable), B (beneficial), C (questionable), or D (avoid). FORTA includes minimal information regarding the rationale for their recommendations and no information regarding drug-drug interactions, drug-disease interactions, or renal dosing adjustments. Lexicomp Online and IBM Micromedex are drug-drug interaction tools available online and may be incorporated into some EHR prescribing modules. Alternatives include clinical decision algorithms or questionnaires, such as the Good Palliative-Geriatric Practice Algorithm Medication Appropriateness Index or the 10-Step Drug Minimization Guide. These require more clinical judgment from the prescriber as they include no drug-specific information (Nguyen et al. 2020). The Centers for Medicare and Medicaid Services drug utilization review recommends against the use of eight drugs/drug classes in older adults: digoxin (Lanoxin), calcium channel blockers, ACE inhibitors, H2 blockers, NSAIDs, benzodiazepines, antipsychotics, and antidepressants (Rochon, 2020). 

Three Phases

The deprescribing process should be performed in a stepwise fashion or phases. Phase 1 typically includes engaging the patient to gather data and information, such as which medications they are taking, any problems they have noticed that they believe are related to the medication(s), and how their medications fit into the bigger picture of their life/health. Their preferences should be accounted for and incorporated into the treatment plan. Phase 1 should involve updating the patient’s medication list with dosages, frequency, indication, duration of use, and the patient’s experience (i.e., is it effective or difficult to take? Does it cause any side effects? Is the patient receiving/taking the medication consistently?). This phase should also include education for the patient and family/caregiver regarding the deprescribing process. Phase 2 should involve the identification of medications that should be deprescribed. This process should follow the previously described method of identifying commonly deprescribed medications (e.g., PIMs, high-risk, ineffective, not indicated, causing adverse drug reaction, etc.). This phase should also be cooperative, allowing the patient and caregiver(s) to share in the decision-making. Phase 3 includes planning, implementation, monitoring, and follow-up. Medications should be prioritized based on the harm being caused (or risk) and patient preference. Typically, one medication should be stopped at a time to improve monitoring. However, occasionally, two medications can be simultaneously discontinued if they are causing an adverse reaction(s) and there is minimal risk of withdrawal. Deprescribing should be viewed as a trial that can be reversed if the patient experiences an increase in unpleasant symptoms (e.g., an increase in heartburn after deprescribing a PPI). Most medications should be tapered, which may inadvertently identify a lower effective dose. In the absence of clear guidelines on how to taper a particular medication, most medications can be tapered safely by cutting the dose in half every 2-4 weeks. The patient should be monitored at each dose reduction and again 2-4 weeks after cessation. Patients and caregivers should be given information about symptoms to monitor for and frequency of follow-up with their provider. The deprescribing plan should be communicated clearly to the patient, the family/caregivers, other healthcare team members, the patient’s pharmacy/pharmacist, and documented in the patient’s EHR (Steinman & Reeve, 2020). 

Expect Challenges

Certain medications may be more difficult to deprescribe, such as benzodiazepines, which may require a 25% dose reduction every 2 weeks, as well as an alternate nonpharmacological or pharmacological therapy to replace its effects. Withdrawal symptoms, such as insomnia, anxiety, irritability, and GI symptoms, are common, especially once the dose has been reduced to 25% of the original dose. PPIs are commonly targeted as they are often unintentionally continued indefinitely. The dose can be cut in half for 2 weeks and then discontinued altogether in most cases, with monitoring for symptom recurrence for 4-12 weeks after cessation. Those with occasional symptoms can be directed to utilize a chewable antacid or H2 blocker as needed. Antipsychotics are often prescribed for patients with dementia to manage behavioral or psychological symptoms or insomnia, despite warnings that they increase the mortality risk in this patient population. Antipsychotic dosages can typically be reduced by 25%, then 50%, then 75% every week or two while monitoring closely for symptoms of withdrawal (i.e., psychosis, aggression, or hallucinations). Caregivers should be trained in behavioral and environmental treatment strategies. Glucose-lowering medications may be deprescribed safely, especially in those with multiple medical comorbidities, renal impairment, dementia, limited life expectancy, a history of hypoglycemia, impaired ability to sense or respond to hypoglycemia. Sulfonylureas or insulin are the most likely to cause episodes of hypoglycemia. The American Diabetes Association offers a suggested algorithm for switching patients from a complex to a simple regimen. Patients with end-stage dementia or those with substantial worsening of their cognitive function despite treatment with a cholinesterase inhibitor or memantine (Namenda) should be evaluated for deprescription of these agents. The dose should be decreased by no more than 50% every 4 weeks, as reports of severe withdrawal symptoms have been reported in patients who abruptly discontinue these medications. If agitation, aggression, or hallucinations occur within the first week after a dose reduction, the previous dose should be promptly restarted. If symptoms worsen within 2-6 weeks of a dosage adjustment, this may indicate that the medication provided significant benefit and warrant a discussion of restarting the medication at that prior dose level. Antidepressant discontinuation can cause withdrawal symptoms of insomnia, dizziness, fatigue, headache, nausea, anxiety, and flu-like symptoms. These symptoms may be more prominent after stopping some antidepressants (paroxetine [Paxil] or fluvoxamine [Luvox]) in comparison to others (fluoxetine [Prozac]). As in the early phases and planning, shared decision-making with the patient and caregiver(s) should continue throughout the monitoring and follow-up phases (Steinman & Reeve, 2020).

References

Agarwal, K. (2020). Failure to thrive in older adults: Evaluation. UpToDate. Retrieved February 25, 2021, from https://www.uptodate.com/contents/failure-to-thrive-in-older-adults-evaluation

The American Geriatrics Society Beers Criteria Update Expert Panel. (2019). American Geriatrics Society 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 67(4), 674–694. https://doi.org/10.1111/jgs.15767

Brown-O’Hara, T. (2013). Geriatric syndromes and their implications for nursing. Nursing2021, 43(1), 1–3. https://doi.org/10.1097/01.NURSE.0000423097.95416.50

Chan, N. C., & Eikelboom, J. W. (2019). How I manage anticoagulant therapy in older individuals with atrial fibrillation or venous thromboembolism. Blood, 133 (21): 2269–2278. https://doi.org/10.1182/blood-2019-01-846048

Fixen, D. R. (2019). 2019 AGS Beers Criteria for older adults. Pharmacy Today, 25(11), P42-54. https://www.pharmacytoday.org/article/S1042-0991(19)31235-6/fulltext

Kiel, D. P. (2020). Falls: Prevention in community-dwelling older persons. UpToDate. Retrieved February 9, 2021, from https://www.uptodate.com/contents/falls-prevention-in-community-dwelling-older-persons

Nguyen, T., Wong, E., & Ciummo, F. (2020). Polypharmacy in older adults: Practical applications alongside a patient case. The Journal for Nurse Practitioners, 16(3), 205–209. https://doi.org/10.1016/j.nurpra.2019.11.017

Rochon, P. A. (2020).  Drug prescribing for older adults. UpToDate. Retrieved February 11, 2021, from https://www.uptodate.com/contents/drug-prescribing-for-older-adults

Saljoughian, M. (2019). Polypharmacy and drug adherence in elderly patients. US Pharmacist, 44(7), 33-36. https://www.uspharmacist.com/article/polypharmacy-and-drug-adherence-in-elderly-patients

Steinman, M., & Reeve, E. (2020). Deprescribing. UpToDate. Retrieved February 10, 2021, from https://www.uptodate.com/contents/deprescribing

Terrery, C. L., & Nicoteri, J. A. L. (2016). The 2015 American Geriatric Society Beers Criteria: Implications for nurse practitioners. The Journal for Nurse Practitioners, 12(3), 192–200. https://doi.org/10.1016/j.nurpra.2015.11.027

Ward, K. T., & Reuben, D. B. (2020). Comprehensive geriatric assessment. UpToDate. Retrieved February 5, 2021, from www.uptodate.com/contents/comprehensive-geriatric-assessment