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4 Steps to Successful Deprescribing
January 15, 2024More chronic conditions, legacy prescribing, and complicated prescription regimens are all contributors to polypharmacy. And there’s no question that it is a significant issue for older adults; symptoms caused by polypharmacy can range from drowsiness and gastrointestinal issues to falls, confusion, and general decline. Deprescribing, the process of tapering, stopping, discontinuing, or withdrawing medications, can be an effective tool to combat polypharmacy, but it must be approached with care. Staff, residents, and their families need to be involved in decision making and must fully understand the process, along with its risks and benefits.
STEP 1: Review Medications
If staff, the resident, or family members raise concerns, work with the consultant pharmacist to complete a review of the resident’s regimen.
• Are all of the medications still necessary?
• Are they benefiting the resident?
• Are certain medications or combinations of medications increasing the risk of adverse events?
• Do all the medications align with the goals of care?
STEP 2: Create and Implement a Deprescribing Plan
If recommended and the resident and/or their family agrees, work with the pharmacist to develop a plan to move forward with deprescribing.
• Determine if the medication can be stopped, or if the dose can be reduced.
• Develop schedules for tapering as necessary.
• Have a conversation about deprescribing with the resident and/or family (see the FRAME approach, below).
• Keep the resident and/or family informed as the medication regimen changes.
STEP 3: Monitor
Once changes are made, staff will need to monitor the resident and watch for any adverse effects.
• Monitor the resident’s condition and response to the changes in regimen.
• Check in with the resident to see if they are experiencing any changes, positive or negative.
• Monitor for adverse effects caused by withdrawal.
• Support the resident throughout the deprescribing process.
STEP 4: Document
Staff should document the deprescribing process and results.
• Document the reasons for deprescribing.
• Document the changes made to the resident’s medication regimen.
• Document all positive and negative outcomes.
• Record any details that may help with future care or prescribing decisions
The FRAME Approach
Using this approach helps residents and family members feel more comfortable with the deprescribing process and reminds them that they have an important voice in the resident’s care.
• Fortify trust. Callous deprescribing can lead to mistrust, feelings of abandonment, or a sense of futility about previous compliance. First, establish a trusting relationship in which they understand the medical goals of their care.
• Recognize the resident’s willingness to make changes or their barriers to deprescribing.
• Align deprescribing recommendations to the resident’s goals of care.
• Manage cognitive dissonance. Cognitive dissonance occurs when a person experiences mental discomfort from simultaneous contradictory beliefs, ideas, or values. Residents may struggle with cognitive dissonance after a formal deprescribing recommendation is given because they
associate medications with making them better, not putting them at risk for harm. Residents may not be open to deprescribing if cognitive dissonance isn’t addressed.
• Empower residents and caregivers to continue the conversation. Deprescribing conversations shouldn’t be limited to one point in care. Instead, nurses should schedule future conversations and employ motivational interviewing techniques to keep residents involved and feeling in control. For example, a nurse can say something like, “I encourage you to ask your cardiologist what benefit metoprolol is providing you and what it may look like if you were to discontinue it.”
Common Causes of Polypharmacy Issues
Some of the most common causes of issues related to polypharmacy are tied to medications found in many residents’ regimens. Here are some examples:
• Warfarin: When combined with certain antibiotics, including ciprofloxacin, levofloxacin, metronidazole, and azithromycin, serious bleeds can occur.
• Omeprazole and levothyroxine: When these medications are combined, it can lower the absorption of levothyroxine, making it less effective.
• Antidepressants and proton pump inhibitors: These medications are often prescribed for an indefinite period but are left in the medication regimen long term (legacy prescribing). This can also happen with drugs started in the emergency room or prescribed by specialists to treat a short-term problem but are continued without evaluation.
Your Consultant Pharmacist Can Help
Many symptoms associated with polypharmacy are also associated with other conditions or advancing age, making it challenging for nurses to pinpoint the root cause. The first thing to look for is whether there’s a new medication in the resident’s regimen or if the dose has recently changed. However, problems can also arise when a resident has been on a medication for an extended period of time. A review by your consultant pharmacist is the best way confirm that the issue is related to polypharmacy or to rule it out.