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Wiser Meds:

Deprescribing for Older People

Dr. Rita McCracken, MD, PhD(c)rita.mccracken@ubc.ca / @DrRitaMc

Declaration of Conflicts of Interest

• Faculty: Dr. Rita McCracken• Relationships with commercial interests: NONE

– Grants/Research Support: St. Paul’s Foundation, VCH/PHC Innovation Fund, BCCFP Research Fund

– Speakers Bureau/Honoraria: BC College of Family Physicians– Consulting Fees: none– Other: 

• Family Physician, paid via BC’s PMA, • Associate Head, Dept. of Family and Community Medicine paid by Providence Health 

Care• Site Faculty for Resident Research, Family Practice Residents, paid by UBC

• Disclosure of Commercial Support– This program has NOT received financial support from anyone.– This program has NOT received in‐kind support from anyone. 

• Potential for conflict(s) of interest:– n/a

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Mitigating Potential Bias

• I deprescribe, a lot, but I still have patients with polypharmacy.

• I provide references for statements of fact/evidence.

• I welcome challenges and questions

Learning objectives

1. Triage, where to start - identify which meds might cause problems, and develop a process to reduce polypharmacy

2. Worth the hassle? Describe risks and benefits of deprescribing

3. Toolbox - Increase awareness of existing tools that may aid in deprescribing

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Ref: Otis Historical Archives Nat'l Museum of Health & Medicine, Creative Commons 2.0

Where to Start

What is polypharmacy?

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138 published definitions.

Masnoon, et al, BMC Geri, 2017PMID: 29017448

Which pills are currently causing harm? 

• Financial (e.g. advair, 150$ x12 months)

• Pill burden, (e.g. acetaminophen 650 QID = 8 tablets)

• Adverse effects (e.g. falls (& z-drugs), dry mouth (& TCA’s),

decreased appetite (& ACh-I’s), constipation (acetaminophen/calcium), etc)

• No obvious indication (e.g. metoprolol 12.5mg started >5 years

ago and no one remembers why)

• “Excessive” effect (e.g. A1c 5.9% and on metformin & glyburide)

• Used the think it was a good idea (e.g. ASA for

primary prevention or vitamin D for almost anything)

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Make a list

1. Drug name and dose

2. Indication

3. Goal/Target

4. Reasonable estimate of benefit, e.g. NNT

5. Reasonable estimate of harm, e.g. NNH

6. Patient’s understanding/perception of value

Where to start

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Which pills does the patient want to stop?

Reference: Creative Commons https://pixabay.com/en/old‐man‐portrait‐street‐man‐old‐2687112/

Ref: Otis Historical Archives Nat'l Museum of Health & Medicine, Creative Commons 2.0

Harms and Benefits

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Adverse drug reactions from “good drugs”

Table 3:Most commonly implicated drugs

What can you expect to happen when you deprescribe?

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A little of this, a little of that

What are you afraid of?

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https://pixabay.com/en/emergency‐cardiac‐rescue‐3016877/

If you stop HTN Meds, what happens?

1) In 16 weeks, cognitive function does not improve.2) Rates of adverse events EQUAL to if you keep them on the meds.3) Blood pressure goes up, but maybe not as high as you would expect…

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Still think a bit of dizziness worth a mortality benefit…??

If SBP <130 and on 2 or more HTN meds, Hazard ratio for MORTALITY = 1.78

Death is 100% unavoidable

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the right questions1. What is your understanding of where you

are and of your illness?2. Your fears or worries for the future?3. Your goals and priorities?4. What outcomes are unacceptable to you?5. What are you willing to sacrifice and not?6. What would a good day look like?

Reference: Atul Gawande, Being Mortal, review and highlights: http://www.nytimes.com/2014/10/05/opinion/sunday/the-best-possible-day.html?_r=1

ToolkitRef: Mark Knobil, flickr, creative commons license

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https://www.acfp.ca/tools‐for‐practice/about‐tools‐for‐practice/

http://deprescribing.org/resources/deprescribing-guidelines-algorithms/

• PPI

• Antihyperglycemic

• Atypical Antipsychotic

• Benzo’s

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MedStopper.com

• http://www.thennt.com/

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TI Letters (ti.ubc.ca)

PathClinic.ca

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• https://pixabay.com/en/dependent-dementia-woman-old-age-100343/

CASE DISCUSSION

• Cheerful, but tired looking 83 year old just admitted to NURSING HOME

• … her presentation to hospital:– Concerned neighbour had found her on floor

– EHS noted home cluttered and dirty

– Admission BMI 17, poorly groomed, MMSE 13/25

• Social Hx– Single retired legal secretary with elderly brother in Nanaimo -

she loves to tell stories about their happy youth together

• Advance Care Plan=Resuscitation status listed on 3 month old discharge summary (had 17 day stay for “failure to thrive” from VGH), says she is “full code”

• Multiple GP’s listed on med rec, patient keeps saying that her family doctor is someone you know to be retired.

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PMHx(info from admission form and old discharge summary)

Type 2 diabetesHypertensionOsteoporosisCoronary artery diseaseHysterectomy age 20A1c=7.6, GFR = 50, Hgb = 109

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Medications:

Metformin 250mg BID

Glyburide 2.5mg BID

Sliding scale insulin

Ramipril 5mg OD

Amlodipine 5mg BID

Vitamin D 1000IU daily

Calcium Carbonate 1250mg daily

Acetaminophen 650mg QID

Alendronate

Elder care bowel protocol

Zopiclone 3.75mg prn

Quetiapine 12.5mg prn

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RN admission report• BP 108/70, HR 60• Ambulating to bathroom, unsteady,

sometimes with walker• Asking nurses to phone her brother >

10x/day• Needs cuing and assistance with toileting and

dressing.• Complains of nausea every morning• Eating ~ 25-50% meal portions• Loves bingo and hymn singing

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Case Summary 1. Try identifying an indication for each medication.

2. What do you think would be reasonable targets?

3. What about frailty?Dementia?

4. What other information do you need? Want?

5. What are her baseline risks?

6. How could drugs help her?

7. Any drugs you think should be stopped today (active harm)

8. Any drugs you want to include in a deprescribing plan?

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Medications:

Metformin 250mg BID

Glyburide 2.5mg BID

Sliding scale insulin

Ramipril 5mg OD

Amlodipine 5mg BID

Vitamin D 1000IU daily

Calcium Carbonate 1250mg OD

Acetaminophen 650mg QID

Alendronate

Elder care bowel protocol

Zopiclone 3.75mg prn

Quetiapine 12.5mg prn 

PMHx Type 2 diabetesHypertensionOsteoporosisCoronary artery diseaseHysterectomy age 20A1c=7.6, GFR = 50, Hgb = 109

• BP 108/70, HR 60

• Ambulating to bathroom, unsteady, sometimes with walker

• Asking nurses to phone her brother > 10x/day

• Needs cuing and assistance with toileting and dressing.

• Complains of nausea every morning

• Eating ~ 25‐50% meal portions

• Loves bingo and hymn singing

Advance Care Plan = Resuscitation status listed on 3 month old discharge summary (had 17 day stay for “failure to thrive” from VGH), says she is “full code”

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what makes a good day for our patient?

1. Good enough mobility2. Regular bowel movements and a manageable

bladder habit.3. Clarity of thought

– (minimal daytime drowsiness, can have a conversation, go to Bingo, read the paper, etc)

4. Enjoyment of foods and drinks that are meaningful and pleasurable for them – (as opposed to adhering to a “special diet”)

5. Time with loved ones (usually).6. Days NOT consumed by doctors appointments,

trips to the pharmacy and pill taking. 35

patient goals and preferences should guide de/prescribing

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Make a listDrug Name & Dose Indication Goal/ 

TargetNNT? NNH? Pt 

understanding/preference

1

2

3

4

5

6

7

8

9

10

11

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Care Plan, (OSCAR: other Meds)

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Care PlanGoals of care: • Celebrate family relationships (photo albums, phone calls, visits

• Enjoy favorite food/bev treats (no restrictions)

• Attend bingo and music therapy (as much as possible, may need encouragement)

• Do not prevent natural death and avoid future hospitalizations (DNAR 2)

Problem List:Frailty 7/9 CFS, Dementia, 5-6/7 GDS(fxn: ambulates w walker, continent x 2, hearing and vision WNL, mood stable)

Diabetes, dx date: unknown, >5 yearsA1c goal 8-9%, measure q 6 months Current meds: none, consider if symptoms of hyperglycemia or if A1c > 9.5 x 2.CBG’s: not indicated, do only if acutely unwellMeds d/c’ed dt overtreatment: May 2015 Glyburide, metformin insulin SS(ref: Evidence-Informed Guidelines for Treating Frail Older Adults With Type 2 Diabetes: From the Diabetes Care Program of Nova Scotia (DCPNS) and the Palliative and Therapeutic Harmonization (PATH) Program Mallery, Laurie Herzig et al. JAMDA, Vol 14, Iss 11, 801-808)

Hypertension, dx date >10 ySBP goal: 140-160, measure monthly, Current meds: none indicated, consider only after 2 consecutive readings above targetMeds d/c’ed dt overtreatment: ramipril and amlodipine(ref: Mossello E, Effects of Low Blood Pressure in Cognitively Impaired Elderly Patients Treated With Antihypertensive Drugs. JAMA Intern Med.2015;175(4):578–585.)

Bone HealthKeep ambulating, attend as many PE activities as possible, keep BMI> 20Current meds: noneMeds d/c’ed dt lack of applicable evidence: Ca2+, vit D, alendronate, refs: Theodoratou E, et al Vitamin D and multiple health outcomes: umbrella review of systematic reviews and meta-analyses of observational studies and randomised trials BMJ 2014; 348 :g2035 AND http://www.thennt.com/nnt/bisphosphonates-for-fracture-prevention-in-post-menopausal-women-without-prior-fractures/)

InsomniaMinimize daytime napping.If not asleep by 1030, melatonin 1-3mg prnMeds d/c’ed: zopiclone 3.75mg prn dt adverse effect profile

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