What is the approach to drug rationalization in the elderly?

Drug Rationalization in the Elderly

Drug rationalization in older adults should follow a systematic approach centered on comprehensive medication review using validated tools (particularly Beers Criteria or STOPP/START criteria), prioritizing deprescribing of potentially inappropriate medications, and aligning therapy with patient-centered goals including life expectancy, functional status, and quality of life rather than disease-specific targets alone. 1

Core Framework for Medication Rationalization

Step 1: Conduct Structured Medication Review

• Perform comprehensive medication assessment including all prescription drugs, over-the-counter medications, herbal products, and supplements at every care transition (hospital admission, discharge, outpatient visits) 1
• Apply validated screening tools to identify potentially inappropriate medications:
  • Beers Criteria (updated 2023): Identifies medications with unfavorable benefit-risk ratios in older adults, medications to avoid with specific conditions, dose adjustments needed for renal function, and high-risk drug-drug interactions 2
  • STOPP/START criteria: 65 criteria for potentially inappropriate prescriptions and evidence-based prescribing omissions, organized by physiological systems 1
• Document medication history including indication for each drug, duration of therapy, previous adverse effects, and adherence patterns 3

Step 2: Identify Medications for Deprescribing

Prioritize removal of drugs in the following categories 1:

• Medications with unfavorable benefit-risk ratio regardless of condition: NSAIDs (increased GI bleeding, acute kidney injury, heart failure exacerbation), benzodiazepines (cognitive impairment, delirium, falls, fractures) 2
• Drugs with questionable efficacy in the elderly population 4
• Medications causing prescribing cascades: Drugs prescribed to treat side effects of other medications (e.g., metoclopramide for NSAID-induced dyspepsia) 1
• Preventive medications exceeding time-to-benefit: In patients with limited life expectancy (<1-3 years), discontinue statins, bisphosphonates, and tight glycemic control agents that require years to show benefit 1

Step 3: Assess Patient-Specific Factors

Evaluate the following domains before making prescribing decisions 1:

• Life expectancy vs. time-to-benefit: Discontinue preventive medications when estimated life expectancy is shorter than the drug's time-to-benefit (typically several years for statins, osteoporosis medications) 1
• Functional and cognitive status: Use comprehensive geriatric assessment to determine impact of medications on activities of daily living, mobility, and cognition 5
• Multimorbidity burden: Consider drug-disease interactions and whether treating one condition worsens another 1
• Patient goals of care: Prioritize symptom relief and quality of life over disease-specific targets in frail elderly or those with advanced illness 1

Step 4: Reduce Polypharmacy Systematically

Target reduction of total medication burden 1:

• Define polypharmacy: ≥5 chronic medications; hyperpolypharmacy: ≥10 medications 3
• Achieve measurable reductions: Studies demonstrate feasible reduction of 1-2 medications per patient through systematic review 3, 5
• Avoid therapeutic duplication: Identify multiple drugs from same class or with overlapping mechanisms 4
• Simplify dosing regimens: Reduce frequency of administration to improve adherence 1

Step 5: Consider Pharmacokinetic and Pharmacodynamic Changes

Account for age-related physiological changes 1, 6:

• Increased volume of distribution for lipophilic drugs (e.g., diazepam) leading to prolonged half-life 6
• Reduced drug clearance (e.g., digoxin) due to decreased renal function, requiring dose adjustment 6
• Enhanced pharmacodynamic sensitivity to opioids, sedatives, and anticholinergics at equivalent plasma concentrations 6
• Review renal function and adjust doses accordingly for renally cleared medications 2

Step 6: Implement Person-Centered Prescribing

Align medication decisions with individual circumstances 1:

• For patients with normal life expectancy: Apply standard Beers Criteria and STOPP/START tools 2
• For frail elderly with <1 year life expectancy: Use STOPPFrail criteria; discontinue medications unlikely to provide benefit within remaining lifespan 1
• For advanced dementia or palliative patients: Focus exclusively on symptom management; discontinue preventive therapies 1
• Incorporate patient preferences: Engage in shared decision-making regarding treatment goals (longevity vs. quality of life vs. symptom control) 1

Critical Implementation Strategies

Timing of Medication Review

• At every care transition: Hospital admission, ICU transfer, hospital discharge (66% of hospitalized elderly continue potentially inappropriate medications at discharge) 1
• Periodic outpatient reassessment: Every 3-6 months for stable patients 1
• When functional decline occurs: Reassess medication appropriateness with any change in cognitive or physical status 5

Team-Based Approach

Integrate pharmacist-led interventions within comprehensive geriatric assessment teams 3:

• Pharmacist clinical interviews and structured medication reviews reduce polypharmacy by 10.2%, hyperpolypharmacy by 16.6%, and drug-related problems significantly 3
• Multidisciplinary teams including physicians, pharmacists, nurses improve medication appropriateness more than physician-only reviews 1

Monitoring After Deprescribing

Track outcomes following medication changes 5, 7:

• Positive outcomes: Improved depression scores, mobility, nutritional status, and preserved cognition and ADL function with reduced medication burden 5
• Persistence of changes: Approximately 58% of medications discontinued remain stopped at 1 year; 25% are reintroduced by other prescribers 7
• Coordinate across providers: Communicate medication changes to all prescribers to prevent reintroduction of inappropriate medications 7

Common Pitfalls to Avoid

• Disease-specific guideline adherence without considering multimorbidity: Clinical practice guidelines are typically disease-focused and may recommend conflicting therapies; prioritize patient-centered goals over achieving multiple disease-specific targets 1
• Ignoring drug-drug interactions: Risk increases exponentially with polypharmacy; use interaction screening tools systematically 4
• Failing to reassess at care transitions: 85% of potentially inappropriate medications continue unchanged at hospital discharge without active review 1
• Overlooking non-prescription medications: Include OTC drugs, supplements, and herbal products in medication reconciliation 4
• Applying chronological age alone: Base decisions on comprehensive geriatric assessment including frailty, function, and life expectancy rather than age cutoffs 1

Expected Outcomes

Medication rationalization guided by comprehensive geriatric assessment demonstrates 3, 5:

• Significant reduction in polypharmacy and hyperpolypharmacy
• Decreased drug-related problems and adverse events
• Improved nutritional, physical, and psychosocial status
• Preserved or improved functional independence and quality of life
• Reduced healthcare utilization and hospitalizations 1