People are increasingly living longer and so the number and proportion of older adults in the UK continues to rise. Health often deteriorates with advancing age and prescribing in older adults is challenging. This article highlights three important considerations for prescribing in older people; appropriate prescribing, deprescribing and adherence.
Appropriate prescribing in older people
A large proportion of older people in the UK have multimorbidity, and within this population the use of multiple medicines (polypharmacy) is common. There is no universal definition of polypharmacy, but it is widely considered to refer to use of four or more regular medicines.1 It is important to differentiate between patients who are taking too many drugs (inappropriate polypharmacy) and those who are simply taking many drugs, which may be entirely appropriate.
Medicines are appropriately prescribed according to best evidence and when their use has been optimised.2 The overall aim is to maintain good quality of life, improve longevity and minimise harm from medicines.
Appropriate medication selection in older patients is determined by age-related changes in pharmacokinetics and pharmacodynamics, numbers of concurrent medications, functional status and burden of comorbid illness.
The difficulty for prescribers is potentially inappropriate prescribing, when the risks associated with prescribing a medication outweigh its potential benefits.3 Inappropriate prescribing may also occur if the intended benefit of the medication is not realised,2 for example because of errors in prescribing or non-adherence.
Prescribing guidelines typically focus on single diseases and often fail to provide guidance on how to prioritise treatment recommendations. To overcome this, NICE has developed guidelines on medicines optimisation4, which outline a patient-centred approach to ensuring safe and appropriate medicine use, and for the clinical assessment and management of patients with multimorbidity.5
Deprescribing in older people
Inappropriate prescribing in older people is associated with an increased risk of falls, adverse drug events, hospitalisations and death. Deprescribing is one approach to addressing inappropriate prescribing and polypharmacy in this population.
The term deprescribing describes the practice of reducing or discontinuing medications that may no longer be of benefit or may cause adverse effects, with the goal of reducing medication burden and potential for harm.
For example, it is widely accepted that the risk to benefit ratio of preventive pharmacotherapy (e.g. statins, aspirin, warfarin and bisphosphonates) becomes less favourable as a person becomes frailer and their life expectancy shortens. Additionally, multiple medications prescribed for the same indication and those lacking a valid, evidence-based indication are prime targets for deprescribing.
Decisions to stop or reduce a medication should ideally be made in conjunction with the patient and their family. Various tools have been developed to provide a structured framework to support deprescribing decision-making, for example, the Scott algorithm:6
(1) ascertain all drugs the patient is taking and the reasons for each one
(2) consider overall risk of drug-induced harm in individual patients
(3) assess each drug’s benefit potential compared with harm or burden potential
(4) prioritise drugs for discontinuation that have the lowest benefit-harm ratio and lowest likelihood of adverse withdrawal reactions
(5) implement a discontinuation regimen and monitor patients closely
The Screening Tool of Older People's potentially inappropriate Prescriptions (STOPP)7 can also be used to help prescribers make evidence-based decisions on deprescribing specific medications, as part of a comprehensive medication review.
Some medicines can be safely stopped without dose tapering but others, such as antidepressants, antipsychotics and benzodiazepines, need to be withdrawn more cautiously to avoid adverse withdrawal effects. In some cases, it may be better to reduce the dosage or switch to ‘as required’ usage, rather than withdraw a medication completely.
Medication adherence in older people
Adherence to medication is an important consideration in older patients, especially those with multimorbidity and polypharmacy. It has been estimated that up to 50% of medicines taken for long-term conditions are not taken as prescribed.8 Factors affecting adherence include:
- the patient, for example, patients with cognitive impairment may struggle to understand information or directions
- the disease, for example, patients with arthritis may struggle to open medication packaging or use an inhaler device correctly
- the medicine, for example, medicines with frequent dosing schedules may have lower rates of adherence.
Patient adherence to medication should be routinely assessed in a non-judgemental way as part of a structured medication review. Prescribers and other healthcare professionals need to understand a patient’s reasons for being non-adherent.
Prescribing should reflect the patient’s own wishes, beliefs and personal circumstances.9 It may become increasingly difficult for patients with dementia to be involved in decision-making because of fluctuations in mental capacity, so family members and carers should be encouraged to oversee and assist with medicines in these instances.
Interventions to improve adherence should be targeted to the patient’s need, and may include something as simple as rationalising the dosing regimen or using alternative packaging. Some patients may benefit from using a compliance aid.
Future changes in the healthcare system such as cohesive IT systems, improved access to medical records and expanded roles for pharmacists within primary care, have the potential to improve prescribing in older people.
- Dr Heather Barry, Dr Audrey Rankin and Dr Anna Millar are research fellows, Primary Care Research Group, Queen’s University Belfast
- Patterson SM, Hughes C, Kerse N et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database of Systematic Reviews. 2012; 5 (5): CD008165. doi: 10.1002/14651858.CD008165.pub2
- The King’s Fund. Polypharmacy and medicines optimisation: making it safe and sound. Available at: https://www.kingsfund.org.uk/publications/polypharmacy-and-medicines-optimisation (accessed 20 Mar 2017).
- Cahir C, Fahey T, Teeling M et al. Potentially inappropriate prescribing and cost outcomes for older people: A national population study. Br J Clin Pharmacol 2010; 69 (5): 543-552.
- NICE. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes [NG5]. 2015. Available at: https://www.nice.org.uk/guidance/ng5 (accessed 20 Mar 2017).
- NICE. Multimorbidity: clinical assessment and management [NG56]. 2016. Available at: https://www.nice.org.uk/guidance/ng56 (accessed 20 Mar 2017).
- Scott IA, Hilmer SN, Reeve E et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med 2015; 175 (5): 827–34.
- O'Mahony D, O'Sullivan D, Byrne S et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing 2015; 44 (2): 213-18.
- NICE. Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence [CG76]. 2009. Available at: https://www.nice.org.uk/guidance/cg76 (accessed 20 Mar 2017).
- Royal Pharmaceutical Society. Medicines optimisation: helping patients to make the most of their medicines. 2013. Available at: http://www.rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf (accessed 7 Feb 2018).