Tips for Deprescribing in the Nursing Home

Polypharmacy, the use of multiple medications, is a significant problem in nursing homes (NHs); it may be associated with a myriad of negative clinical consequences such as increased risk of adverse drug reactions, complications created by drug-drug interactions, medication nonadherence, reduced functional capacity, multiple geriatric syndromes, hospitalizations, increased risk of mortality, and greater health care costs.¹ Each year, 700,000 emergency department visits and 120,000 hospitalizations are due to adverse drug reactions.² NH residents are particularly vulnerable to polypharmacy due to their multiple comorbidities. In the United States, up to 50% of NH residents are on 9 or more medications,³ and the rate of adverse drug reactions is twice as high in NH residents taking 9 or more medications compared with those taking less.⁴ There is a need for effective intervention to improve medication management in NHs.³ 

Deprescribing—the process of tapering, stopping, or withdrawing medications that are unnecessary or inappropriate—is an effective way to minimize polypharmacy and improve health outcomes.¹ However, it can be a challenge to know when, how, and which medications to discontinue in the NH.

Several guidelines/algorithms have been created to help guide clinicians on the process of safe deprescribing.^5-8 In 2013, Scott and colleagues⁷ developed a 10-step, evidence-based, deprescribing guide to help decrease medication use and to reduce the number of inappropriate medications prescribed. More recently, Scott et al⁸ proposed a simple 5-step deprescribing protocol along with an algorithm to assist clinicians with deprescribing.

Another important resource that may help with the selection of medications to consider deprescribing is the American Geriatric Society’s (AGS) Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, which includes lists of potentially inappropriate drugs that can help with the selection of medications to consider deprescribing. These criteria were revised and updated in 2015.⁹ New drugs on the lists that should be avoided in older adults include non-benzodiazepine and benzodiazepine receptor agonist hypnotics (eg, eszopiclone, zaleplon, zolpidem), especially for those with cognitive impairment or dementia. The AGS Beers criteria also recommends avoiding the use of proton pump inhibitors (PPIs) in older adults for more than 8 weeks unless patients are at high risk for gastrointestinal disease, such as chronic users of nonsteroidal anti-inflammatory drugs, those with Barrett’s esophagus or hypersecretory states, or those who require PPI maintenance therapy.⁹ Farell et al¹⁰ recently created evidence-based clinical practice guidelines to support clinicians in safely reducing or stopping PPIs.

Although deprescribing is an important component of geriatric practice, it is often overlooked due to time pressures encountered by clinicians.¹¹ As a result, unnecessary medications are often not identified. In addition, common geriatric symptoms such as falls, weight loss, constipation, and delirium may not be recognized as the result of an adverse drug reaction.¹ Consequently, clinicians may prescribe another medication instead of discontinuing the offending one.
In order to help clinicians easily and safely engage in deprescribing, as well as identify potential medications that can be discontinued, we created a step-by-step guide in the form of a Tip Sheet, using our experience and the current literature on deprescribing as resources.

This Tip Sheet was created as a practical guide for clinicians to reduce unnecessary and potentially high-risk medications in NHs. Careful review of the resident’s medication list is needed with any acute change in condition to evaluate whether any medications may also be worsening the resident’s symptoms. Table 1 provides common examples of medications that may no longer be indicated in older adults. Often, adverse effects of medications may be mistaken for common geriatric presentations such as falls, confusion, and weight loss (Table 2). Clinicians must also consider tapering or discontinuing a medication before prescribing a new medication as NH residents often present with symptoms that are drug related. Failure to do so may lead to a prescribing cascade, in which a medication causes a new symptom and the symptom is then treated by adding a new drug. Table 3 provides common examples of prescribing cascades.

Some practical ways to use this guide may include placing the Tip Sheet in the Pharmacy Recommendations section of the chart/electronic medical record (EMR) and/or attaching it in the Medication Orders section, so that the clinician would be prompted to assess all medications during acute and routine visits. In NHs that use EMRs, a hard copy of the Tip Sheet could also be given to the clinician. This Tip Sheet may help serve as a useful reminder for clinicians to always consider adverse drugs effects as a possible etiology of a new symptom or problem. The Tip Sheet can also be used in coordination with the consultant pharmacist’s monthly Medication Regimen Reviews. Collaborating directly with the consultant pharmacist regarding safe deprescribing guidelines may enhance clinicians’ response to and compliance with their recommendations. The consultant pharmacist can be an important resource for staff and clinicians. Routine collaboration with the pharmacist in the deprescribing effort is likely to be mutually beneficial and effective in the interest of better resident care. The Tip Sheet can also be used as an educational tool to help all members of the health care team understand the essential components of safe deprescribing in the NHs. A solid understanding of the rationale and principles for deprescribing will allow individual team members to confidently support the effort and facilitate resident, family, and all health care team members’ understanding and acceptance of the process. In addition, NHs and their Quality Improvement (QI) staff can brainstorm about how to best implement the use of the Tip Sheet and its principles to establish and attain measurable goals in reducing polypharmacy, improving health outcomes, reducing medication costs and administration time.

Future research could be conducted using this Tip Sheet. Some examples include using a specific tracking sheet to help monitor medications being discontinued, collecting data on results for QI, or tallying cost savings resulting from medication discontinuation.

Safe, rational deprescribing is necessary in order to combat polypharmacy in NHs.¹² It is important to be cautious when implementing a deprescribing plan. Less-than-thoughtful medication changes of any kind can result in undesirable health outcomes. Familiarity with the guidelines and resources available, as well as the use of the accompanying Tip Sheet, should provide a safe starting point and guide. At every visit, clinicians need to thoroughly and thoughtfully review medications; engage and communicate with nursing staff, residents/families, and other prescribers on the team; document rationale; and monitor and record outcomes at every step. Emphasis should be on choosing medications wisely with a clear rationale, limiting the deprescribing effort to only one medication at a time. Slow tapers will allow for gentle physiologic adjustments and may help to avoid any potential adverse effects from medication discontinuation. Table 4 lists some of the common potential adverse effects that clinicians should assess for when discontinuing certain drug classes.

Despite solid rationale for deprescribing and close oversight, there may be deterrents to implementation. Deterrents may include resistance from residents, families, collaborative partners, and nursing staff. Resistance may be the result of certain beliefs and attitudes, and can manifest in language such as: “don’t rock the boat”; “but she has always taken this medicine”; “the neurologist said she can never come off this medicine”; or “we tried that before and it didn’t work.” Sensitive negotiation and skillful communication, based on a clearly articulated rationale and an assurance that monitoring parameters will be utilized, can help nudge the process into gear. However, not all deterrents of this nature are surmountable, and there are times when the effort may have to be abandoned and revisited at a later time. Other deterrents include clinicians themselves, who worry about stopping a medication ordered by another prescriber or worry about the adverse effects from stopping a medication.¹² Time expenditure is another significant potential deterrent. All clinicians experience time management challenges, and a thorough medication review typically require extra time to explore previous records and history, interview staff, and communicate and document rationale to residents and families. However, if more unnecessary or potentially unsafe medications were gradually eliminated, less time would be required for medication reviews as there would be fewer target medications to address.

Deprescribing can be rewarding. The potential benefits of reducing polypharmacy are indisputable in terms of better health outcomes; fewer hospitalizations; financial savings; and reduced nursing medication administration.¹³

Safe and appropriate discontinuation of medications requires a solid commitment from the clinicians and nursing staff. Success depends upon understanding and embracing the principles of prescribing for the geriatric population in a holistic and individualized manner. Clinicians should integrate deprescribing into routine clinical practice in order to improve the health of the patient as well as to minimize potential harm and costs associated with inappropriate or unnecessary medication use. We hope this Tip Sheet may be helpful in achieving this worthy goal. 

Authors: Linda M Liu, DNP, ANP-BC, GNP-BC, ACHPN • Irene G Campbell, MSN, APRN, GNP

Affiliation:
UnitedHealthcare Community Plan Waltham, MA

Disclosures: 
The authors represent that such information, opinions, and clinical guidance in this article are provided under the authors’ personal clinical licensure and are not opinions or guidance of UnitedHealthcare.

Address correspondence to:
Linda M Liu, DNP, ANP-BC, GNP-BC,
ACHPN
950 Winter St, Suite 3800
Waltham, MA 02451
Email: linda_m_liu@uhc.com