It’s common knowledge among pharmacists: older people are more vulnerable to medicine-related harms, not only because of polypharmacy and inappropriate prescribing, but also because of changes in drug distribution, metabolism and elimination with age. Too often, medicines may be the cause of confusion or cognitive decline, falls, hospitalisation and even death in this population.
Medicine-related harm is a worldwide epidemic. The World Health Organization flagged it as a health priority in 2017 for its third Global Patient Safety Challenge: Medication Without Harm
. A total of 66% of older people in Canada take at least five medicines, with 27% taking ten or more
. Older people are hospitalised five times more often than people aged under 65 years because of harmful medicine effects in Canada
In 2015, a group of Canadian policymakers, healthcare professionals, patient advocates and researchers agreed it was time for action. Deprescribing — the planned and supervised process of reducing or stopping medicines that may no longer be of benefit or may be causing harm — was identified as a major solution, combined with access to safer non-pharmacologic therapy. A grassroots movement called the Canadian Deprescribing Network (CaDeN) was born.
Patients at the core
Although education of healthcare professionals is a priority, the main thrust of our campaign is directed towards patients. Patients are receptive; according to one study, more than 70% would be willing to stop taking a medicine if their doctor said it was possible
. A major goal is to encourage patients to feel comfortable asking their health provider: “Do I still need this medication?”
Another goal is to empower patients with information about their medicines by providing free and credible advice. We have developed educational tools and resources, including brochures about specific inappropriate prescriptions, such as sedative-hypnotics, which led to a 27% deprescribing rate over six months
. We have also published online quizzes about antipsychotics, bi-monthly webinars, and peer champion deprescribing stories.
Slowly but surely, we are driving a change in culture. Now, when patients see a prescriber, they don’t only think “will I get a new prescription?” but are empowered to ask if all of their medicines are still necessary.
Research and lobbying
Deprescribing research is another priority. The D-PRESCRIBE randomised trial
looked at the use of a patient brochure coupled with pharmacists making evidence-based recommendations to physicians. This led to deprescribing among 43% of chronic sedative-hypnotic users, 58% of non-steroidal anti-inflammatory drug users and 31% of glyburide users. Other evidence-based tools, such as deprescribing algorithms, are freely available.
Raising awareness among policymakers is crucial. We are working with provincial and territorial governments to identify which policies could best promote appropriate prescribing in their jurisdiction.
The future of deprescibing
We have come a long way in only four years. Medicines safety and deprescribing are now on the radar of Canadian community organisations, the government, patients and healthcare providers. There has also been increased interest in traditional and social media, with appropriate medicine use now at the forefront of public health concerns. Older people are having meaningful conversations with their health providers.
Deprescribing promotes and maintains trust between patients and their pharmacist
. Pharmacists everywhere can support efforts to reduce polypharmacy, prevent medicine-related harms among older people and deprescribe when appropriate.
Cara Tannenbaum is a geriatrician and director at the Canadian Deprescribing Network. For more information on deprescribing visit: www.deprescribingnetwork.ca
World Health Organization. The third WHO Global Patient Safety Challenge: Medication Without Harm. Available at: https://www.who.int/patientsafety/medication-safety/en/ (accessed February 2019)
Canadian Institute for Health Information. Drug use among seniors in Canada, 2016. 2018. Available at: https://www.cihi.ca/sites/default/files/document/drug-use-among-seniors-2016-en-web.pdf (accessed February 2019)
Canadian Institute for Health Information. Adverse drug reaction-related hospitalizations among seniors, 2006 to 2011. 2013. Available at: https://secure.cihi.ca/free_products/Hospitalizations%20for%20ADR-ENweb.pdf (accessed February 2019)
Tannenbaum C, Martin P, Tamblyn R et al. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient eEducation: The EMPOWER cluster randomised trial. JAMA Intern Med 2014;174(6):890–898. doi: 10.1001/jamainternmed.2014.949
Martin P, Tamblyn R, Benedetti A et al. Effect of a pharmacist-led educational intervention on inappropriate medication prescriptions in older adults: the D-PRESCRIBE randomized clinical trial. JAMA 2018;320(18):1889–1898. doi: 10.1001/jama.2018.16131