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Polypharmacy and deprescribing in geriatric care
Polifarmacia y deprescripción en atención geriátrica
J.A. Sánchez-Duquea,b,
, D.M. Perilla-Orozcoc, J.A. Herrera-Guerrerod, G.V. García-Ruize
Corresponding author
a Grupo de Investigación GeriaUNAL - Griego. Programa de Geriatría, Departamento de Medicina Interna, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá D.C., Colombia
b Grupo de Investigación Epidemiología, Salud y Violencia. Departamento de Medicina Comunitaria, Facultad de Ciencias de la Salud, Universidad Tecnológica de Pereira. Pereira, Risaralda, Colombia
c Grupo de Investigación Salud, Familia y Sociedad. Programa de Medicina Familiar, Departamento de Medicina Social y Salud Familiar, Facultad de Ciencias de la Salud, Universidad el Cauca, Popayán, Cauca, Colombia
d Programa de Geriatría, Departamento de Medicina Familiar, Facultad de Salud, Universidad del Valle, Cali, Valle del Cauca, Colombia
e Programa de Medicina, Departamento de Medicina, Facultad de Ciencias de la Salud, Universidad de Manizales, Manizales, Caldas, Colombia
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Programa de Medicina Familiar, Departamento de Medicina Social y Salud Familiar, Facultad de Ciencias de la Salud, Universidad el Cauca, Popayán, Cauca, Colombia" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Programa de Geriatría, Departamento de Medicina Familiar, Facultad de Salud, Universidad del Valle, Cali, Valle del Cauca, Colombia" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Programa de Medicina, Departamento de Medicina, Facultad de Ciencias de la Salud, Universidad de Manizales, Manizales, Caldas, Colombia" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Polifarmacia y deprescripción en atención geriátrica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1896 "Ancho" => 3508 "Tamanyo" => 342724 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Deprescribing algorithm in older adults.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The world is facing a rapid demographic transition in which the older adult population is growing alongside the prevalence of noncommunicable chronic diseases and the phenomenon of polypharmacy.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Medications are the main therapeutic resource used in older adult care. Therefore, in order to preserve the efficacy and safety of each therapy, inappropriate polypharmacy must be prevented.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Each new pharmacological intervention requires an approach centered on the older adult patient in which a medication reconciliation is performed and the presence or risk of inappropriate polypharmacy is verified.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It must include a controlled deprescribing strategy, if necessary, in order to later devise a plan with periodic objectives, prioritizing medications with a better risk-benefit profile and the best dosing regimens according to each specific case. It should also not ignore the need for continuous monitoring in order to identify errors or flaws that could go unnoticed.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">There are older adults with specific conditions for whom the appropriateness of starting a deprescribing strategy must always be considered: (1) Polypharmacy (five or more medications); (2) Frailty; (3). Advanced-stage neurodegenerative disease; (4) End-stage disease.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Therefore, explicit criteria for inappropriate polypharmacy must be known and applied in this population or according to the attending physician’s judgment. These criteria include: (1) Beers Criteria; (2) STOPP/START Criteria; (3) IPET Criteria; (4) PRISCUS List; (5). Medication Appropriateness Index, among others.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The deprescribing algorithm in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> is proposed in order to facilitate implementation of a quaternary prevention strategy in the older adult population</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Among the medications that are usually prescribed in older adults, those that are most susceptible to being withdrawn are: (1) Antihypertensives; (2) Antidiabetics; (3) Lipid-lowering drugs; (4) Hypnotics; (5) Antidepressants; (6) Anticholinergics; (7) Neuroleptics; (8) Nonsteroidal anti-inflammatory drugs; (9) Antiulcer agents.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a> Successful deprescribing is a dynamic process linked to clinical progress and the scientific evidence. Therefore, it is vital to know the tapering regimens for each medicine prior to its complete deprescribing for some drug classes, such as neuroleptics (gradual 10%–25% reduction in the total daily dose each week), antipsychotics (25%–50% reduction every 2 weeks), and antiulcer agents (50% reduction in two weeks, then space out the interval until withdrawal).<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">As part of a comprehensive geriatric assessment, both treatment adherence<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and adherence to deprescribing plans must be monitored.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Errors or noncompliance with the medication tapering strategy can generate adverse effects or the need to restart the medication.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> On the other hand, successful deprescribing from inappropriate polypharmacy can lead to a reduction in the risk of falls, hospitalizations, and mortality.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">There have been many scientific advances and the development of instruments to identify and control inappropriate polypharmacy in the older adult population. Paradoxically, we are facing the challenge of achieving the systematic implementation of tools to solve the public health challenge of inappropriate polypharmacy, a problem that has been generated due to a lack of information and training on quaternary prevention in older adults.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–9</span></a> Current evidence suggests that in order to combat the phenomenon of polypharmacy, continuing medical education programs on clinical pharmacology, especially on deprescribing, should be established not only for undergraduate and graduate students, but also for physicians and other health professionals who are practicing. These programs should be led by geriatricians and family physicians.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,9,10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">For this reason, it is hoped that these strategies are included in a protocolized manner in the various institutions and departments which manage older adult patients. It is time to overcome the fear of deprescribing and replace it with a fear of falling into clinical or treatment inertia.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors of this article have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1896 "Ancho" => 3508 "Tamanyo" => 342724 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Deprescribing algorithm in older adults.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prescripción inapropiada en adultos mayores: una mirada desde la atención primaria" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.D. 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