Welcome to our 10th guest blog post. Today Dr. Joshua Niznik of the University of North Carolina will tell us about his work on overtreatment and deprescribing in nursing home residents in the US. Take it away!
Nursing Home Residents are a Priority Population for Deprescribing
It’s no secret that “medication overload”, or polypharmacy, is a highly prevalent problem in the older adult population. This problem is amplified in nursing homes, where around 2/3 of residents receive 10 or more medications daily.
And it’s not just about medication numbers. Among residents with dementia, more than half receive at least one medication with questionable benefit. These include medications that are not appropriate based on an individual’s goals of care, treatment targets, and remaining life expectancy, as well as the time until benefit of the medication. Due to their limited life expectancy, many nursing home residents also receive medications with uncertain long-term benefits. Swallowing problems are also common, further compromising the tolerability and appropriateness of medications.
Summing up: There is a clear need to reconcile medication use with goals of care that are specific to this medically complex population.
Cholinesterase inhibitors are among the most frequently prescribed medications with questionable benefit. While cholinesterase inhibitors might produce statistically significant improvements in cognition, the clinical significance of these benefits is uncertain. Moreover, there is limited evidence for continued benefit as individuals progress to severe stages of dementia.
Cholinesterase inhibitors are ripe for the picking when it comes to deprescribing, particularly considering the harmful adverse effects associated with these medications (e.g. GI upset, bradycardia, falls).
Deprescribing dementia medications
In collaboration with investigators from the University of Pittsburgh, the University of North Carolina, and the VA Pittsburgh Health System, we conducted a series of longitudinal analyses examining patterns and outcomes associated with deprescribing cholinesterase inhibitors in a sample of Medicare nursing home residents with severe dementia. Here’s what we found:
- Over a 1-year period, the cumulative incidence of deprescribing was just under 30% and was primarily driven by resident characteristics suggestive of poor prognosis.
- Contrary to concerns that may be expressed by providers, we found that deprescribing was not associated with a worsening of behavioural symptoms, nor was it associated with an increase in the use of antipsychotic medications to head off the emergence of these symptoms.
- Deprescribing was not associated with an increased likelihood for all-cause negative events and was actually associated with a reduced likelihood for serious falls and fractures – potentially as a result of reduced incidence of medication-induced bradycardia.
Taken together, our findings suggest that deprescribing cholinesterase inhibitors are a safe strategy to reduce medication burden and potential medication-induced adverse events in nursing home residents with severe dementia.
Addressing overtreatment of chronic conditions
Deprescribing medications with questionable effectiveness seems intuitive. However, overtreatment of chronic conditions such as diabetes, hypertension, and hyperlipidemia is an equally important issue. This is particularly relevant in the nursing home, where the reduced life expectancy of this population may preclude any long-term preventive benefits that would be gained from stringent treatment goals.
Dr. Carolyn Thorpe (University of North Carolina Eshelman School of Pharmacy and VA Pittsburgh Center for Health Equity Research and Promotion) is leading a series of investigations examining potential overtreatment of diabetes, hypertension, hyperlipidemia, and aspirin use among Veteran nursing home residents with severe dementia and/or reduced life expectancy.
In the first study, we identified that more than 40% of residents were potentially overtreated for diabetes, yet less than half of overtreated individuals eventually had their treatment regimen de-intensified. Deintensification of diabetes medications was more strongly associated with low HbA1c values and use of medications with high risk for hypoglycemia, rather than other resident characteristics.
The second study, led by Dr. Sydney Springer, identified that approximately 25% of residents discontinued aspirin for secondary prevention. Multiple specific markers of poor prognosis were associated with a greater likelihood of discontinuation of aspirin.
The findings of both studies suggest an awareness of the limited benefit of these medications for individuals approaching end of life, but future studies are needed to determine the implications of deprescribing on outcomes.
Our group has also conducted analyses examining patterns of overtreatment and deintensification of statins and antihypertensives, which are currently in press at the Journal of the American Geriatrics Society and the Journal of the American Medical Directors Association, respectively. As an extension of our work, we are currently conducting analyses to examine outcomes following deintensification of diabetes, antihypertensive, and statin regimens in this population – more to come soon!
Deprescribing in nursing homes – lots of work to do
There seems to be a lot of opportunity for deprescribing in the nursing home setting. Although our findings suggest that deprescribing is occurring in real-world clinical practice, there is still room for improvement. Interventions to increase the uptake and implementation of deprescribing as the standard of care in this population are needed. Future studies are also needed to determine the benefits and potential harms of deprescribing medications of questionable benefit in older adults. Observational studies leveraging existing data from electronic health records or health insurance claims, such as those described here, can be useful for generating the much-needed evidence to justify the safety of deprescribing.