Geriatricians routinely see older adults who are prescribed an overload of medicines that may not benefit them or be aligned with their goals —and that often cause harm including falls, cognitive impairment, hospitalization and death.
Johns Hopkins geriatrician and clinician-researcher Ariel Green wants to change that. Her research aims to improve communication among older adults, their family caregivers and clinicians about medication use — so that treatment decisions are patient-centered and not purely disease-oriented and guideline-driven.
Qualitative research by Green’s team shows that communication about medicines is often suboptimal, leading to treatment decisions that are poorly informed.
Deprescribing is the process of reducing or stopping use of medicines that may cause harm or no longer be of benefit. It is an important and underused approach to reducing iatrogenic harm for older adults. While many older adults and caregivers are eager to deprescribe, others may have concerns about stopping medicines. If clinicians don’t explain deprescribing in a way that resonates with patients and caregivers, it is not likely to succeed.
In a recent study, Green and colleagues examined older adults’ preferences regarding rationales a clinician may use for why a patient should stop an unnecessary or potentially harmful medicine. Their results were published in JAMA Network Open in 2021.
The large national survey used two common scenarios, one in which a statin was being used for primary prevention and another in which zolpidem was being used for insomnia.
Phrases that resonated the most with older adults focused on the risk of side effects, highlighting the importance of informing patients about potential harms of medicines, such as falls and cognitive impairment. Previous research by Green’s team suggests that these adverse effects may rarely be discussed in current practice, even for older adults who have already experienced them.
A phrase that did not resonate with participants was, “I think we should focus on how you feel now rather than what might happen years down the road.” This survey result suggests that a recommendation to deprescribe may be perceived as rationing or withdrawal of care if not framed as a way to preserve well-being.
Findings from this study are directly informing development of educational materials for patients, families, primary care providers and clinical pharmacists. Green’s team is testing these materials in pragmatic approaches to deprescribing in primary care. This work is funded by the National Institute on Aging.
“In my clinic, I often see older patients feel better when they take fewer medicines,” Green says. “I love discovering patient-centered approaches to [communication about deprescribing], and fostering a culture of thoughtful prescribing and deprescribing that I can bring to my patients.”