Can We Treat the Elderly Better by Treating Less?

There is an increasing use of medication in society, particularly among the elderly. Overmedication is a growing issue that not only diminishes the quality of life for the elderly but also places a significant burden on the healthcare system.

We asked Carina Lundby, research leader at the Hospital Pharmacy of Funen and Assistant Professor at the Department of Health Services Research, about the challenges and barriers associated with reducing medication and why it is important for both patients and doctors to consider discontinuing unnecessary treatments.

How is the use of medication among the elderly?

- Generally speaking, both in Denmark and worldwide, there is an increasing use of medication. The consumption is particularly high among the elderly. For instance, it is now common for Danes aged 80 and above to be prescribed five or more different medications. In Danish nursing homes, residents on average use eight different medications.

What are the consequences of using many medications?

- Taking multiple medications is, in itself, the greatest risk factor for adverse drug effects. The elderly are particularly vulnerable to side effects and interactions between medications because their ability to absorb and metabolise drugs changes as they age.

Additionally, we often have limited evidence for the effectiveness of many of the medications we use to treat the elderly, as clinical trials often exclude older individuals and are primarily conducted on younger, healthier people. This means that the elderly are treated with medications that are often not optimally tested for them.

- For elderly individuals with limited life expectancy, the appropriateness of treatment can also change because some preventive medications require several years of use to have a positive effect. For elderly nursing home residents, who often have limited life expectancy, the benefit of continuing certain treatments may be questionable.

Moreover, the practical management of many medications can be challenging. For instance, having to take numerous tablets each day can be a considerable burden for elderly individuals.

What is deprescribing?

- Deprescribing is about continuously re-evaluating medical treatment and possibly discontinuing unnecessary and harmful treatments. It is a holistic process where we review the entire medication list and weigh the potentially beneficial effects against the potentially harmful effects of treatment. The aim of deprescribing is to ensure that each patient only takes medications that are necessary, safe, effective, and aligned with their treatment goals and personal preferences.

What barriers exist for deprescribing?

- Even though both patients, relatives, and healthcare professionals agree on the need for ongoing review and potential adjustment of treatment, deprescribing can be difficult in practice. This is due to many barriers.

For instance, many patients and relatives may be reluctant to stop medication due to fear of relapse and withdrawal symptoms. A valid concern might be that their health could deteriorate if they discontinue the medication. Doctors might hesitate to deprescribe due to a lack of clinical guidelines that offer specific advice on discontinuing treatments.

Additionally, there are often multiple doctors involved in the elderly's medication, which can create uncertainty about who is responsible for discontinuing a given treatment. Furthermore, we generally have a prescribing culture in Denmark, where we as patients often expect to receive something when we visit the doctor—whether it be medication, tests, or referrals.

Can you provide an example of successful deprescribing?

- Yes, I can mention a case from Canada where an elderly woman who had been on antidepressant medication more or less since she was a teenager was deprescribed through an outpatient programme. She had been referred to a geriatric clinic with suspected Alzheimer's as she was experiencing memory problems and difficulties with daily tasks. During the process, all her medications were reviewed, and it was found that several of them had so-called anticholinergic effects, which could potentially negatively affect her cognition, including the antidepressant treatment.

She was taking 15 different medications regularly, plus four as needed. Since she no longer felt depressed, she wanted to try tapering off the antidepressant medication. A tapering plan was developed for the drug, which she eventually stopped taking entirely. She experienced no withdrawal symptoms, which we had been worried about. Upon discharge, her cognition had significantly improved. She was now able to perform tasks she had previously struggled with, such as using her mobile phone and cooking from a recipe.

- At discharge, she was no longer suspected of having Alzheimer's but rather mild cognitive impairment.

The example shows why it is essential to continuously review and adjust medication. Although deprescribing is not always the solution, it was for this woman who ended up feeling much better after stopping an antidepressant medication.

What can be done to improve deprescribing?

- To improve deprescribing, more research and clinical guidelines that provide guidance on stopping treatment are needed.