Deprescribing No Easy Job
Written by Jan Hallam
Thursday, 30 November 2017
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A complex set of clinical and cultural factors govern the relationship between the prescriber of medication and those taking it. That relationship is complicated further when the patient is aged and cognitively frail.

Geriatrician and clinical pharmacologist A/Prof Christopher Etherton-Beer, of the WA Centre for Health and Ageing, who has spent much of his research time endeavouring to understand the effects of polypharmacy on the elderly, knows how passionate people can be about their medications.  

201712-Christopher-Etherton-Beer-AProf Feb16A/Prof Christopher Etherton-Beer“Our first deprescribing pilot, that was over a decade ago now, was with volunteers in the community who had very strong beliefs about their medicine,” he said.

“Our ideas have evolved over that time. We turned to aged care facilities and discovered we could have quite sophisticated discussions even with impaired older people and with their families around the risk-benefits of some of their medicines. For many older people, a lot of medicines were started years earlier when they were robust and now there is a greater risk of interactions and side effects.”

Readers will remember the articles published on former Geraldton GP Kathleen Potter’s deprescribing study five years ago, which was part of her PhD. Chris was her supervisor and said the study used a well-defined algorithm but it was an open study of only about 100 people, which had its limitations.

Research is tricky

 “We thought it was important to do a larger, blinded study which we’re running currently called Optimed, but it’s a bit like pushing a boulder up a hill! It’s been hard to run and hard to recruit. We have about 200 in WA and less in NSW. It will be larger than our previous study but we’re not sure if we will get to our 500.”

“However, we felt the blinded study was important because people bring a lot of bias when it comes to their medicine – both in terms of placebo and for those who believe their medicines are causing them problems. We know from the placebo controlled trials that people taking placebos get a lot of what they think a medicine should do. So it’s certainly not a straightforward story.”

“We have tried to broaden the work. PhD student Amy Page has developed the Medication Appropriateness Tool for Comorbid Health conditions in Dementia (MATCH-D), which we will use to help determine to what extent improved medication management produces better health and functional outcomes for people living with dementia.”

Chris and his team were awarded a $586,000 NHMRC grant in August for this work.

This study and other studies will hopefully help GPs to navigate the complex area of medication use.

Doctors need support

“Doctors are the ones who must manage the risk factor of polypharmacy and GPs are really conscious of the problem. The feedback we get is that they’re looking for tools to help. They are bombarded with advice on how to start medicines but not much on how to stop prescribing and how to have those conversations with patients,” Chris said.

“Looking back over the years we’ve been doing this research, we’ve had those same concerns. Satins are quite a good example of this dilemma. People said ‘isn’t it ridiculous this doctor prescribing a statin or a bisphosphanate to a 95-year-old in a nursing home’. So what do you say if that 95-year-old has a hip fracture or stroke that can impair their quality of life. It’s often not black and white.”

“When we started work we were quite concerned that there needed to be more high quality data. Dr Doron Garfinkel published uncontrolled work in a palliative population, which showed that if you withdrew people’s medicine you could increase survival.”

“We started with this data because it had a large magnitude of effect – 50% increase of survival in the course of the study but it was uncontrolled and we were sceptical about that. But going through the work we do see positive results, anecdotally people feel better.”

“Kathleen’s study had only about 100 people and was not powered for mortality, but there did not seem to be any harm indicated. We are starting to feel more positively that if you reduce the burden of people’s medicine, they might actually feel better and live longer. It’s a tantalising possibility.”

Ageing in the home

While this research is focused on aged care facilities, people are ageing in their own homes longer and more effectively.

“The conversation with a lot of our patients is around risk and asking the question, what is the worst that can happen? We need to explore the person’s tolerance for that risk because we know that there are a lot of challenges in residential care too with the heavy burden of falls and infection.”

“We are often saying to people, the difference is not always comparing living in a structure environment with living at home. It’s about support. We need to make the risk explicit and have clear conversations with the person and their family. We have a responsibility to exhaust all the options.”

“We are so fortunate that we have extended lives to look forward to – we have to work to ensure they are not only longer but healthier lives.”