Deprescribing Interventions for Older Adults with Cancer and Polypharmacy

Andrew Whitman, PharmD BCOP
Lead Clinical Pharmacist—Oncology/Palliative Care
University of Virginia Health System
Charlottesville, VA

Polypharmacy has been called “America’s other drug problem.”1 Overuse of medications, especially in older adults, is a multifaceted issue and a large burden to our healthcare system. A diagnosis of cancer adds an additional layer of complexity.¹ A common barrier to evaluating polypharmacy is the heterogeneity of definitions and processes in the current medical literature. The study reviewed here, “Pharmacist-Led Medication Assessment and Deprescribing Intervention for Older Adults with Cancer and Polypharmacy: A Pilot Study,” attempted to standardize polypharmacy assessment and subsequent deprescribing interventions in older adults with cancer.²

In this study, adult patients age 65 years or older with a diagnosis of cancer (of any type) were assessed in the Geriatric Oncology Clinic at the University of Virginia Health System.² Each patient was evaluated by a nurse, physical therapist, pharmacist, and geriatric oncologist. The pharmacist’s role on this team was to complete a polypharmacy assessment and add it to the overall comprehensive geriatric assessment (CGA) score. A CGA helps determine existing, treatable health problems in older adults and aims to improve overall care outcomes (a detailed review of the CGA is beyond the scope of this review³). The first step to any effective deprescribing intervention is creating an accurate medication list. Therefore, the majority of the time was spent consolidating medication information. This included review of electronic health records, outside pharmacy records, patient reports, and caregiver feedback. All types of medications and supplements were included in the polypharmacy review. A deprescribing process was then applied to each inappropriate therapy.

The following themes were core to the success of the deprescribing interventions in this study:

Medication-condition matching

As displayed in (Figure 1-see PDF) in the study, the medication-condition matching chart helped organize and highlight the specific indications for each therapy. Medications without obvious indications were flagged for further investigation and deemed potential deprescribing candidates. The chart also included “potential problems” in the medication-condition matching chart in order to help identify prescribing cascades or new medication-related adverse effects.

Why is this important?
This visual representation of medications brings to light the extent of medication burden and is often shocking to patients and providers. A missing indication can help prompt the question of whether prescribing cascades or prescribing inertia has occurred.

Comprehensive potentially inappropriate medication review (utilizing three assessment tools)

In this study, a three-tool assessment was used in order to be as comprehensive as possible. The Beers Criteria, Screening Tool of Older Persons’ Prescriptions, and Medication Appropriateness Index have the strongest data supporting use in older adults with cancer.

Why is this important?
The concurrent, sequential use of these tools was chosen to maximize PIM identification; this combination of implicit and explicit screening tools proved to be effective. This is a novel method of polypharmacy evaluation that had not been evaluated in other studies in older adults with cancer.

Determination of medication-related “goals”

In this study, medication-related goals were assessed. This entailed verbal discussions regarding patient and caregiver opinions and attitudes toward general medication use (e.g., minimizing pill burden, optimizing quality of life, focusing on chronic disease state management). The study recognized that a limitation to evaluating medication-related goals was the lack of a well-validated patient-reported goals metric.

Why is this important?
In the course of pursuing deprescribing interventions, it is essential to be person-centric in making decisions. Patients with existing attitudes and opinions about deprescribing can make the action of deprescribing easier and more efficient. Methods to assess patient-reported outcomes related to medication “goals” warrants additional exploration in future studies.

Discussion of barriers to deprescribing

Patient and caregiver barriers to deprescribing were informally evaluated during each direct patient encounter. Each patient appointment was on average 15 minutes, and the majority of time was spent directly discussing patient and caregiving questions and fears about deprescribing. Barriers to deprescribing for providers were not assessed in this study.

Why is this important?
A growing body of literature is evaluating patient and provider barriers to deprescribing. It is important to identify barriers to deprescribing as soon as possible—this helps to drive decision making and improves transparency between providers. Since the completion of this pilot, studies looking at a method of assessing barriers to deprescribing has been validated (i.e., the Patients’ Attitudes Towards Deprescribing questionnaire).^4-6 Common barriers for providers include reluctance to stop medications initiated by other providers, lack of ownership of the deprescribing process, and underappreciation of the scale of polypharmacy-related harm. Common barriers for patients include the belief that taking a medicine to prevent or treat a disease is always needed (“pill for every ill”), fear of drug withdrawal, and feeling “abandoned” or not worthy of treatment.

In our study,² data were collected for 26 patients during an 8-month period. The 26 patients in this study were taking a total of 312 medications, of which 197 were prescription and 113 were over-the-counter or alternative therapies. The mean number of medications per patient was 12. The Beers Criteria alone identified 38 potentially inappropriate medications (PIMs) compared to 119 PIMs with the three-tool assessment; a mean of 5 PIMs per patient was identified. After the application of the three-tool assessment, 73% of PIMs identified were deprescribed in real time by the pharmacist and geriatric oncologist, resulting in a mean of three medications deprescribed per patient. Based on University Health System Consortium outcomes cost data, healthcare expenditures of $111,390 were potentially avoided as a result of PIM assessment and deprescribing. Fifty-two percent of patients reported no barriers related to stopping medications and felt comfortable with the process. Of the patient-reported barriers to deprescribing, the most common concern was fear of return of symptoms or worsening of the underlying condition being treated.

This is one of the first studies to demonstrate the effectiveness of a standard approach to polypharmacy assessment and deprescribing in older adults with cancer. The three-tool assessment process should be incorporated into interdisciplinary assessments of older patients with cancer and validated in future studies. Deprescribing should be seen as an individualized assessment of medications that is driven by patient and caregiver goals as well as evidence-based medicine.

References

1. Guharoy R. Polypharmacy: America’s other drug problem. Am J Health Syst Pharm. 2017;74:1305-1306.
2. Whitman AM, DeGregory KA, Morris AL, et al. Pharmacist-led medication assessment and deprescribing intervention for older adults with cancer and polypharmacy: a pilot study. Support Care Cancer. 2018;26:4105-4113.
3. Parker SG, McCue P, Phelps K, et al. What is a comprehensive geriatric assessment (CGA)? An umbrella review. Age Ageing. 2018;47:149-155.
4. Reeve E, Shakib S, Hendrix I, et al. Development and validation of the Patients’ Attitude Towards Deprescribing (PATD) questionnaire. Int J Clin Pharm. 2013;35:51-56.
5. Reeve E, Low LF, Shakib S, Hilmer SN. Development and validation of the revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire: versions for older adults and caregivers. Drugs Aging. 2016;33 (12):913-928.
6. Reeve E, Anthony AC, Kouladjian O’Donnell L, et al. Development and pilot testing of the revised Patients’ Attitudes Towards Deprescribing questionnaire for people with cognitive impairment. Australas J Ageing. 2018;37:e150-e154.