On average, seniors have the highest number of chronic conditions and, as a result, are prescribed more drugs than any other age group.1 Dr. Cheryl Sadowski, a professor with the Faculty of Pharmacy and Pharmaceutical Sciences at the University of Alberta, has specialized in geriatrics for most of her pharmacy career. She has been a longtime advocate for improving prescribing practices for seniors.
“There are many seniors who are on 10, 15, or 20 medications,” she said. “So many seniors are taking medications that are not working anymore that are just adding costs and increasing the potential for negative drug interactions. We’ve been working for decades to advocate for quality pharmacy care for seniors and to help pharmacy professionals consider their prescribing practices.”
Cheryl said the conversation started to change about 20 years ago when the concept of “deprescribing” was first popularized. This term was identified to capture the concept of reducing or stopping medications that may not be beneficial or may be causing harm with the goal of maintaining or improving the patient’s quality of life.2
The movement gained momentum when the Canadian Medication Appropriateness and Deprescribing Network was founded in 2015. Through their advocacy and policy work, the network strives to reduce medication burden and harm, while maintaining or improving quality of life for patients.
Cheryl said, for senior patients, reducing their medication burden could significantly improve quality of life, as many seniors’ day-to-day lives are highly medicalized due to the high number of prescriptions they take every day, throughout the day.
“Seniors often have to arrange their meals, activities, and work around their medication and all of the things they have to do to monitor and manage their health conditions,” she said. “It truly changes their identity and how they live their lives. What we want to see is a patient’s medication regimen feeling manageable and fitting their lifestyle.”
She added that seniors’ identities should not revolve around their health conditions.
“The fewer medications someone is taking, the less they have to think about themselves as a person with a disease—if they’re not spending all day monitoring their medications, they can focus on other parts of their lives,” she said. “We want people to identify not just as a person with a disease. Their health conditions are important but should not be the only consideration in how they live their lives.”
Cheryl recognized that it can be difficult for pharmacy teams to stop medications once they’ve been prescribed.
“Once a medication has been started, it can seem really difficult to stop it. Ideally, we want to think about good prescribing in the first place and avoid potentially inappropriate medications right from the start,” said Cheryl. “Good prescribing for older adults will reduce the need for deprescribing but deprescribing will always be important as someone’s health changes and there is always that important option to improve medication safety and reduce the burden on the patient.”
The process of deprescribing can be daunting in a busy pharmacy environment, but Cheryl said it doesn’t have to be a time-consuming process.
“It doesn’t always have to take a long time and it might just be starting with something small like one drug class,” she said. “When you’re working with senior patients, just remember to ask yourself, ‘Should these medications be continued? Does the patient actually need this medication? Is there another alternative way we can treat this condition?’”
Cheryl provided a few examples of where to start.
“If you’re just starting this process, perhaps give deprescribing more consideration for patients who are on 10 or more medications, for patients 80 years of age or older, or for patients who are taking certain drug classes like sleeping pills.”
Cheryl added that patients know their conditions and priorities best, so it is imperative to ensure the patient is always included in deprescribing decisions.
“Whether prescribing or deprescribing, it is important to discuss any implications with the patient—what are the benefits, the side effects, and the timeline? I would like to see seniors more involved in all medication decisions, not just deprescribing,” said Cheryl.
When pharmacy teams change their approach to work collaboratively with their senior patients and identify opportunities to deprescribe, an important perspective shift can occur. Cheryl said, when a pharmacy team receives a prescription, she hopes to see a shift away from automatically assuming the patient needs the medication. Instead, she encourages pharmacy teams to take the approach of “this medication is indicated and is available for the patient,” and then going through the steps of shared decision making with the patient.
Cheryl encouraged pharmacy teams to refer to the Canadian Medication Appropriateness and Deprescribing Network website, which offers valuable resources for healthcare providers, as well as resources for patients.
“We focus so much on starting medications in our healthcare system,” said Cheryl. “Once we start rethinking our approach to justifying each time why we should start medications, or why we need to continue those medications, we will support better outcomes for our senior patients.”
