< = > less is more De-diagnosing De-prescribing Non-testing
Who says? Overdiagnosis Polypharmacy False positives Too much medicine Risk aversion $$$
Sources Prof David Le Couteur, Clin Pharm and Aged Care Preventing Overdiagnosis Conference 2016
Sources Evidence-Based Medicine 2012
Language IMU = inappropriate medication use IMUP = inappropriate med use w polypharmacy PIM = potentially inappropriate medication POM = prescribing optimisation method ADR = adverse drug reactions DDIs = drug-drug interactions DBI = drug burden index VOCODFLEX = very old age, the extent of comorbidity, dementia, frailty and limited life expectancy CRIME = Criteria to Assess Appropriate Medication Use Among Elderly Complex Patients
Concept of De-Diagnosis Age-appropriate BP vs hypertension Diabetic control in the elderly Bacteruria vs UTI Ankle oedema High cholesterol Don t have it -> no need to treat it.
Need to understand: The individual, robust vs frail, their therapeutic goals The benefits and risks of all of their medicines + combination Ethics of autonomy, dignity of risk, preferences Very limited evidence on the safety and efficacy of medicines in older adults, particularly in the frail, who often have multiple comorbidities and functional impairments. In robust older patients, therapy usually aims to delay or cure disease and to minimise functional impairment. In frail older patients, symptom control, maintaining function and addressing end-of-life issues become the main priorities.
Patient-based issues Fear of change My doctor said I should stay on it for life Worry about what might happen: They said I could get a stroke or heart attack All my friends are on it for life Generational: perceived benefit of medications Perception of age discrimination -> need explanation and reassurance cooperation with primary care provider (Help patient negotiate with PCP)
Which meds? Statins, gastric acid suppressive agents, angiotensin-converting enzyme inhibitors/angiotensin receptor antagonists and inhaled bronchodilators were the most frequently ceased medications ANTICHOLINERGICS
Prescription cascade pain due to osteoarthrosis NSAID prescribed NSAID induces hypertension more antihypertensive drugs drug-induced nausea metoclopramide extrapyramidal symptoms wrong diagnosis of Parkinson s disease levodopa orthostatic hypotension (falls) and delirium antipsychotics; dihydropyridine-induced leg edema furosemide and potassium automatically prescribing H2 blockers to patients on NSAID delirium in older people erroneous treatment with neuroleptics cold medications containing compounds with anticholinergic properties urinary retention α blocker falls (Source: Ther Adv Drug Safety 2015 Routine deprescribing of chronic medications to combat polypharmacy)
Tools STOPP/START criteria Beers criteria Medication Appropriateness Index Improved prescribing in the Elderly Tool (IPET)
Beers criteria List of over 50 drugs or drug classes to be avoided in older ppl, incl:
Medication Appropriateness Index
BUT...risks Withdrawal reaction Return of previously controlled diseases
Non-testing Not yet well-developed literature Take a good history, work out likely pathophysiology, explain to patient Discuss balance of risks not confirming diagnosis vs false +ve/discomfort/cost Agree on a plan for f/up /review ( If you still have it next week...)
Latest issue EMA Review: Probiotics to prevent antibiotic-associated diarrhoea in kids: Antibiotics are commonly prescribed for children, sometimes even when clinically indicated From a societal perspective, more benefit could probably be achieved by only prescribing antibiotics to children who truly need them