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<div class="editorbox"> '''Original Editor '''- [[User:User Name|Debbie Kenny]] '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
=='''Introduction'''==
=='''Introduction'''==
'' what is the current issue with overprescription and define deprescription''
[[File:Polypharmacy.jpeg|thumb|399x399px|Polypharmacy]]
=== Learning Outcomes ===
Over the last 30 years, people have been prescribed increasing number of medicines, in particular [[Medication and Older People|older people]]. The reasons are manifold and include:
This resource will enable the reader to:
# Define deprescription and its relevance to the Health Care system  
# Explain the role of the physiotherapy profession in deprescription
# Justify the value of deprescription within AHP’s and its application within health care
# Recognize populations at risk of over-prescription and identify common clinical problems/scenarios and medications involved
# Rationalize appropriate non-pharmacological alternatives
# Explain how multidisciplinary teams can work together to better promote/apply deprescription
# Evaluate one’s own practice in relation to the movement of deprescription
===Audience===
This resource is intended for qualified or pre-reg student physiotherapists who are interested in recognizing clinical circumstances of overprescription and further educating themselves on the potential role that could play is addressing this growing issue. All other allied health professionals, academics or individuals interested in the topic are also welcome.
== Benefits and Harm of Deprescription ==
== Knowledge and Skills Required to Have a Role in Deprescription ==


== Common Populations at Risk ==
* A rise in [[multimorbidity]] and ageing populations
The use of multiple drugs is not always an indicator of poor drug treatment or overmedication (Tamminga 2011). Appropriate medication depends on whether or not the advantages outweigh the disadvantages which is subjective to both the individual and their given condition(s). It can be very hard to predict the side-effects or clinical effects of a drug combination without testing it on the specific individual as the effects all very based on the individual's genome-specific pharmocokinetics (Taminga 2011).  
* Use of [[Evidence Based Practice (EBP)|evidence-based practice]]
=== '''1. Elderly Populations''' ===
* Greater expectations for outcomes from patients and their families<ref name=":0">NHS UK [https://www.sps.nhs.uk/articles/understanding-polypharmacy-overprescribing-and-deprescribing/ Understanding polypharmacy, overprescribing and deprescribing] Available:https://www.sps.nhs.uk/articles/understanding-polypharmacy-overprescribing-and-deprescribing/ (accessed 29.12.2022)</ref>
As a result of improvements in health care services and modern technology, the aging baby-boomer generation has a longer life-expectancy than previous generations. However, the risk of multiple chronic diseases increases with age requiring multiple medications. Various studies have shown that on average, older adults are consuming 2-9 medication per day with a shocking prevalence of inappropriate medication use of 11.5-62.5% (Hajjar et al. 2007; Kwan et al. 2014). Elderly populations are specifically at risk of adverse drug reactions (ADR) as a result of age related changes such as increased medication sensitivity, slower-metabolism and slower drug elimination. There appears to be a virtually linear relationship between the occurrence of ADRs with every drug taken as well as a cumulative potential for adverse side-effects (Viktil et al. 2007; Kwan et al. 2014). What is more concerning is the fact that signs of polypharmacy are often masked as usual signs and symptoms of aging including: tiredness, decreased alertness, constipation, diarrhea, incontinence, lack of appetite, confusion, depression or lack of interest in usual activities, weakness, visual or auditory hallucinations, anxiety, dizziness. 


Polypharmacy in elderly populations can also lead to poor quality of life, increase the risk of falls and poor compliance with medication. The concept of  a "pill burden" is recognized as having so many different drugs or pills to take on a regular basis that it can be challenging to organize, store, consume, let alone understand their purpose or appropriate regimes. In turn, "pill burden" increases the risk of hospitalization, medication errors, and has negative effects of healthcare outcomes and costs (Malhotra et al. 2001; [https://www.karger.com/Article/Pdf/365328 Gomez et al. 2015]).
The dangers of using multiple medicines include greater chances of:  


Reconsidering this population's prescription on a regular basis is important to maximize their quality of life throughout their remaining years. The relief achieved from reducing their medication load may potentially lead to better outcomes. Special attention may also be needed towards those considered to have frailty, the clinically recognized state of increased vulnerability, as they are even less resistant to adversity and not considered as a separate entity in most clinical guidelines (Sergi et al. 2011).
* Adverse drug experiences
* Hospital admissions and health care costs
* Non-adherence to medication<ref name=":0" />


=== '''2. Psychiatric Patients''' ===
Overprescribing may occur when:
Psychiatric disorders are complex our understanding of these conditions remains inadequate. Although the complexity of illnesses such as schizophrenia may understandably require a polypharmaceutical approach, Tamminga et al. (2011) believes "it is incumbent upon us to step forward and test these assumptions so that validated combination treatments are demonstrated to enhance therapeutic outcomes and not only ameliorate side effects." There is insufficient and conflicting evidence regarding the benefit or detriment of polypharmacy emphasizing its subjectivity and need for further research.
* A better alternative is available but not suggested
* The drug is suitable for a condition but not the individual.
* A condition alters and the medicine is no longer suitable/relevant.
* The patient has ceased needing the medicine but it continues to be prescribed.<ref>BBC news [https://www.bbc.com/news/health-58639253 Overprescribing of medicines must stop, says government] Available:https://www.bbc.com/news/health-58639253 (accessed 28.12.2022)</ref>


Polypharmacy may be recommended to treat adverse effects of the primary drug, the provide acute improvements while waiting for delayed effects of another prescription, to boost the effectiveness of a primary drug or to treat intervening illnesses such as depression during the course of their schizophrenia ([https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3653237/ Kukreja et al. 2013]) however, due to the lack of research in the demerits of drug combinations and increased risk of adverse drug to drug interactions, special attention must be paid towards education, proper screening, and further research.
== Deprescribing ==
[[File:Drug interaction .png|591x591px|alt=|thumb|Chance of adverse reactions with multiple medications]]
Deprescribing is the complicated process undertaken for the safe and effective withdrawal of inappropriate medication. A lot of of the evidence underpinning deprescribing is from observation, being based on the patient’s physical functioning, co-morbidities, preferences and lifestyle.


=== '''3. Other Populations''' ===
Deprescribing:
* Co-morbidities
* Recent hospitalizations
*


* Should be part of good prescribing, with re-evaluation of dosages periodically.
* Involves health care professional direction and supervision with the same level of expertise and attention that prescribing entails <ref name=":6">Reeve E, Thompson W, Farrell B. Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. European Journal of Internal Medicine.2017;38:3-11.
</ref>.
The following videos provides an easy to follow in-depth discussion regarding the concept (6 minutes){{#ev:youtube|zjUsqABxaEs}}
== Overprescribing ==
[[File:Pill organising safe.png|thumb|384x384px|Medications: review regularly]]
Overprescribing is when people are prescribed medicines:
* They no longer need or want
* The medicine has greater possible harmful than beneficial effects.
* When a more effective alternative is not prescribed
* Where the medicine is correct for a condition but not the individual.
* When a condition alters and the medicine is no longer appropriate.<ref name=":0" />
The extensiveness of polypharmacy reported in literature differs, being between 10% to 90% according to the age group, definition used, healthcare and geographical setting of the study.<ref name=":1" />
== Patient Engagement ==
Medication reviews, joint decision-making and deprescribing rely on people becoming involved in decisions regarding their health care. Information to give patients and their carers about the medicines they are taking should be a priority, taking into account language, culture and level of health literacy.<ref>UK Government [https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1019475/good-for-you-good-for-us-good-for-everybody.pdf Good for you, good for us, good for everybody] Available:https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1019475/good-for-you-good-for-us-good-for-everybody.pdf (accessed 29.12.20220</ref>
== Common Populations at Risk ==
[[File:Elderly woman.jpeg|thumb|Age: risk factor for over medicated.]]
The use of multiple drugs is not always an indicator of poor drug treatment or overmedication<ref name=":12">Tamminga C. When Is Polypharmacy an Advantage?. American Journal of Psychiatry. 2011;168(7):663-663.</ref>. Appropriate medication depends on whether or not the advantages outweigh the disadvantages which is subjective to both the individual and their given condition(s). It can be very hard to predict the side-effects or clinical effects of a drug combination without testing it on the specific individual as the effects all very based on the individual's genome-specific pharmocokinetics<ref name=":12" />. 
At risk populations include:
* [[Introduction to Frailty|Frail]]
* [[Obesity]]
* [[Older People - Patterns of Illness, Physiological Changes and Multiple Pathology|Elderly Populations]]
* [[Mental Health]] Patients
* [[Multimorbidity]]
* Recent hospitalizations/major [[Surgery and General Anaesthetic|surgery]]
* People seeing multiple doctors
* [[Oncology and Palliative Care|Terminally ill patients]]
Sex, educational level, and [[Smoking Cessation and Brief Intervention|smoking]] apparently appear not to be related to polypharmacy.<ref name=":1">FAQs clear [https://www.faqsclear.com/what-population-is-at-risk-for-polypharmacy/ What Population Is At Risk For Polypharmacy?] Available:https://www.faqsclear.com/what-population-is-at-risk-for-polypharmacy/ (accessed 29.11.2022)</ref>
==The Potential Role of the Physiotherapist in Deprescribing==
[[File:Non-pharma approaches.png|frameless|558x558px|alt=|right]]
Available literature linking physiotherapy with deprescribing has focused only on the role of physiotherapy as a supplementary treatment for pain relief when reducing opioid dosage.  
General advice that may be given on the effects of medication. For example the general side effects of non-steroidal anti-inflammatory drugs (NSAIDs). While providing advice it should also be recommended that the patient should seek advice from a pharmacist or independent prescriber before altering any medication they currently take<ref name=":33">Chartered Society of Physiotherapy. Medicines, prescribing and physiotherapy [Internet]. CSP; 2016. Available from: <nowiki>http://www.csp.org.uk/publications/medicines-prescribing-physiotherapy-4th-edition</nowiki></ref>.
'''Is patient taking their medication incorrectly?:''' If a non-prescriber physiotherapist notices a patient is not taking their medication correctly, they can refer the patient to the medications instructions and remind them how and when/ dose they should be taking their medication as prescribed<ref name=":33" />. This can also apply to medication devices, e.g. an inhaler, advice can be given how to use it according to guidelines.
Adverse Effects:Physiotherapists can refer the patient back to the GP/pharmacists or can contact the GP directly providing information on their concerns re adverse effects <ref name=":3">Reznik J, Keren O, Morris J, Biran I. ''Pharmacology Handbook for Physiotherapists.'' Australia: Elsevier; 2016.
</ref>.
== Non-Pharmacological Interventions==
== Non-Pharmacological Interventions==
Physiotherapists are reminded to stay within their scope of practice and always discuss any treatment options preferred as an alternative to drug therapies with the patient’s multidisciplinary team (MDT) or general practitioner (GP). Non-clinical readers are advised to discuss any preferable options with their GP before seeking treatment<ref>[[Non Pharmacological Interventions|Non-Pharmacological Approaches to Deprescription]]</ref>. See this page for more: [[Non Pharmacological Interventions|Non-Pharmacological Interventions]]
== References ==
<references />
[[Category:Pharmacology]]
[[Category:Falls]]
[[Category:Interventions]]
[[Category:Pharmacology for Older People]]
[[Category:Older People/Geriatrics]]
[[Category:Older People/Geriatrics - Interventions]]
[[Category:Mental Health]]
[[Category:Mental Health - Interventions]]
[[Category:Cardiopulmonary]]
[[Category:Cardiopulmonary - Interventions]]

Latest revision as of 00:19, 20 February 2023

Original Editor - Debbie Kenny Top Contributors - Debbie Kenny, Lucinda hampton, Peter Lynch, Kim Jackson, Lauren Lopez and Aminat Abolade

Introduction[edit | edit source]

Polypharmacy

Over the last 30 years, people have been prescribed increasing number of medicines, in particular older people. The reasons are manifold and include:

The dangers of using multiple medicines include greater chances of:

  • Adverse drug experiences
  • Hospital admissions and health care costs
  • Non-adherence to medication[1]

Overprescribing may occur when:

  • A better alternative is available but not suggested
  • The drug is suitable for a condition but not the individual.
  • A condition alters and the medicine is no longer suitable/relevant.
  • The patient has ceased needing the medicine but it continues to be prescribed.[2]

Deprescribing[edit | edit source]

Chance of adverse reactions with multiple medications

Deprescribing is the complicated process undertaken for the safe and effective withdrawal of inappropriate medication. A lot of of the evidence underpinning deprescribing is from observation, being based on the patient’s physical functioning, co-morbidities, preferences and lifestyle.

Deprescribing:

  • Should be part of good prescribing, with re-evaluation of dosages periodically.
  • Involves health care professional direction and supervision with the same level of expertise and attention that prescribing entails [3].

The following videos provides an easy to follow in-depth discussion regarding the concept (6 minutes)

Overprescribing[edit | edit source]

Medications: review regularly

Overprescribing is when people are prescribed medicines:

  • They no longer need or want
  • The medicine has greater possible harmful than beneficial effects.
  • When a more effective alternative is not prescribed
  • Where the medicine is correct for a condition but not the individual.
  • When a condition alters and the medicine is no longer appropriate.[1]

The extensiveness of polypharmacy reported in literature differs, being between 10% to 90% according to the age group, definition used, healthcare and geographical setting of the study.[4]

Patient Engagement[edit | edit source]

Medication reviews, joint decision-making and deprescribing rely on people becoming involved in decisions regarding their health care. Information to give patients and their carers about the medicines they are taking should be a priority, taking into account language, culture and level of health literacy.[5]

Common Populations at Risk[edit | edit source]

Age: risk factor for over medicated.

The use of multiple drugs is not always an indicator of poor drug treatment or overmedication[6]. Appropriate medication depends on whether or not the advantages outweigh the disadvantages which is subjective to both the individual and their given condition(s). It can be very hard to predict the side-effects or clinical effects of a drug combination without testing it on the specific individual as the effects all very based on the individual's genome-specific pharmocokinetics[6].

At risk populations include:

Sex, educational level, and smoking apparently appear not to be related to polypharmacy.[4]

The Potential Role of the Physiotherapist in Deprescribing[edit | edit source]

Available literature linking physiotherapy with deprescribing has focused only on the role of physiotherapy as a supplementary treatment for pain relief when reducing opioid dosage.  

General advice that may be given on the effects of medication. For example the general side effects of non-steroidal anti-inflammatory drugs (NSAIDs). While providing advice it should also be recommended that the patient should seek advice from a pharmacist or independent prescriber before altering any medication they currently take[7].

Is patient taking their medication incorrectly?: If a non-prescriber physiotherapist notices a patient is not taking their medication correctly, they can refer the patient to the medications instructions and remind them how and when/ dose they should be taking their medication as prescribed[7]. This can also apply to medication devices, e.g. an inhaler, advice can be given how to use it according to guidelines.

Adverse Effects:Physiotherapists can refer the patient back to the GP/pharmacists or can contact the GP directly providing information on their concerns re adverse effects [8].

Non-Pharmacological Interventions[edit | edit source]

Physiotherapists are reminded to stay within their scope of practice and always discuss any treatment options preferred as an alternative to drug therapies with the patient’s multidisciplinary team (MDT) or general practitioner (GP). Non-clinical readers are advised to discuss any preferable options with their GP before seeking treatment[9]. See this page for more: Non-Pharmacological Interventions

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 NHS UK Understanding polypharmacy, overprescribing and deprescribing Available:https://www.sps.nhs.uk/articles/understanding-polypharmacy-overprescribing-and-deprescribing/ (accessed 29.12.2022)
  2. ↑ BBC news Overprescribing of medicines must stop, says government Available:https://www.bbc.com/news/health-58639253 (accessed 28.12.2022)
  3. ↑ Reeve E, Thompson W, Farrell B. Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. European Journal of Internal Medicine.2017;38:3-11.
  4. ↑ 4.0 4.1 FAQs clear What Population Is At Risk For Polypharmacy? Available:https://www.faqsclear.com/what-population-is-at-risk-for-polypharmacy/ (accessed 29.11.2022)
  5. ↑ UK Government Good for you, good for us, good for everybody Available:https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1019475/good-for-you-good-for-us-good-for-everybody.pdf (accessed 29.12.20220
  6. ↑ 6.0 6.1 Tamminga C. When Is Polypharmacy an Advantage?. American Journal of Psychiatry. 2011;168(7):663-663.
  7. ↑ 7.0 7.1 Chartered Society of Physiotherapy. Medicines, prescribing and physiotherapy [Internet]. CSP; 2016. Available from: http://www.csp.org.uk/publications/medicines-prescribing-physiotherapy-4th-edition
  8. ↑ Reznik J, Keren O, Morris J, Biran I. Pharmacology Handbook for Physiotherapists. Australia: Elsevier; 2016.
  9. ↑ Non-Pharmacological Approaches to Deprescription
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