Tackling Overprescription

Introduction

what is the current issue with overprescription and define deprescription

Learning Outcomes

This resource will enable the reader to:

1. Define deprescription and its relevance to the Health Care system  
2. Explain the role of the physiotherapy profession in deprescription
3. Justify the value of deprescription within AHP’s and its application within health care
4. Recognize populations at risk of over-prescription and identify common clinical problems/scenarios and medications involved
5. Rationalize appropriate non-pharmacological alternatives
6. Explain how multidisciplinary teams can work together to better promote/apply deprescription
7. 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.

Common Populations at Risk

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).

1. Elderly Populations

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; Gomez et al. 2015).

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).

2. Psychiatric Patients

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.

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 (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.

3. Other Populations

• Co-morbidities
• Recent hospitalizations