Tackling Overprescription

Introduction

Overview of medication over prescription

According to health projections conducted by Kingston et al. (2018), due to an increasingly ageing population, the prevalence of multi-morbidity in the UK is predicted to rise significantly. Multi-morbidity can be described as the presence of two or more chronic medical conditions in an individual (Wallace et al. 2015). Over the next twenty years, the prevalence of multi-morbidity is predicted to increase by 26% in the 65-74 age group, 64.5% in the 75-84 age group and 211% in the 85+ age group (Kingston et al. 2018). With each morbidity or disease, there are different recommendations for treatment medications in accordance with disease-specific guidelines. Whilst guidelines are readily available, they are very much tailored to be disease-specific. The guidelines do not modify or consider the applicability for patients taking medications for multi-morbidity, where adhering to guidelines for each and every drug will inevitably lead to overconsumption of medications (Sönnichsen et al. 2016). This over consumption of medications is commonly known as ‘Polypharmacy’.

Despite the topical use of the term polypharmacy to describe the use of multiple medications, a clear definition is still lacking. Some authors define polypharmacy as taking more than five medications (Bushardt et al. 2008), whilst others define polypharmacy as taking medication which lacks an indication, is ineffective, or duplicating the treatment offered by another medication (McGrath et al. 2017). According to (MIKES BOOK), the term polypharmacy itself should not be used as a universal term, but instead be considered as either ‘Appropriate’ or ‘Problematic’ polypharmacy. Appropriate polypharmacy are medicines which, when prescribed according to best evidence, can extend life expectancy and improve quality of life, by treating a specific condition or illness. However, problematic polypharmacy is the inappropriate prescribing of multiple medicines, or where the intended benefit of the medicines are not realized (NICE. 2017). According to (MIKES BOOK), problematic polypharmacy increases the risk of interactions and adverse drug events (ADEs) as well as affecting patient compliance and quality of life. 

This lack of clarity reflects the difficulty in setting an accurate cut-off point for not only when polypharmacy begins, but also at which point polypharmacy becomes problematic. According to a review of Bushardt et al. (2008), the most common point at which polypharmacy is considered to begin is the use of more than five medications (Bushardt et al. 2008). If applying the cut-off point outlined by Bushardt et al. (2008), research highlights that in certain settings, between twenty-five and fifty percent of all patients aged seventy-five or older are exposed to polypharmacy on a daily basis (Banerjee et al. 2011; Junius-Walker et al. 2007; Sigurdardottir et al. 2011; Slabaugh et al. 2010). Factors such as patient age, updated medication treatment criteria, cross-activity, interference and effect on metabolism should be considered when trying to determine if the patient’s polypharmacy is appropriate or problematic (MIKES BOOK).

Research has suggested that problematic polypharmacy is associated with multiple negative consequences, for both health and finance. Consequences associated with problematic polypharmacy include:

• Increased risk for ADEs (Bourgeois et al. 2010; Nair et al. 2016)
• Reduced functional capacity (Crenstil et al. 2010)
• Reduced cognitive impairment (Jyrkka et al. 2010)
• Increased risk of falls (Fletcher et al. 2009)
• Negative affect on nutritional status (Jyrkka et al. 2010)
• Overall increased risk of mortality (Espino et al. 2006).
• Increased health care costs for both the patient and the health care system (Akazawa et al. 2010).

Problematic polypharmacy is generally seen as the result of a cascade of prescribing (Mcgrath et al. 2017). This cascade is often initiated when an adverse drug effect is misinterpreted as a new medical problem, leading to the prescribing of more medication to treat the initial drug-induced symptom(s). Potentially inappropriate medications (PIMs) (medications which should be avoided in older adults and those with certain health conditions), are also increasingly probable to be prescribed in the setting of problematic polypharmacy (Mcgrath et al. 2017; Steinman et al. 2006). Means to addressing problematic polypharmacy has long been a topic of interest, and according to Moriarty et al. (2017), the majority of consequences of problematic polypharmacy can be minimized or even prevented by using a patient-centered, structured process with planning, tapering and close monitoring during, and after medication withdrawal. According to Moriarty et al. (2017) and much of the literature, this process is known as Deprescribing.

Deprescribing

Deprescribing is defined as the process of withdrawal (and/or dose reduction) of inappropriate medications supervised by a health care professional (Reeve et al. 2017; Thompson & Farrell, 2013). The term “Deprescribing” first appeared in literature in 2003 (Woodward. 2003). The term has become more widespread in recent years, with a review by Iyer et al. (2008) recommending that the term Deprescribing should be internationally adopted in order to create a universal understanding, both in research and practice, of this specific concept of medication withdrawal or reduction.

The following videos provides an easy to follow in-depth discussion regarding the concept. [1]

With increasing concern about the negative effects of overuse of medications, there in growing attention being paid to approaches which can minimize harm and promote healthy wellbeing. Focus is shifting from prescribing, which is the starting or renewing of medications, toward this concept of Deprescribing, especially within an ageing population (Reeve et al. 2017). It is very important to note that Deprescribing is very different to non-adherence or non-compliance. Desprescription involves health care professional direction and supervision with the same level of expertise and attention that prescribing entails. (Reeve et al. 2017).

As well as the misinterpretation of symptoms discussed previous, whilst medications may be prescribed and initiated for an appropriate reason, potential insufficient monitoring, follow-up, and transfer between providers and care settings may contribute to medications being continued indefinitely and inappropriately (Moriarty et al. 2017). According to research by Morin et al. (2016) and Todd et al. (2017), there are high levels of inappropriate medication use in older adults across a variety of settings and countries, proposing that there are currently vast unrealized opportunities for Deprescription. As well as opportunity, research suggests there is a desire for this desire for this concept of deprecribing to be introduced. Page et al. (2016) suggests that despite a moderate agreement in the specific medicines to deprescribe, both physicians and pharmacists in the study had ‘substantial’ agreement that desprecribing is beneficial for the patient. As well as Health Professionals, research by Sirois et al. (2017) suggests that older individuals themselves are “eager” to undertake deprescribing. The authors’ suggested that this desire was linked to the individuals’ feeling of taking a large number of medications and with the belief that some of the medications were no longer necessary (Sirois et al. 2017).

With an increasing interest in deprescribing, this resource aims to provide understanding of the potential role that the Physiotherapist can play in this growing concept

Role of the Physiotherapist in Deprescribing

The authors of this resource are students of Physiotherapy, and not Supplementary Prescribers (SPs) or Independent Prescribers (IPs). Therefore the discussion of the role of the Physiotherapist in supplementing alternative and complimentary options to polypharmacy will be approached whilst considering our scope of practice.

As an emerging role, the role played by the Physiotherapist in Deprescribing has previously not been examined, to the knowledge of the authors. Therefore, this resource aims to investigate the potential role the Physiotherapist can play in this growing concept.

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.  

Research by Townsend et al. (2008), Huffman et al. (2013) and Hooten et al. (2007) suggest that patients in severe pain, despite use of high-dose opioids, may experience significant improvement in pain severity, functioning, and mood when their opioid is tapered to a lower, safer dose. In this research, opioid-dose reduction was supplemented by interdisciplinary rehabilitation programs, including physiotherapy, cognitive behavioural therapy and occupational therapy, which showed long-term improvements in pain, functioning and emotional health (Townsend et al. 2008; Huffman et al. 2013; Hooten et al. 2007). There was no distinction of which individual treatment modality was most effective. In addition, guidelines for opioid use developed by Kahan et al. (2011) and Berna et al. (2015) recommend that patients with long term complex pain should have their opioid dosage regularly reviewed, with removal or reduction of opioids supplemented with non-opioid analgesics or non-drug treatments such as physiotherapy, where appropriate.

This resource aims to bridge a gap in literature by investigating the potential role the Physiotherapist can play in the deprescribing process itself.

Deprescribing in other healthcare professions

As well as identification of polypharmacy, there are other roles to share in the deprescription process (Reeve et al. 2017). Reeve et al. (2014) and Scott et al. (2015) suggest that the following elements are fundamental in the process of Deprescribing.

• Collect a complete and comprehensive medication history
• Assess overall risk of harm and benefit and individual patient factors which may affect deprescribing
• Identify potentially inappropriate medications
• Decide on medication withdrawal
• Plan tapering or withdrawal process and monitoring with documentation and communication to all persons relevant to care
• Conduct monitoring and support
• Documentation

Whilst the elements are easily classifiable, the specific profession of the multidisciplinary team responsible for each is not as easily distinguished. Instead, much of the available literature recommends sharing the process.

Shared, informed decision making is crucial to delivering patient-centered care, and it is just as important to delivering Deprecription. (Reeve et al. 2017). While some patients evidently may still seek recommendation from their physician, or seek their physician to make decisions regarding medication (Belcher et al. 2006; Levinson et al. 2005), shared multidisciplinary decision making can still occur through discussion of options, benefits, harms and consideration of patient preferences (Reeve et al. 2016). When Deprescribing medication(s), patients’ should be provided with sufficient knowledge of the decision to be made, have realistic expectations for outcomes and be confident in their decision (Stacey et al. 2014). Members of the multidisciplinary team are ideally located to play a part in this process.

As well as physicians, general practitioners (GPs), nurses, medical specialists and pharmacist have all been highlighted in the literature to being involved in leading or contributing to deprescribing efforts. Research indicates that multidisciplinary interventions are generally the most effective at reducing polypharmacy and inappropriate medication use (Kaur et al. 2009; Reeve et al. 2017). Steinman. (2016) recommends that pharmacists and nurses be involved in the deprescribing process in practice. The author suggests that patients are generally more comfortable with the involvement of a pharmacist or nurse in the process of deprescribing.  

Evidence suggests that patients are more willing to have a medication deprescribed if it is recommended by a health professional whom they have a relationship with (Reeve et al. 2013; Linsky et al. 2015; Reeve et al. 2016). The health professionals elucidated in the studies were physicians, GPs and medical specialists. Furthermore, Reeve et al. (2014) suggest that interventions with close involvement of the local GP are more likely to be successful in achieving deprescribing than those which are conducted by an external research team. When considering the avenue of GP desprecribing, it must be noted that the primary care setting provides access to prescription history and medical records and provides opportunity for monitoring after discontinuation, which the GP cannot offer. Anderson et al. (2014) recommend that effective communication between GP’s and specialists with access to this information may serve as a viable solution to this issue.

Regardless of specific elements or mechanical tasks in the Deprescribing process, it is clear from the evidence that sharing the process amongst the multidisciplinary team provides the greatest platform for success.

The following sections will provide in-depth discussion regarding the potential roles that the Physiotherapist could play in this Deprescribing process

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/major surgery
• People seeing multiple doctors
• Terminally ill patients