Chaitoff A, Haff N, Lauffenburger JC, Choudhry NK. Medication de-escalation opportunities among frail older adults with strictly-controlled cardiometabolic disease [published online ahead of print, 2023 Apr 4]. J Am Geriatr Soc. 2023;10.1111/jgs.18368. doi:10.1111/jgs.18368
Many patients with hypertension, diabetes, and heart disease benefit from cardiometabolic disease medications. However, the number of medications available and potential downstream complications put patients at risk of polypharmacy. For frail older adults with strictly-controlled cardiometabolic disease, risk-benefit tradeoffs may favor de-escalating medications. A team of researchers at the Center for Healthcare Delivery Sciences at the Brigham and Women’s Hospital set out to clarify potential opportunities to de-escalate medications within this patient population.
Using data from the National Health and Nutrition Examination Survey (NHANES) collected between 2005-2018, researchers evaluated adults age 65 and older with frailty. Researchers noted potential opportunity for de-escalating if the patient was taking medication for hypertension, diabetes, or heart disease and exceeded targets for well-controlled disease. Medication use was based on pill bottle review (prescriptions) or self-report (aspirin).
Since NHANES only asked about aspirin use from 2011-2018, the aspirin-containing cohort is limited to 226 older adults with frailty who participated in the survey during that time frame. The aspirin-excluded cohort includes 400 older adults with frailty from the entire 2005-2018 survey time frame.
In the aspirin-containing group, 46% had strictly-controlled disease and were on at least one medication with potential for de-escalation (105/226). In the aspirin-excluded cohort, 23% had strictly-controlled disease and were on at least one medication with potential for de-escalation (94/400). Older age was the only demographic trait associated with the presence of de-escalation opportunity in the aspirin-containing cohort. No traits were associated with de-escalation opportunity in the aspirin-excluded cohort.
The majority of frail older adults with strictly-controlled cardiometabolic disease were still taking medications. Given the negative side effects and financial/time burden of these medications on patients and caregivers, researchers suggest de-escalating cardiometabolic disease medications among frail older adults.
Primary author Alexander Chaitoff reflects on how we arrived at this issue to begin with:
“I think there are probably many drivers, but one to highlight is the lack of guideline-directed evidence for stopping medications. Guidelines are much more likely to provide specific cutoffs for starting medications, but they rarely explicitly state to stop medications. The American Diabetes Association probably does the best job of all the major societies in describing how disease control targets should be individualized to the patient, but even in their documents much less space is given to how exactly to de-escalate medications than is given to ramping up treatments. Certainly some of the reason for this disparity in time spent on deprescribing in guidelines is a lack of clinical effectiveness research, but I think getting more about de-escalation into the major societal guidelines is imperative for getting this issue on the minds of clinicians.”
The author also reflects on the best ways for clinicians to prevent this issue moving forward:
“I think there are several approaches. On an individual level, clinicians should frequently review the necessity of medications with patients. If a patient isn’t benefiting from a medication, or if they have strictly-controlled disease and may no longer need a medication, a trial off medication may be warranted. On a clinic/process level, it would be great to better integrate measures of frailty into primary care settings. Geriatric clinics certainly do this already, but I think there is a gap in getting objectives versions of these scores into primary care. Finally, I think system changes are needed – such as better decision-making aids for deprescribing specifically, more time for clinicians so that they can fully discuss long medication lists with patients, and more team-based care models where pharmacists can play an active role in medication de-escalation. It will be a long process, but there are certainly action items for clinicians, medical directors, and policy thinkers alike to help make deprescribing potentially inappropriate medications more common.”