The Perfect Ten
In 1976, Nadia Comaneci was the youngest gymnast ever to score a perfect 10. Some of our older residents will remember her accomplishment. Today, another perfect 10 is being pursued, this one by AMDA — The Society for Long-Term Care and Post-Acute Medicine and its goal is to reduce the number of medications taken by older adults to 10 or less. Part of a new deprescribing working group, a collection of long-term care leaders working with AMDA has set a goal of reducing the number of medications by 25% each year. This is a worthy goal as the impact of polypharmacy is well known.
The Data We Have
For years, the topic of polypharmacy and deprescribing has been on our radar. By 2019 AMDA considered it a top issue in need of attention. By 2020 this issue became increasingly urgent as the pandemic further reduced the resources needed to administer all the medications prescribed in long-term care settings. The intent of the AMDA effort is not only to reduce the number of medications being prescribed. It also aims to optimize administration to reduce the staff needed to deliver the medications and to manage the potential of side effects. Likewise, there will be a push to discontinue any medications no longer needed or beneficial and to review those where risks outweigh the benefits.
AMDA’s working group is multidisciplinary and includes senior care pharmacists and nursing leaders who understand the impact on resources of better medication management. They also have real-world knowledge of the importance of communicating with families and residents about medication changes.
The Communication We Need
This communication piece is critical. One study shows how deprescribing contributes to acceptance of the process by patients and families. This study noted that when the clinician emphasized the potential for improved function, community-dwelling older adults accepted the decision to deprescribe. For nursing home residents and their families, deprescribing was more accepted when staff emphasized the goal for achieving the best quality of life with the least side effects, and coupled this with reassurance of close monitoring and a restart of the medication if needed. Clearly, the words we use matter.
So What Are OUR Goals?
In geriatric medicine, our overarching goals include the prevention of adverse outcomes and iatrogenic illness while diagnosing and treating what cannot be avoided and can be managed well. Doing this in the context of frailty adds another layer of deliberation to our medication management. We know that frailty increases the risk of sensitivity to previously tolerated medications.
In addition, as frailty increases and chronic illnesses continue to create deficits, it is always good clinical care to review all medications for continued appropriateness, dosage optimization, risks versus benefits, and more. This requires ongoing monitoring and reassessments and revisiting care plans when there is a change in condition.
Ten might not be the perfect number to describe polypharmacy, but it is a good place to start. AMDA has done a great job of starting the conversation, setting the tone, and leading the way. We also have interdisciplinary teams of experts to guide our initiatives. Let’s collaborate and bring this to fruition in every setting where we have frail adults dependent on our competence, care, concern.
Patient Pattern has tools to identify the real risk of conditions that are likely to cause a prescribing cascade and polypharmacy using a paradigm of frailty instead of relying on a diagnosis. This enables the care team to identify and address condition changes quickly. They also can see all relevant information in real-time. Contact us for more information at patientpattern.com.