What more could I add to the literature and musings that now surround the most influential event of recent times? For one, the hope is that whatever the new norm is, it will come soon and uneventfully. With this in mind, it might be time to start considering some of the opportunities that have arisen and lessons we have learned during the last three months in the LTC trenches.
Among the many hardships that facilities dealt with, staffing became critical. This, in part, can be explained by the mandated prolonged absence from work for COVID + diagnosed employees and the refusal of some employees to work in a facility where there were afflicted patients. In preparation for a nursing crisis, Genesis instituted a “non-essential medication initiative.” With the consent of patients or the POA’s, our medical directors and clinicians put non-essential medications on hold for 14 days, and depending on the status of the building, renewed this hold for another 14 days. At the end of the “holding period,” we encouraged clinicians, where it felt appropriate, to deprescribe some of these meds completely. This was performed in many cases, and was done safely and without adverse outcome.
Historically, one of the focuses of LTC medicine, and Geriatrics in general, is polypharmacy. To some degree, medications are never discontinued. Instead, they become “the gift that keeps on giving,” even when no longer demonstrating any beneficial therapeutic effect. Monthly medication reconciliations become nothing more than the reordering of the existing list of meds, with no thought to reduction in number, dosage, or to ongoing need or benefit.
To put it simply, there are six reasons to deprescribe: drugs should be eliminated when they are not indicated, not efficacious, do not achieve a patient's goals, have risks that outweigh benefits, make no sense whatsoever, or where nursing time could be better spent than administering these meds.
The University of Maryland School of Pharmacy in conjunction with the US Deprescribing Research Network has produced an outstanding guideline entitled
Optimizing Medication Management during the COVID-19 Pandemic: Implementation Guide for Post-Acute and Long-Term Care.
The recommendations included are easily utilized in the world after COVID-19, and it behooves us to be opportunistic and make these changes now. In the April 2020 edition of JAGS*, the following points were made in support of deprescribing in the LTC population:
- Polypharmacy in this population is strongly associated with an increased risk of adverse drug events
- In the United States, the median length of stay in a nursing home before death is 5 months
- In this context, patients frequently do not live long enough to realize the benefit of their prescribed medicines
- The consumption of multiple pills may be physically and emotionally burdensome
*JAGS 68:762-769, 2020
Below is a list of some of the medications that should be considered early on for discontinuation:
- MVI
- Herbal/naturopathic/homeopathic medication
- Antihistamines
- Decongestants
- Fish Oil
- Probiotics
- Docusate
- Statins and all hypercholesterolemia drugs
- H2 Antagonists
- PPIs
Other medications that should be considered include:
- Cholinesterase inhibitors
- Memantine
- Long term oral steroids
- Long term oral NSAIDS
- Bisphosphonates
- The Beers list
Deprescribing is a process that should not only be incorporated into the routine of visits, both monthly and regulatory, but should also be considered at admission. It is a task that should be borne by all primary care providers and considered to be part of the IDT/QAPI meeting. Though it has not been demonstrated to prolong life, it has been shown to improve the quality of life associated with decreased severity of drug related side effects. For these reasons and more, I would take advantage of the march to the new norm and
Carpe Diem
, Seize the Day, and begin to deprescribe.
Any views or opinions presented in this article are solely those of the author and do not necessarily represent any policy or position of PAMED, PMDA, AMDA, its affiliates and members.
