The projected number of geriatricians in 2030 is woefully inadequate to meet the needs of frail older patients due to the rapid growth in the over-65 population and the low numbers of trainees entering geriatrics.1 As general internists, we must assume a greater role in the care of our older patients by focusing on their quality of life, helping them remain functional and socially connected, and avoiding polypharmacy (taking five or more medications daily) with its potential adverse drug reactions (e.g., cognitive decline, falls, and depression).
General internists are well suited to assist geriatricians in caring for elderly patients by identifying polypharmacy and, when appropriate, deprescribing medications. We routinely manage complex medical conditions and medications and frequently work in teams that help us coordinate patient care and engage with subspecialists. We have a comprehensive whole person approach and long-term relationships with patients, which facilitates our ability to educate our patients and participate in shared decision-making. These characteristics are important in taking on the challenge of polypharmacy and deprescribing.
Deprescribing is the process of recognizing, and then tapering or stopping unnecessary or potentially harmful medications.2 It is easy to recognize the need to deprescribe in some patients. These are patients who dislike taking medications and ask about stopping them, patients who walk into clinic with a large suitcase when asked to bring in their medications, and patients on known high-risk medications (e.g., opioids, benzodiazepines). For other patients and medications, it’s complicated. We first need to recognize that the benefits of a medication, in reducing the risk of an outcome such as cardiovascular events, no longer outweigh the risks of adverse outcomes, such as falls or increasing cognitive decline.
Although I care for elderly patients with long medication lists, I realize I am not addressing polypharmacy and deprescribing as often as I should. This occurs even though I am required to review medication lists with patients and reconcile the list against what they are taking. For this geriatrics theme issue of SGIM Forum, I summarize what we know about the barriers to deprescribing and what might improve our ability to deprescribe. I hope SGIM members in primary care and inpatient settings will join our geriatrics colleagues in addressing polypharmacy and become better role models for trainees in recognizing and tackling this problem.
Barriers to Deprescribing
Several recent qualitative studies of patients, caregivers, and physicians identify some of the barriers and facilitators to deprescribing.3-5 These studies echo findings of earlier studies. Barriers to deprescribing fall into three interdependent categories: health system, physician, and patient barriers.
Health system barriers include:
- Time constraints during visits
- Reimbursement for cognitive services
- Inadequate team support for deprescribing
- Physician continuity
- Little focus on polypharmacy in routine screening
- Guidelines and performance metrics that inhibit instead of support deprescribing.
Physician barriers include:
- Clinical inertia—it’s easier to continue prescribing
- Inadequate information about the risks and benefits of deprescribing for a patient
- Uncertainty about patients’ overall prognosis to determine if it’s the right time to deprescribe for specific patients
- Language and terms used with patients when prescribing (e.g., “you need this medication,” “it will prevent a heart attack”) and discussing deprescribing
- Inadequate skills in shared decision making
- Perceived authority of subspecialists who first prescribed the medication(s).
Patient barriers include:
- Fear of bad outcomes if a medication is stopped
- Perceived authority of subspecialists who first prescribed the medication(s)
- Perception that pills are better than lifestyle changes in treating a condition.
Facilitators of Deprescribing
Many of the identified facilitators for deprescribing focus on physicians and what we can do to address physician and patient barriers. First is recognizing polypharmacy and deciding to deprescribe. Introduce the concept of deprescribing by noting the number of medications patients are taking and asking them if they would like to consider tapering off some of their medications. Add deprescribing to your plan for your next visit with the patient. This allows time for the next step—gathering information about the patient’s overall prognosis from prognostic calculators (e.g., ePrognosis) and the benefits and risks of deprescribing specific medications. Consulting with subspecialists who started or assist with monitoring a medication may reassure physicians and patients that deprescribing is the right strategy.
The next set of facilitators comes into play when discussing tapering or stopping medications with patients. These discussions rely on relationships and the trust patients have in their primary care and inpatient physicians, which are built over time or frequent contact with patients. It can be enhanced by involving multidisciplinary teams and caregivers who can work with physicians over time to accomplish deprescribing. As general internists, we can learn more about deprescribing and build skills in shared decision making to improve our ability to deprescribe. (We are fortunate to offer a pre-course at the 2024 SGIM annual meeting that will address deprescribing and the latest research from the National Institutes of Health-funded US Deprescribing Research Network.)
Finally, we can advocate for more support from our health systems and payors to address the system barriers to deprescribing and ask guideline groups to consider guidance on when to stop medications, as well as when to start them. Even within our clinics and inpatient settings, we can add polypharmacy to the prevention and health maintenance checklists and electronic health record templates we use. When appropriate, we can add polypharmacy to patients’ problem lists to remind us to look for opportunities to deprescribe. Health system facilitators are less well defined yet important to deprescribing. My hope is that those us involved in quality improvement, implementation, and learning health system research will focus some of our work on polypharmacy and deprescribing.