Engaging patients in conversations about deprescribing

KEYWORDS:

• Deprescribing
• polypharmacy
• medication review
• shared decision-making
• patient engagement
• geriatrics

1. Introduction

As a pharmacist working in a Geriatric Day Hospital (GDH), I see many patients taking multiple medications. Often, the patient has no clear idea of the reasons for or benefit from each medication; side effects are not always interpreted as such so prescribing cascades are common; cognitive impairment and falls are frequently drug-induced and the choices of, or doses of medications have not been adjusted to account for frailty and age. The goal of our program is to help older people maintain their independence. My role is to help people gain the most benefit from their medications with the least burden and harm. With patients visiting the GDH twice a week for 10 weeks, the program provides an excellent opportunity to review medications and to make changes.

Over 24 years in this practice setting, I have developed an approach to engaging patients in discussions about ‘deprescribing’ – the planned and supervised process of dose reduction or cessation of medication that may be causing harm or no longer be providing benefit. In sharing this approach with physicians, nurses and other pharmacists, I’ve often heard how difficult health care providers find it to encourage their patients to think about medication reduction. Yet, patients have told me they’re often afraid to bring up the idea of medication reduction for fear of offending or alienating their prescriber. There’s an obvious disconnect. Better conversations are needed.

In this article, I describe my approach to engaging patients in discussion about their medications in the context of a full medication review, share strategies that I have found helpful to encourage people to think about dose reduction or stopping medications and outline the relevant and growing research field, as well as system-level strategies to support medication review and deprescribing conversations.

2. What works for me

If I had to describe in one word what works to engage people in deprescribing discussions, it would be to LISTEN. I try to make space to hear people’s stories and experiences with their medications by using a structured approach to listening and assessment. Below, I outline this approach and provide an estimate of the amount of time I take for each step, including the time needed to complete an assessment and carry out a care plan with a patient.

My preparation to conduct a medication review begins with collecting lists of the patient’s medications from various sources, organizing them according to disease or symptom being treated and gathering information about the patient’s current condition and major life changes (20 minutes).

In my initial meeting with a patient, I introduce myself and my role (‘to ensure medications are working and not causing problems’). Then, I start by asking ‘What questions do you have about your medications?’ I find this open-ended approach often results in many questions, including ‘Why am I taking so many?’ – a perfect segue into suggesting I can look at which medications are still providing a lot of benefit, and which are not. Next, I ask a series of questions about each medication (moving through all the medications related to a condition together – e.g. first the antihypertensives, then other cardiac or stroke prevention medications, then antihyperglycemics, then antidepressants, then sedatives, etc.) Starting with medications that people perceive as important but to which they lack an emotional attachment works well. Patients get used to the types of questions that I’m asking and then when we reach medications that may be harder for them to talk about (e.g. antidepressants, sleeping pills), they seem to trust the process and appear less resistant to discussing them. My questions about each medication include: ‘How long have you been taking this?’ ‘What time of day do you usually take it?’ ‘What was it originally started for?’ ‘How did it help at the time?’ ‘How do you feel about how it’s working now?’ ‘What sort of problems have you had with it?’ ‘What happens if you miss a dose?’ Throughout, I use active listening skills – waiting silently for people to answer, maintaining eye contact, restating and summarizing what they’ve said (e.g. ‘let me make sure I understand this correctly’). We also go over medications that were stopped in the past, and why – including whether there have been any allergies or side effects that make the person feel they would not want to use the medication again. I try to watch for signs of the patient not being sure about a medication’s effectiveness, or evidence that not taking the medication has no effect on symptoms to raise the idea that I can review that medication for them and give some options about how long to continue it. At this point, if the patient seems open to discussing potential reductions, I may provide some general information such as explaining that as people get older, it’s reasonable to reduce doses since kidney and liver function is not as good as when they were younger, so drugs stay in the body longer at higher levels. Finally, at the end of this initial interview, I summarize our discussion, explain that I will check all the doses of their medications for their kidney function, check for drug interactions and see if any of their medications might be contributing to falls or cognitive impairment (depending on their reason for referral to the GDH) or other symptoms they’re experiencing (e.g. tremor, diarrhea). I explain that ‘my goal is to help them make sure each drug is working as intended, to ensure it’s not causing bothersome side effects and see if anything can be reduced to the lowest effective dose.’ At this point, if it’s not clear already, I’ll ask if there are any medications that they feel could be reduced or stopped and add this to my list of items to investigate. In conclusion, I explain that I will discuss my review with the GDH physician and then one of us will meet with them again to discuss options for what they might decide to do next with their medications (45–60 minutes).

Following the initial patient interview, I complete a written consult; this involves compiling information learned from the patient, medical records, specialist consults, and dispensing records. I also discuss my findings with the GDH physician to gain their input and perspective. These steps help me determine whether any signs/symptoms have potential medication-related causes, the original indication for each medication, if each medication continues to be indicated and how well it’s working, if and how the patient is taking the medications and whether there are side effects. The process includes reviewing doses of all medications with regard to renal function, conducting a drug interaction review and calculating overall anticholinergic burden (2 hours or more depending on number of medications).

After completing my consult, I meet with the patient to review the possibility that some medications may no longer be needed or may be contributing to their symptoms (or signs) and to get input on their perspective and preferences for next steps to finalize the care plan. I highlight which medications we feel could be problematic (more potential harm than benefit) then present options that may include 1) leave as is 2) reduce the dose 3) ‘pause and monitor.’ If there are several medications contributing to a problem (e.g. falls), I present those and ask the patient’s opinion on which of those medications they feel could be reduced. I explain the potential for withdrawal symptoms or return of original symptoms for which the drug might have been prescribed, including how severe these symptoms might be, when and how long they may last. This information helps people decide on dates for dose changes, as well as tapering rates. I find that knowing what to expect and when to expect it is very important for people to make confident decisions. People also appreciate knowing they can change their mind, slow a tapering rate or restart a medication as needed (15–30 minutes).

Once the patient has decided how they would like to proceed, I develop a written medication chart that includes specific information about why each medication is being used, how effective the medication appears to be (both in the patient’s words and using objective data) and the plans for that medication, including tapering and monitoring. Patients use the chart to keep track of what dose they are taking, what they should monitor and how well they’re doing. Throughout the GDH admission, one of our team (myself, the physician or nurse) meets regularly with the patient to review progress with dose changes, to provide reassurance and to make adjustments if needed (30 minutes, and as needed throughout admission).

At discharge, our physician provides a detailed summary of medication changes for the primary care provider, and I update the patient’s medication chart to include both progress and potential changes to consider in the future; a copy of this chart is sent to the primary care provider and community pharmacist (15–30 minutes).

3. Challenges

Patients typically have two main concerns that can make conversations challenging. They often raise the question as to why their doctor has been prescribing a medication that we have now suggested may not be necessary or might be problematic. I address this by emphasizing that medications are typically correctly started to treat a symptom or prevent/slow the progression of disease but as people get older, medications may stay longer in the body and people may respond to medications differently – and that our clinic provides support to primary care providers to help them determine when to reduce or stop medications. People taking medications for mental health conditions, pain or sleep are often very worried about reducing or stopping, and discussions need to carefully consider past experiences and reactions, as well as how they might feel about changes. Support from their other providers (e.g. psychiatrist, endocrinologist, cardiologist) is essential; we communicate with these providers regarding potential changes and this transparent communication is often reassuring to patients.

4. Practical advice

1. Don’t tell the patient what you want them to do (avoid paternalism).

2. Be mindful of how the patient may feel about each of their medications.

3. When discussing each medication, ask about why it was prescribed and whether any precipitating events (or, ‘triggers’) have resolved.

4. Ask the patient what matters to them in terms of their medications.

5. Validate the patient’s worry and concerns about change (it’s normal to be apprehensive).

6. Ask about the patient’s previous challenges or successes to stopping medications (and/or smoking).

7. Share pros and cons of different options.

8. Use ‘pause and monitor’ language so the patient knows they can change back to their previous dose or restart a medication as an option.

9. Confirm uncertainty (e.g. ‘you may or may not notice any difference’ ‘we don’t know how effective this medication is when used in people of your age’ ‘this drug may be contributing to your confusion but we won’t know for sure until we reduce the dose or stop it’).

10. Invite questions.

11. Involve the patient in decision-making: ask how they feel and what their preferences are (e.g. ‘is that feasible?’ ‘what do you think?’ ‘what would you like to do?’).

12. Have the patient choose the dates and rates of dose changes, as well as frequency of monitoring.

13. Anticipate potential obstacles and have a plan for how to deal with them; set the patient up for success! (e.g. ‘what if I am sleeping poorly?’).

14. Follow-up (e.g. ‘how did it go this week?’ ‘what was the most difficult thing about making this change?’ ‘how can we make the next dose change easier?’ ‘have you changed your mind about continuing?’).

15. Recognize success (e.g.”‘your ankle swelling is gone and your blood pressure has been normal”).

5. What can be learned from the literature

This approach to engaging patients in deprescribing discussions and decisions addresses many of the barriers that have been identified; these include patients’ disagreement or agreement with the appropriateness of ceasing a medication (related to understanding of effectiveness, benefit and side effects, fear of withdrawal effects or return of condition), and a lack of a clear process for doing so (support, time and details of how to reduce doses or stop, knowing that the process can be paused or a medication restarted) [1]. Sharing the pros and cons of options that include continuing a medication, lowering the dose or stopping it, along with confirming uncertainty and exploring patient preferences for various options aligns with the steps of shared decision-making [2]. The article by Jansen and colleagues on this topic is a must-read for anyone looking to improve their conversations with patients about deprescribing. Older people have also been interviewed about deprescribing and have expressed preferences for explanations that focus on risk of side effects, harmful numbers of medications, benefits not outweighing risks and working together to slowly reduce doses [3]. Motivational interviewing is another communication strategy that is useful for these types of conversations, involving open-ended questions and empathetic listening, affirming past successes, reflecting and summarizing discussions, determining interest or willingness to pursue changes, exchanging information that recognizes both patient and provider expertise and empowering self-efficacy by noticing even small changes during follow-up [4]. Readers interested in learning more about motivational interviewing techniques are encouraged to participate in one of the many available training programs. A proposed curricular framework for deprescribing includes competencies, knowledge and skills requirements that support this overall approach to patient engagement in deprescribing conversations [5].

6. Expert opinion

Our GDH team has published several case reports that outline the success of this approach to patient engagement in medication review and deprescribing in reducing the numbers of medications people are taking as well as improving clinical outcomes [6–13]. However, we recognize that our approach works in part because patients attending the GDH program may be ready to take steps to address problems like falls and cognitive challenges, because we have a dedicated pharmacist to carry out medication reviews and because the program itself allows sufficient time for discussion, assessment, changes and follow-up.

Some may consider that a process that can take 4 to 5 hours per patient may be unrealistic and not cost-effective. To increase the efficiency of discussion about medications with patients and enable routine medication review consult processes, I propose several individual practice and system-level recommendations that address some of the root causes of polypharmacy and that are in line with proceedings from a 2017 Canadian Frailty Network Summit [14].

Firstly, my sense is that patients would likely be more open to deprescribing If prescribers routinely told patients at the time of prescribing the specific reason for the medication (the purpose and how to tell if it’s working), and that the dose may be lowered, or even completely stopped in future if the prescriber and the patient agree it’s no longer needed or causing a side effect. This introduces the concept of shared decision-making about medications early on. Limiting amounts and refills can also be helpful to encourage thinking about the concept of eventually stopping a medication (e.g. give 15 tablets of a benzodiazepine for sleep vs. 30). Asking patients at the initial prescribing ‘What questions do you have?’ would help reduce patient fear of asking questions about their medications.

In my experience, many side effects of medications go unnoticed as such and result in investigations and the addition of more medications. Prescribers need to be better educated to suspect and recognize the adverse effects of medications to prevent or help resolve prescribing cascades through the deprescribing of medication that may be contributing to a side effect before starting another medication to treat it [15].

Shared decision-making is an important approach to both starting a medication and deprescribing but we often lack information to explain how well a medication really works in older people and those with frailty. Being able to weigh pros and cons of continuing medications as people age and develop comorbidities would help with faster and easier decision-making conversations for both health care providers and patients. We therefore need better information about the effectiveness (and limitations) of medications in older age and with comorbidities. This requires changes to what regulators require from pharmaceutical manufacturers to approve drugs (i.e. involvement of older, frail people in clinical and follow-up trials so that we understand more about effectiveness and side effects in this population – particularly those that affect quality of life and activities of daily living; and information about how absorption, distribution, metabolism and pharmacodynamics of medications changes with age and frailty). We also need research on what happens when medication doses are tapered or stopped – including the incidence, timing and severity of adverse drug withdrawal events, as well as when and by how much potential side effects (e.g. cognitive impairment) could be reversed. This information, particularly if incorporated into deprescribing sections of clinical guidelines, will inform more effective approaches to explaining pros and cons of different options, including what might happen (in terms of withdrawal effects) and planning tapering and monitoring steps with patients [16].

The lack of information about the original reason for a medication can make it very difficult for a health care provider to introduce the idea of reducing or stopping the medication later on. If prescribers documented the reason for prescribing a medication and the proposed duration (preferably electronically for the care team, and in writing for the patient), this would help with subsequent decision-making conversations about continuing or stopping a medication.

Finally, mandatory regular medication reviews (e.g. annually for anyone over 80–85 years) would make the process more efficient by keeping the medication list limited to only those medications which are meaningful to the patient and more beneficial than harmful, and if conducted with the above approach, encourage patients to think positively about the idea of deprescribing. A regular review would help patients understand this is a normal component of the prescribing process and make it easier for them to engage in these conversations. Routine medication reviews for a list of 10 medications seems like it would be more efficient than waiting until the number reaches 25 or 30. Finally, health care systems need to evolve to include structures and payment systems that make it easier to spend the necessary time for these patient-provider discussions and follow-up to take place.

7. Conclusion

If we are to minimize the negative impact of polypharmacy, as health care providers, we must be able to communicate with our patients about medication effectiveness and the possibility of, and approach to deprescribing. And, in turn, we must be supported by research and evidence that informs these discussions so that we can present clear risks and benefits (of either continuing, reducing or stopping a medications) and help people make decisions aligned with what matters most to them.

Declaration of interest

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.