Josh Niznik, PharmD, PhD, Assistant Professor, Division of Geriatric Medicine and Division of Pharmaceutical Outcomes and Policy at the Eshelman School of Pharmacy, is a geriatric health services researcher with clinical training in the pharmaceutical sciences. His research is focused on evaluating the quality of medications in older adults to improve the safety of medication use in this population.
Do you think that older adults have high rates of medication burden?
Of course – and to the point where it’s very problematic. More than half of older adults are exposed to polypharmacy and the unfortunate thing is that those people are more susceptible to side effects and they’re more vulnerable to drug-drug interactions. In a report by the Lown Institute, medication overload has been called ‘America’s other drug problem.’
There are many opportunities to re-evaluate the appropriateness of a lot of medications particularly in the work that I do with deprescribing. We could do a much better job talking with patients and families about things like time until benefits and how long benefits actually persist for. When we think about the scale of harms and benefits, at what point are we not doing what we set out to do, which is to prevent complications from disease rather than causing unintended consequences of medication exposure…?
What’s ‘time until benefit’?
‘Time until benefit’ is how long someone needs to take a medication at the recommended dose until they would see the intended benefit of the medication. For instance in osteoporosis medications, to see reduced risk of fractures, a patient would essentially have to be on those medications at least a year to see that benefit. For someone who maybe has a limited life expectancy, we need to be very clear about what we’re doing so that we’re not putting people on medications unnecessarily – and wasting money.
How many medications equate to ‘polypharmacy’?
There are varying definitions of polypharmacy but I tend to say 5 or more. A lot of older adults are on 10 or more medications. In nursing homes at least half of residents are on10, with the mean number being closer to 15.
When did you realize that de-prescribing would be your key area of focus?
I didn’t really decide on this direction until I was in graduate school and started doing research more seriously. I did a few rotations my last year of pharmacy school where I saw a lot of older patients. This highlighted the opportunity that pharmacists have to optimize medication use for these patients, particularly when you’re thinking about whether a medication is causing a side effect. In a lot of cases, a specific medication actually is what’s causing the problem.
Providers are generally trained when we see problems to think about medications can be used to treat it. We don’t often think of the reverse: ‘this is the problem – what medication is causing it?’ For a lot of older adults, the medication is causing a problem or side effect.
My grandmother had Alzheimer’s disease and end-stage renal disease. She was on a list of more than 10 medications. Her dementia progressed to the point where she couldn’t ambulate for herself or really have any activities of daily living (ADLs). Yet many of her medications were preventive – things like anti-dementia and osteoporosis medications which were very unlikely to be providing any benefit at that point.
I think that she really could have benefitted from deprescribing some of her medications particularly at the later stages. It was eye-opening and has served as one of the drivers of why I’m very passionate about this. It’s important for physicians, patients, and caregivers to realistically discuss the benefits a medication can and can’t provide, and to have a plan for de-escalating or stopping certain medications.
Tell us about your recently published paper in Journal of American Geriatrics (JAGS).
This study on the “Risk for Health Events After Deprescribing Acetylcholinesterase Inhibitors in Nursing Home Residents with Severe Dementia” has gotten a lot of attention, I think because there’s a growing consensus that anti-dementia medications are not that useful. They have lots of side effects, some with 2 to 5 times more risk of side effects compared with patients who aren’t on them.
For managing dementia, particularly in the later stages, we’re thinking about comfort and palliative goals of care. Yet the side effect of anti-dementia medications are directly in conflict with those goals of care: GI issues, headaches, and weight loss and more. The potential for benefit with these meds is very modest, and these are all side effects that negatively impact quality of life. Any evidence to justify stopping them is really what we need, and this paper presents that evidence.
Is there any benefit to using anti-dementia medications?
In some cases there is modest benefit, but prescribing appropriately requires a patient-centered approach. Different interpretations of the evidence about use – and the evidence can at times seem mixed – can lead to clinicians and families deciding to ‘give it a try’ with a certain medication. My counter argument to the ‘give is a try’ approach is be sure you’re thinking adequately about quality of life.
If you’re taking that approach, begin by setting reasonable expectations for what to expect. Have a plan to monitor whether medications are working and a plan for knowing when to stop.