Deprescribing in Older Adults With Serious Mental Illness

SPECIAL REPORT: GERIATRIC PSYCHIATRY

Polypharmacy and potentially inappropriate medication (PIM) use is associated with adverse drug events, increased health care use, and greater health care costs.^1-3 These risks are increased for adults 65 years and older, as nearly half of older adults are exposed to polypharmacy. While there is moderately certain evidence that deprescribing (defined as a systematic process of identifying and discontinuing drugs where existing or potential harms outweigh existing or potential benefits within the context of an individual patient’s care goals) is associated with reduced polypharmacy and PIM,⁴ there is less evidence on how to implement deprescribing processes effectively.⁵ The following case is meant to highlight barriers to deprescribing that are less commonly discussed, specifically focusing on common challenges in inpatient psychiatric settings where polypharmacy is more likely to occur.⁶ This is important because, to date, deprescribing research has focused mainly on long-term care (LTC) instead of other care settings such as acute and postacute care.⁷

Case Study 

The medical director of an inpatient psychiatric hospital has scheduled an interdisciplinary case review meeting, including psychiatrists, nursing, pharmacy, social work, occupational therapy, and dietitians. They meet to discuss the case of “Harold,” a 60-year-old man with schizoaffective disorder, polysubstance use disorder, anemia, gastroesophageal reflux disease (GERD), and recurrent aspiration pneumonia who becomes frustrated easily and exhibits poor impulse control. He has had more than 60 hospitalizations as an adult spanning over 40 years. More recently, he has had several medical hospitalizations for shortness of breath secondary to severe chronic obstructive pulmonary disease (COPD) and recurrent aspiration pneumonia/chemical pneumonitis. At the time of the review, he was prescribed haloperidol 10 mg twice daily, quetiapine 900 mg daily, lorazepam 2 mg 3 times daily, valproic acid syrup 1000 mg twice daily, ferrous sulfate 325 mg every other day, omeprazole 40 mg twice daily, and glycopyrrolate/formoterol fumarate 2 puffs twice daily. Each member of the interdisciplinary team was asked to weigh in on the patient’s treatment plan.

The clinical pharmacist voiced the following concerns during the meeting: (1) Harold is prescribed scheduled lorazepam despite a comorbid diagnosis of severe COPD, with chronically low oxygen saturation and recurrent pneumonia/pneumonitis; (2) Harold’s documented recurring episodes of agitation are behavioral in nature and not secondary to psychosis; (3) Harold’s quetiapine is above the recommended maximum dose, with notes indicating chronic constipation and severe GERD likely contributing to aspiration episodes. It is also noted that the risks of ongoing scheduled benzodiazepines and high-dose quetiapine likely outweigh potential benefits as the patient’s behaviors remain unchanged, indicating a deprescribing plan for these 2 medications. The rationale provided by the attending psychiatrist for continuing the medication regimen as is, instead of implementing the deprescribing recommendations, is that Harold is currently too agitated/aggressive to be tapered off the scheduled benzodiazepine, and that Harold’s multiple monotherapy antipsychotic regimens have failed, necessitating dual antipsychotic therapy.

Resistance to Deprescribe

Harold’s case is not a unique exception to how discussions regarding deprescribing often go for patients with serious mental illness (SMI). This is particularly true in cases where the patient has limited capacity to participate in shared decision-making, a recommended practice of deprescribing. When deprescribing is indicated, prescribers and staff may voice concerns regarding decompensation and safety that are difficult to challenge, as keeping patients and staff safe is of the highest priority.

In addition, it is not uncommon for prescribing clinicians to show a similar level of resistance to discontinuing medications in patients who are psychiatrically stable. They often convey the, “if it ain’t broke, don’t fix it” mentality, which is also known as prescribing inertia. Unfortunately, this occurs with even the most vulnerable patients, such as older adults who have a greater risk of mortality associated with PIM use.⁸ The reluctance to deprescribe psychotropics is exacerbated even more in settings with high provider turnover.⁹ No matter how egregious a polypharmacy regimen may seem to a new provider, the potential risk of causing a patient to destabilize may seem greater than the risk of continuing the regimen as is.

Addressing Agitation

Patients with SMI have a higher likelihood of developing neurocognitive disorder(s) compared with individuals without SMI.¹⁰ Agitation is one of the most common behavioral and psychological symptoms of dementia (BPSD), and one of the most challenging to manage, leading to caregiver burden and stress that often result in LTC placement.¹¹ To manage agitation secondary to BPSD, guidelines recommend nonpharmacologic treatment, which is highly resource intensive and may not be covered by the patient’s insurance.

Because most institutions lack the resources to manage agitation without pharmacologic treatments in older adults with SMI and/or neurocognitive disorders, psychotropic medications are often used as a last resort—even though pharmacologic interventions tend to be less effective and carry a higher risk of adverse effects (eg, increased risk of death associated with antipsychotic use in older adults with dementia).^12-14 However, the use of these PIMs is generally not because psychiatric clinicians are unaware of the risks of using psychotropic medications in patients with BPSD. Rather, it is because the patient’s agitation poses a more immediate risk of danger to the patient/staff in absence of other solutions, such as behavioral interventions.

With increased scrutiny on LTC facilities to minimize psychotropic use in patients with dementia or otherwise face repercussions related to facility reimbursement, LTC teams are often quick to send patients to the hospital for “medication adjustment” in the event of acute agitation, even when medication adjustments likely will not make a substantial difference in the frequency of future behaviors. More interdisciplinary education is likely needed on realistic treatment expectations when it comes to the effectiveness of pharmacologic interventions for various neuropsychiatric disorders in older adults. Additionally, more consideration may need to be given when a patient has reached the point of futility when deciding whether to continue/discontinue PIMs.¹⁵

Inpatient Complications

Patients hospitalized due to agitation and a request for medication adjustment are also at risk for quicker fixes and problematic prescribing. Research shows antipsychotics are often initiated and titrated to high doses quickly in acute psychiatric hospitals due to the need to discharge patients as soon as possible, despite knowing that the medications often take weeks to months to take effect.¹⁶ Titrating psychotropic doses too quickly before giving the medication time to reach steady state at lower doses (to prevent polypharmacy from developing in the first place) is a real concern.¹⁶ The need for higher doses or more medications is often justified by the patient’s high severity of illness, despite no evidence to support this practice.¹⁷

This practice of rapidly titrating antipsychotic doses is of even greater concern in older adults with SMI, as pharmacodynamic and pharmacokinetic changes in older adults necessitate slower dose titrations to optimize patient safety.

Other Challenges

This is not meant to suggest that prescribers are not receptive to deprescribing interventions; research indicates clinical pharmacist treatment recommendations are often accepted and implemented.^5,18,19 Existing research has limitations that may not tell the full story. For example, some clinical pharmacists are just required to document accepted treatment recommendations to demonstrate indirect cost-savings to leadership (because pharmacists are often unable to bill for clinical services). As such, there is likely insufficient research that reliably captures how frequently deprescribing treatment recommendations are not accepted in routine practice.

Timely communication regarding deprescribing recommendations is also a commonly cited barrier,⁵ suggesting a need for improved lines of communication between those providing deprescribing recommendations and the patient’s prescriber.

Implementing processes for continually reassessing the appropriateness of existing medications, as recommended by Goldberg’s recent review,²⁰ may not be enough to significantly increase the practice of deprescribing. Prescribers are often aware of polypharmacy but believe there is sufficient rationale to continue the medications as prescribed (known as rational polypharmacy).²¹ As such, the recommendation to continue educating psychiatric providers on the importance of deprescribing may be less impactful to those who believe they are already doing this to the best of their abilities.

Studies are needed to determine how often clinicians agree/disagree with the need to continue or discontinue a medication and the rationale for doing so. Additionally, more randomized controlled trials are needed to determine how to safely and effectively deprescribe different types of medications.²² Clinicians may be quicker to adopt deprescribing practices if guidelines are able to recommend this process strongly.

Shared Decision-Making

Lastly, when patients/caregivers have decision- making capacity, they should be involved in the deprescribing process. Patients often believe they take a large number of medications, spend too much money on them, and would like their prescribers to reduce the dose of their medicines; a few (13.8%) report bad experiences when stopping their medicines.²³ While some patients may be hesitant to deprescribe their medications, others may be open to it, especially when their providers agree with the plan. Creating a culture where deprescribing is considered at every visit may help to minimize reluctance and fear surrounding medication cessation.

The Figure illustrates steps that can be taken to successfully apply deprescribing in practice.²⁴ To make deprescribing practices more feasible, polypharmacy should be better defined and charted as a billable problem/condition. This way, clinicians can bill for the time spent addressing this issue,⁵ whether it is continuing medications, discontinuing them, or lowering the dosages.

Concluding Thoughts

Deprescribing requires a shared mental model among interprofessional teams and shared decision-making with patients and their caregivers. Systematically identifying priority medications to deprescribe and developing evidence-based approaches for deprescribing is necessary to support prescribers and other clinicians in ensuring safe and effective medication use for patients.

Dr Vadiei is a clinical associate professor of pharmacotherapy and translational sciences at the University of Texas at Austin and a psychiatric pharmacist at San Antonio State Hospital. Dr Wang is a professor at UT Health San Antonio School of Nursing. Dr Catanzano is a clinical associate professor of pharmacy practice at the University of Texas at Austin and a psychiatric pharmacist at UT Health Austin.

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