Among U.S. adults at least 65 years of age, falls are the leading cause of injuries and deaths. Effective falls prevention includes removing tripping hazards from the home and doing strength and balance exercises. Researchers at the University of Iowa are studying a less researched falls prevention strategy, called deprescribing.
Deprescribing is when doctors and pharmacists work with their patients to help them stop or replace certain prescription and over the counter medications or reduce medication dosage. While medications can benefit health and save lives, they can also cause interactions with other medications and certain health conditions, putting older adults at particularly high risk for injury, illness, and death.
Medications that can affect balance, coordination, and cognitive function, and increase the likelihood of falls, include opioids, benzodiazepines, and anticholinergics, among others. While these medications may be tolerable in younger adults, they are processed differently as we age.
Around 1/2 of U.S. older adults, many with multiple chronic health conditions, take five or more prescribed and/or non-prescribed medications. The use of multiple medications daily, including over the counter medications, is known as polypharmacy. The higher the number of medications older adults take, the greater risk they have of experiencing bad effects, including falls.
Dr. Korey Kennelty, a geriatrics pharmacist at the University of Iowa Hospitals and Clinics, has worked with over 100 primary clinics across the U.S. in her research.
“Much focus has been on the prescribing of medications but not on deprescribing medications,” she said. “This deprescribing process is important because medications that worked when we were 20 years old may not work the same when we are 80 years old. Our bodies change, including our kidneys and liver function.”
See new CDC video featuring Dr. Kennelty: Aging and Deprescribing Medications
Kennelty is addressing older adult falls related to polypharmacy through deprescribing. In this planned process, pharmacists and providers identify patients’ problematic medications that are not working the way they are intended or have too many side effects. Then, they may recommend that patients discontinue medications that have potential harms which outweigh the benefits of that medication. Patients are monitored closely during this process.
Deprescribing can include immediately stopping a medication, tapering (slowly taking less of that medication until stopping to lesson withdrawal effects) or lowering the dose (finding the lowest effective dose). Often pharmacists recommend switching to alternative medications or non-pharmacological interventions.
About half of U.S. older adults are taking one or more potentially inappropriate prescribed medications. For instance, they take a medication without a clear medical indication, take duplicate medications targeting the same symptoms, or use a medication with known hazards for older adults, such as an increased risk of falling.
MEDS Study
The Medication Empowerment and Deprescribing for Safety (MEDS) Fall Prevention Study is co-led by Kennelty and Dr. Carri Casteel, professor at the UI College of Public Health and director of the UI Injury Prevention Research Center. Their study examined the effectiveness of deprescribing plans in reducing falls among older adults seen in rural primary care clinics in Iowa and evaluated their useability and relevance among healthcare system administrators, clinics, doctors, and patients.
“The MEDS Study has been important in understanding how deprescribing inappropriate medications affects fall rates among rural older adults, including serious fall-related injuries that require medical treatment,” Casteel said.
The MEDS study was a collaboration between researchers and clinical pharmacists at the University of Iowa and a clinical team from MercyOneTM Iowa, a healthcare system with significant reach into rural Iowa communities through their critical access hospitals.
“Medication management needs a team-based care approach. We know team-based care improves patient outcomes and this is no different for deprescribing,” Kennelty said. “Engaging with the patient, their caregivers, and their provider is necessary for a successful deprescribing.”
A total of 212 patients received medication deprescribing plans, which were delivered and monitored by MercyOneTM health coaches. Another 185 patients enrolled in the study as control participants and received usual care and information for falls prevention. 96% of patients in both groups reported taking at least five medications at the start of the study. The study is looking at differences in falls between these two groups after one year. Study data are still being analyzed.
86% of patients surveyed about their experiences with the deprescribing plan said they would recommend the process to a friend or family member. The primary challenges reported by patients were health or caretaking responsibilities that arose or adjusting to side effects during the process like pain and difficulties sleeping.
Kennelty said a stakeholder group of doctors, pharmacists, and older adults have provided education, motivation, and other assistance to the study’s deprescribing process.
“Their input has helped the research team develop a medication action plan tailored to the individual patient to aid them in reducing the amount of pharmaceuticals they are consuming,” she said.
The study’s medication deprescribing plan documents current medications, relevant past medications and reason for discontinuation, taper/dose reduction recommendations from a pharmacist to the primary care provider, and specific rationale for the pharmacist’s recommendations. It also has a monitoring plan, provider comments, a taper schedule, and a patient education handout (with the importance and benefits of discontinuing/reducing dose of medication and symptoms to watch for while tapering).
Casteel said, “If you are interested in changing or stopping your medications, please consult with your pharmacist or prescriber first. It can be dangerous to your health and safety to modify your medications on your own.”
Components of the MEDS study have been integrated into University of Iowa family medicine clinics. Kennelty helped develop a pharmacy service using the deprescribing model developed from the MEDS study, particularly the medication action plan.
Kennelty said, “We are also partnering with the CDC, University of North Carolina, and University of Washington to co-brand some of our study materials to be publicly available.”
Kennelty and Casteel are expanding this research to include other settings such as assisted living communities.
“I feel like much research has been done in nursing home and community-dwelling older adults but little in assisted living communities,” Kennelty said.
Published February 13, 2024
Some resources:
Rounding@Iowa podcast: Deprescribing and polypharmacy
New study to focus on preventing falls through elimination of high-risk medications
American Family Physician Journal: Deprescribing is an essential part of good prescribing