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Deprescribing in long-term care

Written by

Dr. Gurpreet Singh Padda, MD, MBA, MHP

in

Deprescribing is a formal discipline with named tools — Beers, STOPP/START v3, STOPPFrail — not an improvisation. What it is and how a facility supports it.

A long medication list in a nursing home is rarely anyone’s decision. It is the sum of several people’s reasonable decisions, none of whom saw the whole list.

How lists get long

A resident arrives from a hospital admission, which arrived from home, which accumulated from a primary care relationship and two specialists. Each prescriber added something defensible. Nobody subtracted, because subtracting requires knowing why something was started, and that reason is often no longer in any record anyone can see.

Then the cascade: a drug produces a symptom, the symptom is read as a new condition, the new condition is treated, and the second drug produces a symptom of its own. It is visible only if you read the list in date order as one document.

Deprescribing is a discipline, not a lapse

It has named tools and a literature.

  • AGS Beers Criteria — the American Geriatrics Society’s expert-consensus list of medications that are often inappropriate in older adults.
  • STOPP/START criteria, version 3 (2023) — covering both potentially inappropriate medications and potential prescribing omissions, including falls risk.
  • STOPPFrail — for limited life expectancy, where a preventive drug’s time to benefit may exceed the time available to receive it.

The two harms worth naming

Falls from antihypertensives. An over-tight dose produces orthostatic hypotension, which produces dizziness and syncope on standing, which produces falls, fractures and head injuries. Beers and STOPP/START both single out centrally acting antihypertensives and alpha-blockers as not recommended for routine hypertension treatment in older adults. More on that pathway.

Statins and glycemia. The FDA added a class-wide label change on February 28, 2012 warning of increased HbA1c and fasting glucose. It is a trade-off, not a prohibition. More on that trade-off.

What a facility contributes

Deprescribing is a prescriber’s decision, but it fails without the facility.

  • A baseline at intake, so later change is measurable rather than remembered. Ongoing monitoring.
  • Observation that gets written down. A resident who is steadier on their feet three weeks after a dose reduction is evidence, if anyone recorded that they were unsteady before.
  • Something in place of the drug. Structure, activity, social engagement, an environment that is not producing agitation. The eight interventions.
  • A care plan that is actually revised. Adjusting care plans.

Nobody should change a medication on the strength of an article. Abrupt withdrawal of several classes causes rebound effects, and several must be tapered. The ask is a conversation with the prescriber.

DWARAA is CareGuard’s deprescribing and dementia care program.

The evidence base

How much medication is actually on the list

The SHELTER study surveyed 4,023 residents across 57 nursing homes in eight European countries and found polypharmacy (5 to 9 drugs) in 49.7% of residents and excessive polypharmacy (10 or more) in 24.3%. A separate cohort of 3,234 nursing home residents found essentially the same split (50% and 24%) and reported that residents on polypharmacy and on excessive polypharmacy had significantly greater one-year decline in cognitive performance score (beta 0.10, 95% CI 0.01 to 0.20 and beta 0.13, 95% CI 0.01 to 0.24 respectively), with no significant difference in activities of daily living.

A systematic review of 13 studies covering 140 nursing homes and more than 6,900 residents found potentially inappropriate prescriptions in 67.8% to 87.7% of residents by STOPP criteria, and potential prescribing omissions in 39.5% to 99.7% by START criteria. The width of those ranges is itself a finding: practice varies enormously between buildings.

The tools, with their current versions

  • AGS Beers Criteria, 2023 update. Intended, in the panel’s own words, “to be applied to adults 65 years old and older in all ambulatory, acute, and institutionalized settings of care, except hospice and end-of-life care settings.”
  • STOPP/START version 3 (2023). Validated by a Delphi panel of 11 academic physicians from eight European countries over four rounds, from a literature review covering April 2014 to March 2022. It contains 190 criteria in total — 133 STOPP and 57 START — a 66.7% increase on version 2 (2015). Earlier versions were published in 2008 and 2015; a published correction accompanies version 3.
  • STOPPFrail version 2 (2021). For older people approaching end of life: a method for identifying who is approaching end of life, plus 25 deprescribing criteria, with new guidance on antihypertensives, anti-anginal medication and vitamin D.

Does deprescribing change outcomes?

This is where an honest page differs from a brochure. The 2016 systematic review and meta-analysis of 132 papers and 34,143 participants found deprescribing polypharmacy significantly reduced mortality in non-randomized studies (OR 0.32, 95% CI 0.17 to 0.60) but not in randomized studies (OR 0.82, 95% CI 0.61 to 1.11). The 2024 update, covering 259 studies, found no significant mortality reduction in either randomized (OR 0.96, 95% CI 0.84 to 1.09) or non-randomized studies (OR 0.70, 95% CI 0.36 to 1.38).

The signal that does survive is about how it is done. In the 2016 analysis, patient-specific deprescribing interventions reduced mortality (OR 0.62, 95% CI 0.43 to 0.88) while generalized educational programs did not (OR 1.21, 95% CI 0.86 to 1.69). The 2024 update found the same direction for patient-specific interventions (OR 0.79, 95% CI 0.63 to 0.99).

That is the case for doing this resident by resident with a prescriber, and against doing it as a facility-wide policy campaign. It is also why deprescribing sits inside a program here rather than standing on its own.

References

  1. Onder G, et al. 2012. Polypharmacy in nursing home in Europe: results from the SHELTER study. Journals of Gerontology Series A 67(6):698-704. [cross-sectional, 4,023 residents, 8 countries] · PMID 22219520 · doi:10.1093/gerona/glr233
  2. Vetrano DL, et al. 2018. Association of polypharmacy with 1-year trajectories of cognitive and physical function in nursing home residents. Journal of the American Medical Directors Association 19(8):710-713. [longitudinal cohort, 3,234 residents] · PMID 29861194 · doi:10.1016/j.jamda.2018.04.008
  3. Díaz Planelles I, et al. 2023. Prevalence of potentially inappropriate prescriptions according to the new STOPP/START criteria in nursing homes: a systematic review. Healthcare (Basel) 11(3):422. [systematic review, 13 studies, 140 nursing homes] · PMID 36766997 · doi:10.3390/healthcare11030422
  4. American Geriatrics Society Beers Criteria Update Expert Panel 2023. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society 71(7):2052-2081. [clinical practice guideline] · PMID 37139824 · doi:10.1111/jgs.18372
  5. O’Mahony D, Cherubini A, Guiteras AR, et al. 2023. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. European Geriatric Medicine 14(4):625-632. [Delphi-validated criteria] · PMID 37256475 · doi:10.1007/s41999-023-00777-y
  6. O’Mahony D, et al. 2023. Correction: STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. European Geriatric Medicine 14(4):633. [published correction] · PMID 37326916 · doi:10.1007/s41999-023-00812-y
  7. Curtin D, Gallagher P, O’Mahony D 2021. Deprescribing in older people approaching end-of-life: development and validation of STOPPFrail version 2. Age and Ageing 50(2):465-471. [Delphi-validated criteria] · PMID 32997135 · doi:10.1093/ageing/afaa159
  8. Page AT, et al. 2016. The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis. British Journal of Clinical Pharmacology 82(3):583-623. [systematic review and meta-analysis, 34,143 participants] · PMID 27077231 · doi:10.1111/bcp.12975
  9. Quek HW, Page A, Lee K, et al. 2024. The effect of deprescribing interventions on mortality and health outcomes in older people: an updated systematic review and meta-analysis. British Journal of Clinical Pharmacology 90(10):2409-2482. [systematic review and meta-analysis, 259 studies] · PMID 39164070 · doi:10.1111/bcp.16200

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