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According to a new report, if prescribing patterns do not change in the US, older adults will experience at least 74 million adverse drug events requiring medical care and will be hospitalized nearly 5 million times in the next decade. Eliminating Medication Overload: A National Action Plan, a report issued by the Lown Institute, is based on input from national experts, and highlights the risks of overprescribing and overuse of medications, particularly in older adults. The report is both a wakeup call and a roadmap that offers policy recommendations and guidance for health care institutions, clinicians, and older adults to reduce harm from multiple medication use.
While medications are helpful for many people, medication overload is the use of multiple drugs that pose a greater risk of harm than benefit. Polypharmacy, as medication overload is often called in the scientific literature, is one of the geriatric syndromes that can lead to serious adverse events, including death. There are challenges in prescribing for older adults, particularly those with multiple, interacting conditions. Polypharmacy may result from an older adult seeking medical care from multiple providers who often do not communicate with one another. Furthermore, medication errors are more common and often more serious when older people move from one setting to another, for example, going from outpatient to inpatient hospital care, transferring from hospital to skilled nursing facility (SNF), or from SNF to home.
Recommendations for Addressing Medication Overload
Medication overload is driven by three aspects of our health care system. First, providers and older adults live in a “culture of prescribing.” In other words, it is easier to ask for or write a prescription for a medication than to take time to explore non-pharmacological interventions. Second, medical schools often fail to teach ways to effectively de-prescribe, particularly in older adults with multiple chronic conditions. Third, the US health care system includes a patchwork of different prescribers across settings, and there is often no single clinician coordinating multiple medications.
The Lown report provides a framework for increasing engagement in the medication use process, including encouraging more effective communication between older people and their care teams. Improving older adult personal investment in medication use and highlighting the benefits of careful medication management can promote independence and self-confidence and may prevent serious medication interactions with poor outcomes.
Many opportunities to reduce medication overload exist. The Lown report suggests the following actions to reduce adverse events, emergency department visits, and hospitalizations related to medication overuse:
- Older adults and family members or care partners should learn about the risks of medication overload and request a prescription check-up to talk about medications with their providers.
- Clinicians should learn about the risks of medication overload.
- Clinicians should strive to be “pharma free” and have deprescribing guidelines available at the point of care.
- Hospitals, clinics, and long-term care communities should launch a campaign for clinicians to raise awareness about medication overload.
- Hospitals, clinics, and long-term care communities should implement prescription check-ups and make deprescribing guidelines available to clinicians.
- Health professional schools and academic medical centers should incorporate training on careful prescribing and deprescribing into their curricula and offer continuing education programs on these topics.
- Health professional schools and academic medical centers should implement a “Deprescribing Champions” program, raise awareness, and make deprescribing guidelines available to prescribers and clinicians.
- Government agencies and policymakers should support a medication overload public awareness campaign and research, create a Medicare reimbursement code for prescription check-ups, or allow bundling of this practice into wellness visits.
- Government agencies and policymakers should work to improve adverse event reporting, restrict or better regulate direct-to-consumer advertising, and fund in-person education to reduce inappropriate prescribing.
- Foundations and nonprofits should support a pilot campaign for prescription check-ups, a public awareness campaign about medication overload, and a convening of clinician specialty groups to identify changes needed to clinical practice guidelines.
The Role of Age-Friendly Health Systems (AFHS)
Work is underway around the country that aligns with the Lown report recommendations. Many health care and community organizations are working to become Age-Friendly Health Systems with support from The John A. Hartford Foundation and the Institute for Healthcare Improvement in partnership with the American Hospital Association and the Catholic Health Association of the United States. Age-friendly organizations reliably provide a set of specific, evidence-based geriatric best practices for all older adults in their health system. Over 450 teams from hospitals, post-acute care communities, home health agencies, outpatient practices, and other settings are working towards reliable implementation of the 4Ms interventions (What Matters, Medication, Mentation, and Mobility). The 4Ms framework provides a way of streamlining workflow and helping interdisciplinary teams organize their practices, interpersonal approaches, and documentation.
Implementing the Age-Friendly Health Systems 4Ms are one way to put the Lown report’s recommendations into action. For example, the medication component of the 4Ms — like the Lown report — addresses reducing medication overload, avoiding medications that are not safe for older adults, and deprescribing when appropriate.
The other elements of the 4Ms are also intertwined with reducing medication overload for older adults. For example, reducing polypharmacy may promote mobility and reduce cognitive changes (mentation). Addressing medication overload may also have a positive effect on what matters most to a patient, allowing them, for example, to safely move from a nursing or rehabilitation community back to their own home and familiar neighborhood.
Designing a strategy for the care of older adults must be a high priority as the US population ages. IHI welcomes contributions like the Lown report that shine a spotlight on issues that are too often ignored or misunderstood. We look forward to putting this important plan into action in partnership with health systems, clinicians, and older adults and their families.
Alice Bonner is IHI’s Senior Advisor on Aging. Leslie Pelton is Director of IHI’s Age-Friendly Health Systems initiative.
You may also be interested in:
The Age-Friendly Action Community — Starting in March 2020, the Action Community will offer seven months of webinars, peer-to-peer learning and coaching, supportive tools and resources, and one in-person meeting. Contact AFHS@ihi.org for more information.
Age-Friendly tools and resources, including a Business Case for Becoming an Age-Friendly Health System and EHR Implementation Guides.