There is more and stronger evidence to support standardized hospital insulin protocols to prevent hypoglycemia than there is to support teach-back methods to improve medication management. Teach-back is in a formative stage in that enhanced definitions and typologies of teach-back methods are needed before it will be possible to collate the clinical evidence. However, better-designed studies on both patient safety practices are needed to establish a firm evidence base. Reducing adverse drug events in older adults People are living longer than ever. In the United States, the number of Americans age 65 years and older increased from 37.2 million in 2006 to 49.2 million in 2016 (33% increase) and is projected to reach 98 million by 2060. With age comes the likelihood of increasing morbidity. An estimated 98% of people age 65 years and older have at least two chronic diseases and take at least five prescription medications. 93 As the medical field develops clinical therapies, protocols, and treatments to help the elderly population better manage, prevent, and/or enhance quality of life, there are also risks. For instance, polypharmacy—taking multiple medications concurrently—and the use of potentially inappropriate medicines (PIMs) pose the greatest risk of drug-related adverse events (ADEs) for older adults, who are more likely than younger people to take multiple medications at the same time. 94 Broadly defined as injuries that result from drug-related medical interventions (e.g., medication errors, adverse drug reactions, allergic reactions, or overdoses), ADEs have been associated with thousands of visits to the emergency department (ED) and hospitalizations. However, up to half of identified ADEs are preventable, and ADEs are one of the most common types of preventable adverse events across all healthcare settings. Common consequences of ADEs include drug-related morbidity and mortality, heart and/or renal failure, gastrointestinal and internal bleeding, and negative drug-drug interactions. Polypharmacy and the use of inappropriate medications present a risk for ADEs. Driven by the need to identify the most precise way to identify ineffective and/or unnecessary medications, several intervention strategies report varied success in implementation and effectiveness. This section focuses on two emerging approaches: (1) deprescribing to reduce polypharmacy and (2) the use of the Screening Tool of Older Person’s inappropriate Prescriptions (STOPP) criteria to reduce PIMs. Deprescribing involves reducing doses or stopping medications that are not useful or are no longer needed in order to reduce polypharmacy, reduce harm, and improve health. STOPP is a validated, evidence-based list of 80 criteria for potentially inappropriate prescribing in older adults, first published in 2008 and revised in 2014. While it is a fairly new tool, evidence suggests that STOPP may be better at predicting PIMs in older adults than other tools, such as the American
Geriatrics Society’s Beers Criteria, hereafter referred to as the Beers Criteria. While this patient safety practice (PSP) specifically emphasizes the use of the STOPP criteria, it is often used with a companion screener, the Screening Tool to Alert to Right Treatment (START). START includes a set of 34 evidence-based and validated prescribing indicators for common diseases for the same population. Both have been more commonly used in non-U.S. settings. Deprescribing As previously discussed, deprescribing addresses polypharmacy by reducing inappropriate prescriptions and can lead to improved clinical outcomes. However, clinical outcomes can vary with the specific approach to deprescribing. Ocampo et al. (2015) found that a pharmacist-led medication review with an 18-month follow-up period in community pharmacies identified 408 negative outcomes related to prescriptions and resolved 393 of these problems, resulting in a significant decrease in hospitalizations and ED visits. 95 Physical and mental health summary scales increased from 65.8 to 82.7 and 66 to 81, respectively, while patients who were nonadherent decreased from 68 to 1. Others reported that discontinuing multiple medications simultaneously was significantly associated with reductions in both the number of reported falls and frailty scores for older adults. 96 These researchers also examined collaborative medication reviews with general practitioners of patients age 65 years and older in a residential care facility. Their study noted a significant reduction in drug burden index scores, reflecting a decrease in the cumulative exposure to medications, and the number of falls and frailty measured using the Edmonton frailty scale dropped by a mean difference of 1.35 (p<0.05). Additionally, the number of adverse drug reactions decreased by 4.24 (p<0.05) after 6 months. Protocols, algorithms, and clinical decision support systems Patients had a significant decrease in the number of medications prescribed in studies focusing on the use of protocols, algorithms, and clinical decision support systems to promote deprescribing. A patient-centered deprescribing protocol called Shed-MEDS is implemented in four phases: (1) confirm medication history and list, (2) evaluate medication for deprescribing, (3) decide with the patients, (4) synthesize and communicate recommendations. Petersen et al. (2018) found that, among Medicare beneficiaries prescribed five or more medications, the mean number of prescribed medications was significantly reduced, from 11.6 to 9.1 (p=0.032), for those receiving the protocol. 97 McKean et al. (2016) worked with patients age 65 or older taking eight or more medications to implement an intervention consisting of a formal medication review among rounding clinicians, followed by receipt of a paper-based or
computerized form listing clinical and medication data linked with a five-step clinical decision support tool to determine drugs eligible for discontinuation. 98 The intervention led to a 34% decrease in regular medications, a small but nonsignificant decrease in PRN (as needed) medications, and a significant decrease in the number of medications per patient at discharge compared with admission. Education-improvement interventions, which directly educate consumers, have also been associated with medication discontinuation to reduce polypharmacy. Tannenbaum et al. (2014) found that a direct- to-consumer education intervention using an 8-page booklet to describe the risks of benzodiazepine use and a step-wise tapering protocol led to a 27% discontinuation of benzodiazepines among community pharmacy patients age 65 or older in the intervention group, compared with 5% in the control group 6 months after the intervention. 99 A consumer-based education intervention led by pharmacists in community pharmacies providing an educational brochure to patients age 65 and older resulted in 43% of the intervention group no longer filling inappropriate medications, compared with 12% of the control group. 100 Pharmacist or clinician-led medication reviews Pharmacist-led medication review interventions across a number of settings have also promoted deprescribing. Lenander et al. (2014) found that a pharmacist-led medication review in a primary care setting targeting patients 65 and older with five or more different medications led to a decrease in drug-related problems. 101 Using the Beers Criteria, after 12 months, drug-related problems decreased for the intervention group from 1.73 to 1.31 (p<0.05). There was also a larger reduction in the number of drugs prescribed in the intervention group (p<0.046). Medication reviews involving both pharmacists and clinicians can effectively decrease medication use. Chan and others (2014) determined the effectiveness of a medications safety review clinic for geriatric outpatients age 65 or older who were prescribed eight or more chronic medications or who had visited at least three different physicians at the two participating hospitals within 3 months. Four medication review sessions were performed by two research assistants, one clinical pharmacist, and one geriatrician, leading to a mean decrease in chronic medications from 9.0 to 8.6 (p<0.05). 102 Key findings • Geriatrician and clinical pharmacist reviews can effectively reduce the use of unnecessary medications. • Educating patients and their families helps them better communicate their medication use to providers in order to discontinue unnecessary medications. • Deprescribing reduces medication- related costs for patients and healthcare systems.
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