Stacy Kish

Older adults often need to manage multiple medications to treat different conditions, but the pharmacological mix can have negative interactions that cause unintentional harm. For this reason, many clinicians who care for older patients engage in the process of deprescribing—identifying and discontinuing medications that cause more harm than benefit.

Deprescribing begins with a conversation between the clinician and patient, but this step has proven to be a daunting obstacle for both sides engaged in the dialogue. That’s because the patient doesn’t always understand the benefit of stopping certain medications, while the clinician may not fully appreciate the patient’s treatment preferences.

To develop a framework to improve the deprescribing conversation across healthcare and community organizations, 

, MD, Humana Foundation Professor of Medicine at Yale School of Medicine, led a multi-institutional, international Communications Working Group composed of 14 experts in geriatrics, pharmacology, and communication, along with community outreach stakeholders who conducted a literature search of deprescribing articles published over the past two decades. The results, which included recommendations for improvements, were recently published in the 

“More is not always better,” said Fried. “We have to recognize that when we add on medications to treat multiple chronic conditions, inevitably there is a tipping point where having more is associated with greater risks.”

Prescribing guidelines may not benefit older adults

Currently, clinicians follow clinical practice guidelines, typically written by professional medical organizations, when providing care, but this approach may be counterproductive for older adults. Fried points to high blood pressure medications as an example. The medication can lower a patient’s blood pressure to a target range, but it could also make the individual vulnerable to dizzy spells and falls.

“In many ways, deprescribing is going against years and years of effort to promote appropriate prescribing,” said Fried. “Physicians can follow clinical practice guidelines that make it easy to prescribe the correct medications for, say, diabetes or high blood pressure, but following these guidelines can sometimes cause more harm than good. When older persons with multiple conditions are prescribed all of the individual medications included in the different guidelines, these medications can interact with one another, side effects can begin to accumulate, and a medication prescribed to help one condition may worsen another. Medications need to be prioritized depending upon the outcomes that matter most to the patient.”

A new communication framework for prescribing practices takes form

The working group conducted a review of articles, published over the past two decades, that explored different approaches to deprescribing—a term that was introduced in an article published in 2003 in the 

Journal of Pharmacy Practice and Research

 describing the principles and practice of removing unnecessary or inappropriate medications and avoiding polypharmacy.

From the 78 papers identified, the Communications Working Group determined that most interventions consist of a clinician being alerted to a potential problem with the patient’s medication but does not provide guidance to the clinician about how to communicate with the patient. Moreover, these interventions do not consider the larger context in which a patient’s view of medications is shaped.

To improve this effort, the team developed a framework that expands the sphere of influence for this important decision-making process. The framework consists of “nested spheres,” in which the innermost sphere is the traditional doctor–patient office visit. Each additional sphere captures opportunities to initiate and continue the deprescribing conversation across the greater healthcare system as well as at different community interactions. This framework allows for input from additional practitioners, including nurses and other specialists, and community partners, such as pharmacists, faith-based groups, and other community-focused organizations.

“Broadening the spheres in which communication about deprescribing occurs can help to normalize the process, address concerns that deprescribing is somehow related to rationing, and help to counteract the prevailing messaging around medications that ‘more is better,’” said Fried.

The literature review is limited by the content that has been published, which only addresses the patients’ priorities and views concerning the benefits and risks of their current medication regimen. While the proposed framework offers a new approach that incorporates shared decision-making, Fried acknowledges that more studies are needed to explore how the deprescribing conversation unfolds during an office visit. These studies could evaluate communication content and style to advance this conversation, especially addressing sensitivities among a more diverse patient population.

“Our community partners helped us remember the bigger world beyond the individual patient and clinician, and reminded us of the need to build trust in the patient–clinician relationship,” said Fried. “Our insights will benefit the next generation of interventions that will be designed for deprescribing.”

Fried and her team received funding from the National Health and Medical Research Council and the National Institute on Aging.

Articles

Deprescribing in older adults is crucial to mitigate negative drug interactions, yet challenging due to communication barriers between clinicians and patients. A multi-institutional team led by Dr. Terri Fried developed a framework to enhance deprescribing conversations, emphasizing shared decision-making and broader community involvement. Current prescribing guidelines may not suit older adults, as they can lead to harmful polypharmacy. The new framework involves "nested spheres" to facilitate deprescribing discussions beyond traditional doctor-patient interactions, involving various healthcare and community stakeholders. Further studies are needed to refine communication strategies.

Most deprescribing interventions consist of a clinician being alerted to a potential problem with the patient’s medication but does not provide guidance to the clinician about how to communicate with the patient.

When Drugs Cause More Harm Than Good for Older Adults

Athletes who undergo ablation to treat their irregular heartbeat caused by atrial fibrillation (AF) experience greater improvement in sports performance compared to those who use antiarrhythmic medications, 

, Robert W Berliner Professor of Medicine in the Section of Cardiovascular Medicine at Yale School of Medicine, evaluated data from 1,055 participants (78% male, median age 61–71) who responded to an online survey. The findings, recently published in the journal 

, could help guide decision-making for athletes diagnosed with AF.

“Atrial fibrillation affects everyone, and I see in my own athlete-patients how much it impacts their quality of life,” said Lampert. “These patients have never been studied in a systematic way.”

Athletes at greater risk for atrial fibrillation

 is an arrhythmia (irregular heartbeat) that affects how blood is pumped throughout the body. It can lead to heart palpitations, fatigue, shortness of breath, dizziness, weakness, and rapid heart rate.

Athletes, especially those who participate in endurance sports, such as cycling and running, experience AF at a higher rate than the general population. Patients diagnosed with AF have two treatment options—antiarrhythmic medications or catheter ablation, a minimally invasive procedure that uses heat or cold to produce scar tissue inside the heart to restore a regular heartbeat.

AF patients are also encouraged to adopt lifestyle changes, such as weight loss, exercise, and control of alcohol, caffeine, and tobacco, to decrease arrhythmia symptoms. In this survey, the athletes’ symptoms only rarely improved from these lifestyle changes or from reduced training.

Survey suggests ablation leads to improved sports performance

The study results are based on data gathered by an internet-based survey to understand how AF impacts athletes, and how treatments used by athletes with the heart condition affect their sports performance, training, and symptoms.

“Surveys are preliminary data that rely on who chooses to answer and how they respond,” said Lampert. “The results do allow us, though, to get a sense of what’s going on.”

The results show that many athletes use medications, such as beta-blockers, calcium channel blockers, and the antiarrhythmic drug flecainide to control heart rhythm. This treatment option was reported to be only partially effective and was also reported to be accompanied by unwelcome side effects, including fatigue, low energy, and decreased athletic performance.

Unlike what happens with antiarrhythmic medications, almost half of athletes who underwent ablation did not experience a recurrence of AF symptoms. Compared to those taking medication for the condition, the survey showed that the respondents who received ablation were more likely to report improvement in sports performance and an ability to return to competition. Strengths of the study include the large sample size and community-based participation. The respondents were self-described as “athletes” and had a range of athletic participation.

The survey results suggest that, for athletes, ablation may be more effective for treating AF as well as for minimizing the negative side effects associated with antiarrhythmic medications. These outcomes may improve the likelihood that athletes can regain the level of sports performance they experienced prior to the onset of AF. Lampert stresses that prospective studies are needed to confirm the impact of AF and its treatment in athletes.

Athletes with atrial fibrillation (AF) who undergo catheter ablation show greater improvement in sports performance compared to those using antiarrhythmic medications, according to recent research. The study, led by Dr. Rachel Lampert at Yale School of Medicine, analyzed data from 1,055 athletes, revealing that ablation is more effective in reducing AF symptoms and enhancing athletic performance. While antiarrhythmic medications often result in side effects like fatigue and decreased performance, ablation offers a promising alternative. However, further prospective studies are necessary to confirm these findings.

A survey suggests ablation leads to improved sports performance in athletes with atrial fibrillation.