By Stacey Kusterbeck
Many older patients take multiple high-risk medications, and might receive additional pills during an ED visit. For emergency physicians (EPs), this poses significant patient safety and liability concerns.
“We continue to see older adults coming in with polypharmacy and high comorbidities,” reports Sangil Lee, MD, MS, an EP at University of Iowa Hospitals & Clinics.
Lee and colleagues developed an evidence-based program for deprescribing older adults in the ED.1 Eight healthcare workers who care for older adults in the acute care setting participated in a focus group on patients who were taking high-risk medications. The researchers also interviewed 20 patients (and caregivers of those patients) taking more than four medications. Participants reported many different safety concerns.
For example, clinicians described barriers to finding accurate medication histories in the ED setting. Similarly, patients worried no one was checking on how newly prescribed medications would interact with their other medications. To learn more, one EP talked about interviewing family members to learn about a patient’s medications.
Clinicians reported medication side effects were a common reason for ED visits, and that there was no standardized process to identify high-risk medications. In fact, clinicians recalled older adults with altered mental status they suspect was caused by medications.
These can be challenging situations. Another resident talked about discomfort deprescribing a medication that another provider, outside the ED, had prescribed to the patient. Regardless, one resident underscored the importance of reviewing high-risk medications regularly for older adults with mental status changes. “Clinicians in the outpatient setting are increasingly aware that high-risk medications can be cut a bit for the older adults,” says Lee, clinical associate professor in the department of emergency medicine at the University of Iowa.
In contrast, EDs typically see the patient, take care of the acute issue, and release the patient to outpatient providers.
“Traditionally, our focus has been to prescribe new medications. The EDs that are focused on medication management are still a minority,” Lee explains.
Many emergency providers are hesitant to deprescribe medications taken by a patient they just met. Some are more open to the idea in certain cases, such as blood pressure medications associated with side effects or adverse outcomes.
“But if the patient cannot identify the high-risk medications they’re taking, or if the link between the medication and the chief complaint is pretty weak, it makes it more challenging,” Lee says.
Overall, the focus groups and interviews suggested that despite some challenges, deprescribing high-risk medications was within the scope of ED providers.
Another group of researchers examined the effects of a pharmacist-led deprescribing intervention for adults age 75 years or older in the ED.2 “Medication side effects and interactions are a well-established risk for aging patients, especially those who require emergency care. However, high-risk medications may or may not be identified as contributing to the immediate need for emergency care,” says Alice Mitchell, MD, MS, FACEP, one of the study authors and an associate professor of emergency medicine at Indiana University School of Medicine.
Pharmacists reviewed the patient’s medications, identified potentially inappropriate prescriptions, and alerted primary care physicians of the recommendations. It was left to the outpatient providers’ discretion to discontinue, adjust, or continue the medications.
“We wanted to introduce a process for expert pharmacy review of medications used by vulnerable aging patients treated in our ED, and to provide a connection with their primary care clinics in minimizing medication risks,” Mitchell explains.
Before the intervention, the rate of deprescribing was 11.1%. After the intervention, the rate of deprescribing was 57.1%. The researchers acknowledged there are barriers to identifying and addressing high-risk medication use in the ED. “Collaboration with pharmacy expertise is highly effective in improving this area of care,” Mitchell says.
REFERENCES
1. Lee S, Bobb Swanson M, Fillman A, et al. Challenges and opportunities in creating a deprescribing program in the emergency department: A qualitative study. J Am Geriatr Soc 2023;71:62-76.
2. Jovevski JJ, Smith CR, Roberts JL, et al. Implementation of a compulsory clinical pharmacist-led medication deprescribing intervention in high-risk seniors in the emergency department. Acad Emerg Med 2023; Feb 15. doi: 10.1111/acem.14699. [Online ahead of print].
Many emergency providers are hesitant to deprescribe medications taken by a patient they just met. Some are more open to the idea in certain cases, such as blood pressure medications associated with side effects or adverse outcomes. But if patients cannot identify the high-risk medications they are taking, or if the link between the medication and the chief complaint is weak, it makes the task harder.
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