Josh Niznik, PharmD, PhD, Assistant Professor, Division of Geriatric Medicine and Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, is a geriatric health services researcher with clinical training in the pharmaceutical sciences. His research interests are focused on evaluating the quality of medications in older adults to improve the safety of medication use in this population.
Most recently his work has focused on evaluating the impact of deprescribing or discontinuing chronic medications that may no longer have value in nursing home residents with severe dementia as a means for evaluating the quality of prescribing in this population.
Do you think that older adults have high rates of medication burden?
Of course 鈥� and to the point where it鈥檚 very problematic. More than half of older adults are exposed to polypharmacy and the unfortunate thing is that those people are more susceptible to side effects and they鈥檙e more vulnerable to drug-drug interactions. Medication overload has been called 鈥楢merica鈥檚 other drug problem鈥� in a report by the Lown Institute.
There are many opportunities to re-evaluate the appropriateness of a lot of medications particularly in the work that I do with deprescribing. We could do a much better job talking with patients and families about things like time until benefits and how long benefits actually persist for. When we think about the scale of harms and benefits, at what point are we not doing what we set out to do, which is to prevent complications from disease rather than causing unintended consequences of medication exposure鈥�?
What鈥檚 鈥榯ime until benefit鈥�?
鈥楾ime until benefit鈥� is how long someone needs to take a medication at the recommended dose until they would see the intended benefit of the medication. For instance in osteoporosis medications, to see reduced risk of fractures, a patient would essentially have to be on those medications at least a year to see that benefit. For someone who maybe has a limited life expectancy, we need to be very clear about what we鈥檙e doing so that we鈥檙e not putting people on medications unnecessarily 鈥� and wasting money.
How many medications equate to 鈥榩olypharmacy鈥�?
There are varying definitions of polypharmacy but I tend to say 5 or more. A lot of older adults are on 10 or more medications. In nursing homes at least half of residents are on10, with the mean number being closer to 15.
When did you realize that de-prescribing would be your key area of focus?
I didn鈥檛 really decide on this direction until I was in graduate school and started doing research more seriously. I did a few rotations my last year of pharmacy school where I saw a lot of older patients. This highlighted the opportunity that pharmacists have to optimize medication use for these patients, particularly when you鈥檙e thinking about whether a medication is causing a side effect. In a lot of cases, a specific medication actually is what鈥檚 causing the problem.
Providers are generally trained when we see problems to think about medications can be used to treat it. We don鈥檛 often think of the reverse: 鈥榯his is the problem 鈥� what medication is causing it?鈥� For a lot of older adults, the medication is causing a problem or side effect.
My grandmother had Alzheimer鈥檚 disease and end-stage renal disease. She was on a list of more than 10 medications. Her dementia progressed to the point where she couldn鈥檛 ambulate for herself or really have any activities of daily living (ADLs). Yet many of her medications were preventive 鈥� things like anti-dementia and osteoporosis medications which were very unlikely to be providing any benefit at that point.
I think that she really could have benefitted from deprescribing some of her medications particularly at the later stages. It was eye-opening and has served as one of the drivers of why I鈥檓 very passionate about this. It鈥檚 important for physicians, patients, and caregivers to realistically discuss the benefits a medication can and can鈥檛 provide, and to have a plan for de-escalating or stopping certain medications.
Tell us about your recently published paper in Journal of American Geriatrics (JAGS). 聽
This on the 鈥淩isk for Health Events After Deprescribing Acetylcholinesterase Inhibitors in Nursing Home Residents with Severe Dementia鈥� has gotten a lot of attention, I think because there鈥檚 a growing consensus that anti-dementia medications are not that useful. They have lots of side effects, some with 2 to 5 times more risk of side effects compared with patients who aren鈥檛 on them.
For managing dementia, particularly in the later stages, we鈥檙e thinking about comfort and palliative goals of care. Yet the side effect of anti-dementia medications are directly in conflict with those goals of care: GI issues, headaches, and weight loss and more. The potential for benefit with these meds is very modest, and these are all side effects that negatively impact quality of life. Any evidence to justify stopping them is really what we need, and this paper presents that evidence.
Is there any benefit to using anti-dementia medications?
In some cases there is modest benefit, but prescribing appropriately requires a patient-centered approach. Different interpretations of the evidence about use 鈥� and the evidence can at times seem mixed 鈥� can lead to clinicians and families deciding to 鈥榞ive it a try鈥� with a certain medication. My counter argument to the 鈥榞ive is a try鈥� approach is be sure you鈥檙e thinking adequately about quality of life.
If you鈥檙e taking that approach, begin by setting reasonable expectations for what to expect. Have a plan to monitor whether medications are working and a plan for knowing when to stop.