Upstate Medical University is using a $350,000 grant from the New York State Health Foundation to look at how systematically deprescribing medications in older adults can improve patient health and save money.

Upstate has teamed with the Loretto Health System on the project, which started in early 2020 and was stalled due to the COVID-19 pandemic. The project, which received an extension and started up again in the fall, focuses on 1,305 vulnerable older adults served by Loretto. Sharon Brangman, MD, chair of the Department of Geriatrics is principal investigator and Christopher Morley, PhD, chair of the Department of Public Health and Preventive Medicine, is co-principal investigator.

The project addresses the number and cost of preventable medication-related adverse drug events among frail older adults due to negative drug-to-drug interactions, high risk medications and taking too many medications. Nationally, between 39.7 percent and 47.5 percent of older adults are on five or more medications, double any other age group. Up to 30 percent of older adult hospitalizations are medication-related and as many as 95 percent of nursing home patients have drug-related health issues. 

Examining a patient’s medications, their interactions and side effects takes time but can be very worthwhile, Brangman said.

“In geriatrics we have been concerned for years about the number of medications our patients take,” she said. “We don’t want to just stop meds arbitrarily and potentially destabilize a patient’s health status. We want to stop meds appropriately and continue meds that are still needed and are still effective. We want to develop an organized way for physicians to make appropriate choices about the medications older adults are taking.”

One patient can have several doctors prescribing different medications. There may not always be any particular physician who is providing oversight for all the medications and medical conditions for that patient. This becomes even more complicated if a patient is hospitalized and then admitted to a nursing home. It may not always be clear which medications that were started in the hospital are still needed in the nursing home. Patients, their families and their caregivers also are often concerned about the number of medications that are prescribed and rely on their physicians to make the right prescribing decisions, Brangman said.

“If people are prescribed something by a physician, they will often keep refilling and taking it, even if they shouldn’t be on it anymore,” Morley said. “Patients end up with long lists of medications that they’re taking, and it can go unchecked. Often, if there isn’t one care provider coordinating that list, it ends up including medications they probably haven’t needed in a long time. Some of those unneeded medications are actually are bad to take together, and some might be causing other problems.”

Brangman and Morley both gave the example of a statin, which has been used to prevent a first-time heart attack in adults older than 75. But statins can have side effects including weakness that can lead to a fall or loss of appetite with weight loss, they said.

“The benefit of using a statin to reduce the risk of a first-time heart attack may be small in some patients in their 80s or 90s, but the problem of these patients having a fall with an injury or not eating and losing weight because they are taking a statin may have a big and immediate impact on their health,” Brangman said, noting a statin may be important to continue for some older adults. “Some patients take 10 pills in the morning and then they feel so full that they don’t feel like eating breakfast. That’s a big problem if someone loses their appetite because they are taking so many medications, many of which may not even be needed.”

Residents at Loretto have been eager to participate in the project to find ways to reduce the number of medications they take throughout the day, said Joelle Margrey, vice president of skilled nursing at Loretto.

“We have seen first-hand that it is best to maximize one medication for effective results, instead of using multiple medications to treat one disease,” Margrey said. “For this to be successful, there must be a commitment from the doctor, nursing staff, pharmacist, the patient, and any family caregivers to evaluate medications on a monthly basis. This not only helps prevent over-prescribing, but also allows for evaluation of medications to ensure the dose is effective and to change any dosage with a gradual reduction.”

The annual cost of adverse drug events in the US is estimated at $30.1 billion, at an average cost of $72,000 per hospital and per-event cost of $13,994 for non-intensive care and $19,685 for intensive care.

“We hope to explore whether it is possible to reduce the number of medications people are on,” Morley said. “If we can demonstrate it is possible to reduce medications without increasing adverse events in the population, or even improve adverse events rates, that is even better. If it ends up both lowering adverse events, while also being a cost savings and potentially saving the system money at the same time, it is a win for all.”