Multimorbidity is common among older adults, which often means taking multiple medications, also known as polypharmacy. It is estimated that older adults in developed countries now take around 7 medications daily (1,2). Although polypharmacy can be beneficial and sometimes necessary for symptom management, it can contribute to the burden of treatment. Medication side effects, adverse effects, medication interactions, reduced medication adherence, and complex regimens are medication-related factors that independently, or in combination, contribute to treatment burden of the patient and may compromise the patient’s ability to cope (2-7). There is an increased risk of adverse drug reactions as the number medications increase from 2 to 5 and finally to 7 or more with a risk of 13%, 58% and 82%, respectively (3,8). Adverse drugs reactions inevitably put older adults at an increased risk of mobility-related functional decline, falls, hospitalizations, impaired cognition, and reduced quality of life (4-5, 7).
Canada’s health care system lacks a systematic approach to minimizing these negative effects in routine care. The aim of TAPER is to embed a reduction of medication burden through medication review and ‘deprescribing’ as part of regular preventive care in older adults. In a population with increasing multimorbidity and polypharmacy, decisions about when to stop treatment may prove to determine care quality as much as those to start.
Policy makers can support the growth of TAPER by helping us engage with decision-makers working with patient and provider groups focusing on older adults. Policy makers can also support by helping to facilitate and incentivize health care systems to incorporate TAPER into normal clinical workflow models.
Health care teams in Canada can begin to offer TAPER immediately after a short onboarding process. Teams in the United States, New Zealand, or Australia may choose to customize the clinical pathway prior to implementing the program, for example, by adding or subtracting different domains to the patient questionnaire in order to make the process a better fit for these locations.
One quality indicator directly related to TAPER is the number of residents prescribed anti-psychotic medications. TAPER directly links to a number of guidelines and algorithms on deprescribing anti-psychotic medications, such as the recent Canadian clinical practice guidelines. In addition to reducing anti-psychotic prescription, TAPER will assist care facilities with reducing the overall number of medications residents take, which can improve physical function and reduce falls. We are currently piloting TAPER in two Ontario long-term care facilities with plans to expand in the near term.
Over-medication is costly in terms of hospital admissions and treatments for adverse effects (9).In Canada, adverse drug reactions cause an estimated 70,000 preventable hospital admissions per year (10). Taking five or more drugs results in adverse drug reactions requiring medical care, affecting 13% of Canadian seniors: 1/3 are thought preventable. These are costly to the individual and costly to the health care system. Canada’s health care system lacks a systematic approach to minimizing these negative effects in routine care (11). TAPER is designed to fill that gap.
Please contact us directly for more information about bringing TAPER to your community.
- Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults. Addressing polypharmacy. Arch Intern Med. 2010; 170 (18): 1648- 1654. doi:10.1001/archinternmed.2010.355
- McCarthy L, Dolovich L, Haq M, Thabane L, Kaczorowski J. Frequency of Risk Factors That Potentially Increase Harm From Medications in Older Adults Receiving Primary Care. Can J Clin Pharmacol. 2007;14(3):283-290.
- Bhavik MS and Hajjar ER 2012. Polypharmacy, adverse drug reactions, and geriatric syndromes. 2012
- Tinetti ME, Han L, Lee DH, et al. Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA Internal Medicine. 2014
- Hilmer SN, Gnjidic D. The effects of polypharmacy in older adults. Clin Pharmacol Ther. 2009;85(1):86-8.
- May C, Montori VM, Mair FS. We need minimally disruptive medicine2009 2009-08-11 23:06:19.
- Lu W-H, Wen Y-W, Chen L-K, Hsiao F-Y. Effect of polypharmacy, potentially inappropriate medications and anticholinergic burden on clinical outcomes: a retrospective cohort study. Canadian Medical Association Journal. 2015.
- Prybys K, Melville K, Hanna J, et al. Polypharmacy in the elderly: Clinical challenges in emergency practice: Part 1: Overview, etiology, and drug interactions. Emerg Med Rep 2002;23:145–53.
- Field TS, Gilman BH, Subramanian S, et al. The costs associated with adverse drug events among older adults in the ambulatory setting. Med Care 2005;43(12):1171-76
- Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal. 2004;170(11):1678-86
- Seniors and the Health Care System: What Is the Impact of Multiple Chronic Conditions? Canadian Institute for Health Information, 2011