Upwards of 11 million Americans are living with cognitive loss. And those with cognitive loss are likely to have other medical conditions so that many people are taking 5-10 medications. As we age, our physiology may change. Helpful medications may begin to cause more risk than benefit. But how do we know? How do we decide what should be discontinued?
Of course, these are discussions to have with our doctors. But how to start them? How to guide them once started?
Goals of Care
Goals of care are an excellent place to begin our decisions and discussions. You know yourself or your family member better than anyone. All medications have trade-offs—the balance of the risk vs. the benefit.
Many of us consider quality of life. I had several patients on antihypertensive medications (beta-blocker) that caused extreme fatigue and /or depression. Though it may have been the best medication for their cardiac condition, in the long run, they were not willing to live with the worn-out feeling today.
In the same vein, medications that may help urine symptoms today may increase our risk of accelerated cognitive loss., such as anti-cholinergic medications.
It is what matters to you most, after reflecting on your overall life wishes, that helps make these decisions.
As you communicate what matters most to you, ask your doctor –
- What are the benefits today?
- What are the harms today?
- Are there any long-term benefits?
- Are there any long-term harms?
Then, you make more informed and personal decisions when your doctor understands your values, and you know short- and long-term harms and benefits.
Avoiding side effects
The more medications we take, the higher the risk of side effects. Cognitive loss also increases the risk of side effects. It is necessary to think about tapering or stopping medications avoiding burdens of medicine.
Many patients or family members tell me, “I can’t stop that! I need to take it for life!” Very few medications are meant for life – the medicine’s benefit is not life long, or the side effects begin to outweigh the benefit. A drug once helpful can be tapered. Sometimes, just relieving the person of the burden of taking pills is beneficial enough.
Engage the Team
When medications are being discontinued or tapered, ask for help from the entire team. If a blood pressure medicine is suspended, can the nurse offer a blood pressure reading and reassurance that the new numbers are ok? Can the pharmacist answer questions about a good schedule to remove the medications? Can you have a follow-up sooner with your doctor to review the discontinuation and address your questions and concerns?
- Is today’s quality of life more important than longevity? Even longevity is the goal, can medications help with that goal?
- What are the trade-offs for taking the medications? Is there a benefit to discontinuing the medication?
- Less pill burden
- Better sleep
- Less need for blood work or another medication to offset side effects of the initial medication
- Be sure to use the entire healthcare team to address your concerns.
Ariel R Green et al. Designing a primary care-based Deprescribing intervention for patients with dementia and multiple chronic conditions: a qualitative study. J Gen Intern Med ahead of pub July 28, 2020
Ariel R Green et al. How clinicians discuss medications during primary care encounters among older adults with cognitive impairment. J Gen Intern Med 2019;35:237-46.
Photo by Sharon McCutcheon