what deprescribing in the elderly?

what deprescribing in the elderly?

Paris, France — Does the prevention of cardiovascular diseases in the elderly have its particularities? During the European Days of the French Society of Cardiology (JESFC 2023)a joint session with the French federation of c cardiology (FFC) addressed this issue.

After the interest of statins in the prevention of cardiovascular risk (see our article Statins in the elderly: stop or again?) and the management of arterial hypertension (HTA) (see Hypertension: what management in the elderly ?), the question of the deprescription of drugs used in the treatment of cardiovascular diseases was addressed [1].

Antihypertensives are the first medications that can be deprescribed in these patients, said the Prof Olivier Hanon (Hôpital Broca, AP-HP, Paris), which also listed several tools available to help adapt treatments to this population.

Seven drugs on average per day

In France, the prescription of the patient aged 75 and over includes an average of seven drugs to be taken per day, mainly to treat cardiovascular pathologies, recalled the cardiologist. A polymedication which is not without consequences since iatrogenics and lack of medication compliance represent the first cause of avoidable hospitalization in the elderly patient, just before the fall.

Drugs used in cardiology top the list of most prescribed drugs in elderly patients and can be potentially dangerous combinations, the cardiologist pointed out. Central antihypertensives, type I and III antiarrhythmics, antiaggregants, anticoagulants and diuretics thus represent a risk for these patients.

Several tools are available to detect potentially inappropriate drug combinations and anticipate adverse effects that may lead to hospitalization in elderly patients. Some have also been developed to help adapt the prescription to this population.

The Beers criteria of the American Geriatrics Society (AGS) are a reference in this field. [2]. These criteria, which have recently been updated [3]propose a list of potentially inappropriate drugs in subjects over the age of 65.

Among the drugs used in the treatment of cardiovascular diseases and considered inappropriate in this population, we find class 3 antiarrhythmics, which are “often prescribed by cardiologists”, such as amiodarone, or even alpha-blockers , said Professor Hanon.

“Good drug prescription” sheets

The Beers criteria also distinguish those which must be used with caution in the elderly population, in particular by adapting the doses. This is the case, for example, of spironolactone, a diuretic used in the management of heart failure or arterial hypertension, which must be prescribed “at the right dose”.

In France, the Laroche guide establishes the list of potentially inappropriate medicines which should be avoided in general and as far as possible in people aged 75 and over. [4]. The list “includes roughly the same drugs” as those cited in the American criteria. The French experts “However, were less harsh on antiarrhythmics”, specifies the cardiologist.

The document serves as a guide to drug prescriptions in geriatrics in common clinical situations, but also as a tool to help revise prescriptions in the elderly. It has the advantage of being adapted to French practice and of offering alternatives for each potentially inappropriate drug.

Another commonly used tool: the list of STOPP/START criteria, which helps with deprescribing, but also with prescribing in the elderly (> 65 years old). The list has been adapted as an online application.

Finally, the paid guide PAPA (Medical prescriptions adapted to the elderly) was produced by the French Society of Geriatrics and Gerontology (SFGG) and the National Professional Geriatrics Council (CNP)[5]. It includes 42 “good drug prescription” sheets adapted to subjects over 75 years of age.

Beta-blockers, major cause of orthostatic hypotension

Professor Hanon gave some examples of deprescribing in cardiology in the elderly.

Regarding the management of hypertension, “we can ask ourselves the question of a de-escalation of treatment when the blood pressure drops below 130 mm Hg”, at least in the most fragile patients. If the patient takes two antihypertensives, one of the two can be withdrawn. Central anti-hypertension and alpha blockers should be stopped first, then diuretics.

One can ask the question of a de-escalation of treatment when blood pressure drops below 130 mm Hg.

It is also important to screen for orthostatic hypotension (low blood pressure when going from lying down to standing up). This is responsible for a 36% increase in mortality, recalled the practitioner.

With a seven-fold increased risk of orthostatic hypotension, treatment with beta-blockers is a major cause. To a lesser extent, alpha-blockers and central anti-hypertensives can also cause orthostatic hypotension.

“You need good arguments to use beta-blockers”, in the elderly population, commented Professor Hanon. In the event of orthostatic hypotension, “we must reduce the doses and resort to chronotherapy” by distributing the doses between the morning and the evening.

The loop diuretic furosemide has no place in the treatment of hypertension, any more than diuretics in chronic edema. Calcium channel blockers and ACE inhibitors/Sartan should be preferred.

Regarding aspirin, it is not recommended for primary prevention of cardiovascular risk. “Randomized studies show an absence of benefit, and a haemorrhagic risk multiplied by two”.

For statins, it is not justified to start a treatment in primary prevention, except in case of risk factor. On the other hand, it is recommended to maintain it in secondary prevention, given the benefit observed (see Statins in the elderly: stop or again? ). After acute coronary syndrome, double aggregation is not recommended in the long term.

You need good arguments to use beta-blockers.

Keep anticoagulants if possible

As for anticoagulants, they remain essential during atrial fibrillation, said Professor Hanon. In the event of a fall, the treatment is interrupted and reconsidered. Stopping anticoagulant treatment can be considered and replaced by closure of the left auricle, “but a priori there is more benefit in maintaining anticoagulants”.

On the side of antidiabetics, “it is especially necessary to stop hypoglycemic sulfonamides”. Targeted glycated hemoglobin thresholds vary according to physical condition. We propose 7% in the robust elderly patient, 8% in the fragile elderly patient and 9% in those in an accommodation establishment for the elderly (Ehpad).

Finally, antiarrhythmics are among the drugs to be avoided in the elderly population. It is advisable not to use antiarrhythmics of classes I and III and be wary of psychotropic drugs, which can induce an elongation of the QTc space, especially since there is no heart rate monitoring in nursing homes, said the cardiologist.

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