THE ETHICS OF DEPRESCRIBING IN OLDER ADULTS

Older adults consume a disproportionate amount of medicinal products. Polypharmacy may increase the risk of adverse effects, result in poor medication adherence and unfavorable outcomes. There is considerable evidence that older adults are prescribed unnecessary or excessive medications. Treatment outcomes can be improved owing to controlled discontinuation of medicinal products. The deprescribing principles include analysis of all current prescriptions, detecting the medications that must be discontinued, dosage replacement or reduction, discussing the deprescribing regimen together with a patient, patient’s control and support. Clear comprehension of indications and benefit of the conducted pharmacotherapy, objective risk assessment by prescribing physicians and by a patient, and a deliberate deprescribing plan can improve treatment outcomes of the elderly.

Polypharmacy, which is the simultaneous use of multiple medications (M) [1], is very common.Recent analysis has shown that 25 to 40% of adults older than 65 years are prescribed at least five M [2].Using most of the M can be considered inappropriate [3].Though older adults can gain benefit from multiple M, inappropriate polypharmacy, where harm outweighs the benefit, can constitute significant risks and losses both for an older adult and for the entire society.In fact, inappropriate polypharmacy can result in adverse reactions, drug-drug interaction, hospitalization and, rarely, lethal outcome.Cumulatively, inappropriate polypharmacy represents a unique dilemma regarding a balance of benefit to harm, autonomy and justice [4].
The term 'deprescribing' first appeared in literature in 2003 [5].Due to the growing global concern about negative consequences of excessive use of some M, approaches to minimization of harm seek increasing attention.The focus shifts from prescribing, which is traditionally the beginning of administration or restarting of a M, to deprescribing, especially with age.Deprescribing was defined as 'discontinuation of an inappropriate M under supervision of a medical professional to manage polypharmacy and improve outcomes' [6].Dose reduction and transition to safer M are also discontinuation strategies, which are still effective when harm is minimized.The term 'inappropriate M' denotes a medicine, benefits of which outweigh its known risks.These are medicines with a high risk of causing harm, unnecessary or ineffective medicines, the ones that do not correspond to treatment objectives (for instance, products for prophylactic use among palliative care patients) or values and preferences of a patient, and the ones, the use of which is too burdensome [7].It should be noted that 'medication discontinuation' is significantly different from noncompliance with prescribed medication or noncompliance with the treatment dosage regimen.Both medication prescribing and deprescribing should be done by a medical professional with an equal level of knowledge and attention.
Polypharmacy and use of potentially inappropriate products are associated (based on the data of some observational trials) with some negative health effects, including a decreased quality of life, side effects, falls, regimen noncompliance, ОБЗОР ЛИТЕРАТУРЫ hospitalization and lethal outcome [8,9].For instance, Passarelli et al. [10] have found that an older patient who was prescribed a potentially inappropriate medical product can twice as likely have an adverse drug reaction as compared with an older patient who didn't take a potentially inappropriate medical product.It is believed that harm can be decreased if the dose is reduced, inappropriate M are discontinued and administered medicines are minimized.However, the potential benefit can be balanced with any risks that can arise due to discontinuation of M.
Regular review of medication therapy and discontinuation (controlled discontinuation) of inappropriate M are components of an optimal medical aid provided to the elderly (Tab.1).It can lead to advantages including prevention of side effects, better treatment adherence and reduction in expenditure [11].In practice, however, there exist many obstacles to deprescribing.
Four principles of biomedical ethics such as 1) benefit, 2) no harm, 3) autonomy, 4) justice should be followed by deprescribing physicians in older adults.
Taking deprescribing as an action rather than inaction creates stronger moral obligations.can also be due to the fear of negative consequences, which prevents deprescribing [12] (Tab.2).
Comprehending a patient's experience is the principle of prescribing optimization and taking joint decisions [14].Taking joint decisions is promoted not because it is acceptable from an ethical point of view and constitutes a patient's right, but because it can prevent a waste of time, resources and medications, and improve medication adherence and treatment outcomes [13,15].
It is difficult to respect autonomy of older adults as they may not want active participation in taking decisions; their cognitive function can be impaired and family members will probably interfere in the process.
People are rarely informed about changes in risks and advantages of long-term administration of drugs with ageing.Refusal from inappropriate medications has a major financial benefit for a human being and the entire society.However, the principle of justice also means implementing equal rights irrespective of age [12].

CONCLUSIONS
Withdrawal of inappropriate medicinal agents can be a better clinical decision.It can result in significant clinical advantages, including a decreased number of falls.The basic reasons for medication discontinuation among the elderly can include a decreased risk of adverse effects, reduced probability of drug interaction and easier prescription regimen.Factors that influence deprescribing Remarks General practitioners are the key drivers of deprescribing as they produce a great effect not only on prescription, but also on perception and decisions of patients regarding medical care -General practitioners (GPs) should be aware of their influence and be ready for a patient's resistance.-GPs should be provided better support to make deprescribing in general practice possible The deprescribing process -Discussion should be held between a medical professional and a patient/caregiver.
-Explain why the medication should be discontinued, whether any constant benefit and long-term harm are available and why the medication can't be used for treatment any longer.-Patients and caregivers are ready for observation and expect to be informed by a medical professional what they should pay attention to and do if their condition is changed.-It should be stressed that the deprescribing is experimental If a patient/caregiver resists termination of treatment -Subsequent treatment will reveal why they are hesitating (for instance, previous experience).-Taking joint decisions is necessary to get a favorable outcome and support doctor-patient relationships

Table 1 .
Deprescribing context: examples of clinical, psychological, social, financial and physical factors that need to be considered in deprescribing[4]with administration of M as compared to harm; a number of patients who require treatment; expected time to benefit; life prognosis; types of medicines (for instance, prophylactic or symptomatic treatment); physician who prescribed the M for the first time; presence/absence of triggers; presence/absence of symptoms; available alternatives (including non-drug methods of treatment); skills/knowledge/trust in physician; available evidence; ethical standards; healthcare system (high or low level)