Dave Dixon
Welcome to Voices in Pharmacy Innovation, the podcast where we spotlight bold ideas and groundbreaking practices that are transforming pharmacy practice and healthcare care delivery. I'm Dave Dixon, professor and chair at the Virginia Commonwealth University School of Pharmacy and core faculty member of the Center for Pharmacy Practice Innovation. In each episode, we'll sit down with pharmacists, healthcare care leaders, and changemakers who are rethinking how pharmacy can improve patient care and push the boundaries of what's possible in our profession. Together, we'll share stories, explore new models of practice, and amplify the voices driving pharmacy innovation forward. Today, I'm thrilled to have Dr. Delon Canterbury here with the CEO of Geriatrics, and that's RX at the end, a telehealth concierge deprescribing consulting service that helps patients, providers, and senior-facing businesses optimize health outcomes through evidence-based therapies and innovative solutions focused on deprescribing unnecessary medications. Polypharmacy, commonly defined as the use of five or more long-term medications, has become increasingly common in recent decades. In part, this reflects important advances in our ability to prevent and treat disease, but it can also result from unnecessary or inappropriate prescribing. As medication regimens have become more and more complex, patients may face greater challenges with adherence, lower health-related quality of life, and even a high risk of adverse outcomes. So today we're speaking with Dr. Canterbury about the scope and seriousness of this issue and the work that he is doing to help address it. DeLon, thanks so much for joining us on today's podcast.
DeLon Canterbury
Yeah, it's an absolute pleasure. Thank you for having me on.
Dave Dixon
Fantastic. And like we were chatting before we started recording, it was just kind of noting, really discovering your work through LinkedIn and really enjoyed following you on your journey. And so I'm excited to to dive into that today. And so before we get into our topic as it relates to polypharmacy and all things deprescribing, tell our listeners a little bit more about your background.
DeLon Canterbury
Yeah, happy to. um Yeah, so I attended the University of North Carolina, Chapel Hill, graduating in 2014. I am also board certified geriatric pharmacist, got that credential in 2017. and have since then um essentially founded Geriatrics to really hone in on ways clinicians can become proponents for advocating for less is more in the aging-friendly space. So serving as a founder, I'm CEO, I'm currently actively um clinically managing, of course, our patients, looking for opportunities to discuss deprescribing. And even finding ways to truly support an underserved population, which are our caregivers. You know, each and every one of us, if you're not one now, you will be a caregiver. So understanding the mindset of what it takes to navigate a very complex system. let alone managing the medications, the health conditions, appointments, social barriers. I find that this population is is essentially drowning without many resources for support. And I feel pharmacists are the best kept secret for them. I mean, we know all the loopholes and and ways of getting meds cheaper. know how to fight for our patients. And um essentially, we've built this business to become that voice.
Dave Dixon
That's great background. And I did note the UNC background. my My wife is also a UNC School of Pharmacy graduate. I grew up a Tar Heels fan, ah but did go to Campbell University, unfortunately. So don't have those alumni ties. But yes, you raise ah excellent points related to the importance of this issue. And that's that's why we're happy to have you on. So to kind of start with, let's kind of help our listeners fully understand the the problem. And so we we often define polypharmacy as taking five or more medications, but obviously the number of medications doesn't really tell the whole story. So how do you distinguish between appropriate polypharmacy and problematic polypharmacy?
DeLon Canterbury
No, that's a great question. um and you're right. I'm glad there we're discussing the nuances of it. There are times where people will be on meds and it might be 7, 10, what have you, and they all may have an appropriate clinical indication. um We tend to define polypharmacy as more than five, and some of the evidence shows higher associations of potential harm. um But again, each and every medicine, OTC, supplement, what have you, should have an appropriate risk-benefit conversation. And so it's really not about slashing things until you hit five. It's addressing what really matters most to your patient, what matters most to the family, employing the aging friendly mnemonic to care. So the four M's, what matters most, how do we preserve mobility, how do we preserve mindset? And of course, how do we look and see the meds are aging friendly? And oftentimes in our population, people are going to be on most likely more than nine or 10 meds or more. And yeah it really still drives the question of for where we are today and where we are for the goals of our patient, is this absolutely vital and important for them to live? And if it's not vital and if it's not important for their quality of life, then the next step should be to have a a discussion on whether this is necessary to continue or should we consider if deprescribing is an option and what are the risks and benefits of deprescribing along with simply continuing medication. So knowing a bit more on the specificity of why Has this medication been on board for 20 years and your conditions have been controlled for 20 years? Have we ever discussed, hey you've been doing so great. How do you feel about potentially stopping this and seeing how your numbers look after a month or two? it's going to end up becoming a shared decision between the caregiver, the patient, and yourself as the deprescribing advocate or so or a specialist. And then eventually, of course, the provider, once we assess buy-in and you know interest in even having a deprescribing conversation.
Dave Dixon
That's great. And I think the key point that you brought up there around shared decision-making is obviously really critical in thinking about what does the the patient want, what Are there primary you know outcomes of interest? Are they really trying to live longer? i think sometimes we emphasize mortality probably too much at times. A lot of cases of my experience in the cardiovascular world often make a lot of progress with patients when we start talking about how can we stay out of the hospital, right? How can we stay out of the emergency room? How can we um feel better day to day? How can we make sure that you're able to do those you know activities of daily living and being productive and living the life that you want to live for however long that may or may not be? um So I think that's a great point. um What are some of the most common warning signs that a medication regimen is is maybe getting out of hands and and causing potentially more harm than benefits? What what have you seen to be some indicators in your own practice?
DeLon Canterbury
Yeah, there are a number of red flags that jump out. It's not always like we mentioned just a total count of prescriptions, but really where I hone in on are the symptoms and potential side effects someone's dealing with. So a patient may come up, you know, they may have noticed more diarrhea or constipation in the last few days. And it ends up really just becoming a probing conversation about, hey, man, what's what's been going on? What do you feel in the morning? What are you feeling at night? Are you noticing differences after you take a certain medication? Do you notice anything at all? Or... um In what ways are you finding your quality of life starting to diminish? and what In any capacity, is it trouble finding words? Is it difficulty remembering how to get home or cooking a meal? Is it, you know, problems with IADLs like bathing and dressing? Are we noticing changes in your walk, your gait, your strength, your mobility? Yeah. Keeping it really tied first to, of course, what matters to them and your clinical goals, but then sussing out, all right, based on what you've told me with X issue, is this something that's tied to or associated with a medication or even a combination of medications? um Or maybe there's an interaction that's going on that hasn't been caught. So it's always a ah probing discussion based on, I feel, symptomology first, quality of life issues second, and then tying that to what the main problems our client might be having. That's how you're able to hone in on the med list and then start making any potential changes or um maybe observations of a potential drug interaction, maybe a a medication on the beers list that's no longer aging friendly. It can go a number of ways. So keeping them those clinical tools at play, um understanding, of course, the main issue that's in front of your person, that's not only going to help you identify a potential issue with a man, but it just builds trust and it leads with the empathetic care that us clinicians are trained to to lead with. And that not only leads to better outcomes, but better communication. And when you have that, you're able to get into more of it. And again, continue until we whittle down any other problematic issues.
Dave Dixon
Fantastic. that's ah That's a great segue. and sort of the the next thing I wanted to touch on, and that's prescribing cascades. So if you could ah explain kind of the concept of the prescribing cascade and maybe give us an example from your experience of how this can unfold, particularly in an older adult population and and lead to um adverse outcomes.
DeLon Canterbury
Yeah, prescribing cascades um can often go unnoticed for quite a while. ah But in a nutshell, is when a potential side effect of a medication is misrepresented as an entirely new health condition. And that issue is being treated as an entirely new health condition and thus a new medication. So, you know, we often see amlodipine as a great example. um We have people have amlodipine and amlodipine can cause peripheral edema in some patients. And so instead of us seeing that side effect and just switching to another drug, ah Some providers may just write a diuretic. And so now you're taking a diuretic to treat the foot swelling in our amiodipine full grade. The swelling is gone, but now your diuretic is causing over diuresis and thus over reactive bladder. So now got to go to the bathroom all the time. And now we find ourselves adding a medication to stop you from going to the bathroom and, and you know, oxybutynin, whatever. And now we have anticholinergic issues. And now ah you're, I don't know, maybe now you're constipated from the oxybutynin or whatever. You're having memory loss if you have dementia. you know There's so many ways it can go. But we end up adding another medication to treat those new set of issues. So the cycle can continue and continue and continue if we don't have a trained guy looking to see what's the root cause and what's the source of these other potential medications. um And even with that, i sample with a diuretic, you know, chronic long-term over-diuresing can throw off electrolytes for our older adults. So we're talking about low sodium, right? Low potassium. And so you've got people now on potassium supplements or NACL supplements and trying again, chase the dragon on something could have been preempted had we gotten to that root initial causative issue. So having the understanding of, them again, symptomology, side effects can be really the cutting edge piece to aging friendly care and assessing management and training the next wave of prescribers and clinicians to be very versed in seeing this before it becomes a bigger issue.
Dave Dixon
Yeah, I think the Amalitpene example you gave is ah is a classic one and then certainly one that that I think plays out far too often still. And yeah, the edema is is not very well managed by adding a teguretic to your point. It actually just creates more problems. So it's a really great example. Yeah. I want to start ah shifting away from polypharmacy and touch on deprescribing. Some patients and and clinicians even hear deprescribe and assume it means simply just stopping medication. So what does thoughtful, evidence-based deprescribing actually look like?
DeLon Canterbury
Mm-hmm. You know, really, really good prescribing would minimize the need for de-prescribing. And I think there are two sides to the same coin. um When you have actively methodical ah prescribing habits, it can, again... ah mitigate the need for having excessive T prescribing. But ultimately, it's a reiterative conversation. Look, on average, people are taking between 12 and 18 meds or more. And ultimately, it's this game of reverse thinking or reverse engineering all the stuff we learned from pharmacy school with all the guidelines. But where it's really a discussion between, hey, look, your patient, your provider, And yourself. And we're coming up with a plan with. Are the benefits of continuing this one medicine outweighing the the potential risks or harms of us stopping it? And so it's a dance, if you will. It's literally just an ongoing conversation of, all right, you've done great on this. Let's see what happens if you were to consider stoppering or tapering or even just lowering the dose on something. can to me be identified as a deprescribing opportunity. um But it's going to always tie back to if there's an issue of what problems or issues or symptoms are our patients dealing with. So there are some opportunities that might be high priority. Like say we got someone falling and we've got, you know, benzo and an opioid on board. Two major red flags we know as clinicians for opportunities to discuss tapering. And then there's some that are just not as clear, right? You may have patients who had controlled diabetes and they're on three or four diabetic agents. And it's been great. A1C is perfect. They still have diabetes. But is there an opportunity for us to discuss tapering one? All of these. Facets have to be weighed in determining what level of optimization we're going towards. Right. um Again, this aligns with goals of therapy, patients goals, potential issues, risk and benefits. You know, we blanketly put every diabetic on statins. Is that something we need to do for everyone who's over 90 or 80? The evidence doesn't quite support that all the time, especially depending on the goals of care. So it really becomes this battle of what is helping or harming the person in front of you? And is there enough evidence that says, sure, let's continue using this? And it's a new space. Deprescribing, to me, doesn't start with a med list. It starts with a conversation. It starts with, again, understanding your patient's wants and needs. um It starts with having a clarity on why something is on board. Do they even understand why they've been on baby aspirin for 30 years without any cardiovascular history? It ends up just becoming a discussion on how would you feel literally doing away with one or two nets? Would that make a difference in your day-to-day? Would that make you feel happy? And some people are like, ooh, no, I need that one because that's what I've been told I needed years. So we're really getting into the root of a person's identity when it comes to net lists. They can be very sensitive to people, but they can also be, in a way, ah a way for people to free themselves with less. like People feel buried by taking so many, and they identify as, I am sick, therefore I must have x Y, Z. So it is a bit of a psychological dance, but to me it's ah a hopeful discussion on a new way people can live in an aging-friendly world.
Dave Dixon
So what I hear you saying is that this requires a great level of of nuance and appreciation of of details as it relates to the patient, what's going on with them, not just simply what the guidelines would suggest that we do, which, again, can apply to a lot of situations. But as that patient's on that journey throughout life, there can be times where we have to revisit that. And just because someone has been has required therapy does not mean that they're going to need it forever and that their care regimen should evolve with them as they age. Is that a good summary, you think?
DeLon Canterbury
Yeah, 100%.
Dave Dixon
So one thing that I know... can't be a challenge is trying to communicate recommendations for deprescribing to other providers. ah Any tips or thoughts on on how pharmacists that might be listening to this can be more effective in making those kinds of recommendations?
DeLon Canterbury
Yeah, absolutely. There are a number of tools in our arsenal to reference and cite to um help you build that confidence in having that discussion. i think it's also safe to say that... you know Not a lot of our clinical providers are trained in aging-friendly approaches to care, so kind of use that as a feather in your hat, if you will, on ways to educate people on some of these very same clinical tools. A really popular one I love to reference is the American Geriatric Society. There's criteria If I'm doing a medit review, I'm constantly looking at that list, seeing if anything on there has a justifiable reason, um um what we may want to avoid in our patient population, and citing the rationale behind it. I can't share enough how people are not as familiar with using that. And it you're still going to see tons of beersless medications. Just this week, we've had three clients who are on Doxapin over the six milligram mark that's identified as the anticholinergic burden limit for but for it for that for insomnia. And again, now I'm seeing someone with an anticholionage of burden of six or seven, and now they're presenting with constipation and and dry eyes. And so it's kind of time in things that are glaringly obvious to us as clinicians or as pharmacists, really, and just breaking that down to to providers, make it really simple, stupid. Hey, look, I looked at this based on what we've seen, based on what your patient told me, ah This might be causing more harm than good. What are your thoughts on us revising or switching or what have you? So making it more of a collegial thing, more than just like a this is wrong, do this, can go a long way. But that starts with building rapport, having trust with your doctors. um And then, of course, having the confidence to speak up to what you know isn't jiving well for our patient, especially when you're saying, hey, look, the patient's literally telling me what's wrong. Can we modify this? I am concerned this might be an issue for their quality of life. And ultimately, That responsibility will still fall on the provider, and we don't want that. We don't want people to be readmitted or having other issues. But to me, that's the secret sauce that providers want. They they want pharmacists to to call this out, and so we shouldn't be afraid to make these these highlights known. It's actually in high demand. Yeah. Not that he had their own pharmacist to just reference in their back pocket. So that to me is the opportunity side of deprescribing that I think is necessary to really just bring about this new age of aging friendly care.
Dave Dixon
Yeah, that's great. I think it's a great opportunity to educate our colleagues, right? And and so in in making those recommendations, I think, yeah, it's don't just view it as ah telling them what they should or shouldn't be doing. It's it's really an opportunity to to provide education and, again, provide that rationale, right, for why it may be necessary to deprescribe or decrease the dose or modify a therapy. Yeah. So I'd love to shift gears to really learn a bit more about geriatrics. And so what what gap in the healthcare system were you trying to fill when you founded the company? And what is is is different in your model that a conventional medication review or reconciliation doesn't quite provide? What what makes it unique?
DeLon Canterbury
Yeah, I appreciate that. So part of our approach is essentially becoming the patient advocate alongside them and really relating to the caregiver who's navigating all these levels of health care. Now, in our service, our our practice is a bit unique. We work with patients directly, but we also work within other aging-friendly businesses. So we partner with other physical therapists, for instance. We partner with care managers. We partner with senior centers. We partner with nonprofits in dementia spaces. So the art of deprescribing can range from simply showing up, doing a talk, doing a lunch and learn, doing a deprescribing workshop where we do case studies with people in real time and partner with church communities to give them valuable insights. Or we could become a part of a business model that's integrated into other those practices I've mentioned. And we have patients through those ecosystems. So it's a unique service in that we have angles where we're helping people directly. We have opportunities where we integrate into businesses and businesses are able to basically differentiate and advertise themselves as having, hey, we got our own deprescribing pharmacist. We want everyone to use this. And then also, we like to provide a pharmacogenomic screening. So we use that as another tool to give people insights who might be dealing with psych, dementia, all types of other mental health conditions managed by those meds. And so PGX is a huge part of our workups for our more complicated cases who have failed a number of meds and we're finding some patterns in the adverse event profile. So it can range from that level of concierge pharmacy is how I kind of describe us as a practice ah to training and education for clinicians. We've also trained other clinicians to become deprescribing advocates with our deprescribing accelerator. and So that was designed to get our social workers, nurses, pharmacists, and physicians and prescribers all in the same mind frame around shifting this attitude about overprescribing and bringing it back to the holistic side, the lifestyle side, the integrative approach, as you will, to how we look at meds and how we look at diet and spirituality and healing and even alternative approaches as need be. So we go where our patients want to go If we have a patient who's interested in psychedelics and wants to find another alternative approach to to use that, we will help them find that. If they want to go down a naturopathic route, we'll make a referral and do so. If we need people who are in transition and they need a voice and they don't have a guardian, we are hired to do so as well. um So there are a number of ways we can kind of plug and play, but ultimately it's Speaking that language, that ah you know that medical talk that can kind of go over people's heads when you're in the middle of crisis. But that's where we come in is we decipher what's wrong. We look for what's potentially harmful. And we don't just do it once. We do it in perpetuity until the the issue is resolved um or ah you know or the patient may transition. But our job is to do things either an ongoing basis so that there's constant communication and contact, closing the loops, if you will, and building that trust among our community partners. and That's really found phenomenal.
Dave Dixon
And I'm curious and on this journey, what has surprised you the most?
DeLon Canterbury
I mean, you're talking about an entrepreneur. So there's always going to be a surprise, curveball, something unique. um What surprises me the most? I wouldn't say there were quite surprises, but let's see... Yeah, you know, I've had some interesting encounters. So I've had patients who've hired me to help them get off medications, and then they refuse to take the advice, which is interesting. It's like they were actually questioning the rationale and the evidence. Right, twenty right. um Okay, now I have a bigger surprise. um If you want to really get into the nitty-gritty, And this might not be everyone's opinion, but ah we don't care about older adults in this country. Unconventional opinion, but we don't care. We pretend to care. And we it really isn't designed for people to get old gracefully. I see problematic medlists in the elite of the elites to the low to low. It doesn't matter.
Dave Dixon
I don't think you're that far off when it comes to our older adult population. ah When I was in school, one of the things I was told on my geriatric rotation was every time you look at an older adult, look in their eyes, and if you look carefully, you'll see the teenager they once were, 20-something-year-old, et cetera, et cetera, because it's easy to forget, right? You just view, there's this 85 year old in front of you and it's easy to sort of forget this journey that they've been on that we all go on, hopefully. And, um, you know, they were once young too. They were once, you know, just like you in many ways. And, uh, I think sometimes we, we treat them differently and in a negative way. Um, so I hear
DeLon Canterbury
It gives them Israel, you know, I don't think we trained enough to discuss, uh, Inherent medical ageism. It's a real thing. We throw it on a diagnosis code because of an age and we don't address that. And the numbers show that ageism kills your patients, whether it's inherent to the patient or whether it's a clinical provider labeling it as you're just getting old, which I have heard and still hear those things. So I think us becoming aging experts, we have to be aware of that and our own implicit biases.
Dave Dixon
So we will ah move on to kind of closing out our chat with a few questions that we ask all of our guests. So what resources have you found most influential in your thinking about innovation and pharmacy practice, and particularly from the perspective of building your business?
DeLon Canterbury
Well, AI is not going away. doesn't matter well how you look at it. um ah For me... ah There are some amazing electronic tools out there. So trying to make the work for deprescribing easier on myself, I like to use some of those module models to train AI to become a deprescriber. And finding ways to incorporate, for instance, steady falls risk criteria from the CDC, stop-start criteria out of Europe, which we use to, again, address omissions and potentially inappropriate meds for older adults. AGS-Beers criteria is always going to be high the list. A big one of like to incorporate is acbcalc.com. So calculating the anticholinergic burden for your clients, any dementia, any memory impairment, try to make sure that's done. You should probably just get in the habit of just doing it anyway. um Medstopper.com is a great one. Deprescribing.org is another fantastic resource for guidelines and algorithms to help you with having conversations. They have patient-friendly brochures. They have patient-friendly videos. They have clinical training toolkits you can use to bring deep prescribing into your communities. Tons of amazing work coming out of Canada um for that, along with Australia. um But I, you know you know, Google is still pretty awesome and really good at getting savvy with PubMed searches and Google scholars. So using that to get your data is going to always be helpful. and And if you could train your your AIs to start doing that, it might give you some extra edge.
Dave Dixon
Great. Thanks for sharing those resources, and we can certainly link to those in the show notes. ah So shifting gears to pharmacists-to-be, so how should pharmacy education and training evolve to prepare students for practice and in this changing landscape as it relates to ah deprescribing and polypharmacy and the work that you do with older adults?
DeLon Canterbury
Sure. I believe there should be a bit more of an emphasis on deprescribing. It's kind of difficult when you're still learning the basics of how to really prescribe and understand guideline-directed therapy, but geriatrics needs to be required. um When I was in school, I think I only had a day or two of geriatrics, so I understand it's elective, but the general population is older than the youngest, so I feel like that should be embedded into more of the curriculum on when do we have a deep prescribing discussion versus, well, we're just following the guidelines and you get to the real world and you're on all this stuff. How do you really know where to start? So I i would say having a more collaborative analysis on Aging-friendly care would be great. I think for any student, if you're interested in this, um take the 4Ms certification from ASCP. They have an aging-friendly badge. It's free CEs, but it's something that will get you comfortable in discussing what matters most, mindset, mobility, and medications, and making sure that things are Aging friendly. I feel that everyone should be required to do aging friendly training. And the way these health systems are moving is they're shifting to become aging friendly. So those are excellence. So this will become a HEDIS measured thing. They're going to start tracking. How are you embedding those four M's into your care? And are you showing that proof in your notes? So I think the sooner we all from prescriber to nurse to pharmacist approach those four M's into care, that the better we'd be prepared for this, you know, the silver tsunami. They want to call it. i don't like that term too much, but it's just of truth. It's a truth we all have to face where everyone has a loved one who's dealing with this and, know, You're going to want to get comfortable because you're probably getting asked the questions anyway on hey, does this make sense? Is this right? So knowing those resources is going to help you, but knowing how to kind of piece together any barriers in their quality of life to a potential side effect, to a potential med, is going to sharpen your acumen and get you prepared for the reality we're all facing.
Dave Dixon
All said. Our last question here. What's something that you're looking forward to in the next six to 12 months? And that could be personally or professionally.
DeLon Canterbury
i I am excited for where the opportunities are going in the aging industry. i do believe pharmacists have a wonderful opportunity to think about a bit differently about their career paths and embed into practices that bring them joy. I'd say part of my work is to show that there is a deeper joy to what we were called to do here. It's not just you're a pharmacist. You've got some awesome gift. And I feel the more empathetic our healthcare care system comes or whether it maybe just you become. I'm not sure if healthcare care is there yet, but you as a clinician can control what you can control. And I feel when we start seeing people patients as people you can connect with, with aging-friendly care, with empathy-based care, with um cultural sensitivity, with a continually growing diverse population, ah feel pharmacists are the best-kept secret to really hitting the needle on some of these clinical measures, these clinical outcomes that are being tracked, but ah embedding us into these more integrative practices.
Dave Dixon
Great, great, great. So thank you, Dylan, so much for helping us better understand the challenges of polypharmacy and the important role that pharmacists can play in identifying inappropriate medications, simplifying treatment regimens, and improving outcomes for older adults. Your work demonstrates how pharmacist-led medication reviews can make a meaningful difference for patients as well as their caregivers. So please let our listeners know where they can connect with you and learn more about your work.
DeLon Canterbury
Yes, please follow us on all of our social media platforms. We're on LinkedIn, Facebook, Instagram, at Geriatrics with an R-X, G-E-R-I-A-T-R-X. And you can also visit us at geriatrics.org if you want to connect. You can always just send me a DM on LinkedIn and we'll link you up.
Dave Dixon
Fantastic. I also want to thank our listeners for tuning in to this episode of Voices in Pharmacy Innovation. If you enjoyed today's episode, please subscribe, share it with a colleague, and join us next time as we continue to spotlight the innovations that are shaping the future of pharmacy practice and healthcare. care Thank you for listening to today's episode. Voices in Pharmacy Innovation is published monthly. You can listen on Apple Podcasts, Spotify, or by visiting our website linked in the show notes. If you have any questions or comments, you can contact us through our email cppi at vcu.edu. We appreciate your engagement and look forward to having you join us next month.