Deprescribing in the Last Year of Life

An Internationally Derived Process of Healthcare Professionals' Proactive Deprescribing Steps and Constituent Activities

Proactive deprescribing is the process of tapering or stopping a medicine before harm occurs. This study aimed to specify and validate, with an international sample of healthcare professionals, a proactive deprescribing process of steps and constituent activities. We developed a proactive deprescribing process framework of steps which we populated with literature-derived activities required to be undertaken by healthcare professionals. We distributed a survey to healthcare professionals internationally, requesting for each activity the frequency of its occurrence in practice and whether it was important. Extended response questions investigated barriers and enablers to deprescribing. The 263 survey respondents were from 25 countries. A proactive deprescribing process was developed comprising four steps: (1) identify a patient for potential stop of a medicine, (2) evaluate a patient for potential stop of a medicine, (3) stop a medicine(s), and (4) monitor after a medicine has been stopped, and 17 activities. All activities were considered important by ≥70% of respondents. Nine activities required healthcare professionals to undertake in direct partnership with the patient and/or caregiver, of which seven were only sometimes undertaken. Deprescribing interventions should include a focus on addressing the barriers and enablers of healthcare professionals undertaking the activities that require direct partnership with the patient and/or caregiver.

Rationalizing prescription via deprescribing in oncology practice

OBJECTIVE

To provide an integrated approach for deprescribing practice in oncology setting.

DATA SOURCES

The data on deprescribing in oncology settings has been retrieved from the PubMed, Scopus and Google Scholar. We used "deprescribing," "potentially inappropriate medication" and "cancer" as a keyword for the conducting general search. The articles relevant to guidelines or tools used to deprescribe in cancer care were included.

DATA SUMMARY

The nature of cancer, its treatment strategies, adverse effects of therapy and multimorbidity impact negatively on quality of life (QoL). Further, they invite polypharmacy which puts the patient at higher risk of drug-related problems like drug interactions, adverse drug reactions and addition of potentially improper medications, etc. In older adults with cancer, the incidence of potentially inappropriate medications (PIMs) was between 41% and 52%. Over the decades, multiple strategies have been developed to assess the appropriateness of therapy. One such approach is deprescribing. OncPal and oncoSTRIP (Systematic Tool to Reduce Inappropriate Prescribing) are the cancer specific guidelines whereas BEERs criteria, Screening Tool to Alert to Right Treatment/Screening Tool of Older Person's Prescriptions criteria (START/STOPP criteria), medication appropriateness index (MAI) are the cancer nonspecific tools to identify PIM among cancer patients. Here, we provided an integrative approach and algorithm for deprescribing in oncology setting which includes patient and caregiver goals, life expectancy (LE), review of medications, determining medication appropriateness, assessment of time to benefit (TTB), symptomatic and asymptomatic care, identifying medications to cease, implementation of the plan, monitoring and reviewing.

CONCLUSION

Deprescribing in oncology setting is a novel and effective patient-centric approach to counteract the use of PIM, which helps to mitigate polypharmacy, drug-drug interactions, and adverse effects.

Examining patterns of traditional Chinese medicine use in pediatric oncology: A systematic review, meta-analysis and data-mining study

BACKGROUND

Traditional Chinese medicine (TCM) is becoming a popular complementary approach in pediatric oncology. However, few or no meta-analyses have focused on clinical studies of the use of TCM in pediatric oncology.

OBJECTIVE

We explored the patterns of TCM use and its efficacy in children with cancer, using a systematic review, meta-analysis and data mining study.

SEARCH STRATEGY

We conducted a search of five English (Allied and Complementary Medicine Database, Embase, PubMed, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov) and four Chinese databases (Wanfang Data, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, and VIP Chinese Science and Technology Periodicals Database) for clinical studies published before October 2021, using keywords related to "pediatric," "cancer," and "TCM."

INCLUSION CRITERIA

We included studies which were randomized controlled trials (RCTs) or observational clinical studies, focused on patients aged < 19 years old who had been diagnosed with cancer, and included at least one group of subjects receiving TCM treatment.

DATA EXTRACTION AND ANALYSIS

The methodological quality of RCTs and observational studies was assessed using the six-item Jadad scale and the Effective Public Healthcare Panacea Project Quality Assessment Tool, respectively. Meta-analysis was used to evaluate the efficacy of combining TCM with chemotherapy. Study outcomes included the treatment response rate and occurrence of cancer-related symptoms. Association rule mining (ARM) was used to investigate the associations among medicinal herbs and patient symptoms.

RESULTS

The 54 studies included in this analysis were comprised of RCTs (63.0%) and observational studies (37.0%). Most RCTs focused on hematological malignancies (41.2%). The study outcomes included chemotherapy-induced toxicities (76.5%), infection rate (35.3%), and response, survival or relapse rate (23.5%). The methodological quality of most of the RCTs (82.4%) and observational studies (80.0%) was rated as "moderate." In studies of leukemia patients, adding TCM to conventional treatment significantly improved the clinical response rate (odds ratio [OR] = 2.55; 95% confidence interval [CI] = 1.49-4.36), lowered infection rate (OR = 0.23; 95% CI = 0.13-0.40), and reduced nausea and vomiting (OR = 0.13; 95% CI = 0.08-0.23). ARM showed that Radix Astragali, the most commonly used medicinal herb (58.0%), was associated with treating myelosuppression, gastrointestinal complications, and infection.

CONCLUSION

There is growing evidence that TCM is an effective adjuvant therapy for children with cancer. We proposed a checklist to improve the quality of TCM trials in pediatric oncology. Future work will examine the use of ARM techniques on real-world data to evaluate the efficacy of medicinal herbs and drug-herb interactions in children receiving TCM as a part of integrated cancer therapy.

Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis

BACKGROUND

Tackling problematic polypharmacy requires tailoring the use of medicines to individual needs and circumstances. This may involve stopping medicines (deprescribing) but patients and clinicians report uncertainty on how best to do this. The TAILOR medication synthesis sought to help understand how best to support deprescribing in older people living with multimorbidity and polypharmacy.

OBJECTIVES

We identified two research questions: (1) what evidence exists to support the safe, effective and acceptable stopping of medication in this patient group, and (2) how, for whom and in what contexts can safe and effective tailoring of clinical decisions related to medication use work to produce desired outcomes? We thus described three objectives: (1) to undertake a robust scoping review of the literature on stopping medicines in this group to describe what is being done, where and for what effect; (2) to undertake a realist synthesis review to construct a programme theory that describes 'best practice' and helps explain the heterogeneity of deprescribing approaches; and (3) to translate findings into resources to support tailored prescribing in clinical practice.

DATA SOURCES

Experienced information specialists conducted comprehensive searches in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (targeted searches).

REVIEW METHODS

The scoping review followed the five steps described by the Joanna Briggs Institute methodology for conducting a scoping review. The realist review followed the methodological and publication standards for realist reviews described by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) group. Patient and public involvement partners ensured that our analysis retained a patient-centred focus.

RESULTS

Our scoping review identified 9528 abstracts: 8847 were removed at screening and 662 were removed at full-text review. This left 20 studies (published between 2009 and 2020) that examined the effectiveness, safety and acceptability of deprescribing in adults (aged ≥ 50 years) with polypharmacy (five or more prescribed medications) and multimorbidity (two or more conditions). Our analysis revealed that deprescribing under research conditions mapped well to expert guidance on the steps needed for good clinical practice. Our findings offer evidence-informed support to clinicians regarding the safety, clinician acceptability and potential effectiveness of clinical decision-making that demonstrates a structured approach to deprescribing decisions. Our realist review identified 2602 studies with 119 included in the final analysis. The analysis outlined 34 context-mechanism-outcome configurations describing the knowledge work of tailored prescribing under eight headings related to organisational, health-care professional and patient factors, and interventions to improve deprescribing. We conclude that robust tailored deprescribing requires attention to providing an enabling infrastructure, access to data, tailored explanations and trust.

LIMITATIONS

Strict application of our definition of multimorbidity during the scoping review may have had an impact on the relevance of the review to clinical practice. The realist review was limited by the data (evidence) available.

CONCLUSIONS

Our combined reviews recognise deprescribing as a complex intervention and provide support for the safety of structured approaches to deprescribing, but also highlight the need to integrate patient-centred and contextual factors into best practice models.

FUTURE WORK

The TAILOR study has informed new funded research tackling deprescribing in sleep management, and professional education. Further research is being developed to implement tailored prescribing into routine primary care practice.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018107544 and PROSPERO CRD42018104176.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 32. See the NIHR Journals Library website for further project information.

Thoughtful Prescribing and Deprescribing

Polypharmacy, the use of five or more medications, is common in older adults. It can lead to the use of potentially inappropriate medications and severe adverse outcomes. Deprescribing is an essential step of the thoughtful prescribing process and it can decrease the use of potentially inappropriate medications. Studies have demonstrated that deprescribing is feasible in the clinical setting, especially when it incorporates patient preferences, shared decision making, and an interdisciplinary team. Medication-specific algorithms can facilitate deprescribing in the clinical setting.

Impact of a pharmacist-administered deprescribing intervention on nursing home residents: a randomized controlled trial

Background Polypharmacy is prevalent among long-term care residents in Canada, with 48.4% receiving ten or more different medications and 40.7% chronically prescribed potentially inappropriate medications. Objective We implemented a pharmacist-administered deprescribing program in a long-term care facility to determine if the number of medications taken per resident could be reduced.

SETTING

A long-term care facility in Newfoundland and Labrador, Canada from February 2017 to February 2018.

METHOD

Residents were randomized to receive either a deprescribing-focused medication review by a pharmacist or usual care. Main outcome measure Change in the number of medications at 3 and 6 months. Results Forty-five residents enrolled in the study (n = 22 intervention, n = 23 control). Seventy-eight deprescribing recommendations were made, and 85.1% were successfully implemented. The average number of medications taken by residents in the intervention group was 2.68 less than the control group (p < 0.02; 95% CI - 4.284, - 1.071) at 3 months and 2.88 less (p = 0.02, 95% CI - 4.543, - 1.112) at 6 months. In 14.9% of cases, a medication had to be restarted after deprescribing was attempted because symptoms returned.

CONCLUSION

A pharmacist-led deprescribing intervention can reduce the number of unnecessary and potentially harmful medications taken by LTC residents.

Generic instruments for drug discontinuation in primary care: A systematic review

Aims

The aim of this systematic review was to identify generic instruments for drug discontinuation in patients with polypharmacy in the primary care setting.

Methods

We systematically searched PubMed and EMBASE, 8 guideline databases (AWMF, NICE, NGC, SIGN, NHMRC, CPG, KCE), the Cochrane Library and grey literature (Google) in 2016 and 2017. Two independent researchers screened and analysed data. The drug discontinuation instruments of the included publications were described and classified.

Results

We identified 16 relevant publications. Here we found complex algorithms as well as instruments composed of distinct sequential steps. Two guidelines are constructed as electronic web‐applications. Instruments revealed diverging emphases on the stages of deprescribing, i.e. preparation, drug evaluation, decision‐making and implementation. Accordingly, 3 types of instruments emerged: general frameworks, detailed drug assessment tools and comprehensive discontinuation guidelines.

Conclusion

Diverse generic instruments exist for different areas of applications in regard to drug discontinuation. However, there is still a need for practical and user‐friendly tools that support physicians in communicational aspects, visualise trade‐offs and also enhance patient involvement.

Deprescribing of non-antiretroviral therapy in HIV-infected patients

PURPOSE

In recent decades, the life expectancy of HIV-infected patients has increased considerably, to the extent that the disease can now be considered chronic. In this context of progressive aging, HIV-infected persons have a greater prevalence of comorbid conditions. Consequently, they usually take more non-antiretroviral drugs, and their drug therapy are more complex. This supposes a greater risk of drug interactions, of hospitalization, falls, and death. In the last years, deprescribing has gained attention as a means to rationalize medication use.

METHODS

Review of the different therapeutic approach that includes optimization of polypharmacy and control and reduction of potentially inappropriate prescription.

RESULTS

There are several protocols for systematizing the deprescribing process. The most widely used tool is the Medication Regimen Complexity Index, an index validated in HIV-infected persons. Anticholinergic medications are the agents that have been most associated with major adverse effects so, various scales have been employed to measure it. Other tools should be employed to detect and prevent the use of potentially inappropriate drugs. Prioritization of candidates should be based, among others, on drugs that should always be avoided and drugs with no justified indication.

CONCLUSIONS

The deprescribing process shared by professionals and patients definitively would improve management of treatment in this population. Because polypharmacy in HIV-infected patients show that a considerable percentage of patients could be candidates for deprescribing, we must understand the importance of deprescribing and that HIV-infected persons should be a priority group. This process would be highly feasible and effective in HIV-infected persons.

Person-Centred Care Including Deprescribing for Older People

There is concern internationally that many older people are using an inappropriate number of medicines, and that complex combinations of medicines may cause more harm than good. This article discusses how person-centred medicines optimisation for older people can be conducted in clinical practice, including the process of deprescribing. The evidence supports that if clinicians actively include people in decision making, it leads to better outcomes. We share techniques, frameworks, and tools that can be used to deprescribe safely whilst placing the person's views, values, and beliefs about their medicines at the heart of any deprescribing discussions. This includes the person-centred approach to deprescribing (seven steps), which incorporates the identification of the person's priorities and the clinician's priorities in relation to treatment with medication and promotes shared decision making, agreed goals, good communication, and follow up. The authors believe that delivering deprescribing consultations in this manner is effective, as the person is integral to the deprescribing decision-making process, and we illustrate how this approach can be applied in real-life case studies.

Deprescribing at the end of life in older patients

In the United States, the adult population that will need hospice and palliative care is expected to double in the next 40 years. In primary care, providers are often faced with tough decisions on how to manage patients' medications at the end of life. This article describes how to deprescribe in the last year of life.

Health care professionals' attitudes towards deprescribing in older patients with limited life expectancy: A systematic review

AIMS

The aim of this systematic review was to explore health care professionals' attitudes towards deprescribing in older people with limited life expectancy.

METHODS

A systematic literature search was conducted from inception to December 2017 using MEDLINE, EMBASE and CINAHL. Studies were included if they specifically concerned older people (≥65 years) with limited life expectancy, including those residing in any type of aged care facility, or were based on representative patient profiles. Results were analyzed inspired by the Joanna Briggs Institute's method for synthesis of qualitative data. Studies were characterized using a checklist for reporting of qualitative research.

RESULTS

Eight studies were included. Six studies explored health care professionals' views on deprescribing in general, and two studies focused specifically on psychotropic agents. All eight studies explored the views of physicians, mostly general practitioners, while three studies also considered other health care professionals. Four themes related to health care professionals' attitudes towards deprescribing were identified: (i) patient and relative involvement; (ii) the importance of teamwork; (iii) health care professionals' self-assurance and skills; and (iv) the impact of organizational factors. Within each of these themes, 3-4 subthemes were identified and analysed.

CONCLUSIONS

Our results suggest that health care professionals' decisions to engage in deprescribing activities with older people with limited life expectancy depend on multiple factors which are highly interdependent. Consequently, there is an urgent need for more research on how to approach deprescribing in clinical practice within this population.

Deprescription in Advanced Cancer Patients

The use of multiple drugs is often referred to as polypharmacy, although this term has not been precisely defined. Frequently, drugs are used unwisely in multiple combinations increasing the risk of adverse reactions, or for the long-term prevention of diseases in patients with a short life expectancy who, therefore, will not benefit from them. The reflection on this has led to the introduction of the concept of deprescription. There are many reasons for the inappropriate drug prescription and barriers to reduce medications. Tools were developed to help prescribers to limit the number of prescribed drugs that patients are taking. Several studies have shown that deprescription of some drugs is possible and safe and can even have a positive influence on wellbeing, cognitive function, falls, and admission to a hospital. Deprescription should be individualized and carried out, as far as possible, in agreement with patients and their families. A six-step method for deprescription is proposed.

Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action

Deprescribing can be defined as the process of withdrawal or dose reduction of medications which are considered inappropriate in an individual. The aim of this narrative review is to provide an overview of "deprescribing"; firstly discussing the potential benefits and harms followed by the barriers to and enablers of deprescribing. We also provide practical recommendations to recognise opportunities and strategies for deprescribing in practice. Studies focused on minimizing polypharmacy indicate that deprescribing may be associated with potential benefits including resolution of adverse drug reactions, improved quality of life and medication adherence and a reduction in drug costs. While the data on the benefits is inconsistent, deprescribing appears to be safe. There are, however, potential harms including return of medical conditions or symptoms and adverse drug withdrawal reactions which emphasise the need for the process to be supervised and monitored by a health care professional. Taking action on deprescribing can be facilitated by knowledge of potential barriers, implementing a deprescribing process (utilising developed tools and resources) and identifying opportunities for deprescribing through engaging with patients and caregivers and other health care professionals and considering deprescribing in a variety of populations. Important areas for future research include the suitability of deprescribing of certain medications in specific populations, how to implement deprescribing processes into clinical care in a feasible and cost effective manner and how to engage consumers throughout the process to achieve positive health and quality of life outcomes.

Challenges of deprescribing in the multimorbid patient

Older patients often have multimorbidity, frequently resulting in polypharmacy. Independently, multimorbidity and polypharmacy are among the biggest risk factors for inappropriate medication, adverse drug reactions, adverse drug events and morbidity, leading to patient harm and hospitalisations. After a medication review, discontinuation of medication or deprescribing is one of the most common recommendations but is likely to be ignored. The deprescribing process includes some or all of the following elements: a review of current medications, identification of medications to be discontinued, a discontinuation regimen, involvement of patients and a review with follow-up. In addition to the complexity presented by prescribing or deprescribing for older multimorbid patients, other factors act as barriers to discontinuation of medications in these patients; these include interprofessional relationships, difficulties with medication reviews, deficiencies in knowledge and evidence and patients' preferences/resistance to change. These challenges are compounded by the need to manage the shared treatment of multiple conditions by several prescribers from different specialties based on disease-specific guidelines without evidence of effects on the older, frailer, multimorbid patients. The interdisciplinary effort in the treatment of such patients needs to improve to ensure that we treat the patient holistically and not just the individual conditions of the multimorbid patient, according to guidelines. We must first, however, equip prescribers to identify instances where deprescribing is appropriate and then make the necessary changes to pharmacotherapy.

A systematic review of the emerging definition of 'deprescribing' with network analysis: implications for future research and clinical practice

AIMS

The aim of this study was to identify what definitions have been published for the term 'deprescribing', and determine whether a unifying definition could be reached. A secondary aim was to uncover patterns between the published definitions which could explain any variation.

METHODS

Systematic literature searches were performed (earliest records to February 2014) in MEDLINE, Embase, CINAHL, Informit, Scopus and Google Scholar. The terms deprescrib* or de-prescrib* were employed as a keyword search in all fields. Conventional content analysis and word frequencies were used to identify characteristics of the definitions. Network analysis was conducted to visualize characteristic distribution across authors and articles.

RESULTS

Following removal of duplicates, 231 articles were retrieved, 37 of which included a definition. Eight characteristics of the definitions were identified: use of the term stop/withdraw/cease/discontinue (35 articles), aspect of prescribing included e.g. long term therapy/inappropriate medications (n = 18), use of the term 'process' or 'structured' (n = 13), withdrawal is planned/supervised/judicious (n = 11), involving multiple steps (n = 7), includes dose reduction/substitution (n = 7), desired goals/outcomes described (n = 5) and involves tapering (n = 4). Network analysis did not reveal patterns responsible for variations in previously used definitions.

CONCLUSIONS

These findings show that there is lack of consensus on the definition of deprescribing. This article proposes the following definition: 'Deprescribing is the process of withdrawal of an inappropriate medication, supervised by a health care professional with the goal of managing polypharmacy and improving outcomes'. This definition has not yet been externally validated and further work is required to develop an internationally accepted and appropriate definition.

The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis

AIMS

Deprescribing is a suggested intervention to reverse the potential iatrogenic harms of inappropriate polypharmacy. The review aimed to determine whether or not deprescribing is a safe, effective and feasible intervention to modify mortality and health outcomes in older adults.

METHODS

Specified databases were searched from inception to February 2015. Two researchers independently screened all retrieved articles for inclusion, assessed study quality and extracted data. Data were pooled using RevMan v5.3. Eligible studies included those where older adults had at least one medication deprescribed. The primary outcome was mortality. Secondary outcomes were adverse drug withdrawal events, psychological and physical health outcomes, quality of life, and medication usage (e.g. successful deprescribing, number of medications prescribed, potentially inappropriate medication use).

RESULTS

A total of 132 papers met the inclusion criteria, which included 34 143 participants aged 73.8 ± 5.4 years. In nonrandomized studies, deprescribing polypharmacy was shown to significantly decrease mortality (OR 0.32, 95% CI: 0.17-0.60). However, this was not statistically significant in the randomized studies (OR 0.82, 95% CI 0.61-1.11). Subgroup analysis revealed patient-specific interventions to deprescribe demonstrated a significant reduction in mortality (OR 0.62, 95% CI 0.43-0.88). However, generalized educational programmes did not change mortality (OR 1.21, 95% CI 0.86-1.69).

CONCLUSIONS

Although nonrandomized data suggested that deprescribing reduces mortality, deprescribing was not shown to alter mortality in randomized studies. Mortality was significantly reduced when applying patient-specific interventions to deprescribe in randomized studies.

What factors are important for deprescribing in Australian long-term care facilities? Perspectives of residents and health professionals

OBJECTIVES

Polypharmacy and multimorbidity are common in long-term care facilities (LTCFs). Reducing polypharmacy may reduce adverse events and maintain quality of life. Deprescribing refers to reducing medications after consideration of therapeutic goals, benefits and risks, and medical ethics. The objective was to use nominal group technique (NGT) to generate then rank factors that general medical practitioners (GPs), nurses, pharmacists and residents or their representatives perceive are most important when deciding whether or not to deprescribe medications.

DESIGN

Qualitative research using NGT.

SETTING

Participants were invited if they worked with, or resided in LTCFs across metropolitan and regional South Australia.

PARTICIPANTS

11 residents/representatives, 19 GPs, 12 nurses and 14 pharmacists participated across six separate groups.

METHODS

Individual groups of GPs, nurses, pharmacists and residents/representatives were convened. Using NGT each group ranked factors perceived to be most important when deciding whether or not to deprescribe. Then, using NGT, the prioritised factors from individual groups were discussed and prioritised by a multidisciplinary metropolitan and regional group comprised of resident representatives, GPs, nurses and pharmacists.

RESULTS

No two groups had the same priorities. GPs ranked 'evidence for deprescribing' and 'communication with family/resident' as most important factors. Nurses ranked 'GP receptivity to deprescribing' and 'nurses ability to advocate for residents' as most important. Pharmacists ranked 'clinical appropriateness of therapy' and 'identifying residents' goals of care' as most important. Residents ranked 'wellbeing of the resident' and 'continuity of nursing staff' as most important. The multidisciplinary groups ranked 'adequacy of medical and medication history' and 'identifying residents' goals of care' as most important.

CONCLUSIONS

While each group prioritised different factors, common and contrasting factors emerged. Future deprescribing interventions need to consider the similarities and differences within the range of factors prioritised by residents and health professionals.

Review of deprescribing processes and development of an evidence-based, patient-centred deprescribing process

Inappropriate use of medication is widespread, especially in older people, and is associated with risks, including adverse drug reactions, hospitalization and increased mortality. Optimization of appropriate medication use to minimize these harms is an ongoing challenge in healthcare. The term 'deprescribing' has been used to describe the complex process that is required for safe and effective cessation of medication. Patients play an important role in their own health and, while they may complain about the number of medications they have to take, they may also be reluctant to cease a medication when given the opportunity to do so. A review of previously proposed deprescribing processes and relevant literature was used to develop the patient-centred deprescribing process, which is a five-step cycle that encompasses gaining a comprehensive medication history, identifying potentially inappropriate medications, determining whether the potentially inappropriate medication can be ceased, planning the withdrawal regimen (e.g. tapering where necessary) and provision of monitoring, support and documentation. This is the first deprescribing process developed using knowledge of the patients' views of medication cessation; it focuses on engaging patients throughout the process, with the aim of improving long-term health outcomes. Despite a comprehensive review of the literature, there is still a lack in the evidence base on which to conduct deprescribing. The next step in broadening the evidence to support deprescribing will be to test the developed process to determine feasibility in the clinical setting.

What are priorities for deprescribing for elderly patients? Capturing the voice of practitioners: a modified delphi process

Polypharmacy and inappropriate medication use among older adults contribute to adverse drug reactions, falls, cognitive impairment, noncompliance, hospitalization and mortality. While deprescribing - tapering, reducing or stopping a medication - is feasible and relatively safe, clinicians find it difficult to carry out. Deprescribing guidelines would facilitate this process. The aim of this paper is to identify and prioritize medication classes where evidence-based deprescribing guidelines would be of benefit to clinicians. A modified Delphi approach included a literature review to identify potentially inappropriate medications for the elderly, an expert panel to develop survey content and three survey rounds to seek consensus on priorities. Panel participants included three pharmacists, two family physicians and one social scientist. Sixty-five Canadian geriatrics experts (36 pharmacists, 19 physicians and 10 nurse practitioners) participated in the survey. Twenty-nine drugs/drug classes were included in the first survey with 14 reaching the required (≥ 70%) level of consensus, and 2 new drug classes added from qualitative comments. Fifty-three participants completed round two, and 47 participants completed round three. The final five priorities were benzodiazepines, atypical antipsychotics, statins, tricyclic antidepressants, and proton pump inhibitors; nine other drug classes were also identified as being in need of evidence-based deprescribing guidelines. The Delphi consensus process identified five priority drug classes for which expert clinicians felt guidance is needed for deprescribing. The classes of drugs that emerged strongly from the rankings dealt with mental health, cardiovascular, gastroenterological, and neurological conditions. The results suggest that deprescribing and overtreatment occurs through the full spectrum of primary care, and that evidence-based deprescribing guidelines are a priority in the care of the elderly.

Benefits of deprescribing on patients' adherence to medications

Deprescribing is a holistic process of medication cessation that encompasses gaining a comprehensive medication list, identifying potentially inappropriate medications, deciding if the identified medication can be ceased, planning the withdrawal regimen and monitoring, support and follow-up. It is currently being investigated as a mechanism to reduce unnecessary or redundant medications. However, given the systematic and patient-centred nature of the deprescribing process, it is possible that it may also confer additional benefits such as improving adherence to medications, even if there is no net reduction in overall medication use. Specifically, deprescribing may improve adherence via reducing polypharmacy, reducing the financial costs associated with medication taking, increasing the patient's medication knowledge through education, increasing patient engagement in medication management and resolution of adverse drug reactions. More research into deprescribing must be conducted to establish if these potential benefits can be realised, in addition to establishing any negative consequences.

Patient barriers to and enablers of deprescribing: a systematic review

BACKGROUND

Inappropriate medication use is common in the elderly and the risks associated with their use are well known. The term deprescribing has been utilised to describe the complex process that is required for the safe and effective cessation of inappropriate medications. Given the primacy of the consumer in health care, their views must be central in the development of any deprescribing process.

OBJECTIVES

The aim of this study was to identify barriers and enablers that may influence a patient's decision to cease a medication.

DATA SOURCES

A systematic search of MEDLINE, International Pharmaceutical Abstracts, EMBASE, CINAHL, Informit and Scopus was conducted and augmented with a manual search. Numerous search terms relating to withdrawal of medications and consumers' beliefs were utilised.

STUDY ELIGIBILITY CRITERIA

Articles were included if the barriers or enablers were directly patient/carer reported and related to long-term medication(s) that they were currently taking or had recently ceased.

STUDY APPRAISAL AND SYNTHESIS METHODS

Determination of relevance and data extraction was performed independently by two reviewers. Content analysis with coding was utilised for synthesis of results.

RESULTS

Twenty-one articles met the criteria and were included in the review. Three themes, disagreement/agreement with 'appropriateness' of cessation, absence/presence of a 'process' for cessation, and negative/positive 'influences' to cease medication, were identified as both potential barriers and enablers, with 'fear' of cessation and 'dislike' of medications as a fourth barrier and enabler, respectively. The most common barrier/enabler identified was 'appropriateness' of cessation, with 15 studies identifying this as a barrier and 18 as an enabler.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

The decision to stop a medication by an individual is influenced by multiple competing barriers and enablers. Knowledge of these will aid in the development of a deprescribing process, particularly in approaching the topic of cessation with the patient and what process should be utilised. However, further research is required to determine if the proposed patient-centred deprescribing process will result in improved patient outcomes.

Medication Regimen Complexity and Unplanned Hospital Readmissions in Older People

BACKGROUND

Medication-related problems and adverse drug events are leading causes of preventable hospitalizations. Few previous studies have investigated the possible association between medication regimen complexity and unplanned rehospitalization.

OBJECTIVE

To investigate the association between discharge medication regimen complexity and unplanned rehospitalization over a 12-month period.

METHOD

The prospective study comprised patients aged ≥70 years old consecutively admitted to a Geriatrics Evaluation and Management (GEM) unit between October 2010 and December 2011. Medication regimen complexity at discharge was calculated using the 65-item validated Medication Regimen Complexity Index (MRCI). Cox proportional-hazards regression was used to compute unadjusted and adjusted hazard ratios (HRs) with 95% CIs for factors associated with rehospitalization over a 12-month follow-up period.

RESULT

Of 163 eligible patients, 99 patients had one or more unplanned hospital readmissions. When adjusting for age, sex, activities of daily living, depression, comorbidity, cognitive status, and discharge destination, MRCI (HR = 1.01; 95% CI = 0.81-1.26), number of discharge medications (HR = 1.01; 95% CI = 0.94-1.08), and polypharmacy (≥9 medications; HR = 1.12; 95% CI = 0.69-1.80) were not associated with rehospitalization. In patients discharged to nonhome settings, there was an association between rehospitalization and the number of discharge medications (HR = 1.12; 95% CI = 1.01-1.25) and polypharmacy (HR = 2.24; 95% CI = 1.02-4.94) but not between rehospitalization and MRCI (HR = 1.32; 95% CI = 0.98-1.78).

CONCLUSION

Medication regimen complexity was not associated with unplanned hospital readmission in older people. However, in patients discharged to nonhome settings, the number of discharge medications and polypharmacy predicted rehospitalization. A patient's discharge destination is an important factor in unplanned medication-related readmissions.

Appropriate prescribing in older people

Prescribing for older people is often complex and challenging. With age, people almost invariably develop diseases leading to the prescription of drugs and the risk of multiple prescribing increases, especially if there is strict adherence to single disease guidelines. There remains a paucity of evidence from clinical trials as to the efficacy of many drugs in patients aged over 80 years due to the gross under-representation of older people in clinical trials. Older people are also at increased risk of adverse drug events, which are an important cause of morbidity and mortality. A significant percentage of these are both predictable and potentially avoidable.

In this updated review the concept of appropriate prescribing in older people is explored, including the importance of individualized care and shared decision-making. The available tools to enhance prescribing practice are examined, including those aimed at reducing inappropriate prescriptions and under prescribing. The limitations of existing tools are discussed and areas with particular promise and scope for advancement are highlighted, including the development of integrated IT systems and software engines to aid clinicians in appropriate prescribing.

[Polypharmacy in frail elderly patients: is deprescribing the answer?]

Deprescribing is the process of reconstructing multiple medication use by review and analysis and which concludes with dose modification, replacement or elimination of some drugs or adding others. Its development is intended to resolve tensions and contradictions between two sets of questions: 1/is life expectancy shorter than the time the drug takes to obtain a benefit?, and 2/are the goals of prescribing-deprescribing consistent with those of care? The validity of the rationale on deprescribing is based on scientific and ethical reasons. The usefulness and safety of many drugs that frail elderly or terminally ill takes is unknown, and other drugs may cause troublesome or severe side effects. Thus, in some cases their removal could be justified, being substantially safe doing so.