Polypharmacy and medication deprescribing: A survey among multimorbid older adults in Denmark

Outcomes of a Medication Optimization Virtual Interdisciplinary Geriatric Specialist (MOVING) Program: A Feasibility Study

BACKGROUND

Adverse drug events among older adults result in significant mortality, morbidity and cost. This harm may be mitigated with appropriate prescribing and deprescribing. We sought to understand the prescribing outcomes of an interdisciplinary geriatric virtual consultation service.

METHODS

We conducted a retrospective, before-and-after feasibility study to measure prescribing outcomes for a medication optimization virtual interdisciplinary geriatric specialist (MOVING) programme comprised of expertise from geriatric clinical pharmacology, pharmacy and psychiatry for older adults (aged ≥ 65 years) between June and December 2018, Ontario, Canada. The primary outcome was the number of distinct prescriptions and the presence of polypharmacy (defined as ≥ 4 medications) before and after the service. Secondary outcomes included the number of as needed and regularly administered prescriptions, number of potentially inappropriate prescriptions as defined by the Beers and STOPP criteria, and number of prescriptions for psychotropics, long-acting opioids and diabetic medications.

RESULTS

We studied 40 patients with a mean age of 80.6 [standard deviation (SD) 8.8] years who received a MOVING consult. We found no significant change in the mean total number of prescriptions per patient before (12.02, SD 5.83) and after the intervention (11.58, SD 5.28), with a mean difference of -0.45 [95% confidence interval (CI) -0.94 to 0.04; p = 0.07]. We found statistically significant decreases in as needed prescriptions (mean difference - 0.30, 95% CI - 0.45 to - 0.15; p<0.001), and potentially harmful medications as identified by the Beers (mean difference -1.25, 95% CI -2.00 to -0.50; p = 0.002) and STOPP (mean difference -1.65, 95% CI -2.33 to -0.97; p < 0.001) scores. Without including the cost savings from hospital diversion by a MOVING consult, the costs of a MOVING consult were $545.80-$629.80 per person, compared with the costs associated with traditional in-person consults involving similar specialist clinical services ($904.89-$1270.69 per person).

CONCLUSION

A MOVING model of care is associated with decreases in prescriptions for potentially inappropriate medications in older adults. These findings support further evaluation to ascertain health system impacts.

Attitudes and barriers towards deprescribing in older patients experiencing polypharmacy: a narrative review

Polypharmacy, commonly defined as ≥5 medications, is a rising public health concern due to its many risks of harm. One commonly recommended strategy to address polypharmacy is medication reviews, with subsequent deprescription of inappropriate medications. In this review, we explore the intersection of older age, polypharmacy, and deprescribing in a contemporary context by appraising the published literature (2012-2022) to identify articles that included new primary data on deprescribing medications in patients aged ≥65 years currently taking ≥5 medications. We found 31 articles were found which describe the current perceptions of clinicians towards deprescribing, the identified barriers, key enabling factors, and future directions in approaching deprescribing. Currently, clinicians believe that deprescribing is a complex process, and despite the majority of clinicians reporting feeling comfortable in deprescribing, fewer engage with this process regularly. Common barriers cited include a lack of knowledge and training around the deprescribing process, a lack of time, a breakdown in communication, perceived 'abandonment of care', fear of adverse consequences, and resistance from patients and/or their carers. Common enabling factors of deprescribing include recognition of key opportunities to instigate this process, regular medication reviews, improving lines of communication, education of both patients and clinicians and a multidisciplinary approach towards patient care. Addressing polypharmacy requires a nuanced approach in a generally complex group of patients. Key strategies to reducing the risks of polypharmacy include education of patients and clinicians, in addition to improving communication between healthcare providers in a multidisciplinary approach.

Optimization of the Danish National Electronic Prescribing System to Improve Patient Safety: Development of a User-Friendly Prototype of the Digital Platform Shared Medication Record

This study uses a participatory design to develop a user-friendly prototype of the current Danish digital platform, Shared Medication Record (SMR), to improve patient safety and minimize medication errors for patients with multimorbidity. A fundamental challenge for medication prescribing is the lack of access to an accurate medication list, which impairs effective communication between healthcare professionals and increases the risk of medication errors. We used a participatory design to identify the major problems with the existing SMR and develop a prototype for a redesigned SMR that addresses these problems. We argue that this prototype will improve communication between healthcare providers, promote patient involvement in their own care, and ultimately reduce medication errors related to the SMR. Moreover, we argue that the participatory design with its emphasis on user involvement and design iterations is a strong approach when designing IT solutions for complex problems in healthcare.

Polypharmacy and Clinical Outcomes in Hospitalized Patients With Acute Decompensated Heart Failure

BACKGROUND

Polypharmacy is a common problem among patients with acute decompensated heart failure (ADHF) who often have multiple comorbidities.

OBJECTIVE

The aim of this study was to define the number of medications at hospital discharge and whether it is associated with clinical outcomes at 1 year.

METHODS

We evaluated the number of medications in 2578 patients with ADHF who were ambulatory at hospital discharge in the Kyoto Congestive Heart Failure Registry and compared 1-year outcomes in 4 groups categorized by quartiles of the number of medications (quartile 1, ≤ 5; quartile 2, 6-8; quartile 3, 9-11; and quartile 4, ≥ 12).

RESULTS

At hospital discharge, the median number of medications was 8 (interquartile range, 6-11) with 81.5% and 27.8% taking more than 5 and more than 10 medications, respectively. The cumulative 1-year incidence of a composite of death or rehospitalization (primary outcome measure) increased incrementally with an increasing number of medications (quartile 1, 30.8%; quartile 2, 31.6%; quartile 3, 39.7%; quartile 4, 50.3%; P < .0001). After adjusting for confounders, the excess risks of quartile 4 relative to those of quartile 1 remained significant ( P = .01).

CONCLUSIONS

In the contemporary cohort of patients with ADHF in Japan, polypharmacy at hospital discharge was common, and excessive polypharmacy was associated with a higher risk of mortality and rehospitalizations within a 1-year period. Collaborative disease management programs that include a careful review of medication lists and an appropriate deprescribing protocol should be implemented for these patients.

Exploring Older Adult Health Literacy in the Day-to-Day Management of Polypharmacy and Making Decisions About Deprescribing: A Mixed Methods Study

BACKGROUND

Polypharmacy use in older adults is increasing and sometimes leads to poor health outcomes. The influence of health literacy in managing polypharmacy and making decisions about stopping medication has received limited attention.

OBJECTIVE

A mixed methods design was used to measure and investigate the influence of health literacy in the management of polypharmacy and decisions about deprescribing. Phase 1 involved two cross-sectional surveys, one with older adults using five or more medications and the other with general practitioners (GPs).

METHODS

Older adult health literacy was measured using the All Aspects of Health Literacy Scale. Phase 2 employed individual interviews with both older adults and GPs and further explored the reported use of health literacy in practice. SPSS version 24 was used to conduct descriptive statistical analysis of the Phase 1 survey responses and Phase 2 interviews were analyzed using thematic analysis with the assistance of NVivo 12.

KEY RESULTS

Phase 1 survey responses were received from 85 GPs and 137 older adults. Phase 2 interviews were conducted with 16 GPs and 25 older adults. Phase 1 results indicated that self-reported older adult health literacy was high, and that GPs believed older patients could engage in decisions about deprescribing. Phase 2 findings showed that older adults developed and employed complex health literacy practices to manage medications between consultations; however, few reported using their health literacy skills in consultations with their GPs. GPs noted that older adult involvement in decision-making varied and generally thought that older adults had low health literacy.

CONCLUSION

Older adults reported using health literacy practices in the management of their sometimes-complex medication regimens. However, the role of health literacy in deprescribing decision-making was limited. The mixed methods approach allowed greater insight into older adult and GP practices that influence the acquisition and use of health literacy. [HLRP: Health Literacy Research and Practice. 2023;7(1):e14-e25.] Plain Language Summary: This report explores health literacy in the use of multiple medications and decisions to stop using medication/s in older age. Older adults reported good heath literacy and practiced many health literacy skills in the management of their medications. However, they did not always report the use of their health literacy skills when discussing their medications with their family doctor.

Involving patients in medicines optimisation in general practice: a development study of the “PREparing Patients for Active Involvement in medication Review” (PREPAIR) tool

Background

Many patients have multiple health conditions and take multiple medications (polypharmacy). Active patient involvement may improve treatment outcomes and ensure patient-centred care. Yet, patient involvement remains a challenge in clinical practice. We aimed to develop and pilot test a questionnaire-based preparation and dialogue tool, the PREparing Patients for Active Involvement in medication Review (PREPAIR) tool, to encourage the involvement of patients with polypharmacy in medicines optimisation in general practice.

Methods

We conducted a literature review followed by a co-production process to develop the tool: a workshop with six GPs and pilot testing, including observations and interviews, with 22 patients, three GPs and three practice staff. During this process, we made continuous adaptations to the prototype. We analysed the qualitative data thematically, focusing on the development process and mechanisms of impact.

Findings

The final PREPAIR tool included five items concerning the patient’s experience of 1) adverse drug reactions, 2) excess medication, 3) unnecessary medication, 4) medication satisfaction and 5) medication-related topics to discuss with the GP (open-ended question). The applied workflow during testing was as follows; the patient completed the PREPAIR tool at home, to encourage reflection on the medication, and brought it to the GP consultation. During the consultation, the GP and the patient reviewed the patient’s responses and discussed potential medication-related problems. For some patients, the increased reflection led to worries about the medications. Still, the pilot testing showed that, when using the PREPAIR tool, the patients arrived at the clinic well prepared and empowered to speak. From the PREPAIR-supported dialogue, the GPs obtained a better understanding of patients’ perspectives and provided a more patient-centred consultation. For the patients, the PREPAIR-supported dialogue ultimately promoted an increased sense of security, satisfaction and insight into their medication, despite initial worries for some patients.

Conclusions

We developed a brief tool to support active patient involvement in medication review in general practice. The PREPAIR-tool was well received by both patients and GPs and fitted well into the existing clinical practice. Our findings suggest that the PREPAIR-tool can support patient involvement during consultations and facilitate patient-centred care.

Beliefs and attitudes of residents, family members and healthcare professionals regarding deprescribing in long-term care: a qualitative study

BACKGROUND

Polypharmacy is prevalent among long-term care (LTC) residents and can cause significant morbidity. In 2018, we concluded a deprescribing pilot study that reduced potentially inappropriate medication use among LTC residents.

AIM

We sought to understand the experience and views of physicians, nurses, pharmacists, LTC residents and family members who participated in the pilot study.

METHOD

Qualitative semi-structured interviews were conducted with residents and families, a physician, pharmacist and pharmacy student, and licensed-practical nurses. Interviews were audio recorded, transcribed, and analyzed using an inductive thematic analysis approach.

RESULTS

Interviews with 13 participants yielded themes in 3 categories: (1) views about medication use in LTC and willingness to engage in deprescribing, (2) perceived barriers and enablers for deprescribing, and (3) impact of participating in deprescribing study. Participants were willing to engage in deprescribing; residents were motivated by physician suggestions, and family members prioritized quality of life in decision-making and wanted to be part of the decision-making process. Solutions to overcome barriers included assigning responsibility to identify deprescribing opportunities to pharmacists, scheduling rounds to enable face-to-face team discussions, and consulting families to provide missing medical history to inform deprescribing decisions. Participating in a deprescribing intervention resulted in improved healthcare professional (HCP) confidence and interprofessional collaboration, and caused continued practice change after the study.

CONCLUSION

Residents, families, and HCPs are concerned about problems associated with polypharmacy in LTC and are willing to consider deprescribing. Barriers to deprescribing in LTC exist but are not insurmountable. Results provide valuable insight into strategies to optimize deprescribing interventions within LTC.

Attitudes towards adherence and deprescribing among polypharmacy patients: a cross-sectional study

Objectives

Deprescribing is the process of optimization of medication regimens through cessation of potentially inappropriate or unnecessary medications or adjustment of doses with the goal of managing polypharmacy and improving outcomes. Deprescribing potentially improves adherence by reducing polypharmacy. This study aimed to assess polypharmacy patients’ adherence attitudes and their attitudes towards deprescribing.

Methods

A cross-sectional study that targeted polypharmacy patients at outpatient clinics at King Abdullah University Hospital. The inclusion criteria were (1) patients ≥18 years old, (2) patients taking five or more medications, and (3) patients who do not require a caregiver or assistance at home. We excluded patients that showed any signs of moderate or severe cognitive impairment. Patients who met the inclusion/exclusion criteria were interviewed by a clinical pharmacist and completed two survey instruments: revised Patients’ Attitudes Toward Deprescribing (rPATD) and Adherence Attitude Inventory (AAI).

Key findings

In total, 501 patients took part in this study. Over half of the participants were not satisfied with their current medicines and over 70% of them perceived that their current medications are a burden to them and would like their prescribers to initiate deprescribing. The majority of the participants have low to medium adherence attitudes primarily due to ineffective patient–provider communication. Logistic regression analysis revealed that self-efficacy, commitment to adherence, education and age were significantly associated with participants’ willingness to stop one or more of their medications.

Conclusions

Our findings suggest that polypharmacy patients have negative attitudes towards their medication therapy and favour deprescribing. These reported attitudes had been associated with negative adherence attitudes. Study findings offer schematic direction for future investigations of the role of adherence on key health-related outcomes in patients on polypharmacy. Furthermore, research is warranted to investigate the impact of deprescribing on polypharmacy patients’ medication adherence.

A Study on the Perceptions of Korean Older Adult Patients and Caregivers about Polypharmacy and Deprescribing

Polypharmacy is continuously increasing among older adults. The resultant potentially inappropriate medications (PIMs) can be harmful to patient health. Deprescribing refers to stopping or reducing PIMs. In this study, the current status of polypharmacy and willingness of older adults to deprescribe were investigated among patients and caregivers who are not associated with one another. The survey used the Korean translated version of the revised Patients' Attitude Towards Deprescribing (rPATD) Scale. Data were collected through an online survey of 500 participants (250 patients and caregivers each) in this study. The following results were found for patients and caregivers, respectively: 74.8% and 63.6% felt their number of medications was high, 64.4% and 55.6% desired to reduce their medications, 70.4% and 60.8% were concerned about medication discontinuation, 63.2% and 61.2% had a good understanding of their medications, 77.6% and 76.4% were willing to be well informed, and 79.6% and 72% wanted to reduce the number of medications if medically feasible. Patients and caregivers commonly agreed to the burden of the number of medications they were taking, and were willing to reduce the number of medications if the doctor said it was possible. Doctors should consider this information during the deprescribing process, and promote deprescription while involving patients and caregivers in the decision-making process.

Attitudes of older adults and their carers towards de-prescribing: A systematic review

AIM

The aim of this systematic review is to explore the attitudes of older adults (≥65 years old) and their carers towards de-prescribing.

METHODS

We identified relevant studies from three databases; MEDLINE, CINAHL and Web of Science. Two reviewers (MS, SS) independently extracted data from each selected study using a standardised self-developed data extraction form. Main findings of the studies were summarised descriptively.

RESULTS

A total of 35 studies were included in the review. Of them, 19 were questionnaire studies, 11 semi-structured interviews, 4 focus groups and 1 study used the nominal group technique approach. Most older adults and their carers were willing to have medication de-prescribed if told to do so by a healthcare professional (HCP). Other factors that increased willingness to de-prescribing included; trust in the HCP, side effects and inconvenience from medications as well as the prospect of follow-up and monitoring during de-prescribing. In contrast, perceived effectiveness, unawareness of lack of benefit, negative expectations of ageing and fear were factors preventing de-prescribing.

CONCLUSION

De-prescribing is an important concept in older people given the harm associated with polypharmacy in this age group. Overall, older adults and their carers are willing to have medication de-prescribed if facilitated by their HCP. However, there remain a few barriers to de-prescribing which may need to be addressed in certain patients, through discussions between older adults/their carers and a HCP, to allow de-prescribing to be more effective.

Understanding medication use behaviors and perspectives in an older cardiovascular patient population: Opportunities for patient-centered deprescribing

Study objective

Describe self-reported medication use behaviors and perspectives to identify opportunities for collaborative deprescribing among older cardiovascular patients.

Design

Patient survey using convenience sampling.

Setting

Private cardiology practice in Maricopa County, Arizona, USA.

Participants

Established patients aged ≥65 years with an active medication list indicating prescription polypharmacy (≥5 medications) and/or use of ≥1 high risk medication (anticoagulant, antiarrhythmic, anti-hypotensive, insulin).

Intervention

Anonymous online survey.

Main outcome measures

Current medication use (prescription and over-the-counter), self-reported medication use behaviors measured by the Adherence to Refills and Medications Scale (ARMS-12), and perspectives on deprescribing.

Results

Overall, 138 participants were recruited, with a mean age of 76.7 years. All but two self-identified as Caucasian. Prescription polypharmacy was reported by 80 (58.0 %), with use of 5-9 medications by 66 (47.8 %) and use of ≥10 medications (excessive polypharmacy) by 14 (10.1 %). Approximately one-third (n = 45, 32.6 %) had ARMS = 12, indicating adherence to taking and refilling medications. More than 1 in 10 patients (11.6 %) used >1 high-risk medication. About 4 in 10 (40.6 %) used ≥5 OTC medications. Most highly prioritized reasons for continuing medications were to prolong life (40 %), feel better (17 %), and reduce stroke risk (15 %). Despite 66.7 % of patients indicating taking "just the right amount of medications," willingness to stop ≥1 medication was very high at 80.4 %.

Conclusion

Among older cardiovascular patients, prescription polypharmacy is prevalent as are medication use behaviors associated with some degree of nonadherence. Patients are supportive of deprescribing. Prioritizing what matters most to patients and focusing efforts to deprescribe potentially inappropriate medications is recommended.

Older Patient and Surrogate Attitudes Toward Deprescribing During the Transition From Acute to Post-Acute Care

Attitudes toward deprescribing among hospitalized older patients transitioning to post-acute care in the United States are less known. This study describes older patients' and their surrogate's attitudes using all items of the Patient Attitudes Toward Deprescribing (PATD) questionnaire and compares perceived pill burden to the actual count of total daily pills and potentially inappropriate medications (PIMs). Overall, 93% of participants were willing to deprescribe if their physician agreed. Compared to patients, surrogates had 64% reduced odds (95% CI: 0.18-0.74) of believing that all of the care recipient's medications were necessary and 61% reduced odds (95% CI: 0.17-0.88) of attributing cost as a factor in deprescribing. Perceptions of medication burden were associated with patients' total daily pills (median 16) and PIMS (median 7), yet 61% agreed that all their medicines were necessary. Patients and surrogates typically express a willingness to deprescribe but have differing perceptions of medication appropriateness.

Home care patients’ experiences from living with polypharmacy - a qualitative interview study

Background

Patients with home care (HC) are frail and multi-diseased older persons who are often treated with many medicines. Their perspectives on polypharmacy have previously been sparsely explored.

Aim

To investigate these patients’ experiences and perceptions regarding polypharmacy.

Design & setting

Semi-structured interviews with seventeen patients with HC in Stockholm, Sweden. The informants’ median age was 83,5 years (range 74–97 years) and the median number of prescribed medicines was 11 (range 5-30).

Method

The interview questions were open and aimed to encourage informants to speak freely about their personal experiences of living with polypharmacy. Data was analysed using an inductive thematic analysis.

Results

Two themes were identified: 1) Experiences from daily life with polypharmacy, and 2) Dependency on the relationship to healthcare professionals. The first theme contains the main finding which was the diversity in how older persons experienced polypharmacy and how they coped with polypharmacy in everyday life. While some were satisfied despite having multiple medicines, others experienced such psychological unease due to polypharmacy that it led to reduced quality of life. The second theme reflects the importance of the relationship between the older person and healthcare professionals for medicine-related ideas and attitudes.

Conclusions

The individual variation in experiences regarding polypharmacy points to the value of interprofessional teamwork with the patient as an active partner. Therefore, healthcare professionals need to adapt a more person-centred approach where the patient’s perspectives are respected and considered in medicine-related decision-making.

How Willing Are Patients or Their Caregivers to Deprescribe: a Systematic Review and Meta-analysis

BACKGROUND

Polypharmacy is associated with the increased use of potentially inappropriate medications, where the risks of medicine use outweigh its benefits. Stopping medicines (deprescribing) that are no longer needed can be beneficial to reduce the risk of adverse events. We summarized the willingness of patients and their caregivers towards deprescribing.

METHODS

A systematic search was conducted in four databases from inception until April 30, 2021 as well as search of citation of included articles. Studies that reported patients' and/or their caregivers' attitude towards deprescribing quantitatively were included. All studies were independently screened, reviewed, and data extracted in duplicates. Patients and caregivers willingness to deprescribe their regular medication was pooled using random effects meta-analysis of proportions.

RESULTS

Twenty-nine unique studies involving 11,049 participants were included. All studies focused on the attitude of the patients towards deprescribing, and 7 studies included caregivers' perspective. Overall, 87.6% (95% CI: 83.3 to 91.4%) patients were willing to deprescribe their medication, based upon the doctors' suggestions. This was lower among caregivers, with only 74.8% (49.8% to 93.8%) willing to deprescribe their care recipients' medications. Patients' or caregivers' willingness to deprescribe were not influenced by study location, study population, or the number of medications they took.

DISCUSSION

Most patients and their caregivers were willing to deprescribe their medications, whenever possible and thus should be offered a trial of deprescribing. Nevertheless, as these tools have a poor predictive ability, patients and their caregivers should be engaged during the deprescribing process to ensure that the values and opinions are heard, which would ultimately improve patient safety. In terms of limitation, as not all studies may published the methods and results of measurement they used, this may impact the methodological quality and thus our findings. OPEN SCIENCE FRAMEWORK REGISTRATION: https:// osf.io/fhg94.

Patient values and preferences on polypharmacy and deprescribing: a scoping review

Background Understanding how patient values and preferences towards polypharmacy and deprescribing have been studied is important to gain insight on current knowledge in this area and to identify knowledge gaps. Aim To describe methods and outcomes for studying patient values and preferences towards polypharmacy and deprescribing, and to identify gaps in the existing literature. Method A scoping review was conducted on English-language studies that examined patient preferences and values related to polypharmacy and/or deprescribing among community-dwelling adults. MEDLINE, Embase, PubMed, PsycINFO, EconLit, Social Science Citation Index, Science Citation Index Expanded, International Pharmaceutical Abstracts, and CINAHL/AgeLine were searched. Results Thirty articles were included. Surveys (n = 17, 56.7%), interviews/focus groups (n = 9, 30.0%), and mixed methods (n = 3, 10.0%), were commonly used methods. Patients Attitudes Towards Deprescribing (PATD) was the most common tool used (n = 9, 30.0%). Twelve themes related to attitudes, social pressure, and control of polypharmacy/deprescribing were identified. The most frequently-encountered themes included desire or willingness to reduce medication load and influence of healthcare provider on medication use. Conclusion PATD was commonly used to assess preferences and values towards polypharmacy and limited knowledge on patient-important outcomes were addressed. Future research should focus on shared decision-making and communicating risk versus benefit of medications.

Consumer attitudes towards deprescribing: a systematic review and meta-analysis

Background

Harmful and/or unnecessary medication use in older adults is common. This indicates deprescribing (supervised withdrawal of inappropriate medicines) is not happening as often as it should. This study aimed to synthesize the results of the Patients’ Attitudes Towards Deprescribing (PATD) questionnaire (and revised versions).

Methods

Databases were searched from January 2013 to March 2020. Google Scholar was used for citation searching of the development and validation manuscripts to identify original research using the validated PATD, revised PATD (older adult and caregiver versions), and the version for people with cognitive impairment (rPATDcog). Two authors extracted data independently. A meta-analysis of proportions (random-effects model) was conducted with subgroup meta-analyses for setting and population. The primary outcome was the question: “If my doctor said it was possible, I would be willing to stop one or more of my medicines.” Secondary outcomes were associations between participant characteristics and primary outcome and other (r)PATD results.

Results

We included 46 articles describing 40 studies (n = 10,816 participants). The meta-analysis found the proportion of participants who agreed or strongly agreed with this statement was 84% (95% CI 81%–88%) and 80% (95% CI 74%–86%) in patients and caregivers, respectively, with significant heterogeneity (I² = 95% and 77%).

Conclusion

Consumers reported willingness to have a medication deprescribed although results should be interpreted with caution due to heterogeneity. The findings from this study moves toward understanding attitudes toward deprescribing, which could increase the discussion and uptake of deprescribing recommendations in clinical practice.

Polypharmacy and saliva volumes in the northeast of Germany - The Study of Health in Pomerania

OBJECTIVES

Associations between saliva volumes or salivary flow rates and potentially xerogenic medication are rarely evaluated in cohorts with a wide age range. This cross-sectional cohort study investigated possible relationships between the regular consumption of potentially xerogenic medication and stimulated saliva volumes.

METHODS

Data from the German Studies of Health in Pomerania (SHIP-2 and SHIP-Trend-0) were pooled. Potentially xerogenic medications were identified using the Workshop on Oral Medicine VI criteria. Stimulated saliva was sampled using Salivette®, and saliva volumes expressed as μl/min were determined. Applying linear mixed models with adjustment for time point of saliva collection, associations of (a) age and sex with regularly consumed medication, (b) age and sex with saliva volumes, and (c) the number of regularly consumed xerogenic medications with saliva volumes were evaluated.

RESULTS

Six thousand seven hundred and fifty-three participants aged 20-83 years (mean 53.4 ± 14.9) were included. The average number of medications did not differ markedly between females (2.21 ± 2.46) and males (2.24 ± 2.83). Males took more potentially xerogenic medication (1.0 ± 1.3) than did females (0.9 ± 1.3). Also, males took more potentially xerogenic cardiovascular medications than did females (0.9 ± 1.2 versus 0.7 ± 1.1), while females were prescribed a higher number of potentially xerogenic medications affecting the nervous system (0.2 ± 0.5 versus 0.1 ± 0.4). The average stimulated saliva volume was 967.0 ± 433.3 µL/min. Regularly consumed and potentially xerogenic medications were associated with lower saliva volumes. Older age correlated not only with a higher number of total medications and a higher number of xerogenic medications affecting either the cardiovascular (in males) or the nervous system (in females), but also with lower saliva volumes.

CONCLUSIONS

Ageing was associated with polypharmacy, especially with the intake of potentially xerogenic medication, and lower average saliva volumes. With regard to complications of dry mouth, anamnesis of medication consumption is of high importance.

Exploring Patients' Attitudes Toward Deprescribing and Their Perception of Pharmacist Involvement in a European Country: A Cross-Sectional Study

PURPOSE

To explore how adult patients perceive deprescribing in a country with developing pharmaceutical care.

PATIENTS AND METHODS

This was a multicenter cross-sectional study conducted in ten community pharmacies across Croatia. Community-dwelling adults 40 years and older, taking at least one prescription medication long term, were invited to participate. The revised and validated Patients' Attitude Towards Deprescribing Questionnaire was used to investigate community-dwelling adults' opinions on potential medication discontinuation. Questions regarding the patients' perception of pharmacist competences and involvement as well as patients' preferences in deprescribing were added. Collected data were analyzed using IBM SPSS Statistics using descriptive and inferential statistical analysis. Binary logistic regression was used to explore potential predictive factors of willingness to have medication deprescribed. All tests were performed as two-tailed and a p < 0.05 was considered statistically significant.

RESULTS

A total of 315 adults aged 40 years and older completed the questionnaire. Majority of participants, 83.81% (95% CI, 79.72% to 87.90%) stated that they were satisfied with their medications, and 83.81% (95% CI, 79.72% to 87.90%) would be willing to deprescribe one or more medications. Participants expressed a positive attitude toward pharmacists' competences (68.89%, 95% CI, 63.75% to 74.03%) and involvement in deprescribing (71.11%, 95% CI, 66.08% to 76.14%). Participants who stated specific medication as deprescribing preference were more likely show dissatisfaction with current medication and show greater willingness to have medication deprescribed. Three factors were found to be associated with a positive attitude towards deprescribing: low concerns about stopping factor score (aOR 0.54, 95% CU=0.35-0.84; p=0.006), low appropriateness factor score (aOR 0.62, 95% CI=0.39-0.98; p=0.039), and a positive opinion on pharmacist involvement (aOR 2.35, 95% CI=1.18-4.70; p= 0.016).

CONCLUSION

This study showed the patient's willingness for deprescription as well as their positive attitude towards pharmacists being involved in the process. Results favour transition to a patient-centred care and shared-decision making model.

Cross-cultural adaptation and psychometric validation of the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire in French

BACKGROUND

The revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire allows capture of the beliefs and attitudes of older adults and caregivers towards deprescribing.

OBJECTIVES

To translate and validate the rPATD questionnaire into French.

METHODS

The French rPATD was translated using forward-backward translation. Psychometric properties were evaluated in both older adults ≥65 years living in the community or in institutions and who were taking at least one chronic medication and in caregivers of older adults with similar characteristics. Participants were recruited in four French-speaking countries (Belgium, Canada, France and Switzerland). Face and content validity were assessed during the translation process. Construct validity (exploratory factor analysis (EFA)) and internal consistency (Cronbach's alpha) were investigated in questionnaires without missing data. Test-retest reliability was evaluated using intra-class correlation coefficient (ICC) in a sample of participants.

RESULTS

In total, 320 questionnaires from older adults and 215 questionnaires from caregivers were included to evaluate construct validity and internal consistency. EFA extracted four factors in the older adults' and caregivers' versions of the questionnaire consistent with the English rPATD. The extracted factors related to the perceived burden of medication taking, the beliefs in appropriateness of medications, concerns about stopping medications and the level of involvement in making decisions and of knowledge of medications. Internal consistency was satisfactory for three factors for both versions (Cronbach's alpha >0.70), with lower internal consistency in the concerns about stopping factor. Test-retest reliability was overall good for all factors in the caregivers' version (ICC > 0.75) while for the older adults' version, moderate (ICC range: 0.75-0.50) to good ICC values were found.

CONCLUSIONS

The French rPATD presents globally good psychometric properties and can be used to explore attitudes towards deprescribing in French-speaking older adults and caregivers.

What do older adults with multimorbidity and polypharmacy think about deprescribing? The LESS study - a primary care-based survey

Background

Multimorbidity and polypharmacy are very common in older adults in primary care. Ideally, general practitioners (GPs), should regularly review medication lists to identify inappropriate medication(s) and, where appropriate, deprescribe. However, it remains challenging to deprescribe given time constraints and few recommendations from guidelines. Further, patient related barriers and enablers to deprescribing have to be accounted for. The aim of this study was to identify barriers and enablers to deprescribing as reported by older adults with polypharmacy and multimorbidity.

Methods

We conducted a survey among participants aged ≥70 years, with multimorbidity (≥3 chronic conditions) and polypharmacy (≥5 chronic medications). We invited Swiss GPs, to recruit eligible patients who then completed a paper-based survey on demographics, medications and chronic conditions. We used the revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire and added twelve additional Likert scale questions and two open-ended questions to assess barriers and enablers towards deprescribing, which we coded and categorized into meaningful themes.

Result

Sixty four Swiss GPs consented to recruit 5–6 patients each and returned 300 participant responses. Participants were 79.1 years (SD 5.7), 47% female, 34% lived alone, and 86% managed their medications themselves. Sixty-seven percent of participants took 5–9 regular medicines and 24% took ≥10 medicines. The majority of participants (77%) were willing to deprescribe one or more of their medicines if their doctor said it was possible. There was no association with sex, age or the number of medicines and willingness to deprescribe. After adjustment for baseline characteristics, there was a strong positive association between willingness to deprescribe and saying that because they have a good relationship with their GP, they would feel that deprescribing was safe OR 11.3 (95% CI: 4.64–27.3) and agreeing that they would be willing to deprescribe if new studies showed an avoidable risk OR 8.0 (95% CI 3.79–16.9). From the open questions, the most mentioned barriers towards deprescribing were patients feeling well on their current medicines and being convinced that they need all their medicines.

Conclusions

Most older adults with polypharmacy are willing to deprescribe. GPs may be able to increase deprescribing by building trust with their patients and communicating evidence about the risks of medication use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-020-01843-x.

Medication-related experiences of patients with polypharmacy: a systematic review of qualitative studies

BACKGROUND

We aimed to synthesise qualitative studies exploring medication-related experiences of polypharmacy among patients with multimorbidity.

METHODS

We systematically searched PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature in February 2020 for primary, peer-reviewed qualitative studies about multimorbid patients' medication-related experiences with polypharmacy, defined as the use of four or more medications. Identified studies were appraised for methodological quality by applying the Critical Appraisal Skills Programme checklist for qualitative research, and data were extracted and synthesised by the meta-aggregation approach.

RESULTS

We included 13 qualitative studies, representing 499 patients with polypharmacy and a wide range of chronic conditions. Overall, most Critical Appraisal Skills Programme items were reported in the studies. We extracted 140 findings, synthesised these into 17 categories, and developed five interrelated syntheses: (1) patients with polypharmacy are a heterogeneous group in terms of needing and appraising medication information; (2) patients are aware of the importance of medication adherence, but it is difficult to achieve; (3) decision-making about medications is complex; (4) multiple relational factors affect communication between patients and physicians, and these factors can prevent patients from disclosing important information; and (5) polypharmacy affects patients' lives and self-perception, and challenges with polypharmacy are not limited to practical issues of medication-taking.

DISCUSSION

Polypharmacy poses many challenges to patients, which have a negative impact on quality of life and adherence. Thus, when dealing with polypharmacy patients, it is crucial that healthcare professionals actively solicit individual patients' perspectives on challenges related to polypharmacy. Based on the reported experiences, we recommend that healthcare professionals upscale communicative efforts and involve patients' social network on an individualised basis to facilitate shared decision-making and treatment adherence in multimorbidpatients with polypharmacy.

A complex intervention for multimorbidity in primary care: A feasibility study

Aim

To assess the feasibility of a patient-centered complex intervention for multimorbidity (CIM) based on general practice in collaboration with community health-care centers and outpatient clinics.

Methods

Inclusion criteria were age ≥18 years, diagnoses of two or more of three chronic conditions (diabetes, chronic obstructive pulmonary disease (COPD), and chronic heart conditions), and a hospital contact during the previous year. The CIM included extended consultations and nurse care manager support in general practice and intensified cross-sectorial collaboration. Elements included a structured care plan based on patients' care goals, coordination of services, and, if appropriate, shifting outpatient clinic visits to general practice, medication review, referral to rehabilitation, and home care. The acceptability dimension of feasibility was assessed with validated questionnaires, observations, and focus groups.

Results

Forty-eight patients were included (mean age 72.2 (standard deviation (SD) 9.5, range 52-89); 23 (48%) were men. Thirty-seven patients had two diseases; most commonly COPD and cardiovascular disease (46%), followed by diabetes and cardiovascular disease (23%), and COPD and diabetes (15%). Eleven (23%) patients had all three conditions. Focus group interviews with patients with multimorbidity identified three main themes: (1) lack of care coordination existed across health-care sectors before the CIM, (2) extended consultations provided better care coordination, and (3) patients want to be involved in planning their treatment and care. In focus groups, health-care professionals discussed two main themes: (1) patient-centered care and (2) culture and organizational change. Completion rates for questionnaires were 98% (47/48).

Conclusions

Patients and health-care professionals found the CIM acceptable.

Barriers and Enablers of Older Patients to Deprescribing of Cardiometabolic Medication: A Focus Group Study

Background

Deprescribing has been recommended for managing polypharmacy but deprescribing preventive medication in older patients is still uncommon. We aimed to investigate older patients’ barriers to and enablers of deprescribing cardiometabolic medication.

Methods

Two focus groups were conducted among patients ≥70 years with polypharmacy, including cardiometabolic medication. Purposive sampling through four community pharmacies was used in two regions in the Netherlands. A topic list was developed using literature and the theoretical domains framework (TDF). The meetings were audio recorded, transcribed verbatim and coded using thematic coding, attribute coding and the TDF. In addition, patients were categorized on attitudes towards medication and willingness to stop.

Results

The meetings were attended by 17 patients and 1 caregiver (71 to 84 years). In total 15 barriers and 13 enablers were identified within four themes, partly related to beliefs, fears and experiences regarding using or stopping medication, and partly related to the relationship with the health care professional and the conditions to stop. Some patients attributed their wellbeing to their medication and were therefore unwilling to stop. Reducing cardiometabolic medication because of less strict treatment targets confused some patients and was a barrier to deprescribing. Having options to monitor clinical measurements and restart medication were enablers. Patients were only willing to stop cardiometabolic medication when this was proposed by a HCP they trusted. Patients with a positive attitude towards medication varied in their willingness to stop cardiometabolic medication. Patients with a negative attitude towards medication were generally willing to stop medication but still perceived several barriers and may consider some medication as being essential.

Conclusion

Fears, beliefs, and experiences regarding using and stopping medication as well as trust in the HCP influence willingness to have medication deprescribed. Attitudes towards medication in general do not necessarily translate into willingness or unwillingness to stop specific medication. For deprescribing cardiometabolic medication, patient involvement when setting new treatment targets and monitoring the effects on short-term outcomes are important.

Patterns and characteristics of polypharmacy among elderly residents in Danish nursing homes

Aim:

To identify patterns and characteristics of polypharmacy among elderly residents in Danish nursing homes in the Northern region of Denmark.

Materials & methods:

Twenty-five nursing homes were contacted, where each supplied 20 randomly selected anonymized residents’ information. Residents were 65 years or older, concurrently taking five or more medications. Drug–drug interactions and potential adverse effects were investigated.

Results:

One hundred residents (68% females; 32% males) were included. The most prevalent co-morbid condition was cardiovascular disease, and the most prevalent medications were for gastrointestinal- and metabolism-related conditions. Age influenced the number of drugs (p = 0.013) and drug–drug interactions per resident (p = 0.039), with a positive correlation.

Conclusion:

Elderly residents of the studied nursing homes were potentially affected by an inappropriate polypharmacy.

Multimorbidity is common among elderly and a leading factor for polypharmacy. We conducted this study on 100 Danish elderly residents (>65 years, on ≥5 medications) in 25 nursing homes, anonymously and randomly chosen in Northern region of Denmark, to find characteristics of potential inappropriate polypharmacy. We found that age influenced the number of drugs (p = 0.013) and number of drug–drug interactions per resident (p = 0.039), but no sex-related difference was evident. Positive correlations were present between the number of drugs and drug–drug interactions. Elderly residents of the studied nursing homes were potentially affected by an inappropriate polypharmacy.

One-year persistence of potentially inappropriate medication use in older adults: A population-based study

AIMS

To assess the 1-year persistence of potentially inappropriate medication (PIM) use and identify associated factors in community-dwelling older adults in Quebec, Canada.

METHODS

A population-based cohort study was conducted using the Quebec Integrated Chronic Disease Surveillance System. Individuals insured by the public drug plan and aged ≥66 years who initiated a PIM between 1 April 2014 and 31 March 2015 were followed-up for 1 year. PIMs were identified using the 2015 Beers criteria. One-year persistence of PIM use was defined as continuous treatment with any PIM, without interruption for more than 60 days between prescriptions refills. Poisson regression models were performed to identify factors associated with 1-year persistence of any PIM.

RESULTS

In total, 25.1% of PIM initiators were persistent at 1 year. In non-persistent individuals, the median time to PIM discontinuation was 31 days (interquartile range 21-92). Individuals were more persistent at 1 year with antipsychotics (43.9%), long-duration sulphonylureas (40.2%), antiarrhythmics/immediate-release nifedipine (36.5%) and proton pump inhibitors (36.0%). Factors significantly associated with persistence were an increased age, being a man and having a high number of medications and chronic diseases, especially dementia, diabetes and cardiovascular diseases.

CONCLUSIONS

One-quarter of community-dwelling older adults are continuously exposed to PIMs. To optimize medication prescribing in the older population, further interventions are needed to limit the use of PIMs most likely to be continued, especially in individuals most at risk of being persistent and also particularly vulnerable to adverse events.

Deprescribing as a Clinical Improvement Focus

OBJECTIVES

Polypharmacy is a concern in the practice of geriatrics because of consequences such as adverse drug events and poorer quality of life. Deprescribing, a response to polypharmacy, refers to the systematic, programmed, and appropriate reduction in drug number and dose. Although now broadly recognized, challenges exist in practice for effective implementation. This study was conducted to determine the deprescribing success rate and relate it to drug classes and clinical settings, and to identify factors that influence the deprescribing process.

DESIGN

As a performance improvement (PI) project, fellows in geriatric medicine, under supervision of faculty geriatricians, attempted deprescribing during at least 1 encounter daily at 2 long-term care (LTC) facilities and an outpatient geriatrics clinic (C) in Bronx, New York, from August 2018 to January 2019. Deprescribing was initiated following discussion and consent from patient or caregiver. Following the data collection, involved fellows and faculty physicians participated in a survey to identify factors that influenced the process.

RESULTS

Out of 449 encounters, 383 encounters were included for analysis. Average patient age was 78.2 years (LTC: 77.9, C: 79.1). Average patient comorbidities was 6.5 (LTC: 6.7, C: 5.8). Deprescribing was successful in 90.1% of encounters (LTC: 96.9%, C: 67.4%). On average, 1.3 medications were deprescribed per encounter (LTC: 1.4, C: 1.0). Analgesics (32.2%), multivitamin-minerals supplements (29.7%), lipid-lowering agents (22.9%), antihistamines (46.7%), and acid blockers (26.2%) had highest success.

CONCLUSIONS AND IMPLICATIONS

Deprescribing is possible in practice in both LTC and community settings at each encounter, until it is no longer applicable. Factors that contribute to successful deprescribing primarily include meaningful and earnest provider effort, ideally in collaboration with interdisciplinary team members (nurses, pharmacists, social worker, and others), besides interactions with consultants for the patient. Certain medication classes such as vitamins, minerals, analgesics, and proton pump inhibitors can be deprescribed with high success, as noted in our study, whereas antipsychotic agents, antidepressants, and ophthalmic preparations, prescribed by specialists, proved harder to deprescribe. An understanding of barriers to deprescribing (outlined in the article) and addressing them are crucial in enabling success. The study demonstrates that as a performance improvement project in collaborative effort with multiple disciplines, deprescribing is possible in health care. Factors promoting success and barriers to deprescribing are detailed. Appropriate deprescribing has the potential to help lower adverse drug events, costs of care, and possibly improve quality of life.