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Huisman BAA, Geijteman ECT, Dees MK, van Zuylen L, van der Heide A, Perez RSGM. Better drug use in advanced disease: an international Delphi study. BMJ Support Palliat Care 2023; 13:e115-e121. [PMID: 30446489 PMCID: PMC10646859 DOI: 10.1136/bmjspcare-2018-001623] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 10/24/2018] [Accepted: 11/01/2018] [Indexed: 11/03/2022]
Abstract
Patients with a limited life expectancy use many medications, some of which may be questionable. OBJECTIVES : To identify possible solutions for difficulties concerning medication management and formulate recommendations to improve medication management at the end of life. METHODS : A two-round Delphi study with experts in the field of medication management and end-of-life care (based on ranking in the citation index in Web of Science and relevant publications). We developed a questionnaire with 58 possible solutions for problems regarding medication management at the end of life that were identified in previously performed studies. RESULTS : A total of 42 experts from 13 countries participated. Response rate in the first round was 93%, mean agreement between experts for all solutions was 87 % (range 62%-100%); additional suggestions were given by 51%. The response rate in the second round was 74%. Awareness, education and timely communication about medication management came forward as top priorities for guidelines. In addition, solutions considered crucial by many of the experts were development of a list of inappropriate medications at the end of life and incorporation of recommendations for end-of-life medication management in disease-specific guidelines. CONCLUSIONS : In this international Delphi study, experts reached a high level of consensus on recommendations to improve medication management in end-of-life care. These findings may contribute to the development of clinical practice guidelines for medication management in end-of-life care.
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Affiliation(s)
- Bregje A A Huisman
- Department of Anesthesiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Eric C T Geijteman
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marianne K Dees
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Roberto S G M Perez
- Department of Anesthesiology, VU University Medical Center, Amsterdam, The Netherlands
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2
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Cabrera JA, Mota M, Pais C, Morais A. Deprescription in Palliative Care. Cureus 2023; 15:e39578. [PMID: 37378207 PMCID: PMC10292863 DOI: 10.7759/cureus.39578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2023] [Indexed: 06/29/2023] Open
Abstract
Individuals with limited life expectancy represent a significant proportion of healthcare consumers and are usually patients with multiple diseases and high levels of frailty. Polypharmacy and the prescription of long lists of drugs are frequent in patients with reduced life expectancy and often, as the patient's health status deteriorates, the list of drugs increases substantially as new medications are introduced to address new symptoms or complications. A key priority for healthcare professionals managing the care of these patients should be balancing the pharmacological approach to chronic diseases with the palliation of acute symptoms and complications. An important element of this process is to ensure that the benefit of any prescription decision outweighs potential risks. We reviewed the pros and cons of deprescribing drugs in individuals with limited life expectancy, how to identify the expected disease trajectory, which drugs are to be discontinued, identified some models trying to achieve rigorous deprescribing criteria, and the psychosocial effects of deprescribing in late phases of life. Deprescribing is not a one-time event but rather a continuous process that requires ongoing evaluation and monitoring. It is vital to continuously monitor and evaluate the pharmacological and non-pharmacological prescriptions for patients with chronic illnesses to align them with their goals of care and life expectancy.
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Affiliation(s)
- Joana A Cabrera
- Internal Medicine, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
| | - Margarida Mota
- Infectious Diseases, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
| | - Carmen Pais
- Internal Medicine, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, PRT
| | - Anabela Morais
- Internal Medicine, Centro Hospitalar de Trás os Montes e Alto Douro, Vila Real, PRT
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Shrestha S, Poudel A, Forough AS, Steadman KJ, Nissen LM. A systematic review on methods for developing and validating deprescribing tools for older adults with limited life expectancy. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2023; 31:3-14. [PMID: 36472946 DOI: 10.1093/ijpp/riac094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 11/09/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES A number of deprescribing tools are available to assist clinicians to make decisions on medication management. We aimed to review deprescribing tools that may be used with older adults that have limited life expectancy (LLE), including those at the palliative and end-of-life stage, and consider the rigour with which the tools were developed and validated. KEY FINDINGS Literature was searched in PubMed, Embase, CINHAL and Google Scholar until February 2021 for studies involving the development and/or consensus validation of deprescribing tools targeting those aged ≥65 years with LLE. We were interested in the tool development process, tool validation process and clinical components addressed by the tool.Six studies were included. The approaches followed for tool development were systematic review (n = 3), expert-literature review (n = 2) and concept data (n = 1). The content included a list of disease-non-specific medications divided with or without recommendations (n = 4) and disease-specific medications with recommendations (n = 2). The tool validation was performed using the Delphi method (n = 4) or GRADE framework (n = 2) with panel size ranging from 8 to 17 and 60-80% consensus agreement with or without a rating scale. LLE targeted were ≤1 year (n = 2) or ≤3 months (n = 1). SUMMARY There is a limited number of deprescribing tools with consensus validation available for use in older adults with LLE. These tools are either targeted for disease-specific medication/medication class guided by the GRADE framework or targeted for a list of medications or medication classes irrespective of disease that are developed using a combination of approaches and validated using a Delphi method.
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Affiliation(s)
- Shakti Shrestha
- School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
| | - Arjun Poudel
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ayda S Forough
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Kathryn J Steadman
- School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
| | - Lisa M Nissen
- Centre for the Business and Economics of Health, The University of Queensland, Brisbane, Queensland, Australia
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Lüthold RV, Jungo KT, Weir KR, Geier AK, Scholtes B, Kurpas D, Wild DMG, Petrazzuoli F, Thulesius H, Lingner H, Assenova R, Poortvliet RKE, Lazic V, Rozsnyai Z, Streit S. Understanding older patients' willingness to have medications deprescribed in primary care: a protocol for a cross-sectional survey study in nine European countries. BMC Geriatr 2022; 22:920. [PMID: 36451180 PMCID: PMC9709365 DOI: 10.1186/s12877-022-03562-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 10/25/2022] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION To reduce inappropriate polypharmacy, deprescribing should be part of patients' regular care. Yet deprescribing is difficult to implement, as shown in several studies. Understanding patients' attitudes towards deprescribing at the individual and country level may reveal effective ways to involve older adults in decisions about medications and help to implement deprescribing in primary care settings. In this study we aim to investigate older adults' perceptions and views on deprescribing in different European countries. Specific objectives are to investigate the patients' willingness to have medications deprescribed by medication type and to have herbal or dietary supplements reduced or stopped, the role of the Patient Typology (on medication perspectives), and the impact of the patient-GP relationship in these decisions. METHODS AND ANALYSIS This cross-sectional survey study has two parts: Part A and Part B. Data collection for Part A will take place in nine countries, in which per country 10 GPs will recruit 10 older patients (≥65 years old) each (n = 900). Part B will be conducted in Switzerland only, in which an additional 35 GPs will recruit five patients each and respond to a questionnaire themselves, with questions about the patients' medications, their willingness to deprescribe those, and their patient-provider relationship. For both Part A and part B, a questionnaire will be used to assess the willingness of older patients with polypharmacy to have medications deprescribed and other relevant information. For Part B, this same questionnaire will have additional questions on the use of herbal and dietary supplements. DISCUSSION The international study design will allow comparisons of patient perspectives on deprescribing from different countries. We will collect information about willingness to have medications deprescribed by medication type and regarding herbal and dietary supplements, which adds important information to the literature on patients' preferences. In addition, GPs in Switzerland will also be surveyed, allowing us to compare GPs' and patients' views and preferences on stopping or reducing specific medications. Our findings will help to understand patients' attitudes towards deprescribing, contributing to improvements in the design and implementation of deprescribing interventions that are better tailored to patients' preferences.
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Affiliation(s)
- Renata Vidonscky Lüthold
- grid.5734.50000 0001 0726 5157Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland ,grid.5734.50000 0001 0726 5157Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Katharina Tabea Jungo
- grid.5734.50000 0001 0726 5157Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
| | - Kristie Rebecca Weir
- grid.5734.50000 0001 0726 5157Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland ,grid.1013.30000 0004 1936 834XSydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Anne-Kathrin Geier
- grid.9647.c0000 0004 7669 9786Department of General Practice, Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Beatrice Scholtes
- grid.4861.b0000 0001 0805 7253Research Unit of Primary Care and Health, Department of General Medicine, Faculty of Medicine, University of Liège, Liège, Belgium
| | - Donata Kurpas
- grid.4495.c0000 0001 1090 049XFamily Medicine Department, Wrocław Medical University, Wrocław, Poland
| | - Dorothea M. G. Wild
- grid.10388.320000 0001 2240 3300Institute of Family Medicine and General Practice, University Hospital Bonn, Bonn University, Bonn, Germany
| | - Ferdinando Petrazzuoli
- Sezione SNaMID Caserta, Caserta, Italy ,grid.4514.40000 0001 0930 2361Center for Primary Health Care Research, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Hans Thulesius
- grid.8148.50000 0001 2174 3522Department of Medicine and Optometry, Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden ,grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Heidrun Lingner
- grid.10423.340000 0000 9529 9877Hannover Medical School, Center for Public Health and Healthcare, Hannover, Germany
| | - Radost Assenova
- grid.35371.330000 0001 0726 0380Department of Urology and General Practice, Faculty of Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Rosalinde K. E. Poortvliet
- grid.10419.3d0000000089452978University Network for the Care sector Zuid-Holland, Leiden University Medical Center, Leiden, The Netherlands ,grid.10419.3d0000000089452978Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Vanja Lazic
- Health center Zagreb – Centar, Zagreb, Croatia
| | - Zsofia Rozsnyai
- grid.5734.50000 0001 0726 5157Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
| | - Sven Streit
- grid.5734.50000 0001 0726 5157Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
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Live well, die well – an international cohort study on experiences, concerns and preferences of patients in the last phase of life: the research protocol of the iLIVE study. BMJ Open 2022. [PMCID: PMC9362824 DOI: 10.1136/bmjopen-2021-057229] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Introduction Adequately addressing the needs of patients at the end of life and their relatives is pivotal in preventing unnecessary suffering and optimising their quality of life. The purpose of the iLIVE study is to contribute to high-quality personalised care at the end of life in different countries and cultures, by investigating the experiences, concerns, preferences and use of care of terminally ill patients and their families. Methods and analysis The iLIVE study is an international cohort study in which patients with an estimated life expectancy of 6 months or less are followed up until they die. In total, 2200 patients will be included in 11 countries, that is, 200 per country. In addition, one relative per patient is invited to participate. All participants will be asked to fill in a questionnaire, at baseline and after 4 weeks. If a patient dies within 6 months of follow-up, the relative will be asked to fill in a post-bereavement questionnaire. Healthcare use in the last week of life will be evaluated as well; healthcare staff who attended the patient will be asked to fill in a brief questionnaire to evaluate the care that was provided. Qualitative interviews will be conducted with patients, relatives and healthcare professionals in all countries to gain more in-depth insights. Ethics and dissemination The cohort study has been approved by ethics committees and the institutional review boards (IRBs) of participating institutes in all countries. Results will be disseminated through the project website, publications in scientific journals and at conferences. Within the project, there will be a working group focusing on enhancing the engagement of the community at large with the reality of death and dying. Trial registration number NCT04271085.
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Bognar J. Palliative Care: A Primary Care Pharmacist Perspective. PHARMACY 2022; 10:pharmacy10040081. [PMID: 35893719 PMCID: PMC9326660 DOI: 10.3390/pharmacy10040081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/05/2022] [Accepted: 07/08/2022] [Indexed: 11/16/2022] Open
Abstract
The overview approaches pharmacy practice in palliative care from a global viewpoint and aims to provide insight into front-line pharmacist–patient relationships by sharing case studies and personal experiences.
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Peralta T, Castel-Branco MM, Reis-Pina P, Figueiredo IV, Dourado M. Prescription trends at the end of life in a palliative care unit: observational study. BMC Palliat Care 2022; 21:65. [PMID: 35505394 PMCID: PMC9066954 DOI: 10.1186/s12904-022-00954-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 04/22/2022] [Indexed: 11/30/2022] Open
Abstract
Background Symptomatic control is essential in palliative care, particularly in end-of-life, in which the pathophysiological changes that characterize this last phase of life strengthen the need to carry out an early therapeutic review. Hence, we aim to evaluate the prescribing pattern at a palliative care unit at two different time points: on admission and the day of the patient’s death. Methods Quantitative, analytic, longitudinal, retrospective and observational study. Participants were adult patients who were admitted and died in a palliative care unit, in Portugal. Sociodemographic, clinical and pharmacological data were collected, including frequencies and routes of administration of schedule prescribed drugs and rescue drugs, from the day of admission until the day of death. Results 115 patients were included with an average age of 70.0 ± 12.9 years old, 53.9 were male, mostly referred by the Hospital Palliative Care Support Teams. The most common pathology was cancer, mainly in advanced stage. On admission, the median scheduled prescription was seven and “as needed” was three drugs. On the day of death, a decrease of prescriptions was observed. Opioids were always the most prescribed drugs. Near death, there was a higher tendency to prescribe butylscopolamine, midazolam, diazepam and levomepromazine. The most frequent route of drug administration was oral on admission and subcutaneous on the day of death. Conclusions Polypharmacy is a reality in palliative care despite specialist palliative care teams. A reduction of prescribed drugs was verified, essentially due less comorbidity-oriented drugs. Further studies are required to analyse the importance of Hospital Palliative Care Support Teams.
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Affiliation(s)
- Tatiana Peralta
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
| | - Maria Margarida Castel-Branco
- Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal.,Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Paulo Reis-Pina
- Palliative Care Unit "Bento Menni", Casa de Saúde da Idanha, Sintra, Portugal.,Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Isabel Vitória Figueiredo
- Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal.,Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Marília Dourado
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Center for Studies and Development of Continuous and Palliative Care (CEDCCP), Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Centre for Health Studies and Research of the University of Coimbra (CEISUC), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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8
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Shrestha S, Poudel A, Reeve E, Linsky AM, Steadman KJ, Nissen LM. Development and validation of a tool to understand health care professionals' attitudes towards deprescribing (HATD) in older adults with limited life expectancy. Res Social Adm Pharm 2022; 18:3596-3601. [DOI: 10.1016/j.sapharm.2022.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/13/2022] [Accepted: 03/04/2022] [Indexed: 10/18/2022]
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Thiruchelvam K, Byles J, Hasan SS, Egan N, Kairuz T. Residential Medication Management Reviews and continuous polypharmacy among older Australian women. Int J Clin Pharm 2021; 43:1619-1629. [PMID: 34091857 DOI: 10.1007/s11096-021-01294-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/31/2021] [Indexed: 10/21/2022]
Abstract
Background Polypharmacy is an important consideration for the provision of Residential Medication Management Reviews (RMMRs) among older women given their enhanced risk of medication-related problems and admission to residential aged care (RAC). Objectives To determine the prevalence of the use of RMMRs among older women in RAC, and the association between RMMRs and polypharmacy, medications, and costs. Setting Older Australian women aged 79-84 years in 2005 who had at least one Medicare Benefits Schedule and Pharmaceutical Benefits Scheme record, received a service in aged care, and consented to data linkage. Methods Generalised estimating equations were used to determine the association between polypharmacy and RMMRs, while adjusting for confounding variables. Main outcome measures Prevalence of the use of RMMRs among older women in RAC, association between RMMRs and polypharmacy, medications, and costs. Results Most participants did not have continuous polypharmacy and did not receive RMMRs from 2005 [451 (67.4%)] until 2017 [666 (66.6%)]. Participants with continuous polypharmacy were 17% more likely to receive a RMMR (risk ratio 1.17; 95% confidence interval 1.11, 1.25). Participants in their final year of life and residing in outer regional/remote/very remote Australia were less likely to receive RMMRs. Out-of-pocket medication costs increased over time, and alendronate and aspirin were common contributors to polypharmacy among participants who received RMMRs. Conclusion Polypharmacy was associated with receiving RMMRs and around two-thirds of women who are entitled to a RMMR never received one. There is potential to improve the use of medicines by increasing awareness of the service among eligible individuals, their carers and health care professionals.
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Affiliation(s)
- Kaeshaelya Thiruchelvam
- University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia. .,International Medical University, 126 Jalan Jalil Perkasa 19, Bukit Jalil, 57000, Kuala Lumpur, Malaysia.
| | - Julie Byles
- University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,Priority Research Centre for Generational Health and Ageing, Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
| | - Syed Shahzad Hasan
- University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,University of Huddersfield, Queensgate, Huddersfield, HD1 3DH, UK
| | - Nicholas Egan
- University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,Priority Research Centre for Generational Health and Ageing, Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
| | - Therese Kairuz
- University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,International Medical University, 126 Jalan Jalil Perkasa 19, Bukit Jalil, 57000, Kuala Lumpur, Malaysia
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Lau S, Lun P, Ang W, Tan KT, Ding YY. Barriers to effective prescribing in older adults: applying the theoretical domains framework in the ambulatory setting - a scoping review. BMC Geriatr 2020; 20:459. [PMID: 33167898 PMCID: PMC7650160 DOI: 10.1186/s12877-020-01766-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 09/10/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND As the population ages, potentially inappropriate prescribing (PIP) in the older adults may become increasingly prevalent. This undermines patient safety and creates a potential source of major morbidity and mortality. Understanding the factors that influence prescribing behaviour may allow development of interventions to reduce PIP. The aim of this study is to apply the Theoretical Domains Framework (TDF) to explore barriers to effective prescribing for older adults in the ambulatory setting. METHODS A scoping review was performed based on the five-stage methodological framework developed by Arksey and O'Malley. From 30 Aug 2018 to 5 Sep 2018, we conducted our search on PubMed, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews, and Web of Science. We also searched five electronic journals, Google and Google Scholar to identify additional sources and grey literature. Two reviewers applied eligibility criteria to the title and abstract screening, followed by full text screening, before systematically charting the data. RESULTS A total of 5731 articles were screened. Twenty-nine studies met the selection criteria for qualitative analysis. We mapped our results using the 14-domain TDF, eventually identifying 10 domains of interest for barriers to effective prescribing. Of these, significant domains include physician-related factors such as "Knowledge", "Skills", and "Social/Professional Role and Identity"; issues with "Environmental Context and Resources"; and the impact of "Social Influences" and "Emotion" on prescribing behaviour. CONCLUSION The TDF elicited multiple domains which both independently and collectively lead to barriers to effective prescribing for older adults in the ambulatory setting. Changing the prescribing climate will thus require interventions targeting multiple stakeholders, including physicians, patients and hospital/clinic systems. Further work is needed to explore individual domains and guide development of frameworks to aid guide prescribing for older adults in the ambulatory setting.
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Affiliation(s)
- Sabrina Lau
- Department of Geriatric Medicine, Tan Tock Seng Hospital, TTSH Annex 2, Level 3, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
| | - Penny Lun
- Geriatric Education & Research Institute, Singapore, Singapore
| | - Wendy Ang
- Pharmacy, Changi General Hospital, Singapore, Singapore
| | - Keng Teng Tan
- Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yew Yoong Ding
- Department of Geriatric Medicine, Tan Tock Seng Hospital, TTSH Annex 2, Level 3, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
- Geriatric Education & Research Institute, Singapore, Singapore
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Lonchampt S, Gerber F, Aubry JM, Desmeules J, Besson M, Kosel M. TOP-ID: a Delphi technique-guided development of a prescription and deprescription tool for adults with intellectual disabilities. BMJ Open 2020; 10:e039208. [PMID: 33148748 PMCID: PMC7643515 DOI: 10.1136/bmjopen-2020-039208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 09/22/2020] [Accepted: 10/11/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Adults with an intellectual disability (AWID) are often polymedicated because of somatic and psychiatric health problems. Besides, they may display challenging behaviours, leading to off-label prescription of psychotropic drugs, without efficacy and with numerous adverse effects. In this context, a prescription/deprescription tool (Tool for Optimising Prescription in Intellectual Disability/TOP-ID) was developed to improve the care of AWID. This paper describes how TOP-ID was designed. DESIGN Four-step consensus-based process involving a review of the literature, eight semistructured interviews and a two-round Delphi process. SETTING Seventeen general practices and university and general hospitals from Belgium, France and Switzerland. PARTICIPANTS Eighteen French-speaking physicians from different domains of expertise participated in the Delphi process. PRIMARY AND SECONDARY OUTCOME MEASURES For the Delphi iteration process, consensus was defined as at least a 65% agreement between the experts. RESULTS Two rounds were needed for the Delphi process. Eighty-one items of the tool were submitted to 18 out of 35 recruited French-speaking experts during the first round. Sixty-nine per cent of the items reached a rate of agreement of 65% or more in that round. Thirteen questions were reformulated and resubmitted for the second Delphi iteration round. All of the statements reached a rate of agreement of 65% or more in the second round. CONCLUSION TOP-ID is the first prescription-deprescription tool developed specifically for AWIDs in French. It is intended to help prescribers document patient care in order to reduce prescription errors and to improve safety. The next steps of the project include the development of an electronic version of TOP-ID and a utility study.
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Affiliation(s)
- Sophie Lonchampt
- Psychopharmacology Unit, Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive care, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
- Unit for Intellectual Disabilities and Autism in Adults, Division of Psychiatric Specialties, Department of Psychiatry, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
- School of Pharmaceutical Sciences of Geneva and Lausanne, Faculty of Science, University of Geneva, Geneva, Switzerland
| | - Fabienne Gerber
- Unit for Intellectual Disabilities and Autism in Adults, Division of Psychiatric Specialties, Department of Psychiatry, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Jean-Michel Aubry
- Division of Psychiatric Specialties, Department of Psychiatry and Mental Health, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Jules Desmeules
- School of Pharmaceutical Sciences of Geneva and Lausanne, Faculty of Science, University of Geneva, Geneva, Switzerland
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Marie Besson
- Psychopharmacology Unit, Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive care, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
- Multidisciplinary Pain Center, Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Intensive care and Pharmacology, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Markus Kosel
- Unit for Intellectual Disabilities and Autism in Adults, Division of Psychiatric Specialties, Department of Psychiatry, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
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Rozsnyai Z, Jungo KT, Reeve E, Poortvliet RKE, Rodondi N, Gussekloo J, Streit S. What do older adults with multimorbidity and polypharmacy think about deprescribing? The LESS study - a primary care-based survey. BMC Geriatr 2020; 20:435. [PMID: 33129274 PMCID: PMC7602330 DOI: 10.1186/s12877-020-01843-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 10/21/2020] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- Zsofia Rozsnyai
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland
| | - Katharina Tabea Jungo
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland.,Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia.,NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,Geriatric Medicine Research and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
| | - Rosalinde K E Poortvliet
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Nicolas Rodondi
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland.,Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Section Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sven Streit
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland.
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13
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McCarthy C, Moriarty F, Wallace E, Smith SM. The evolution of an evidence based intervention designed to improve prescribing and reduce polypharmacy in older people with multimorbidity and significant polypharmacy in primary care (SPPiRE). JOURNAL OF COMORBIDITY 2020; 10:2235042X20946243. [PMID: 32974211 PMCID: PMC7493276 DOI: 10.1177/2235042x20946243] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 07/06/2020] [Indexed: 11/16/2022]
Abstract
Introduction By the time an intervention is ready for evaluation in a definitive RCT the context of the evidence base may have evolved. To avoid research waste, it is imperative that intervention design and evaluation is an adaptive process incorporating emerging evidence and novel concepts. The aim of this study is to describe changes that were made to an evidence based intervention at the protocol stage of the definitive RCT to incorporate emerging evidence. Methods The original evidence based intervention, a GP delivered web guided medication review, was modified in a five step process:Identification of core components of the original intervention.Literature review.Modification of the intervention.Pilot study.Final refinements. A framework, developed in public health research, was utilised to describe the modification process. Results The population under investigation changed from older people with a potentially inappropriate prescription (PIP) to older people with significant polypharmacy, a proxy marker for complex multimorbidity. An assessment of treatment priorities and brown bag medication review, with a focus on deprescribing were incorporated into the original intervention. The number of repeat medicines was added as a primary outcome measure as were additional secondary patient reported outcome measures to assess treatment burden and attitudes towards deprescribing. Conclusions A framework was used to systematically describe how and why the original intervention was modified, allowing the new intervention to build upon an effective and robustly developed intervention but also to be relevant in the context of the current evidence base.
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Affiliation(s)
- Caroline McCarthy
- HRB Centre for Primary Care Research and RCSI Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Frank Moriarty
- HRB Centre for Primary Care Research and RCSI Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Emma Wallace
- HRB Centre for Primary Care Research and RCSI Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Susan M Smith
- HRB Centre for Primary Care Research and RCSI Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
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14
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Arriagada L, Carrasco T, Araya M. Polifarmacia y deprescripción en personas mayores. REVISTA MÉDICA CLÍNICA LAS CONDES 2020. [DOI: 10.1016/j.rmclc.2020.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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15
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Mohamed MR, Ramsdale E, Loh KP, Arastu A, Xu H, Obrecht S, Castillo D, Sharma M, Holmes HM, Nightingale G, Juba KM, Mohile SG. Associations of Polypharmacy and Inappropriate Medications with Adverse Outcomes in Older Adults with Cancer: A Systematic Review and Meta-Analysis. Oncologist 2020; 25:e94-e108. [PMID: 31570516 PMCID: PMC6964156 DOI: 10.1634/theoncologist.2019-0406] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/11/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Polypharmacy (PP) and potentially inappropriate medications (PIM) are highly prevalent in older adults with cancer. This study systematically reviews the associations of PP and/or PIM with outcomes and, through a meta-analysis, obtains estimates of postoperative outcomes associated with PP in this population. MATERIALS AND METHODS We searched PubMed, Embase, Web of Science, and Cochrane Register of Clinical Trials using standardized terms for concepts of PP, PIM, and cancer. Eligible studies included cohort studies, cross-sectional studies, meta-analyses, and clinical trials which examined outcomes associated with PP and/or PIM and included older adults with cancer. A random effects model included studies in which definitions of PP were consistent to examine the association of PP with postoperative complications. RESULTS Forty-seven articles met the inclusion criteria. PP was defined as five or more medications in 57% of the studies. Commonly examined outcomes included chemotherapy toxicities, postoperative complications, functional decline, hospitalization, and overall survival. PP was associated with chemotherapy toxicities (4/9 studies), falls (3/3 studies), functional decline (3/3 studies), and overall survival (2/11 studies). A meta-analysis of four studies indicated an association between PP (≥5 medications) and postoperative complications (overall odds ratio, 1.3; 95% confidence interval [1.3-2.8]). PIM was associated with adverse outcomes in 3 of 11 studies. CONCLUSION PP is associated with postoperative complications, chemotherapy toxicities, and physical and functional decline. Only three studies showed an association between PIM and outcomes. However, because of inconsistent definitions, heterogeneous populations, and variable study designs, these associations should be further investigated in prospective studies. IMPLICATIONS FOR PRACTICE Polypharmacy and potentially inappropriate medications (PIM) are prevalent in older adults with cancer. This systematic review summarizes the associations of polypharmacy and PIM with health outcomes in older patients with cancer. Polypharmacy and PIM have been associated with postoperative complications, frailty, falls, medication nonadherence, chemotherapy toxicity, and mortality. These findings emphasize the prognostic importance of careful medication review and identification of PIM by oncology teams. They also underscore the need to develop and test interventions to address polypharmacy and PIM in older patients with cancer, with the goal of improving outcomes in these patients.
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Affiliation(s)
- Mostafa R. Mohamed
- James P. Wilmot Cancer Center, University of Rochester Medical CenterRochesterNew YorkUSA
| | - Erika Ramsdale
- James P. Wilmot Cancer Center, University of Rochester Medical CenterRochesterNew YorkUSA
| | - Kah Poh Loh
- James P. Wilmot Cancer Center, University of Rochester Medical CenterRochesterNew YorkUSA
| | - Asad Arastu
- James P. Wilmot Cancer Center, University of Rochester Medical CenterRochesterNew YorkUSA
| | - Huiwen Xu
- James P. Wilmot Cancer Center, University of Rochester Medical CenterRochesterNew YorkUSA
- Department of Public Health, University of Rochester School of Medicine and DentistryRochesterNew YorkUSA
| | - Spencer Obrecht
- James P. Wilmot Cancer Center, University of Rochester Medical CenterRochesterNew YorkUSA
| | - Daniel Castillo
- MLIS‐Miner Library, University of Rochester School of Medicine and DentistryRochesterNew YorkUSA
| | - Manvi Sharma
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, UniversityMississippiUSA
| | - Holly M. Holmes
- The University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Ginah Nightingale
- Department of Pharmacy Practice, Thomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Katherine M. Juba
- Department of Pharmacy, University of Rochester Medical CenterRochesterNew YorkUSA
- Department of Pharmacy Practice, Wegmans School of PharmacyRochesterNew YorkUSA
| | - Supriya G. Mohile
- James P. Wilmot Cancer Center, University of Rochester Medical CenterRochesterNew YorkUSA
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16
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Zueger PM, Holmes HM, Calip GS, Qato DM, Pickard AS, Lee TA. Older Medicare Beneficiaries Frequently Continue Medications with Limited Benefit Following Hospice Admission. J Gen Intern Med 2019; 34:2029-2037. [PMID: 31346909 PMCID: PMC6816724 DOI: 10.1007/s11606-019-05152-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 02/06/2019] [Accepted: 05/01/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND The use of medications not relieving symptoms or maximizing quality of life should be minimized following hospice enrollment. OBJECTIVE To evaluate the frequency of and predictive factors for continuation of medications with limited benefit after hospice admission among those admitted for cancer- and non-cancer-related causes. DESIGN Cohort study using the Surveillance, Epidemiology and End Results-Medicare linked database. PATIENTS Medicare Part D-enrolled beneficiaries 66 years and older who were admitted to and died under hospice care between January 1, 2008, and December 31, 2013 (N = 70,035). MAIN MEASURES Patients were followed from hospice enrollment through death for Part D dispensing of limited benefit medications (LBMs) they had used in the 6 months prior to hospice admission, including anti-hyperlipidemics, anti-hypertensives, oral anti-diabetics, anti-platelets, anti-dementia medications, anti-osteoporotic medications, and proton pump inhibitors. The proportion of patients continuing an LBM after hospice admission was evaluated. Adjusted relative risks (RRs) were estimated for factors associated with LBM continuation. KEY RESULTS Overall, 29.8% and 30.5% of patients admitted to hospice for a cancer- and non-cancer-related cause, respectively, continued at least one LBM after hospice admission. Anti-dementia medications were continued most frequently (29.3%) while anti-osteoporotic medications were continued least often (14.1%). Compared to home hospice, LBM continuation was greater in hospice patients residing in skilled nursing (RR 1.25, 95% CI 1.20-1.29), non-skilled nursing (RR 1.29, 95% CI 1.25-1.32), and assisted living facilities (RR 1.28, 95% CI 1.24-1.32). Patients with hospice stays ≥ 180 days were more likely to continue at least one LBM compared to those with stays of 1 week or less (RR 13.11, 95% CI 12.25-14.02). CONCLUSIONS A substantial proportion of Medicare hospice beneficiaries continued to receive LBMs following hospice enrollment. Providers should evaluate the necessity of continuing non-palliative medications at the end of life through a careful, patient-centric consideration of their potential risks and benefits.
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Affiliation(s)
- Patrick M Zueger
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Holly M Holmes
- Division of Geriatric and Palliative Medicine, UTHealth McGovern Medical School, Houston, TX, USA
| | - Gregory S Calip
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
- Division of Public Health Sciences, Epidemiology Program, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Dima M Qato
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
| | - A Simon Pickard
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA.
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA.
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17
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Morin L, Barclay S, Wastesson JW, Johnell K, Todd A. Reply to Deprescription during last year of life in patients with pancreatic cancer: Optimization or nihilism? Cancer 2019; 125:3471-3472. [DOI: 10.1002/cncr.32390] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Lucas Morin
- Aging Research Center Karolinska Institute Stockholm Sweden
| | - Stephen Barclay
- Department of Public Health and Primary Care University of Cambridge Cambridge United Kingdom
| | | | | | - Adam Todd
- Faculty of Medical Sciences, School of Pharmacy Newcastle University Newcastle United Kingdom
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18
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Seidu S, Kunutsor SK, Topsever P, Hambling CE, Cos FX, Khunti K. Deintensification in older patients with type 2 diabetes: A systematic review of approaches, rates and outcomes. Diabetes Obes Metab 2019; 21:1668-1679. [PMID: 30938038 DOI: 10.1111/dom.13724] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/19/2019] [Accepted: 03/27/2019] [Indexed: 02/06/2023]
Abstract
AIM To assess deintensification approaches and rates and evaluate the harm and benefits of deintensification with antidiabetic medication and other therapies among older people (≥ 65 years) with type 2 diabetes with or without cardiometabolic conditions. METHODS We identified relevant studies in a literature search of MEDLINE, Embase, Web of Science and Cochrane databases to 30 October 2018. Data were extracted on baseline characteristics, details on deintensification and outcomes, and was synthesized using a narrative approach. RESULTS Ten studies (observational cohorts and interventional studies) with data on 26 558 patients with comorbidities were eligible. Deintensification approaches included complete withdrawal, discontinuation, reducing dosage, conversion, or substitution of at least one medication, but the majority of studies were based on complete withdrawal or discontinuation of antihyperglycaemic medication. Rates of deintensification approaches ranged from 13.4%-75%. The majority of studies reported no deterioration in HbA1c levels, hypoglycaemic episodes, falls or hospitalizations on deintensification. On adverse events and mortality, no significant differences were observed among the comparison groups in the majority of studies. CONCLUSION Available but limited evidence suggests that the benefits of deintensification outweigh the harm in older people with type 2 diabetes with or without comorbidities. Given the heterogeneity of patients with diabetes, further research is warranted on which deintensification approaches are appropriate and beneficial for each specific patient population.
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Affiliation(s)
- Samuel Seidu
- Diabetes Research Centre, Diabetes & Metabolic Medicine, University of Leicester, Leicester, UK
| | - Setor K Kunutsor
- Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, NHS Foundation, National Institute for Health Research Bristol, Biomedical Research Centre, University Hospitals Bristol Trust and University of Bristol, Bristol, UK
| | - Pinar Topsever
- Department of Family Medicine, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Clare E Hambling
- Department of Public Health and Primary Care, School of Clinical Medicine, Cambridge, UK
| | - Francesc X Cos
- Diabetes & Metabolic Medicine, Jordi Gol Institute for Research in Primary Care, The Foundation University Institute for Primary Health, Barcelona, Spain
| | - Kamlesh Khunti
- Diabetes Research Centre, Diabetes & Metabolic Medicine, University of Leicester, Leicester, UK
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Abstract
The use of multiple medications is common in palliative care, putting patients at risk of adverse events and a high tablet burden. Deprescribing is the process of reviewing and stopping potentially inappropriate medications in order to improve quality of life. Barriers to deprescribing exist meaning many patients will take multiple medications despite being in the final months of life. The OncPal deprescribing guideline is a useful tool to support the process for patients with a limited life expectancy. There is evidence for the safety of stopping certain medications, particularly those aimed at primary prevention. A systematic process of reviewing individual medications and their appropriateness is recommended.
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Affiliation(s)
- Jo Thompson
- Royal Surrey County Hospital / St Luke's Cancer Centre, Guildford, UK
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20
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Roux B, Morin L, Papon A, Laroche ML. Prescription and deprescription of medications for older adults receiving palliative care during the last 3 months of life: a single-center retrospective cohort study. Eur Geriatr Med 2019; 10:463-471. [PMID: 34652792 DOI: 10.1007/s41999-019-00175-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/18/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Near the end of life, drugs to ensure comfort and improve quality of life should be prioritized, and unnecessary drugs should be avoided. The aim was to assess the evolution and quality of drug therapy throughout the last 3 months of life of older adults in need of palliative care. METHODS A single-center retrospective cohort study included older adults (≥ 65 years) who died in a teaching hospital between 1 January 2014 and 30 June 2014 and had been identified as patients in need of palliative care in their last 3 months of life. Drugs were collected from electronic medical records and defined as 'unnecessary' or 'essential' based on a review of the literature. RESULTS A total of 149 patients were included [age: 82.1 (SD 8.6) years, women: 46.3%]. The mean number of medications varied from 6.7 (SD 3.3) drugs 90 days before death, to 7.5 (SD 4.1) 7 days before death, to 5.6 (SD 3.6) on the day of death. During the final week of life, one additional prescription of essential drugs was observed for 75.2% of patients and 79.3% of patients had at least one unnecessary drug deprescribed. The most prescribed and deprescribed drug classes were, respectively, analgesics (56.4%) and antithrombotic agents (38.2%) during the last week of life. CONCLUSIONS Near the end of life, medication therapy is adapted to the goals of palliative care. However, this only occurs during the last week of life. Earlier transition to palliative care is necessary to avoid exposure to unnecessary drugs.
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Affiliation(s)
- Barbara Roux
- Department of Pharmacology, Toxicology and Pharmacovigilance, University Hospital of Limoges, 2 avenue Martin Luther King, 87042, Limoges Cedex, France. .,INSERM UMR 1248, University of Limoges, Limoges, France.
| | - Lucas Morin
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Arnaud Papon
- Department of Geriatric Medicine, University Hospital of Limoges, Limoges, France
| | - Marie-Laure Laroche
- Department of Pharmacology, Toxicology and Pharmacovigilance, University Hospital of Limoges, 2 avenue Martin Luther King, 87042, Limoges Cedex, France.,INSERM UMR 1248, University of Limoges, Limoges, France
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21
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Todd A, Jansen J, Colvin J, McLachlan AJ. The deprescribing rainbow: a conceptual framework highlighting the importance of patient context when stopping medication in older people. BMC Geriatr 2018; 18:295. [PMID: 30497404 PMCID: PMC6267905 DOI: 10.1186/s12877-018-0978-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 11/13/2018] [Indexed: 02/06/2023] Open
Abstract
The area of "deprescribing" has rapidly expanded in recent years as a positive intervention to reduce inappropriate polypharmacy and improve health outcomes for (older) people with multimorbidity. While our understanding of deprescribing as a process has greatly improved and existing approaches all have patient-centered elements, there is still limited literature exploring the importance of the individual patient context in deprescribing decision-making. This is clearly an important consideration to ensure that any deprescribing approach is ethical, respectful, and successful. To address this gap in the literature, we have developed a conceptual framework in the form of a rainbow - with five different deprescribing determinants - and place the person at the center of the deprescribing process. This framework is informed by literature on patient-centered care for older people and people with multimorbidity. We illustrate the potential application of this framework to a complex patient case to highlight the importance of the different clinical, psychological, social, financial and physical deprescribing determinants, and how this approach could be adopted by those working in clinical practice.
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Affiliation(s)
- Adam Todd
- School of Pharmacy, Faculty of Applied Sciences, Newcastle University, NE17RU, Newcastle upon Tyne, UK
| | - Jesse Jansen
- Wiser Healthcare, Sydney School of Public Health, The University of Sydney, Rm 226a, Edward Ford Building A27, Sydney, 2006, NSW, Australia. .,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Rm 226a, Edward Ford Building A27, Sydney, 2006, NSW, Australia.
| | - Jim Colvin
- Health Consumers New South Wales, Sydney, Australia
| | - Andrew J McLachlan
- The University of Sydney, Sydney Pharmacy School and Centre for Education and Research on Ageing, The University of Sydney, Sydney, 2006, NSW, Australia
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22
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Mantelli S, Jungo KT, Rozsnyai Z, Reeve E, Luymes CH, Poortvliet RKE, Chiolero A, Rodondi N, Gussekloo J, Streit S. How general practitioners would deprescribe in frail oldest-old with polypharmacy - the LESS study. BMC FAMILY PRACTICE 2018; 19:169. [PMID: 30314468 PMCID: PMC6186124 DOI: 10.1186/s12875-018-0856-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 10/03/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Many oldest-old (> 80-years) with multimorbidity and polypharmacy are at high risk of inappropriate use of medication, but we know little about whether and how GPs would deprescribe, especially in the frail oldest-old. We aimed to determine whether, how, and why Swiss GPs deprescribe for this population. METHODS GPs took an online survey that presented case-vignettes of a frail oldest-old patient with and without history of cardiovascular disease (CVD) and asked if they would deprescribe any of seven medications. We calculated percentages of GPs willing to deprescribe at least one medication in the case with CVD and compared these with the case without CVD using paired t-tests. We also included open-ended questions to capture reasons for deprescribing and asked which factors could influence their decision to deprescribe by asking for their agreement on a 5-point-Likert-scale. RESULTS Of the 282 GPs we invited, 157 (56%) responded: 73% were men; mean age was 56. In the case-vignette without CVD, 98% of GPs deprescribed at least one medication (usually cardiovascular preventive medications) stating it had no indication nor benefit. They would lower the dose or prescribe pain medication as needed to reduce side effects. Their response was much the same when the patient had a history of CVD. GPs reported they were influenced by 'risk' and 'benefit' of medications, 'quality of life', and 'life expectancy', and prioritized the patient's wishes and priorities when deprescribing. CONCLUSION Swiss GPs were willing to deprescribe cardiovascular preventive medication when it lacked indication but tended to retain pain medication. Developing tools for GPs to assist them in balancing the risks and benefits of medication in the context of patient values may improve deprescribing activities in practice.
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Affiliation(s)
- Sophie Mantelli
- Institute of Primary Health Care Bern(BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
| | - Katharina Tabea Jungo
- Institute of Primary Health Care Bern(BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
| | - Zsofia Rozsnyai
- Institute of Primary Health Care Bern(BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
| | - Emily Reeve
- NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Geriatric Medicine Research, Dalhousie University and Nova Scotia Health Authority, Halifax, NS Canada
- College of Pharmacy, Dalhousie University, Halifax, NS Canada
| | - Clare H. Luymes
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Arnaud Chiolero
- Institute of Primary Health Care Bern(BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Nicolas Rodondi
- Institute of Primary Health Care Bern(BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, section Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Sven Streit
- Institute of Primary Health Care Bern(BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland
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23
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Page A, Clifford R, Potter K, Etherton-Beer C. A concept analysis of deprescribing medications in older people. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2018. [DOI: 10.1002/jppr.1361] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Amy Page
- School of Medicine and Pharmacology; University of Western Australia; Crawley Australia
| | - Rhonda Clifford
- School of Medicine and Pharmacology; University of Western Australia; Crawley Australia
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24
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Zueger PM, Holmes HM, Calip GS, Qato DM, Pickard AS, Lee TA. Medicare Part D Use of Older Medicare Beneficiaries Admitted to Hospice. J Am Geriatr Soc 2018; 66:937-944. [DOI: 10.1111/jgs.15328] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Patrick M. Zueger
- Department of Pharmacy Systems, Outcomes and PolicyUniversity of Illinois at ChicagoChicago Illinois
| | - Holly M. Holmes
- Division of Geriatric and Palliative MedicineUTHealth McGovern Medical SchoolHouston Texas
| | - Gregory S. Calip
- Department of Pharmacy Systems, Outcomes and PolicyUniversity of Illinois at ChicagoChicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic ResearchUniversity of Illinois at ChicagoChicago Illinois
- Division of Public Health Sciences, Epidemiology ProgramFred Hutchinson Cancer Research CenterSeattle Washington
| | - Dima M. Qato
- Department of Pharmacy Systems, Outcomes and PolicyUniversity of Illinois at ChicagoChicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic ResearchUniversity of Illinois at ChicagoChicago Illinois
| | - A. Simon Pickard
- Department of Pharmacy Systems, Outcomes and PolicyUniversity of Illinois at ChicagoChicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic ResearchUniversity of Illinois at ChicagoChicago Illinois
| | - Todd A. Lee
- Department of Pharmacy Systems, Outcomes and PolicyUniversity of Illinois at ChicagoChicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic ResearchUniversity of Illinois at ChicagoChicago Illinois
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McCarthy C, Clyne B, Corrigan D, Boland F, Wallace E, Moriarty F, Fahey T, Hughes C, Gillespie P, Smith SM. Supporting prescribing in older people with multimorbidity and significant polypharmacy in primary care (SPPiRE): a cluster randomised controlled trial protocol and pilot. Implement Sci 2017; 12:99. [PMID: 28764753 PMCID: PMC5539883 DOI: 10.1186/s13012-017-0629-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 07/13/2017] [Indexed: 12/11/2022] Open
Abstract
Background Multimorbidity, defined as the presence of at least two chronic conditions, becomes increasingly common in older people and is associated with poorer health outcomes and significant polypharmacy. The National Institute for Clinical Excellence (NICE) recently published a multimorbidity guideline that advises providing an individualised medication review for all people prescribed 15 or more repeat medicines. This study incorporates this guideline and aims to assess the effectiveness of a complex intervention designed to support general practitioners (GPs) to reduce potentially inappropriate prescribing and consider deprescribing in older people with multimorbidity and significant polypharmacy in Irish primary care. Methods This study is a cluster randomised controlled trial, involving 30 general practices and 450 patients throughout Ireland. Practices will be eligible to participate if they have at least 300 patients aged 65 years and over on their patient panel and if they use either one of the two predominant practice management software systems in use in Ireland. Using a software patient finder tool, practices will identify and recruit patients aged 65 years and over, who are prescribed at least 15 repeat medicines. Once baseline data collection is complete, practices will be randomised using minimisation by an independent third party to either intervention or control. Given the nature of the intervention, it is not possible to blind participants or study personnel. GPs in intervention practices will receive login details to a website where they will access training videos and a template for conducting an individualised structured medication review, which they will undertake with each of their included patients. Control practices will deliver usual care over the 6-month study period. Primary outcome measures pertain to the individual patient level and are the proportion of patients with any PIP and the number of repeat medicines. Discussion Disease-specific approaches in multimorbidity may be inappropriate and result in fragmented and poorly co-ordinated care. This pragmatic study is evaluating a complex intervention that is relevant across multiple conditions and addresses potential concerns around medicines safety in this vulnerable group of patients. The potential for system-wide implementation will be explored with a parallel mixed methods process evaluation. Trial registration ISRCTN: 12752680, Registered 20 October 2016.
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Affiliation(s)
- Caroline McCarthy
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Beaux Lane House, Lower Mercer Street, Dublin 2, Ireland.
| | - Barbara Clyne
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Beaux Lane House, Lower Mercer Street, Dublin 2, Ireland
| | - Derek Corrigan
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Beaux Lane House, Lower Mercer Street, Dublin 2, Ireland
| | - Fiona Boland
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Beaux Lane House, Lower Mercer Street, Dublin 2, Ireland
| | - Emma Wallace
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Beaux Lane House, Lower Mercer Street, Dublin 2, Ireland
| | - Frank Moriarty
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Beaux Lane House, Lower Mercer Street, Dublin 2, Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Beaux Lane House, Lower Mercer Street, Dublin 2, Ireland
| | - Carmel Hughes
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
| | - Paddy Gillespie
- School of Business & Economics, National University of Ireland Galway, Galway, Co. Galway, Ireland
| | - Susan M Smith
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Beaux Lane House, Lower Mercer Street, Dublin 2, Ireland
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Poudel A, Yates P, Rowett D, Nissen LM. Use of Preventive Medication in Patients With Limited Life Expectancy: A Systematic Review. J Pain Symptom Manage 2017; 53:1097-1110.e1. [PMID: 28192226 DOI: 10.1016/j.jpainsymman.2016.12.350] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 12/05/2016] [Accepted: 12/29/2016] [Indexed: 01/20/2023]
Abstract
CONTEXT Optimal prescribing in patients with limited life expectancy (LLE) remains unclear. OBJECTIVES This study systematically reviews the published literature regarding the use of preventive medication in patients with reduced life expectancy. METHODS A systematic literature search was conducted using three databases (MEDLINE, EMBASE, and CINAHL). Articles published in English from January 1995 to December 2015 were retrieved for analysis to identify peer-reviewed, observational studies assessing use of preventive medications in patients with LLE. Inclusion criteria were: patients with a LLE (less than or equal to two years); prescribed/used preventive medications. RESULTS Of the 15 studies meeting our eligibility criteria, six were from inpatient hospital settings, five in palliative care, three in nursing homes, and one in community settings. The most common life-limiting illnesses described in the studies were cancer (n = 6), cardiovascular diseases (n = 4), dementia and cognitive impairment (n = 2), and other life-limiting illnesses (n = 3). Lipid-lowering medications, especially the statins were frequently prescribed preventive medication followed by antiplatelets, angiotensin converting enzyme inhibitors and angiotensin receptor blockers, anti-osteoporosis medications, and calcium channel blockers. Only four studies reported the instances of medication withdrawal. CONCLUSION Patients continue to receive medications that are not prescribed as symptomatic treatment despite having a LLE. Very few rigorous studies have been conducted on minimizing preventive medications in patients with LLE, and expert opinion varies on medication optimization at the end of life. A consensus guideline that addresses this gap is of paramount importance.
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Affiliation(s)
- Arjun Poudel
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia.
| | - Patsy Yates
- School of Nursing, Queensland University of Technology, Brisbane, Australia
| | - Debra Rowett
- Repatriation General Hospital, Adelaide, Australia
| | - Lisa M Nissen
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
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Morin L, Vetrano DL, Grande G, Fratiglioni L, Fastbom J, Johnell K. Use of Medications of Questionable Benefit During the Last Year of Life of Older Adults With Dementia. J Am Med Dir Assoc 2017; 18:551.e1-551.e7. [PMID: 28431913 DOI: 10.1016/j.jamda.2017.02.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 02/28/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To investigate the prevalence and factors associated with the use of medications of questionable benefit throughout the final year of life of older adults who died with dementia. DESIGN Register-based, longitudinal cohort study. SETTING Entire Sweden. PARTICIPANTS All older adults (≥75 years) who died with dementia between 2007 and 2013 (n = 120,067). MEASUREMENTS Exposure to medications of questionable benefit was calculated for each of the last 12 months before death, based on longitudinal data from the Swedish Prescribed Drug Register. RESULTS The proportion of older adults with dementia who received at least 1 medication of questionable benefit decreased from 38.6% 12 months before death to 34.7% during the final month before death (P < .001 for trend). Among older adults with dementia who used at least 1 medication of questionable benefit 12 months before death, 74.8% remained exposed until their last month of life. Living in an institution was independently associated with a 15% reduction of the likelihood to receive ≥1 medication of questionable benefit during the last month before death (odds ratio 0.85, 95% confidence interval 0.88-0.83). Antidementia drugs accounted for one-fifth of the total number of medications of questionable benefit. Lipid-lowering agents were used by 8.3% of individuals during their final month of life (10.2% of community-dwellers and 6.6% of institutionalized people, P < .001). CONCLUSION Clinicians caring for older adults with advanced dementia should be provided with reliable tools to help them reduce the burden of medications of questionable benefit near the end of life.
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Affiliation(s)
- Lucas Morin
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden.
| | - Davide L Vetrano
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden; Department of Geriatrics, Catholic University of Rome, Rome, Italy
| | - Giulia Grande
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden; Center for Research and Treatment on Cognitive Dysfunctions, Biomedical and Clinical Sciences Department, "Luigi Sacco" Hospital, University of Milan, Milan, Italy
| | - Laura Fratiglioni
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Johan Fastbom
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Kristina Johnell
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
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28
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Abstract
Polypharmacy and the use of inappropriate medications has become an increasing problem globally. Deprescribing has gained attention as a means to rationalize medication use. Deprescribing interventions have been shown to be generally feasible and safe; in the few studies in which patient preferences are assessed, such interventions also seem to be acceptable to patients. Qualitative studies suggest that patients are interested in reducing medications, may need education about their medications to facilitate deprescribing, and highly value communication with their providers around deprescribing. This article focuses on patient preferences for deprescribing and highlights practical recommendations to overcome barriers to deprescribing.
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Affiliation(s)
- Holly M Holmes
- Division of Geriatric and Palliative Medicine, UTHealth McGovern Medical School, 6431 Fannin Street, MSB 5.116, Houston, TX 77030, USA.
| | - Adam Todd
- Division of Pharmacy, School of Medicine, Pharmacy and Health, Durham University, C138 Holliday Building, Queen's Campus, Stockton-on-Tees TS176BH, UK
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29
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Hall RK. Reply to: Comment on: "Incorporating Geriatric Assessment into a Nephrology Clinic: Preliminary Data from Two Models of Care". J Am Geriatr Soc 2017; 65:880. [PMID: 28102894 DOI: 10.1111/jgs.14587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Rasheeda K Hall
- Geriatric Research, Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina
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30
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Hoffmann F, Boeschen D, Dörks M, Herget-Rosenthal S, Petersen J, Schmiemann G. Renal Insufficiency and Medication in Nursing Home Residents. A Cross-Sectional Study (IMREN). DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 113:92-8. [PMID: 26931625 DOI: 10.3238/arztebl.2016.0092] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Revised: 09/30/2015] [Accepted: 09/30/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Nursing home residents often suffer from a multiplicity of medical conditions and take many different drugs. Many drugs are eliminated via the kidneys and thus require dose adjustment in patients with renal insufficiency. This is the first study to address the prevalence of renal insufficiency among nursing home residents in Germany, and the extent to which such persons take drugs that are contraindicated or incorrectly dosed because of renal insufficiency. METHODS We carried out a cross-sectional study in nursing homes in the German regions of Bremen and Lower Saxony. Data were collected by nursing staff and given to us anonymously. Whenever the nursing home data did not include a current creatinine value, the patient's general practitioner was asked to supply this value. The estimated creatinine clearance (eCCr) was calculated with the Cockcroft-Gault formula. RESULTS 852 residents of 21 nursing homes were included in the study; eCCr values were obtainable for 685 (80.4%) of them (average age, 83.3 years; 75.2% female). 48.2% of these patients (95% confidence interval [CI] 41.8-54.5) had moderate renal insufficiency (eCCr 59-30 mL/min), and 15.5% (95% CI 12.4-18.6) had severe renal insufficiency (eCCr <30 mL/min). 19.7% were regularly taking at least one medication that was contraindicated or incorrectly dosed in the light of renal insufficiency. Predictors for such inappropriate drug use were advanced age, female sex, arterial hypertension, and polypharmacy. The drugs that were most often inappropriately used were metformin, ramipril, and potassium chloride. CONCLUSION Nursing home residents often suffer from renal insufficiency and should therefore have their creatinine levels measured regularly. A knowledge of the creatinine level is a prerequisite for the proper adjustment of drug doses (if necessary). A practical and compact summary of dose-adjustment recommendations for patients with renal insufficiency would be desirable but is not yet available.
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Affiliation(s)
- Falk Hoffmann
- Department of Health Services Research, Medicine and Health Sciences, Carl von Ossietzky Universität Oldenburg, Medical Clinic, Rotes-Kreuz-Krankenhaus, Bremen, Department of Health, Nursing and Age Studies, SOCIUM - Research Center on Inequality and Social Policy, University of Bremen, Department for Health Services Research, Institute for Public Health and Nursing Research, University of Bremen and Health Sciences Bremen
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An Ecological Approach to Reducing Potentially Inappropriate Medication Use: Canadian Deprescribing Network. Can J Aging 2017; 36:97-107. [PMID: 28091333 DOI: 10.1017/s0714980816000702] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Polypharmacy is growing in Canada, along with adverse drug events and drug-related costs. Part of the solution may be deprescribing, the planned and supervised process of dose reduction or stopping of medications that may be causing harm or are no longer providing benefit. Deprescribing can be a complex process, involving the intersection of patients, health care providers, and organizational and policy factors serving as enablers or barriers. This article describes the justification, theoretical foundation, and process for developing a Canadian Deprescribing Network (CaDeN), a network of individuals, organizations, and decision-makers committed to promoting the appropriate use of medications and non-pharmacological approaches to care, especially among older people in Canada. CaDeN will deploy multiple levels of action across multiple stakeholder groups simultaneously in an ecological approach to health system change. CaDeN proposes a unique model that might be applied both in national settings and for different transformational challenges in health care.
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Duncan P, Duerden M, Payne RA. Deprescribing: a primary care perspective. Eur J Hosp Pharm 2017; 24:37-42. [PMID: 31156896 PMCID: PMC6451545 DOI: 10.1136/ejhpharm-2016-000967] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 09/02/2016] [Accepted: 09/08/2016] [Indexed: 12/20/2022] Open
Abstract
Polypharmacy is an increasing and global issue affecting primary care. Although sometimes appropriate, polypharmacy can also be problematic, leading to a range of adverse consequences. Deprescribing is the process of supervised withdrawal of an inappropriate medication and has the potential to reduce some of the problems associated with polypharmacy. It is a complex and sensitive process. We examine the issue of deprescribing from the perspective of primary care. Key steps in the deprescribing process are a review of medications and corresponding indications, consideration of harms, assessment of eligibility for discontinuation, prioritisation of medications and implementation of a stopping plan with appropriate monitoring. Patient involvement is a key feature of this process. Deprescribing should be considered in the context of end-of-life care and medication safety, but approaches are also required to identify other situations where deprescribing is appropriate. General practitioners are well positioned to facilitate deprescribing, usually through formal medication review, with decisions informed by a range of other healthcare professionals. Guidelines are available that help guide these processes. A range of studies have explored attitudes towards deprescribing; patients are generally supportive of the concept, although clinician views are varied. The successful implementation of deprescribing strategies still requires important patient and clinician barriers to be overcome, and clinical trial evidence of effectiveness and safety is essential.
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Affiliation(s)
- Polly Duncan
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Martin Duerden
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Rupert A Payne
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
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33
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Abstract
Avoiding inappropriate polypharmacy has become increasingly recognised as a safety imperative for older patient care. Deprescribing is an active process of reviewing all medications being used by individual patients that prompts clinicians to consider which medications have unfavourable risk-benefit trade-offs in the context of illness severity, advanced age, multi-morbidity, physical and emotional capacity, life expectancy, care goals and personal preferences. Structured guides to deprescribing include algorithms, flow charts or tables which are patient-directed and aim to guide the clinician through sequential steps in deciding which medications should be targeted for discontinuation. In this narrative review, we describe seven structured deprescribing guides whose stated purpose included the reduction of polypharmacy, their use was not restricted to a single drug or drug class and they had undergone some form of efficacy testing. There was considerable heterogeneity in guide design and content, with some guides constituting little more than a set of principles while others entail detailed processes and sub-steps which addressed multiple determinants of drug appropriateness. Evidence of effectiveness for each guide was limited in that none have been evaluated in randomised controlled trials, that pilot or feasibility studies have involved relatively small patient samples, that intra-rater and inter-rater reliabilities have not been determined and that most have been studied in hospital settings. Which is most useful to clinicians is unknown in the absence of head-to-head comparisons. While most guides have face validity, more research is needed for determining effectiveness and ease of use in routine clinical practice, especially in primary care settings.
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Affiliation(s)
- Ian Scott
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.,Centre of Research Excellence in Quality & Safety in Integrated Primary-Secondary Care, School of Medicine, The University of Queensland, Brisbane, Australia
| | - Kristen Anderson
- Centre of Research Excellence in Quality & Safety in Integrated Primary-Secondary Care, School of Medicine, The University of Queensland, Brisbane, Australia
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Baqir W, Hughes J, Jones T, Barrett S, Desai N, Copeland R, Campbell D, Laverty A. Impact of medication review, within a shared decision-making framework, on deprescribing in people living in care homes. Eur J Hosp Pharm 2016; 24:30-33. [PMID: 31156894 DOI: 10.1136/ejhpharm-2016-000900] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objectives The key objectives of this study were to quantify extent of prescribing, reasons for deprescribing, common therapeutic groups of medicines deprescribed and adverse events. Methods A retrospective analysis was carried out on a quality improvement project where 422 care home residents in 20 care homes received a medicines optimisation review with a pharmacist and other members of the healthcare team (general medical practitioner, care home nurse). Data on number, type and cost of medicines were collected. Statistical analysis was performed to test for differences between pharmacist-only review and the pharmacist plus general practitioner (GP), and to identify any correlation between the original number of medicines and the number of medicines stopped. Results Of the 422 patients reviewed, 298 (70.6%) had at least one medicine stopped with 704 medicines being stopped. This represented 19.5% of the medicines originally prescribed (3602 medicines). There was no statistically significant difference between pharmacist only and pharmacist plus GP in terms of stopping medicines. The main groups of medicines stopped were laxatives, skin products and bone protection. There was weak correlation between the original number of medicines prescribed and the number stopped. Conclusions This study has shown that medicines optimisation reviews can lead to a reduction in polypharmacy for care home residents through a deprescribing process. Patients' medicine regimens were simplified and optimised while making financial significant savings for the National Health Service.
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Affiliation(s)
- Wasim Baqir
- Department of Pharmacy, Northumbria Healthcare NHS Foundation Trust, North Shields, UK.,Department of Pharmacy, University of Bradford, School of Pharmacy, Bradford, Bradford, UK
| | - Julian Hughes
- Department of Pharmacy, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Tania Jones
- Department of Pharmacy Health and Well-being, University of Sunderland, Sunderland, UK
| | - Steven Barrett
- Department of Pharmacy, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Nisha Desai
- Department of Pharmacy, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Richard Copeland
- Department of Pharmacy, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - David Campbell
- Department of Pharmacy, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Annie Laverty
- Department of Pharmacy, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
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35
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Dewhurst F, Baker L, Andrew I, Todd A. Blood pressure evaluation and review of antihypertensive medication in patients with life limiting illness. Int J Clin Pharm 2016; 38:1044-7. [PMID: 27343121 DOI: 10.1007/s11096-016-0327-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 05/26/2016] [Indexed: 10/21/2022]
Abstract
Background Patients with life limiting illness commonly have multiple co-morbidities that require the use of complex, costly pharmacotherapy. One such example is using medications to treat hypertension in life limiting illness. Objective To: (1) assess the prevalence of previously documented hypertension and associated blood pressure in a cohort of patients with life limiting illness; and, (2) assess the appropriateness of antihypertensive medication in this patient group. Method This was a single centre study at a tertiary, specialist palliative care centre in Northern England. Electronic medical notes were reviewed and data were extracted. Antihypertensive medication was assessed for appropriateness using a conceptual framework. Results A total number of 54 patients were included in the study. Twenty six (48.1 %) had previously documented hypertension: the mean blood pressure of which was 122/65 mmHg (SD 17.0/10.5), while for the normotensive patients it was 122/73 mmHg (SD 21.0/11.6). Of the 26 patients using antihypertensive medication, 25 were assessed as using the medication inappropriately. Conclusions The blood pressure for patients with previously documented hypertension who access specialist palliative care day services is commonly below the NICE target threshold. The majority of these patients are prescribed antihypertensive medications inappropriately.
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Affiliation(s)
- Felicity Dewhurst
- Centre for Specialist Palliative Care, St Benedict's Hospice, Sunderland, UK
| | - Lisa Baker
- Centre for Specialist Palliative Care, St Benedict's Hospice, Sunderland, UK
| | - Inga Andrew
- Centre for Specialist Palliative Care, St Benedict's Hospice, Sunderland, UK
| | - Adam Todd
- Division of Pharmacy, School of Medicine, Pharmacy and Health, Durham University, Stockton-on-Tees, UK.
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36
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Andreassen LM, Kjome RLS, Sølvik UØ, Houghton J, Desborough JA. The potential for deprescribing in care home residents with Type 2 diabetes. Int J Clin Pharm 2016; 38:977-84. [PMID: 27241345 PMCID: PMC4929175 DOI: 10.1007/s11096-016-0323-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 05/13/2016] [Indexed: 01/21/2023]
Abstract
Background Type 2 diabetes is a common diagnosis in care home residents that is associated with potentially inappropriate prescribing and thus risk of additional suffering. Previous studies found that diabetes medicines can be safely withdrawn in care home residents, encouraging further investigation of the potential for deprescribing amongst these patients. Objectives Describe comorbidities and medicine use in care home residents with Type 2 diabetes; identify number of potentially inappropriate medicines prescribed for these residents using a medicines optimisation tool; assess clinical applicability of the tool. Setting Thirty care homes for older people, East Anglia, UK. Method Data on diagnoses and medicines were extracted from medical records of 826 residents. Potentially inappropriate medicines were identified using the tool 'Optimising Safe and Appropriate Medicines Use'. Twenty percent of results were validated by a care home physician. Main outcome measure Number of potentially inappropriate medicines. Results The 106 residents with Type 2 diabetes had more comorbidities and prescriptions than those without. Over 90 % of residents with Type 2 diabetes had at least one potentially inappropriate medication. The most common was absence of valid indication. The physician unreservedly endorsed 39 % of the suggested deprescribing, and would consider discontinuing all but one of the remaining medicines following access to additional information. Conclusion UK care home residents with Type 2 diabetes had an increased burden of comorbidities and prescriptions. The majority of these patients were prescribed potentially inappropriate medicines. Validation by a care home physician supported the clinical applicability of the medicines optimisation tool.
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Affiliation(s)
- Lillan Mo Andreassen
- Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, PO Box 7804, 5020, Bergen, Norway.
| | - Reidun Lisbet Skeide Kjome
- Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, PO Box 7804, 5020, Bergen, Norway
| | - Una Ørvim Sølvik
- Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, PO Box 7804, 5020, Bergen, Norway
| | - Julie Houghton
- School of Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
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37
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Affiliation(s)
- Marc Riachi
- Marc Riachi is a clinical editor at the Canadian Pharmacists Association and works as a community pharmacist at Centrepointe Pharmacy in Ottawa, Ontario
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38
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Todd A, Holmes H, Pearson S, Hughes C, Andrew I, Baker L, Husband A. 'I don't think I'd be frightened if the statins went': a phenomenological qualitative study exploring medicines use in palliative care patients, carers and healthcare professionals. BMC Palliat Care 2016; 15:13. [PMID: 26822776 PMCID: PMC4731932 DOI: 10.1186/s12904-016-0086-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 01/25/2016] [Indexed: 11/10/2022] Open
Abstract
Background There is a growing body of evidence suggesting patients with life-limiting illness use medicines inappropriately and unnecessarily. In this context, the perspective of patients, their carers and the healthcare professionals responsible for prescribing and monitoring their medication is important for developing deprescribing strategies. The aim of this study was to explore the lived experience of patients, carers and healthcare professionals in the context of medication use in life-limiting illness. Methods In-depth interviews, using a phenomenological approach: methods of transcendental phenomenology were used for the patient and carer interviews, while hermeneutic phenomenology was used for the healthcare professional interviews. Results The study highlighted that medication formed a significant part of a patient’s day-to-day routine; this was also apparent for their carers who took on an active role-as a gatekeeper of care-in managing medication. Patients described the experience of a point in which, in their disease journey, they placed less importance on taking certain medications; healthcare professionals also recognize this and refer it as a ‘transition’. This point appeared to occur when the patient became accepting of their illness and associated life expectancy. There was also willingness by patients, carers and healthcare professionals to review and alter the medication used by patients in the context of life-limiting illness. Conclusions There is a need to develop deprescribing strategies for patients with life-limiting illness. Such strategies should seek to establish patient expectations, consider the timing of the discussion about ceasing treatment and encourage the involvement of other stakeholders in the decision-making progress.
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Affiliation(s)
- Adam Todd
- Division of Pharmacy, School of Medicine, Pharmacy and Health, Durham University, Queen's Campus, University Boulevard, Thornaby, Stockton-on-Tees, TS17 6BH, UK.
| | - Holly Holmes
- Division of Geriatric and Palliative Medicine, The University of Texas Health Science Center, Houston, TX, USA.
| | - Sallie Pearson
- Faculty of Pharmacy and School of Public Health, The University of Sydney, Sydney, Australia.
| | - Carmel Hughes
- School of Pharmacy, Queen's University, Belfast, UK.
| | - Inga Andrew
- St Benedict's Hospice and Centre for Specialist Palliative Care, Ryhope, Sunderland, UK.
| | - Lisa Baker
- St Benedict's Hospice and Centre for Specialist Palliative Care, Ryhope, Sunderland, UK.
| | - Andy Husband
- Division of Pharmacy, School of Medicine, Pharmacy and Health, Durham University, Queen's Campus, University Boulevard, Thornaby, Stockton-on-Tees, TS17 6BH, UK.
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