The Ethics of Deprescribing in Older Adults

Deprescribing in Older Adults: Attitudes, Awareness, Training, and Clinical Practice Among Portuguese Physicians

INTRODUCTION

The importance of deprescribing in clinical practice is growing, particularly in aging populations with polypharmacy scenarios, making it a crucial matter in Portugal, one of Europe's most aged nations. The aim of this study was to investigate deprescribing awareness, training, attitudes, and practices among Portuguese physicians to inform future healthcare strategies.

METHODS

A cross-sectional study using an anonymous online questionnaire was disseminated through the Portuguese Medical Association. It gathered sociodemographic and professional data, and insights into deprescribing awareness, attitudes, training, and practices. Descriptive statistics were summarized as frequencies, percentages, medians, and interquartile ranges. For inferential analysis, the Chi-square test and Fisher's exact test were used to evaluate categorical variables, and the Mann-Whitney U test was used for continuous variables. The significance level was set at p < 0.05.

RESULTS

A total of 425 valid questionnaires were included. The participants were mostly women (61.6%), with a median age of 45 (IQR 34 - 42). General practice/family medicine (34.1%) and internal medicine (16.2%) were the most common medical specialties. While 81.2% of the respondents were familiar with the term 'deprescribing', 55.4% reported no training. A vast majority (91.9%) reported practicing deprescribing, but a smaller fraction employed specific methodologies to deprescribe (39.8%) and criteria for identifying potentially inappropriate medications (38.7%). Training in deprescribing was significantly associated with higher deprescribing awareness (p < 0.001), the use of specific deprescribing methods (p < 0.001), the use of criteria to identify potentially inappropriate medications (p < 0.001) and having certification in geriatrics by the Portuguese Medical Association (p = 0.006). Family physicians showed higher familiarity with and training in deprescribing than hospital-based specialists (p < 0.001). Deprescribing methodologies were adopted more often by family physicians than by hospital-based specialists (p = 0.004).

CONCLUSION

This study highlights widespread deprescribing awareness among Portuguese physicians, while simultaneously uncovering considerable gaps in training and inconsistencies in its application. These findings highlight the pressing need for targeted educational initiatives that could contribute to medication optimization for older adults in the national healthcare system. Furthermore, these findings emphasize the importance of policy development and medical education in promoting safe deprescribing.

Deprescribing in older adults with polypharmacy

Polypharmacy is common in older adults and is associated with adverse drug events, cognitive and functional impairment, increased healthcare costs, and increased risk of frailty, falls, hospitalizations, and mortality. Many barriers exist to deprescribing, but increased efforts have been made to develop and implement deprescribing interventions that overcome them. This narrative review describes intervention components and summarizes findings from published randomized controlled trials that have tested deprescribing interventions in older adults with polypharmacy, as well as reports on ongoing trials, guidelines, and resources that can be used to facilitate deprescribing. Most interventions were medication reviews in primary care settings, and many contained components such as shared decision making and/or a focus on patient care priorities, training for healthcare professionals, patient facing education materials, and involvement of family members, representing great heterogeneity in interventions addressing polypharmacy in older adults. Just over half of study interventions were found to perform better than usual care in at least one of their primary outcomes, and most study interventions were assessed over 12 months or less.

Validated medication deprescribing instruments for patients with palliative care needs palliative care: A systematic review

OBJECTIVES

Patients with life-limiting illnesses are prone to unnecessary polypharmacy. Deprescribing tools may contribute to minimizing negative outcomes. Thus, the aims of the study were to identify validated instruments for deprescribing inappropriate medications for patients with palliative care needs and to assess the impact on clinical, humanistic, and economic outcomes.

METHODS

A systematic review was conducted in LILACS, PUBMED, EMBASE, COCHRANE, and WEB OF SCIENCE databases (until May 2021). A manual search was performed in the references of enrolled articles. The screening, eligibility, extraction, and bias risk assessment were carried out by two independent researchers. Experimental and observational studies were eligible for inclusion.

RESULTS

Out of the 5,791 studies retrieved, after excluding duplicates (n = 1,050), conducting title/abstract screening (n = 4,741), and full reading (n = 41), only one study met the inclusion criteria. In this included study, a randomized controlled trial was conducted, which showed a high level of bias risk overall. Adults 75 years or older (n = 130) with limited life expectancy and polypharmacy were allocated to two groups [intervention arm (deprescribing); and control arm (usual care)]. Deprescribing was performed with the aid of the STOPPFrail tool. The mean number of inappropriate medications and monthly medication costs were significantly lower in the intervention arm. No statistically significant differences were found in terms of unscheduled hospital presentations, falls, fractures, mortality, and quality of life.

CONCLUSIONS

Despite the availability of several instruments to support deprescribing in patients with palliative care needs, only one of them has undergone validation and robust assessment for effectiveness in clinical practice. The STOPPFrail tool appears to reduce the number of inappropriate medications for older people with limited life expectancy (and probably palliative care needs) and decrease the monthly costs of pharmacotherapy. Nevertheless, the impact on patient safety and humanistic outcomes remain unclear.

Validated medication deprescribing instruments for patients with palliative care needs: a systematic review

OBJECTIVES

Patients with life-limiting illnesses are prone to unnecessary polypharmacy. Deprescribing tools may contribute to minimizing negative outcomes. Thus, the aims of the study were to identify validated instruments for deprescribing inappropriate medications for patients with palliative care needs and to assess the impact on clinical, humanistic, and economic outcomes.

METHODS

A systematic review was conducted in LILACS, PUBMED, EMBASE, COCHRANE, and WEB OF SCIENCE databases (until May 2021). A manual search was performed in the references of enrolled articles. The screening, eligibility, extraction, and bias risk assessment were carried out by 2 independent researchers. Experimental and observational studies were eligible for inclusion.

RESULTS

Out of the 5791 studies retrieved, after excluding duplicates (n = 1050), conducting title/abstract screening (n = 4741), and full reading (n = 41), only 1 study met the inclusion criteria. In this included study, a randomized controlled trial was conducted, which showed a high level of bias risk overall. Adults 75 years or older (n = 130) with limited life expectancy and polypharmacy were allocated to 2 groups [intervention arm (deprescribing); and control arm (usual care)]. Deprescribing was performed with the aid of the STOPPFrail tool. The mean number of inappropriate medications and monthly medication costs were significantly lower in the intervention arm. No statistically significant differences were found in terms of unscheduled hospital presentations, falls, fractures, mortality, and quality of life.

CONCLUSIONS

Despite the availability of several instruments to support deprescribing in patients with palliative care needs, only 1 of them has undergone validation and robust assessment for effectiveness in clinical practice. The STOPPFrail tool appears to reduce the number of inappropriate medications for older people with limited life expectancy (and probably palliative care needs) and decrease the monthly costs of pharmacotherapy. Nevertheless, the impact on patient safety and humanistic outcomes remain unclear.

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

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

Evaluating the Safety of an Educational Deprescribing Intervention: Lessons from the Optimize Trial

BACKGROUND

Patients, family members, and clinicians express concerns about potential adverse drug withdrawal events (ADWEs) following medication discontinuation or fears of upsetting a stable medical equilibrium as key barriers to deprescribing. Currently, there are limited methods to pragmatically assess the safety of deprescribing and ascertain ADWEs. We report the methods and results of safety monitoring for the OPTIMIZE trial of deprescribing education for patients, family members, and clinicians.

METHODS

This was a pragmatic cluster randomized trial with multivariable Poisson regression comparing outcome rates between study arms. We conducted clinical record review and adjudication of sampled records to assess potential causal relationships between medication discontinuation and outcomes. This study included adults aged 65+ with dementia or mild cognitive impairment, one or more additional chronic conditions, and prescribed 5+ chronic medications. The intervention included an educational brochure on deprescribing that was mailed to patients prior to primary care visits, a clinician notification about individual brochure mailings, and an educational tip sheets was provided monthly to primary care clinicians. The outcomes of the safety monitoring were rates of hospitalizations and mortality during the 4 months following brochure mailings and results of record review and adjudication. The adjudication process was conducted throughout the trial and included classifications: likely, possibly, and unlikely.

RESULTS

There was a total of 3012 (1433 intervention and 1579 control) participants. There were 420 total hospitalizations involving 269 (18.8%) people in the intervention versus 517 total hospitalizations involving 317 (20.1%) people in the control groups. Adjusted risk ratios comparing intervention to control groups were 0.92 [95% confidence interval (CI) 0.72, 1.16] for hospitalization and 1.19 (95% CI 0.67, 2.11) for mortality. Both groups had zero deaths "likely" attributed to a medication change prior to the event. A total of 3 out of 30 (10%) intervention group hospitalizations and 7 out of 35 (20%) control group hospitalizations were considered "likely" due to a medication change.

CONCLUSIONS

Population-based deprescribing education is safe in the older adult population with cognitive impairment in our study. Pragmatic methods for safety monitoring are needed to further inform deprescribing interventions.

TRIAL REGISTRATION

NCT03984396. Registered on 13 June 2019.

Deprescribing in cardiometabolic conditions in older patients: a systematic review

We conduct a systematic review to investigate current deprescribing practices and evaluate outcomes and adverse events with deprescribing of preventive medications in older patients with either an end-of-life designation or residing in long-term care facilities with cardiometabolic conditions. Studies were identified using a literature search of MEDLINE, EMBASE, Web of Science, clinicaltrials.gov.uk, CINAHLS, and the Cochrane Register from inception to March 2022. Studies reviewed included observational studies and randomised control trials (RCTs). Data was extracted on baseline characteristics, deprescribing rates, adverse events and outcomes, and quality of life indicators, and was discussed using a narrative approach. Thirteen studies were identified for inclusion. Deprescribing approaches included complete withdrawal, dose reduction or tapering, or switching to an alternative medication, for at least one preventive medication. Deprescribing success rates ranged from 27 to 94.7%. The studies reported no significant changes in laboratory values or adverse outcomes but did find mixed outcomes for hospitalisations and a slight increase in mortality rates when comparing the intervention and control groups. Lack of good-quality randomised control trials suggests that deprescribing in the older population residing in long-term care facilities with cardiometabolic conditions and multimorbidity is feasible when controlled and regularly monitored by an appropriate healthcare clinician, and that the benefits outweigh the potential harm in this cohort of patients. Due to the limited evidence and the heterogeneity of studies, a meta-analysis was not performed and as such further research is required to assess the benefits of deprescribing in this patient population. Systematic review registration: PROSPERO CRD42021291061.

Translation, cultural adaptation and validation of the revised patients' attitudes towards deprescribing (rPATD) questionnaire in Romanian older adults

BACKGROUND

Deprescribing is part of ensuring appropriate medication use and may reduce medication-related harm. Capturing the beliefs and attitudes of patients towards deprescribing by using a validated tool may support optimizing medication use in practice.

OBJECTIVES

To translate, culturally adapt and validate the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire in Romanian and to investigate the attitudes and beliefs of older adults towards deprescribing.

METHODS

The rPATD questionnaire was translated using forward-backward translation into Romanian and culturally adapted. The psychometric properties were evaluated in older adults ≥65 years of age. Structural validity was assessed by item load on factors using an exploratory factor analysis (EFA) which was compared to the original English version and the internal consistency by Cronbach's alpha. Construct validity was evaluated by calculating the Spearman's rank correlation coefficients between the factor scores obtained using the revised version of the Romanian rPATD and scores on the Beliefs about Medicines Questionnaire (BMQ) Specific Concerns Romanian version. Floor and ceiling effect were also examined.

RESULTS

We translated the questionnaire and administered it to 224 participants (median age 72 years [interquartile range: 68.0; 77.0]). In the EFA individual items loaded onto 4 factors, grouped similarly to the English version (Involvement, Burden, Appropriateness, Concerns about Stopping factors). Two items from each of the Involvement and Appropriateness factors were removed to improve factor loading and avoid cross-loading. The Cronbach's alpha values for the 4 factors ranged between 0.522 and 0.773. The scores for Burden and Concerns about Stopping factors were found to be positively correlated with BMQ Specific Concerns score. We identified a ceiling effect for one of the four factors (Involvement) and no floor effects.

CONCLUSIONS

The Romanian rPATD was validated in 4 factor structure similar to the original English questionnaire. The Romanian version of the questionnaire may support the health care professionals in Romania to initiate and support patient-centered deprescribing.

Ethical Aspects of Physician Decision-Making for Deprescribing Among Older Adults With Dementia

Importance

Physicians endorse deprescribing of risky or unnecessary medications for older adults (aged ≥65 years) with dementia, but there is a lack of information on what influences decisions to deprescribe in this population.

Objective

To understand how physicians make decisions to deprescribe for older adults with moderate dementia and ethical and pragmatic concerns influencing those decisions.

Design, Setting, and Participants

A cross-sectional national mailed survey study of a random sample of 3000 primary care physicians from the American Medical Association Physician Masterfile who care for older adults was conducted from January 15 to December 31, 2021.

Main Outcomes and Measures

The study randomized participants to consider 2 clinical scenarios in which a physician may decide to deprescribe a medication for older adults with moderate dementia: 1 in which the medication could cause an adverse drug event if continued and the other in which there is no evidence of benefit. Participants ranked 9 factors related to possible ethical and pragmatic concerns through best-worst scaling methods (from greatest barrier to smallest barrier to deprescribing). Conditional logit regression quantified the relative importance for each factor as a barrier to deprescribing.

Results

A total of 890 physicians (35.0%) returned surveys; 511 (57.4%) were male, and the mean (SD) years since graduation was 26.0 (11.7). Most physicians had a primary specialty in family practice (50.4% [449 of 890]) and internal medicine (43.5% [387 of 890]). A total of 689 surveys were sufficiently complete to analyze. In both clinical scenarios, the 2 greatest barriers to deprescribing were (1) the patient or family reporting symptomatic benefit from the medication (beneficence and autonomy) and (2) the medication having been prescribed by another physician (autonomy and nonmaleficence). The least influential factor was ease of paying for the medication (justice).

Conclusions and Relevance

Findings from this national survey study of primary care physicians suggests that understanding ethical aspects of physician decision-making can inform clinician education about medication management and deprescribing decisions for older adults with moderate dementia.

Deprescribing, Polypharmacy and Prescribing Cascades in Older People with Type 2 Diabetes: A Focused Review

Deprescribing is the process by which medications are reduced without compromising safety to the patient (Jude et al. in 2022 Diabetes Ther 13: 619–634, 2022). The purpose of this narrative review is to discuss deprescribing as a topic, firstly discussing the benefits and pitfalls to such pharmacological interventions along with the current barriers and enablers to such a controversial topic, and then discussing deprescribing with respect to preventive medications, namely those that reduce the long term impacts of a condition or disease. Research that has previously focused on reducing polypharmacy has highlighted the benefits of such interventions, including reduction of adverse reactions or complications, improved patient satisfaction and quality of life, and improved cost effectiveness and drug compliance. Some potential harms that have been highlighted include an increased number of complications, increased symptoms of previously dampened conditions, and negligible changes in patient satisfaction that have stressed the importance of this intervention being patient centred and individualized to each patient. The implementation of deprescribing processes could drastically change the way people think about deprescribing and could be extremely beneficial to older patients living with type 2 diabetes worldwide. Developments in preventive medication deprescribing could pave the way for this intervention to become more common place improving the quality of life in patient’s final years.

Prescribing and deprescribing in very old age: perceptions of very old adults, caregivers and health professionals

BACKGROUND

although they are major consumers of medications, there is little evidence-based data to guide prescribing and deprescribing of medications for very old adults (80+ years).

OBJECTIVES

to discover the perceptions of very old adults, caregivers and health professionals in order to further examine the clinical and ethical issues raised by prescribing and deprescribing in very old age.

METHODS

individual interviews were conducted with very old adults (n = 10) and caregivers (n = 6), whereas group interviews were conducted with health professionals (n = 11). The themes covered included perceptions of medication use, polypharmacy, deprescribing and patient-health professional relationships. Thematic analysis was used to identify areas of convergence and divergence.

RESULTS

very old adults are satisfied with the medications they are taking, do not see the need to reduce their medication use and consider their doctor as the expert who should make the decisions regarding treatment. The perceptions of caregivers are similar to those of older adults, whereas health professionals believe that very old adults take a lot of inappropriate medications and list multiple barriers to deprescribing. All participants describe a normalisation of medication use with ageing.

CONCLUSION

there is a dichotomy between the perception of the very old adults/caregivers and that of health professionals regarding the safety of medication in very old age. A cultural change regarding medication use seems essential to optimise therapy and support deprescribing in clinical practice since the potential issues raised by researchers do not resonate with the main stakeholders.

Patients' attitudes toward deprescribing and their experiences communicating with clinicians and pharmacists

Purpose:

Developing effective deprescribing interventions relies on understanding attitudes, beliefs, and communication challenges of those involved in the deprescribing decision-making process, including the patient, the primary care clinician, and the pharmacist. The objective of this study was to assess patients’ beliefs and attitudes and identify facilitators of and barriers to deprescribing.

Methods:

As part of a larger study, we recruited patients ⩾18 years of age taking ⩾3 chronic medications. Participants were recruited from retail pharmacies associated with the University of Kentucky HealthCare system. They completed an electronic survey that included demographic information, questions about communication with their primary care clinician and pharmacists, and the revised Patients’ Attitudes Toward Deprescribing (rPATD) questionnaire.

Results:

Our analyses included 103 participants (n = 65 identified as female and n = 74 as White/Caucasian) with a mean age of 50.4 years [standard deviation (SD) = 15.5]. Participants reported taking an average of 8.4 daily medications (SD = 6.1). Most participants reported effective communication with clinicians and pharmacists (66.9%) and expressed willingness to stop one of their medications if their clinician said it was possible (83.5%). Predictors of willingness to accept deprescribing were older age [odds ratio (OR) = 2.99, 95% confidence interval (CI) = 1.45–6.2], college/graduate degree (OR = 55.25, 95% CI = 5.74–531.4), perceiving medications as less appropriate (OR = 8.99, 95% CI = 1.1–73.62), and perceived effectiveness of communication with the clinician or pharmacist (OR = 4.56, 95% CI = 0.85–24.35).

Conclusion:

Adults taking ⩾3 chronic medications expressed high willingness to accept deprescribing of medications when their doctor said it was possible. Targeted strategies to facilitate communication within the patient–primary care clinician–pharmacist triad that consider patient characteristics such as age and education level may be necessary ingredients for developing successful deprescribing interventions.

Plain Language Summary

Are patients willing to accept stopping medications?

Sometimes, medicines that a patient takes regularly become inappropriate. In other words, the risks of adverse effects might be greater than a medicine’s potential benefits. The decision to stop such medicines should involve the patient and consider their preferences. We surveyed a group of patients taking multiple medicines to see how they felt about having those medicines stopped. We also asked patients whether and how much they talk to their primary care clinician and pharmacists about their medicines. To qualify for this study, patients had to be at least 18 years old and to take three or more medicines daily; they also needed to speak English. Participants provided demographic information and answered questions about their medicines, their communication with primary care clinicians and pharmacists, and their feelings about having one or more of their medicines stopped. We recruited 107 people and were able to use responses from 103 of them. Their average age was 50 years; 65 of them identified as female, and 75 identified as White/Caucasian. Most of our participants mentioned having conversations with primary care clinicians and pharmacists and said they would be willing to stop a medication if their clinician said it was possible. Older participants, those with more years of education, those who thought their medications might lead to side effects, and those who communicated with their clinician or pharmacists were more willing to have one of their medicines stopped.

Our results indicate that patient characteristics and communication with clinicians and pharmacists are factors to consider when designing interventions to reduce the use of inappropriate medicines.

Using the behavior change wheel to link published deprescribing strategies to identified local primary healthcare needs

BACKGROUND

Polypharmacy is a major global problem. Evidence in primary care shows deprescribing can be beneficial. Behaviour change theories such as the Theoretical Domains Framework (TDF) and the Behaviour Change Wheel (BCW) can help develop successful implementation of deprescribing initiatives.

OBJECTIVES

To link locally identified deprescribing influencers with components of successfully trialed deprescribing strategies, with the aim of informing the development of local deprescribing initiatives.

METHODS

Two background studies were completed. A qualitative study of interviews and focus groups identified influencers of deprescribing from local primary care physicians, nurse practitioners, and pharmacists. Transcripts were coded using the TDF and mapped to the Intervention Functions of the BCW. A scoping review identified studies that investigated primary care deprescribing strategies, which were mapped to the BCW Intervention Functions and the Behaviour Change Techniques (BCTs). For this analysis, six main TDF domains from the qualitative study were linked to the BCTs identified in the scoping review through the Intervention Functions of the BCW.

RESULTS

Within the BCW component Capability, one TDF domain identified in the qualitative study, Memory, Attention and Decision Process, was linked to strategies like academic detailing from the scoping review. For the Opportunity component, two TDF domains, Social Influences and Environmental Context and Resources, were linked to strategies such as pharmacist medication reviews, providing patient information leaflets, and evidence-based deprescribing tools. For the Motivation component, three TDF domains, Social/Professional Role and Identity, Intentions, and Beliefs about Consequences, were linked to strategies such as sending deprescribing information to prescribers, using tools to identify eligible patients, and having patients report adverse events of medications.

CONCLUSIONS

This analysis identified deprescribing strategies that can be used to address influencers related to behaviour change from the perspective of primary care providers, and to assist with future deprescribing initiative development and implementation in the local context.

Ethical Tenets of PRN Medicines Management in Healthcare Settings: A Clinical Perspective

Prescription and administration of pro re nata (PRN) medications has remained a poorly discussed area of the international literature regarding ethical tenets influencing this type of medication practice. In this commentary, ethical tenets of PRN medicines management from the clinical perspective based on available international literature and published research have been discussed. Three categories were developed by the authors for summarising review findings as follows: 'benefiting the patient', 'making well-informed decision', and 'follow up assessment' as pre-intervention, through-intervention, and post-intervention aspects, respectively. PRN medicines management is mainly intertwined with the ethical tenets of beneficence, nonmaleficence, dignity, autonomy, justice, informed consent, and error disclosure. It is a dynamic process and needs close collaboration between healthcare professionals especially nurses and patients to prevent unethical practice.

Patient harm from cardiovascular medications

Background

Medication harm can lead to hospital admission, prolonged hospital stay and poor patient outcomes. Reducing medication harm is a priority for healthcare organisations worldwide. Recent Australian studies demonstrate cardiovascular (CV) medications are a leading cause of harm. However, they appear to receive less recognition as ‘high risk’ medications compared with those classified by the medication safety acronym, ‘APINCH’ (antimicrobials, potassium, insulin, narcotics, chemotherapeutics, heparin). Our aim was to determine the scale and type of medication harm caused by CV medications in healthcare.

Methods

A narrative review of adult (>16 years) medication harm literature identified from PubMed and CINAHL databases was undertaken. Studies with the primary outcome of measuring the incidence of medication harm were included. Harm caused by CV medications was described and ranked against other medication classes at four key stages of a patient’s healthcare journey. Where specified, the implicated medications and type of harm were investigated.

Results

A total of 75 studies were identified, including seven systematic reviews and three meta-analyses, with most focussing on harm causing hospital admission. CV medications were responsible for approximately 20% of medication harm; however, this proportion increased to 50% in older populations. CV medications were consistently ranked in the top five medication categories causing harm and were often listed as the leading cause.

Conclusion

CV medications are a leading cause of medication harm, particularly in older adults, and should be the focus of harm mitigation strategies. A practical approach to generate awareness among health professionals is to incorporate ‘C’ (for CV medications) into the ‘APINCH’ acronym.

Plain language summary

A systematic review of the evidence for deprescribing interventions among older people living with frailty

BACKGROUND

Older people living with frailty are often exposed to polypharmacy and potential harm from medications. Targeted deprescribing in this population represents an important component of optimizing medication. This systematic review aims to summarise the current evidence for deprescribing among older people living with frailty.

METHODS

The literature was searched using Medline, Embase, CINAHL, PsycInfo, Web of Science, and the Cochrane library up to May 2020. Interventional studies with any design or setting were included if they reported deprescribing interventions among people aged 65+ who live with frailty identified using reliable measures. The primary outcome was safety of deprescribing; whereas secondary outcomes included clinical outcomes, medication-related outcomes, feasibility, acceptability and cost-related outcomes. Narrative synthesis was used to summarise findings and study quality was assessed using Joanna Briggs Institute checklists.

RESULTS

Two thousand three hundred twenty-two articles were identified and six (two randomised controlled trials) were included with 657 participants in total (mean age range 79-87 years). Studies were heterogeneous in their designs, settings and outcomes. Deprescribing interventions were pharmacist-led (n = 3) or multidisciplinary team-led (n = 3). Frailty was identified using several measures and deprescribing was implemented using either explicit or implicit tools or both. Three studies reported safety outcomes and showed no significant changes in adverse events, hospitalisation or mortality rates. Three studies reported positive impact on clinical outcomes including depression, mental health status, function and frailty; with mixed findings on falls and cognition; and no significant impact on quality of life. All studies described medication-related outcomes and reported a reduction in potentially inappropriate medications and total number of medications per-patient. Feasibility of deprescribing was reported in four studies which showed that 72-91% of recommendations made were implemented. Two studies evaluated and reported the acceptability of their interventions and further two described cost saving.

CONCLUSION

There is a paucity of research about the impact of deprescribing in older people living with frailty. However, included studies suggest that deprescribing could be safe, feasible, well tolerated and can lead to important benefits. Research should now focus on understanding the impact of deprescribing on frailty status in high risk populations.

TRIAL REGISTRATION

The review was registered on the international prospective register of systematic reviews (PROSPERO) ID number: CRD42019153367 .

Evidence for deprescription in primary care through an umbrella review

BACKGROUND

There is a high prevalence of potentially inappropriate prescriptions in primary care. This is associated with more frequent adverse events, lower quality of life and more frequent visits to hospital accident & emergency departments. The aim of the present study is to summarise available evidence on the effectiveness of deprescription interventions in primary care, and to describe the barriers and enablers of the process from the point of view of patients and healthcare professionals.

METHODS

We designed an umbrella review which includes nine systematic reviews. More than 50% of included studies were performed with adults in primary care. Two reviewers independently performed data extraction and analysis.

RESULTS

In considering studies of the effectiveness of interventions, it can be observed that the educational component of deprescription procedures is a key factor, whilst procedures tailored towards the patient's situation offer better results. With regards to studies involving healthcare professionals, the main explored areas were the balance between risks and benefits, and the need to improve communication with patients as well as other colleagues involved in patient care. Amongst the identified barriers we found lack of time, inability to access all information, being stuck in a routine, resistance to change and a lack of willingness to question the prescription decisions made by healthcare colleagues. With regards to patients, it is clear that they have worries and doubts. In order to overcome these issues, a good relationship with healthcare professionals and receipt of their support is required during the process.

CONCLUSIONS

Optimizing medication through targeted deprescribing is an important part of managing chronic conditions, avoiding adverse effects and improving outcomes. The majority of deprescription interventions in primary care are effective. Good communication between healthcare professionals is a key element for success in the deprescription process.

Views of medical practitioners about deprescribing in older adults: Findings from an Italian qualitative study

BACKGROUND

Even though increasing attention is given to deprescribing owing to the risks related to polypharmacy in older adults, deprescribing is not yet part of clinical culture.

METHODS

We conducted three focus groups with 25 internists, geriatricians and general practitioners to explore the factors influencing the implementation of deprescribing in the Italian context, and more specifically: i. to investigate the barriers to deprescribing; ii. to define strategies and actions to address these barriers; and iii. to identify skills and tools that may assist in implementing deprescribing in clinical practice. Thematic analysis was used.

RESULTS

Six themes were identified: Good reasons for deprescribing, Difficulties and doubts about deprescribing, System factors affecting polypharmacy and deprescribing, Perspectives on how to practically approach polypharmacy, Need for effective communication with patients and caregivers, Taking responsibility and starting action. Participants reported a willingness to challenge themselves by addressing the barriers to deprescribing through regular review of prescriptions and collaboration with colleagues and patients.

CONCLUSIONS

Italian internists, geriatricians and general practitioners reported many system-level barriers to deprescribing as well as some doubts about its necessity. Strategies to address the barriers to deprescribing include regular medication review and enhancing collaboration with colleagues and patients. Additionally, participants were willing to challenge themselves and use uncertainty as an impetus for deprescribing.

Barriers and Facilitators of Conducting Medication Reviews in Nursing Home Residents: A Qualitative Study

Objectives: Inappropriate medication prescribing is a recognized clinical problem in nursing home residents of whom many have polypharmacy. However, results about the effectiveness of medication reviews targeted at improving prescribing and deprescribing have been equivocal. We therefore examined barriers and facilitators of conducting medication reviews. Method: We purposively sampled medication reviews to capture salient barriers and facilitators of conducting medication reviews both in nursing home care units for dementia and disabling conditions. We held semi-structured interviews about consecutive steps of medication reviews. Interviews were transcribed verbatim and analyzed with the "method of constant comparison." Results: Six nursing home residents/relatives of nursing home residents, 8 elder care physicians, 5 pharmacists, and 10 nurses took part in the semi-structured interviews. We observed four overarching themes of barriers and facilitators: "realizing fidelity of the patient perspective (theme 1)," "level of comprehensiveness of medication reviews (theme 2)," "inclinations of healthcare providers (theme 3)," and "inter-professional collaboration and alliances (theme 4)." Theme 1 "realizing fidelity of the patient perspective" referred to the observation that assessing the patient perspective was a delicate balance between the value and the impediments of a proper assessment of the patient perspective. Theme 2 "level of comprehensiveness of medication reviews" reflected the struggle of practitioners to find an optimum between medication reviews being both comprehensive and feasible. Theme 3 "inclinations of healthcare providers" concerned setting intervention targets that were complementary to the practices of physicians and keeping the pharmacist blind to the patient perspective as a countermeasure to physicians' inclinations. Finally, theme 4 "inter-professional collaboration and alliances" highlighted mutual support and inter-professional collaboration to strengthen healthcare practitioners' contributions. Discussion: These themes of barriers and facilitators emphasize the need to improve meta-communication during the medication review process. This pertains to the need for healthcare providers to appraise the fidelity of the patient perspective in a dialogue with residents/relatives. Furthermore, discourse between healthcare practitioners is needed beforehand about the level of comprehensiveness intervention targets, and inter-professional collaboration.

Barriers and Facilitators of Conducting Medication Reviews in Nursing Home Residents: A Qualitative Study

Objectives: Inappropriate medication prescribing is a recognized clinical problem in nursing home residents of whom many have polypharmacy. However, results about the effectiveness of medication reviews targeted at improving prescribing and deprescribing have been equivocal. We therefore examined barriers and facilitators of conducting medication reviews. Method: We purposively sampled medication reviews to capture salient barriers and facilitators of conducting medication reviews both in nursing home care units for dementia and disabling conditions. We held semi-structured interviews about consecutive steps of medication reviews. Interviews were transcribed verbatim and analyzed with the "method of constant comparison." Results: Six nursing home residents/relatives of nursing home residents, 8 elder care physicians, 5 pharmacists, and 10 nurses took part in the semi-structured interviews. We observed four overarching themes of barriers and facilitators: "realizing fidelity of the patient perspective (theme 1)," "level of comprehensiveness of medication reviews (theme 2)," "inclinations of healthcare providers (theme 3)," and "inter-professional collaboration and alliances (theme 4)." Theme 1 "realizing fidelity of the patient perspective" referred to the observation that assessing the patient perspective was a delicate balance between the value and the impediments of a proper assessment of the patient perspective. Theme 2 "level of comprehensiveness of medication reviews" reflected the struggle of practitioners to find an optimum between medication reviews being both comprehensive and feasible. Theme 3 "inclinations of healthcare providers" concerned setting intervention targets that were complementary to the practices of physicians and keeping the pharmacist blind to the patient perspective as a countermeasure to physicians' inclinations. Finally, theme 4 "inter-professional collaboration and alliances" highlighted mutual support and inter-professional collaboration to strengthen healthcare practitioners' contributions. Discussion: These themes of barriers and facilitators emphasize the need to improve meta-communication during the medication review process. This pertains to the need for healthcare providers to appraise the fidelity of the patient perspective in a dialogue with residents/relatives. Furthermore, discourse between healthcare practitioners is needed beforehand about the level of comprehensiveness intervention targets, and inter-professional collaboration.

How many older adults receive drugs of questionable clinical benefit near the end of life? A cohort study

BACKGROUND

The high burden of disease-oriented drugs among older adults with limited life expectancy raises important questions about the potential futility of care.

AIM

To describe the use of drugs of questionable clinical benefit during the last 3 months of life of older adults who died from life-limiting conditions.

DESIGN

Longitudinal, retrospective cohort study of decedents. Death certificate data were linked to administrative and healthcare registries with national coverage in Sweden.

SETTING

Older adults (≥75 years) who died from conditions potentially amenable to palliative care between 1 January and 31 December 2015 in Sweden. We identified drugs of questionable clinical benefit from a set of consensus-based criteria.

RESULTS

A total of 58,415 decedents were included (mean age, 87.0 years). During their last 3 months of life, they received on average 8.9 different drugs. Overall, 32.0% of older adults continued and 14.0% initiated at least one drug of questionable clinical benefit (e.g. statins, calcium supplements, vitamin D, bisphosphonates, antidementia drugs). These proportions were highest among younger individuals (i.e. aged 75-84 years), among people who died from organ failure and among those with a large number of coexisting chronic conditions. Excluding people who died from acute and potentially unpredictable fatal events had little influence on the results.

CONCLUSION

A substantial share of older persons with life-limiting diseases receive drugs of questionable clinical benefit during their last months of life. Adequate training, guidance and resources are needed to rationalize and deprescribe drug treatments for older adults near the end of life.

Health professionals' and researchers' opinions on conducting clinical deprescribing trials

While clinical deprescribing trials are increasingly being performed, there is no guidance on the optimum conduction of such studies. The aim of this survey was to explore the perspectives, attitudes, interests, barriers, and enablers of conducting clinical deprescribing trials among health professionals and researchers. An anonymous survey was developed, reviewed, and piloted by all investigators and informed by consultation with experts, as well as current deprescribing guidelines. The questions were formulated around current clinical trial frameworks and incorporated identified enablers and barriers of performing deprescribing studies. The survey was sent to members of Australian and international deprescribing, pharmacological, and pharmacy organizations, and other researchers published in deprescribing. A total of 96 respondents completed the survey (92.3% completion rate). Respondents indicated the main deprescribing trial rationale is to generate evidence to optimize patient-centered outcomes (79.2%). Common barriers identified included the time and effort required (18.2%), and apprehension of health professionals involved in trials (17.1%). Studies are enabled by positive attitudes toward deprescribing of treating prescribers (24.4%) and patients (20.9%). Classical randomized controlled trials (RCTs) were deemed the most appropriate methodology (93.2%). Sixty percent of participants indicated a good clinical practice framework is required to guide the conduct of deprescribing trials. There were no significant differences in responses based on previous experience in conducting clinical deprescribing trials. In conclusion, clinical deprescribing trials should be conducted to investigate whether deprescribing medications improves patient care. A future deprescribing trial framework should use classical RCTs as a model, ensure participant safety, and target patient-centered outcomes.

The deprescribing rainbow: a conceptual framework highlighting the importance of patient context when stopping medication in older people

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.

Deprescribing antipsychotics: a guide for clinicians

Polypharmacy and the risks of long term use of antipsychotic medications point toward the need for identifying practices for deprescribing in psychiatry. The following article gives a brief overview of key points around deprescribing antipsychotic medications in psychiatry, including identifying risks and benefits, considerations around timing, and steps involved.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

Deprescribing medications for older adults in the primary care context: A mixed studies review

AIMS

This review investigates the factors that influence deprescribing of medications in primary care from the perspective of general practitioners (GPs) and community-living older adults.

METHODS

A mixed studies review structure was adopted searching Scopus, CINAHL, PsychINFO, ProQuest, and PubMed from January 2000 to December 2017. A manual search of reference lists was also conducted. Studies were included if they were original research available in English and explored general deprescribing rather than deprescribing of a specific class of medications. The Mixed Methods Assessment Tool was used to assess the quality of studies, and content analysis generated common categories across studies.

RESULTS

Thirty-eight articles were included, and 7 key categories were identified. The review found that the factors that influence deprescribing are similar across and within health systems and mostly act as barriers. These factors remained unchanged across the review period. The structural organisation of health systems remains poorly suited to facilitate deprescribing. Individual knowledge gaps of both GPs and older adults influence practices and attitudes towards deprescribing, and significant communication gaps occur between GPs and specialists and between GPs and older adults. As a result, deprescribing decision making is characterised by uncertainty, and deprescribing is often considered only when medication problems have already arisen. Trust plays a complex role, acting as both a barrier and facilitator of deprescribing.

CONCLUSIONS

Deprescribing is influenced by many factors. Despite recent interest, little change has occurred. Multilevel strategies aimed at reforming aspects of the health system and managing uncertainty at the practice and individual level, notably reducing knowledge limitations and closing communications gaps, may achieve change.

Adequate, questionable, and inadequate drug prescribing for older adults at the end of life: a European expert consensus

Background

Clinical guidance is needed to initiate, continue, and discontinue drug treatments near the end of life.

Aim

To identify drugs and drug classes most often adequate, questionable, or inadequate for older people at the end of life.

Design

Delphi consensus survey.

Setting/participants

Forty European experts in geriatrics, clinical pharmacology, and palliative medicine from 10 different countries. Panelists were asked to characterize drug classes as “often adequate,” “questionable,” or “often inadequate” for use in older adults aged 75 years or older with an estimated life expectancy of ≤ 3 months. We distinguished the continuation of a drug class that was previously prescribed from the initiation of a new drug. Consensus was considered achieved for a given drug or drug class if the level of agreement was ≥ 75%.

Results

The expert panel reached consensus on a set of 14 drug classes deemed as “often adequate,” 28 drug classes deemed “questionable,” and 10 drug classes deemed “often inadequate” for continuation during the last 3 months of life. Regarding the initiation of new drug treatments, the panel reached consensus on a set of 10 drug classes deemed “often adequate,” 23 drug classes deemed “questionable,” and 23 drug classes deemed “often inadequate”. Consensus remained unachieved for some very commonly prescribed drug treatments (e.g., proton-pump inhibitors, furosemide, haloperidol, olanzapine, zopiclone, and selective serotonin reuptake inhibitors).

Conclusion

In the absence of high-quality evidence from randomized clinical trials, these consensus-based criteria provide guidance to rationalize drug prescribing for older adults near the end of life.

Electronic supplementary material

The online version of this article (10.1007/s00228-018-2507-4) contains supplementary material, which is available to authorized users.

Poly-de-prescribing to treat polypharmacy: efficacy and safety

BACKGROUND

The aim of this study was to evaluate efficacy and safety of poly-de-prescribing (PDP) based on the Garfinkel method in older people with polypharmacy.

METHODS

A longitudinal, prospective, nonrandomized study in Israel was carried out between 2009 and 2016. Comprehensive geriatric assessments were performed at home in people age ⩾66 years consuming ⩾6 prescription drugs. Exclusion criteria were life expectancy <6 months and a seeming unwillingness to cooperate (poor compliance). PDP of ⩾3 prescription drugs was recommended. Follow up was at ⩾3 years. Between April 2015 and April 2016 Likert scale questionnaires were filled by all participants/families to evaluate overall satisfaction and clinical outcomes. The outcome measures were change in functional, mental and cognitive status, sleep quality, appetite, continence; major complication, hospitalizations, mortality, and family doctor's cooperation.

RESULTS

Poly-de-prescribing of ⩾3 drugs was eventually achieved by 122 participants (PDP group); ⩽2 drugs stopped by 55 'nonresponders' (NR group). The average age was 83.4 ± 5.3 in the PDP group, and 80.8 ± 6.3 in the NR group (p = 0.0045). Follow up was 43.6 ± 14 months (PDP) and 39.5 ± 16.6 months (NR) (p = 0.09). The prevalence of most diseases/symptoms was comparable except for a higher prevalence for dementia, incontinence and functional decline in the PDP group. The main barrier to de-prescribing was the family doctor's unwillingness to adopt PDP recommendations (p < 0.0001). The baseline median number of medications taken by both groups was 10 (IQR 8 to 12) (p = 0.55). On the last follow up, the drug count was 11 (IQR 8 to 12) in the NR group and 4 (IQR 2 to 5) in the PDP group (p =0.0001). The PDP group showed significantly less deterioration (sometimes improvement) in general satisfaction, functional, mental and cognitive status, sleep quality, appetite, sphincter control, and the number of major complications was significantly reduced (p < 0.002 in all). The rate of hospitalizations and mortality was comparable. Health improvement occurred within 3 months after de-prescribing in 83%, and persisted for ⩾2 years in 68%.

CONCLUSIONS

This self-selected sample longitudinal research strongly suggests that the negative, usually invisible effects of polypharmacy are reversible. PDP is well tolerated and associated with improved clinical outcomes, in comparison with outcomes of older people who adhere to all clinical guidelines and take all medications conventionally. Future double-blind studies will probably prove beneficial economic outcomes as well.

A narrative review of the safety concerns of deprescribing in older adults and strategies to mitigate potential harms

INTRODUCTION

As with prescribing or continuing medications, deprescribing brings with it the potential for harm as well as benefit. Uncertainty and avoidance of harm has been reported as a barrier to deprescribing in practice and may contribute to continuation of inappropriate medications.

AREAS COVERED

This narrative review covers four main safety concerns/potential harms of deprescribing in older adults: adverse drug withdrawal events, return of medical condition(s), reversal of drug-drug interactions and damage to the doctor-patient relationship. These are discussed in relation to medications in general, with some examples of medication classes used to illustrate the potential safety concerns. The majority of these harms can be minimized or even prevented by using a patient-centered, structured deprescribing process with planning, tapering and close monitoring during, and after medication withdrawal.

EXPERT OPINION

More research is needed into the safety concerns of deprescribing, however, avenues exist during drug development and post-marketing surveillance to gain knowledge on this topic. Questions remain about when it is suitable to discontinue certain medications/medication classes and there is uncertainty about the harms and benefits of both medication continuation and discontinuation in complex older adults.

N-of-1 trials for assessing the effects of deprescribing medications on short-term clinical outcomes in older adults: a systematic review

OBJECTIVES

The objective of this study was to determine the applicability of utilizing the N-of-1 method for deprescribing trials in older adults.

STUDY DESIGN AND SETTING

Systematic review of any human studies conducted in older adults (≥50 years), deprescribing any long-term treatment over less than a year using the N-of-1 trial method was performed. Two authors independently reviewed all articles for eligibility and extracted data. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Quality assessment of trials was carried out using the Physiotherapy Evidence Database scale.

RESULTS

Six studies were identified and extracted. Trials investigated the efficacy of pharmacological and non-pharmacological therapies for treating diseases. Four trials demonstrated non-significant benefits of treatment, with a significant number of patients discontinuing their medications in two trials where follow-up data was collected (N = 8/18, 9/14 [44.4--64.3%]). In two studies, where treatment was beneficial, all participants were found to be maintaining regimen at follow-up.

CONCLUSION

The N-of-1 trial methodology can be used to generate patient-specific evidence of medication and inform prescribing decisions. Future studies are required to assess the feasibility of using the N-of-1 method to determine the effects of deprescribing medications on short-term outcomes.

Polypharmacy and Medication Management in Older Adults

Polypharmacy in older adults is a global problem that has recently worsened. Approximately 30% of adults aged 65 years and older in developed countries take 5 or more medications. Although prescribed and over-the-counter medications may improve a wide range of health problems, they also may cause or contribute to harm, especially in older adults. Polypharmacy in older adults is associated with worsening of geriatric syndromes and adverse drug events. Given the risks and burdens of polypharmacy and potentially inappropriate medications, nurses must use patient-centered approaches and nonpharmacologic strategies to treat common symptoms and to optimize patient function and quality of life.

Deprescribing for frail older people - Learning from the case of Mrs. Hansen

Drug treatment is often an essential part in treatment and prevention of diseases in older people, but there is much concern about inappropriate medication use. This paper aims to describe the complexity of medication safety issues and clinical judgments when optimizing prescribing in older individuals. It uses the case of Mrs. Hansen, an aged nursing home resident, to illustrate the facilitators and barriers of this process. With decreasing life expectancy, medication use should shift from cure to care, focusing on symptomatic treatment to increase the patient's well-being. In Mrs. Hansen's case, the number of (potentially) dangerous medications were reduced, and non-pharmacological alternatives were considered. There were some medicines added, as underprescribing can also be a problem in older people. Deprescribing long-standing treatment can be interpreted by the patient and family as "giving up hope". More clinical evidence and practical communication tools are needed to guide deprescribing decisions, taking medical and patient-centered priorities into account. Studies evaluating such interventions should select outcome measures that are particularly relevant for frail old individuals.