Post Hoc Analyses of a Randomized Controlled Trial for the Effect of Pharmacist Deprescribing Intervention on the Anticholinergic Burden in Frail Community-Dwelling Older Adults

Deprescribing in Community-Dwelling Older Adults: A Systematic Review and Meta-Analysis

Importance

Deprescribing has the potential to improve patient safety and quality of care by reducing polypharmacy and potentially inappropriate medications (PIMs), which in turn may reduce adverse drug events. Questions remain about the effectiveness of deprescribing interventions in outpatient settings.

Objective

To determine the association of deprescribing interventions with reducing medication count and PIMs in community-dwelling older adults.

Data Sources

Included studies were English-language human studies in PubMed and the Cochrane Library published from January 2019 to July 26, 2024, and results were supplemented with reference-mining and expert consultation.

Study Selection

Studies were eligible if they were solely or primarily about deprescribing, focused on community-dwelling adults, were multisite, used a randomized trial design, and reported on the primary or secondary outcome.

Data Extraction and Synthesis

Two authors extracted study design, intervention characteristics, population characteristics, and follow-up. Outcomes were extracted by the statistician and checked by a second author. Meta-analyses were conducted using random effects with the Hartung-Knapp-Sidik-Jonkman method. The study was reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria.

Main Outcomes and Measures

The primary outcome was the number of PIMs or total medications, and the secondary outcome was proportion of persons prescribed at least 1 PIM.

Results

Two authors independently screened 1586 titles from PubMed and Cochrane and 33 from other sources; 321 abstracts and 133 full-text studies were further reviewed, and disagreements were reconciled through discussion, resulting in 17 studies in 18 publications. A total of 8 studies of interventions targeting multiple medications were identified for primary outcome analysis; the random-effects pooled analysis found a mean difference of -0.14 (95% CI, -0.27 to -0.01) medications prescribed. A total of 6 studies of interventions targeting multiple medications were identified for secondary outcome analysis; the random effects pooled analysis found no significant reduction in the proportion of persons prescribed at least 1 PIM (odds ratio, 0.92 [95% CI, 0.74 to 1.14]).

Conclusions and Relevance

This systematic review and meta-analysis found moderate-certainty evidence that deprescribing interventions were associated with reduced PIM and medication counts in community-dwelling older adults. While the individual-level association was very small, on an aggregated population level, the outcomes may be large, given the high prevalence of polypharmacy and PIMs in community-dwelling older adults.

Impact of a Clinical Decision Support System on the Change over Time in the Anticholinergic Load in Geriatric Patients: The SADP-Antichol Study

PURPOSE

Anticholinergic drugs can cause adverse events (AEs) in older adults. Clinical decision support systems (CDSSs) can detect prescriptions with a high anticholinergic load. Our starting hypothesis was that the anticholinergic load could be reduced by combining a CDSS with a strategy for generating pharmacist interventions. The objective of the present study was to assess the impact of this combination on the change over time in the anticholinergic load in hospitalized older adults.

METHODS

This prospective, single-centre study was divided into two 6-week periods. During the interventional period, a pharmacist analyzed the alerts generated by the CDSS for 30 targeted anticholinergic drugs and decided whether to issue a pharmacist intervention. A control period corresponds to standard care. The primary endpoint of the study is the delta of the anticholinergic load between the alert and hospital discharge; the secondary endpoint is the incidence of anticholinergic adverse events (AEs).

RESULTS

Of the 144 alerts generated, 87 were considered to be relevant (36 in the interventional period and 51 in the control period). A significant difference was observed between the delta anticholinergic load between the experimental and control periods (1.61 vs. 0.67, p-value = 0.0115). For the targeted drugs (n = 94) over the 87 alerts, 46.8% were for antihistamines and 21.3% were for desloratadine. Of the 36 pharmacist interventions sent by the pharmacist, 19 (52.8%) were accepted. The most deprescribed drug class was the antihistamine class (n = 7), and the most deprescribed drug was amitriptyline (n = 5). Among these 87 patients with alerts, the correlation between the anticholinergic load and the number of AEs was not statistically significant (p = 0.887). The most common AE affecting the peripheral nervous system was constipation (28.6%), and the most common AE affecting the central nervous system was confusion (29.9%).

CONCLUSIONS

Our results showed that the combination of specific CDSS rules with pharmacist-mediated risk management procedures could further reduce the anticholinergic load in hospitalized older adults, relative to routine care. It remains to be determined whether this reduction in the anticholinergic load has an impact on the incidence of peripheral and central anticholinergic AEs, and thus the health of these patients.

The effect of deprescribing interventions on mortality and health outcomes in older people: An updated systematic review and meta-analysis

AIMS

Previous systematic reviews suggest that deprescribing may improve survival, particularly in frail older people. Evidence is rapidly accumulating, suggesting a need for an updated review of the literature.

METHODS

We updated a 2016 systematic review and meta-analysis to include studies published from inception to 26 April 2024 from specified databases. Studies in which older people had at least one medication deprescribed were included and grouped by study designs and targeted medications. The risk of bias was assessed using the Cochrane tool and the Newcastle-Ottawa tool. Odds ratios (OR) or mean differences were calculated as the effect measures using either the Mantel-Haenszel or generic inverse-variance method with fixed- or random-effects meta-analyses. The primary outcome was mortality. Secondary outcomes were adverse drug withdrawal events, physical health, cognitive function, quality of life and effect on medication regimen. Subgroup analyses were performed based on age and intervention types.

RESULTS

A total of 259 studies (reported in 286 papers) were included in this updated review. Deprescribing polypharmacy did not result in a significant reduction in mortality in both randomized (OR 0.96, 95% confidence interval [CI] 0.84-1.09) and non-randomized studies (OR 0.70, 95% CI 0.36-1.38). Further subgroup analyses of randomized studies on deprescribing polypharmacy demonstrated a significant reduction in mortality in the young old (aged 65-79) (OR 0.71, 95% CI 0.51-0.99) and when patient-specific interventions were applied (OR 0.79, 95% CI 0.63-0.99).

CONCLUSIONS

Deprescribing can be achieved with potentially important benefits in terms of improved survival, particularly when patient-specific interventions are applied and initiated early in the young old.

Frailty as an Effect Modifier in Randomized Controlled Trials: A Systematic Review

BACKGROUND

The effect of clinical interventions may vary by patients' frailty status. Understanding treatment effect heterogeneity by frailty could lead to frailty-guided treatment strategies and reduce overtreatment and undertreatment. This systematic review aimed to examine the effect modification by frailty in randomized controlled trials (RCTs) that evaluate pharmacological, non-pharmacological, and multicomponent interventions.

METHODS

We searched PubMed, Web of Science, EMBASE, and ClinicalTrial.gov, from their inception to 8 December 2023. Two reviewers independently extracted trial data and examined the study quality with senior authors.

RESULTS

Sixty-one RCTs that evaluated the interaction between frailty and treatment effects in older adults were included. Frailty was evaluated using different tools such as the deficit accumulation frailty index, frailty phenotype, and other methods. The effect of several pharmacological interventions (e.g., edoxaban, sacubitril/valsartan, prasugrel, and chemotherapy) varied according to the degree of frailty, whereas other treatments (e.g., antihypertensives, vaccinations, osteoporosis medications, and androgen medications) demonstrated consistent benefits across different frailty levels. Some non-pharmacological interventions had greater benefits in patients with higher (e.g., chair yoga, functional walking, physical rehabilitation, and higher dose exercise program) or lower (e.g., intensive lifestyle intervention, psychosocial intervention) levels of frailty, while others (e.g., resistance-type exercise training, moderate-intensive physical activity, walking and nutrition or walking) produced similar intervention effects. Specific combined interventions (e.g., hospital-based disease management programs) demonstrated inconsistent effects across different frailty levels.

DISCUSSION

The efficacy of clinical interventions often varied by frailty levels, suggesting that frailty is an important factor to consider in recommending clinical interventions in older adults.

REGISTRATION

PROSPERO registration number CRD42021283051.