Deprescribing Interventions for Older Patients: A Systematic Review and Meta-Analysis

Frailty-aware Care in the Emergency Department

Older adults living with frailty are a growing population that will increasingly present to the emergency department (ED). This is a population that is at increased risk of adverse health outcomes and most EDs are not designed with their needs in mind. Instead of characterizing patients based on chronologic age or existing triage tools, frailty assessment offers an accurate, feasible, and patient-centered approach to improving care, and should be performed in the ED.

Prevalence and Factors with Potentially Inappropriate Prescribing among Older Surgical Outpatients in China: A Nationwide Cross-sectional Study in 100 Hospitals

BACKGROUND

Older outpatients face a heightened risk of potentially inappropriate prescribing (PIP). However, there is a paucity of evidence evaluating PIP in older outpatients attending surgical outpatient departments in China using Chinese-specific criteria. This study aimed to assess the prevalence of PIP and identify associated factors within this population.

METHODS

A cross-sectional design was employed, utilizing prescription data from older surgical outpatients across 100 hospitals in seven Chinese cities between January and December 2021. PIP was assessed based on Chinese criteria, and multivariate logistic regression analysis was performed to identify risk factors. Trends were analyzed using the average annual percent change (AAPC) via joinpoint regression.

RESULTS

A total of 357,135 prescriptions for older surgical outpatients were analyzed. The prevalence of PIP according to Chinese criteria was 13.06%. The five most commonly identified potentially inappropriate medications (PIMs) were doxazosin, clopidogrel, tolterodine, estazolam, and the concurrent use of more than two NSAIDs, which together accounted for 52.73% of all PIMs. From January to December, the prevalence of PIP exhibited a slight decrease, from 13.29 to 13.21% (AAPC: -0.278%). Logistic regression revealed that factors such as tertiary-level hospital status, polypharmacy, pain, sleep disorders, hypertension, benign prostatic hyperplasia, and stone disease were positively associated with PIP in older surgical outpatients.

CONCLUSIONS

The study found that while the prevalence of PIP among older surgical outpatients in China is relatively low, attention is needed to the widespread use of certain PIMs.

Deprescribing strategies in older patients with heart failure

Older patients with heart failure are particularly vulnerable due to a wide range of associated comorbidities, disability, and frailty. This population often receives multiple prescriptions, increasing the risk of adverse drug reactions, non-adherence, and drug interactions. Deprescribing, which involves reducing the number of medications to the lowest clinically reasonable limit, has the potential to decrease the risk of drug interactions and enhance patients' quality of life. Moreover, simplifying medication regimens may improve adherence to essential heart failure therapies. This scientific review aims to comprehensively examine deprescribing strategies in older patients with heart failure. It explores the rationale, challenges, benefits, and potential approaches to optimizing medication regimens in this vulnerable population. Furthermore, the review suggests a practical, step-by-step approach for performing deprescribing in older patients with heart failure.

Impact of a Multidisciplinary Approach to Polypharmacy Management in Community-Dwelling Older Adults: Insights From a Specialized Outpatient Clinic

Objectives

The increase in polypharmacy among older adults increases the risk of drug-related problems, making multidisciplinary interventions essential. This study evaluated the impact of a multidisciplinary polypharmacy consultation on medication management and outcomes in older outpatients.

Methods

This prospective observational study at a Spanish teaching hospital involved geriatricians, clinical pharmacists, and nurses. Older adults (≥ 75 years) with polypharmacy underwent medication review at baseline and at 3 and 6 months. Data on medication use, adherence to Screening Tool of Older Person's Prescriptions (STOOP) criteria, and anticholinergic burden were analyzed.

Results

The study included 104 older adults (mean age 86.2 years; 66% female). An average of 3.6 recommendations per participant was made (63.8% acceptance rate). Common drug-related problems were adverse effects (20%), non-adherence (18.1%), and incorrect dose/regimen (14.4%). Interventions led to an average reduction of 1.7 medications per patient, with 1.3 dosage or regimen changes and 1.1 new prescriptions. The mean number of medications decreased from 9.6 at baseline to 8.9 at 3 months (p < 0.001) and remained below baseline at 6 months. STOPP criteria violations per patient dropped from 1.2 to 1.0 (p = 0.036). Of the 126 medications flagged by STOPP criteria, 68.3% were addressed, 24.6% discontinued, mainly psychotropics, and 89.3% of these discontinuations were maintained. The anticholinergic burden decreased from 1.3 to 1.1 at 3 months (p = 0.036) and remained below baseline at 6 months.

Conclusions

A multidisciplinary clinic effectively managed polypharmacy in older adults by reducing medication load and improving appropriateness per STOPP criteria, highlighting the importance of proactive medication management.

Trial Registration

ClinicalTrials.gov: NCT05408598 (March 1, 2022).

Pharmacist-Mediated Deprescribing in Long-Term Care Facilities: A Systematic Review

Multimorbidity and polypharmacy are prevalent among Long-Term Care (LTC) users. Older people, who most use LTC services, are more prone to drug-related problems, which polypharmacy aggravates. Deprescribing is a key intervention to address polypharmacy and inappropriate medication. Evidence shows that pharmacists' expertise in medicines and their growing involvement in clinical-oriented activities have proven to play an essential role across many healthcare settings, including LTC. Thus, this study aimed to identify and assess LTC pharmacist-mediated deprescribing. A systematic review was undertaken following the PRISMA checklist, using three literature databases (PubMed, Scopus, and Web of Knowledge). A set of 18 keywords, divided into three domains (professional, type of care, and type of setting), were combined into search equations. The studies selected were assessed through the Quality Assessment Tool for Quantitative Studies. Fifteen studies met the inclusion criteria out of 288 initial hits. Pharmacist-mediated deprescribing was divided into specific (targeted to a medicine group) and non-specific. Half of the studies were graded as low quality (53%). In total, the studies enrolled 6928 patients and 45 pharmacists. The ATC groups A, C, M, and N, as well as medicines with anticholinergic properties, were the most addressed medicines groups. Acceptance rates of pharmacists' recommendations ranged between 30% and 100%. Generically, the number of medicines was reduced after the intervention. Mixed results were found for falls and quality of life outcomes. Cost savings associated with the interventions ranged from neutral to as high as 3800 €/patient/year. Barriers to deprescribing were mainly linked to patients' or family members' refusal to change. In conclusion, pharmacist-mediated deprescribing seems feasible in LTC. The studies' methodological heterogeneity hampers robust comparisons and conclusions. The medicine groups targeted by deprescribing can help tailor interventions to optimize the use of medicines in LTC. A detailed understanding of barriers and enablers to deprescribing would support developing and implementing these interventions.

Adherence Challenges and Strategies in Specific Groups With Asthma: Adolescents, Pregnancy, and Older Adults

Poor adherence to controller therapies is a universal challenge to asthma control. Several high-risk groups, including adolescents, pregnant women, and older adults, have their own unique challenges to adherence. The rates of asthma controller therapy use are low in each of these populations, but secondary to different causes. Adolescents have increased independence and a transition to new self-management responsibilities; pregnant women may be concerned about adverse effects of medications to the fetus; and older adults may have age-related physical and cognitive challenges to effectively taking medication. Only by understanding the nuances of care in these populations can health care professionals develop strategies to address barriers to adherence. Tailored education focused on empowering patients and dispelling misconceptions can serve as tools to improve adherence and ultimately asthma control.

Clinician's Guide to Geriatric Assessment

The population of older adults is rapidly growing worldwide. Because of the substantial shortage of geriatricians, all clinicians need basic fluency in older adult care. In our approach to evaluating an older adult in the clinic or at the bedside, we apply the "Geriatric 5Ms" framework to manage the patient's care. The Geriatric 5Ms consist of the following key steps. First, consider the mind: the cognitive and psychological domains of a patient's health. Second, evaluate mobility and fall risk. Third, review and reconcile medications, particularly high-risk medications. Fourth, ask what matters most to the patient. Fifth, assess multicomplexity: how the intersection of multiple chronic conditions and social determinants of health influence the patient's health care management. Herein, we provide clinicians with practical suggestions and resources for quickly and effectively applying the Geriatric 5Ms to the care of 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.

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.

Pharmacists' attitudes towards interprofessional collaboration to optimise medication use in older patients in Switzerland: a survey study

BACKGROUND

Collaboration between physicians and pharmacists facilitates the conduct of medication optimisation efforts. In the context of deprescribing, pharmacists' roles are often described as making deprescribing recommendations to physicians. Little is known about factors associated with pharmacists' willingness to make deprescribing recommendations and their interprofessional collaboration with physicians in Swiss primary care settings.

OBJECTIVE

To explore pharmacists' perspectives on medication optimisation and deprescribing in older adults, and their preferences for interprofessional collaboration in Swiss primary care settings.

METHODS

In this cross-sectional study, a random sample of 1000 pharmacist members of the Swiss Pharmacists Association pharmaSuisse was invited to participate in a survey on medication optimisation, deprescribing, and interprofessional collaboration. The survey contained three case vignettes of multimorbid patients with polypharmacy aged ≥ 80 years old, with different levels of dependency in activities in daily living (ADL) and cardiovascular disease (CVD). For each case vignette, pharmacists were asked if and which medications they would deprescribe. We calculated proportions of pharmacists' willingness to deprescribe by case vignette and performed a multilevel logistic regression to assess associations between CVD, ADL, and willingness to deprescribe.

RESULTS

One hundred thirty-eight (14%) pharmacists responded to the survey: 113 (82%) were female, their mean age was 44 years (SD = 11), and 66% (n = 77) reported having never received any specific training on how to conduct structured medication reviews. Eighty-three (72%) pharmacists reported to be confident in identifying deprescribing opportunities. All pharmacists were willing to deprescribe ≥ 1 medication in all vignettes. Patients with CVD were at lower odds of having medications deprescribed (OR = 0.27, 95%CI 0.21 to 0.36). Willingness to deprescribe was lower with higher dependency in ADL (medium versus low dependency: OR = 0.68, 95%CI 0.54 to 0.87, high versus low dependency: OR = 0.72, 95%CI 0.56 to 0.91). However, the effect of dependency in ADL on willingness to deprescribe was significantly modified by the history of CVD. One hundred five pharmacists (97%) reported to interact with physicians to clarify questions regarding prescriptions at least once a week and 88 (81%) wished to be more involved in deprescribing and medication review.

CONCLUSION

Pharmacists were willing to make deprescribing suggestions for older patients with polypharmacy, but two-thirds reported having received no formal training on how to perform structured medication reviews. Pharmacists would like to be more involved in the process of medication review and deprescribing, which should be leveraged in the context of Swiss primary care settings.

The Impact of Deprescribing Interventions on the Drug Burden Index and Other Outcomes: A Systematic Review

OBJECTIVES

The Drug Burden Index (DBI) calculates a person's exposure to anticholinergic and sedative medications. We aimed to review randomized controlled trials (RCTs) of deprescribing interventions that reported the DBI as an outcome, their characteristics, effectiveness in reducing the DBI, and impact on other outcomes.

DESIGN

Systematic review with meta-analysis.

SETTING AND PARTICIPANTS

RCTs of deprescribing interventions where the DBI was measured as a primary or secondary outcome in humans within any setting were included.

METHODS

Electronic databases, citation indexes, and gray literature were searched from April 1, 2007, to September 1, 2023. Quality was assessed using the Cochrane risk-of-bias tool.

RESULTS

Of 1721 records identified, 9 met the inclusion criteria. Six interventions were delivered by pharmacists and 3 were delivered by pharmacists/nurses or pharmacists/geriatricians. All interventions required at least intermediate-level skills and involved multiple components and target groups. Studies were conducted in the community (n = 5), nursing homes (n = 2), and hospitals (n = 2). The mean or median age was ≥75 years and most participants were women in all studies. Most (n = 6) studies were underpowered. The follow-up period ranged from 3 to 12 months. Three studies reported a lower DBI in the intervention group compared with control: 1 pharmacist independent prescriber-delivered in nursing homes (adjusted rate ratio, 0.83; 95% CI, 0.74 to 0.92), 1 pharmacist/nurse practitioner-delivered in hospital (adjusted mean difference (MD), -0.28; 95% CI, -0.51 to -0.04), and 1 geriatrician/pharmacist-delivered in hospital (MD, -0.28; 95% CI, -0.52 to -0.04). Meta-analysis showed no difference in the change in DBI between control and intervention groups in the community including nursing homes (MD, -0.03; 95% CI, -0.08 to 0.01) or hospital setting (MD, -0.19; 95% CI, -0.45 to 0.06). Interventions had inconsistent effects on cognition and no effect on other reported outcomes.

CONCLUSIONS AND IMPLICATIONS

RCTs of deprescribing interventions had no significant impact on reducing DBI or improving outcomes. Further suitably powered studies are required.

Medication Optimization Protocol Efficacy for Geriatric Inpatients: A Randomized Clinical Trial

Importance

There is currently no consensus on clinically effective interventions for polypharmacy among older inpatients.

Objective

To evaluate the effect of multidisciplinary team-based medication optimization on survival, unscheduled hospital visits, and rehospitalization in older inpatients with polypharmacy.

Design, Setting, and Participants

This open-label randomized clinical trial was conducted at 8 internal medicine inpatient wards within a community hospital in Japan. Participants included medical inpatients 65 years or older who were receiving 5 or more regular medications. Enrollment took place between May 21, 2019, and March 14, 2022. Statistical analysis was performed from September 2023 to May 2024.

Intervention

The participants were randomly assigned to receive either an intervention for medication optimization or usual care including medication reconciliation. The intervention consisted of a medication review using the STOPP (Screening Tool of Older Persons' Prescriptions)/START (Screening Tool to Alert to Right Treatment) criteria, followed by a medication optimization proposal for participants and their attending physicians developed by a multidisciplinary team. On discharge, the medication optimization summary was sent to patients' primary care physicians and community pharmacists.

Main Outcomes and Measures

The primary outcome was a composite of death, unscheduled hospital visits, and rehospitalization within 12 months. Secondary outcomes included the number of prescribed medications, falls, and adverse events.

Results

Between May 21, 2019, and March 14, 2022, 442 participants (mean [SD] age, 81.8 [7.1] years; 223 [50.5%] women) were randomly assigned to the intervention (n = 215) and usual care (n = 227). The intervention group had a significantly lower percentage of patients with 1 or more potentially inappropriate medications than the usual care group at discharge (26.2% vs 33.0%; adjusted odds ratio [OR], 0.56 [95% CI, 0.33-0.94]; P = .03), at 6 months (27.7% vs 37.5%; adjusted OR, 0.50 [95% CI, 0.29-0.86]; P = .01), and at 12 months (26.7% vs 37.4%; adjusted OR, 0.45 [95% CI, 0.25-0.80]; P = .007). The primary composite outcome occurred in 106 participants (49.3%) in the intervention group and 117 (51.5%) in the usual care group (stratified hazard ratio, 0.98 [95% CI, 0.75-1.27]). Adverse events were similar between each group (123 [57.2%] in the intervention group and 135 [59.5%] in the usual care group).

Conclusions and Relevance

In this randomized clinical trial of older inpatients with polypharmacy, the multidisciplinary deprescribing intervention did not reduce death, unscheduled hospital visits, or rehospitalization within 12 months. The intervention was effective in reducing the number of medications with no significant adverse effects on clinical outcomes, even among older inpatients with polypharmacy.

Trial Registration

UMIN Clinical Trials Registry: UMIN000035265.

Pharmacist-led telehealth deprescribing for people living with dementia and polypharmacy in primary care: A pilot study

BACKGROUND

People living with dementia (PLWD) have complex medication regimens, exposing them to increased risk of harm. Pragmatic deprescribing strategies that align with patient-care partner goals are needed.

METHODS

A pilot study of a pharmacist-led intervention to optimize medications with patient-care partner priorities, ran May 2021-2022 at two health systems. PLWD with ≥7 medications in primary care and a care partner were enrolled. After an introductory mailing, dyads were randomized to a pharmacist telehealth intervention immediately (intervention) or delayed by 3 months (control). Feasibility outcomes were enrollment, intervention completion, pharmacist time, and primary care provider (PCP) acceptance of recommendations. To refine pragmatic data collection protocols, we assessed the Medication Regimen Complexity Index (MRCI; primary efficacy outcome) and the Family Caregiver Medication Administration Hassles Scale (FCMAHS).

RESULTS

69 dyads enrolled; 27 of 34 (79%) randomized to intervention and 28 of 35 (80%) randomized to control completed the intervention. Most visits (93%) took more than 20 min and required multiple follow-up interactions (62%). PCPs responded to 82% of the pharmacists' first messages and agreed with 98% of recommendations. At 3 months, 22 (81%) patients in the intervention and 14 (50%) in the control had ≥1 medication discontinued; 21 (78%) and 12 (43%), respectively, had ≥1 new medication added. The mean number of medications decreased by 0.6 (3.4) in the intervention and 0.2 (1.7) in the control, reflecting a non-clinically meaningful 1.0 (±12.4) point reduction in the MRCI among intervention patients and a 1.2 (±12.9) point increase among control. FCMAHS scores decreased by 3.3 (±18.8) points in the intervention and 2.5 (±14.4) points in the control.

CONCLUSION

Though complex, pharmacist-led telehealth deprescribing is feasible and may reduce medication burden in PLWD. To align with patient-care partner goals, pharmacists recommended deprescribing and prescribing. If scalable, such interventions may optimize goal-concordant care for PLWD.

Drug-Related Problems in Elderly Patients Attended to by Emergency Services

The progressive aging and comorbidities of the population have led to an increase in the number of patients with polypharmacy attended to in the emergency department. Drug-related problems (DRPs) have become a major cause of admission to these units, as well as a high rate of short-term readmissions. Anticoagulants, antibiotics, antidiabetics, and opioids have been shown to be the most common drugs involved in this issue. Inappropriate polypharmacy has been pointed out as one of the major causes of these emergency visits. Different ways of conducting chronic medication reviews at discharge, primary care coordination, and phone contact with patients at discharge have been shown to reduce new hospitalizations and new emergency room visits due to DRPs, and they are key elements for improving the quality of care provided by emergency services.