Barriers and enablers for deprescribing among older, multimorbid patients with polypharmacy: an explorative study from Switzerland

Exploring the need for a clinical decision support system for deprescribing - A qualitative interview study

Background

Deprescribing (i.e., the process of discontinuing an inappropriate medication) requires time, knowledge, and care, but there is a lack of education, support, and guidelines for this important clinical task. A clinical decision support system (CDSS) aims to influence the quality of care by combining structured medical knowledge with patient-specific information to generate recommendations.

Objective

The objective was to examine the need to develop a CDSS for drug deprescribing. Furthermore, this study aimed to examine the obstacles to deprescribing and potential users' requirements for a CDSS for deprescribing.

Methods

The qualitative design consisted of semistructured interviews with physicians (n = 10) in Sweden from different disciplines, including geriatrics, primary care and internal medicine. The interviews were conducted using a predefined guide containing multiple questions about any challenges related to deprescribing and the perceived need for a CDSS. A qualitative content analysis was performed to analyse the empirical data.

Results

The interviews provided several aspects of the difficulty of deprescribing medicines. The structure and usability of the CDSS knowledge database in clinical practice needs to be ensured from the outset. Physicians needs fast, simple and up-to-date information filtered, summarized and synthesized from reliable sources. The information should preferably be integrated into pre-existing electronic health record.

Conclusion

There is a need to develop a CDSS for deprescribing. There is little, if any, guidelines or support for deprescribing, which is regarded as a large obstacle. The current findings contribute to further knowledge regarding the perspective of physicians when deprescribing medication.

Social Determinants of Uncorrected Distance and Near Visual Impairment in an Older Adult Population

Purpose

Uncorrected visual impairment (VI) significantly impacts life quality and exacerbates age-related health issues. Social determinants of health (SDOH) are associated with uncorrected VI, but quantitative evidence is limited. This study investigated the link between SDOH and uncorrected VI among aging adults to identify disparities and improve vision care.

Methods

We used data from the Atherosclerosis Risk in Communities (ARIC) study visits 4 and 6 and the ancillary Eye Determinants of Cognition (EyeDOC) study. We included subjects who were >70 years old and extracted their sex, race, residence, household income, education level, having an eye doctor, health insurance status, and Area Deprivation Index (ADI) and vision outcomes. Uncorrected VI was categorized into uncorrected distance (UDVI) or near visual impairment (UNVI). Associations between SDOH indicators and VI were evaluated using logistic regressions.

Results

Among 967 adults (mean ± SD age, 78.6 ± 4.35 years; 37.9% male), UDVI was found in 293 and UNVI in 186. Living in Jackson, MS, was associated with lower odds for UNVI (adjusted odds ratio [aOR] = 0.36; 95% CI, 0.20-0.65). Higher odds for UNVI were associated with male sex (aOR = 2.01; 95% CI, 1.41-2.87), low educational attainment (aOR for not completing high school = 2.32; 95% CI, 1.37-3.92; aOR for high school only = 1.92; 95% CI, 1.26-2.92), no eye doctor (aOR = 1.58; 95% CI, 1.05-2.39), and having government health insurance only (aOR = 1.48; 95% CI, 1.00-2.17). Associations between SDOH factors and UDVI were weaker or non-existent.

Conclusions

This study links SDOH factors to uncorrected VI among older adults.

Translational Relevance

SDOH should be considered when designing interventions to reduce VI in vulnerable communities.

Deprescribing attitudes and predictors among older adults attending geriatric clinics in Kuwait

Deprescribing is defined as the reduction of medications to improve patient care. For effective deprescribing regular evaluation of medication adjustment regimens is required as it is documented to be an effective method to reduce polypharmacy and potentially inappropriate medications while improving patient well-being. Several factors, including patient-related aspects, influence the deprescribing process. Among these factors, patient willingness plays a pivotal role, making it essential to better understand their perspectives and attitudes towards medication use and deprescribing to successfully implement and maintain a deprescribing approach. We investigated the attitudes of older patients attending geriatric clinics in Kuwait toward deprescribing and identified predictors that influence their willingness to undergo this process. We enrolled patients aged ≥65 years who were attending geriatric clinics in primary care settings in Kuwait. These participants completed the revised Arabic version of the Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. The questionnaire was designed to assess the participants' willingness to participate actively in medication decision-making and their inclination toward discontinuing certain medicines. Descriptive statistics was applied to gain insight into the characteristics of the participants and their responses to the rPATD questionnaire. Binary logistic regression identified predictors influencing the desire to deprescribe among participants. The study included 535 participants, out of which 388 were analyzed, with 233 (43.6%) being women. The majority, 77% (n = 412), were aged between 65 and 74 years. Out of the total, 205 patients (38.4%) had one to two medical conditions and were prescribed between one and five medications. The participants showed a high willingness to deprescribe, and this willingness was inversely associated with sex (p = 0.15), age (p = 0.15), and polypharmacy (p = 0.044). Many older patients visiting geriatric clinics in primary care settings in Kuwait were receptive to the concept of deprescribing medications, particularly if advised by their doctor. Nevertheless, it was observed that male patients, individuals on more than 5 medications, and older age groups showed lower willingness to deprescribe.

Physicians and hospital pharmacists' knowledge, attitudes, and practices towards polypharmacy in older patients with chronic diseases

This web-based cross-sectional study aimed to evaluate the knowledge, attitudes, and practices of physicians and hospital pharmacists towards polypharmacy in older adult patients with chronic diseases in China. This study enrolled 374 physicians and pharmacists (270 females, 92 physicians) in 20 Chinese provinces between December 2022 and March 2023. The knowledge, attitude, and practice scores were 12.65 ± 2.05 (possible range, 0-18), 29.07 ± 2.68 (possible range, 7-35), and 26.16 ± 5.56 (possible range, 7-35), respectively. Working as a hospital pharmacist (vs. physician) was independently associated with adequate knowledge (OR = 2.190; 95% CI = 1.291-2.713; P = 0.004). Working in a tertiary hospital (OR = 4.296; 95% CI = 1.390-13.272; P = 0.011) was independently associated with a positive attitude. Knowledge score (OR = 1.176; 95%CI = 1.038-1.333; P = 0.011), hospital pharmacist (OR = 0.276; 95% CI = 0.137-0.557; P < 0.001), master's degree or higher (OR = 1.754; 95% CI  = 1.011-3.045; P = 0.046) and senior professional title (OR = 2.020; 95% CI = 1.032-3.952; P = 0.040) were independently associated with proactive practice toward polypharmacy in older adults. Physicians and hospital pharmacists had favorable knowledge, positive attitudes, and proactive practice toward polypharmacy. In conclusion, enhancing knowledge through continuous education, promoting interprofessional collaboration, educating patients, and conducting regular evaluations for quality improvement are necessary to improve the KAP of healthcare professionals toward polypharmacy in older adults.

Current Landscape and Future Directions of Deprescribing and Polypharmacy Practices in Jordan

This review explores the current landscape and future directions of deprescribing and polypharmacy practices in Jordan. The prevalence of polypharmacy, defined as the concurrent use of multiple medications by an individual, has been increasing in recent years due to various factors, such as population aging and the greater availability of medications. However, polypharmacy can lead to adverse drug events, suboptimal medication adherence, increased healthcare costs, and reduced quality of life. Deprescribing, on the other hand, involves the discontinuation or reduction of unnecessary or potentially harmful medications to improve patient outcomes. The findings presented in this review highlight the current state of deprescribing and polypharmacy practices in Jordan, including factors influencing their prevalence. Additionally, it discusses the challenges healthcare professionals face in implementing deprescribing strategies and identifies potential solutions for enhancing these practices in Jordanian healthcare settings. Moreover, this paper provides insights into future directions for deprescribing and polypharmacy practices in Jordan. Overall, this review offers valuable insights into the current landscape of deprescribing and polypharmacy practices in Jordan while also providing recommendations for future directions to optimize medication management strategies that can ultimately benefit patient outcomes within a sound healthcare system framework.

Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scoping review

INTRODUCTION

Polypharmacy and multimorbidity pose escalating challenges. Despite numerous attempts, interventions have yet to show consistent improvements in health outcomes. A key factor may be varied approaches to targeting patients for intervention.

OBJECTIVES

To explore how patients are targeted for intervention by examining the literature with respect to: understanding how polypharmacy is defined; identifying problematic polypharmacy in practice; and addressing problematic polypharmacy through interventions.

DESIGN

We performed a scoping review as defined by the Joanna Briggs Institute.

SETTING

The focus was on primary care settings.

DATA SOURCES

Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and Cochrane along with ClinicalTrials.gov, Science.gov and WorldCat.org were searched from January 2004 to February 2024.

ELIGIBILITY CRITERIA

We included all articles that had a focus on problematic polypharmacy in multimorbidity and primary care, incorporating multiple types of evidence, such as reviews, quantitative trials, qualitative studies and policy documents. Articles focussing on a single index disease or not written in English were excluded.

EXTRACTION AND ANALYSIS

We performed a narrative synthesis, comparing themes and findings across the collective evidence to draw contextualised insights and conclusions.

RESULTS

In total, 157 articles were included. Case-finding methods often rely on basic medication counts (often five or more) without considering medical history or whether individual medications are clinically appropriate. Other approaches highlight specific drug indicators and interactions as potentially inappropriate prescribing, failing to capture a proportion of patients not fitting criteria. Different potentially inappropriate prescribing criteria also show significant inconsistencies in determining the appropriateness of medications, often neglecting to consider multimorbidity and underprescribing. This may hinder the identification of the precise population requiring intervention.

CONCLUSIONS

Improved strategies are needed to target patients with polypharmacy, which should consider patient perspectives, individual factors and clinical appropriateness. The development of a cross-cutting measure of problematic polypharmacy that consistently incorporates adjustment for multimorbidity may be a valuable next step to address frequent confounding.

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.

Effectiveness and cost-effectiveness of a collaborative deprescribing intervention of proton-pump-inhibitors on community-dwelling older adults: Protocol for the C-SENIoR, a pragmatic non-randomized controlled trial

INTRODUCTION

Worldwide, demographic ageing is a major social, economic and health challenge. Despite the increase in life expectancy, elderly often live with multiple chronic conditions, exposing them to multiple medications. Concerns have been raised about the growing issue of inappropriate long-term usage of proton-pump inhibitors (PPI), which have been associated with adverse outcomes and increased healthcare costs. Deprescribing is a recommended intervention to reduce or withdraw medicines that might be causing harm or might no longer be of benefit. This protocol details a trial to assess the effectiveness and cost-effectiveness of a collaborative deprescribing intervention of PPI among community-dwelling elderly, involving community pharmacists and general practitioners.

METHODS AND ANALYSIS

A pragmatic, multicentre, two-arm, non-randomised controlled trial of a structured PPI collaborative deprescribing intervention in the primary care setting with a 6-month follow-up will be conducted. Patients must be 65 years old or older, live in the community and have been using PPI for more than 8 weeks. We hypothesize that the intervention will reduce the PPI usage in the intervention group compared to the control group. The primary outcome is the successful discontinuation or dose decrease of any PPI, defined as a statistically significant absolute 20% reduction in medication use between the intervention and control groups at 3- and 6-month follow-ups. An economic evaluation will be conducted alongside the trial. This study was approved by the Ethics Research Committee of Nova Medical School, NOVA University of Lisbon and by the Ethics Committee from the Local Health Unit Alto Minho, Portugal.

DISCUSSION

This pragmatic trial will provide evidence on the effectiveness and cost-effectiveness of a patient-centred collaborative deprescribing intervention in the community setting in Portugal. It will also inform improvements for the development of future multi-faceted interventions that aim to optimise medication for the community-dwelling elderly.

CLINICAL TRIAL REGISTRATION

ISRCTN 49637686.

The Frailty Reduction via Implementation of Exercise, Nutrition, and Deprescribing (FRIEND) Trial: Study Protocol and Recruitment Results

INTRODUCTION

Virtually all adults in aged care facilities are frail, a condition which contributes to falls, cognitive decline, hospitalisation, and mortality. Polypharmacy, malnutrition, sedentariness, and sarcopenia are risk factors amenable to intervention. The Asia-Pacific Frailty Management Guidelines recommend anabolic exercise and the optimisation of medications and nutrition. However, no study has evaluated this best practice intervention triad in aged care.

METHODS

The Frailty Reduction via the Implementation of Exercise, Nutrition, and Deprescribing (FRIEND) Trial (ANZCTR No.ACTRN12622000926730p) is a staged 6-month translational trial evaluating resident outcomes, staff/caregiver knowledge, and institutional implementation in a Townsville aged care facility. Residents received high-intensity resistance exercise and balance training and medication and nutrition optimisation co-implemented by investigators (exercise physiologist, geriatrician, pharmacist, and nutritionist) and facility staff. Staff and caregivers completed comprehensive education modules and training. We report the trial protocol and recruitment results.

RESULTS

29 residents (21 female, age: 88.6 ± 6.3 years) were recruited. At baseline, the residents were frail (frailty scale nursing home (FRAIL-NH); 6.3 ± 2.4/14), cognitively impaired (Montreal Cognitive Assessment; 13.8 ± 6.8/30), functionally impaired (Short Physical Performance Battery; 4.9 ± 3.1/12, 6 min walk distance; 222.2 ± 104.4 m), and were prescribed numerous medications (15.5 ± 5.9). Two residents died and one withdrew before the intervention's commencement. Thirty family members and 19 staff (carers, allied health assistants, nurse managers, registered nurses, lifestyle-leisure officers, kitchen/hospitality staff, and senior leadership) were recruited to receive frailty education modules.

CONCLUSIONS

The FRIEND trial is currently being implemented with results expected in mid-2024. This is the first trial to evaluate the implementation of the best practice frailty guidelines including anabolic exercise and medication/nutritional optimisation in residential aged care.

Barriers and enablers to deprescribing of older adults and their caregivers: a systematic review and meta-synthesis

PURPOSE

The primary objective of this study was to identify the barriers and enablers to deprescribing from the viewpoint of community-dwelling older adults and their caregivers.

METHODS

This meta-synthesis included a systematic review of the literature and an inductive thematic synthesis. Medline and EMBASE were searched for studies that qualitatively explored the perspectives of older adults or their caregivers on deprescribing. Studies had to use qualitative methodologies and include community-dwelling adults (or their caregivers) aged 60 years or older who were taking one or more chronic medications. The quality of studies was assessed using the CASP tool.

RESULTS

Fourteen studies were included in the meta-synthesis. All studies included older adults, and 3 included caregivers or companions. Four barriers were identified: favorable perceptions of medications, fear of medication discontinuation, the complexity of the healthcare system and discouragement from healthcare professionals; and seven enablers were identified: medication safety concerns, patient autonomy and confidence, education, follow-up, deprescribing strategies, relationships with physicians, and patient-perceived benefits of deprescribing.

CONCLUSION

Multiple barriers and enablers to deprescribing exist within the older adult population. Health system complexity and direct discouragement from healthcare providers were barriers uniquely identified in the older adult population. This population would benefit from interventions to increase their medication literacy, confidence, and autonomy in the deprescribing journey.

Impact of a deprescribing tool on the use of sedative hypnotics among older patients: study protocol for a cluster randomised controlled trial in Swiss primary care (the HYPE trial)

INTRODUCTION

Benzodiazepines and other sedative hypnotics (BSH) are potentially inappropriate and harmful medications in older people due to their higher susceptibility for adverse drug events. BSH prescription rates are constantly high among elderly patients and even increase with higher age and comorbidity. Deprescribing BSH can be challenging both for healthcare providers and for patients for various reasons. Thus, physicians and patients may benefit from a supportive tool to facilitate BSH deprescribing in primary care consultations. This study intends to explore effectiveness, safety, acceptance and feasibility of such a tool.

METHODS AND ANALYSIS

In this prospective, cluster randomised, controlled, two-arm, double-blinded trial in the ambulatory primary care setting, we will include general practitioners (GPs) from German-speaking Switzerland and their BSH consuming patients aged 65 years or older, living at home or in nursing homes. GPs will be randomly assigned to either intervention or control group. In the intervention group, GPs will participate in a 1-hour online training on how to use a patient support tool (decision-making guidance plus tapering schedule and non-pharmaceutical alternative treatment suggestions for insomnia). The control group GPs will participate in a 1-hour online instruction about BSH epidemiology and sleep hygiene counselling. This minimal intervention aims to prevent unblinding of control group GPs without jeopardising their 'usual care'.The primary outcome will be the percentage of patients who change their BSH use (ie, stop, reduce or switch to a non-BSH insomnia treatment) within 6 months from the initial consultation.

EXPECTED BENEFIT

Based on the results of the study, we will learn how GPs and their patients benefit from a supportive tool that facilitates BSH deprescribing in primary care consultations. The study will emphasise on exploring barriers and facilitators to BSH deprescribing among patients and providers. Positive results given, the study will improve medication safety and the quality of care for patients with sleeping disorders.

ETHICS AND DISSEMINATION

The study has been approved by the Ethics Committee of the Canton of Zurich (KEK-ZH Ref no. 2023-00054, 4 April 2023). Informed consent will be sought from all participating GPs and patients. The results of the study will be publicly disseminated.

TRIAL REGISTRATION NUMBER

ISRCTN34363838.

The Barriers to Deprescription in Older Patients: A Survey of Spanish Clinicians

BACKGROUND AND OBJECTIVE

There are barriers to deprescription that hinder its implementation in clinical practice. The objective of this study was to analyse the main barriers and limitations of the deprescription process perceived by physicians who care for multipathological patients.

MATERIALS AND METHODS

The "deprescription questionnaire of elderly patients" was adapted to an online format and sent to physicians in geriatrics. Question 1 is a reference to establish agreement or disagreement with this practice. The influence of different aspects of deprescription was analysed via the demographic characteristics of the clinicians and perceptions of the various barriers (questions 2-9) by means of bivariate analysis. Based on the latter, a multivariate model was carried out to demonstrate the relationship between barriers and the degree of deprescription agreement among respondents.

RESULTS

Of the 72 respondents, 72.2% were in favour of deprescribing. Regarding the analyses, the demographic characteristics did not influence rankings. The deprescription of preventive drugs and consensus with patients were associated with a positive attitude towards deprescribing, while withdrawing drugs prescribed by other professionals, time constraints and patient reluctance emerged as possible barriers. The only factor independently associated with deprescribing was lack of time.

CONCLUSIONS

Time was found to be the main barrier to deprescription. Training, the creation of multidisciplinary teams and integrated health systems are key facilitators.

Feasibility and effectiveness of deprescribing benzodiazepines and Z-drugs: systematic review and meta-analysis

BACKGROUND AND AIMS

A total of 2.4 million adults in England were dispensed a benzodiazepine or Z-drug (BZRA) in 2017/18, and more than 250 000 patients in the UK take BZRAs beyond the recommended duration. Deprescribing is a clinician-guided process of withdrawing inappropriate drugs. This review aimed to evaluate the evidence base supporting the feasibility and clinical effectiveness of all forms of deprescribing initiatives used to discontinue long-term (≥ 4 weeks) BZRAs.

METHOD

Systematic review of randomized controlled trials evaluating BZRAs deprescribing among adults in community, primary or outpatient settings. MEDLINE, Embase and PsycINFO were searched from inception to February 2021. Primary outcomes were successful discontinuation in the short (< 4 weeks) or long term (≥ 4 weeks) and the occurrence of withdrawal symptoms, behavioural or psychological symptoms. Studies were categorized as pharmacological or non-pharmacological supported interventions. Study quality was assessed using the Cochrane risk-of-bias tool. Where appropriate, risk ratios (RRs), mean differences and 95% confidence intervals (CIs) were calculated, and Mantel-Haenszel methods using the random-effect meta-analysis was undertaken to calculate summary effect estimates.

RESULTS

Ten studies were included (n = 1431 participants). Heterogeneity in study design and effect was observed. Benzodiazepines were successfully deprescribed when gradually tapered with non-pharmacological support compared with gradual tapering alone in the short term (n = 124; RR = 2.02; 95% CI = 1.41, 2.89) and long term (n = 123; RR = 2.45; 95% CI = 1.56, 3.85). Benzodiazepine deprescribing was more successful when supported by non-pharmacological methods versus routine care (n = 189; RR = 3.26; 95% CI = 2.36, 4.51). Quality of evidence reporting effectiveness was very low to low.

CONCLUSIONS

It may be feasible to deprescribe benzodiazepines depending on the process and support mechanisms employed.

Barriers and facilitators to deprescribing of cardiovascular medications: a systematic review

OBJECTIVE

To synthesise the current knowledge on barriers and facilitators to deprescribing cardiovascular medications (CVMs) at the levels of patients, informal caregivers and healthcare providers (HCPs).

DESIGN/SETTING

We conducted a systematic review of studies exploring/assessing patient, informal caregiver and/or HCP barriers and/or facilitators to deprescribing CVMs.

DATA SOURCES

Ovid/MEDLINE and Embase from January 2003 to November 2021.

DATA EXTRACTION AND SYNTHESIS

We performed a deductive thematic analysis based on the framework of specific barriers and facilitators to deprescribing CVMs created by Goyal et al. We added a quantification of the occurrence of categories and themes in the selected articles to identify the resounding themes that indicate the greater impetus to address in future research.

RESULTS

Most frequent deprescribing barriers for patients, informal caregivers and HCPs included uncertainty due to lack of evidence regarding CVM deprescribing (in n=10 studies), fear of negative consequences following deprescribing (n=13) and social influences (n=14). A frequently reported facilitator to deprescribing, especially for patients and informal caregivers, was the occurrence of adverse drug events (n=7). Another frequently reported facilitator for patients were dislike of CVMs (n=9). Necessity and benefit of CVMs were seen as barriers or facilitators similarly by patients and HCPs.

CONCLUSION

The differences in patient, informal caregiver and HCP regarding barriers and facilitators to deprescribing CVMs stress the need for ground discussions about beliefs and preferences of each stakeholder implicated in deprescribing decisions. Furthermore, HCP uncertainty regarding CVM deprescribing highlights the need to provide HCPs with tools that enable sharing the risks and benefits of deprescribing with patients and ensure a safe deprescribing process.

PROSPERO REGISTRATION NUMBER

CRD42020221973.

Feasibility of a protocol for deprescribing antihypertensive medication in older patients in Dutch general practices

BACKGROUND

Older patients using antihypertensive medication may experience Adverse Drug Events (ADEs), and thus benefit from deprescribing. The lack of a practical protocol may hamper deprescribing. Therefore, we aimed to develop a deprescribing protocol, based on a review of literature, combined with a feasibility test in a small number of patients.

METHODS

A deprescribing protocol for general practitioners was drafted and tested in older patients using multiple antihypertensive medication in a single arm intervention. Patients were included if they were 75 years or older, were using two or more antihypertensives, had at least one ADE linked to antihypertensive medication and deprescribing was considered to be safe by their general practitioner. The primary outcome was the percentage of patients for whom one or more antihypertensive drugs were stopped or reduced in dose after 12 months of follow up while maintaining safe blood pressures. Secondary outcomes were the proportion of patients reporting no ADEs after 12 months and the number of deprescribed antihypertensives. Patient's opinions on deprescribing and enablers and barriers for study participation were also collected.

RESULTS

Nine general practitioners included 14 patients to deprescribe antihypertensive medication using the deprescribing protocol. After 12 months antihypertensive drug use was lowered in 11 patients (79%). These patients had a mean systolic blood pressure increase of 16 mmHg and a mean diastolic blood pressure increase of 8 mmHg. Nine patients (64%) reported experiencing no ADEs anymore after twelve months. The mean number of deprescribed antihypertensives was 1.1 in all patients and 1.4 (range: 0.5 to 3.5) in patients who successfully lowered their medication. At baseline, being able to use less medication was the most frequently mentioned enabler to participate in this study. The most frequently mentioned positive experience at the end of the study was using less medication, which was in line with the most mentioned enabler to participate in this study.

CONCLUSION

A protocol for deprescribing antihypertensives in older patients was considered feasible, as it resulted in a substantial degree of safe deprescribing in this pilot study. Larger studies are needed to demonstrate the effect and safety of deprescribing antihypertensives in older patients.

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.

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

BACKGROUND

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis

BACKGROUND

Tackling problematic polypharmacy requires tailoring the use of medicines to individual needs and circumstances. This may involve stopping medicines (deprescribing) but patients and clinicians report uncertainty on how best to do this. The TAILOR medication synthesis sought to help understand how best to support deprescribing in older people living with multimorbidity and polypharmacy.

OBJECTIVES

We identified two research questions: (1) what evidence exists to support the safe, effective and acceptable stopping of medication in this patient group, and (2) how, for whom and in what contexts can safe and effective tailoring of clinical decisions related to medication use work to produce desired outcomes? We thus described three objectives: (1) to undertake a robust scoping review of the literature on stopping medicines in this group to describe what is being done, where and for what effect; (2) to undertake a realist synthesis review to construct a programme theory that describes 'best practice' and helps explain the heterogeneity of deprescribing approaches; and (3) to translate findings into resources to support tailored prescribing in clinical practice.

DATA SOURCES

Experienced information specialists conducted comprehensive searches in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (targeted searches).

REVIEW METHODS

The scoping review followed the five steps described by the Joanna Briggs Institute methodology for conducting a scoping review. The realist review followed the methodological and publication standards for realist reviews described by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) group. Patient and public involvement partners ensured that our analysis retained a patient-centred focus.

RESULTS

Our scoping review identified 9528 abstracts: 8847 were removed at screening and 662 were removed at full-text review. This left 20 studies (published between 2009 and 2020) that examined the effectiveness, safety and acceptability of deprescribing in adults (aged ≥ 50 years) with polypharmacy (five or more prescribed medications) and multimorbidity (two or more conditions). Our analysis revealed that deprescribing under research conditions mapped well to expert guidance on the steps needed for good clinical practice. Our findings offer evidence-informed support to clinicians regarding the safety, clinician acceptability and potential effectiveness of clinical decision-making that demonstrates a structured approach to deprescribing decisions. Our realist review identified 2602 studies with 119 included in the final analysis. The analysis outlined 34 context-mechanism-outcome configurations describing the knowledge work of tailored prescribing under eight headings related to organisational, health-care professional and patient factors, and interventions to improve deprescribing. We conclude that robust tailored deprescribing requires attention to providing an enabling infrastructure, access to data, tailored explanations and trust.

LIMITATIONS

Strict application of our definition of multimorbidity during the scoping review may have had an impact on the relevance of the review to clinical practice. The realist review was limited by the data (evidence) available.

CONCLUSIONS

Our combined reviews recognise deprescribing as a complex intervention and provide support for the safety of structured approaches to deprescribing, but also highlight the need to integrate patient-centred and contextual factors into best practice models.

FUTURE WORK

The TAILOR study has informed new funded research tackling deprescribing in sleep management, and professional education. Further research is being developed to implement tailored prescribing into routine primary care practice.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018107544 and PROSPERO CRD42018104176.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 32. See the NIHR Journals Library website for further project information.

The Prevalence of Polypharmacy and Potentially Inappropriate Medications and Its Relationship with Cognitive Status in Portuguese Institutionalized Older Adults: A Cross-Sectional Study

The aim of this study was to evaluate the prevalence of polypharmacy and potentially inappropriate medications (PIMs) in a population of older adults living in nursing homes. Furthermore, we also intended to assess the possible association between polypharmacy, potentially inappropriate medications and cognitive impairment in institutionalized older adults. A cross-sectional study analyzed data from 193 nursing home residents in the district of Viseu, Portugal, between September 2018 and June 2019, with a mean age of 82.4 ± 6.2 years (ranging from 65 to 95 years old); 72.5% (n = 140) were female participants. Major polypharmacy was presented in 80.8% of the study population, who took 7.6 ± 3.3 drugs per day. Using the Beers Criteria, we found that 79.3% took PIMs. There was a positive association between polypharmacy and PIM (p < 0.001), showing that higher medicines intake increased the number of PIMs. Polypharmacy was not associated with the functionality of the older adults to perform activities of daily living, but was associated with cognitive impairment. The older adults with lower scores on the Mini Mental State Examination (MMSE) took more drugs (p = 0.039) and used more PIM (p < 0.001). Moreover, patients taking five or more prescription drugs per day (major polypharmacy) consuming any psychiatric, gastrointestinal or oral antidiabetic agents (regardless of whether they were considered potentially inappropriate or not) had higher odds of displaying cognitive impairment than those who did not (p < 0.05). Older adult residents of the studied nursing homes were potentially affected by polypharmacy and inappropriate polypharmacy. This observation reveals the need to adopt and implement strategies that make drug therapy more adequate and safer for older adults.

Barriers and enablers to deprescribing in long-term care facilities: a 'best-fit' framework synthesis of the qualitative evidence

INTRODUCTION

older adults are at risk of adverse outcomes due to a high prevalence of polypharmacy and potentially inappropriate medications (PIMs). Deprescribing interventions have been demonstrated to reduce polypharmacy and PIMs. However, deprescribing is not performed routinely in long-term care facilities (LTCFs). This qualitative evidence synthesis aims to identify the factors which limit and enable health care workers' (HCWs) engagement with deprescribing in LTCFs.

METHODS

the 'best-fit' framework approach was used to synthesise evidence by using the Theoretical Domains Framework (TDF) as the a priori framework. Included studies were analysed qualitatively to identify LTCF barriers and enablers of deprescribing and were mapped to the TDF. Constructs within domains were refined to best represent the LTCF context. A conceptual model was created, hypothesising relationships between barriers and enablers.

RESULTS

of 655 records identified, 14 met the inclusion criteria. The 'best-fit' framework included 17 barriers and 16 enablers, which mapped to 11 of the 14 TDF domains. Deprescribing barriers included perceptions of an 'established hierarchy' within LTCFs, negatively affecting communication and insufficient resources which limited HCWs' engagement with deprescribing. Enablers included tailored deprescribing guidelines, interprofessional support and working with a patient focus, allowing the patients' condition to influence decisions.

DISCUSSION

this study identified that education, interprofessional support and collaboration can facilitate deprescribing. To overcome deprescribing barriers, change is required to a patient-centred model and HCWs need to be equipped with necessary resources and adequate reimbursement. The LTCF organisational structure must support deprescribing, with communication between health care systems.

Reviewing Potentially Inappropriate Medication in Hospitalized Patients Over 65 Using Explicit Criteria: A Systematic Literature Review

Potentially inappropriate medication (PIM) is a primary health concern affecting the quality of life of patients over 65. PIM is associated with adverse drug reactions including falls, increased healthcare costs, health services utilization and hospital admissions. Various strategies, clinical guidelines and tools (explicit and implicit) have been developed to tackle this health concern. Despite these efforts, evidence still indicates a high prevalence of PIM in the older adult population. This systematic review explored the practice of using explicit tools to review PIM in hospitalized patients and examined the outcomes of PIM reduction. A literature search was conducted in several databases from their inception to 2019. Original studies that had an interventional element using explicit criteria detecting PIM in hospitalized patients over 65 were included. Descriptive narrative synthesis was used to analyze the included studies. The literature search yielded 6116 articles; 25 quantitative studies were included in this systematic literature review. Twenty were prospective studies and five were retrospective. Approximately, 15,500 patients were included in the review. Various healthcare professionals were involved in reviewing PIM including physicians and hospital pharmacists. Several tools were used to review PIM for hospitalized patients over 65, most frequently Beer’s criteria and the STOPP/START tool. The reduction of PIM ranged from 3.5% up to 87%. The most common PIM were benzodiazepines and antipsychotics. This systematic review showed promising outcomes in terms of improving patient outcomes. However, the reduction of PIM varied in the studies, raising the question of the variance between hospitals in the explicit tools used for review. Additional studies need to be conducted to further investigate the outcomes of reviewing PIM at different levels, as well as assessing the cost-effectiveness of using explicit tools in reducing PIM.

Implementation of a complex intervention to improve hospital discharge: process evaluation of a cluster randomised controlled trial

OBJECTIVES

To study the implementation of a cluster randomised controlled effectiveness-implementation hybrid trial testing the effectiveness of a medication review at hospital discharge combined with a communication stimulus between hospital physicians (HPs) and general practitioners (GPs) on rehospitalisation of multimorbid older patients.

DESIGN

Extension of Grant's mixed method process evaluation framework to trials with multilevel clustering.

SETTING

General internal medicine wards in Swiss hospitals.

PARTICIPANTS

Convenience samples of 15 chief physicians (of 21 hospitals participating in the effectiveness trial), 60 (74) senior HPs, 65 (164) junior HPs and 187 (411) GPs.

IMPLEMENTATION STRATEGY

Two-hour teaching sessions for senior HPs on a patient-centred, checklist-guided discharge routine.

PROCESS EVALUATION COMPONENTS

Data collection on recruitment, delivery and response from chief physicians (semistructured interviews), senior HPs, junior HPs, GPs (surveys) and patients (via HPs). Quantitative data were summarised using descriptive statistics, and interviews analysed using thematic analysis.

OUTCOME MEASURES

Intervention dose (quantitative), implementation fidelity (qualitative), feasibility and acceptability, facilitators and barriers, implementation support strategies.

RESULTS

Recruitment of hospitals was laborious but successful, with 21 hospitals recruited. Minimal workload and a perceived benefit for the clinic were crucial factors for participation. Intervention dose was high (95% of checklist activities carried out), but intervention fidelity was limited (discharge letters) or unknown (medication review). Recruitment and retention of patients was challenging, partly due to patient characteristics (old, frail) and the COVID-19 pandemic: Only 612 of the anticipated 2100 patients were recruited, and 31% were lost to follow-up within the first month after discharge. The intervention was deemed feasible and helpful by HPs, and the relevance of the topic appreciated by both HPs and GPs.

CONCLUSIONS

The results from this evaluation will support interpretation of the findings of the effectiveness study and may inform researchers and policy makers who aim at improving hospital discharge.

TRIAL REGISTRATION NUMBER

ISRCTN18427377.

Emerging approaches to polypharmacy among older adults

Polypharmacy is a major health issue for older adults. Entangled with several geriatric syndromes, including frailty, falls and cognitive decline, research focused on polypharmacy has been challenged by heterogeneity in its definition, confounding by comorbidities and limited prospective data. In this Review, we discuss varying definitions for polypharmacy and highlight the need for a uniform definition for future studies. We critically appraise strategies for reducing medication prescriptions and implementing deprescribing as a mechanism to reduce the potential harmful effects of polypharmacy. As we look to the future, we assess the role of novel analytics and high-throughput technology, including multiomics profiling, to advance research in polypharmacy and the development of new strategies for risk stratification in the age of precision medicine.

Beliefs and attitudes about deprescription in older HIV-infected patients: ICARD Project

OBJECTIVE

HIV population is aging at an earlier age than those uninfected, requiring more non-HIV medications to treat noncommunicable diseases. In the context of chronic HIV infection, the next therapeutic change would be the polymedication control. This paper has the purpose of explore the attitudes of older people living with HIV toward deprescribing.

METHODS

This was an observational, prospective and multicenter study conducted from March-April, 2018. People living with HIV (PLWH) on highly active antiretroviral therapy and older than 65 years were included. In addition to demographic and pharmacotherapeutic data, attitudes regarding deprescribing were collected through the "Revised Patients' Attitudes Towards Deprescribing Questionnaire".

RESULTS

A total of 42 patients were included in this study. Regarding their attitudes in relation to deprescription, there were three statements with the most consensuses. The first ("I have a good understanding of the reasons I was prescribed each of my medicines") had 91.9% consensus. The second and third questions showed 89.2% consensus in both cases; "Overall, I am satisfied with my current medicines" and "I like to be involved in making decisions about my medicines with my doctors".

CONCLUSIONS

This study is the first to explore the beliefs and attitudes of older PLWH in relation to deprescription process. There are positive attitudes regarding medication knowledge but there also is a percentage of patients who had a negative opinion regarding deprescription. We must study and go deeper in our knowledge of techniques that could help us to better understand their preferences, in order to establish effective and successful deprescription strategies.

Barriers to conducting deprescribing in the elderly population amid the COVID-19 pandemic

Deprescribing aims to reduce polypharmacy, especially in the elderly population, in order to maintain or improve quality of life, reduce harm from medications, and limit healthcare expenditure. Coronavirus disease (COVID-19) is an infectious disease that has led to a pandemic and has changed the lives many throughout the world. The mode of transmission of this virus is from person to person through the transfer of respiratory droplets. Therefore, non-essential healthcare services involving direct patient interactions, including deprescribing, has been on hiatus to reduce spread. Barriers to deprescribing before the pandemic include patient and system related factors, such as resistance to change, patient's knowledge deficit about deprescribing, lack of alternatives for treatment of disease, uncoordinated delivery of health services, prescriber's attitudes and/or experience, limited availability of guidelines for deprescribing, and lack of evidence on preventative therapy. Some of these barriers can be mitigated by using the following interventions:patient education, prioritization of non-pharmacological therapy, incorporation of electronic health record (EHR), continuous prescriber education, and development of research studies on deprescribing. Currently, deprescribing cannot be delivered through in person interactions, so virtual care is a reasonable alternative format. The full incorporation of EHR throughout Canada can add to the success of this strategy. However, there are several challenges of conducting deprescribing virtually in the elderly population. These challenges include, but are not limited, to their inability to use technology, lack of literacy, lack of assistance from others, greater propensity for withdrawal effects, and increased risk of severe consequences, if hospitalized. Virtual care is the future of healthcare and in order to retain the benefits of deprescribing, additional initiatives should be in place to address the challenges that elderly patients may experience in accessing deprescribing virtually. These initiatives should involve teaching elderly patients how to use technology to access health services and with technical support in place to address any concerns.

Effect of a patient-centred deprescribing procedure in older multimorbid patients in Swiss primary care - A cluster-randomised clinical trial

Background

Management of patients with polypharmacy is challenging, and evidence for beneficial effects of deprescribing interventions is mixed. This study aimed to investigate whether a patient-centred deprescribing intervention of PCPs results in a reduction of polypharmacy, without increasing the number of adverse disease events and reducing the quality of life, among their older multimorbid patients.

Methods

This is a cluster-randomised clinical study among 46 primary care physicians (PCPs) with a 12 months follow-up. We randomised PCPs into an intervention and a control group. They recruited 128 and 206 patients if ≥60 years and taking ≥five drugs for ≥6 months. The intervention consisted of a 2-h training of PCPs, encouraging the use of a validated deprescribing-algorithm including shared-decision-making, in comparison to usual care. The primary outcome was the mean difference in the number of drugs per patient (dpp) between baseline and after 12 months. Additional outcomes focused on patient safety and quality of life (QoL) measures.

Results

Three hundred thirty-four patients, mean [SD] age of 76.2 [8.5] years participated. The mean difference in the number of dpp between baseline and after 12 months was 0.379 in the intervention group (8.02 and 7.64; p = 0.059) and 0.374 in the control group (8.05 and 7.68; p = 0.065). The between-group comparison showed no significant difference at all time points, except for immediately after the intervention (p = 0.002). There were no significant differences concerning patient safety nor QoL measures.

Conclusion

Our straight-forward and patient-centred deprescribing procedure is effective immediately after the intervention, but not after 6 and 12 months. Further research needs to determine the optimal interval of repeated deprescribing interventions for a sustainable effect on polypharmacy at mid- and long-term. Integrating SDM in the deprescribing process is a key factor for success.

Trial registration

Current Controlled Trials, prospectively registered ISRCTN16560559 Date assigned 31/10/2014.

The Prevention of Polypharmacy in Primary Care Patients Trial (4P-RCT).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-020-01870-8.

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

Background

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

Methods

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

Result

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

Conclusions

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

Supplementary Information

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

Issues with deprescribing in haemodialysis: a qualitative study of patient and provider experiences

RATIONALE, AIMS AND OBJECTIVES

Patients undergoing haemodialysis receive on average 10-17 medications, which increase the risk of falls, adverse drug reactions and hospitalizations. Supervised discontinuation of potentially inappropriate medications may lower these risks. Although many calls have been made for deprescribing in the haemodialysis setting, little is known about how patients and providers in this setting experience it. The aim of this study is to explore patient and provider experiences and perceptions of one of the rare deprescribing intervention in haemodialysis.

METHODS

Ten semi-structured interviews were held with patients, and a focus group was done with dialysis clinic team members at a Montreal area health network's haemodialysis clinic after the implementation of a standardized deprescribing intervention using the patient-as-partner approach. The interviews and focus group were recorded, and verbatims were coded to determine emerging themes. Grounded theory was used for interview guide design and data analysis.

RESULTS

The three emerging themes were (1) ambivalence towards medication creating a favourable context for deprescribing, (2) the empowering elements of the deprescribing process and (3) the uncertain future of deprescribing in the clinics even though the intervention was considered successful.

CONCLUSION

Haemodialysis patients and providers viewed deprescribing favourably, believed the intervention was valuable, and offered suggestions for long term implementation while expressing concerns about feasibility. Notwithstanding the underlying uncertainties, a structured and integrated approach in routine practice involving all members of the care team may facilitate the continuity of deprescribing as an intervention in the setting of a haemodialysis clinic.

The Double Burden of the COVID-19 Pandemic and Polypharmacy on Geriatric Population - Public Health Implications

COVID-19 pandemic is inducing acute respiratory distress syndrome, multi-organ failure, and eventual death. Respiratory failure is the leading cause of mortality in the elderly population with pre-existing medical conditions. This group is particularly vulnerable to infections due to a declined immune system, comorbidities, geriatric syndrome, and potentially inappropriate polypharmacy. These conditions make the elderly population more susceptible to the harmful effects of medications and the deleterious consequences of infections, including MERS-CoV, SARS-CoV, and SARS-CoV-2. Chronic diseases among elderlies, including respiratory diseases, hypertension, diabetes, and coronary heart diseases, present a significant challenge for healthcare professionals. To comply with the clinical guidelines, the practitioner may prescribe a complex medication regimen that adds up to the burden of pre-existing treatment, potentially inducing adverse drug reactions and leading to harmful side-effects. Consequently, the geriatric population is at increased risk of falls, frailty, and dependence that enhances their susceptibility to morbidity and mortality due to SARS-CoV-2 respiratory syndrome, particularly interstitial pneumonia. The major challenge resides in the detection of infection that may present as atypical manifestations in this age group. Healthy aging can be possible with adequate preventive measures and appropriate medication regimen and follow-up. Adherence to the guidelines and recommendations of WHO, CDC, and other national/regional/international agencies can reduce the risks of SARS-CoV-2 infection. Better training programs are needed to enhance the skill of health care professionals and patient’s caregivers. This review explains the public health implications associated with polypharmacy on the geriatric population with pre-existing co-morbidities during the COVID-19 pandemic.

Deprescribing in nursing homes: Protocol for nested, randomised controlled hybrid trials of deprescribing interventions

INTRODUCTION

Polypharmacy and the use of potentially inappropriate medication (PIMs) are frequent among nursing home (NH) residents, and are associated with adverse health outcomes like falls, hospitalisation and death. Deprescribing has been proposed as a way to curtail both problems; however, the best way to implement deprescribing and its real impact are still unclear. This article describes nested trials of two consecutive deprescribing interventions, the first at the NH level, and the second at the resident level.

METHODS AND ANALYSIS

The first intervention (QC-DeMo) will be a deprescribing module to be carried out in existing interprofessional quality circles in NHs, with the goal to develop a NH-wide deprescribing consensus. Its effects will be evaluated on the use of PIMs and on patient safety outcomes such as death, hospitalisation and falls. All NHs in the cantons of Vaud and Fribourg with an integrated pharmacy service will be eligible. The second intervention (IDeI), at the resident level, will be a deprescribing-focused medication review, resulting in the implementation of a deprescribing plan. Its effects will be evaluated on the use of PIMs and chronic medications, and on quality of life. This second trial will take place in the NHs allocated to the intervention group of the first trial. All residents of these NHs over 65 years old, living in the NH for at least 4 months, and taking 5 or more medications will be eligible to participate. Both trials will be hybrid effectiveness and implementation trials, aiming to understand the implementation process for the interventions, and to identify barriers and facilitators.

ETHICS, REGISTRATION AND FUNDING

Both trials were approved by the relevant ethics committee, registered on ClinicalTrials.gov (QC-DeMo: NCT03688542; IDeI: NCT03655405), and funded by the Swiss National Fund for Scientific Research.