Barriers and enablers for deprescribing benzodiazepine receptor agonists in older adults: a systematic review of qualitative and quantitative studies using the theoretical domains framework

Primary care healthcare professionals supporting patients to discontinue antidepressants: A scoping review of barriers, enablers and interventions

BACKGROUND

Antidepressants are prescribed to treat a range of common mental disorders (CMDs) including depression and anxiety. Most people are prescribed antidepressants for longer than is necessary, leading to avoidable long-term side-effects and exacerbated withdrawal effects, if they eventually discontinue taking them. There is a need for interventions to address the barriers and enablers (determinants) of healthcare professionals (HCPs) who support people to discontinue antidepressants when they are no longer needed.

OBJECTIVE

This scoping review aimed to examine the evidence base regarding the barriers and enablers to HCPs in primary care discontinuing antidepressants prescribed for mild-moderate mental health conditions, as well as interventions to facilitate HCPs to effectively support patients through the discontinuation process.

METHODS

Studies were identified by undertaking a keyword search of the databases MEDLINE, Embase, PsycINFO and Cumulative Index to Nursing and Allied Health Literature (CINAHL). All peer-reviewed studies from inception to January 2024 were included. Two reviewers independently screened studies and extracted data. Findings were synthesised narratively.

RESULTS

Two hundred and fifty-three studies were included in title and abstract screening and 30 studies proceeded to full-text screening. Seventeen studies were included; nine reported HCP barriers and/or enablers and eight reported interventions. Time constraints, conflicting priorities and fear of CMD relapse are commonly reported barriers whilst knowledge and skills about how to discontinue antidepressants were the main enablers. Interventions primarily involved education and training for HCPs and provision of information about how to taper antidepressants.

DISCUSSION

Whilst existing interventions address the main enablers to HCPs discontinuing antidepressants, inclusion of components to address the barriers is a notable omission and may explain the lack of efficacy of existing interventions. Future interventions should be developed using appropriate theory and address all determinants of HCPs supporting people to discontinue antidepressants.

Barriers to Deprescribing Benzodiazepines in Older Adults in a Survey of European Physicians

Importance

The use of benzodiazepine receptor agonists (BZRA) poses serious health risks to older adults. Although several guidelines recommend deprescribing, implementation in clinical practice remains limited.

Objective

To identify physicians' barriers to and enablers of deprescribing BZRA in adults aged 65 years and older taking a BZRA for sleep problems; to determine factors associated with hospital physicians' intention to deprescribe BZRA and their self-reported routine BZRA deprescribing.

Design, Setting, and Participants

This survey study included hospital physicians and general practitioners (GPs) working across 6 European Countries (Belgium, Greece, Norway, Poland, Spain, and Switzerland) between December 2022 and March 2023.

Main Outcomes and Measures

Barriers identification via a 35-item questionnaire based upon the Theoretical Domains Framework (TDF). Responses were categorized as major barriers, moderate barriers, and enablers based on their mean scores. Multivariable logistic regressions were used to identify background characteristics and TDF-based domains associated with hospital physicians' intention to deprescribe and self-reported routine deprescribing.

Results

Questionnaires from 240 hospital physicians and 96 GPs were analyzed. Most participants were women: 144 (61.0%) hospital physicians and 52 (54.2%) GPs. In terms of experience, the most common reported time in practice was less than 5 years for hospital physicians (76 [31.7%]) and between 10 and 14 years for GPs (35 [36.5%]). Most reported deprescribing BZRA routinely (135 hospital physicians [57.2%] and 66 GPs [72.5%]). Major barriers (and TDF domains) were similar for hospital physicians and GPs across the 6 countries. These barriers included: lack of training (skills), low self-efficacy (beliefs about capabilities), prioritization of other health issues (goals), frustration with the challenges of deprescribing (emotions), insufficient staff and time, absence of local policies (environmental context and resources), and reluctance from patients (social influence). Intention to deprescribe was significantly associated with country, occupation type, and 5 TDF domains: memory, attention, and decision process (odds ratio [OR], 1.70; 95% Ci, 1.22-2.40); social and/or professional role and identity (OR, 5.92; 95% CI, 3.28-11.07); beliefs about capabilities (OR, 2.35; 95% CI, 1.55-3.63); beliefs about consequences (OR, 3.00; 95% CI, 1.61-5.71); and reinforcement (OR, 1.49; 95% CI, 1.05-2.15). Routine deprescribing was significantly associated with 3 TDF domains: memory, attention, and decision processes; intentions; and emotions.

Conclusion

In this theory-based survey study of physicians, physicians and general practitioners described numerous barriers to deprescribing BZRA in older adults. Our findings indicate that effective deprescribing efforts require approaches that address both reflective processes (eg, enhancing capability) and impulsive processes (eg, managing emotions).

Medical practitioners' experiences and considerations when managing sleep medication for adolescents and young adults

INTRODUCTION

The prevalence of sleep disorders and use of sleep medication, particularly melatonin, are rising among adolescents and young adults (13-24 years). In Denmark, melatonin is approved for use in children with autism and ADHD up to 18 years of age, with other prescriptions being off-label in these age groups. The perspectives of medical practitioners on prescribing sleep medications to this age group remain largely unexplored.

AIM

This study aims to investigate the considerations of general practitioners (GPs) and child and adolescent psychiatrists (psychiatrists) when prescribing and deprescribing sleep medications for 13-24-year-olds.

METHODS

We conducted qualitative semi-structured interviews with 10 GPs and six psychiatrists. Data were analyzed using an inductive approach.

RESULTS

Psychiatrists typically prescribed melatonin with the expectation that deprescription would occur in general practice. Despite the universal goal of deprescription, it was hindered by various challenges. GPs identified patient motivation and a clear focus on deprescription as facilitative factors and expressed a need for enhanced emphasis on these aspects in general practice.

DISCUSSION AND IMPLICATIONS

The findings align with existing prescription trends and literature on factors that promote and inhibit deprescription. The study underscores the complexities of deprescribing sleep medications for adolescents and young adults, suggesting the need for expanded guidelines and enhanced continuing education for GPs.

CONCLUSIONS

The research highlights significant discrepancies among medical practitioners regarding the deprescription process of sleep medications for young individuals, complicated by multiple factors. This underscores the need for better guidelines and further studies.

Sleep should not be this difficult: An interpretive descriptive study of older adults' perspectives on behaviour change elements in Sleepwell and experiences with benzodiazepine discontinuation

Benzodiazepine receptor agonists are often used for insomnia in older adults contrary to current evidence. The harms outweigh the benefits, which are limited. Cognitive behavioural therapy for insomnia is the first-line recommended treatment. Sleepwell was created as a repository of evidence-based resources to promote cognitive behavioural therapy for insomnia and limit benzodiazepine receptor agonist use. This qualitative study uses an interpretive description design and reflexive thematic analysis to explore older adults' perspectives on behavioural change techniques used in Sleepwell resources. It also explores challenges and opportunities towards benzodiazepine receptor agonist discontinuation and cognitive behavioural therapy for insomnia use. Participants were recruited from the Sleepwell arm of a randomized controlled trial. Data were collected from 15 older adults using semi-structured interviews. Two main themes were developed: (1) sleep should not be this difficult; and (2) whether you know it, or learn it, drugs are bad. Two sub-themes were created within the first theme: (1) justification of benzodiazepine receptor agonist use to achieve sleep goals; (2) efforts of committing to cognitive behavioural therapy for insomnia. Several behavioural change techniques (e.g. information about consequences, anticipated regret, salience of consequences) were enablers of benzodiazepine receptor agonist-related behaviour change. For committing to cognitive behavioural therapy for insomnia, several behavioural change techniques (e.g. self-monitoring of behaviour, distraction, stimulus substitution) were beneficial, but social support, which was perceived as useful, was absent. Older adults experienced tension with benzodiazepine receptor agonist use and deprescribing, despite knowing or learning the potential consequences of benzodiazepine receptor agonists. Cognitive behavioural therapy for insomnia implementation was challenging. Embedded behavioural change techniques in the Sleepwell booklets were identified as helpful, but more (e.g. social support) are needed to optimize cognitive behavioural therapy for insomnia use.

Enhancing older Veterans' care: Insights from medication reviews and deprescribing interventions

BACKGROUND

Patient experience during and after health care is a critical indicator of quality of care that encompasses effective communication, respect, dignity, and emotional support. However, qualitative studies exploring the experiences of older adults after deprescribing interventions are sparse, highlighting a knowledge gap. This project seeks to address this gap by exploring Veterans' experiences during and after a deprescribing intervention provided by a pharmacist. This study aims to: 1. Assess Veteran's experience of the process of their Comprehensive Medication Review and deprescribing intervention visit; 2. Assess the Veteran's experience with the outcomes of their Comprehensive Medication Review and deprescribing intervention.

METHOD

Data was collected from 17 Veterans through semi-structured interviews using an interview guide. The Veteran Affairs study site utilizes the VIONE polypharmacy risk calculator to identify high-risk Veterans; the majority of these Veterans were on at least 10 medications. The interview transcripts were analyzed using inductive content analysis. Two research team members independently coded the data for categories and themes. Similarities were identified, and any divergence was discussed and resolved. To enhance the validity of the findings, member checking was performed with Veterans to confirm the results.

RESULT AND DISCUSSION

Most Veterans viewed the process of the pharmacists' visits and recommendations positively. They expressed confidence in pharmacists' knowledge and instructions. They appreciated the clarity of information pharmacists provided about the purpose, proper administration, and interactions of their medications. These enhanced the Veterans' ability to manage their medication regime. They also desired an increased frequency of interactions with their pharmacist due to these positive interactions. Veterans appreciated interprofessional collaboration between pharmacists, physicians, and other providers. Veterans expressed how pivotal lab test results were for evaluating medication recommendations and effectiveness. Most Veterans reported positive outcomes and/or indicated there were no negative effects as a result of their recent medication changes. Some reported seeking additional information from their providers regarding suggested medication changes to validate recommendations. There was some uncertainty about whether there would be follow-up visits with the professional after the medication change and who should initiate this. A minority indicated problems associated with prior medication discontinuation before the deprescribing intervention and how this limited their openness to future opportunities of deprescribing.

CONCLUSION

This exploration of Veterans' experiences with the process and outcomes of a deprescribing service affirms its importance and overall success in this site as part of the unique publicly funded Veteran healthcare system in the US. Equally important, the positive Veteran response suggests the value of exploring its potential to benefit patients experiencing polypharmacy across a range of other sites and systems.

Patient Self-Guided Interventions to Reduce Sedative Use and Improve Sleep: The YAWNS NB Randomized Clinical Trial

Importance

Direct-to-patient interventions enabling transitions from long-term benzodiazepine receptor agonist (BZRA) use to cognitive behavioral therapy for insomnia (CBTI) by older adults has the potential to reduce BZRA use and related harms while improving sleep outcomes without requiring prearranged clinician involvement.

Objective

To compare 2 direct-to-patient behavior change interventions with treatment as usual (TAU) on BZRA use, sleep, and other health outcomes, and uptake of CBTI techniques.

Design, Setting, and Participants

The Your Answers When Needing Sleep in New Brunswick (YAWNS NB) study was a 3-arm, pragmatic, open-label, minimum-contact, randomized clinical trial. The study began November 2020 and ended June 2022. Participants were randomly allocated to 1 of 3 groups, including 2 different mailed behavior change interventions or no intervention (TAU). Participants were from communities across the province of New Brunswick, Canada, and included adults 65 years and older living independently with long-term use of BZRAs and current or past insomnia.

Interventions

The Sleepwell package (YAWNS-1) consisted of a cover letter and 2 booklets ("How to Stop Sleeping Pills" and "How to Get Your Sleep Back"). The other package (YAWNS-2) included updated versions of the 2 booklets ("You May Be at Risk" and "How to Get a Good Night's Sleep Without Medication") used in the Eliminating Medications Through Patient Ownership of End Results (EMPOWER) study.

Main Outcomes and Measures

BZRA use at 6 months was the primary measure. Secondary measures included CBTI use, sleep, insomnia, daytime sleepiness, safety, anxiety, frailty, and quality of life.

Results

A total of 1295 individuals expressed interest in the study, and 565 (43.6%) completed a baseline assessment. Participants had a mean (SD) age of 72.1 (5.7) years, a mean (SD) BZRA use duration of 11.4 (9.1) years, and 362 (64.1%) were female. Discontinuations and dose reductions of 25% or greater were highest with YAWNS-1 (50 of 191 [26.2%]; 39 of 191 [20.4%]; total, 46.6%) compared with YAWNS-2 (38 of 187 [20.3%]; 27 of 187 [14.4%]; total, 34.8%, P = .02) and TAU (14 of 187 [7.5%]; 24 of 187 [12.8%]; total, 20.3%, P < .001). YAWNS-1 also demonstrated better uptake of CBTI techniques and sleep outcomes compared with YAWNS-2 (new CBTI techniques: 3.1 vs 2.4; P =.03; sleep efficiency change: 4.1% vs -1.7%; P =.001) and reduced insomnia severity and daytime sleepiness compared with TAU (insomnia severity index change: -2.0 vs 0.3; P <.001; Epworth Sleepiness Scale change: -0.8 vs 0.3; P =.001).

Conclusions and Relevance

Results of the YAWNS NB randomized clinical trial show that, as a simple, scalable, direct-to-patient intervention, YAWNS-1 substantially reduced BZRA use and improved sleep outcomes. It could be implemented to transform insomnia care for older adults at the population level.

Trial Registration

ClinicalTrials.gov Identifier: NCT04406103.

A scoping review of motor vehicle operator performance assessments for benzodiazepine receptor agonists

Background

Benzodiazepines and Z-drugs (e.g., zopiclone, zolpidem) (benzodiazepine receptor agonists or BZRAs), are prescribed for anxiety and insomnia disorders. However, they are not indicated as first line therapies for long-term management due to harms and efficacy limitations. BZRAs have also been associated with traffic accident risks. Patients taking BZRAs are told to consult with health care providers regarding motor vehicle operation safety. However, advice on driving is variable. The objective of this scoping review is to identify, map, and characterize the evidence for assessments that measure driving performance in people taking BZRAs.

Methods

Embase (Elsevier), MEDLINE (Ovid), and PsycINFO (EBSCO) were searched. Covidence was used for screening. Each stage of screening included two independent reviewers. A REDCap database was used for data extraction by two independent reviewers. Results were tabulated and summarised as a narrative.

Results

Driving performance was assessed with 20 unique BZRAs across 183 studies (n = 92 experimental; n = 91 observational) in 178 publications. Zopiclone was the most studied. In experimental studies, the Standard Deviation of Lateral Position (SDLP) was used most often (n = 54, 62 %) and many studies (n = 35, 38 %) were conducted in the Netherlands. For observational studies, biological detection (e.g., urine, blood) (n = 73, 80 %) followed by prescription drug/dispensing records (n = 17, 19 %) were the most common impairment measures and Norway (n = 20) is where most studies took place. In experimental studies, most (n = 89, 97 %) were conducted using only one driving setting. Simulated driving in a car (n = 36) and road driving in traffic (n = 36) were common as compared to nontraffic driving course (n = 8) and simulated driving (n = 9). In experimental studies, seventy-eight of the 92 studies (85 %) had at least one measure that identified impairment.

Conclusions

BZRA effects on motor vehicle driving performance have been studied using heterogenous protocols with multiple measures and settings, ranging from simulation to authentic traffic situations in experimental studies to biological detection and dispensing records in observational studies. Many BZRAs have been studied but study representation does not match prescribing pattern prevalence. The interpretation and contextualization of results for clinical practice is challenging due to the complexity (i.e., protocols, measures, settings). Future work in this area should work to improve knowledge translation of results so information is more readily accessible and applicable to health care providers and patients.

Barriers and facilitators to conducting randomised controlled trials within routine care of neurorehabilitation centres: a qualitative study

BACKGROUND

Randomised controlled trials (RCTs) are considered the gold standard for generating clinical evidence. The focus on high internal validity in RCTs challenges the external validity and generalisability of findings, potentially hindering their application in routine care. In neurorehabilitation, limited literature addresses conducting RCTs feasibly and efficiently. We investigated barriers and facilitators to conducting RCTs within routine care of neurorehabilitation centres from the perspective of stakeholders in neurorehabilitation in Germany and Austria.

METHODS

We conducted semi-structured interviews with stakeholders in neurorehabilitation from four centres in Germany and Austria, informed by the Theoretical Domains Framework (TDF) and the Capability, Opportunity, Motivation and Behaviour model (COM-B). Employing a hybrid approach, the interview analysis integrated both deductive, theory-driven analysis based on the TDF domains and COM-B model and inductive, reflexive thematic analysis.

RESULTS

Twelve stakeholders (4 physicians, 4 therapy managers, 4 therapists; 5 females, 7 males; with research experience spanning 0-40 years) were interviewed. Key barriers to conducting RCTs in neurological rehabilitation centres include limited financial, human, and time resources, high clinical workloads, and a lack of interest of some therapists. Ineffective leadership, perceived lack of research expertise, and communication issues were also significant barriers. Social influence factors such as lack of employer support and inadequate training access further contributed to the challenges. Additionally, barriers included insufficient research infrastructure, limited space, internal power struggles, and rigid cost bearer specifications. Key facilitators included physicians' and therapists' motivation to advance the field, contribute to knowledge, and to prioritise patient health. Support from supervisors, joint decision-making, and efficient organisation were crucial facilitators. Flexible therapy planning, mutual support, and interdisciplinary collaboration also played important roles.

CONCLUSION

Our results suggest that increasing professional development and understanding, along with providing adequate financial, human, time, and spatial resources to support research endeavours, implementing effective communication strategies to enhance interdisciplinary collaboration and coordination among team members may contribute to increased motivation and facilitate RCTs within the setting of neurorehabilitation centres.

TRIAL REGISTRATION

This study was prospectively registered with the German Clinical Trials Register (08.04.2021 DRKSID DRKS00024982).

Feasibility of a theory-based intervention towards benzodiazepine deprescribing in Belgian nursing homes: protocol of the END-IT NH cluster-randomised controlled trial

INTRODUCTION

Despite several calls to deprescribe benzodiazepine receptor agonists (BZRA) in older adults, their use among nursing home residents (NHRs) remains high. Therefore, we developed an intervention targeting general practitioners' and healthcare professionals' behaviours regarding BZRA deprescribing in nursing homes (NHs): The END-IT NH (bENzodiazepines Deprescribing InTerventions Nursing homes) 6-component intervention. Before moving on to a large-scale effectiveness and cost-effectiveness evaluation, this feasibility study aims at: (1) assessing the feasibility of the intervention implementation in NHs, (2) assessing the feasibility of conducting a larger-scale evaluation, in terms of recruitment and data collection and (3) conducting an exploratory cost-effectiveness evaluation.

METHODS AND ANALYSIS

We will conduct a cluster-randomised controlled trial in a sample of 6 NHs, with 10-15 NHRs included per NHs. Four NHs will be randomised into the intervention group, and two NHs will deliver usual care (control group). Data collection will occur at baseline, 3, and 6 months (study end). We will collect information to explore implementation fidelity, mechanisms of impact and contextual factors at patient-level, NH-level and healthcare professional-level, using both quantitative and qualitative measures. The feasibility of the study conduction will be assessed by measuring recruitment and attrition rates and completeness of data collection. An exploratory cost-effectiveness evaluation will be conducted based on quality of life and healthcare use and cost data.

ETHICS AND DISSEMINATION

This study protocol received approval from the ethical committee of CHU UCL Namur on the 20 June 2023. All data are confidential and will be anonymised prior to analysis. De-identified data will be shared on a data depository with a 2-year embargo. The results of the study will be disseminated through a scientific paper and will be communicated to local stakeholders and policymakers through a local symposium.

TRIAL REGISTRATION NUMBER

NCT05929443.

Deprescribing benzodiazepine receptor agonists in older adults: a mixed-methods study to adapt the Canadian D-PRESCRIBE intervention to the Belgian community setting

OBJECTIVE

Guidelines recommend deprescribing benzodiazepine receptor agonists (BZRA) in older adults, yet implementation in clinical practice remains limited. Adapting effective, evidence-based interventions to a new context is a resource-saving strategy. In Canada, the D-PRESCRIBE intervention comprised a patient educational brochure and a pharmaceutical opinion inviting physicians to revise BZRA prescribing and consider safer alternatives. Due to its effectiveness on BZRA deprescribing among Canadian older adults, we aimed to adapt the D-PRESCRIBE intervention to the Belgian community setting.

DESIGN

Recommendations from the ADAPT guidance, that provides a systematic approach for adapting interventions to new contexts, were followed. We conducted a mixed-methods study that comprised (1) group discussions and cognitive interviews to assess the acceptability and need for adaptation of the intervention's components and (2) a survey on the adapted pharmaceutical opinion. A research committee involving stakeholders' representatives decided on the adaptations, respecting the core functions of both tools. Changes in intervention components were reported following the Model for Adaptation Design and Impact framework.

SETTING

Belgian French-speaking community setting.

PARTICIPANTS

Six older adults (≥65 years), six general practitioners (GPs) and seven pharmacists participated in the group discussions or interviews. 46 GPs and 91 pharmacists responded to the survey.

RESULTS

Participants welcomed the brochure positively. Still, some changes in the vocabulary, wording, photos and icons were made for several purposes including making the patient feel concerned about the brochure and softening the use of fear. The pharmaceutical opinion aroused mixed perceptions. Its name, layout and content were adapted to enhance its acceptability and fit with our healthcare system, practices and national guidelines. The survey highlighted several enablers and barriers to its use from the perspectives of GP and pharmacist.

CONCLUSIONS

The Canadian D-PRESCRIBE intervention was adapted to the Belgian setting following a thorough and transparent process. Its feasibility will be tested in a future pilot study (NCT:05929417).

Analyzing the barriers and enablers to internet hospital implementation: a qualitative study of a tertiary hospital using TDF and COM-B framework

Background

Internet hospitals have become an important way to improve the accessibility of medical services and promote medical equity in China. However, there is still lack of research on the behavior of medical personnel during the process of using Internet medical services, and the elements of behavior that motivate doctors to actively use or resist the use of Internet hospitals are still not fully analyzed. The study applied the Theoretical Domains Framework to examine the factors affecting the engagement of medical personnel in Internet hospitals, with the aim of guiding the design of intervention to enhance Internet hospital participation.

Methods

This study utilized qualitative analysis. Semi-structured questionnaires based on the Theoretical Domains Framework (TDF) and Capability-Opportunity-Motivation-Behavior (COM-B) model was developed and administered to 40 doctors and nurses at a Grade A tertiary hospital in Guangdong Province. Data was coded and analyzed using qualitative methods including Nvivo software.

Results

The research displayed 19 barriers and 7 enablers for the implementation of Internet hospitals, all 14 TDF domains impacted participation with motivation cited most frequently. Despite challenges, medical personnel exhibited a generally optimistic stance towards utilization of the Internet hospital. Major barriers include the higher requirement of diagnostic ability, objective difficulties brought by online consultation to the decision-making process, limitation of time and other resources, not ideal technological and institutional environment, lack of self-efficacy and negative expectation of results in online consultation. Key enablers include patient needs and the positive impact of online care on the medical process and patient experience.

Discussion

This qualitative study identified a range of barriers and enablers to Internet hospital participation according to medical personnel, providing an conceptual framework to guide further research evaluating implementation strategies. Expanded research and targeted interventions design can help optimize participation in this evolving healthcare delivery model.

Development of a Behavior-Change Intervention toward Benzodiazepine Deprescribing in Older Adults Living in Nursing Homes

OBJECTIVE

We aimed to develop a context-specific intervention toward benzodiazepine deprescribing in nursing homes (NHs), with insights from behavior-change theories and involvement of stakeholders.

DESIGN

Selection of behavior change techniques (BCTs), through online survey and group discussion, followed by operationalization of these BCTs into intervention components.

SETTING AND PARTICIPANTS

The intervention was developed for Belgian NHs, involving various stakeholders: health care professionals (HCPs), NH administrators, and policy makers.

METHODS

Using the Theory and Techniques Tool, we preselected the BCTs linked to one of the 9 Theoretical Domain Framework domains identified as being the main barriers for benzodiazepine deprescribing in Belgian NHs. These were then presented to stakeholders. Based on the APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Ethics) criteria, participants ranked BCTs through an online survey, and then performed final selection during a group discussion. Selected BCTs were operationalized into intervention components, with specific contents and methods of delivery validated by stakeholders.

RESULTS

Thirty-seven potential BCTs were identified. Eighteen stakeholders participated in the survey, and 7 in the group discussion. This led to the final inclusion of 9 BCTs: instruction on how to perform the behavior, information about health consequences, pros and cons, problem solving, goal setting (behavior), social comparison, restructuring physical environment, restructuring social environment, and graded tasks. These BCTs were operationalized into a 6-component intervention: process and goal setting, HCP education, physical environment adaptations, audit and feedback, NH residents' and relatives' increased awareness, and multidisciplinary work.

CONCLUSION AND IMPLICATIONS

Use of a theory-based approach toward intervention development has the potential to improve the probability of its feasibility and effectiveness in tackling barriers to benzodiazepine deprescribing. By doing so, we have developed a multifaceted approach with actions taken at the patient, HCP, and NH levels. Our novel 6-component intervention will be evaluated in a pilot cluster-randomized controlled trial to assess its feasibility.

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.

Barriers, facilitators and needs to deprescribe benzodiazepines and other sedatives in older adults: a mixed methods study of primary care provider perspectives

BACKGROUND

Benzodiazepines and other sedative hypnotic drugs (BSHs) are frequently prescribed for sleep problems, but cause substantial adverse effects, particularly in older adults. Improving knowledge on barriers, facilitators and needs of primary care providers (PCPs) to BSH deprescribing could help reduce BSH use and thus negative effects.

METHODS

We conducted a mixed methods study (February-May 2023) including a survey, semi-structured interviews and focus groups with PCPs in Switzerland. We assessed barriers, facilitators and needs of PCPs to BSH deprescribing. Quantitative data were analyzed descriptively, qualitative data deductively and inductively using the Theoretical Domain Framework (TDF). Quantitative and qualitative data were integrated using meta-interferences.

RESULTS

The survey was completed by 126 PCPs (53% female) and 16 PCPs participated to a focus group or individual interview. The main barriers to BSH deprescribing included patient and PCP lack of knowledge on BSH effects and side effects, lack of PCP education on treatment of sleep problems and BSH deprescribing, patient lack of motivation, PCP lack of time, limited access to cognitive behavioral therapy for insomnia and absence of public dialogue on BSHs. Facilitators included informing on side effects to motivate patients to discontinue BSHs and start of deprescribing during a hospitalization. Main PCP needs were practical recommendations for pharmacological and non-pharmacological treatment of sleep problems and deprescribing schemes. Patient brochures were wished by 69% of PCPs. PCPs suggested the brochures to contain explanations about risks and benefits of BSHs, sleep hygiene and sleep physiology, alternative treatments, discontinuation process and tapering schemes.

CONCLUSION

The barriers and facilitators as well as PCP needs and opinions on patient material we identified can be used to develop PCP training and material on BSH deprescribing, which could help reduce the inappropriate use of BSHs for sleep problems.

Prescribing and deprescribing guidance for benzodiazepine and benzodiazepine receptor agonist use in adults with depression, anxiety, and insomnia: an international scoping review

Background

Clinical practice guidelines and guidance documents routinely offer prescribing clinicians' recommendations and instruction on the use of psychotropic drugs for mental illness. We sought to characterise parameters relevant to prescribing and deprescribing of benzodiazepine (BZD) and benzodiazepine receptor agonist (BZRA), in clinical practice guidelines and guidance documents internationally, for adult patients with unipolar depression, anxiety disorders and insomnia to understand similarities and discrepancies between evidence-based expert opinion.

Methods

A Scoping Review was conducted to characterize documents that offered evidence-based and/or consensus pharmacologic guidance on the management of unipolar depression, anxiety disorders, obsessive-compulsive disorders, post-traumatic stress disorders and insomnia. A systematic search was conducted of PubMed, SCOPUS, PsycINFO and CINAHL from inception to October 13, 2023 and supplemented by a gray literature search. Documents were screened in Covidence for eligibility. Subsequent data-charting on eligible documents collected information on aspects of both prescribing and deprescribing.

Findings

113 documents offering guidance on BZD/BZRA use were data-charted. Overall, documents gathered were from Asia (n = 11), Europe (n = 34), North America (n = 37), Oceania (n = 7), and South America (n = 4) with the remainder being "International" (n = 20) and not representative to any particular region or country. By condition the documents reviewed covered unipolar depressive disorders (n = 28), anxiety disorders, obsessive-compulsive disorder and post-traumatic stress disorder (n = 42) and Insomnia (n = 25). Few documents (n = 18) were sufficiently specific and complete to consider as de-prescribing focused documents.

Interpretation

Documents were in concordance in terms of BZD and BZRA not being used routinely as first-line pharmacologic agents. When used, it is advisable to restrict their duration to "short-term" use with the most commonly recommended duration being less than four weeks. Documents were less consistent in terms of prescriptive recommendations for specific drug, dosing and administration pattern (i.e regular or 'as needed') selection for each condition. Deprescribing documents were unanimously in favor of gradual dose reduction and patient shared decision-making. However, approaches towards dose-tapering differed substantially. Finally, there were inconsistencies and/or insufficiency of detail, among deprescribing documents, in terms of switching to a long-acting BZD, use of adjunctive pharmacotherapies and micro-tapering.

Funding

The authors received no funding for this work.

Deprescribing potential of commonly used medications among community-dwelling older adults: insights from a pharmacist's geriatric assessment

Pharmacist's geriatric assessment can provide valuable insights into potential deprescribing targets, while including important information on various health-related domains. Data collected from a geriatric assessment questionnaire, for 388 patients, from the Croatian cohort of the EuroAgeism H2020 ESR 7 international project, along with guideline-based deprescribing criteria, were used to analyse potentially inappropriate prescribing of four medication groups (benzodiazepines (BZN), proton pump inhibitors (PPI), opioids, and non-steroidal anti-inflammatory drugs (NSAID)), and to assess the deprescribing potential. Binary logistic regression was used to explore the effects of age, gender, number of medicines and diagnoses, self-reported health, frailty score, and healthcare utilization on the likelihood of needing deprescribing. More than half of participants (n = 216, 55.2%) are candidates for deprescribing, with 31.1% of PPI, 74.8% of NSAID, 75% of opioid, and 96.1% of BZN users meeting at least one criterion. Most common criteria for deprescribing were inappropriately long use and safety concerns. Women (aOR = 2.58; p < 0.001), those reporting poor self-reported health (aOR = 5.14; p < 0.001), and those exposed to polypharmacy (aOR = 1.29; p < 0.001) had higher odds of needing to have medicines deprescribed. The high rate of deprescribing potential warrants prompt action to increase patient safety and decrease polypharmacy. Pharmacist's geriatric assessment and deprescribing-focused medication review could be used to lead a personalised approach.

Barriers and Enablers for Deprescribing Glucose-Lowering Treatment in Older Adults: A Systematic Review

OBJECTIVES

Overtreatment with glucose-lowering treatment (GLT) is frequent and a source of high morbidity and mortality in older adults with type 2 diabetes mellitus (T2DM). This study aimed to identify and synthesize barriers and enablers for deprescribing GLT in older adults (≥65 years) with T2DM.

DESIGN

Systematic review of qualitative and mixed-methods studies.

SETTING AND PARTICIPANTS

Older adults with T2DM, any participants [patients, health care providers (HCPs), caregivers], any settings.

METHODS

Two researchers (and a referred third researcher at all stages) independently screened original articles reporting qualitative and mixed-methods studies exploring barriers and enablers for deprescribing GLT in older adults published during 2010-2023, identified from MEDLINE, Embase, CINAHL, and gray literature. Quality of the included studies was assessed with the Mixed-Methods Appraisal Tool. Verbatim statements on barriers and enablers were extracted, and determinants of behaviors were identified with the Theoretical Domains Framework (TDF) version 2, and related intervention functions (targets for future interventions) were proposed according to the Behavior Change Wheel (BCW).

RESULTS

We identified only 4 studies from 2 countries (United States and the Netherlands), all recently published (2019-2023), that primarily reported barriers to GLT deprescribing from interviews or focus groups of patients or HCPs practicing outpatient medicine. Knowledge, fear, poor communication, inertia, and trust with HCPs were the main determinants of behaviors that influenced deprescribing, and education, training, persuasion and environmental restructuring were the main intervention functions for proposing future interventions. Studies did not cover financial aspects, physician characteristics, or caregiver and family viewpoints.

CONCLUSIONS AND IMPLICATIONS

The use of a behavioral theory and a validated implementation framework provided a comprehensive approach to identifying barriers and enablers for deprescribing GLT in older adults (≥65 years) with T2DM. The behavioral determinants identified may be useful in tailoring interventions to improve the implementation of GLT deprescribing in older adults in ambulatory settings.

Prevalence and predictors of inappropriate prescribing in outpatients with severe mental illness

Background

Potentially inappropriate prescribing (PIP) is frequent in geriatrics and results in an increased risk for adverse effects, morbidity, mortality and reduced quality of life. Research on PIP in psychiatry has mainly focused on elderly patients and inpatients.

Objectives

To determine the prevalence and the predictors of PIP of psychotropic medication in outpatients with severe mental illness.

Design

This study is part of the Muva study, a pragmatic open Stepped Wedge Cluster Randomized Trial of a physical activity intervention for patients (age ⩾ 16 years) with severe mental illness.

Methods

A structured medication interview, questionnaires on social functioning, quality of life and psychiatric symptoms, and BMI and waist circumference measurements were performed followed by a structured medication review. Patients were divided into groups: PIP versus no PIP. Between-group differences were calculated and a multivariate binary logistic regression was performed to examine predictors for PIP. A receiver operating characteristics analysis was performed to determine the area under the curve (AUC).

Results

In 75 patients, an average of 5.2 medications of which 2.5 psychotropic medication was used. 35 (46.7%) patients were identified with PIP. Unindicated long-term benzodiazepine use was the most frequently occurring PIP (34.1%). Predictors of PIP were female gender [odds ratio (OR) = 4.88, confidence interval (CI) = 1.16-20.58, p = 0.03], number of medications (OR = 1.41, CI = 1.07-1.86, p = 0.02) and lower social functioning (OR = 1.42, CI = 1.01-2.00, p = 0.05). The AUC was 0.88 for the combined prediction model.

Conclusion

The prevalence of PIP of psychotropic medication in outpatients with severe mental illness is high. It is therefore important to identify, and where possible, resolve PIP by frequently performing a medication review with specific attention to females, patients with a higher number of medications and patients with lower social functioning.

Trial registration

This trial was registered in The Netherlands Trial Register (NTR) as NTR NL9163 on 20 December 2020 (https://trialsearch.who.int/Trial2.aspx?TrialID=NL9163).

Optimizing treatment for older adults with depression

This review presents a comprehensive guide for optimizing medication management in older adults with depression within an outpatient setting. Medication optimization involves tailoring the antidepressant strategy to the individual, ensuring the administration of appropriate medications at optimal dosages. In the case of older adults, this process necessitates not only adjusting or changing antidepressants but also addressing the concurrent use of inappropriate medications, many of which have cognitive side effects. This review outlines various strategies for medication optimization in late-life depression: (1) Utilizing the full dose range of a medication to maximize therapeutic benefits and strive for remission. (2) Transitioning to alternative classes (such as a serotonin and norepinephrine reuptake inhibitor [SNRI], bupropion, or mirtazapine) when first-line treatment with selective serotonin reuptake inhibitors [SSRIs] proves inadequate. (3) Exploring augmentation strategies like aripiprazole for treatment-resistant depression. (4) Implementing measurement-based care to help adjust treatment. (5) Sustaining an effective antidepressant strategy for at least 1 year following depression remission, with longer durations for recurrent episodes or severe presentations. (6) Safely discontinuing anticholinergic medications and benzodiazepines by employing a tapering method when necessary, coupled with counseling about the benefits of stopping them. Additionally, this article explores favorable medications for depression, as well as alternatives for managing anxiety, insomnia, allergy, overactive bladder, psychosis, and muscle spasm in order to avoid potent anticholinergics and benzodiazepines.

Implementation of interprofessional quality circles on deprescribing in Swiss nursing homes: an observational study

BACKGROUND

Polypharmacy and potentially inappropriate medications (PIMs) are still frequent among older adults in nursing homes. Deprescribing is an intervention that has been shown to be effective in reducing their use. However, the implementation of deprescribing in clinical practice has not yet been widely evaluated. The Quality Circle Deprescribing Module (QC-DeMo) intervention has been trialled through an effectiveness-implementation hybrid type 2 design. The intervention consists of a quality circle workshop session between healthcare professionals HCPs (physicians, nurses, and pharmacists) within a nursing home, in which they define a consensus to deprescribe specific PIMs classes. The aim of this study was to evaluate the implementation of the QC-DeMo intervention in nursing homes.

METHODS

This observational study focuses on the implementation part of the QC-DeMo trial. Implementation was based on the Framework for Implementation of Pharmacy Services (FISpH). Questionnaires at baseline and follow-up were used to evaluate reach, adoption, implementation effectiveness, fidelity, implementation, maintenance and the implementation strategies. Other data were collected from the QC-DeMo trial and routine data collected as part of the integrated pharmacy service where the QC-Demo trial was embedded. Implementation strategies included training of pharmacists, integration of the intervention into an existing quality circle dynamic and definition of tailored strategies to operationalise the consensus by each nursing home.

RESULTS

The QC-DeMo intervention was successfully implemented in 26 nursing homes in terms of reach, fidelity, adoption, implementation and implementation effectiveness. However, the intervention was found to be implemented with low maintenance as none of the nursing homes repeated the intervention after the trial. Implementation strategies were well received by HCPs: training was adequate according to pharmacists. Pre-existing quality circle dynamic facilitated interprofessional collaboration as involvement and support of each HCP was rated as high. HCPs recognized a specific and important role for each HCP in the deprescribing process. The most relevant tailored strategies to implement the consensus defined by each nursing home were identification of the patients by the pharmacist and a systematic review of medication's patients.

CONCLUSIONS

The implementation of a Quality Circle on Deprescribing is feasible but its maintenance in practice remains challenging. This study explores multiple implementation outcomes to better inform future implementation efforts of these types of interventions.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT03688542 ), registered on 26.09.2018.

Pharmacists' contribution to benzodiazepine deprescribing in older outpatients: a systematic review and meta-analysis

BACKGROUND

Consolidated and reliable evidence regarding the effectiveness of pharmacist interventions for deprescribing benzodiazepines in older outpatients is lacking.

AIM

This study evaluated and summarized the impact of pharmacist interventions on benzodiazepine deprescribing among older outpatients.

METHOD

A literature search was conducted until August 2022 in PubMed, PsycINFO, and the Cochrane Central Register of Controlled Trials databases. The review included randomized controlled trials that assessed the impact of pharmacist interventions on deprescribing benzodiazepine in older outpatients. Two independent investigators conducted the study selection, data extraction, and risk of bias assessment. Meta-analyses were conducted using random-effect models in the RStudio software.

RESULTS

A total of 893 records were identified. Five studies, including 3,879 patients, met the inclusion criteria and were included in the systematic review. All five studies used health education as an intervention strategy, and three also conducted medication reviews. There was no evidence of the pharmacist's authority to modify prescriptions during benzodiazepine deprescribing. One study was classified as having a low risk of bias, whereas the other had some concerns or a high risk of bias. Three studies were included in the meta-analysis and a significant impact of pharmacist interventions on benzodiazepines deprescribing rates in older outpatients was observed (RR = 2.75 [95%CI 1.29; 5.89]; p = 0.04; I2 = 69%; low certainty of evidence).

CONCLUSION

Pharmacists may contribute to deprescribing benzodiazepines in older outpatients. Further studies are needed to increase the reliability of these findings. PROSPERO registration number: CRD42022358563.

Use of psychotropic drugs in the elderly in France: Are we condemned to remain at high tide?

Psychotropics are widely used drugs, especially in the elderly, especially in France. This, and the risks associated to their use, logically led to concerns that resulted in numerous studies, reports, and regulatory actions intending to limit this use. This review objective was to provide an overview of psychotropic use in elderly subjects in France for antipsychotics, antidepressants, and benzodiazepines and related drugs. The narrative review performed is structured in two parts. The first reminds the initial steps of psychotropic use monitoring in the general French population. The second provides information on psychotropic use in elderly in France using the latest open data released by the French Health Insurance system and processed using the dedicated DrugSurv tool developed within the DRUGS-SAFE® and DRUGS-SAFE® programs. This was completed examining the most recent studies regarding psychotropic use in elderly in France, whether they consisted in publications or reports. At least before the COVID-19 epidemic, decreases in psychotropic prevalence of use among the elderly in France could be observed, mostly for antipsychotics or benzodiazepines (e.g. antipsychotics, 2006-2013: 10.3% decrease and benzodiazepines 2012-2020: decrease from 30.6% to 24.7% in subjects aged ≥65). Psychotropic prevalence of use remained however very high overall (e.g. antidepressants, 2013: 13% in subjects aged 65-74 and 18% in aged ≥65), exceeding that of most other countries, with a significant proportion of inappropriate use (e.g. in 30% of benzodiazepine users, all ages) carrying a clearly identified risks for uncertain benefit. Initiatives have been multiplied at the national level to reduce psychotropic overuse in the elderly. The reported prevalences demonstrate their effectiveness is obviously insufficient. This limited effectiveness is not specific to psychotropics and might reside in a failure to create strong adherence to messages and recommendations. Other levels should be considered, especially regional, for interventions coupled with pharmacoepidemiologic monitoring allowing impact assessment.

Evaluation of the effectiveness of a joint general practitioner-pharmacist intervention on the implementation of benzodiazepine deprescribing in older adults (BESTOPH-MG trial): protocol for a cluster-randomized controlled trial

Background

Deprescribing benzodiazepines and related drugs (BZDR) is a challenge due to a lack of time on physicians' part, a lack of involvement of other health professionals, and the need for adapted tools. This study is based on primary care collaboration, by evaluating the effectiveness of a joint intervention between general practitioners and community pharmacists on the implementation of BZDR deprescribing in older adults.

Methods

This is a cluster randomized controlled trial in which each cluster will be formed by a physician-pharmacist pair. Within a cluster allocated to the intervention, the pharmacist will be trained in motivational interviewing (MI), and will offer the patient 3 interviews after inclusion by the physician. They will base their intervention on validated deprescribing guidelines. The pharmacist will receive methodological support during the first interviews. Interprofessional collaboration will be encouraged by writing reports for the physician after each interview. The following implementation outcomes will be evaluated: acceptability/adoption, appropriateness, cost, and fidelity. They will be measured by means of sociological interviews, observations, logbooks, and cost-utility analysis. Focus groups with physicians and pharmacists will be carried out to identify levers and barriers experienced in this collaboration. Observations will be conducted with pharmacists to assess their approach of the MIs. Effectiveness outcomes will be based on medication (discontinuation or reduction of BZDR) and clinical outcomes (such as quality of life, insomnia or anxiety), assessed by health insurance databases and validated questionnaires.

Discussion

This study will determine whether collaboration in primary care between physicians and pharmacists, as well as training and coaching of pharmacists in motivational interviewing, allows the implementation of BZDR deprescribing in the older adults.This study will provide an understanding of the processes used to implement deprescribing guidelines, and the contribution of collaborative practice in implementing BZDR discontinuation. The cluster methodology will allow to assess the experience of the relationship between the different primary care actors, and the related obstacles and levers.The results obtained will make it possible to produce guidelines on the involvement of community pharmacists in the management of substance abuse in older adults, or even to legislate new missions or care pathways.

Clinical trial registration

ClinicalTrials.gov, identifier, NCT05765656.

Reduction of Sleep Medications via a Combined Digital Insomnia and Pharmacist-Led Deprescribing Intervention: Protocol for a Feasibility Trial

BACKGROUND

Chronic insomnia is one of the most common health problems among veterans and negatively impacts their health, function, and quality of life. Although cognitive behavioral therapy for insomnia (CBT-I) is the first-line recommended treatment, sedative-hypnotic medications remain the most common. Sedative-hypnotics, however, have mixed effectiveness, are frequently prescribed longer than recommended, and are associated with numerous risks and adverse effects that negatively impact veteran function. Meeting the treatment needs of veterans impacted by insomnia requires delivering gold standard behavioral care, like CBT-I, and the reduction of sedative-hypnotics through innovative methods.

OBJECTIVE

The objective of this feasibility clinical trial is to test a digital CBT-I approach combined with deprescribing to improve the success of sedative-hypnotic reduction among veterans. The intervention combines Noctem Health Clinician Operated Assistive Sleep Technology (COAST), an effective and efficient, scalable, and adaptable digital platform to deliver CBT-I, with clinical pharmacy practitioner (CPP)-led deprescribing of sedative-hypnotic medications.

METHODS

In this nonrandomized single-group clinical trial, 50 veterans will be recruited and enrolled to receive CBT-I delivered via Noctem COAST and CPP-led deprescribing for up to 12 weeks. Assessments will occur at baseline, posttreatment, and 3-month follow-up. The aims are to (1) assess the feasibility of recruiting veterans with chronic sedative-hypnotic use to participate in the combined intervention, (2) evaluate veterans' acceptability and usability of the COAST platform, and (3) measure changes in veterans' sleep, sedative-hypnotic use, and function at baseline, posttreatment, and 3-month follow-up.

RESULTS

The institutional review board approved the study in October 2021 and the trial was initiated in May 2022. Recruitment and data collection began in September 2022 and is anticipated to be completed in April 2024. Aim 1 will be measured by tracking the response to a mail-centric recruitment approach using electronic medical records to identify potentially eligible veterans based on sedative-hypnotic use. Aim 2 will be measured using the Post-Study System Usability Questionnaire, assessing overall usability as well as system usefulness, information quality, and interface quality. Aim 3 will use the Insomnia Severity Index and sleep diaries to measure change in insomnia outcomes, the Patient-Reported Outcome Measurement Information System Profile to measure change in physical function, anxiety, depression, fatigue, sleep disturbance, participation in social roles, pain, cognitive function, and self-reported sedative-hypnotic use to measure change in dose and frequency of use.

CONCLUSIONS

Findings will inform the utility of a combined digital CBT-I and CPP-led deprescribing intervention and the development of an adequately powered clinical trial to test the effectiveness in a diverse sample of veterans. Further, findings will help inform potential new approaches to deliver care and improve access to care for veterans with insomnia, many of whom use sedative-hypnotics that may be ineffective and increase the risk for negative outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05027438; https://classic.clinicaltrials.gov/ct2/show/NCT05027438.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47636.

Adaptation and validation of the revised Patients' Attitudes towards Deprescribing (rPATD) questionnaire for benzodiazepine receptor agonists

BACKGROUND

The revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire explores older adults' views on deprescribing in general. Those views may differ, however, when the target is a specific drug such as benzodiazepine receptor agonists (BZRA).

OBJECTIVE

This study aimed to adapt the 22-item French rPATD questionnaire to create a BZRA-specific instrument and to assess the psychometric properties of this new tool.

METHODS

The adaptation of the questionnaire comprised 3 steps: 1) item transformation during group discussions with 8 healthcare providers and 8 BZRA users (aged ≥65 years), 2) pre-test of the questionnaire with 12 other older adults to ensure items understanding, 3) evaluation of the psychometric properties of the new questionnaire with 221 older BZRA users recruited in Belgium, France, and Switzerland. Construct validity was assessed using exploratory factor analysis (EFA), internal consistency with Cronbach's alpha, and test-retest reliability with intraclass correlation coefficient (ICC).

RESULTS

After the pre-test, the questionnaire had 24 items (19 adapted from the French rPATD, 3 removed, and 5 added). The EFA, however, found that several items performed poorly. Eleven items were consequently removed, based on statistical performance and clinical relevance. Three factors were extracted from the EFA performed on the 11 retained items and were named "Concerns about stopping BZRA", "BZRA inappropriateness", and "Dependence on BZRA". The questionnaire also includes two global questions about willingness to reduce BZRA dosage and willingness to discontinue BZRA. All factors showed acceptable internal consistency (0.68 ≤ Cronbach's alpha ≤0.74). Two factors showed acceptable test-retest reliability. The "Concerns about stopping BZRA" factor was found to vary over time (ICC [95%CI]: 0.35[-0.02; 0.64]).

CONCLUSIONS

We developed and validated a 13-item questionnaire to evaluate the attitudes of older people towards BZRA deprescribing. Despite some limitations, this questionnaire appears to be a useful tool for facilitating shared decision-making on BZRA deprescribing.

Benzodiazepine Receptor Agonists Use and Cessation Among Multimorbid Older Adults with Polypharmacy: Secondary Analysis from the OPERAM Trial

BACKGROUND

Benzodiazepine receptor agonists (BZRAs) are commonly prescribed in older adults despite an unfavorable risk-benefit ratio. Hospitalizations may provide a unique opportunity to initiate BZRA cessation, yet little is known about cessation during and after hospitalization. We aimed to measure the prevalence of BZRA use before hospitalization and the rate of cessation 6 months later, and to identify factors associated with these outcomes.

METHODS

We conducted a secondary analysis of a cluster randomized controlled trial (OPtimising thERapy to prevent Avoidable hospital admissions in the Multimorbid elderly [OPERAM]), comparing usual care and in-hospital pharmacotherapy optimization in adults aged 70 years or over with multimorbidity and polypharmacy in four European countries. BZRA cessation was defined as taking one or more BZRA before hospitalization and not taking any BZRA at the 6-month follow-up. Multivariable logistic regression was performed to identify factors associated with BZRA use before hospitalization and with cessation at 6 months.

RESULTS

Among 1601 participants with complete 6-month follow-up data, 378 (23.6%) were BZRA users before hospitalization. Female sex (odds ratio [OR] 1.52 [95% confidence interval 1.18-1.96]), a higher reported level of depression/anxiety (OR up to 2.45 [1.54-3.89]), a higher number of daily drugs (OR 1.08 [1.05-1.12]), use of an antidepressant (OR 1.74 [1.31-2.31]) or an antiepileptic (OR 1.46 [1.02-2.07]), and trial site were associated with BZRA use. Diabetes mellitus (OR 0.60 [0.44-0.80]) was associated with a lower probability of BZRA use. BZRA cessation occurred in 86 BZRA users (22.8%). Antidepressant use (OR 1.74 [1.06-2.86]) and a history of falling in the previous 12 months (OR 1.75 [1.10-2.78]) were associated with higher BZRA cessation, and chronic obstructive pulmonary disease (COPD) (OR 0.45 [0.20-0.91]) with lower BZRA cessation.

CONCLUSION

BZRA prevalence was high among included multimorbid older adults, and BZRA cessation occurred in almost a quarter of them within 6 months after hospitalization. Targeted BZRA deprescribing programs could further enhance cessation. Specific attention is needed for females, central nervous system-acting co-medication, and COPD co-morbidity.

REGISTRATION

ClinicalTrials.gov identifier: NCT02986425. December 8, 2016.

Multidisciplinary DEprescribing review for Frail oldER adults in long-term care (DEFERAL): Implementation strategy design using behaviour science tools and stakeholder engagement

INTRODUCTION

Deprescribing is a strategy for reducing the use of potentially inappropriate medications for older adults. Limited evidence exists on the development of strategies to support healthcare professionals (HCPs) deprescribing for frail older adults in long-term care (LTC).

OBJECTIVE

To design an implementation strategy, informed by theory, behavioural science and consensus from HCPs, which facilitates deprescribing in LTC.

METHODS

This study was consisted of 3 phases. First, factors influencing deprescribing in LTC were mapped to behaviour change techniques (BCTs) using the Behaviour Change Wheel and two published BCT taxonomies. Second, a Delphi survey of purposively sampled HCPs (general practitioners, pharmacists, nurses, geriatricians and psychiatrists) was conducted to select feasible BCTs to support deprescribing. The Delphi consisted of two rounds. Using Delphi results and literature on BCTs used in effective deprescribing interventions, BCTs which could form an implementation strategy were shortlisted by the research team based on acceptability, practicability and effectiveness. Finally, a roundtable discussion was held with a purposeful, convenience sample of LTC general practitioners, pharmacists and nurses to prioritise factors influencing deprescribing and tailor the proposed strategies for LTC.

RESULTS

Factors influencing deprescribing in LTC were mapped to 34 BCTs. The Delphi survey was completed by 16 participants. Participants reached consensus that 26 BCTs were feasible. Following the research team assessment, 21 BCTs were included in the roundtable. The roundtable discussion identified lack of resources as the primary barrier to address. The agreed implementation strategy incorporated 11 BCTs and consisted of an education-enhanced 3-monthly multidisciplinary team deprescribing review, led by a nurse, conducted at the LTC site.

CONCLUSION

The deprescribing strategy incorporates HCPs' experiential understanding of the nuances of LTC and thus addresses systemic barriers to deprescribing in this context. The strategy designed addresses five determinants of behaviour to best support HCPs engaging with deprescribing.

A systematic review of randomised-controlled trials on deprescribing outcomes in older adults with polypharmacy

BACKGROUND

Mixed findings about deprescribing impact have emerged from varied study designs, interventions, outcome measures and targeting sub-categories of medications or morbidities. This systematic review controls for study design by reviewing randomised-controlled trials (RCTs) of deprescribing interventions using comprehensive medication profiles. The goal is to provide a synthesis of interventions and patient outcomes to inform healthcare providers and policy makers about deprescribing effectiveness.

OBJECTIVES

This systematic review aims to (1) review RCT deprescribing studies focusing on complete medication reviews of older adults with polypharmacy across all health settings, (2) map patients' clinical and economic outcomes against intervention and implementation strategies and (3) inform research agendas based on observed benefits and best practices.

METHODS

The PRISMA framework for systematic reviews was followed. Databases used were EBSCO Medline, PubMed, Cochrane Library, Scopus and Web of Science. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomised trials.

RESULTS

Fourteen articles were included. Interventions varied in setting, preparation, use of interdisciplinary teams, validated guidelines and tools, patient-centredness and implementation strategy. Thirteen studies (92.9%) found deprescribing interventions reduced the number of drugs and/or doses taken. No studies found threats to patient safety in terms of primary outcomes including morbidity, hospitalisations, emergency room use and falls. Four of five studies identifying health quality of life as a primary outcome found significant effects associated with deprescribing. Both studies with cost as their primary outcome found significant effects as did two with cost as a secondary outcome. Studies did not systematically study how intervention components influenced deprescribing impact. To explore this gap, this review mapped studies' primary outcomes to deprescribing intervention components using the Consolidated Framework for Implementation Research. Five studies had significant, positive primary outcomes related to health-related quality of life (HRQOL), cost and/or hospitalisation, with four reporting patient-centred elements in their intervention.

CONCLUSIONS

RCT primary outcomes found deprescribing is safe and reduces drug number or dose. Five RCTs found a significant deprescribing impact on HRQOL, cost or hospitalisation. Important future research agendas include analysing (1) understudied outcomes like cost, and (2) intervention and implementation components that enhance effectiveness, such as patient-centred elements.

Barriers and enablers towards benzodiazepine-receptor agonists deprescribing in nursing homes: A qualitative study of stakeholder groups

Background

Despite recommendations to deprescribe chronic benzodiazepine receptor agonists (BZRA) among older adults, the prevalence of their use in Belgian nursing homes (NHs) remains above 50%. The use of a behavioral science approach, starting with the evaluation of barriers and enablers for BZRA deprescribing, has the potential to decrease BZRA prescribing.

Objectives

To identify barriers and enablers for BZRA deprescribing perceived by the different stakeholders involved in nursing home care in Belgium.

Methods

In a purposive sample of 6 NHs, we conducted face-to-face interviews with general practitioners (GPs), and focus groups with other healthcare providers (HCPs), including nurses, pharmacists, occupational therapists, physical therapists, and with NH residents and relatives. All interviews with HCPs were analyzed through deductive thematic analysis, using the theoretical domains framework (TDF) as the coding framework. Residents' and relatives' interviews were analyzed using an inductive thematic approach.

Results

We interviewed 13 GPs, 35 other HCPs, 22 nursing home residents, and 5 relatives. Overall, 9 TDF domains were identified as most relevant among HCPs interviewed: Skills, Beliefs about capabilities, Goals, Memory attention and decision processes, Environmental context and resources, Social influences, Knowledge, Social/professional role and identity, and Beliefs about consequences. Five additional themes emerged from residents' and relatives' interviews: knowledge on medications used, communication with NH staff and GPs, perceived efficacy and necessity of BZRA, influence of the environment, and reluctance towards BZRA deprescribing. Some domains and themes differ between stakeholders (e.g., knowledge), while others match between groups (e.g., environmental aspects).

Conclusion

BZRA deprescribing is influenced by knowledge and skills gaps, automatic BZRA refilling, competing priorities, social challenges, environmental factors and poor nursing home residents involvement. Targeting these barriers will be a key step for implementation of BZRA deprescribing.