Optimizing Medication Use Through Deprescribing: Tactics for This Approach

Medicine Optimisation and Deprescribing Intervention Outcomes for Older People with Dementia or Mild Cognitive Impairment: A Systematic Review

BACKGROUND

Polypharmacy is common amongst older people with dementia or mild cognitive impairment (MCI), increasing the risk of medication-related harm. Medicine optimisation and deprescribing to reduce polypharmacy is considered feasible, safe and can lead to improved health. However, for those living with dementia or MCI, this can be challenging. This systematic review aimed to summarise the evidence on the outcomes of medicine optimisation and deprescribing interventions for older people with dementia or MCI.

METHODS

Literature was searched using CINAHL, Embase, Medline, PsychINFO, Web of Science and the Cochrane Library from database inception to January 2024. Papers reporting data specific to people with dementia or MCI from medicine optimisation and deprescribing interventional research studies of any design and in any setting were included. A narrative synthesis was conducted owing to heterogeneity of study designs and outcomes. Quality was assessed using the Mixed Methods Appraisal Tool.

RESULTS

A total of 32 papers reporting on 28 studies were included, with samples ranging from 29 to 17,933 patients and a mean patient age ranging from 74 to 88 years. Of the studies, 60% were undertaken in long-term care settings. Involvement of patients and/or carers in interventions was limited. Papers were grouped as either incorporating a medication review component (n = 13), education component (n = 5) or both (n = 14). Studies primarily focussed on medication-related outcomes, generally showing a positive effect on decreasing the number and improving appropriateness of medications. Fewer papers reported clinical outcomes (behavioural and psychological symptoms of dementia, falls, quality of life and cognition) with mixed findings. A reduction or no change in mortality or hospital attendance demonstrated safety of the interventions in the few papers reporting these outcomes. The quality of the evidence was mixed.

CONCLUSIONS

Medicine optimisation and deprescribing interventions generally reduced the number and increased the appropriateness of medications, and although less frequently reported, these interventions seemed to be safe and showed an absence of worsening of clinical outcomes. This review highlights a need for further research, particularly in people with dementia or MCI living at home, with more focus on clinical outcomes and a greater involvement of patients and informal carers.

PROTOCOL REGISTRATION

The protocol was published in the International Prospective Register of Systematic Reviews (PROSPERO) [Ref: CRD42023398139].

Central nervous system medication use around hospitalization

BACKGROUND

Central nervous system (CNS) medication use is common among older adults, yet the impact of hospitalizations on use remains unclear. This study details CNS medication use, discontinuations, and user profiles during hospitalization periods.

METHODS

Retrospective cohort study using electronic health records on patients ≥65 years, from three hospitals (2018-2020), and prescribed a CNS medication around hospitalization (90 days prior to 90 days after). Latent class transitions analysis (LCTA) examined profiles of CNS medication class users across four time points (90 days prior, admission, discharge, 90 days after hospitalization).

RESULTS

Among 4666 patients (mean age 74.3 ± 9.3 years; 63% female; 70% White; mean length of stay 4.6 ± 5.6 days (median 3.0 [2.0, 6.0]), the most commonly prescribed CNS medications were antidepressants (56%) and opioids (49%). Overall, 74% (n = 3446) of patients were persistent users of a CNS medication across all four time points; 7% (n = 388) had discontinuations during hospitalization, but of these, 64% (216/388) had new starts or restarts within 90 days after hospitalization. LCTA identified three profile groups: (1) low CNS medication users, 54%-60% of patients; (2) mental health medication users, 30%-36%; and (3) acute/chronic pain medication users, 9%-10%. Probability of staying in same group across the four time points was high (0.88-1.00). Transitioning to the low CNS medication use group was highest from admission to discharge (probability of 9% for pain medication users, 5% for mental health medication users). Female gender increased (OR 2.4, 95% CI 1.3-4.3), while chronic kidney disease lowered (OR 0.5, 0.2-0.9) the odds of transitioning to the low CNS medication use profile between admission and discharge.

CONCLUSIONS

CNS medication use stays consistent around hospitalization, with discontinuation more likely between admission and discharge, especially among pain medication users. Further research on patient outcomes is needed to understand the benefits and harms of hospital deprescribing, particularly for medications requiring gradual tapering.

Attitudes of Lebanese community-dwelling older adults towards deprescribing using the rPATD tool

OBJECTIVES

To assess the attitude of community-dwelling Lebanese older adults towards deprescribing using the Revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire and to determine patient-related factors that impact their willingness for deprescribing.

METHODS

A cross-sectional face-to-face survey was conducted in Lebanon over the period extending between October 2021 and March 2022 using the validated Arabic version of the rPATD questionnaire. It included ambulatory older adults who were 65 years of age or older, presenting to the community pharmacy, taking at least one chronic medication, and having intact cognition.

KEY FINDINGS

Of the 400 patients approached 300 (87%) agreed to participate. The mean age of participants was 65 (range 65-85 years) and 148 (56.3%) were females. The mean number of medications taken per patient was 5.8 ± 2.67 (range 1-18) and polypharmacy was reported among 188 patients (71.8%). Nearly all of study subjects 233 (89.0%) were willing to discontinue one or more of their regular medications if their physician said it was possible. The multivariate logistic regression analysis showed that the appropriateness of medications factor (OR= 3.9, 95% CI 1.308, 12.16, p=0.015) and patients' concern about stopping the medications factor (OR=0.116, 95% CI 0.033, 0.40, p = 0.001) were significantly associated with patients' willingness to deprescribe.

CONCLUSION

A noteworthy percentage of the Lebanese older outpatients were willing to stop one or more of their regular medications if their doctor recommends so. Patients' belief in appropriateness of medications and concerns about stopping were noted to significantly influence their willingness to deprescribe in this sample population.

Optimizing Older Adults' Medication Use

This article is the third in a series, Supporting Family Caregivers in the 4Ms of an Age-Friendly Health System, published in collaboration with the AARP Public Policy Institute as part of the ongoing Supporting Family Caregivers: No Longer Home Alone series. The 4Ms of an Age-Friendly Health System (What Matters, Medication, Mentation, and Mobility) is an evidence-based framework for assessing and acting on critical issues in the care of older adults across settings and transitions of care. Engaging the health care team, including older adults and their family caregivers, with the 4Ms framework can help to ensure that every older adult gets the best care possible, is not harmed by health care, and is satisfied with the care they receive. The articles in this series present considerations for implementing the 4Ms framework in the inpatient hospital setting and incorporating family caregivers in doing so. Resources for both nurses and family caregivers, including a series of accompanying videos developed by AARP and the Rush Center for Excellence in Aging and funded by The John A. Hartford Foundation, are also provided. Nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses.

Patient and Provider Perspectives on Deprescribing Proton Pump Inhibitors

The aim of the current study is to describe proton pump inhibitor (PPI) prescribing trends in an older adult population and elucidate perspectives regarding PPI deprescribing. A retrospective chart review and a prospective cross-sectional analysis of provider and patient surveys were conducted. The retrospective chart review identified 107 patients age ≥65 who were prescribed PPI therapy. Nineteen patients on PPI therapy and 74 providers completed surveys regarding their perspectives on PPI deprescribing. PPI therapy was potentially inappropriate for 66% of patients based on dose, duration, and/or indication. Provider barriers to deprescribing included fear of outcomes, access to documentation, and uncertainty of current guidelines. This study illustrates the prevalence of long-term PPI use in geriatric patients without associated clinical indications, as well as perceived barriers to deprescribing. Long-term PPI use is associated with significant side effects; therefore, successful deprescribing must address these perceived barriers. [Journal of Gerontological Nursing, 45(10), 9-17.].

Deprescribing: a primary care perspective

Polypharmacy is an increasing and global issue affecting primary care. Although sometimes appropriate, polypharmacy can also be problematic, leading to a range of adverse consequences. Deprescribing is the process of supervised withdrawal of an inappropriate medication and has the potential to reduce some of the problems associated with polypharmacy. It is a complex and sensitive process. We examine the issue of deprescribing from the perspective of primary care. Key steps in the deprescribing process are a review of medications and corresponding indications, consideration of harms, assessment of eligibility for discontinuation, prioritisation of medications and implementation of a stopping plan with appropriate monitoring. Patient involvement is a key feature of this process. Deprescribing should be considered in the context of end-of-life care and medication safety, but approaches are also required to identify other situations where deprescribing is appropriate. General practitioners are well positioned to facilitate deprescribing, usually through formal medication review, with decisions informed by a range of other healthcare professionals. Guidelines are available that help guide these processes. A range of studies have explored attitudes towards deprescribing; patients are generally supportive of the concept, although clinician views are varied. The successful implementation of deprescribing strategies still requires important patient and clinician barriers to be overcome, and clinical trial evidence of effectiveness and safety is essential.