Older patients' perception of deprescribing in resource-limited settings: a cross-sectional study in an Ethiopia university hospital

OBJECTIVE

To assess older patients' attitude towards deprescribing of inappropriate medications.

DESIGN

This was an institutional-based, quantitative, cross-sectional survey.

SETTING

Outpatient clinics of the University of Gondar Referral and Teaching Hospital in Ethiopia.

PARTICIPANTS

Patients aged 65 or older with at least one medication were enrolled in the study from 1 March to 30 June 2017. Excluded patients were those who had severe physical or psychological problems and who refused to participate.

MAIN OUTCOME MEASURES

Older patients' attitude towards deprescribing was measured using a validated instrument, 'the revised Patients' Attitudes towards Deprescribing' (rPATD) tool for older patients. Data were collected on sociodemographic characteristics and clinical data such as comorbidity and polypharmacy, and the main outcome was older patients' willingness to deprescribe inappropriate medications.

RESULTS

Of the 351 eligible participants, 316 patients completed the survey. Of the 316 patients, 54.7% were men and were taking a median of 3 (IQR: 2-4) medications daily. Overall, most of the participants (92.1%; 95% CI 89% to 95%) were satisfied with the medications they were taking; however, still a significant number of participants (81.6%; 95% CI 77% to 86%) were willing to stop one or more of their medications if possible and agreed by their doctors. This willingness was correlated with seven items of the rPATD, including a strong correlation with the overall satisfaction of patients with the medications taken.

CONCLUSION

Many older patients have shown their willingness to reduce one or more of their medications if their doctors said it was possible. Healthcare providers should be proactive in discussing and evaluating potentially inappropriate medications for better clinical decision making.

Improving Pharmacists' Targeting of Patients for Medication Review and Deprescription

Background: In an acute hospital setting, a multi-disciplinary approach to medication review can improve prescribing and medicine selection in patients with frailty. There is a need for a clear understanding of the roles and responsibilities of pharmacists to ensure that interventions have the greatest impact on patient care. Aim: To use a consensus building process to produce guidance for pharmacists to support the identification of patients at risk from their medicines, and to articulate expected actions and escalation processes. Methods: A literature search was conducted and evidence used to establish a set of ten scenarios often encountered in hospitalised patients, with six or more possible actions. Four consultant physicians and four senior pharmacists ranked their levels of agreement with the listed actions. The process was redrafted and repeated until consensus was reached and interventions were defined. Outcome: Generalised guidance for reviewing older adults' medicines was developed, alongside escalation processes that should be followed in a specific set of clinical situations. The panel agreed that both pharmacists and physicians have an active role to play in medication review, and face-to-face communication is always preferable to facilitate informed decision making. Only prescribers should deprescribe, however pharmacists who are not also trained as prescribers may temporarily "hold" medications in the best interests of the patient with appropriate documentation and a follow up discussion with the prescribing team. The consensus was that a combination of age, problematic polypharmacy, and the presence of medication-related problems, were the most important factors in the identification of patients who would benefit most from a comprehensive medication review. Conclusions: Guidance on the identification of patients on inappropriate medicines, and subsequent pharmacist-led intervention to prompt and promote deprescribing, has been developed for implementation in an acute hospital.

Does a Consumer-Targeted Deprescribing Intervention Compromise Patient-Healthcare Provider Trust?

One in four community-dwelling older adults is prescribed an inappropriate medication. Educational interventions aimed at patients to reduce inappropriate medications may cause patients to question their prescriber’s judgment. The objective of this study was to determine whether a patient-focused deprescribing intervention compromised trust between older adults and their healthcare providers. An educational brochure was distributed to community-dwelling older adults by community pharmacists in order to trigger deprescribing conversations. At baseline and 6-months post-intervention, participants completed the Primary Care Assessment Survey, which measures patient trust in doctors and pharmacists. Changes in trust were ascertained post-intervention. Proportions with 95% confidence intervals (CI), and logistic regression were used to determine a shift in trust and associated predictors. 352 participants responded to the questionnaire at both time points. The majority of participants had no change or gained trust in their doctors for items related to the choice of medical care (78.5%, 95% CI = 74.2–82.8), communication transparency (75.4%, 95% CI = 70.7–79.8), and overall trust (81.9%, 95% CI = 77.9–86.0). Similar results were obtained for participants’ perceptions of their pharmacists, with trust remaining intact for items related to the choice of medical care (79.4%, 95% CI = 75.3–83.9), transparency in communicating (82.0%, 95% CI = 78.0–86.1), and overall trust (81.6%, 95% CI = 77.5–85.7). Neither age, sex nor the medication class targeted for deprescribing was associated with a loss of trust. Overall, the results indicate that patient-focused deprescribing interventions do not shift patients’ trust in their healthcare providers in a negative direction.

A Province-wide, Cross-sectional Study of Demographics and Medication Use of Patients in Hemodialysis Units Across Ontario

Background:

Hemodialysis patients are at an increased risk of polypharmacy as they have the highest pill burden of all chronically ill patient populations, with an estimated average of 12 medications per day.

Objectives:

The aim of this study was to evaluate prescribing patterns of outpatient medications in patients receiving in-center hemodialysis. This was done to identify potential candidate medications for future quality improvement initiations to optimize prescribing.

Design:

We conducted a descriptive retrospective cross-sectional study in the province of Ontario, Canada, using several linked health care databases housed at the Institute for Clinical Evaluative Sciences (ICES).

Setting:

We considered outpatient medications dispensed to patients eligible for the Ontario Drug Benefit program.

Patients:

Patients were receiving chronic in-center hemodialysis at one of the 69 facilities in the province of Ontario, Canada as of October 1, 2013.

Measurements:

We assessed whether any of our 28 study medications of interest were recently dispensed (within the prior 120 days), the type of prescribing physician, and the associated medication costs. The 28 included medications of interest (ie, proton pump inhibitors, benzodiazepines) were selected because they may not have a true indication for dialysis patients and/or there are safety concerns with their use in this population. Results are presented as median (25th, 75th percentile).

Methods:

We conducted this study at ICES according to a prespecified protocol approved by the Research Ethics Board at Sunnybrook Health Sciences Centre (Toronto, Ontario).

Results:

A total of 3094 patients on chronic in-center hemodialysis received a study drug of interest (age: 76.5 years [SD: 7.3]), 44% women). Patients were dispensed 11 (8, 14) unique medication products with more than two-thirds of patients dispensed 9 or more different medications. The median number of annual health care visits was 7 (3-15) with more than half the cohort receiving prescriptions from 3 or more specialists. The 10 most commonly dispensed study medications cost more than 3 million dollars in direct costs in 1 year.

Limitations:

Our study was also subjected to some limitations of health care databases.

Conclusions:

Polypharmacy is frequent in in-center hemodialysis patients. To decrease polypharmacy and its associated negative outcomes, health care providers need to implement tools to optimize medication use and deprescribe medications that lack evidence for efficacy and safety in hemodialysis patients. Therefore, strategies to improve prescribing and discontinue ineffective medications warrant testing for better patient outcomes and reduced health care costs.

A Systematic Review of Practice Guidelines and Recommendations for Discontinuation of Cholinesterase Inhibitors in Dementia

Cholinesterase inhibitors (ChEIs) are the primary pharmacological treatment for symptom management of Alzheimer disease (AD), but they carry known risks during long-term use, and do not guarantee clinical effects over time. The balance of risks and benefits may warrant discontinuation at different points during the disease course. Indeed, although there is limited scientific study of deprescribing ChEIs, clinicians routinely face practical decisions about whether to continue or stop medications. This review examined published practice recommendations for discontinuation of ChEIs in AD. To characterize the scientific basis for recommendations, we first summarized randomized controlled trials of ChEI discontinuation. We then identified practice guidelines by professional societies and in textbooks and classified them according to 1) whether they made a recommendation about discontinuation, 2) what the recommendation was, and 3) the proposed grounds for discontinuation. There was no consensus in guidelines and textbooks about discontinuation. Most recommended individualized discontinuation decisions, but there was essentially no agreement about what findings or situations would warrant discontinuation, or even about what domains to consider in this process. The only relevant domain identified by most guidelines and textbooks was a lack of response or a loss of effectiveness, both of which can be difficult to ascertain in the course of a progressive condition. Well-designed, long-term studies of discontinuation have not been conducted; such evidence is needed to provide a scientific basis for practice guidelines. It seems reasonable to apply an individualized approach to discontinuation while engaging patients and families in treatment decisions. .

Changes in Prescribing Symptomatic and Preventive Medications in the Last Year of Life in Older Nursing Home Residents

Background: At the end of life goals of care change from disease prevention to symptomatic control, however, little is known about the patterns of medication prescribing at this stage.

Objectives: To explore changes in prescribing of symptomatic and preventive medication in the last year of life in older nursing home residents.

Methods: A retrospective cohort study was conducted using pharmacy medication supply data of 553 residents from 16 nursing home facilities around Sydney, Australia. Residents received 24-h nursing care, were aged ≥ 65 years, died between June 2008 and June 2010 and were using at least one medication 1 year before death. Medications were classified as symptomatic, preventive, or other. A linear mixed model was used to compare changes in prescribing in the last year of life.

Results: 68.1% of residents were female, mean age was 88.0 (SD: 7.5) years and residents used a mean of 9.1 (SD: 4.1) medications 1 year before death. The mean number of symptomatic medications per resident increased from 4.6 medications 1 year before death to 5.1 medications at death [95% CI 4.4–4.7 to 5.9–5.2, P = 0.000], while preventive medication decreased from 2.0 to 1.4 medications [95% CI 1.9–2.1 to 1.3–1.5, P = 0.000]. Symptomatic medications were used longer in the last year of life, compared to preventive medications (336.3 days [95% CI 331.8–340.8] versus 310.9 days [95% CI 305.2–316.7], P = 0.000).

Conclusion: Use of medications for symptom relief increased throughout the last year of life, while medications for prevention of long-term complications decreased. But changes were slight and clinical relevance can be questioned.

Discontinuing Psychiatric Medications: A Survey of Long-Term Users

OBJECTIVE

Individuals undergoing long-term psychiatric treatment frequently choose to stop taking psychiatric medications. To enhance service user choice and prevent undesirable outcomes, this first U.S. survey of a large sample of longer-term users sought to increase knowledge about users' experience of medication discontinuation.

METHODS

A sample of 250 U.S. adults with a diagnosis of serious mental illness and a recent goal to stop up to two prescribed psychiatric medications, which they had taken for at least nine months, completed a web-based survey about experiences, strategies, and supports during discontinuation.

RESULTS

About half (54%) met their goal of completely discontinuing one or more medications; 46% reported another outcome (use was reduced, use increased, or use stayed the same). Concerns about medications' effects (for example, long-term effects and side effects) prompted the decision to discontinue for 74% of respondents. They used various strategies to cope with withdrawal symptoms, which 54% rated as severe. Self-education and contact with friends and with others who had discontinued or reduced medications were most frequently cited as helpful. Although more than half rated the initial medication decision with prescribers as largely collaborative, only 45% rated prescribers as helpful during discontinuation. Of respondents who completely discontinued, 82% were satisfied with their decision.

CONCLUSIONS

Discontinuing psychiatric medication appears to be a complicated and difficult process, although most respondents reported satisfaction with their decision. Future research should guide health care systems and providers to better support patient choice and self-determination regarding the use and discontinuation of psychiatric medication.

Proceedings of the Canadian Frailty Network Summit: Medication Optimization for Frail Older Canadians, Toronto, Monday April 24, 2017

Appropriate and optimal use of medication and polypharmacy are especially relevant to the care of older Canadians living with frailty, often impacting their health outcomes and quality of life. A majority (two thirds) of older adults (65 or older) are prescribed five or more drug classes and over one-quarter are prescribed 10 or more drugs. The risk of adverse drug-induced events is even greater for those aged 85 or older where 40% are estimated to take drugs from 10 or more drug classes. The Canadian Frailty Network (CFN), a pan-Canadian non-for-profit organization funded by the Government of Canada through the Networks of Centres of Excellence Program (NCE), is dedicated to improving the care of older Canadian living with frailty and, as part of its mandate, convened a meeting of stakeholders from across Canada to seek their perspectives on appropriate medication prescription. The CFN Medication Optimization Summit identified priorities to help inform the design of future research and knowledge mobilization efforts to facilitate optimal medication prescribing in older adults living with frailty. The priorities were developed and selected through a modified Delphi process commencing before and concluding during the summit. Herein we describe the overall approach/process to the summit, a summary of all the presentations and discussions, and the top ten priorities selected by the participants.

A narrative review of the safety concerns of deprescribing in older adults and strategies to mitigate potential harms

INTRODUCTION

As with prescribing or continuing medications, deprescribing brings with it the potential for harm as well as benefit. Uncertainty and avoidance of harm has been reported as a barrier to deprescribing in practice and may contribute to continuation of inappropriate medications.

AREAS COVERED

This narrative review covers four main safety concerns/potential harms of deprescribing in older adults: adverse drug withdrawal events, return of medical condition(s), reversal of drug-drug interactions and damage to the doctor-patient relationship. These are discussed in relation to medications in general, with some examples of medication classes used to illustrate the potential safety concerns. The majority of these harms can be minimized or even prevented by using a patient-centered, structured deprescribing process with planning, tapering and close monitoring during, and after medication withdrawal.

EXPERT OPINION

More research is needed into the safety concerns of deprescribing, however, avenues exist during drug development and post-marketing surveillance to gain knowledge on this topic. Questions remain about when it is suitable to discontinue certain medications/medication classes and there is uncertainty about the harms and benefits of both medication continuation and discontinuation in complex older adults.

Older Adults' Awareness of Deprescribing: A Population-Based Survey

Objectives

To determine older adults’ awareness of the concept of medication‐induced harm and their familiarity with the term “deprescribing.” Secondary objectives were to ascertain determinants of self‐initiated deprescribing conversations and to identify how older adults seek information on medication harms.

Design

Cross‐sectional population‐based household telephone survey using random‐digit dialling.

Setting

Canada.

Participants

Community‐dwelling adults aged 65 and older (N = 2,665; n = 898 men, n = 1,767 women, mean age 74.9 ± 7.2, range 65–100).

Measurements

Information was gathered on age; sex; awareness of the term “deprescribing”; knowledge and information‐seeking behaviors related to medication harms; and previous initiation of a deprescribing conversation with a healthcare professional. Three targeted classes of potentially inappropriate prescriptions were asked about: sedative‐hypnotics, glyburide, and proton pump inhibitors. Descriptive statistics and regression analyses were used to quantify associations.

Results

Two‐thirds (65.2%, 95% confidence interval (CI) = 63.4–67.0%) of participants were familiar with the concept of medication‐induced harms. Only 6.9% (95% CI = 5.9–7.8%) recognized the term deprescribing; 48% (95% CI = 46–50%) had researched medication‐related harms. Older adults most commonly sought information from the Internet (35.5%, 95% CI = 33.4–37.6%), and from health care professionals (32.2%, 95% CI = 30.1–34.3%). Patient‐initiated deprescribing conversations were associated with awareness of medication harms (odds ratio (OR) = 1.74, 95% CI = 1.46–2.07), familiarity with the term deprescribing (OR = 1.55, 95% CI = 1.13–2.12), and information‐seeking behaviors (OR = 4.57, 95% CI = 3.84–5.45), independent of age and sex.

Conclusion

Healthcare providers can facilitate patient‐initiated deprescribing conversations by providing information on medication harms and using the term “deprescribing.”

We have had a gutful: The need for deprescribing proton pump inhibitors

WHAT IS KNOWN AND OBJECTIVE

Proton pump inhibitor (PPI) prescribing may often be inappropriate and expose patients to a risk of adverse effects, while incurring unnecessary healthcare expenditure. Our objective was to determine PPI usage in Australia since 2002 and review international studies investigating inappropriate PPI prescribing, including those that discussed interventions to address this issue.

METHODS

Australian Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS) data were analysed. A narrative literature review relevant to the objective was conducted. Time series analysis was also used to examine the trend of reported PPI appropriate use across the international studies included in this review.

RESULTS AND DISCUSSION

Proton pump inhibitor use in Australia increased between 2002 and 2010 and then gradually decreased. Estimates of the extent of inappropriate use in the international literature had a wide variation (11-84%). There appeared to be little change in the extent of appropriate PPI use reported through 34 international studies from 2000 to 2016. Interventions to address inappropriate use included patient-centred deprescribing, academic detailing, educational programmes and drug safety notifications.

WHAT IS NEW AND CONCLUSION

Proton pump inhibitors continue to be overused worldwide and should be a focus for deprescribing programmes. Ongoing education and awareness campaigns for health professionals and patients, including electronic reminders at the point of prescribing, are strategies that have potential to reduce PPI use in individuals who do not have an evidence-based clinical indication for their long-term use.

Exploring the enablers and barriers to implementing the Medication Appropriateness Tool for Comorbid Health conditions during Dementia (MATCH-D) criteria in Australia: a qualitative study

OBJECTIVES

The Medication Appropriateness Tool for Comorbid Health conditions in Dementia (MATCH-D) criteria provide expert consensus guidance about medication use for people with dementia. This study aimed to identify enablers and barriers to implementing the criteria in practice.

SETTING

Participants came from both rural and metropolitan communities in two Australian states.

PARTICIPANTS

Focus groups were held with consumers, general practitioners, nurses and pharmacists.

OUTCOMES

data were analysed thematically.

RESULTS

Nine focus groups were conducted. Fifty-five participants validated the content of MATCH-D, appraising them as providing patient-centred principles of care. Participants identified potential applications (including the use of MATCH-D as a discussion aid or educational tool for consumers about medicines) and suggested supporting resources.

CONCLUSION

Participants provided insights into applying MATCH-D in practice and suggested resources to be included in an accompanying toolkit. These data provide external validation of MATCH-D and an empiric basis for their translation to practice. Following resource development, we plan to evaluate the feasibility and efficacy of implementation in practice.

Deprescribing Using the Guidelines for Medical Treatment and Its Safety in the Elderly and Changes in Patient QOL and Activities of Daily Living

Pharmacists applied deprescribing, which is a process for the rational use of drugs, for 13 at-home patients. The standard used for the rational use of drugs was the "Guidelines for Medical Treatment and Its Safety in the Elderly" (the Guidelines). The results of the deprescribing were discussed with physicians to determine prescriptions. After the prescription change, activities of daily living (ADL) and QOL were assessed using the Barthel Index and SF-36v2, respectively. Potentially inappropriate medications (PIMs) were detected in 10 of the 13 patients (76.9%). This detection rate is higher than previous PIM detection rates of 48.4% and 40.4% reported in prescriptions for home-care patients in Japan under the Beers and STOPP/START criteria. The Guidelines appeared useful as a decision support tool for deprescribing. The patients continuing the changed prescriptions showed no decrease in ADL or QOL after deprescribing, suggesting its rationality. The 10 measurement items of the Barthel Index were all suitable for evaluating the physical conditions of the patients. Meanwhile, SF-36v2 includes many items, but few indexes were directly applicable.

Halting Antipsychotic Use in Long-Term care (HALT): a single-arm longitudinal study aiming to reduce inappropriate antipsychotic use in long-term care residents with behavioral and psychological symptoms of dementia

BACKGROUND

Inappropriate use of antipsychotic medications to manage Behavioral and Psychological Symptoms of Dementia (BPSD) continues despite revised guidelines and evidence for the associated risks and side effects. The aim of the Halting Antipsychotic Use in Long-Term care (HALT) project is to identify residents of long-term care (LTC) facilities on antipsychotic medications, and undertake an intervention to deprescribe (or cease) these medicines and improve non-pharmacological behavior management.

METHODS

LTC facilities will be recruited across Sydney, Australia. Resident inclusion criteria will be aged over 60 years, on regular antipsychotic medication, and without a primary psychotic illness or very severe BPSD, as measured using the Neuropsychiatric Inventory (NPI). Data collection will take place one month and one week prior to commencement of deprescribing; and 3, 6 and 12 months later. During the period prior to deprescribing, training will be provided for care staff on how to reduce and manage BPSD using person-centered approaches, and general practitioners of participants will be provided academic detailing. The primary outcome measure will be reduction of regular antipsychotic medication without use of substitute psychotropic medications. Secondary outcome measures will be NPI total and domain scores, Cohen-Mansfield Agitation Inventory scores and adverse events, including falls and hospitalizations.

CONCLUSION

While previous studies have described strategies to minimize inappropriate use of antipsychotic medications in people with dementia living in long-term care, sustainability and a culture of prescribing for BPSD in aged care remain challenges. The HALT project aims to evaluate the feasibility of a multi-disciplinary approach for deprescribing antipsychotics in this population.

Pharmacist-initiated deprescribing in hospitalised elderly: prevalence and acceptance by physicians

Objectives

Deprescribing can help reduce polypharmacy in the elderly and hospitalisation presents an opportunity to re-evaluate the use of medications. The aim of this study was to describe the drugs that were commonly suggested by pharmacists to be deprescribed in hospitalised elderly, and the factors associated with acceptance by physicians.

Methods

A retrospective, cross-sectional study was conducted in a tertiary hospital in Singapore. All pharmacist interventions on deprescribing in inpatient elderly aged ≥65 years, made between July and December 2015 were included. Comparisons between groups were made and independent factors associated with physician acceptance were determined.

Results

A total of 503 interventions were included and 392 (77.9%) were accepted by physicians. Most interventions were on gastrointestinal agents (49.7%) and supplements (42.7%). The common reasons for deprescribing were: overduration of treatment (44.5%), unclear indication (23.9%) and the overdosage (20.7%). No significant differences were found between the reasons for deprescribing and acceptance by physicians. Use of <9 medications (OR 1.92, 95% CI 1.20 to 3.07), gastrointestinal agents (OR 3.46, 95% CI 1.06 to 11.26) and supplements (OR 3.20, 95% CI 1.06 to 9.69) were associated with higher physician acceptance (p<0.05).

Conclusions

In our cohort of hospitalised elderly, gastrointestinal agents and supplements were most commonly suggested by pharmacists to be deprescribed and at least three quarters of these interventions were accepted by physicians.

STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy): consensus validation

Objective

to validate STOPPFrail, a list of explicit criteria for potentially inappropriate medication (PIM) use in frail older adults with limited life expectancy.

Design

a Delphi consensus survey of an expert panel comprising academic geriatricians, clinical pharmacologists, palliative care physicians, old age psychiatrists, general practitioners and clinical pharmacists.

Setting

Ireland.

Subjects

seventeen panellists.

Methods

STOPPFrail criteria were initially created by the authors based on clinical experience and literature appraisal. Criteria were organised according to the physiological system; each criterion accompanied by an explanation. Using Delphi consensus methodology, panellists ranked their agreement with each criterion on a 5-point Likert scale and provided written feedback. Criteria with a median Likert response of 4/5 (agree/strongly agree) and a 25th centile of ≥4 were included in the final list.

Results

all panellists completed three Delphi rounds. Thirty criteria were proposed, 27 were accepted. The first two criteria suggest deprescribing medications without indication or where compliance is poor. The remaining 25 criteria include lipid-lowering therapies, alpha-blockers for hypertension, anti-platelets, neuroleptics, memantine, proton-pump inhibitors, H2-receptor antagonists, anti-spasmodic agents, theophylline, leukotriene antagonists, calcium supplements, bone anti-resorptive therapy, selective oestrogen receptor modulators, non-steroidal anti-inflammatories, corticosteroids, 5-alpha-reductase inhibitors, alpha-1-selective blockers, muscarinic antagonists, oral diabetic agents, ACE-inhibitors, angiotensin receptor blockers, systemic oestrogens, multivitamins, nutritional supplements and prophylactic antibiotics. Consensus could not be reached on the inclusion of acetylcholinesterase inhibitors. Full consensus was reached on the exclusion of anticoagulants and antidepressants from the list.

Conclusion

STOPPFrail comprises 27 criteria relating to medications that are potentially inappropriate in frail older patients with limited life expectancy. STOPPFrail may assist physicians in deprescribing medications in these patients.

Swimming Against the Tide: Primary Care Physicians' Views on Deprescribing in Everyday Practice

PURPOSE

Avoidable hospitalizations due to adverse drug events and high-risk prescribing are common in older people. Primary care physicians prescribe most on-going medicines. Deprescribing has long been essential to best prescribing practice. We sought to explore the views of primary care physicians on the barriers and facilitators to deprescribing in everyday practice to inform the development of an intervention to support safer prescribing.

METHODS

We used a snowball sampling technique to identify potential participants. Physicians were selected on the basis of years in practice, employment status, and practice setting, with an additional focus on information-rich participants. Twenty-four semistructured interviews were audio-recorded, transcribed verbatim, and analyzed to identify emergent themes.

RESULTS

Physicians described deprescribing as "swimming against the tide" of patient expectations, the medical culture of prescribing, and organizational constraints. They said deprescribing came with inherent risks for both themselves and patients and conveyed a sense of vulnerability in practice. The only incentive to deprescribing they identified was the duty to do what was right for the patient. Physicians recommended organizational changes to support safer prescribing, including targeted funding for annual medicines review, computer prompts, improved information flows between prescribers, improved access to expert advice and user-friendly decision support, increased availability of non-pharmaceutical therapies, and enhanced patient engagement in medicines management.

CONCLUSIONS

Interventions to support safer prescribing in everyday practice should consider the sociocultural, personal, relational, and organizational constraints on deprescribing. Regulations and policies should be designed to support physicians in practicing according to their professional ethical values.

Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site: Quality Improvement Project

BACKGROUND

Increased prescribing of proton pump inhibitors (PPIs) in the past few decades can be attributed mainly to long-term use of this type of therapy. Recent evidence indicates signals of harm associated with long-term use of PPIs, such as increased risk of Clostridium difficile infection, recurrence of C. difficile infection, and fracture. A few studies have assessed the effectiveness of step-down management of patients receiving long-term PPI therapy in ambulatory care settings. However, it is unknown whether PPIs can be discontinued in older people without return of gastrointestinal symptoms.

OBJECTIVES

To determine the proportion of residents receiving long-term PPI therapy who were able to discontinue the drug without experiencing gastrointestinal symptoms warranting recommencement of the PPI or initiation of a histamine-2 receptor antagonist.

METHODS

The records of residents who had been taking a PPI for longer than 6 months at a single residential care site were audited by one pharmacist to determine the PPI indication. For residents who fit the criteria for discontinuation (no indication for long-term PPI therapy, not currently experiencing gastrointestinal symptoms, no previous trial of PPI discontinuation without success, and no anxiety when medications are discontinued), the pharmacist faxed a recommendation to discontinue PPI therapy without tapering to the physicians' offices. For cases in which the recommendation was accepted, 3 pharmacists followed the residents weekly for 8 weeks to assess whether gastrointestinal symptoms returned.

RESULTS

The pharmacist identified 28 residents who fit the criteria, and the recommendation to discontinue therapy was accepted for 27. At 8 weeks after the intervention, 19 (70%) of these residents were still asymptomatic and did not require re-initiation of medications to manage their gastrointestinal symptoms.

CONCLUSIONS

These results support discontinuation of long-term PPI therapy for older people who fit the criteria for discontinuation. The study provided limited evidence to support the use of tapering. However, tapering can be used to identify the lowest effective dose and may increase patient comfort with deprescribing. Further research is needed to determine the effects of and best approaches to PPI discontinuation in older populations.

Novel tool for deprescribing in chronic patients with multimorbidity: List of Evidence-Based Deprescribing for Chronic Patients criteria

AIM

To create a tool to identify drugs and clinical situations that offers an opportunity of deprescribing in patients with multimorbidity.

METHODS

A literature review completed with electronic brainstorming, and subsequently, a panel of experts using the Delphi methodology were applied. The experts assessed the criteria identified in the literature and brainstorming as possible situations for deprescribing. They were also asked to assess the influence of life prognosis in each criterion. A tool was composed of the most appropriate criteria according to the strength of their evidence, usefulness in patients with multimorbidity and applicability in clinical practice.

RESULTS

Out of a total of 100, 27 criteria were selected to be included in the final list. It was named the LESS-CHRON criteria (List of Evidence-baSed depreScribing for CHRONic patients), and was organized by the anatomical group of the Anatomical, Therapeutic, Chemical (ATC) classification system of the drug to be deprescribed. Each criterion contains: drug indication for which it is prescribed, clinical situation that offers an opportunity to deprescribe, clinical variable to be monitored and the minimum time to follow up the patient after deprescribing.

CONCLUSIONS

The "LESS-CHRON criteria" are the result of a comprehensive and standardized methodology to identify clinical situations for deprescribing drugs in chronic patients with multimorbidity. Geriatr Gerontol Int 2017; 17: 2200-2207.

Perceptions of Statin Discontinuation among Patients with Life-Limiting Illness

BACKGROUND

Optimal management of chronic medications for patients with life-limiting illness is uncertain. Medication deprescribing may improve outcomes in this population, but patient concerns regarding deprescribing are unclear.

OBJECTIVE

The aim of this study was to quantify the perceived benefits and concerns of statin discontinuation among patients with life-limiting illness.

DESIGN

Baseline data from a multicenter, pragmatic clinical trial of statin discontinuation were used.

SETTING/SUBJECTS

Cognitively intact participants with a life expectancy of 1-12 months receiving statin medications for primary or secondary prevention were enrolled.

MEASUREMENTS

Responses to a 9-item questionnaire addressing patient concerns about discontinuing statins were collected. We used Pearson chi-square tests to compare responses by primary life-limiting diagnosis (cancer, cardiovascular disease, other).

RESULTS

Of 297 eligible participants, 58% had cancer, 8% had cardiovascular disease, and 30% other primary diagnoses. Mean (standard deviation) age was 72 (11) years. Fewer than 5% of participants expressed concern that statin deprescribing indicated physician abandonment. About one in five participants reported being told to take statins for the rest of their life (18%) or feeling that discontinuation represented prior wasted effort (18%). Many participants reported benefits of stopping statins, including spending less money on medications (63%), potentially stopping other medications (34%), and having a better quality of life (25%). More participants with cardiovascular disease as a primary diagnosis perceived that quality-of-life benefits related to statin discontinuation (52%) than participants with cancer (27%) or noncardiovascular disease diagnoses (27%) [p = 0.034].

CONCLUSION

Few participants expressed concerns about discontinuing statins; many perceived potential benefits. Cardiovascular disease patients perceived greater potential positive impact from statin discontinuation.

A realist evaluation of patients' decisions to deprescribe in the EMPOWER trial

BACKGROUND AND OBJECTIVES

Successful mechanisms for engaging patients in the deprescribing process remain unknown but may include: (1) triggering motivation to deprescribe by increasing patients' knowledge and concern about medications; (2) building capacity to taper by augmenting self-efficacy and (3) creating opportunities to discuss and receive support for deprescribing from a healthcare provider. We tested these mechanisms during theEliminating Medications through Patient Ownership of End Results (EMPOWER) () trial and investigated the contexts that led to positive and negative deprescribing outcomes.

DESIGN

A realist evaluation using a sequential mixed methods approach, conducted alongside the EMPOWER randomised clinical trial.

SETTING

Community, Quebec, Canada.

PARTICIPANTS

261 older chronic benzodiazepine consumers, who received the EMPOWER intervention and had complete 6-month follow-up data.

INTERVENTION

Mailed deprescribing brochure on benzodiazepines.

MEASUREMENTS

Motivation (intent to discuss deprescribing; change in knowledge test score; change in beliefs about the risk-benefits of benzodiazepines, measured with the Beliefs about Medicines Questionnaire), capacity (self-efficacy for tapering) and opportunity (support from a physician or pharmacist).

RESULTS

The intervention triggered the motivation to deprescribe among 167 (n=64%) participants (mean age 74.6 years±6.3, 72% women), demonstrated by improved knowledge (risk difference, 58.50% (95% CI 46.98% to 67.44%)) and increased concern about taking benzodiazepines (risk difference, 67.67% (95% CI 57.36% to 74.91%)). Those who attempted to taper exhibited increased self-efficacy (risk difference, 56.90% (95% CI 45.41% to 65.77%)). Contexts where the deprescribing mechanisms failed included lack of support from a healthcare provider, a focus on short-term quality of life, intolerance to withdrawal symptoms and perceived poor health.

CONCLUSION

Deprescribing mechanisms that target patient motivation and capacity to deprescribe yield successful outcomes in contexts where healthcare providers are supportive, and patients do not have internal competing desires to remain on drug therapy.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT01148186.

An Ecological Approach to Reducing Potentially Inappropriate Medication Use: Canadian Deprescribing Network

Polypharmacy is growing in Canada, along with adverse drug events and drug-related costs. Part of the solution may be deprescribing, the planned and supervised process of dose reduction or stopping of medications that may be causing harm or are no longer providing benefit. Deprescribing can be a complex process, involving the intersection of patients, health care providers, and organizational and policy factors serving as enablers or barriers. This article describes the justification, theoretical foundation, and process for developing a Canadian Deprescribing Network (CaDeN), a network of individuals, organizations, and decision-makers committed to promoting the appropriate use of medications and non-pharmacological approaches to care, especially among older people in Canada. CaDeN will deploy multiple levels of action across multiple stakeholder groups simultaneously in an ecological approach to health system change. CaDeN proposes a unique model that might be applied both in national settings and for different transformational challenges in health care.

Deprescribing of psychotropic medication in a 30-year-old man with learning disability

A 30-year-old man with learning disability, living in a residential home with no documented mental health diagnosis, on the autistic spectrum was prescribed carbamazepine, olanzapine and propranolol to manage behaviour on a long-term basis. He was able to successfully discontinue both of his psychotropic medicines. The reduction was carried out in the community under the supervision of the learning disability psychiatrist. He is less tired, more alert and better able to express himself. He has expanded his activities and increased his access to the community. He is able to cope better with changes to his routine. His behaviours are well managed by the behavioural strategies in place and he has now been discharged by the psychiatrist to the general practitioner.