Attitudes of ambulatory care older Nepalese patients towards deprescribing and predictors of their willingness to deprescribe

INTRODUCTION

Older adults continue to receive potentially inappropriate medications necessitating the need for medication optimization, by deprescribing. To ensure a holistic approach to deprescribing, it is essential to understand the perception of older adults towards deprescribing. This study aimed to assess the attitude of older ambulatory patients towards deprescribing and to identify factors predicting their willingness to deprescribe.

METHODS

A cross-sectional survey was conducted in central Nepal between March and September 2019 among 385 older ambulatory care patients (aged ⩾65 years) who were taking at least one regular medicine. The perception of patients towards deprescribing was assessed using the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire via a face-to-face interview method. Descriptive statistics were performed to describe patients' characteristics and their attitudes towards deprescribing. A multivariate logistic regression analysis was used to determine predictors of the willingness of older ambulatory patients towards deprescribing.

RESULTS

The median [interquartile range (IQR)] age of patients was 72 (8) years. Nearly three in five patients (64.9%) had hypertension, with 11.2% having polypharmacy. More than half of the patients (57.4%) would be willing to stop one or more of their regular medicines if their doctor said it was possible to do so. Regression analysis showed that age [odds ratio (OR) 0.946; 95% CI 0.913, 0.981; p = 0.003] and concerns about stopping medicine score (OR 0.541; 95% CI 0.334, 0.876; p = 0.013) were predictors of the willingness of the older patients towards deprescribing.

CONCLUSION

One in two older ambulatory care patients in Nepal would be willing to have one or more of their medicines deprescribed. The factors predicting their willingness to deprescribe are their age and concerns about stopping medicines. Clinicians should consider discussing the possibility of deprescribing with older patients for the prevention of potential medication-related harms.

PLAIN LANGUAGE SUMMARY

What do older Nepalese patients think about withdrawal or dose reduction of an inappropriate medication?Introduction: Research suggests that older adults (aged ⩾65 years) continue to receive medications that have the potential for harm rather than a benefit. This necessitates the need for withdrawal or dose reduction of such inappropriate medications, the process known as deprescribing. Understanding what older patients think about this process could be a stepping-stone to the general approach for its implementation. Data on deprescribing is lacking from Nepal. Therefore, we designed a survey to explore the attitude of older patients towards deprescribing and factors that could predict their willingness to deprescribe.Methods: This study was conducted between March to September 2019 among 385 older patients who were taking at least one regular medicine and were visiting selected hospitals of Nepal for outpatient services. We performed a face-to-face interview to assess the attitude of patients towards deprescribing using a validated tool called revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire that quantified the response through scoring. The data were subjected to statistical analysis to determine the attitudes of Nepalese older patients towards deprescribing and to develop a model to predict their willingness to deprescribe.Results: The average age of the participant was 72 years with 65% having hypertension and 11% using more than five medications. Our data suggested that one in two older Nepalese patients would be willing to stop one or more of their regular medications if their doctors said it was possible to do so. Their willingness to deprescribe could be predicted from their age and concerns about stopping medications.Conclusion: Clinicians should consider discussing the possibility of deprescribing with older patients for the prevention of potential medication-related harms.

Implementing a specialist paediatric clinical pharmacology service in a UK children's hospital

Aims

Royal College of Paediatrics and Child Health subspecialist training in Paediatric Clinical Pharmacology and Therapeutics has been delivered in the UK for 20 years, but no specialist clinical services have been set up previously.

Methods

Prospective audit and service evaluation of paediatric clinical pharmacology service pilot phase and dedicated service at a UK children's hospital.

Results

Pilot scheme (May–October 2019), then weekly service (established June 2020). Service covers the High Dependency Unit, and inpatients with polypharmacy. The pilot demonstrated high levels of acceptance, with 89% of suggested medication changes agreed by lead clinical team, and success, with 97.5% of suggested changes continued until discharge/pilot completion. Economic analysis estimated direct annualised cost savings on medications of up to £10 000. After 20 ward rounds of the established service, 270 potential medication changes were identified, 213 were carried out (78.9%). The most common were deprescribing (n = 143), prescribing (n = 47) and dose adjustment (n = 8). Seventy‐five different medications were deprescribed, most commonly chloral hydrate (n = 12), Lactulose, ibuprofen, Bio‐Kult and sodium alginate (all n = 4). The percentage of inpatients prescribed ≥10 medications decreased from 38.5 to 32.1%, while the subset prescribed ≥20 medications decreased from 11.0 to 5.67%. The mean number of medicines prescribed decreased from 9.0 to 8.0, while the median was unchanged at 7. Annual Yellow Card reports of suspected adverse drug reactions more than doubled (n = 66).

Conclusion

A UK model for subspecialist paediatric clinical pharmacology service delivery has demonstrated a positive clinical impact and could be replicated at other UK secondary/tertiary children's hospitals.

A narrative review of evidence to guide deprescribing among older adults

Potentially inappropriate prescription and polypharmacy are well‐known risk factors for morbidity and mortality among older adults. However, recent systematic reviews have failed to demonstrate the overall survival benefits of deprescribing. Thus, it is necessary to synthesize the current evidence to provide a practical direction for future research and clinical practice. This review summarizes the existing body of evidence regarding deprescribing to identify useful intervention elements. There is evidence that even simple interventions, such as direct deprescribing targeted at risky medications and explicit criteria‐based approaches, effectively reduce inappropriate prescribing. On the other hand, if the goal is to improve clinical outcomes such as hospitalization and emergency department visits, patient‐centered multimodal interventions such as a combination of medication review, multidisciplinary collaboration, and patient education are likely to be more effective. We also consider the opportunities and challenges for deprescribing within the Japanese healthcare system.

Attitudes toward deprescribing among adults with heart failure with preserved ejection fraction

BACKGROUND/OBJECTIVES

Attitudes toward deprescribing could vary among subpopulations. We sought to understand patient attitudes toward deprescribing among patients with heart failure with preserved ejection fraction (HFpEF).

DESIGN

Retrospective cohort study.

SETTING

Academic medical center in New York City.

PARTICIPANTS

Consecutive patients with HFpEF seen in July 2018-December 2019 at a program dedicated to providing care to older adults with HFpEF.

MEASUREMENTS

We assessed the prevalence of vulnerabilities outlined in the domain management approach for caring for patients with heart failure and examined data on patient attitudes toward having their medicines deprescribed via the revised Patient Attitudes Toward Deprescribing (rPATD).

RESULTS

Among 134 patients with HFpEF, median age was 75 (interquartile range 69-82), 60.4% were women, and 35.8% were nonwhite. Almost all patients had polypharmacy (94.0%) and 56.0% had hyperpolypharmacy; multimorbidity (80.6%) and frailty (78.7%) were also common. Overall, 90.3% reported that they would be willing to have one or more of their medicines deprescribed if told it was possible by their doctors; and 26.9% reported that they would like to try stopping one of their medicines to see how they feel without it. Notably, 91.8% of patients reported that they would like to be involved in decisions about their medicines. In bivariate logistic regression, nonwhite participants were less likely to want to try stopping one of their medicines to see how they feel without it (odds ratio 0.25, 95% confidence interval [0.09-0.62], p = 0.005).

CONCLUSIONS

Patients with HFpEF contend with many vulnerabilities that could prompt consideration for deprescribing. Most patients with HFpEF were amenable to deprescribing. Race may be an important factor that impacts patient attitudes toward deprescribing.

Anticholinergic burden in older adult inpatients: patterns from admission to discharge and associations with hospital outcomes

Background:

Anticholinergic medications are associated with adverse outcomes in older adults and should be prescribed cautiously. We describe the Anticholinergic Risk Scale (ARS) scores of older inpatients and associations with outcomes.

Methods:

We included all emergency, first admissions of adults ⩾65 years old admitted to one hospital over 4 years. Demographics, discharge specialty, dementia/history of cognitive concern, illness acuity and medications were retrieved from electronic records. ARS scores were calculated as the sum of anticholinergic potential for each medication (0 = limited/none; 1 = moderate; 2 = strong and 3 = very strong). We categorised patients based on admission ARS score [ARS = 0 (reference); ARS = 1; ARS = 2; ARS ⩾ 3] and change in ARS score from admission to discharge [admission and discharge ARS = 0 (reference); same; decreased; increased]. We described anticholinergic prescribing patterns by discharge specialty and explored multivariable associations between ARS score categories and mortality using logistic regression [odds ratios (ORs), 95% confidence intervals (CIs)].

Results:

From 33,360 patients, 10,183 (31%) were prescribed an anticholinergic medication on admission. Mean admission ARS scores were: Cardiology and Stroke = 0.56; General Medicine = 0.78; Geriatric Medicine = 0.83; Other medicine = 0.81; Trauma and Orthopaedics = 0.66; Other Surgery = 0.65. Mean ARS did not increase from admission to discharge in any specialty but reductions varied significantly, from 4.6% (Other Surgery) to 27.7% (Geriatric Medicine) (p < 0.001). The odds of both 30-day inpatient and 30-day post-discharge mortality increased with admission ARS = 1 (OR = 1.21, 95% CI 1.01–1.44 and OR = 1.44, 1.18–1.74) but not with ARS = 2 or ARS ⩾ 3. The odds of 30-day post-discharge mortality were higher in all ARS change categories, relative to no anticholinergic exposure (same: OR = 1.45, 1.21–1.74, decreased: OR = 1.27, 1.01–1.57, increased: OR = 2.48, 1.98–3.08).

Conclusion:

The inconsistent dose–response associations with mortality may be due to confounding and measurement error which may be addressed by a prospective trial. Definitive evidence for this prevalent modifiable risk factor is required to support clinician behaviour-change, thus reducing variation in anticholinergic deprescribing by inpatient speciality.

Plain language summary

We describe how commonly medicines which block the chemical acetylcholine are prescribed to older adults admitted to hospital as an emergency and explore links between these medicines and death during or soon after hospital admission

Backgroud: Medicines which block the chemical acetylcholine are commonly prescribed to treat symptoms such as itch and difficulty sleeping or to treat medical conditions such as depression. However, some studies in older adults have found potential links between these medicines and confusion and falls. Therefore, doctors are recommended to prescribe these drugs cautiously in adults aged 65 years and over.

Methods: In our paper we use data collected as part of routine medical care at one university hospital to describe how often these medicines are prescribed in a large sample of older adults admitted to hospital as an emergency. We look at the medicines patients are prescribed on admission to the hospital and also when they are later discharged.

Results: We find that these medicines are frequently prescribed. We also find that, in general, patients are prescribed fewer of these potentially harmful medicines on hospital discharge compared with hospital admission. This suggests that clinicians are aware of advice to prescribe acetylcholine blocking medicines cautiously and they are more often stopped in hospital than started. However, we find a lot of variation in practice depending on which hospital specialty was caring for the patient during their inpatient stay. We also find potential links with these medicines and death during the admission or soon after hospital discharge, but these potential links are not always consistent.

Conclusion: Further study is needed to fully understand links between medicines that block acetylcholine and late life health. This will be important to reduce variation in prescribing practices.

The Smarter Sleep educational interventions: an initiative to reduce hypnotic prescribing in in-patient psychiatric care

AIMS AND METHOD

In-patients on mental health wards are commonly prescribed hypnotics for the long-term management of disturbed sleep. Specific sleep disorders remain underdiagnosed and effective behavioural interventions are underused. We developed a suite of three educational interventions (a video, poster and handbook) about sleep, sleep disorders, the safe prescribing of hypnotics and use of psychological strategies (sleep hygiene and cognitive-behavioural therapy for insomnia, CBTi) using co-design and multiprofessional stakeholder involvement. This controlled before-and-after study evaluated the effectiveness of these interventions across seven in-patient psychiatric wards, examining their impact on hypnotic prescribing rates and staff confidence scores (data collected by retrospective drug chart analysis and survey respectively).

RESULTS

A marked reduction was seen in the percentage of patients prescribed hypnotics on in-patient prescription charts (-24%), with a 41% reduction in the number of hypnotics administered per patient (mean reduction -1.142 administrations/patient).

CLINICAL IMPLICATIONS

These simple educational strategies about the causes and treatment of insomnia can reduce hypnotic prescribing rates and increase staff confidence in both the medical and psychological management of insomnia.

Anticholinergic drugs and risk of dementia: Time for action?

Evidence suggests that the prescription of bladder anticholinergics is increasing. Recent studies have accentuated concerns about whether certain prescribed medications could increase risk of dementia, including anticholinergic drugs, and specifically anticholinergics used for bladder symptoms. Nevertheless, it can be difficult to draw together the evidence to review the case for possible causation. Recognising this issue in 1965, Bradford-Hill set out nine criteria to help assess whether evidence of a causal relationship could be inferred between a presumed cause and an observed effect. In this commentary, we explore the extent to which associations between anticholinergics and dementia satisfy the Bradford-Hill criteria and examine the potential implications. First, we look at studies that have examined the relationship between anticholinergic drugs with urological properties (bladder drugs) and the onset of dementia, and then present those studies which specifically focus on the cognitive effects of bladder drugs that affect muscarinic receptors in the brain versus the bladder on older people along with suggestions for future research. We also discuss the risks and benefits of these drugs for treating overactive bladder. If it can be shown that certain medications carry a specific risk of dementia, it is possible that initiatives to change prescribing could become a key tool in reducing the risk of dementia and may be easier to implement than some lifestyle changes.

National Trends in Statin Use among the United States Nursing Home Population (2011-2016)

BACKGROUND

Little is known about trends in statin use in United States (US) nursing homes.

OBJECTIVES

The aim of this study was to describe national trends in statin use in nursing homes and evaluate the impact of the introduction of generic statins, safety warnings, and guideline recommendations on statin use.

METHODS

This study employed a repeated cross-sectional prevalence design to evaluate monthly statin use in long-stay US nursing home residents enrolled in Medicare fee-for-service using the Minimum Data Set 3.0 and Medicare Part D claims between April 2011 and December 2016. Stratified by age (65-75 years, ≥ 76 years), analyses estimated trends and level changes with 95% confidence intervals (CI) following statin-related events (the availability of generic statins, American Heart Association/American College of Cardiology guideline updates, and US FDA safety warnings) through segmented regression models corrected for autocorrelation.

RESULTS

Statin use increased from April 2011 to December 2016 (65-75 years: 38.6-43.3%; ≥ 76 years: 26.5% to 30.0%), as did high-intensity statin use (65-75 years: 4.8-9.5%; ≥ 76 years: 2.3-4.5%). The introduction of generic statins yielded little impact on the prevalence of statins in nursing home residents. Positive trend changes in high-intensity statin use occurred following national guideline updates in December 2011 (65-75 years: β = 0.16, 95% CI 0.09-0.22; ≥ 76 years: β = 0.09, 95% CI 0.06-0.12) and November 2013 (65-75 years: β = 0.11, 95% CI 0.09-0.13; ≥ 76 years: β = 0.04, 95% CI 0.03-0.05). There were negative trend changes for any statin use concurrent with FDA statin safety warnings in March 2012 among both age groups (65-75 years: β trend change = - 0.06, 95% CI - 0.10 to - 0.02; ≥ 76 years: β trend change = - 0.05, 95% CI - 0.08 to - 0.01). The publication of the results of a statin deprescribing trial yielded a decrease in any statin use among the ≥ 76 years age group (β level change = - 0.25, 95% CI - 0.48 to - 0.09; β trend change = - 0.03, 95% CI - 0.04 to - 0.01), with both age groups observing a positive trend change with high-intensity statins (65-75 years: β = 0.11, 95% CI 0.02-0.21; ≥ 76 years: β = 0.05, 95% CI 0.01-0.09).

CONCLUSION

Overall, statin use in US nursing homes increased from 2011 to 2016. Guidelines and statin-related events appeared to impact use in the nursing home setting. As such, statin guidelines and messaging should provide special consideration for nursing home populations, who may have more risk than benefit from statin pharmacotherapy.

Clinical Outcomes After Discontinuation of Thyroid Hormone Replacement: A Systematic Review and Meta-Analysis

Background: Levothyroxine (LT4) is one of the most commonly prescribed medications. Although considered a life-long replacement therapy, LT4 therapy can be discontinued for some patients. This study aims at: (i) reviewing the evidence on clinical outcomes of patients undergoing thyroid hormone replacement discontinuation, (ii) identifying the predictors of successful discontinuation, and (iii) systematically appraising frameworks used for deprescribing thyroid hormone. Methods: We searched multiple bibliographic databases, including Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus, from inception to February 2020 for studies in which thyroid hormone replacement was discontinued. Clinical outcomes assessed included: proportion of patients that remained euthyroid or needed to restart thyroid hormone replacement after discontinuation and frequency of clinical symptoms of hypothyroidism and adverse effects. We also evaluated predictors for discontinuation and deprescribing frameworks. Reviewers (F.J.K.T., N.B., N.M.S.O., S.M.) evaluated studies for inclusion, extracted data, and assessed methodological quality independently and in duplicate. Results: Seventeen observational studies at moderate to high risk of bias met inclusion criteria, including a total of 1103 patients (86% women) with an age range of 2-81 years. Approximately a third of patients undergoing thyroid hormone discontinuation remained euthyroid at follow-up (37.2%, 95% confidence interval [CI 24.2-50.1%], I² 97.5%). Subgroup analysis showed that patients with a previous diagnosis of overt hypothyroidism (OH) were less likely to remain euthyroid (11.8% [CI 0.4-23.2%], I² 90.3%) than patients with a prior diagnosis of subclinical hypothyroidism (SCH) (35.6% [CI 8.2-62.9%], I² 94.0%). No study followed a framework for systematically deprescribing LT4. Conclusions: Low-quality evidence suggests that up to a third of patients remained euthyroid after thyroid hormone discontinuation, with a higher proportion of patients with an initial diagnosis of SCH remaining euthyroid than patients with an initial diagnosis of OH. A deprescribing framework focusing on adequate selection of patients for deprescribing LT4 and a systematic process is warranted to guide clinicians in re-evaluating the need for LT4 in their patients.

Rational prescribing in community palliative care

Palliative care is the province of everyone, particularly people managing older patients. Most people die of multimorbidity, frailty and dementia rather than cancer and will never see a palliative care specialist. People dying from non-malignant disease have symptoms and problems that are usually predictable. Common symptoms like pain and dyspnoea can be anticipated. Planning to prevent them, or for when they occur, is more effective than waiting until they happen. Deprescribing is an effective way of preventing morbidity in this group. Getting to know a few medicines well for each symptom is important when providing palliative care for patients. Starting at low doses and increasing slowly is also key.

Managing Polypharmacy in Older Adults with Cancer Across Different Healthcare Settings

The care of older patients with cancer is becoming increasingly complex. Common challenges for this population include management of comorbidities, safe transitions of care, and appropriate medication use. In particular, polypharmacy-generally defined as the regular use of five or more medications-and inappropriate medication use can lead to adverse effects and poor outcomes in older adults with cancer, including falls, hospital readmissions, cognitive impairment, poor adherence to essential medications, chemotherapy toxicity, and increased mortality. Managing polypharmacy across different cancer care settings is often challenging. Providers face barriers to safe and successful medication management that may include lack of time, absence of reimbursement, underappreciation of the scale of polypharmacy-related harm, lack of ownership of deprescribing efforts, and poor communication across care settings. Existing literature on managing inappropriate medication use and polypharmacy in older adults with cancer has often focused on ideal state settings in which resources are plentiful and time is purposefully allocated for medication interventions. This paper presents a narrative, rather than a systematic review, of studies published in the past decade that provided detailed information on medication management and polypharmacy across cancer care settings. This review aims to also summarize different healthcare provider roles in taking action against inappropriate medication use and polypharmacy in older adults with cancer.

The Barriers and Facilitators of Different Stakeholders When Deprescribing Benzodiazepine Receptor Agonists in Older Patients-A Systematic Review

Treatment of older patients with benzodiazepines and Z-drugs (BZRA) is associated with an increased risk of side effects. However, this treatment is still used among these patients. Deprescribing can be a tool to reduce inappropriate medication. This review aims to identify and compare barriers and facilitators of stakeholders involved in BZRA deprescribing in older patients and uncover potential gaps in the research field. The search was conducted in PubMed, EMBASE, PsycINFO, and Cochrane Library. Ten articles based on qualitative data on BZRA deprescribing in older patients (≥65 years) published between 2005-2020 were included. Six articles referred to patients as stakeholders, two referred to physicians, and one to nurses and caregivers, respectively, indicating a need for more studies in the field. More barriers than facilitators were identified. Important findings were the patient willingness to deprescribe BZRA compared to physicians, who did not mention deprescribing to patients due to barriers such as expected patient resistance. Nurses mentioned barriers like lack of knowledge and the feeling that their options were not valued by physicians; education was found to be a shared deprescribing facilitator among the stakeholders. Being aware of deprescribing barriers and facilitators can be helpful in future successful deprescribing interventions.

Blood Pressure Changes Following Antihypertensive Medication Reduction, by Drug Class and Dose Chosen for Withdrawal: Exploratory Analysis of Data From the OPTiMISE Trial

Aims: Deprescribing of antihypertensive drugs is recommended for some older patients with polypharmacy, but there is little evidence to inform which drug (or dose) should be withdrawn. This study used data from the OPTiMISE trial to examine whether short-term outcomes of deprescribing vary by drug class and dose of medication withdrawn. Methods: The OPTiMISE trial included patients aged ≥80 years with controlled systolic blood pressure (SBP; <150 mmHg), receiving ≥2 antihypertensive medications. This study compared SBP control, mean change in SBP and frequency of adverse events after 12 weeks in participants stopping one medication vs. usual care, by drug class and equivalent dose of medication withdrawn. Equivalent dose was determined according to the defined daily dose (DDD) of each medication type. Drugs prescribed below the DDD were classed as low dose and those prescribed at ≥DDD were described as higher dose. Outcomes were examined by generalized linear mixed effects models. Results: A total of 569 participants were randomized, aged 85 ± 3 years with controlled blood pressure (mean 130/69 mmHg). Within patients prescribed calcium channel blockers, higher dose medications were more commonly selected for withdrawal (90 vs. 10%). In those prescribed beta-blockers, low dose medications were more commonly chosen (87 vs. 13%). Withdrawal of calcium channel blockers was associated with an increase in SBP (5 mmHg, 95%CI 0-10 mmHg) and reduced SBP control (adjusted RR 0.89, 95%CI 0.80-0.998) compared to usual care. In contrast, withdrawal of beta-blockers was associated with no change in SBP (-4 mmHg, 95%CI -10 to 2 mmHg) and no difference in SBP control (adjusted RR 1.15, 95%CI 0.96-1.37). Similarly, withdrawal of higher dose medications was associated with an increase in SBP but no change in BP control. Withdrawal of lower dose medications was not associated with a difference in SBP or SBP control. There was no association between withdrawal of specific drug classes and adverse events. Conclusion: These exploratory data suggest withdrawal of higher dose calcium channel blockers should be avoided if the goal is to maintain BP control. However, low dose beta-blockers may be removed with little impact on blood pressure over 12-weeks of follow-up. Larger studies are needed to confirm these associations.

Sex-Differences in Discontinuation of Statin Treatment in Cancer Patients the Year before Death

Statin treatment is often terminated in patients with advanced cancer but guidelines for statin discontinuation are still lacking. The aim of this study was to investigate sex-differences in time-points of statin discontinuation in patients with advanced cancer. Medical records from 1535 deceased patients enrolled at a Palliative Home Care Unit were reviewed. A total of 149 patients (42 women and 107 men) who were diagnosed with cancer, and were treated with statins one year before death, were identified. Statin treatment was terminated earlier in women than in men, 3.0 months prior to death (IQR 0.88–7.25) as compared to 1.5 months (IQR 0.5–4.0) (p < 0.05), respectively. In a longitudinal analysis there was a significant difference between men and women still on statin treatment at all studied time-points, 9, 6, and 3 months before death (p < 0.05), where women terminated statin treatment earlier in the disease trajectory. Baseline demographics were similar between the sexes except that more men than women had a history of previous cardiovascular events (p < 0.01). However, neither the indication for statin treatment, i.e., primary prevention versus secondary prevention, nor age could explain the sex-difference in statin discontinuation. There was no difference in cardiovascular events or mortality between men and women after statin discontinuation.

Case Report: The Complexities of Managing Medications and the Importance of Deprescribing Anticholinergics in Older Adults

Potentially inappropriate anticholinergic medications (including over-the-counter products), polypharmacy, and the existence of communication barriers among members of the interprofessional team frequently contribute to clinical complexity in older adults. We present the case of a frail 86-year old female from the perspective of a community pharmacist managing outpatient medications and transitions of care. CD's past medical history is significant for dementia, multiple falls, recurrent urinary tract infections, depression, cardiac arrhythmia, macular degeneration, chronic pain, depression, and cerebrovascular disease.

An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients

This international multidisciplinary consensus statement was developed to provide balanced guidance on the safe peri-operative use of opioids in adults. An international panel of healthcare professionals evaluated the literature relating to postoperative opioid-related harm, including persistent postoperative opioid use; opioid-induced ventilatory impairment; non-medical opioid use; opioid diversion and dependence; and driving under the influence of prescription opioids. Recommended strategies to reduce harm include pre-operative assessment of the risk of persistent postoperative opioid use; use of an assessment of patient function rather than unidimensional pain scores alone to guide adequacy of analgesia; avoidance of long-acting (modified-release and transdermal patches) opioid formulations and combination analgesics; limiting the number of tablets prescribed at discharge; providing deprescribing advice; avoidance of automatic prescription refills; safe disposal of unused medicines; reducing the risk of opioid diversion; and better education of healthcare professionals, patients and carers. This consensus statement provides a framework for better prescribing practices that could help reduce the risk of postoperative opioid-related harm in adults.

Long-term effectiveness of an intervention to enhance mirabegron use revision and its deprescribing: 36-month follow-up of a quasi-experimental trial in primary care

OBJECTIVE

This is a follow-up study from a multicenter, prospective, before-and-after quasi-experimental, controlled trial to assess effectiveness at 36 months of an intervention designed to promote the revision and deprescribing of mirabegron in primary care in patients with overactive bladder.

METHODS

Intervention included patients who attended in 17 PHCs located in North Barcelona; control included patients who attended in the other 34 PHCs located in South, East and West Barcelona. The primary endpoint was mirabegron review and deprescribing when GPs considered appropriate, which was measured by the percentage of change of the number of patients with treatment at 36 months compared to the baseline. The intervention consisted of meetings with all the directors of the PHCs; distribution of the infographic to the GPs; providing information regarding the intervention for urologist and gynaecologist; and review of the treatments by the GPs. A monthly follow-up was done during the first year, and every three months thereafter until month 36.

RESULTS

Overall, 1932 patients were included, mean age 71.6 years (female 53.8%). A total of 540 patients included in the intervention discontinued mirabegron at some point during the 36 months follow-up (540/762, 70.8%) compared to 759 patients in the control (759/1170, 64.9%), (p < 0.001). A total of 324/433 patients (74.8%) who discontinued mirabegron use at 12 months remained without pharmacological treatment at 36 months. With respect to the baseline cohort, there was a lower introduction of new patients with mirabegron in the intervention (546/762, 71.6%) compared to the control (1246/1170, 106.5%), (p < .001). Regarding the treated patients, there was an increase of 41.6% in the control and a slight increase of 0.8% in the intervention at 36 months, (p < .001).

CONCLUSION

Our data indicate that an intervention can enhance the review use of mirabegron in the primary care setting, and promote their deprescribing.

Use of preventive drugs during the last year of life in older adults with cancer or chronic progressive diseases

PURPOSE

To evaluate the prescription of preventive medications with questionable usefulness in community dwelling elderly adults with cancer or chronic progressive diseases during the last year of life.

METHODS

Through the utilization of the healthcare databases of the Lombardy region, Italy, we identified two retrospective cohorts of patients aged 65 years or more, who died in 2018 and had a diagnosis of either a solid cancer (N = 19 367) or a chronic progressive disease (N = 27 819). We estimated prescription of eight major classes of preventive drugs 1 year and 1 month before death; continuation or initiation of preventive drug use during the last month of life was also investigated.

RESULTS

Over the last year of life, in both oncologic and non-oncologic patients, we observed a modest decrease in the prescription of blood glucose-lowering drugs, anti-hypertensives, lipid-modifying agents, and bisphosphonates, and a slight increase in the prescription of vitamins, minerals, antianemic drugs, and antithrombotic agents (among oncologic patients only). One month before death, the prescription of preventive drugs was still common, particularly for anti-hypertensives, antithrombotics, and antianemics, with more than 60% of patients continuing to be prescribed most preventive drugs and an over 10% starting a therapy with an antithrombotic, an antianemic, or a vitamin or mineral supplement.

CONCLUSION

These findings support the need for an appropriate drug review and improvement in the quality of drug prescription for vulnerable populations at the end-of-life.

A Collaborative Deprescribing Intervention in a Subacute Medical Outpatient Clinic: A Pilot Randomized Controlled Trial

Medication deprescribing is essential to prevent inappropriate medication use in multimorbid patients. However, experience of deprescribing in Danish Subacute Medical Outpatient Clinics (SMOCs) is limited. The objective of our pilot study was to evaluate the feasibility and sustainability of a collaborative deprescribing intervention by a pharmacist and a physician to multimorbid patients in a SMOC. A randomized controlled pilot study was conducted, with phone follow-up at 30 and 365+ days. A senior pharmacist performed a systematic deprescribing intervention using the Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria, the Danish deprescribing list, and patient interviews. A senior physician received the proposed recommendations and decided which should be implemented. The main outcome was the number of patients having ≥1 medication where deprescribing status was sustained 30 days after inclusion. Out of 76 eligible patients, 72 (95%) were included and 67 (93%) completed the study (57% male; mean age 73 years; mean number of 10 prescribed medications). Nineteen patients (56%) in the intervention group and four (12%) in the control group had ≥1 medication where deprescribing status was sustained 30 days after inclusion (p = 0.015). In total, 37 medications were deprescribed in the intervention group and five in the control group. At 365+ days after inclusion, 97% and 100% of the deprescribed medications were sustained in the intervention and control groups, respectively. The three most frequently deprescribed medication groups were analgesics, cardiovascular, and gastrointestinal medications. In conclusion, a collaborative deprescribing intervention for multimorbid patients was feasible and resulted in sustainable deprescribing of medication in a SMOC.

Retrospective analysis of a pilot pharmacist-led hospice deprescribing program initiative

CONTEXT

Medication deprescribing in palliative care settings has been insufficiently studied.

OBJECTIVE

To determine the feasibility of a deprescribing program in hospice patients with limited life expectancy.

DESIGN

Pharmacist-led, single arm, single-centered, retrospective analysis of a pilot deprescribing program in an integrated healthcare delivery organization between 9/1/2018 to 1/31/2019.

OUTCOME MEASURES

The primary outcome was the proportion of patients who achieved ≥50% reduction of the recommended medications to deprescribe.

RESULTS

A total of 97 patients were included in the analysis. The average age was 77.5 ± 23.7 years, with 53.6% being women and 54.6% white. The most common primary diagnosis was cancer (58.8%), with cardiovascular disease the next most common (15.5%). The mean number of baseline comorbidities was 2.0 ± 1.6. Of 698 prescriptions at the start of hospice enrollment, 79.4% of patients achieved a ≥50% reduction in medications recommended for deprescribing. This success was seen mostly in cardiovascular and other nonspecific medications. We found that every 1-unit increase in the number of patient encounters with hospice pharmacists was associated with a 3.2-fold higher odds of achieving a ≥50% reduction in medications that were recommended for deprescribing.

CONCLUSION

The findings from this pilot study revealed that a collaborative, pharmacist-led, collaborative medication deprescribing program initiative was associated with a 79% success in ≥50% medication reduction. More frequent patient encounters had higher odds of success. Future studies, utilizing a control group, should focus on determining the effectiveness of the program and the impact on quality of life.

Multicomponent behavioral intervention to reduce exposure to anticholinergics in primary care older adults

OBJECTIVE

To test the impact of a multicomponent behavioral intervention to reduce the use of high-risk anticholinergic medications in primary care older adults.

DESIGN

Cluster-randomized controlled trial.

SETTING AND PARTICIPANTS

Ten primary care clinics within Eskenazi Health in Indianapolis.

INTERVENTION

The multicomponent intervention included provider- and patient-focused components. The provider-focused component was computerized decision support alerting of the presence of a high-risk anticholinergic and offering dose- and indication-specific alternatives. The patient-focused component was a story-based video providing education and modeling an interaction with a healthcare provider resulting in a medication change. Alerts within the medical record triggered staff to play the video for a patient. Our design intended for parallel, independent priming of both providers and patients immediately before an outpatient face-to-face interaction.

MEASUREMENT

Medication orders were extracted from the electronic medical record system to evaluate the prescribing behavior and population prevalence of anticholinergic users. The intervention was introduced April 1, 2019, through March 31, 2020, and a preintervention observational period of April 1, 2018, through March 31, 2019, facilitated difference in difference comparisons.

RESULTS

A total of 552 older adults had visits at primary care sites during the study period, with mean age of 72.1 (SD 6.4) years and 45.3% African American. Of the 259 provider-focused alerts, only three (1.2%) led to a medication change. Of the 276 staff alerts, 4.7% were confirmed to activate the patient-focused intervention. The intervention resulted in no significant differences in either the number of discontinue orders for anticholinergics (intervention: two additional orders; control: five fewer orders, p = 0.7334) or proportion of the population using anticholinergics following the intervention (preintervention: 6.2% and postintervention: 5.1%, p = 0.6326).

CONCLUSION

This multicomponent intervention did not reduce the use of high-risk anticholinergics in older adults receiving primary care. Improving nudges or a policy-focused component may be necessary to reduce use of high-risk medications.

Deprescribing in Older Adults With Cancer and Limited Life Expectancy: An Integrative Review

Polypharmacy is common in older adults with cancer and deprescribing potentially inappropriate medications becomes very relevant when life expectancy decreases due to metastatic disease. Especially preventive medications may no longer be beneficial, because they may decrease quality of life and reduction in morbidity and mortality may be futile. Although deprescribing of preventive medication is common in the last period of life, it is still unusual during active cancer treatment for advanced disease, although life expectancy is often limited to less than 1 to 2 years in that stage. We performed a systematic search of the literature in Pubmed and Embase on the discontinuation of commonly utilized groups of preventive medication and evaluated the evidence of potential benefits and harms in patients aged 65 years or older with cancer and a limited life expectancy (LLE). From 21 included studies, it can be concluded that deprescribing lipid lowering drugs, antihypertensive drugs, osteoporosis drugs and antihyperglycemic drugs is feasible in a considerable part of patients with a LLE. Discontinuation may be performed safely, without the occurrence of serious adverse events or decrease of survival. The only study that addressed quality of life after deprescribing showed that discontinuation of statins improves quality of life in patients with a LLE. Recurrence of symptoms requiring reintroduction occurred in 0-13% of patients on antihyperglycemic treatment and 8-60% of patients using antihypertensive drugs. In order to reduce pill burden and futile treatment clinicians should discuss deprescribing of preventive medication with older patients with advanced cancer and a LLE.

What I have learnt from helping thousands of people taper off antidepressants and other psychotropic medications

Although psychiatric drug withdrawal syndromes have been recognized since the 1950s - recent studies confirm antidepressant withdrawal syndrome incidence upwards of 40% - medical information about how to safely go off the drugs has been lacking. To fill this gap, over the last 25 years, patients have developed a robust Internet-based subculture of peer support for tapering off psychiatric drugs and recovering from withdrawal syndrome. This account from the founder of such an online community covers lessons learned from thousands of patients regarding common experiences with medical providers, identification of adverse drug reactions, risk factors for withdrawal, tapering techniques, withdrawal symptoms, protracted withdrawal syndrome, and strategies to cope with symptoms, in the context of the existing scientific literature.

Prescriber perspectives on low-value prescribing: A qualitative study

BACKGROUND

Health systems are increasingly implementing interventions to reduce older patients' use of low-value medications. However, prescribers' perspectives on medication value and the acceptability of interventions to reduce low-value prescribing are poorly understood.

OBJECTIVE

To identify the characteristics that affect the value of a medication and those factors influencing low-value prescribing from the perspective of primary care physicians.

DESIGN

Qualitative study using semi-structured interviews.

SETTING

Academic and community primary care practices within University of Pittsburgh Medical Center health system.

PARTICIPANTS

Sixteen primary care physicians.

MEASUREMENTS

We elicited 16 prescribers' perspectives on definitions and examples of low-value prescribing in older adults, the factors that incentivize them to engage in such prescribing, and the characteristics of interventions that would make them less likely to engage in low-value prescribing.

RESULTS

We identified three key themes. First, prescribers viewed low-value prescribing among older adults as common, characterized both by features of the medications themselves and of the particular patients to whom they were prescribed. Second, prescribers described the causes of low-value prescribing as multifactorial, with factors related to patients, prescribers, and the health system as a whole, making low-value prescribing a default practice pattern. Third, interventions addressing low-value prescribing must minimize the cognitive load and time pressures that make low-value prescribing common. Interventions increasing time pressure or cognitive load, such as increased documentation, were considered less acceptable.

CONCLUSIONS

Our findings demonstrate that low-value prescribing is a well-recognized phenomenon, and that interventions to reduce low-value prescribing must consider physicians' perspectives and address the specific patient, prescriber and health system factors that make low-value prescribing a default practice.

Limiting antipsychotic drugs in dementia

Most patients with dementia have behavioural and psychological symptoms. The first-line treatments for these symptoms are not drugs, but behavioural and psychological interventions

Antipsychotic drugs are widely prescribed for people living with dementia. This is despite a high adverse effect burden and limited evidence of efficacy

Most behavioural and psychological symptoms will subside spontaneously within six months. Trials of deprescribing are therefore recommended

Behaviours should be seen as symptoms that have an underlying cause. Treatment should target these causes, rather than the resultant behaviours