101
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Affiliation(s)
- Doron Garfinkel
- Center for Appropriate Medication Use, Sheba Medical Center, Tel Hashomer, Israel
| | - Aaron Bilek
- Geriatric division, Tel Aviv Sourasky Medical Center, Israel
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102
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Bayliss EA, Shetterly SM, Drace ML, Norton J, Green AR, Reeve E, Weffald LA, Wright L, Maciejewski ML, Sheehan OC, Wolff JL, Gleason KS, Kraus C, Maiyani M, Du Vall M, Boyd CM. The OPTIMIZE patient- and family-centered, primary care-based deprescribing intervention for older adults with dementia or mild cognitive impairment and multiple chronic conditions: study protocol for a pragmatic cluster randomized controlled trial. Trials 2020; 21:542. [PMID: 32552857 PMCID: PMC7301527 DOI: 10.1186/s13063-020-04482-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/06/2020] [Indexed: 12/03/2022] Open
Abstract
Background Most individuals with dementia or mild cognitive impairment (MCI) have multiple chronic conditions (MCC). The combination leads to multiple medications and complex medication regimens and is associated with increased risk for significant treatment burden, adverse drug events, cognitive changes, hospitalization, and mortality. Optimizing medications through deprescribing (the process of reducing or stopping the use of inappropriate medications or medications unlikely to be beneficial) may improve outcomes for MCC patients with dementia or MCI. Methods With input from patients, family members, and clinicians, we developed and piloted a patient-centered, pragmatic intervention (OPTIMIZE) to educate and activate patients, family members, and primary care clinicians about deprescribing as part of optimal medication management for older adults with dementia or MCI and MCC. The clinic-based intervention targets patients on 5 or more medications, their family members, and their primary care clinicians using a pragmatic, cluster-randomized design at Kaiser Permanente Colorado. The intervention has two components: a patient/ family component focused on education and activation about the potential value of deprescribing, and a clinician component focused on increasing clinician awareness about options and processes for deprescribing. Primary outcomes are total number of chronic medications and total number of potentially inappropriate medications (PIMs). We estimate that approximately 2400 patients across 9 clinics will receive the intervention. A comparable number of patients from 9 other clinics will serve as wait-list controls. We have > 80% power to detect an average decrease of − 0.70 (< 1 medication). Secondary outcomes include the number of PIM starts, dose reductions for selected PIMs (benzodiazepines, opiates, and antipsychotics), rates of adverse drug events (falls, hemorrhagic events, and hypoglycemic events), ability to perform activities of daily living, and skilled nursing facility, hospital, and emergency department admissions. Discussion The OPTIMIZE trial will examine whether a primary care-based, patient- and family-centered intervention educating patients, family members, and clinicians about deprescribing reduces numbers of chronic medications and PIMs for older adults with dementia or MCI and MCC. Trial registration NCT03984396. Registered on 13 June 2019
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Affiliation(s)
- E A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA. .,Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| | - S M Shetterly
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - M L Drace
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - J Norton
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - E Reeve
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia.,Geriatric Medicine Research, Faculty of Medicine, and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
| | - L A Weffald
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, Aurora, CO, USA
| | - L Wright
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - M L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, Veterans Affairs Medical Center, Durham, NC, USA.,Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - O C Sheehan
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J L Wolff
- School of Public Health, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - K S Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - C Kraus
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - M Maiyani
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - M Du Vall
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, Aurora, CO, USA
| | - C M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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103
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Affiliation(s)
| | - Herm J. Lamberink
- Brain Center Rudolf Magnus, Department of Child Neurology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Kees P. J. Braun
- Brain Center Rudolf Magnus, Department of Child Neurology, University Medical Center Utrecht, Utrecht, the Netherlands
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104
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Oliveira ALML, Nascimento MMGD, Castro-Costa É, Firmo JOA, Lima-Costa MF, Loyola Filho AID. Increased use of benzodiazepines among older adults: Bambuí Project. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2020; 23:e200029. [PMID: 32401915 DOI: 10.1590/1980-549720200029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 12/18/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Benzodiazepines are the most widely used psychoactive drugs, despite the risks associated with their prolonged use, especially among older adults. OBJECTIVE To investigate the use of benzodiazepines among community-dwelling people aged ≥ 75 years. METHODS The study was conducted among members of the baseline (in 1997) and survivors (in 2012) of the Bambuí Project cohort. The prevalence of benzodiazepine use was estimated separately for each year, and the comparison between them was performed using the Poisson regression model with robust variance. RESULTS The prevalence of benzodiazepine use was higher in 2012 (33.9%) compared to 1997 (24.9%). After multiple adjustments, the difference in prevalence did not remain significant in study population (PR = 1.25; 95%CI 0.99 - 1.60), unlike that observed in the female stratum (PR = 1.38; 95%CI 1.04 - 1.84). Clonazepam was the strongest-growing drug between the two years (PR = 4.94; 95%CI 2.54 - 9.62). CONCLUSION This study showed an important increase in benzodiazepine use in an older adult population. These results are concerning as these drugs are contraindicated for use in older adults, mainly if used chronically, and are available in the national list of essential medicines. Health professionals should be aware of the risks involved in its use regarding this population.
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Affiliation(s)
| | | | - Érico Castro-Costa
- Núcleo de Estudos em Saúde Pública e Envelhecimento, Instituto René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, MG, Brazil
| | - Josélia Oliveira Araújo Firmo
- Núcleo de Estudos em Saúde Pública e Envelhecimento, Instituto René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, MG, Brazil
| | - Maria Fernanda Lima-Costa
- Núcleo de Estudos em Saúde Pública e Envelhecimento, Instituto René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, MG, Brazil
| | - Antônio Ignácio de Loyola Filho
- Núcleo de Estudos em Saúde Pública e Envelhecimento, Instituto René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, MG, Brazil
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Abstract
Older adults, particularly those late in life, are at higher risk for medication misadventure, yet bear the burden of increasing polypharmacy. It is incumbent on practitioners who care for this vulnerable population to use one or more approaches to deprescribe medications that impose a greater burden than benefit, including medically futile medications. It is essential that health care providers use compassionate communication skills when explaining these interventions with patients and families, pointing out that this is a positive, patient-centric intervention.
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Affiliation(s)
- Shaida Talebreza
- Geriatric and Academic Palliative Medicine, Division of Geriatrics, University of Utah School of Medicine, George E. Wahlen Salt Lake City Veterans Affairs Medical Center, 30 North 1900 East SOM AB193, Salt Lake City, UT 84132-0001, USA
| | - Mary Lynn McPherson
- Advanced Post-Graduate Education in Palliative Care, Online Master of Science in Palliative Care, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy Baltimore, 20 North Pine Street, S405, Baltimore, MD 21201, USA.
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106
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Turner JP, Martin P, Zhang YZ, Tannenbaum C. Patients beliefs and attitudes towards deprescribing: Can deprescribing success be predicted? Res Social Adm Pharm 2020; 16:599-604. [DOI: 10.1016/j.sapharm.2019.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 07/05/2019] [Accepted: 07/09/2019] [Indexed: 01/06/2023]
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107
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[What do primary care physicians think about deprescription?]. J Healthc Qual Res 2020; 35:87-93. [PMID: 32241729 DOI: 10.1016/j.jhqr.2019.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/29/2019] [Accepted: 11/06/2019] [Indexed: 12/20/2022]
Abstract
INTRODUCTION To learn about the perceptions and attitudes of family doctors regarding deprescription. MATERIAL AND METHODS This is a cross-sectional study conducted at the Organización Sanitaria Integrada Bidasoa, Osakidetza. In November 2018, sessions were held at health centres on deprescribing for family doctors, following which the PACPD-12 questionnaire was handed out, translated into Spanish and adapted. The responses to the questionnaire were collected, together with the socio-demographic variables. RESULTS Forty-two of the 58 doctors who received the survey responded (72%). One hundred percent considered deprescription beneficial in the current scenario. The drug groups that they most frequently considered deprescribing were the benzodiazepines, bisphosphonates and proton pump inhibitors. The main reasons they gave for deprescribing were to reduce harm from adverse effects and that the medication was of minimal benefit in the patient's circumstances, and they indicated that specific training in deprescribing and pharmacist alerts in the clinical history would facilitate deprescription. Barriers highlighted were lack of time, prescribing by other professionals, or resistance on the part of the patient or their family. CONCLUSIONS Knowing what doctors think about deprescribing and its barriers and facilitators are necessary to plan a strategy to facilitate the practice. Although all the respondents indicated that they consider deprescription beneficial, they found barriers in their daily practice to their being able to implement it.
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108
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Edelman M, Jellema P, Hak E, Denig P, Blanker MH. Patients' Attitudes Towards Deprescribing Alpha-Blockers and Their Willingness to Participate in a Discontinuation Trial. Drugs Aging 2020; 36:1133-1139. [PMID: 31515710 PMCID: PMC6884428 DOI: 10.1007/s40266-019-00712-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective The objective of this study was to gain insights into the attitudes of men with lower urinary tract symptoms towards deprescribing alpha-blockers and to assess their willingness to participate in a planned discontinuation trial. Methods This was a cross-sectional questionnaire study. Men aged 30 years and older with lower urinary tract symptoms, who were first prescribed an alpha-blocker in 2015 or 2016, were selected from a population-based prescription database. We recorded lower urinary tract symptom severity (e.g., International Prostate Symptom Score and Overactive Bladder questionnaire) and patient characteristics (e.g., comorbidity and polypharmacy). The linguistically validated Dutch version of the revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire was also used, to which we added ten specific questions on attitudes towards the deprescribing of alpha-blockers. Information about a future discontinuation trial on alpha-blockers was then provided and participants were asked to indicate if they would participate. We explored the explanatory factors for the willingness to participate by logistic regression analyses. Results Of the 1380 patients in the database, 421 were using an alpha-blocker, and 195 completed the questionnaire. Of these, 16 men were excluded because of indwelling catheter use or unknown indication. The mean age of the 179 participants was 69.4 (standard deviation 9.2) years. Most men were satisfied with their current therapy, but almost all (93%) were willing to stop the medicine at the request of a doctor. Therefore, most men (61%) were willing to participate in the proposed alpha-blocker discontinuation trial. Willingness to stop therapy was affected by patients’ perceptions of the appropriateness of alpha-blocker therapy and concerns about stopping that therapy. Conclusions Although men who use alpha-blockers are generally satisfied with their current therapy, most will participate in a discontinuation trial. Electronic supplementary material The online version of this article (10.1007/s40266-019-00712-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Malou Edelman
- Department of General Practice and Elderly Medicine, University Medical Centre Groningen, University of Groningen, Huispostcode FA21, P.O. Box 196, 9700 AD, Groningen, The Netherlands
| | - Petra Jellema
- Department of General Practice and Elderly Medicine, University Medical Centre Groningen, University of Groningen, Huispostcode FA21, P.O. Box 196, 9700 AD, Groningen, The Netherlands
| | - Eelko Hak
- Unit of Pharmaco-Therapy Epidemiology and Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Petra Denig
- Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, The Netherlands
| | - Marco H Blanker
- Department of General Practice and Elderly Medicine, University Medical Centre Groningen, University of Groningen, Huispostcode FA21, P.O. Box 196, 9700 AD, Groningen, The Netherlands.
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Sawan M, Reeve E, Turner J, Todd A, Steinman MA, Petrovic M, Gnjidic D. A systems approach to identifying the challenges of implementing deprescribing in older adults across different health-care settings and countries: a narrative review. Expert Rev Clin Pharmacol 2020; 13:233-245. [PMID: 32056451 DOI: 10.1080/17512433.2020.1730812] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: There is increasing recognition of the need for deprescribing of inappropriate medications in older adults. However, efforts to encourage implementation of deprescribing in clinical practice have resulted in mixed results across settings and countries.Area covered: Searches were conducted in PubMed, Embase, and Google Scholar in June 2019. Reference lists, citation checking, and personal reference libraries were also utilized. Studies capturing the main challenges of, and opportunities for, implementing deprescribing into clinical practice across selected health-care settings internationally, and international deprescribing-orientated policies were included and summarized in this narrative review.Expert opinion: Deprescribing intervention studies are inherently heterogeneous because of the complexity of interventions employed and often do not reflect the real-world. Further research investigating enhanced implementation of deprescribing into clinical practice and across health-care settings is required. Process evaluations in deprescribing intervention studies are needed to determine the contextual factors that are important to the translation of the interventions in the real-world. Deprescribing interventions may need to be individually tailored to target the unique barriers and opportunities to deprescribing in different clinical settings. Introduction of national policies to encourage deprescribing may be beneficial, but need to be evaluated to determine if there are any unintended consequences.
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Affiliation(s)
- Mouna Sawan
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia.,Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, St Leonards, Australia
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Division of Health Sciences, University of South Australia, Adelaide, Australia.,Geriatric Medicine Research, Faculty of Medicine and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority, Halifax, Canada
| | - Justin Turner
- Faculty of Medicine, University of Montreal, Montreal, Canada
| | - Adam Todd
- School of Pharmacy, Faculty of Medical Science, Newcastle University, Newcastle upon Tyne, UK
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco and the San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Mirko Petrovic
- Section of Geriatrics, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
| | - Danijela Gnjidic
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia.,Charles Perkins Centre, The University of Sydney, Camperdown, Australia
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Dearing ME, Bowles S, Isenor J, Kits O, Kouladjian O'Donnell L, Neville H, Hilmer S, Toombs K, Sirois C, Hajizadeh M, Negus A, Rockwood K, Reeve E. Pharmacist-led intervention to improve medication use in older inpatients using the Drug Burden Index: a study protocol for a before/after intervention with a retrospective control group and multiple case analysis. BMJ Open 2020; 10:e035656. [PMID: 32086361 PMCID: PMC7044900 DOI: 10.1136/bmjopen-2019-035656] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Polypharmacy and potentially inappropriate medication use is common in older adults and is associated with adverse outcomes such as falls and hospitalisations. METHODS AND ANALYSIS This study is a pharmacist-led medication optimisation initiative using an electronic tool (the Drug Burden Index (DBI) Calculator) in four hospital sites in the Canadian province of Nova Scotia. The study aims to enrol 160 participants between the preintervention and intervention groups. The Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT 2013 checklist) was used to develop the protocol for this prospective interventional implementation study. A preintervention retrospective control cohort and a multiple case study analysis will also be used to assess the effect of intervention implementation. Statistical analysis will involve change in DBI scores and assessment of clinical outcomes, such as rehospitalisation and mortality using appropriate statistical tests including t-test, χ2, analysis of variance and unadjusted and adjusted regression methods. ETHICS AND DISSEMINATION Ethics approval has been granted by the Nova Scotia Health Authority Research Ethics Board. The findings of this study will be published in peer-reviewed journals and presented at local, national and international conferences. TRIAL REGISTRATION NUMBER NCT03698487.
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Affiliation(s)
- Marci Elizabeth Dearing
- Geriatric Medicine Research, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Department of Pharmacy, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Susan Bowles
- Department of Pharmacy, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jennifer Isenor
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
- Canadian Center for Vaccinology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Olga Kits
- Research Methods Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Kouladjian O'Donnell
- NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Clinical Pharmacology and Aged Care, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - Heather Neville
- Department of Pharmacy, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Sarah Hilmer
- NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Clinical Pharmacology and Aged Care, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - Kent Toombs
- Department of Pharmacy, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Caroline Sirois
- Department of Social and Preventive Medicine, Faculty of Medicine, Universite Laval, Québec city, Quebec, Canada
- Centre for Excellence on Aging of Quebec, Quebec Integrated University Centre for Health and Social Services of the National Capital, Québec city, Québec, Canada
| | - Mohammad Hajizadeh
- School of Health Administration, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Aprill Negus
- Department of Family Medicine, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Kenneth Rockwood
- Geriatric Medicine Research, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Centre for Health Care of the Elderly, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Emily Reeve
- Geriatric Medicine Research, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
- Quality Use of Medicines Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
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Foley RA, Hurard LL, Cateau D, Koutaissoff D, Bugnon O, Niquille A. Physicians', Nurses' and Pharmacists' Perceptions of Determinants to Deprescribing in Nursing Homes Considering Three Levels of Action: A Qualitative Study. PHARMACY 2020; 8:pharmacy8010017. [PMID: 32046022 PMCID: PMC7151677 DOI: 10.3390/pharmacy8010017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 02/03/2020] [Accepted: 02/04/2020] [Indexed: 01/27/2023] Open
Abstract
Background: Polypharmacy and the use of potentially inappropriate medications are frequent safety issues among nursing home (NH) residents. Deprescribing can significantly reduce the number of drugs used, medication costs, and mortality. This qualitative study sought to understand and compare the perceptions and practices of nurses, pharmacists, and physicians regarding deprescribing in Swiss NHs, referring to an implementation approach on three levels of action: the individual, the institution, and the healthcare system. Methods: Two focus groups were held with 21 participants: one focus group with 11 pharmacists, another with 10 nurses and six semi-structured interviews with physicians were conducted and focused on their individual experience and practices. They were audiotaped and fully transcribed, and a content analysis was performed using to MAXQDA (Ver 12) software. Results: (1) At an individual level, physicians were concerned by consequences of deprescribing in terms of safety. Nurses were closest to residents and stressed the importance of finding the right time, creating a bond of trust before deprescribing and considering the purpose of the stay in the NH. Pharmacists relied on structured guides for deprescribing, which led their reflection and practice. All professionals saw the complexity of the clinical situations, as well as residents’ and relatives’ fears of interruption of care. (2) At an institutional level, the professionals stressed the lack of time to discuss patients’ health and treatment, while pre-existing interprofessional collaboration, specifically, quality circles, seemed useful tools to create common knowledge. In order to reduce prescriptions, better coordination between physicians, nurses, pharmacists and specialists seemed crucial. (3) At the health system level, funding still needs to be provided to consolidate the process, go beyond organisational constraints and ensure deprescribing serves the patient’s wellbeing above all. Conclusions: At the individual level of implementation, the different healthcare professionals expressed specific concerns about deprescribing, depending on their defined role in NHs. Their perspective about the different levers to promote deprescribing at institutional and healthcare system levels converge towards interprofessional collaboration supported by the healthcare system. Specific funding and incentives are therefore needed to support a sustainable interprofessional team.
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Affiliation(s)
- Rose-Anna Foley
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, 1011 Lausanne, Switzerland; (R.-A.F.)
- School of Health Sciences (HESAV), University of Applied sciences and Arts, Western Switzerland (HES-SO), 1011 Lausanne, Switzerland
| | - Lucie Lechevalier Hurard
- School of Health Sciences (HESAV), University of Applied sciences and Arts, Western Switzerland (HES-SO), 1011 Lausanne, Switzerland
| | - Damien Cateau
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, 1011 Lausanne, Switzerland; (R.-A.F.)
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, 1211 Geneva, Switzerland
| | - Daria Koutaissoff
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, 1011 Lausanne, Switzerland; (R.-A.F.)
| | - Olivier Bugnon
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, 1011 Lausanne, Switzerland; (R.-A.F.)
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, 1211 Geneva, Switzerland
| | - Anne Niquille
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, 1011 Lausanne, Switzerland; (R.-A.F.)
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, 1211 Geneva, Switzerland
- Correspondence: ; Tel.: +41-21-314-48-45
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Nusair MB, Arabyat R, Al‐Azzam S, El‐Hajji FD, Nusir AT, Al‐Batineh M. Translation and psychometric properties of the Arabic version of the revised Patients' Attitudes Towards Deprescribing questionnaire. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2020. [DOI: 10.1111/jphs.12340] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Mohammad B. Nusair
- Pharmacy Practice Department Faculty of Pharmacy Yarmouk University Irbid Jordan
| | - Rasha Arabyat
- Pharmacy Practice Department Faculty of Pharmacy Yarmouk University Irbid Jordan
| | - Sayer Al‐Azzam
- Faculty of Pharmacy Jordan University of Science and Technology Irbid Jordan
| | | | - Amal T. Nusir
- Arabic Department Faculty of Arts Yarmouk University Irbid Jordan
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Roux B, Sirois C, Simard M, Gagnon ME, Laroche ML. One-year persistence of potentially inappropriate medication use in older adults: A population-based study. Br J Clin Pharmacol 2020; 86:1062-1080. [PMID: 31916266 DOI: 10.1111/bcp.14214] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/25/2019] [Accepted: 12/09/2019] [Indexed: 12/30/2022] Open
Abstract
AIMS To assess the 1-year persistence of potentially inappropriate medication (PIM) use and identify associated factors in community-dwelling older adults in Quebec, Canada. METHODS A population-based cohort study was conducted using the Quebec Integrated Chronic Disease Surveillance System. Individuals insured by the public drug plan and aged ≥66 years who initiated a PIM between 1 April 2014 and 31 March 2015 were followed-up for 1 year. PIMs were identified using the 2015 Beers criteria. One-year persistence of PIM use was defined as continuous treatment with any PIM, without interruption for more than 60 days between prescriptions refills. Poisson regression models were performed to identify factors associated with 1-year persistence of any PIM. RESULTS In total, 25.1% of PIM initiators were persistent at 1 year. In non-persistent individuals, the median time to PIM discontinuation was 31 days (interquartile range 21-92). Individuals were more persistent at 1 year with antipsychotics (43.9%), long-duration sulphonylureas (40.2%), antiarrhythmics/immediate-release nifedipine (36.5%) and proton pump inhibitors (36.0%). Factors significantly associated with persistence were an increased age, being a man and having a high number of medications and chronic diseases, especially dementia, diabetes and cardiovascular diseases. CONCLUSIONS One-quarter of community-dwelling older adults are continuously exposed to PIMs. To optimize medication prescribing in the older population, further interventions are needed to limit the use of PIMs most likely to be continued, especially in individuals most at risk of being persistent and also particularly vulnerable to adverse events.
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Affiliation(s)
- Barbara Roux
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Pharmacology-Toxicology and Centre of Pharmacovigilance, University Hospital of Limoges, Limoges, France.,INSERM UMR 1248, Faculty of Medicine, University of Limoges, Limoges, France.,Quebec National Institute of Public Health, Quebec, Canada
| | - Caroline Sirois
- Quebec National Institute of Public Health, Quebec, Canada.,Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec, Canada.,Centre of Excellence on Aging of Quebec, Integrated University Health and Social Services Centres of the Capitale-Nationale, Québec, Canada
| | - Marc Simard
- Quebec National Institute of Public Health, Quebec, Canada
| | - Marie-Eve Gagnon
- Quebec National Institute of Public Health, Quebec, Canada.,Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec, Canada
| | - Marie-Laure Laroche
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Pharmacology-Toxicology and Centre of Pharmacovigilance, University Hospital of Limoges, Limoges, France.,INSERM UMR 1248, Faculty of Medicine, University of Limoges, Limoges, France
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Thompson W, Jacobsen IT, Jarbøl DE, Haastrup P, Nielsen JB, Lundby C. Nursing Home Residents’ Thoughts on Discussing Deprescribing of Preventive Medications. Drugs Aging 2020; 37:187-192. [DOI: 10.1007/s40266-020-00746-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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D'Avanzo B, Agosti P, Reeve E, Pasina L, Sabbà C, Mannucci PM, Nobili A. Views of medical practitioners about deprescribing in older adults: Findings from an Italian qualitative study. Maturitas 2020; 134:29-33. [PMID: 32143773 DOI: 10.1016/j.maturitas.2020.01.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 01/07/2020] [Accepted: 01/18/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Even though increasing attention is given to deprescribing owing to the risks related to polypharmacy in older adults, deprescribing is not yet part of clinical culture. METHODS We conducted three focus groups with 25 internists, geriatricians and general practitioners to explore the factors influencing the implementation of deprescribing in the Italian context, and more specifically: i. to investigate the barriers to deprescribing; ii. to define strategies and actions to address these barriers; and iii. to identify skills and tools that may assist in implementing deprescribing in clinical practice. Thematic analysis was used. RESULTS Six themes were identified: Good reasons for deprescribing, Difficulties and doubts about deprescribing, System factors affecting polypharmacy and deprescribing, Perspectives on how to practically approach polypharmacy, Need for effective communication with patients and caregivers, Taking responsibility and starting action. Participants reported a willingness to challenge themselves by addressing the barriers to deprescribing through regular review of prescriptions and collaboration with colleagues and patients. CONCLUSIONS Italian internists, geriatricians and general practitioners reported many system-level barriers to deprescribing as well as some doubts about its necessity. Strategies to address the barriers to deprescribing include regular medication review and enhancing collaboration with colleagues and patients. Additionally, participants were willing to challenge themselves and use uncertainty as an impetus for deprescribing.
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Affiliation(s)
- Barbara D'Avanzo
- Laboratory of Quality Assessment of Geriatric Therapies and Services, Istituto di Ricerche Farmacologiche Mario Negri, Via Giuseppe La Masa 19, 20156 Milan, Italy.
| | - Pasquale Agosti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, and Fondazione Luigi Villa, Milan, 20122 Italy
| | - Emily Reeve
- College of Medicine, University of Saskatchewan, Saskatoon, SK, S7N 5E5, Canada; NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Northern Clinical School, Faculty of Medicine and Health, University of Sydney, NSW, 5000, Australia; Geriatric Medicine Research, Faculty of Medicine and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority, NS, B3H 2E1, Canada
| | - Luca Pasina
- Laboratory of Quality Assessment of Geriatric Therapies and Services, Istituto di Ricerche Farmacologiche Mario Negri, Via Giuseppe La Masa 19, 20156 Milan, Italy
| | - Carlo Sabbà
- Interdisciplinary Department of Medicine, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Pier Mannuccio Mannucci
- Scientific Direction, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 28, 20122 Milan, Italy
| | - Alessandro Nobili
- Laboratory of Quality Assessment of Geriatric Therapies and Services, Istituto di Ricerche Farmacologiche Mario Negri, Via Giuseppe La Masa 19, 20156 Milan, Italy
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Kua CH, Reeve E, Tan DSY, Koh T, Soong JL, Sim MJL, Zhang TY, Chen YR, Ratnasingam V, Mak VSL, Lee SWH. Patients’ and Caregivers’ Attitudes Toward Deprescribing in Singapore. J Gerontol A Biol Sci Med Sci 2020; 76:1053-1060. [DOI: 10.1093/gerona/glaa018] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Indexed: 01/01/2023] Open
Abstract
Abstract
Background
Knowledge of decision-making preference of patients and caregivers is needed to facilitate deprescribing. This study aimed to assess the perspectives of caregivers and older adults towards deprescribing in an Asian population. Secondary objectives were to identify and compare characteristics associated with these attitudes and beliefs.
Method
A cross-sectional survey of two groups of participants was conducted using the Revised Patients’ Attitudes Towards Deprescribing questionnaire. Descriptive results were reported for participants’ characteristics and questionnaire responses from four factors (belief in medication inappropriateness, medication burden, concerns about stopping, and involvement) and two global questions. Correlation between participant characteristics and their responses was analyzed.
Results
A total of 1,057 (615 older adults; 442 caregivers) participants were recruited from 10 institutions in Singapore. In which 511 (83.0%) older adults and 385 (87.1%) caregivers reported that they would be willing to stop one or more of their medications if their doctor said it was possible, especially among older adults recruited from acute-care hospitals (85.3%) compared with older adults in community pharmacies (73.6%). Individuals who take more than five medications and those with higher education were correlated with greater agreement in inappropriateness and involvement, respectively.
Conclusions
Clinicians should consider discussing deprescribing with older adults and caregivers in their regular clinical practice, especially when polypharmacy is present. Further research is needed into how to engage older adults and caregivers in shared decision making based on their attitudes toward deprescribing.
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Affiliation(s)
- Chong-Han Kua
- Pharmaceutical Society of Singapore (PSS) Deprescribing Workgroup, Singapore
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Emily Reeve
- Geriatric Medicine Research, Faculty of Medicine and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority, Halifax, Canada
- College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Doreen S Y Tan
- Pharmaceutical Society of Singapore (PSS) Deprescribing Workgroup, Singapore
- Khoo Teck Puat Hospital, Singapore
| | - Tsingyi Koh
- Pharmaceutical Society of Singapore (PSS) Deprescribing Workgroup, Singapore
- National University Hospital, Singapore
| | - Jie Lin Soong
- Pharmaceutical Society of Singapore (PSS) Deprescribing Workgroup, Singapore
- Singapore General Hospital, Singapore
| | - Marvin J L Sim
- Pharmaceutical Society of Singapore (PSS) Deprescribing Workgroup, Singapore
- National Healthcare Group Pharmacy, Singapore
| | - Tracy Y Zhang
- Pharmaceutical Society of Singapore (PSS) Deprescribing Workgroup, Singapore
- Ang Mo Kio-Thye Hua Kwan Hospital, Singapore
| | - Yi Rong Chen
- Pharmaceutical Society of Singapore (PSS) Deprescribing Workgroup, Singapore
- Tan Tock Seng Hospital, Singapore
| | - Vanassa Ratnasingam
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Vivienne S L Mak
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Shaun Wen Huey Lee
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
- School of Pharmacy, Taylor’s University Lakeside Campus, Subang Jaya, Selangor, Malaysia
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Abendroth J, Klement A. [Perioperative management of polymedication in geriatric patients: risk reduction and coordination with the family practitioner]. Chirurg 2020; 91:115-120. [PMID: 31940066 DOI: 10.1007/s00104-019-01094-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The increasing proportion of older and polymorbid people in the population also means an increase in polymedication and its risks. This places new and complex demands on the interdisciplinary and transsectoral collaboration. The preoperative, perioperative and postoperative management of polymedication is described in the article with respect to frequent risks and the chances of a systematic exchange of information. The establishment of an interdisciplinary admission routine in departments of surgery and communication with the family practitioner is crucial for patient safety.
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Affiliation(s)
- J Abendroth
- Institut für Allgemeinmedizin, Universität Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Deutschland
| | - A Klement
- Institut für Allgemeinmedizin, Universität Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Deutschland.
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118
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Green AR, Wolff JL, Echavarria DM, Chapman M, Phung A, Smith D, Boyd CM. How Clinicians Discuss Medications During Primary Care Encounters Among Older Adults with Cognitive Impairment. J Gen Intern Med 2020; 35:237-246. [PMID: 31705465 PMCID: PMC6957586 DOI: 10.1007/s11606-019-05424-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 07/19/2019] [Accepted: 09/06/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND People with cognitive impairment experience high rates of polypharmacy and potentially inappropriate medication use. How clinicians communicate about medications may affect to what extent patients and family companions understand and participate in decisions about medication use. OBJECTIVE To characterize how primary care clinicians discuss medications during encounters with older adults with cognitive impairment and their companions. DESIGN Qualitative content analysis of audio-recorded clinical encounters from SAME Page, a randomized controlled trial to examine the effects of a patient-family agenda setting checklist on primary care visit communication among patients with cognitive impairment. Visits occurred between August 2016 and August 2017. PARTICIPANTS Patients were 65 or older, had > 1 incorrect answer on a cognitive screener, and attended visits with a relative or unpaid companion. Clinicians were physicians, nurse practitioners, or physician assistants at participating practices. APPROACH The encounters were transcribed verbatim. We used qualitative content analysis to identify major themes. KEY RESULTS Patients were on average 79.9 years of age. The average MMSE score was 21.6. About half of clinicians reported practicing for 15 or more years (n = 8). We identified three major themes. First, we found numerous instances in which primary care clinicians introduced patients and companions to key principles of optimal prescribing and deprescribing. Second, clinicians used a variety of approaches to foster shared decision-making about medication use. Third, several challenges prevented clinicians from working together with patients and companions to optimize prescribing and deprescribing. CONCLUSIONS This study offers insight into key language clinicians can use to initiate discussions about optimizing prescribing, as well as barriers they face in doing so. Examples identified in these transcripts should be tested with patients and caregivers to examine how such communications are received and interpreted. Future research should develop and test interventions that seek to overcome obstacles to optimizing prescribing for older adults with cognitive impairment.
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Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Jennifer L Wolff
- Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Diane M Echavarria
- Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Malcolm Chapman
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Annie Phung
- Philadelphia College of Osteopathic Medicine - Georgia, Suwanee, GA, USA
| | - Devon Smith
- Northeast Ohio Medical University, Rootstown, OH, USA
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Goyal P, Anderson T, Bernacki GM, Marcum ZA, Orkaby A, Kim D, Zullo A, Krishnaswami A, Weissman A, Steinman MA, Rich MW. Physician Perspectives on Deprescribing Cardiovascular Medications for Older Adults. J Am Geriatr Soc 2020; 68:78-86. [PMID: 31509233 PMCID: PMC7061460 DOI: 10.1111/jgs.16157] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/06/2019] [Accepted: 08/07/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND/OBJECTIVES Guideline-based management of cardiovascular disease often involves prescribing multiple medications, which contributes to polypharmacy and risk for adverse drug events in older adults. Deprescribing is a potential strategy to mitigate these risks. We sought to characterize and compare clinician perspectives regarding deprescribing cardiovascular medications across three specialties. DESIGN National cross-sectional survey. SETTING Ambulatory. PARTICIPANTS Random sample of geriatricians, general internists, and cardiologists from the American College of Physicians. MEASUREMENTS Electronic survey assessing clinical practice of deprescribing cardiovascular medications, reasons and barriers to deprescribing, and choice of medications to deprescribe in hypothetical clinical cases. RESULTS In each specialty, 750 physicians were surveyed, with a response rate of 26% for geriatricians, 26% for general internists, and 12% for cardiologists. Over 80% of respondents within each specialty reported that they had recently considered deprescribing a cardiovascular medication. Adverse drug reactions were the most common reason for deprescribing for all specialties. Geriatricians also commonly reported deprescribing in the setting of limited life expectancy. Barriers to deprescribing were shared across specialties and included concerns about interfering with other physicians' treatment plans and patient reluctance. In hypothetical cases, over 90% of physicians in each specialty chose to deprescribe when patients experienced adverse drug reactions. Geriatricians were most likely and cardiologists were least likely to consider deprescribing cardiovascular medications in cases of limited life expectancy (all P < .001), such as recurrent metastatic cancer (84% of geriatricians, 68% of general internists, and 45% of cardiologists), Alzheimer dementia (92% of geriatricians, 81% of general internists, and 59% of cardiologists), or significant functional impairment (83% of geriatricians, 68% of general internists, and 45% of cardiologists). CONCLUSIONS While barriers to deprescribing cardiovascular medications are shared across specialties, reasons for deprescribing, especially in the setting of limited life expectancy, varied. Implementing deprescribing will require improved processes for both physician-physician and physician-patient communication. J Am Geriatr Soc 68:78-86, 2019.
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Affiliation(s)
- Parag Goyal
- Department of Medicine, Weill Cornell Medicine (New York, NY)
| | - Timothy Anderson
- Department of Medicine, University of California-San Francisco (San Francisco, CA)
| | - Gwen M. Bernacki
- Cardiology Division, University of Washington (Seattle, WA), Cambia Palliative Care Center of Excellence (Seattle, WA)
| | | | - Ariela Orkaby
- New England Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System, Boston, MA; Division of Aging, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Dae Kim
- Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA
| | - Andrew Zullo
- Departments of Epidemiology and Health Services, Policy, and Practice, Brown University School of Public Health (Providence, RI); Center of Innovation in Long Term Services and Supports, Providence VA Medical Center (Providence, RI)
| | - Ashok Krishnaswami
- Division of Cardiology, Kaiser Permanente San Jose Medical Center (San Jose, CA); Department of Epidemiology and Biostatistics, University of California (San Francisco, CA)
| | | | - Michael A. Steinman
- Department of Medicine, University of California-San Francisco (San Francisco, CA)
- San Francisco Veterans Affairs Medical Center, (San Francisco, CA)
| | - Michael W. Rich
- Cardiovascular Division, Washington University School of Medicine (St. Louis, MO)
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120
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Weiner JZ, Gopalan A, Mishra P, Lipska KJ, Huang ES, Laiteerapong N, Karter AJ, Grant RW. Use and Discontinuation of Insulin Treatment Among Adults Aged 75 to 79 Years With Type 2 Diabetes. JAMA Intern Med 2019; 179:1633-1641. [PMID: 31545376 PMCID: PMC6763990 DOI: 10.1001/jamainternmed.2019.3759] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Among older individuals with type 2 diabetes, those with poor health have greater risk and derive less benefit from tight glycemic control with insulin. OBJECTIVE To examine whether insulin treatment is used less frequently and discontinued more often among older individuals with poor health compared with those in good health. DESIGN, SETTING, AND PARTICIPANTS This longitudinal cohort study included 21 531 individuals with type 2 diabetes followed for up to 4 years starting at age 75 years. Electronic health record data from the Kaiser Permanente Northern California Diabetes Registry was collected to characterize insulin treatment and glycemic control over time. Data were collected from January 1, 2009, through December 31, 2017, and analyzed from February 2, 2018, through June 30, 2019. EXPOSURES Health status was defined as good (<2 comorbid conditions or 2 comorbidities but physically active), intermediate (>2 comorbidities or 2 comorbidities and no self-reported weekly exercise), or poor (having end-stage pulmonary, cardiac, or renal disease; diagnosis of dementia; or metastatic cancer). MAIN OUTCOMES AND MEASURES Insulin use prevalence at age 75 years and discontinuation among insulin users over the next 4 years (or 6 months prior to death if <4 years). RESULTS Of 21 531 patients, 10 396 (48.3%) were women, and the mean (SD) age was 75 (0) years. Nearly one-fifth of 75-year-olds (4076 [18.9%]) used insulin. Prevalence and adjusted risk ratios (aRRs) of insulin use at age 75 years were higher in individuals with poor health (29.4%; aRR, 2.03; 95% CI, 1.87-2.20; P < .01) and intermediate health (27.5%; aRR, 1.85; 95% CI, 1.74-1.97; P < .01) relative to good health (10.5% [reference]). One-third (1335 of 4076 [32.7%]) of insulin users at age 75 years discontinued insulin within 4 years of cohort entry (and at least 6 months prior to death). Likelihood of continued insulin use was higher among individuals in poor health (aRR, 1.47; 95% CI, 1.27-1.67; P < .01) and intermediate health (aRR, 1.16; 95% CI, 1.05-1.30; P < .01) compared with good health (reference). These same prevalence and discontinuation patterns were present in the subset with tight glycemic control (hemoglobin A1c <7.0%). CONCLUSIONS AND RELEVANCE In older individuals with type 2 diabetes, insulin use was most prevalent among those in poor health, whereas subsequent insulin discontinuation after age 75 years was most likely in healthier patients. Changes are needed in current practice to better align with guidelines that recommend reducing treatment intensity as health status declines.
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Affiliation(s)
- Jonathan Z Weiner
- Division of Research,Kaiser Permanente of Northern California, Oakland
| | - Anjali Gopalan
- Division of Research,Kaiser Permanente of Northern California, Oakland
| | - Pranita Mishra
- Division of Research,Kaiser Permanente of Northern California, Oakland
| | - Kasia J Lipska
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Elbert S Huang
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois
| | - Neda Laiteerapong
- Chicago Center for Diabetes Translation Research, University of Chicago, Chicago, Illinois
| | - Andrew J Karter
- Division of Research,Kaiser Permanente of Northern California, Oakland
| | - Richard W Grant
- Division of Research,Kaiser Permanente of Northern California, Oakland
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Going Beyond the Guidelines in Individualising the Use of Antihypertensive Drugs in Older Patients. Drugs Aging 2019; 36:675-685. [PMID: 31175614 DOI: 10.1007/s40266-019-00683-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Hypertension is commonly diagnosed in older patients, with increasing cardiovascular (CV) risk as systolic blood pressure (BP) increases. Maximising CV risk reduction must be reconciled with minimising the risk of treatment-related harms and burden, especially among frail, multi-morbid and older old patients who have been excluded from most randomised trials. Contemporary clinical guidelines, based on such trials, differ in their recommendations as to threshold levels warranting treatment with antihypertensive drugs (AHDs) and target levels that should be achieved. In optimising AHD prescribing in older patients, we propose the following decision framework: decide therapeutic goals in accordance with patient characteristics and preferences; estimate absolute CV risk; measure and profile BP accurately in ways that account for lability in BP levels and minimise error in BP measurement; determine threshold and target BP levels likely to confer net benefit, taking into account age, co-morbidities, frailty and cognitive function; and consider situations that warrant AHD deprescribing on the basis of potential current or future harm. In applying this framework to older persons, and based on a review of relevant randomised trials and observational studies, individuals most likely to benefit from treating systolic BP to no less than 130 mmHg are those of any age who are fit and have high baseline systolic BP (≥ 160 mmHg); high CV risk, i.e. established CV disease or risk of CV events exceeding 20% at 10 years; previous stroke or transient ischaemic attack; heart failure; and stage 3-4 chronic kidney disease with proteinuria. Individuals most likely to be harmed from treating BP to target systolic < 140 mmHg are those who have no CV disease and aged over 80 years; moderate to severe frailty, cognitive impairment or functional limitations; labile BP and/or history of orthostatic hypotension, syncope and falls; or life expectancy < 12 months. Treatment should never be so intense as to reduce diastolic BP to < 60 mmHg in any older person. At a time when guidelines are calling for less conservative management of hypertension in all age groups, we contend that a more temperate approach, such as that offered here and based on the totality of available evidence, may assist in maximising net benefit in older patients.
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Tapper EB, Henderson JB, Parikh ND, Ioannou GN, Lok AS. Incidence of and Risk Factors for Hepatic Encephalopathy in a Population-Based Cohort of Americans With Cirrhosis. Hepatol Commun 2019; 3:1510-1519. [PMID: 31701074 PMCID: PMC6824059 DOI: 10.1002/hep4.1425] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 08/13/2019] [Indexed: 12/12/2022] Open
Abstract
Hepatic encephalopathy (HE) is a devastating complication of cirrhosis. Data are limited regarding the incidence of and risk factors for HE among contemporary patients in the context of the shifting epidemiology of cirrhosis. We examined a 20% random sample of U.S. Medicare enrollees with cirrhosis and Part D prescription coverage from 2008 to 2014. We modelled incident HE using demographic, clinical, and pharmacologic data. Risk factors for HE were evaluated, including demographics/socioeconomics, cirrhosis etiology, severity of liver disease, and pharmacotherapy, along with gastroenterology consultation, as time-varying covariates. Among 166,192 Medicare enrollees with cirrhosis followed for 5.25 (interquartile range [IQR], 2.00-7.00) years, the overall incidence of HE was 11.6 per 100 patient-years. The cohort's median age was 65 years (IQR, 57-72), 31% had alcohol-related cirrhosis, and 49% had likely nonalcoholic fatty liver disease cirrhosis. The two strongest associations with HE were alcohol-related cirrhosis (adjusted hazard ratio [AHR], 1.44; 95% confidence interval [CI], 1.40, 1.47, relative to nonalcoholic nonviral cirrhosis) and the presence of portal hypertension (AHR, 3.42; 95% CI, 3.34, 3.50). Adjusting for confounders, benzodiazepines (AHR, 1.24; 95% CI, 1.21, 1.27), gamma aminobutyric acid (GABA)ergics (AHR, 1.17; 95% CI, 1.14, 1.21), opioids (AHR, 1.24; 95% CI, 1.21, 1.27), and proton pump inhibitors (PPIs) (AHR, 1.41; 95% CI, 1.38, 1.45) were all associated with incident HE. Only benzodiazepines, however, were associated with the risk of hospitalization with HE (incidence-rate ratio, 1.23; 95% CI, 1.20, 1.26). Conclusion: Novel data regarding the risk of HE for contemporary patients with cirrhosis are provided. The incidence of HE in an older population of Americans with cirrhosis is high, particularly among those with alcohol-related cirrhosis and portal hypertension. Several medication classes, namely PPIs, opiates, GABAergics, and benzodiazepines, represent potentially modifiable risk factors for HE.
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Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMI
- Gastroenterology SectionVA Ann Arbor Healthcare SystemAnn ArborMI
| | - James B. Henderson
- Center for Statistical Consultation and ResearchUniversity of MichiganAnn ArborMI
| | - Neehar D. Parikh
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMI
- Gastroenterology SectionVA Ann Arbor Healthcare SystemAnn ArborMI
| | - George N. Ioannou
- Division of GastroenterologyDepartment of MedicineVeterans Affairs Puget Sound Healthcare System and University of WashingtonSeattleWA
| | - Anna S. Lok
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMI
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Deprescribing as a Clinical Improvement Focus. J Am Med Dir Assoc 2019; 21:355-360. [PMID: 31672564 DOI: 10.1016/j.jamda.2019.08.031] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/11/2019] [Accepted: 08/30/2019] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Polypharmacy is a concern in the practice of geriatrics because of consequences such as adverse drug events and poorer quality of life. Deprescribing, a response to polypharmacy, refers to the systematic, programmed, and appropriate reduction in drug number and dose. Although now broadly recognized, challenges exist in practice for effective implementation. This study was conducted to determine the deprescribing success rate and relate it to drug classes and clinical settings, and to identify factors that influence the deprescribing process. DESIGN As a performance improvement (PI) project, fellows in geriatric medicine, under supervision of faculty geriatricians, attempted deprescribing during at least 1 encounter daily at 2 long-term care (LTC) facilities and an outpatient geriatrics clinic (C) in Bronx, New York, from August 2018 to January 2019. Deprescribing was initiated following discussion and consent from patient or caregiver. Following the data collection, involved fellows and faculty physicians participated in a survey to identify factors that influenced the process. RESULTS Out of 449 encounters, 383 encounters were included for analysis. Average patient age was 78.2 years (LTC: 77.9, C: 79.1). Average patient comorbidities was 6.5 (LTC: 6.7, C: 5.8). Deprescribing was successful in 90.1% of encounters (LTC: 96.9%, C: 67.4%). On average, 1.3 medications were deprescribed per encounter (LTC: 1.4, C: 1.0). Analgesics (32.2%), multivitamin-minerals supplements (29.7%), lipid-lowering agents (22.9%), antihistamines (46.7%), and acid blockers (26.2%) had highest success. CONCLUSIONS AND IMPLICATIONS Deprescribing is possible in practice in both LTC and community settings at each encounter, until it is no longer applicable. Factors that contribute to successful deprescribing primarily include meaningful and earnest provider effort, ideally in collaboration with interdisciplinary team members (nurses, pharmacists, social worker, and others), besides interactions with consultants for the patient. Certain medication classes such as vitamins, minerals, analgesics, and proton pump inhibitors can be deprescribed with high success, as noted in our study, whereas antipsychotic agents, antidepressants, and ophthalmic preparations, prescribed by specialists, proved harder to deprescribe. An understanding of barriers to deprescribing (outlined in the article) and addressing them are crucial in enabling success. The study demonstrates that as a performance improvement project in collaborative effort with multiple disciplines, deprescribing is possible in health care. Factors promoting success and barriers to deprescribing are detailed. Appropriate deprescribing has the potential to help lower adverse drug events, costs of care, and possibly improve quality of life.
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Shmuel S, Lund JL, Alvarez C, Hsu CD, Palta P, Kucharska-Newton A, Jordan JM, Nelson AE, Golightly YM. Polypharmacy and Incident Frailty in a Longitudinal Community-Based Cohort Study. J Am Geriatr Soc 2019; 67:2482-2489. [PMID: 31648378 DOI: 10.1111/jgs.16212] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 06/18/2019] [Accepted: 07/26/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Polypharmacy may affect frailty, a common and costly condition among older adults. Frailty prevalence is elevated among racial/ethnic minorities and persons living in the US South, and research is needed to inform future pharmacologic interventions in these populations. Our aim was to quantify the prevalence of frailty and polypharmacy, and to estimate the association between polypharmacy and incident frailty. DESIGN Prospective cohort study. SETTING A community-based cohort study of adults residing in Johnston County, North Carolina. PARTICIPANTS White and African American adults aged 50 to 95 years (n=1697). MEASUREMENTS At each study visit, all prescription and over-the-counter medications were recorded. We calculated annual polypharmacy (5-9 medications) and excessive polypharmacy (≥10 medications) prevalence at the 2006-2010 visit (n = 1697) and operationalized the Fried frailty phenotype to describe prevalent and incident frailty at two consecutive visits (2006-2010 and 2013-2015). We estimated risk ratios (RRs) and 95% confidence intervals (CIs) for the association between polypharmacy and incident frailty using weighted log-binomial regression to account for measured confounding and attrition using inverse probability of treatment and attrition weights, respectively. RESULTS At the 2006-2010 visit, 678 (41%) and 260 (16%) participants were exposed to polypharmacy and excessive polypharmacy, respectively. Overall, 353 (21%) participants and 180 (21%) participants were frail at the 2006-2010 and 2013-2015 visits, respectively. Frailty was more common among participants identifying as white, women, and having less educational attainment relative to those without these characteristics. Incident frailty at the 2013-2015 visit was 15% (mean follow-up = 5.5 years). Our results suggest that polypharmacy is positively associated with incident frailty (weighted RR = 1.4; 95% CI = .9-2.0), yet estimates are imprecise and should be interpreted with caution. CONCLUSION Consistent with the current weight of evidence, our results suggest an association between polypharmacy and incident frailty. Prospective studies evaluating deprescribing interventions are needed to clarify whether reducing polypharmacy decreases frailty incidence. J Am Geriatr Soc 67:2482-2489, 2019.
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Affiliation(s)
- Shahar Shmuel
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jennifer L Lund
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Carolina Alvarez
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Christine D Hsu
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Priya Palta
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anna Kucharska-Newton
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, Kentucky
| | - Joanne M Jordan
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Amanda E Nelson
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Yvonne M Golightly
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Division of Physical Therapy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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125
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Does Deprescribing Improve Quality of Life? A Systematic Review of the Literature. Drugs Aging 2019; 36:1097-1110. [DOI: 10.1007/s40266-019-00717-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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126
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Le Bosquet K, Barnett N, Minshull J. Deprescribing: Practical Ways to Support Person-Centred, Evidence-Based Deprescribing. PHARMACY 2019; 7:E129. [PMID: 31484305 PMCID: PMC6789835 DOI: 10.3390/pharmacy7030129] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 08/14/2019] [Accepted: 08/22/2019] [Indexed: 12/20/2022] Open
Abstract
Deprescribing is complex and multifactorial with multiple approaches described in the literature. Internationally, there are guidelines and tools available to aid clinicians and patients to identify and safely withdraw inappropriate medications, post a shared decision-making medicines optimisation review. The increase in available treatments and use of single disease model guidelines have led to a healthcare system geared towards prescribing, with deprescribing often seen as a separate activity. Deprescribing should be seen as part of prescribing, and is a key element in ensuring patients remain on the most appropriate medications at the correct doses for them. Due to the complex nature of polypharmacy, every patient experience and relationship with medications is unique. The individual's history must be incorporated into a patient-centred medication review, in order for medicines to remain optimal through changes in circumstance and health. Knowledge of the law and appropriate recording is important to ensure consent is adequately gained and recorded in line with processes followed when initiating a medication. In recent years, with the increase in interested clinicians globally, a number of prominent networks have grown, creating crucial links for both research and sharing of good practice.
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Affiliation(s)
| | - Nina Barnett
- NHS Specialist Pharmacy Service, London North West University Healthcare NHS Trust, London HA1 3UJ, UK
| | - John Minshull
- NHS Specialist Pharmacy Service, London North West University Healthcare NHS Trust, London HA1 3UJ, UK
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127
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Morin L, Wastesson JW, Laroche ML, Fastbom J, Johnell K. How many older adults receive drugs of questionable clinical benefit near the end of life? A cohort study. Palliat Med 2019; 33:1080-1090. [PMID: 31172885 PMCID: PMC6691599 DOI: 10.1177/0269216319854013] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The high burden of disease-oriented drugs among older adults with limited life expectancy raises important questions about the potential futility of care. AIM To describe the use of drugs of questionable clinical benefit during the last 3 months of life of older adults who died from life-limiting conditions. DESIGN Longitudinal, retrospective cohort study of decedents. Death certificate data were linked to administrative and healthcare registries with national coverage in Sweden. SETTING Older adults (≥75 years) who died from conditions potentially amenable to palliative care between 1 January and 31 December 2015 in Sweden. We identified drugs of questionable clinical benefit from a set of consensus-based criteria. RESULTS A total of 58,415 decedents were included (mean age, 87.0 years). During their last 3 months of life, they received on average 8.9 different drugs. Overall, 32.0% of older adults continued and 14.0% initiated at least one drug of questionable clinical benefit (e.g. statins, calcium supplements, vitamin D, bisphosphonates, antidementia drugs). These proportions were highest among younger individuals (i.e. aged 75-84 years), among people who died from organ failure and among those with a large number of coexisting chronic conditions. Excluding people who died from acute and potentially unpredictable fatal events had little influence on the results. CONCLUSION A substantial share of older persons with life-limiting diseases receive drugs of questionable clinical benefit during their last months of life. Adequate training, guidance and resources are needed to rationalize and deprescribe drug treatments for older adults near the end of life.
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Affiliation(s)
- Lucas Morin
- 1 Aging Research Center, Karolinska Institutet, Stockholm, Sweden.,2 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jonas W Wastesson
- 1 Aging Research Center, Karolinska Institutet, Stockholm, Sweden.,2 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Marie-Laure Laroche
- 3 Centre de pharmacovigilance et de pharmaco-épidémiologie, Department of Pharmacology-Toxicology and Centre of Pharmacovigilance, CHU Limoges, Limoges, France.,4 INSERM 1248, University of Limoges, CHU Limoges, Limoges, France
| | - Johan Fastbom
- 1 Aging Research Center, Karolinska Institutet, Stockholm, Sweden
| | - Kristina Johnell
- 2 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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128
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McDonald EG, Wu PE, Rashidi B, Forster AJ, Huang A, Pilote L, Papillon‐Ferland L, Bonnici A, Tamblyn R, Whitty R, Porter S, Battu K, Downar J, Lee TC. The MedSafer Study: A Controlled Trial of an Electronic Decision Support Tool for Deprescribing in Acute Care. J Am Geriatr Soc 2019; 67:1843-1850. [DOI: 10.1111/jgs.16040] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/02/2019] [Accepted: 05/06/2019] [Indexed: 01/21/2023]
Affiliation(s)
- Emily G. McDonald
- Division of General Internal Medicine, Department of Medicine McGill University Montréal Québec Canada
- Clinical Practice Assessment Unit McGill University Health Centre Montréal Québec Canada
| | - Peter E. Wu
- Division of General Internal Medicine, Department of Medicine University of Toronto Toronto Ontario Canada
| | - Babak Rashidi
- Division of General Internal Medicine, Department of Medicine University of Ottawa Ottawa Ontario Canada
| | - Alan J. Forster
- Division of General Internal Medicine, Department of Medicine University of Ottawa Ottawa Ontario Canada
| | - Allen Huang
- Division of Geriatric Medicine, Department of Medicine University of Ottawa Ottawa Ontario Canada
| | - Louise Pilote
- Division of General Internal Medicine, Department of Medicine McGill University Montréal Québec Canada
| | | | - André Bonnici
- Department of Pharmacy McGill University Health Centre Montréal Québec Canada
| | - Robyn Tamblyn
- Department of Epidemiology, Biostatistics and Occupational Health McGill University Montréal Québec Canada
| | - Rachel Whitty
- Leslie L. Dan Faculty of Pharmacy University of Toronto Toronto Ontario Canada
| | - Sandra Porter
- Leslie L. Dan Faculty of Pharmacy University of Toronto Toronto Ontario Canada
| | - Kiran Battu
- Leslie L. Dan Faculty of Pharmacy University of Toronto Toronto Ontario Canada
| | - James Downar
- Division of Palliative Care, Department of Medicine University of Ottawa Ottawa Ontario Canada
| | - Todd C. Lee
- Division of General Internal Medicine, Department of Medicine McGill University Montréal Québec Canada
- Clinical Practice Assessment Unit McGill University Health Centre Montréal Québec Canada
- Department of Epidemiology, Biostatistics and Occupational Health McGill University Montréal Québec Canada
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129
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Reeve E, Low LF, Hilmer SN. Reply to: Deprescribing Attitudes of Older Adults Receiving Medication Management Support from Home-Based Nurses. J Am Geriatr Soc 2019; 67:1757-1758. [PMID: 31190352 DOI: 10.1111/jgs.16012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 05/10/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia.,Geriatric Medicine Research, Faculty of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada.,College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Lee-Fay Low
- University of Sydney, Sydney, New South Wales, Australia
| | - Sarah N Hilmer
- NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Northern Clinical School, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia.,Departments of Aged Care and Clinical Pharmacology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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130
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Willie A. Addressing Polypharmacy. J Gerontol Nurs 2019; 45:6-7. [PMID: 31135932 DOI: 10.3928/00989134-20190509-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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131
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Vasilevskis EE, Shah AS, Hollingsworth EK, Shotwell MS, Mixon AS, Bell SP, Kripalani S, Schnelle JF, Simmons SF. A patient-centered deprescribing intervention for hospitalized older patients with polypharmacy: rationale and design of the Shed-MEDS randomized controlled trial. BMC Health Serv Res 2019; 19:165. [PMID: 30871561 PMCID: PMC6416929 DOI: 10.1186/s12913-019-3995-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 03/06/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Polypharmacy is prevalent among hospitalized older adults, particularly those being discharged to a post-care care facility (PAC). The aim of this randomized controlled trial is to determine if a patient-centered deprescribing intervention initiated in the hospital and continued in the PAC setting reduces the total number of medications among older patients. METHODS The Shed-MEDS study is a 5-year, randomized controlled clinical intervention trial comparing a patient-centered describing intervention with usual care among older (≥50 years) hospitalized patients discharged to PAC, either a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IPR). Patient measurements occur at hospital enrollment, hospital discharge, within 7 days of PAC discharge, and at 60 and 90 days following PAC discharge. Patients are randomized in a permuted block fashion, with block sizes of two to four. The overall effectiveness of the intervention will be evaluated using total medication count as the primary outcome measure. We estimate that 576 patients will enroll in the study. Following attrition due to death or loss to follow-up, 420 patients will contribute measurements at 90 days, which provides 90% power to detect a 30% versus 25% reduction in total medications with an alpha error of 0.05. Secondary outcomes include the number of medications associated with geriatric syndromes, drug burden index, medication adherence, the prevalence and severity of geriatric syndromes and functional health status. DISCUSSION The Shed-MEDS trial aims to test the hypothesis that a patient-centered deprescribing intervention initiated in the hospital and continuing through the PAC stay will reduce the total number of medications 90 days following PAC discharge and result in improvements in geriatric syndromes and functional health status. The results of this trial will quantify the health outcomes associated with reducing medications for hospitalized older adults with polypharmacy who are discharged to post-acute care facilities. TRIAL REGISTRATION This trial was prospectively registered at clinicaltrials.gov ( NCT02979353 ). The trial was first registered on 12/1/2016, with an update on 09/28/17 and 10/12/2018.
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Affiliation(s)
- Eduard E. Vasilevskis
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN USA
- Vanderbilt University Medical Center, Section of Hospital Medicine, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
| | - Avantika S. Shah
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
| | | | | | - Amanda S. Mixon
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN USA
- Vanderbilt University Medical Center, Section of Hospital Medicine, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
| | - Susan P. Bell
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- Division of Geriatrics, Vanderbilt University Medical Center, Nashville, TN USA
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN USA
| | - Sunil Kripalani
- Vanderbilt University Medical Center, Section of Hospital Medicine, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
| | - John F. Schnelle
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- Division of Geriatrics, Vanderbilt University Medical Center, Nashville, TN USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
| | - Sandra F. Simmons
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- Division of Geriatrics, Vanderbilt University Medical Center, Nashville, TN USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
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Deprescribing: Right-Sizing Medication Regimens to Optimize Outcomes in Palliative Care. CURRENT GERIATRICS REPORTS 2019. [DOI: 10.1007/s13670-019-0274-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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133
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Chou J, Tong M, Brandt NJ. Combating Polypharmacy Through Deprescribing Potentially Inappropriate Medications. J Gerontol Nurs 2019; 45:9-15. [PMID: 30653232 DOI: 10.3928/00989134-20190102-01] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Polypharmacy, defined as the use of five or more medications, is becoming increasingly prevalent in older adults throughout the United States. Depre-scribing, along with the use of existing tools, such as the American Geriatrics Society Beers Criteria, can help guide health care providers in reducing the risks associated with polypharmacy such as side effects and drug interactions. The framework of deprescribing and the use of existing guidelines and resources are valuable in guiding health care providers in addressing polypharmacy. [Journal of Gerontological Nursing, 45(1), 9-15.].
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