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Ibrahim K, Cox NJ, Stevenson JM, Lim S, Fraser SDS, Roberts HC. A systematic review of the evidence for deprescribing interventions among older people living with frailty. BMC Geriatr 2021; 21:258. [PMID: 33865310 PMCID: PMC8052791 DOI: 10.1186/s12877-021-02208-8] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 04/08/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Older people living with frailty are often exposed to polypharmacy and potential harm from medications. Targeted deprescribing in this population represents an important component of optimizing medication. This systematic review aims to summarise the current evidence for deprescribing among older people living with frailty. METHODS The literature was searched using Medline, Embase, CINAHL, PsycInfo, Web of Science, and the Cochrane library up to May 2020. Interventional studies with any design or setting were included if they reported deprescribing interventions among people aged 65+ who live with frailty identified using reliable measures. The primary outcome was safety of deprescribing; whereas secondary outcomes included clinical outcomes, medication-related outcomes, feasibility, acceptability and cost-related outcomes. Narrative synthesis was used to summarise findings and study quality was assessed using Joanna Briggs Institute checklists. RESULTS Two thousand three hundred twenty-two articles were identified and six (two randomised controlled trials) were included with 657 participants in total (mean age range 79-87 years). Studies were heterogeneous in their designs, settings and outcomes. Deprescribing interventions were pharmacist-led (n = 3) or multidisciplinary team-led (n = 3). Frailty was identified using several measures and deprescribing was implemented using either explicit or implicit tools or both. Three studies reported safety outcomes and showed no significant changes in adverse events, hospitalisation or mortality rates. Three studies reported positive impact on clinical outcomes including depression, mental health status, function and frailty; with mixed findings on falls and cognition; and no significant impact on quality of life. All studies described medication-related outcomes and reported a reduction in potentially inappropriate medications and total number of medications per-patient. Feasibility of deprescribing was reported in four studies which showed that 72-91% of recommendations made were implemented. Two studies evaluated and reported the acceptability of their interventions and further two described cost saving. CONCLUSION There is a paucity of research about the impact of deprescribing in older people living with frailty. However, included studies suggest that deprescribing could be safe, feasible, well tolerated and can lead to important benefits. Research should now focus on understanding the impact of deprescribing on frailty status in high risk populations. TRIAL REGISTRATION The review was registered on the international prospective register of systematic reviews (PROSPERO) ID number: CRD42019153367 .
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Affiliation(s)
- Kinda Ibrahim
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK.
- NIHR Applied Research Collaboration Wessex, Southampton, UK.
| | - Natalie J Cox
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
- Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS FT, Southampton, UK
| | - Jennifer M Stevenson
- Institute of Pharmaceutical Science, King's College London, London, UK
- Pharmacy Department, Guy's and St. Thomas' NHS FT, London, UK
| | - Stephen Lim
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Applied Research Collaboration Wessex, Southampton, UK
| | - Simon D S Fraser
- NIHR Applied Research Collaboration Wessex, Southampton, UK
- Primary Care, Population Science and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Helen C Roberts
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Applied Research Collaboration Wessex, Southampton, UK
- Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS FT, Southampton, UK
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Ailabouni N, Mangin D, Nishtala PS. Deprescribing anticholinergic and sedative medicines: protocol for a Feasibility Trial (DEFEAT-polypharmacy) in residential aged care facilities. BMJ Open 2017; 7:e013800. [PMID: 28416498 PMCID: PMC5775460 DOI: 10.1136/bmjopen-2016-013800] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Targeted deprescribing of anticholinergic and sedative medicines can lead to positive health outcomes in older people; as they have been associated with cognitive and physical functioning decline. This study will examine whether the proposed intervention is feasible at reducing the prescription of anticholinergic and sedative medicines in older people. METHODS AND ANALYSIS The Standard Protocol Items: Recommendations for Interventional trials (SPIRIT checklist) was used to develop and report the protocol. Single group (precomparison and postcomparison) feasibility study design. STUDY POPULATION 3 residential care homes have been recruited. INTERVENTION This will involve a New Zealand registered pharmacist using peer-reviewed deprescribing guidelines, to recommend to general practitioners (GPs), sedative and anticholinergic medicines that can be deprescribed. The cumulative use of anticholinergic and sedative medicines for each participant will be quantified, using the Drug Burden Index (DBI). OUTCOMES The primary outcome will be the change in the participants' DBI total and DBI PRN 3 and 6 months after implementing the deprescribing intervention. Secondary outcomes will include the number of recommendations taken up by the GP, participants' cognitive functioning, depression, quality of life, activities of daily living and number of falls. DATA COLLECTION POINTS Participants' demographic and clinical data will be collected at the time of enrolment, along with the DBI. Outcome measures will be collected at the time of enrolment, 3 and 6 months' postenrolment. ETHICS AND DISSEMINATION Ethics approval has been granted by the Human Disability and Ethics Committee. Ethical approval number (16/NTA/61). TRIAL REGISTRATION NUMBER Pre-results; ACTRN12616000721404.
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Affiliation(s)
| | - Dee Mangin
- University of Otago, Christchurch and David Braley Nancy Gordon, Chair in Family Medicine, McMaster University, Hamilton, Ontario, Canada
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Ailabouni NJ, Nishtala PS, Mangin D, Tordoff JM. General practitioners' insight into deprescribing for the multimorbid older individual: a qualitative study. Int J Clin Pract 2016; 70:261-76. [PMID: 26918508 DOI: 10.1111/ijcp.12780] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION The majority of older people with chronic diseases are prescribed multiple medicines resulting in polypharmacy. The extrapolation of the 'single disease model' represented by disease-specific guidelines is a major driver for polypharmacy. Polypharmacy is associated with negative health outcomes. Safely reducing or discontinuing harmful medicines, commonly referred to as deprescribing, has been shown to reduce adverse health outcomes, healthcare costs and mortality. However, there are barriers to deprescribing such as time constraints, limited appropriate clinical resources and the influence of multiple prescribers. AIM To explore general practitioners' (GPs') opinions and awareness of deprescribing in an older multimorbid patient. METHODS A qualitative study design using face-to-face semi-structured interviews was implemented. GP practices were randomly selected from two cities in New Zealand. Face-to-face in depth interviews were carried out with participants. A hypothetical profile of a multimorbid patient was included to elicit discussions about whether medicines should be continued or discontinued. Interviews were transcribed verbatim for thematic analysis. Transcripts were read and re-read. Themes were identified with iterative building of a coding list until all data were accounted for. Interviews continued until saturation of ideas occurred. RESULTS Forty GPs were contacted and 10 consented to participate. Responses to each medicine in the hypothetical patient profile varied. Opinions on deprescribing preventive and symptomatic medicines varied a great deal. Conflicting opinions existed particularly around the prescription of statins, dipyridamole and bisphosphonates. Dilemmas around the appropriate clinical management of reflux disease and insomnia in older people also came to light. CONCLUSION Gaining an insight into GPs' current prescribing patterns is important in designing any interventions aimed at reducing inappropriate prescribing. This study highlights the lack of clarity around deprescribing in multimorbidity. The participants' individual responses varied considerably. Deprescribing guidelines may help to clarify evidence based medicine relating to controversial areas and could hence decrease this variation.
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Affiliation(s)
- N J Ailabouni
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - P S Nishtala
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - D Mangin
- University of Otago, Christchurch, New Zealand
- David Braley Nancy Gordon, Chair in Family Medicine, McMaster University, Hamilton, ON, Canada
| | - J M Tordoff
- School of Pharmacy, University of Otago, Dunedin, New Zealand
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Matas NA, Nettelbeck T, Burns NR. Dropout during a driving simulator study: A survival analysis. JOURNAL OF SAFETY RESEARCH 2015; 55:159-169. [PMID: 26683559 DOI: 10.1016/j.jsr.2015.08.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 03/18/2015] [Accepted: 08/25/2015] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Simulator sickness is the occurrence of motion-sickness like symptoms that can occur during use of simulators and virtual reality technologies. This study investigated individual factors that contributed to simulator sickness and dropout while using a desktop driving simulator. METHOD Eighty-eight older adult drivers (mean age 72.82±5.42years) attempted a practice drive and two test drives. Participants also completed a battery of cognitive and visual assessments, provided information on their health and driving habits, and reported their experience of simulator sickness symptoms throughout the study. RESULTS Fifty-two participants dropped out before completing the driving tasks. A time-dependent Cox Proportional Hazards model showed that female gender (HR=2.02), prior motion sickness history (HR=2.22), and Mini-SSQ score (HR=1.55) were associated with dropout. There were no differences between dropouts and completers on any of the cognitive abilities tests. CONCLUSIONS Older adults are a high-risk group for simulator sickness. Within this group, female gender and prior motion sickness history are related to simulator dropout. Higher reported experience of symptoms of simulator sickness increased rates of dropout. PRACTICAL APPLICATIONS The results highlight the importance of screening and monitoring of participants in driving simulation studies. Older adults, females, and those with a prior history of motion sickness may be especially at risk.
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Affiliation(s)
- Nicole A Matas
- School of Psychology, University of Adelaide, South Australia 5005, Australia.
| | - Ted Nettelbeck
- School of Psychology, University of Adelaide, South Australia 5005, Australia
| | - Nicholas R Burns
- School of Psychology, University of Adelaide, South Australia 5005, Australia
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Poole SG, Bell JS, Jokanovic N, Kirkpatrick CM, Dooley MJ. A systematic review of medication exposure assessment in prospective cohort studies of community dwelling older australians. PLoS One 2015; 10:e0124247. [PMID: 25909191 PMCID: PMC4409061 DOI: 10.1371/journal.pone.0124247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 02/27/2015] [Indexed: 11/22/2022] Open
Abstract
Introduction It is not known to what extent medication use has been comprehensively assessed in prospective cohort studies of older Australians. Understanding the varying methods to assess medication use is necessary to establish comparability and to understand the opportunities for pharmacoepidemiological analysis. The objective of this review was to compare and contrast how medication-related data have been collected in prospective cohorts of community-dwelling older Australians. Methods MEDLINE and EMBASE (1990–2014) were systematically searched to identify prospective cohorts of ≥1000 older participants that commenced recruitment after 1990. The data collection tools used to assess medication use in each cohort were independently examined by two investigators using a structured approach. Results Thirteen eligible cohorts were included. Baseline medication use was assessed in participant self-completed surveys (n = 3), by an investigator inspecting medications brought to a clinic interview (n = 7), and by interviewing participants in their home (n = 3). Five cohorts sought participant consent to access administrative claims data. Six cohorts used multiple methods to assess medication use across one or more study waves. All cohorts assessed medication use at baseline and 12 cohorts in follow-up waves. Twelve cohorts recorded prescription medications by trade or generic name; 12 cohorts recorded medication strength; and 9 recorded the daily medication dose in at least one wave of the cohort. Seven cohorts asked participants about their “current” medication use without providing a definition of “current”; and nine cohorts asked participants to report medication use over recall periods ranging from 1-week to 3-months in at least one wave of the cohort. Sixty-five original publications, that reported the prevalence or outcomes of medication use, in the 13 cohorts were identified (median = 3, range 1–21). Conclusion There has been considerable variability in the assessment of medication use within and between cohorts. This may limit the comparability of medication data collected in these cohorts.
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Affiliation(s)
- Susan G. Poole
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
- Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia
- * E-mail:
| | - J. Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Natali Jokanovic
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
- Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia
| | - Carl M. Kirkpatrick
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Michael J. Dooley
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
- Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia
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Reeve E, Shakib S, Hendrix I, Roberts MS, Wiese MD. The benefits and harms of deprescribing. Med J Aust 2014; 201:386-9. [PMID: 25296058 DOI: 10.5694/mja13.00200] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 04/01/2014] [Indexed: 11/17/2022]
Abstract
Deprescribing is the process of trial withdrawal of inappropriate medications. Currently, the strongest evidence for benefit of deprescribing is from cohort and observational studies of withdrawal of specific medication classes that have shown better patient outcomes, mainly through resolution of adverse drug reactions. Additional potential benefits of deprescribing include reduced financial costs and improved adherence with other medications. The harms of ceasing medication use include adverse drug withdrawal reactions, pharmacokinetic and pharmacodynamic changes and return of the medical condition. These can be minimised with proper planning (ie, tapering), monitoring after withdrawal, and reinitiation of the medication if the condition returns. More evidence is needed regarding negative, non-reversible effects of ceasing use of certain classes of medication, such as acetylcholinesterase inhibitors. Cessation of use has not been studied for many medication classes, and large-scale randomised controlled trials of systematic deprescribing are required before the true benefits and harms can be known.
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Affiliation(s)
- Emily Reeve
- Division of Health Sciences, University of South Australia, Adelaide, SA, Australia.
| | - Sepehr Shakib
- Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Ivanka Hendrix
- Pharmacy Department, Repatriation General Hospital, Adelaide, SA, Australia
| | - Michael S Roberts
- Division of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Michael D Wiese
- Division of Health Sciences, University of South Australia, Adelaide, SA, Australia
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Smith T, Maidment I, Hebding J, Madzima T, Cheater F, Cross J, Poland F, White J, Young J, Fox C. Systematic review investigating the reporting of comorbidities and medication in randomized controlled trials of people with dementia. Age Ageing 2014; 43:868-72. [PMID: 25038835 DOI: 10.1093/ageing/afu100] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES dementia is a debilitating condition characterised by global loss of cognitive and intellectual functioning, which reduces social and occupational performance. This population frequently presents with medical co-morbidities such as hypertension, cardiovascular disease and diabetes. The CONSORT statement outlines recommended guidance on reporting of participant characteristics in clinical trials. It is, however, unclear how much these are adhered to in trials assessing people with dementia. This paper assesses the reporting of medical co-morbidities and prescribed medications for people with dementia within randomised controlled trial (RCT) reports. DESIGN a systematic review of the published literature from the databases AMED, CINAHL, MEDLINE, EMBASE and the Cochrane Clinical Trial Registry from 1 January 1997 to 9 January 2014 was undertaken in order to identify RCTs detailing baseline medical co-morbidities and prescribed medications . Eligible studies were appraised using the Critical Appraisal Skills Programme (CASP) RCT appraisal tool, and descriptive statistical analyses were calculated to determine point prevalence. RESULTS nine trials, including 1474 people with dementia, were identified presenting medical co-morbidity data. These indicated neurological disorders (prevalence 91%), vascular disorders (prevalence 91%), cardiac disorders (prevalence 74%) and ischaemic cerebrovascular disease (prevalence 53%) were most frequently seen. CONCLUSIONS published RCTs poorly report medical co-morbidities and medications for people with dementia. Future trials should include the report of these items to allow interpretation of whether the results are generalisable to frailer older populations. PROSPERO REGISTRATION CRD42013006735.
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Affiliation(s)
- Toby Smith
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK
| | - Ian Maidment
- School of Life and Health Sciences, Medicines and Devices in Ageing, Aston Research Centre for Healthy Ageing (ARCHA), Aston University, Birmingham, UK
| | | | - Tairo Madzima
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Francine Cheater
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK
| | - Jane Cross
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK
| | - Fiona Poland
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK
| | - Jacqueline White
- Department of Psychological Health and Wellbeing, Faculty of Health and Social Care, University of Hull, Hull, UK
| | - John Young
- Bradford Teaching Hospitals NHS Foundation Trust Head, Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Leeds, UK
| | - Chris Fox
- Norwich Medical School, University of East Anglia, Norwich, UK
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