Deprescribing in multi-morbid older people with polypharmacy: agreement between STOPPFrail explicit criteria and gold standard deprescribing using 100 standardized clinical cases

Validated medication deprescribing instruments for patients with palliative care needs: a systematic review

OBJECTIVES

Patients with life-limiting illnesses are prone to unnecessary polypharmacy. Deprescribing tools may contribute to minimizing negative outcomes. Thus, the aims of the study were to identify validated instruments for deprescribing inappropriate medications for patients with palliative care needs and to assess the impact on clinical, humanistic, and economic outcomes.

METHODS

A systematic review was conducted in LILACS, PUBMED, EMBASE, COCHRANE, and WEB OF SCIENCE databases (until May 2021). A manual search was performed in the references of enrolled articles. The screening, eligibility, extraction, and bias risk assessment were carried out by 2 independent researchers. Experimental and observational studies were eligible for inclusion.

RESULTS

Out of the 5791 studies retrieved, after excluding duplicates (n = 1050), conducting title/abstract screening (n = 4741), and full reading (n = 41), only 1 study met the inclusion criteria. In this included study, a randomized controlled trial was conducted, which showed a high level of bias risk overall. Adults 75 years or older (n = 130) with limited life expectancy and polypharmacy were allocated to 2 groups [intervention arm (deprescribing); and control arm (usual care)]. Deprescribing was performed with the aid of the STOPPFrail tool. The mean number of inappropriate medications and monthly medication costs were significantly lower in the intervention arm. No statistically significant differences were found in terms of unscheduled hospital presentations, falls, fractures, mortality, and quality of life.

CONCLUSIONS

Despite the availability of several instruments to support deprescribing in patients with palliative care needs, only 1 of them has undergone validation and robust assessment for effectiveness in clinical practice. The STOPPFrail tool appears to reduce the number of inappropriate medications for older people with limited life expectancy (and probably palliative care needs) and decrease the monthly costs of pharmacotherapy. Nevertheless, the impact on patient safety and humanistic outcomes remain unclear.

Validated medication deprescribing instruments for patients with palliative care needs palliative care: A systematic review

OBJECTIVES

Patients with life-limiting illnesses are prone to unnecessary polypharmacy. Deprescribing tools may contribute to minimizing negative outcomes. Thus, the aims of the study were to identify validated instruments for deprescribing inappropriate medications for patients with palliative care needs and to assess the impact on clinical, humanistic, and economic outcomes.

METHODS

A systematic review was conducted in LILACS, PUBMED, EMBASE, COCHRANE, and WEB OF SCIENCE databases (until May 2021). A manual search was performed in the references of enrolled articles. The screening, eligibility, extraction, and bias risk assessment were carried out by two independent researchers. Experimental and observational studies were eligible for inclusion.

RESULTS

Out of the 5,791 studies retrieved, after excluding duplicates (n = 1,050), conducting title/abstract screening (n = 4,741), and full reading (n = 41), only one study met the inclusion criteria. In this included study, a randomized controlled trial was conducted, which showed a high level of bias risk overall. Adults 75 years or older (n = 130) with limited life expectancy and polypharmacy were allocated to two groups [intervention arm (deprescribing); and control arm (usual care)]. Deprescribing was performed with the aid of the STOPPFrail tool. The mean number of inappropriate medications and monthly medication costs were significantly lower in the intervention arm. No statistically significant differences were found in terms of unscheduled hospital presentations, falls, fractures, mortality, and quality of life.

CONCLUSIONS

Despite the availability of several instruments to support deprescribing in patients with palliative care needs, only one of them has undergone validation and robust assessment for effectiveness in clinical practice. The STOPPFrail tool appears to reduce the number of inappropriate medications for older people with limited life expectancy (and probably palliative care needs) and decrease the monthly costs of pharmacotherapy. Nevertheless, the impact on patient safety and humanistic outcomes remain unclear.

Prevalence of Potentially Inappropriate Medications in Patients With Multimorbidity According to LESS-CHRON and STOPPFrail Criteria

OBJECTIVE

LESS-CHRON (List of Evidence-Based Deprescribing for Chronic Patients) and STOPPFrail (Screening Tool of Older Persons' Prescriptions in Frail adults with limited life expectancy) are criterion-based deprescribing tools. This study aimed to identify the prevalence of potentially inappropriate medications (PIMs) with these tools in an outpatient, polymedicated, older population with multimorbidity.

DESIGN

Single-center cross-sectional observational study.

SETTING AND PARTICIPANTS

PIMs and criteria subject to deprescribing identified by each tool were collected in patients who were being followed up on outpatient internal medicine consultation.

METHODS

PIMs were identified by STOPPFrail and LESS-CHRON criteria reviewing medical histories and pharmacologic treatments of the patients in the electronic health card system. Sociodemographic, clinical, and pharmacologic variables were recorded. A correlation analysis between treatment tools and clinical values was performed using the nonparametric Spearman rho correlation.

RESULTS

Eighty-three patients with a median of 14.4 (interquartile range 12-17) prescribed drugs were included. The total number of PIMs identified with LESS-CHRON was 158 vs 127 with STOPPFrail. Eight of the 27 criteria (29.6%) for LESS-CHRON and 15 of the 25 for STOPPFrail were found to be not applicable. A significant correlation was obtained for both tools with the number of prescribed drugs at the time of inclusion. The Profund, Barthel, and Frail-VIG index only showed a significant correlation with LESS-CHRON.

CONCLUSION AND IMPLICATIONS

Both tools have shown the capacity to identify PIMs that can be deprescribed in the population studied. However, LESS-CHRON appears to have a greater detection potential in the subgroup of patients analyzed. STOPPFrail brings a certain complementarity in other areas of therapy not covered by LESS-CHRON.

Identification of Potentially Inappropriate Medications in Frail Older Adults Residing in Long-Term Care: A Retrospective Chart Review Study

INTRODUCTION

Deprescribing is associated with positive health outcomes for older adults in long-term care (LTC), however deprescribing is not universally implemented.

OBJECTIVE

The primary aim of this study was to estimate the prevalence of potentially inappropriate medications (PIMs) prescribed to frail older adults in Irish long-term care facilities (LTCFs), as identified by the Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy, version 2 (STOPPFrail v2).

METHODS

A retrospective chart review was conducted in two publicly funded LTCFs in Ireland. Eligible participants were those (1) ≥ 65 years of age; (2) resident in a LTCF; (3) eligible as per the STOPPFrail v2 criteria by the site's Medical Officer; and (4) receiving regular medication. Data collected included age, sex, drug, dose, frequency, regular/pro re nata prescribing and indication/relevant diagnoses. Rates of polypharmacy (taking five or more medications) and excessive polypharmacy (taking 10 or more medications) were calculated. STOPPFrail v2 was used to identify PIMs; however, clinical measurements were not taken. Descriptive and association statistics were calculated.

RESULTS

Of the 103 residents, 89 were ≥ 65 years of age and categorised as frail and were therefore eligible for inclusion in the study. Of those eligible, 85 (95.5%) had polypharmacy and 57 (64%) experienced excessive polypharmacy. The mean number of regular medications was 10.8 (± 3.8), total medications 17.7 (± 5) and diagnoses 5.5 (± 2.5). The mean number of PIMs per resident was 4.8 (± 2.6). Of the eligible participants, 59.6% had at least one medicine without a documented indication, while 61.8%, 42.7% and 30.3% had at least one PIM from the vitamin D, antihypertensives and proton pump inhibitors drug classes, respectively.

CONCLUSION

Medication and PIM use was high among LTC residents, with inappropriate polypharmacy of concern. Lack of clear indication for prescribing medications appears to be an issue in LTC, potentially affecting healthcare professionals' engagement with deprescribing. The prevalence of PIMs may be overestimated in the antihypertensives/antidiabetic classes due to the lack of clinical measurements.

Efficacy and Safety of Dapagliflozin According to Frailty in Patients With Heart Failure: A Prespecified Analysis of the DELIVER Trial

BACKGROUND

Frailty is increasing in prevalence. Because patients with frailty are often perceived to have a less favorable risk/benefit profile, they may be less likely to receive new pharmacologic treatments. We investigated the efficacy and tolerability of dapagliflozin according to frailty status in patients with heart failure with mildly reduced or preserved ejection fraction randomized in DELIVER (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure).

METHODS

Frailty was measured using the Rockwood cumulative deficit approach. The primary end point was time to a first worsening heart failure event or cardiovascular death.

RESULTS

Of the 6263 patients randomized, a frailty index (FI) was calculable in 6258. In total, 2354 (37.6%) patients had class 1 frailty (FI ≤0.210; ie, not frail), 2413 (38.6%) had class 2 frailty (FI 0.211-0.310; ie, more frail), and 1491 (23.8%) had class 3 frailty (FI ≥0.311; ie, most frail). Greater frailty was associated with a higher rate of the primary end point (per 100 person-years): FI class 1, 6.3 (95% CI 5.7-7.1); class 2, 8.3 (7.5-9.1); and class 3, 13.4 (12.1-14.7; P<0.001). The effect of dapagliflozin (as a hazard ratio) on the primary end point from FI class 1 to 3 was 0.85 (95% CI, 0.68-1.06), 0.89 (0.74-1.08), and 0.74 (0.61-0.91), respectively (Pinteraction=0.40). Although patients with a greater degree of frailty had worse Kansas City Cardiomyopathy Questionnaire scores at baseline, their improvement with dapagliflozin was greater than it was in patients with less frailty: placebo-corrected improvement in Kansas City Cardiomyopathy Questionnaire Overall Summary Score at 4 months in FI class 1 was 0.3 (95% CI, -0.9 to 1.4); in class 2, 1.5 (0.3-2.7); and in class 3, 3.4 (1.7-5.1; Pinteraction=0.021). Adverse reactions and treatment discontinuation, although more frequent in patients with a greater degree of frailty, were not more common with dapagliflozin than with placebo irrespective of frailty class.

CONCLUSIONS

In DELIVER, frailty was common and associated with worse outcomes. The benefit of dapagliflozin was consistent across the range of frailty studied. The improvement in health-related quality of life with dapagliflozin occurred early and was greater in patients with a higher level of frailty.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03619213.

Sacubitril/Valsartan and Frailty in Patients With Heart Failure and Preserved Ejection Fraction

BACKGROUND

Frailty is an increasingly common problem, and frail patients are less likely to receive new pharmacologic therapies because the risk-benefit profile is perceived to be less favorable than in nonfrail patients.

OBJECTIVES

This study investigated the efficacy of sacubitril/valsartan according to frailty status in 4,796 patients with heart failure with preserved ejection fraction randomized in the PARAGON-HF (Prospective Comparison of ARNI With ARB Global Outcomes in Heart Failure With Preserved Ejection Fraction) trial.

METHODS

Frailty was measured by using the Rockwood cumulative deficit approach. The primary endpoint was total heart failure hospitalizations or cardiovascular death.

RESULTS

A frailty index (FI) was calculable in 4,795 patients. In total, 45.2% had class 1 frailty (FI ≤0.210, not frail), 43.5% had class 2 frailty (FI 0.211-0.310, more frail), and 11.4% had class 3 frailty (FI ≥0.311, most frail). There was a graded relationship between FI class and the primary endpoint, with a significantly higher risk associated with greater frailty (class 1: reference; class 2 rate ratio: 2.19 [95% CI: 1.85-2.60]; class 3 rate ratio: 3.29 [95% CI: 2.65-4.09]). The effect of sacubitril/valsartan vs valsartan on the primary endpoint from lowest to highest FI class (as a rate ratio) was: 0.98 [95% CI: 0.76-1.27], 0.92 [95% CI: 0.76-1.12], and 0.69 [95% CI: 0.51-0.95]), respectively (P_interaction = 0.23). When FI was examined as a continuous variable, the interaction with treatment was significant for the primary outcome (P_interaction = 0.002) and total heart failure hospitalizations (P_interaction < 0.001), with those most frail deriving greater benefit.

CONCLUSIONS

Frailty was common in heart failure with preserved ejection fraction and associated with worse outcomes. Compared with valsartan, sacubitril/valsartan seemed to show a greater reduction in the primary endpoint with increasing frailty, although this was not significant when FI was examined as a categorical variable. (Prospective Comparison of ARNI With ARB Global Outcomes in Heart Failure With Preserved Ejection Fraction [PARAGON-HF]; NCT01920711).

Efficacy and Safety of Dapagliflozin According to Frailty in Heart Failure With Reduced Ejection Fraction : A Post Hoc Analysis of the DAPA-HF Trial

BACKGROUND

Frailty may modify the risk-benefit profile of certain treatments, and frail patients may have reduced tolerance to treatments.

OBJECTIVE

To investigate the efficacy of dapagliflozin according to frailty status, using the Rockwood cumulative deficit approach, in DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure).

DESIGN

Post hoc analysis of a phase 3 randomized clinical trial. (ClinicalTrials.gov: NCT03036124).

SETTING

410 sites in 20 countries.

PATIENTS

Patients with symptomatic heart failure (HF) with a left ventricular ejection fraction of 40% or less and elevated natriuretic peptide.

INTERVENTION

Addition of once-daily 10 mg of dapagliflozin or placebo to guideline-recommended therapy.

MEASUREMENTS

The primary outcome was worsening HF or cardiovascular death.

RESULTS

Of the 4744 patients randomly assigned in DAPA-HF, a frailty index (FI) was calculable in 4742. In total, 2392 patients (50.4%) were in FI class 1 (FI ≤0.210; not frail), 1606 (33.9%) in FI class 2 (FI 0.211 to 0.310; more frail), and 744 (15.7%) in FI class 3 (FI ≥0.311; most frail). The median follow-up time was 18.2 months. Dapagliflozin reduced the risk for worsening HF or cardiovascular death, regardless of FI class. The differences in event rate per 100 person-years for dapagliflozin versus placebo from lowest to highest FI class were -3.5 (95% CI, -5.7 to -1.2), -3.6 (CI, -6.6 to -0.5), and -7.9 (CI, -13.9 to -1.9). Consistent benefits were observed for other clinical events and health status, but the absolute reductions were generally larger in the most frail patients. Study drug discontinuation and serious adverse events were not more frequent with dapagliflozin than placebo, regardless of FI class.

LIMITATION

Enrollment criteria precluded the inclusion of very high-risk patients.

CONCLUSION

Dapagliflozin improved all outcomes examined, regardless of frailty status. However, the absolute reductions were larger in more frail patients.

PRIMARY FUNDING SOURCE

AstraZeneca.

Methodological Challenges for Epidemiologic Studies of Deprescribing at the End of Life

Purpose of Review

To describe approaches to measuring deprescribing and associated outcomes in studies of patients approaching end of life (EOL).

Recent Findings

We reviewed studies published through 2020 that evaluated deprescribing in patients with limited life expectancy and approaching EOL. Deprescribing includes reducing the number of medications, decreasing medication dose(s), and eliminating potentially inappropriate medications. Tools such as STOPPFrail, OncPal, and the Unnecessary Drug Use Measure can facilitate deprescribing. Outcome measures vary and selection of measures should align with the operationalized deprescribing definition used by study investigators.

Summary

EOL deprescribing considerations include medication appropriateness in the context of patient goals for care, expected benefit from medication given life expectancy, and heightened potential for medication-related harm as death nears. Additional data are needed on how EOL deprescribing impacts patient quality of life, caregiver burden, and out-of-pocket medication-related costs to patients and caregivers. Investigators should design deprescribing studies with this information in mind.

New Horizons in the impact of frailty on pharmacokinetics: latest developments

Frail older people have a high prevalence of drug use and are susceptible to adverse drug reactions. The physiological changes of frailty are likely to affect pharmacokinetics and pharmacodynamics. We reviewed the methods and findings of published studies of pharmacokinetics in frailty. Nine studies describing pharmacokinetics and an additional three of pharmacokinetic pathways in frail older people were identified. Most pharmacokinetic studies investigated a single administration of a medication, dose or formulation, in small populations, often with limited representation of males or females, and applied variable definitions of frailty. Pharmacokinetic sampling designs generally utilised saturated sampling followed by analysis based on the trapezoidal rule for area under the curve, with more recent studies using sparser sampling and more sophisticated modelling to obtain individual and population values of all pharmacokinetic parameters. Overall, the pharmacokinetic studies reported only small changes in some parameters for some drugs with frailty, with the most consistent change reduced hepatic clearance in frail older people. Recommendations for future studies of pharmacokinetics in frailty include (i) standard objective definitions of frailty; (ii) larger studies including people with mild, moderate and severe frailty; (iii) population pharmacokinetic modelling to allow sparser sampling and consideration of multiple influences on pharmacokinetics; (iv) physiologically based modelling as the physiology of frailty emerges and (v) longitudinal pharmacokinetic studies of chronic drug therapy from middle to old age and from robust to pre-frail to frail, including pre-clinical studies. These data, accompanied by pharmacodynamics data in frailty, will inform safe, effective prescribing for frail older people.

Effect of number of medications and complexity of regimens on medication adherence and blood pressure management in hospitalized patients with hypertension

INTRODUCTION

Good adherence of antihypertensives is recommended for the accomplishment of hypertension therapy. The number of medications and characteristics contributing to medication regimen complexity, such as dosage forms and dosing frequency, are known to influence medication adherence. However, the effect of medication regimen complexity on the therapeutic efficacy of medicines remains to be clarified. In the present study, we retrospectively investigated the effect of number of medications and medication regimen complexity on medication adherence and therapeutic efficacy in patients with hypertension.

METHODS

According to the inclusion and exclusion criteria, 1,057 patients, who were on medications including antihypertensives on admission at the Mie University Hospital between July 2018 and December 2018, were enrolled in this study. Poor blood pressure management was defined if the systolic or diastolic blood pressure were ≥140 mmHg or ≥ 90 mmHg. Medication regimen complexity was quantified using the medication regimen complexity index (MRCI) score.

RESULTS

Among 1,057 patients, 164 and 893 patients were categorized into poor and good adherence groups, respectively. The multivariate analyses revealed that age ≥ 71 years and oral MRCI score ≥ 19.5 but not number of oral medications were extracted as risk factors for poor medication adherence. Medication adherence and blood pressure management were poor in the group with oral MRCI score ≥ 19.5, regardless of the age. The rate of readmission was similar.

CONCLUSION

Our study is the first to demonstrate that medication regimen complexity rather than number of medications is closely related to medication adherence and blood pressure management. Hence, physicians and/or pharmacists should consider the complexity of medication regimens while modifying them.

Deprescribing in older people approaching end-of-life: development and validation of STOPPFrail version 2

BACKGROUND

Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy (STOPPFrail) criteria were developed in 2017 to assist physicians with deprescribing decisions in older people approaching end-of-life. Updating was required to make the tool more practical, patient-centred and complete.

METHODS

a thorough literature review was conducted to, first, devise a practical method for identifying older people who are likely to be approaching end-of-life, and second, reassess and update the existing deprescribing criteria. An eight-member panel with a wide-ranging experience in geriatric pharmacotherapy reviewed a new draft of STOPPFrail and were invited to propose new deprescribing criteria. STOPPFrail version 2 was then validated using Delphi consensus methodology.

RESULTS

STOPPFrail version 2 emphasises the importance of shared decision-making in the deprescribing process. A new method for identifying older people who are likely to be approaching end-of-life is included along with 25 deprescribing criteria. Guidance relating to the deprescribing of antihypertensive therapies, anti-anginal medications and vitamin D preparations comprises the new criteria.

CONCLUSIONS

STOPPFrail criteria have been updated to assist physicians in efforts to reduce drug-related morbidity and burden for their frailest older patients. Version 2 is based on an up-to-date literature review and consensus validation by a panel of experts.

Effect of pharmacological treatment prior to admission on the outcome of older hip fracture patients

PURPOSE

We aim to relate the pharmacological treatment at admission of hip fracture patients with their prognosis.

METHODS

We designed a prospective study including 436 hip fracture patients. We classified all the pharmacological treatment prior to admission of each patient into 25 groups according to their active agent and indications. We followed-up patients for one year for survival, emergency department visits (EDV), and in-hospital re-admissions (RAD). Differential analysis was performed by chi-square test, U-Mann Whitney test, and logistic regression. In all cases, p ≤ 0.05 was considered statistically significant.

RESULTS

At 30-day follow-up, 14.9% patients noted EDV, 9.2% RAD, and 3.2% dead. Patients taking beta-blockers (p = 0.046), loop diuretics (p = 0.018) or antiparkinsonian (p = 0.009) showed an increased 30-day EDV; patients taking benzodiazepines (p = 0.014), loop diuretics (p = 0.009) or antiparkinsonian (p = 0.009), an increased 30-day RAD. At one-year follow-up, 50.7% patients noted EDV, 30.7% RAD, and 22.7% dead. Patients taking oral antidiabetics (p = 0.006) noted a greater one-year EDV; patients taking major opioids (p = 0.001), benzodiazepines (p = 0.016), cardiac agents (p = 0.046), loop diuretics (p = 0.042), beta-blockers (p = 0.018), oral anticoagulants (p = 0.013) or gastric prophylaxis (p = 0.020), greater RAD; patients taking cardiac agents (p = 0.024), loop diuretics (p = 0.006) or oral anticoagulants (p = 0.015), increased 1-year mortality rate.

CONCLUSIONS

The pharmacological treatment noted at admission for hip fracture patients is related to the outcome, in a dose-independent way. The pharmacological treatment could be an additional parameter that could help us to improve the decision-making process and the resource assignation of hip fracture patients. A proper medication review upon admission because of a hip fracture is warranted.

Evidence of association between the use of drugs and community-dwelling older people frailty: a cross-sectional study

BACKGROUND

The scientific literature has shown that an association between polypharmacy and frailty exists. However, few studies have also considered drug interactions and the use of potentially inappropriate medications.

OBJECTIVE

To evaluate the association between the use of drugs and frailty among community-dwelling older people.

DESIGN AND SETTING

Cross-sectional study carried out among 580 older people in Uberaba (MG).

METHODS

Data were collected at these older people's homes using instruments validated in Brazil. Descriptive, bivariate and binary logistic regression analyses were performed (P < 0.05).

RESULTS

Most of these individuals were classified as pre-frail (55.7%), while 13.1% were frail. It was found that 31.7% of them presented polypharmacy, 41.7% had drug interactions and 43.8% were using potentially inappropriate medications. In the initial model, polypharmacy (odds ratio, OR = 1.91; confidence interval, CI = 1.27-2.86) and use of potentially inappropriate medications (OR = 2.45; CI = 1.68-3.57) increased the chance that these older people would be pre-frail or frail. In the final adjusted model, use of potentially inappropriate drugs remained associated with the outcome (OR = 2.26; CI = 1.43-3.57).

CONCLUSION

Use of potentially inappropriate medications was the independent variable that explained the occurrence of frailty in a representative sample of community-dwelling older adults.

Polypharmacy in Palliative Care: Two Deprescribing Tools Compared with a Clinical Review

Background: Lack of guidance is highlighted as a barrier to deprescribing in palliative care. Two deprescribing tools exist, but with inclusion and exclusion criteria that limit utility. The tools have not previously been compared directly or used in an unselected palliative population. Objective: To compare the OncPal and STOPPFrail deprescribing tools to an expert review in an unselected palliative population. Secondary aims included a description of medicines incorrectly classified by both tools. Design: Fifty palliative inpatients were retrospectively reviewed by an expert panel, and both tools were independently applied to the patients. Positive and negative predictive values (PPV and NPV) were calculated per patient using the expert review as the gold standard. Results: The median number of medicines per patient was 11, with 19% of medicines deemed inappropriate. The PPV and NPV were 75% (interquartile range 50-100) and 91% (interquartile range 84-100), respectively, for OncPal, and 100% (interquartile range 50-100) and 90% (interquartile range 78-100), respectively, for STOPPFrail. There was no statistically significant difference between the tools (PPV p = 0.42 and NPV p = 0.07). The main medicines incorrectly ceased by OncPal were antianginals for stable coronary artery disease, and haloperidol for nausea by STOPPFrail. Conclusion: There was no significant difference between the tools. Both tools performed well in an unselected population. Some minor amendments could improve the PPV of both tools.

Deprescribing in Older People Approaching End of Life: A Randomized Controlled Trial Using STOPPFrail Criteria

OBJECTIVES

Older people approaching end of life are commonly prescribed multiple medications, many of which may be inappropriate or futile. Our objective was to examine the effect of applying the STOPPFrail, a recently developed deprescribing tool, to the medication regimens of older patients with advanced frailty.

DESIGN

Randomized controlled trial.

SETTING

Two acute hospitals in Ireland.

PARTICIPANTS

Adults 75 years or older (n = 130) with advanced frailty and polypharmacy (five or more drugs), transferring to long-term nursing home care.

INTERVENTION

A STOPPFrail-guided deprescribing plan was presented to attending physicians who judged whether or not to implement recommended medication changes.

MEASUREMENTS

The primary outcome was the change in the number of regular medications at 3 months. Secondary outcomes included unscheduled hospital presentations, falls, quality of life, monthly medication costs, and mortality.

RESULTS

Intervention (n = 65) and control group (n = 65) participants were prescribed a mean (plus or minus standard deviation [SD]) of 11.5 (±3.0) and 10.9 (±3.5) medications, respectively, at baseline. The mean (SD) change in the number of medications at 3 months was -2.6 (±2.73) in the intervention group and -.36 (±2.60) in the control group (mean difference = 2.25 ± .54; 95% confidence interval [CI] = 1.18-3.32; P < .001). The mean change in monthly medication cost was -$74.97 (±$148.32) in the intervention group and -$13.22 (±$110.40) in the control group (mean difference $61.74 ± $26.60; 95% CI = 8.95-114.53; P = .02). No significant differences were found between groups for any of the other secondary outcomes.

CONCLUSION

STOPPFrail-guided deprescribing significantly reduced polypharmacy and medication costs in frail older people. No significant differences between groups were observed with regard to falls, hospital presentations, quality of life, and mortality, although the trial was likely underpowered to detect differences in these outcomes. J Am Geriatr Soc 68:762-769, 2020.

The impact of medication review with version 2 STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) criteria in a French nursing home: a 3-month follow-up study

Background:

Improving medication appropriateness is a priority of French national campaigns in nursing homes. A pilot study was conducted to evaluate the impact of a medication review in a French nursing home with a 3-month follow up.

Method:

A medication review was conducted in 2015 using version 2 STOPP and START criteria. The number and type of drugs meeting a STOPP that were reintroduced and the number and type of drug meeting a START that were stopped during follow up were measured. An expert committee adjudicated whether 3-month hospitalizations and deaths were related to medication review. The impact of medication review on the cost related to drug consumption was calculated for 3 months.

Results:

The 52 residents (age 84 ± 9 years, 83% female) fulfilled, on average, 2 ± 1.4 of the STOPP criteria and 0.7 ± 0.6 of the START criteria. A total of 101 drugs were stopped and 34 drugs were started. Five deaths occurred during follow up and were judged as not related to medication review. Five drugs stopped were reintroduced in five residents for a rebound effect or a symptom occurrence and one resident had stopped a START medication (aspirin) for a minor adverse drug reaction. At 3 months, a gain of 20.21 ± 31.34 euros per resident was observed.

Conclusion:

The medication review using version 2 STOPP and START criteria and involving the physician in charge seems useful for detecting and correcting inappropriate prescribing in a nursing home.