The Role of Patient Preferences in Deprescribing

A nurse practitioner-led deprescribing bundled intervention to reduce rates of polypharmacy in the post-acute care setting

BACKGROUND

In post-acute care (PAC) settings, residents face elevated risks of adverse drug reactions and emergency department visits because of polypharmacy. With over 90% of PAC residents nationally taking five or more medications, targeted deprescribing of inappropriate or unnecessary medications emerges as a critical strategy.

LOCAL PROBLEM

The project site faces high rates of polypharmacy with a root cause analysis revealing a deficiency in evidence-based practices (EBP) for deprescribing potentially inappropriate or unnecessary medications. To address this issue, a bundled deprescribing intervention was implemented as part of a quality improvement project aimed at reducing polypharmacy rates.

METHODS

This project, conducted at a PAC setting in the midwestern United States, used the RE-AIM Model. Data collection involved tracking prescribing rates before and after the intervention for residents admitted to the practice setting over a 5-month period.

INTERVENTION

A bundled EBP intervention comprising a deprescribing framework, pharmacist collaboration, and the utilization of an EBP guideline, established a systematic process guiding deprescribing efforts for each resident on admission to the PAC setting.

RESULTS

Fourty-nine patients received a deprescribing bundle, resulting in a 26.67% reduction in prescribed medications. On average, patients had 5.55 medications deprescribed, with reductions noted across 85 distinct therapeutic drug categories.

CONCLUSION

Nurse practitioners play a pivotal role initiating successful deprescribing interventions within the PAC setting. Using a comprehensive approach, integrating pharmacist collaboration and EBP leads to reductions in prescribing rates among PAC residents. This model demonstrates potential for sustainable improvements in patient outcomes within the PAC environment.

Effectiveness and cost-effectiveness of a collaborative deprescribing intervention of proton-pump-inhibitors on community-dwelling older adults: Protocol for the C-SENIoR, a pragmatic non-randomized controlled trial

INTRODUCTION

Worldwide, demographic ageing is a major social, economic and health challenge. Despite the increase in life expectancy, elderly often live with multiple chronic conditions, exposing them to multiple medications. Concerns have been raised about the growing issue of inappropriate long-term usage of proton-pump inhibitors (PPI), which have been associated with adverse outcomes and increased healthcare costs. Deprescribing is a recommended intervention to reduce or withdraw medicines that might be causing harm or might no longer be of benefit. This protocol details a trial to assess the effectiveness and cost-effectiveness of a collaborative deprescribing intervention of PPI among community-dwelling elderly, involving community pharmacists and general practitioners.

METHODS AND ANALYSIS

A pragmatic, multicentre, two-arm, non-randomised controlled trial of a structured PPI collaborative deprescribing intervention in the primary care setting with a 6-month follow-up will be conducted. Patients must be 65 years old or older, live in the community and have been using PPI for more than 8 weeks. We hypothesize that the intervention will reduce the PPI usage in the intervention group compared to the control group. The primary outcome is the successful discontinuation or dose decrease of any PPI, defined as a statistically significant absolute 20% reduction in medication use between the intervention and control groups at 3- and 6-month follow-ups. An economic evaluation will be conducted alongside the trial. This study was approved by the Ethics Research Committee of Nova Medical School, NOVA University of Lisbon and by the Ethics Committee from the Local Health Unit Alto Minho, Portugal.

DISCUSSION

This pragmatic trial will provide evidence on the effectiveness and cost-effectiveness of a patient-centred collaborative deprescribing intervention in the community setting in Portugal. It will also inform improvements for the development of future multi-faceted interventions that aim to optimise medication for the community-dwelling elderly.

CLINICAL TRIAL REGISTRATION

ISRCTN 49637686.

Efficacy of deprescribing on health outcomes: An umbrella review of systematic reviews with meta-analysis of randomized controlled trials

BACKGROUND

Deprescribing is an important intervention across different settings in medicine, but the literature supporting such a practice is still conflicting. Therefore, we aimed to capture the breadth of outcomes reported and assess the strength of evidence of the use of deprescribing for health outcomes.

METHODS

Umbrella review of systematic reviews of the use of deprescribing searching in Medline, Scopus, and Web of Science until 01 November 2023. The grading of evidence was carried out using the GRADE for intervention studies, whilst data regarding systematic reviews were reported as narrative findings.

RESULTS

Among 456 papers, 12 systematic reviews (six with meta-analysis) for a total of 231 RCTs and 44,193 patients were included. In any setting, deprescribing was able to significantly reduce the number of total and of potentially inappropriate medications (PIMs) in older patients (low certainty of evidence) and to reduce the proportion of participants potentially having several or PIMs (moderate certainty of evidence). In community, supported by a high certainty of evidence, deprescribing was not more effective than standard care in decreasing injurious falls, any falls or number of fallers. In nursing home, deprescribing was associated with a significantly lower PIMs than standard care (very low certainty of evidence). In end-of-life situations, deprescribing significantly reduced mortality rate of approximately 41% (high certainty of evidence).

CONCLUSIONS

Deprescribing is a promising intervention across different settings and situations, but a notable gap in the literature concerning its effects on substantial outcomes still exists.

Barriers and Enablers for Deprescribing Glucose-Lowering Treatment in Older Adults: A Systematic Review

OBJECTIVES

Overtreatment with glucose-lowering treatment (GLT) is frequent and a source of high morbidity and mortality in older adults with type 2 diabetes mellitus (T2DM). This study aimed to identify and synthesize barriers and enablers for deprescribing GLT in older adults (≥65 years) with T2DM.

DESIGN

Systematic review of qualitative and mixed-methods studies.

SETTING AND PARTICIPANTS

Older adults with T2DM, any participants [patients, health care providers (HCPs), caregivers], any settings.

METHODS

Two researchers (and a referred third researcher at all stages) independently screened original articles reporting qualitative and mixed-methods studies exploring barriers and enablers for deprescribing GLT in older adults published during 2010-2023, identified from MEDLINE, Embase, CINAHL, and gray literature. Quality of the included studies was assessed with the Mixed-Methods Appraisal Tool. Verbatim statements on barriers and enablers were extracted, and determinants of behaviors were identified with the Theoretical Domains Framework (TDF) version 2, and related intervention functions (targets for future interventions) were proposed according to the Behavior Change Wheel (BCW).

RESULTS

We identified only 4 studies from 2 countries (United States and the Netherlands), all recently published (2019-2023), that primarily reported barriers to GLT deprescribing from interviews or focus groups of patients or HCPs practicing outpatient medicine. Knowledge, fear, poor communication, inertia, and trust with HCPs were the main determinants of behaviors that influenced deprescribing, and education, training, persuasion and environmental restructuring were the main intervention functions for proposing future interventions. Studies did not cover financial aspects, physician characteristics, or caregiver and family viewpoints.

CONCLUSIONS AND IMPLICATIONS

The use of a behavioral theory and a validated implementation framework provided a comprehensive approach to identifying barriers and enablers for deprescribing GLT in older adults (≥65 years) with T2DM. The behavioral determinants identified may be useful in tailoring interventions to improve the implementation of GLT deprescribing in older adults in ambulatory settings.

Older Adult Perspectives on Statin Continuation and Discontinuation in Primary Cardiovascular Disease Prevention: A Mixed-Methods Study

Background and Purpose

Evidence for statin use for primary cardiovascular disease prevention in older adults is limited. When evidence on risk-benefit profile of a medication is uncertain, using it or not becomes a preference-sensitive decision. We aimed to assess and explore patient perspectives on continuation and discontinuation of statins used for primary cardiovascular prevention in older adults.

Patients and Methods

We used a convergent mixed-methods design, conducting in parallel a survey among 47 patients and three focus groups (FGs) with 14 patients total. We recruited patients aged ≥65 years and taking a statin for primary cardiovascular prevention. The survey and FGs aimed to assess and explore patient experiences of statin use, and views on statin continuation and discontinuation, including patient decision-making. Quantitative and qualitative data were first analyzed separately - descriptive statistics for quantitative data and thematic analysis for qualitative data - and then integrated to create metainferences, using joint displays.

Results

Forty-one percent of patients (N=19) were reluctant to discontinue the statin, whereas 22% (N=10) were willing to try discontinuing it. A reason to continue the statin was its perceived necessity, while self-estimated low cardiovascular risk and wish to reduce medication burden were given as reasons to discontinue it. Lack of expertise assumed by the patients to decide about statin continuation or discontinuation, uncertainty about statin indication, and fear of having a cardiovascular event after discontinuation made many patients uncertain about deciding to continue or discontinue the statin. In this context, 70% (N=33) would rather have their physician choose for them, and 94% (N=44) would continue taking the statin for as long as their physician told them to do so.

Conclusion

This study highlights factors that influence patient willingness to continue or discontinue statins, patient uncertainty about statin continuation or discontinuation, and the important role physicians play in the decision-making process.

Deprescribing Tool for Older PeoPle with Limited-life Expectancy (De-TOPPLE) version 1: Development and validation using a modified Delphi technique

Deprescribing decision making in older adults with limited life expectancy is often challenging for clinicians. We aimed to develop and validate a Deprescribing Tool for Older People with Limited-life Expectancy (De-TOPPLE). Modified Delphi technique was used to gain experts' consensus on the tool and further develop using their feedback. Experts [Round-1 (n = 13), Round-2 (n = 7)] had clinical and/or research background on geriatric medicine, geriatrics, family medicine or pharmacotherapy. Round-1 consensus was achieved on approach taken by the tool to evaluate risk and benefit; distinguishing medications as preventive, symptom control or dual-purpose; referring to established deprescribing process; stepwise approach to deprescribing; and the overall concept. Common feedback was to reflect upon harm-benefit analysis, distinguish medication types earlier, qualify adverse events, use time-to-benefit (TTB), prioritise symptom relief, monitor post-deprescribing, include shared decision making and define terms for clinical familiarisation. After tool update, Round-2 consensus was achieved on usability in clinical setting, flexibility of implicit judgement, ceasing preventive medication with inadequate TTB, ceasing symptom control medication with inadequate symptom relief, ceasing dual-purpose medication (DPM) with inadequate TTB and symptom relief, and continuing DPM with adequate TTB and symptom relief. De-TOPPLE version 1 was developed and validated through two rounds of the Delphi process. Clinical use of the tool needs final validation following the addition of contextual statements to the tool.

Older Adult Attitudes toward Deprescribing Statins in Primary Cardiovascular Prevention Versus General Medications

Background: There is little evidence for statins for primary cardiovascular prevention in older adults. Consequently, it is important to assess patient attitudes toward the use of statins, which might differ from attitudes toward other medications. We aimed to describe older patient attitudes toward deprescribing statins versus general medications. Methods: We conducted a survey using the revised Patients' Attitudes Toward Deprescribing questionnaire in its original version and adapted to statin use in adults ≥65 years taking a statin for primary prevention. Results: Among the 47 participants (mean age 74.6 years), 42 (89%) were satisfied with their current therapy, but still willing to stop ≥1 of their medications upon their doctor's advice. About 68% (N = 32) were satisfied with their statin therapy, while 83% (N = 39) would accept to consider deprescribing. Twenty-six (55%) participants were concerned about missing future benefits when stopping their general medications and 17 (36%) when stopping their statin. Eight (17%) participants believed they were experiencing side effects of statins and twice as many for general medication (38%, N = 18). Conclusion: Our study provides insight about differences and similarities in patient attitudes toward deprescribing general medications and statins in primary prevention. This information could support patient-centered conversations and shared-decision making about deprescribing.

Dementia, osteoporosis and fragility fractures: Intricate epidemiological relationships, plausible biological connections, and twisted clinical practices

Dementia, osteoporosis, and fragility fractures are chronic diseases, often co-existing in older adults. These conditions pose severe morbidity, long-term disability, and mortality, with relevant socioeconomic implications. While in the research arena, the discussion remains on whether dementia is the cause or the consequence of fragility fractures, healthcare professionals need a better understanding of the interplay between such conditions from epidemiological and physiological standpoints. With this review, we summarized the available literature surrounding the relationship between cognitive impairment, dementia, and both low bone mineral density (BMD) and fragility fractures. Given the strength of the bi-directional associations and their impact on the quality of life, we shed light on the biological connections between brain and bone systems, presenting the main mediators, including gut microbioma, and pathological pathways leading to the dysregulation of bone and brain metabolism. Ultimately, we synthesized the evidence about the impact of available pharmacological treatments for the prevention of fragility fractures on cognitive functions and individuals' outcomes when dementia coexists. Vice versa, the effects of symptomatic treatments for dementia on the risk of falls and fragility fractures are explored. Combining evidence alongside clinical practice, we discuss challenges and opportunities related to the management of older adults affected by cognitive impairment or dementia and at high risk for fragility fracture prevention, which leads to not only an improvement in patient health-related outcomes and survival but also a reduction in healthcare cost and socio-economic burden.

Reasons why older adults in three countries agreed with a deprescribing recommendation in a hypothetical vignette

The purpose of this study was to examine factors important to older adults who agreed with a deprescribing recommendation given by a general practitioner (GP) to a hypothetical patient experiencing polypharmacy. We conducted an online, vignette-based, experimental study in the United Kingdom, United States and Australia with participants ≥65 years. The primary outcome was an agreement with a deprescribing recommendation (6-point Likert scale; 1 = strongly disagree and 6 = strongly agree). We performed a content analysis of the free-text reasons provided by participants who agreed with deprescribing (score of 5 or 6). Among 2656 participants who agreed with deprescribing, approximately 53.7% shared a preference for following the GP's recommendation or considered the GP the expert. The medication was referred to as a reason for deprescribing by 35.6% of participants. Less common themes included personal experience with medicine (4.3%) and older age (4.0%). Older adults who agreed with deprescribing in a hypothetical vignette most frequently reported a desire to follow the recommendations given the GP's expertise. Future research should be conducted to help clinicians efficiently identify patients who have a strong desire to follow the doctor's recommendations related to deprescribing, as this may allow for a tailored, brief deprescribing conversation.

Deprescribing as an Opportunity to Facilitate Patient-Centered Care: A Qualitative Study of General Practitioners and Pharmacists in Japan

Deprescribing has recently been applied to address polypharmacy, particularly among older adults. However, the characteristics of deprescribing that are likely to improve health outcomes have not been well studied. This study explored the experiences and perspectives of general practitioners and pharmacists with regard to deprescribing in older adults with multimorbidity. A qualitative study was conducted involving eight semi-structured focus group interviews with 35 physicians and pharmacists from hospitals, clinics, and community pharmacies. Thematic analysis was applied to identify themes using the theory of planned behavior as a guide. The results illustrated a metacognitive process, as well as influencing factors, through which healthcare providers commit to shared decision making for deprescribing. Healthcare providers acted on the basis of their attitudes and beliefs on deprescribing, the influence of subjective norms, and perceived behavioral control for deprescribing. These processes are influenced by factors such as drug class, prescribers, patients, deprescribing experience, and environment/education. Healthcare providers' attitudes, beliefs, and behavioral control (along with deprescribing strategies) evolve in a dynamic interplay with experience, environment, and education. Our results can serve as a foundation for the development of effective patient-centered deprescribing to improve the safety of pharmaceutical care for older adults.

National trends in osteoporosis medication use among Medicare beneficiaries with and without Alzheimer's disease/related dementias

BACKGROUND

Osteoporotic fractures  are a leading cause of disability and premature death in the elderly. Patients with Alzheimer's and related dementia (ADRD) have high rates of osteoporosis (OP) and substantial risk of osteoporotic fractures. Yet research is sparse on trends and predictors of OP medication use in ADRD.

METHODS

Medicare beneficiaries with OP aged ≥ 67 years have Medicare parts A/B/D without HMO from 2016 to 2018. Our outcome was receipt of OP medications in 2018. A multivariable logistic regression assessed association between ADRD and OP drug prescribing, adjusted for age, sex, race, region, Medicare entitlement, dual Medicaid eligibility, chronic conditions, number of provider visits/hospitalizations, and nursing home (NH) resident status. Age/ADRD and NH residency/ADRD interactions were tested.

RESULTS

Our sample consisted of 47,871 people with OP and ADRD and 201,840 with OP without ADRD. OP drug use was 38.6% in ADRD patients vs. 52.7% in non-ADRD. After adjustment for demographics, chronic conditions, and previous hospitalizations/physician visits, the OR for OP drug in ADRD vs. non-ADRD was 0.85 (95% CI: 0.83-0.87). NH residents had lower odds for OP medication (OR: 0.61, 95% CI: 0.58-0.64). There were significant interactions between ADRD and age, and between ADRD and NH residency. The OR for OP drug use associated with ADRD was 0.88 (95% CI: 0.86-0.90) among community-dwelling elders and 0.66 (95% CI: 0.64-0.69) among NH residents.

CONCLUSIONS

ADRD patients received OP drugs at a lower rate than their non-ADRD counterparts. More research is needed on when to prescribe or deprescribe OP drugs in the context of different ADRD severity, patient preferences, remaining life expectancy, and time-to-benefit from OP drugs.

Exploring Older Adult Health Literacy in the Day-to-Day Management of Polypharmacy and Making Decisions About Deprescribing: A Mixed Methods Study

BACKGROUND

Polypharmacy use in older adults is increasing and sometimes leads to poor health outcomes. The influence of health literacy in managing polypharmacy and making decisions about stopping medication has received limited attention.

OBJECTIVE

A mixed methods design was used to measure and investigate the influence of health literacy in the management of polypharmacy and decisions about deprescribing. Phase 1 involved two cross-sectional surveys, one with older adults using five or more medications and the other with general practitioners (GPs).

METHODS

Older adult health literacy was measured using the All Aspects of Health Literacy Scale. Phase 2 employed individual interviews with both older adults and GPs and further explored the reported use of health literacy in practice. SPSS version 24 was used to conduct descriptive statistical analysis of the Phase 1 survey responses and Phase 2 interviews were analyzed using thematic analysis with the assistance of NVivo 12.

KEY RESULTS

Phase 1 survey responses were received from 85 GPs and 137 older adults. Phase 2 interviews were conducted with 16 GPs and 25 older adults. Phase 1 results indicated that self-reported older adult health literacy was high, and that GPs believed older patients could engage in decisions about deprescribing. Phase 2 findings showed that older adults developed and employed complex health literacy practices to manage medications between consultations; however, few reported using their health literacy skills in consultations with their GPs. GPs noted that older adult involvement in decision-making varied and generally thought that older adults had low health literacy.

CONCLUSION

Older adults reported using health literacy practices in the management of their sometimes-complex medication regimens. However, the role of health literacy in deprescribing decision-making was limited. The mixed methods approach allowed greater insight into older adult and GP practices that influence the acquisition and use of health literacy. [HLRP: Health Literacy Research and Practice. 2023;7(1):e14-e25.] Plain Language Summary: This report explores health literacy in the use of multiple medications and decisions to stop using medication/s in older age. Older adults reported good heath literacy and practiced many health literacy skills in the management of their medications. However, they did not always report the use of their health literacy skills when discussing their medications with their family doctor.

Barriers and facilitators to deprescribing of cardiovascular medications: a systematic review

OBJECTIVE

To synthesise the current knowledge on barriers and facilitators to deprescribing cardiovascular medications (CVMs) at the levels of patients, informal caregivers and healthcare providers (HCPs).

DESIGN/SETTING

We conducted a systematic review of studies exploring/assessing patient, informal caregiver and/or HCP barriers and/or facilitators to deprescribing CVMs.

DATA SOURCES

Ovid/MEDLINE and Embase from January 2003 to November 2021.

DATA EXTRACTION AND SYNTHESIS

We performed a deductive thematic analysis based on the framework of specific barriers and facilitators to deprescribing CVMs created by Goyal et al. We added a quantification of the occurrence of categories and themes in the selected articles to identify the resounding themes that indicate the greater impetus to address in future research.

RESULTS

Most frequent deprescribing barriers for patients, informal caregivers and HCPs included uncertainty due to lack of evidence regarding CVM deprescribing (in n=10 studies), fear of negative consequences following deprescribing (n=13) and social influences (n=14). A frequently reported facilitator to deprescribing, especially for patients and informal caregivers, was the occurrence of adverse drug events (n=7). Another frequently reported facilitator for patients were dislike of CVMs (n=9). Necessity and benefit of CVMs were seen as barriers or facilitators similarly by patients and HCPs.

CONCLUSION

The differences in patient, informal caregiver and HCP regarding barriers and facilitators to deprescribing CVMs stress the need for ground discussions about beliefs and preferences of each stakeholder implicated in deprescribing decisions. Furthermore, HCP uncertainty regarding CVM deprescribing highlights the need to provide HCPs with tools that enable sharing the risks and benefits of deprescribing with patients and ensure a safe deprescribing process.

PROSPERO REGISTRATION NUMBER

CRD42020221973.

Patient and Family Participation in Medication Decisions on Discharge to Hospice Care

Background: High-quality hospice care is characterized by patient-centered care and shared decision making between patients, families, and health care workers. However, little is known regarding the frequency and characteristics of patient and family participation in medication decisions on transition to hospice care. Objective: To quantify the frequency and characteristics of patient and/or family participation in medication decisions. Subjects: Adult (age ≥18 years) patients discharged from Oregon Health & Science University Hospital (OHSU) to hospice care between January 1, 2010 and December 31, 2016. Design: Cross-sectional study. Measures: The primary outcome was documented patient and/or family participation. Patient or family participation was defined as documentation of patient or family member discussion surrounding medication decisions in the discharge summary. We used logistic regression to identify patient and admission characteristics associated with documentation of patient or family member participation in medication decisions. Results: Among 348 eligible patients, patient and/or family participation was documented in 22% of discharges to hospice care. Higher Charlson comorbidity index (adjusted odds ratio [aOR]: 1.09, 95% confidence interval [CI]: 1.01-1.17) and having a diagnosis of cancer (aOR: 1.99, 95% CI: 1.16-3.43) were associated with an increased documentation of patient or family member participation in medication decisions. Patients admitted to the intensive care unit were less likely to have patient/family member participation (aOR: 0.55, 95% CI: 0.32-0.94). Having a specialty palliative care consultation was not significantly associated with patient or family member participation in medication decisions (aOR: 0.77, 95% CI: 0.40-1.48). Conclusions: Patient or family participation in medication decisions was documented for only 22% patients on discharge to hospice care. Opportunities to improve participation likely include increasing knowledge and capacity regarding primary palliative care for all clinicians and implementation of specialized interventions for patients and families transitioning to hospice care from acute care settings.

Beliefs and attitudes of residents, family members and healthcare professionals regarding deprescribing in long-term care: a qualitative study

BACKGROUND

Polypharmacy is prevalent among long-term care (LTC) residents and can cause significant morbidity. In 2018, we concluded a deprescribing pilot study that reduced potentially inappropriate medication use among LTC residents.

AIM

We sought to understand the experience and views of physicians, nurses, pharmacists, LTC residents and family members who participated in the pilot study.

METHOD

Qualitative semi-structured interviews were conducted with residents and families, a physician, pharmacist and pharmacy student, and licensed-practical nurses. Interviews were audio recorded, transcribed, and analyzed using an inductive thematic analysis approach.

RESULTS

Interviews with 13 participants yielded themes in 3 categories: (1) views about medication use in LTC and willingness to engage in deprescribing, (2) perceived barriers and enablers for deprescribing, and (3) impact of participating in deprescribing study. Participants were willing to engage in deprescribing; residents were motivated by physician suggestions, and family members prioritized quality of life in decision-making and wanted to be part of the decision-making process. Solutions to overcome barriers included assigning responsibility to identify deprescribing opportunities to pharmacists, scheduling rounds to enable face-to-face team discussions, and consulting families to provide missing medical history to inform deprescribing decisions. Participating in a deprescribing intervention resulted in improved healthcare professional (HCP) confidence and interprofessional collaboration, and caused continued practice change after the study.

CONCLUSION

Residents, families, and HCPs are concerned about problems associated with polypharmacy in LTC and are willing to consider deprescribing. Barriers to deprescribing in LTC exist but are not insurmountable. Results provide valuable insight into strategies to optimize deprescribing interventions within LTC.

Patient and Physician Perspectives of Deprescribing Potentially Inappropriate Medications in Older Adults with a History of Falls: a Qualitative Study

BACKGROUND

High-risk medications pose serious safety risks to older adults, including increasing the risk of falls. Deprescribing potentially inappropriate medications (PIMs) in older adults who have experienced a fall is a key element of fall reduction strategies. However, continued use of PIMs in older adults is common, and clinicians may face substantial deprescribing barriers.

OBJECTIVE

Explore patient and clinician experiences with and perceptions of deprescribing PIMs in patients with a history of falls.

DESIGN

We led guided patient feedback sessions to explore deprescribing scenarios with patient stakeholders and conducted semi-structured interviews with primary care physicians (PCPs) to explore knowledge and awareness of fall risk guidelines, deprescribing experiences, and barriers and facilitators to deprescribing.

PARTICIPANTS

PCPs from Kaiser Permanente Southern California (KPSC) and patient members of the KPSC Regional Patient Advisory Committee.

APPROACH

We used maximum variation sampling to identify PCPs with patients who had a fall, then categorized the resulting PIM dispense distribution for those patients into high and low frequency. We analyzed the data using a hybrid deductive-inductive approach. Coders applied initial deductively derived codes to the data, simultaneously using an open-code inductive approach to capture emergent themes.

KEY RESULTS

Physicians perceived deprescribing discussions as potentially contentious, even among patients with falls. Physicians reported varying comfort levels with deprescribing strategies: some felt that the conversations might be better suited to others (e.g., pharmacists), while others had well-planned negotiation strategies. Patients reported lack of clarity as to the reasons and goals of deprescribing and poor understanding of the seriousness of falls.

CONCLUSIONS

Our study suggests that key barriers to deprescribing include PCP trepidation about raising a contentious topic and insufficient patient awareness of the potential seriousness of falls. Findings suggest the need for multifaceted, multilevel deprescribing approaches with clinician training strategies, patient educational resources, and a focus on building trusting patient-clinician relationships.

Practices and pitfalls in medication adherence in hemodialysis settings - a focus-group study of health care professionals

BACKGROUND

Medication nonadherence is common among patients with hemodialysis, leading to poorer patient outcomes. Health care professionals have an important role in assessing risk of nonadherence and intervening to support adherence. The aim of this study was to explore physicians' and nurses' current medication adherence practices in hemodialysis settings.

METHOD

A generic qualitative design with inductive content analysis and focus group methodology. Focus groups with health care professionals were conducted in four Nephrology Centers, representing three different regions of Denmark. An interview guide was developed in collaboration with 3 patient representatives.

RESULTS

Six focus group interviews involving a total of forty-two health care professionals were conducted. Five main categories were identified; Laboratory tests are the "gold standard" for assessing adherence, suggesting that abnormal results motivated investigation of adherence, Varying practices for supporting adherence, alluding to the impact of individual clinician priority and preference on choice of adherence interventions, Unclear allocation of roles and responsibility, specifically referring to uncertainty in the delegation of roles between physicians and nurses, Navigating time and resource limitations, intimating the resources needed to support medication adherence and Suggestions for future strategies.

CONCLUSIONS

We suggest implementing systematic use of validated patient-reported outcome measures for assessing adherence and deprescribing tools to support adherence, as these instruments might identify the patients who are in most need of support and promote patient adherence to their prescribed medications. The findings also point to a need for interdisciplinary clarification of roles and responsibilities regarding medication adherence, with the aim of building a strong collaborative partnership between professions.

General practitioners' compliance with benzodiazepine discontinuation guidelines in patients treated with long-term lorazepam: A case-vignette cross-sectional survey

AIM

To study determinants associated with GPs' compliance with benzodiazepine discontinuation guidelines through a case-vignette of a patient with multimorbidity treated with long-term lorazepam for insomnia.

METHODS

This cross-sectional survey was performed in a sample of French GPs. The questionnaire included items on their characteristics and questions related to the management of a case-vignette with long-term lorazepam use consulting for a prescription renewal. GPs who proposed a dedicated consultation to discuss discontinuation or progressive discontinuation were considered as "following guidelines", while they were considered as "out-of-guidelines" if they proposed immediate discontinuation or decided not to discontinue lorazepam. A backward selection process was used to select factors to be included in the final logistic regression model. The probabilities of out-of-guidelines practice and their 95% confidence interval (95% CI) were then plotted using a heatmap graph.

RESULTS

Of 1,177 GPs, the majority (92.2%) were aware of the necessity to discontinue lorazepam and reported practice consistent with good practice guidelines. Women GPs aged under 50 years had the lowest estimated probability of out-of-guidelines practice. Conversely, men aged over 58 years with high consideration of patient preferences and low concern about the benefit-risk ratio of lorazepam had the highest probability of out-of-guidelines practice (27.3% [18.7%; 34.7%]).

CONCLUSION

GPs largely reported practice compliant with benzodiazepine discontinuation guidelines, although some GPs, mainly older men who overemphasise patient preferences, were more likely to adopt out-of-guidelines practice.

Older Patients' Perceptions of Medicines and Willingness to Deprescribe

Introduction Major barriers in deprescribing are the ambivalence of patients, resistance to change, and poor acceptance of alternative treatments. Objective To investigate older patients' beliefs, understanding and knowledge, satisfaction with medicine use, health outcome priorities, their attitude toward deprescribing, and to identify associated patient factors. Methods This multi-center cross-sectional, semistructured survey study involved older outpatients (70 years of age and older) with polypharmacy. The survey comprised three validated questionnaires: Beliefs about Medicines Questionnaire, Patients' Attitudes Towards Deprescribing questionnaire, and the Health Outcome Prioritization tool, with additional questions about understanding and satisfaction. The association between questionnaire outcomes and patient characteristics was investigated. Results Fifty participants were included; they used an average of 9 (+/- SD 2.7) medicines. For most participants (82%), the necessity of using medicines outweighed their concerns. Participants could name 35% of their medicines and 43% of the indications. Overall, 76% were satisfied with the effect of their medicines, but 94% would be willing to stop their medication if advised by their doctor. Maintaining independence (46%) and reducing pain (31%) were the most important health outcome priorities reported by the patients; staying alive had the lowest priority (51%). Participants with higher levels of educational attainment had better knowledge and had more concerns about harmful effects. Conclusions Patients are open to deprescribing but would probably not initiate the conversation themselves because they are generally very satisfied with their medicines. Knowledge about their medicines and their indications is poor. If doctors initiate deprescribing, patients are probably willing to follow their advice. Patients' life priorities should be discussed in deprescribing conversations.

Deprescribing in Hospice Patients: Discontinuing Aspirin, Multivitamins, and Statins

Objective

To facilitate deprescribing of aspirin, multivitamins, and statins in hospice patients enrolled in Mayo Clinic Hospice, Rochester, Minnesota.

Patients and Methods

During the fall of 2019, we conducted a quality improvement project to improve care of Mayo Clinic Hospice patients by decreasing the percentage of patients taking aspirin, multivitamins, or statins. Project interventions included the addition of a palliative medicine fellow to the hospice interdisciplinary team, nurse education, and implementation of an evidence-based deprescribing resource tool. The resource tool included a communication framework to guide deprescribing conversations and a literature summary supporting deprescribing. The project team recorded the number of patients taking 1 of these medications by intermittently surveying the hospice census. Process and counterbalance measures were tracked with online surveys of hospice nursing staff.

Results

At the start of the project, 22 of 69 patients (32%) were taking aspirin, a multivitamin, or a statin. After introduction of the deprescribing resource tool and the addition of a palliative medicine fellow to the interdisciplinary team, this was reduced to 20 of 83 patients (24%), a 24% decrease. Results appeared to be driven primarily by a reduction in multivitamin use (33% decrease). Self-reported comfort and knowledge about deprescribing improved among the hospice nursing staff, as did satisfaction in their workflow from 5.4 to 6.0 (maximum, 7).

Conclusion

The addition of a dedicated team member to address medication issues and provision of an evidence-based deprescribing resource tool appear to reduce the use of unnecessary and potentially harmful medications in ambulatory hospice patients.

Medication review and reconciliation in older adults

Older people are frequently exposed to polypharmacy, inappropriate prescribing, and adverse drug events. Two clinical processes can help geriatricians to optimize and increase the safety of drug prescriptions for older adults: medication reconciliation and medication review. Medication reconciliation provides the best possible medication history and identifies and resolves discrepancies in drug prescriptions. During the medication review, the best possible medication history is crosschecked against other data, including morbidities, patient's preferences, or geriatric syndromes, to produce a personalized medication strategy. Alignment of treatment recommendations with patient preferences and goals through shared decision-making is particularly important in medication review. Medication reconciliation and medication review have proven to be effective, but their broad implementation remains difficult. Indeed, these procedures are time-consuming and require specific skills, coordination between different healthcare professionals, organizations and dedicated means. The involvement of geriatricians therefore remains essential for the successful implementation of medication reconciliation and medication review in geriatric settings and among frail older people.

The Effect of a Comprehensive, Interdisciplinary Medication Review on Quality of Life and Medication Use in Community Dwelling Older People with Polypharmacy

Background: We conducted a comprehensive medication review at the patients’ home, using data from electronic patient records, and with input from relevant specialists, general practitioners and pharmacists formulated and implemented recommendations to optimize medication use in patients aged 60+ years with polypharmacy. We evaluated the effect of this medication review on quality of life (QoL) and medication use. Methods: Cluster randomized controlled trial (stepped wedge), randomly assigning general practices to one of three consecutive steps. Patients received usual care until the intervention was implemented. Primary outcome was QoL (SF-36 and EQ-5D); secondary outcomes were medication changes, medication adherence and (instrumental) activities of daily living (ADL, iADL) which were measured at baseline, and around 6- and 12-months post intervention. Results: Twenty-four general practices included 360 women and 410 men with an average age of 75 years (SD 7.5). A positive effect on SF-36 mental health (estimated mean was stable in the intervention, but decreased in the control condition with −6.1, p = 0.009,) was found with a reduced number of medications at follow-up compared to the control condition. No significant effects were found on other QoL subscales, ADL, iADL or medication adherence. Conclusion: The medication review prevented decrease of mental health (SF36), with no significant effects on other outcome measures, apart from a reduction in the number of prescribed medications.

Polypharmacy Management in Older Patients

Medications to treat disease and extend life in our patients often amass in quantities, resulting in what has been termed "polypharmacy." This imprecise label usually describes the accumulation of 5, and often more, medications. Polypharmacy in advancing age frequently results in drug therapy problems related to interactions, drug toxicity, falls with injury, delirium, and nonadherence. Polypharmacy is associated with resulting increased hospitalizations and higher costs of care for individuals and health care systems. To reduce polypharmacy, we delineate a systematic, consultative approach to identify highest-risk medications and drug-therapy problems. We address strategic reductions (deprescribing) of medications in palliative care, long-term care, and ambulatory older adults. Best practices for reducing opioids, benzodiazepines, and other high-risk medications include education about risk and agreement by patients and their families, advocates, and care teams. Addressing deprescribing should be within the framework of patients' health status as their care and goals transition from longevity to a plan of maintaining alertness, comfort, and satisfaction of quality of life. A team approach to address polypharmacy and avoidance of high-risk therapy is optimal within long-term care. Patients with terminal illnesses or those moving toward a comfort-care emphasis benefit from medication adjustments that are recognized beneficially within each patient's care goals. In caring for older adults, the acknowledgement that complicated regimens and high-risk medications requires a care plan to reduce or prevent medication-related problems and costs that are associated with polypharmacy.

Attitudes toward deprescribing in a middle-aged health disparities population

BACKGROUND

Patients' attitudes toward deprescribing are crucial to understand before developing interventions, but no such data exists in the medically underserved, health disparities population of rural Appalachian United States.

OBJECTIVE(S)

Assess Appalachian women's openness to deprescribing medications and determine if polypharmacy influenced their attitudes toward deprescribing.

METHODS

Before and after a cognitive behavioral therapy intervention, middle-aged Appalachian women self-reported medication use and completed the revised Patients' Attitudes Toward Deprescribing Questionnaire (rPATD). Responses were described, stratified by presence of polypharmacy.

RESULTS

30 women completed the rPATD pre- and post-intervention (mean [SD] age 55.8 [6.6] years; 96.7% white). Those with polypharmacy (n = 16) had higher burden and involvement scores (median 2.8 vs 2.0, p = 0.01; 4.9 vs 4.6, p = 0.06), and lower appropriateness scores (3.4 vs 3.9, p = 0.04). Burden, concerns about stopping, and involvement factor scores were similar before and after the intervention (p = 0.08, 0.86, and 0.41 respectively). ≥90% of participants were satisfied with their current medications yet would be willing to stop one or more.

CONCLUSIONS

Middle-aged women in rural Appalachian United States are open to deprescribing; polypharmacy is associated with lower belief in the appropriateness of medications. Larger studies are needed to inform future deprescribing interventions for this and other similarly disadvantaged populations.

Medication use in the last year of life: a cross-sectional hospice study

OBJECTIVES

The issue of polypharmacy and medication use in people with life limiting illness raises important questions from a clinical and ethical viewpoint. The objectives of our study were to (1) explore medication use among people with life limiting illness receiving hospice care; (2) apply consensus criteria to assess medication appropriateness; and (3) determine the overall pill burden in this patient population.

METHODS

Six hospices in the North East of England were included. All deceased adult patients who received hospice care in 2018 were eligible for study inclusion. Descriptive statistics were used to report medication details; while medication appropriateness was assessed according to consensus criteria developed by Morin and colleagues.

RESULTS

Six hundred and ninety patients were included in the study. Patients were using a mean number of 8.8 medications per day, while polypharmacy was evident in 80% of patients. In terms of potentially questionable medication, patients were prescribed a mean number of 1.3 per day. Common potentially questionable medications included vitamin and mineral supplements, antihypertensives, antiplatelets, lipid regulating agents and anticoagulants. The pill burden in this population was also high with, on average, people using 13.7 oral doses per day.

CONCLUSIONS

Polypharmacy is common in patients accessing hospice care, as is the use of potentially questionable medication. The pill burden in this patient population is also high, which may be an additional treatment burden to patients. Holistic deprescribing approaches for this population should be developed and implemented.

[Use and management of proton pump inhibitors: An observational study]

INTRODUCTION

Proton pump inhibitors (PPIs) have improved the management and prevention of digestive diseases, leading to a heavy prescription of this therapy. In 2015, nearly one quarter of the French population had consumed a PPI and half of them were long-term users. The main objective of this study was to analyze, in patients hospitalized in several medical departments, the adequacy of long-term PPI prescriptions to recommendations.

METHOD

The Use and management of proton pump inhibitors: an observational study project (UTOPPIA) is a longitudinal observational study conducted at the University Hospital of Saint-Étienne in the departments of hepato-gastroenterology, infectious and tropical diseases, internal medicine, vascular medicine and nephrology. All patients with PPI treatment on their usual outpatient prescription were interviewed.

RESULTS

Over a 3-month period, 334 of hospitalized patients (30.7%) had received a long-term PPI prescription and 181 patients (54.2%) could be included in the study for a total of 274 indications. Ninety-nine patients (54.7%) had a long-term PPI prescription in accordance with the recommendations. The most frequent indication (70 prescriptions) was the prescription of an antiplatelet drug or anticoagulant for subjects at high risk of bleeding in 70 prescriptions. Fifty-three PPI treatments were amended during the hospital stay, including 9 discontinuations. The justification for the change was documented in the patients' chart in only 17% of cases. Individual interviews of patients revealed that 75.1% of them were in favour of discontinuing their PPI treatment.

CONCLUSIONS

About one-third of hospitalized patients in medical wards in France have long-term PPI treatment and half of these prescriptions do not comply with good practice recommendations. A majority of patients report being willing to try to stop PPI therapy.

One-Year Evaluation of a Targeted Medication Therapy Management Intervention for Older Adults

BACKGROUND

Older adults are especially susceptible to adverse effects of inappropriate medication therapy, and anticholinergic medications are common culprits for cognitive dysfunction due to their action on the central nervous system. Medication therapy management (MTM) interventions can aid in deprescribing and reducing inappropriate medication use in older adults. However, there is sparse literature on the long-term sustainability of these interventions.

OBJECTIVES

To (a) investigate whether the deprescribing of anticholinergic medications during an 8-week randomized controlled trial (RCT) of a targeted MTM intervention is sustained at 1-year postintervention follow-up and (b) compare anticholinergic utilization trends in the study population with a large sample of similar individuals not exposed to the intervention.

METHODS

Participants in the targeted MTM (tMTM) RCT had normal cognition or mild cognitive impairment and were recruited from enrollees in a longitudinal study at the University of Kentucky Alzheimer's Disease Center (ADC) and thus have pertinent medical information gathered approximately annually. In this posttrial observational follow-up, sustainability of the anticholinergic deprescribing intervention was assessed in participants in the RCT, and anticholinergic medication use trends were described from the RCT baseline (which occurred immediately following an ADC visit) to the next annual visit in all participants. Mean change in anticholinergic burden from RCT baseline to the next annual visit was estimated using analysis of covariance, and participants were compared with 2 external samples. Anticholinergic burden was measured using the Anticholinergic Drug Scale (ADS). The odds of decreasing baseline anticholinergic burden and number of total and strong anticholinergic medications at the follow-up study time point was assessed using logistic regression.

RESULTS

Of the deprescribing changes made during the initial RCT, 50% were sustained after 1 year. Participants in the tMTM trial reported decreases in the use of anticholinergic antihistamines and bladder agents (-6.5 and -4.4%, respectively), but there was no change in the use of anticholinergic agents targeted at the central nervous system. While the anticholinergic burden of RCT participants decreased over 1 year (adjusted mean ADS change [95% CI] = -0.33 [-0.72, 0.07]), it was not different than the change observed in 2 external samples at the trial center (-0.20 [-0.42, 0.02]) and nationally (-0.33 [-0.39, -0.26]). There were no statistically significant differences between trial participants and external samples in the odds of decreasing anticholinergic burden nor in decreasing the number of total, or strongly anticholinergic, medications at the 1-year follow-up.

CONCLUSIONS

This study demonstrates that the sustainability of deprescribing is limited to the period of intervention, rather than affording lasting effects even over periods as short as 1 year, which was demonstrated not only in the small group of RCT participants but also by comparison with external groups. Future work should extend the duration of intervention and follow-up periods for MTM interventions to allow further insights regarding the sustainability of deprescribing efforts in older adults.

DISCLOSURES

The original trial was supported by a pilot study award from the University of Kentucky Center for Clinical and Translational Sciences (UL1TR000117). Additional support for this study was provided by the National Institutes of Health/National Institute on Aging (R01 AG054130). Jicha reports contract research for Esai, Biohaven, Alltech, Suven, Novartis, and Lilly. The other authors have nothing to disclose.

Methods to Assess Patient Preferences in Old Age Pharmacotherapy - A Systematic Review

PURPOSE

The aim of this systematic review was to identify methods used to assess medication preferences in older adults and evaluate their advantages and disadvantages with respect to their applicability to the context of multimorbidity and polypharmacy.

MATERIAL AND METHODS

Three electronic databases (PubMed, Web of Science, PsycINFO) were searched. Eligible studies elicited individual treatment or outcome preferences in a context that involved long-term pharmacological treatment options. We included studies with a study population aged ≥ 65 years and/or with a mean or median age of ≥ 75 years. Qualitative studies, studies assessing preferences for only two different treatments, and studies targeting preferences for life-sustaining treatments were excluded. The identified preference measurement methods were evaluated based on four criteria (time budget, cognitive demand, variety of pharmacological aspects, and link with treatment strategies) judged to be relevant for the elicitation of patient preferences in polypharmacy.

RESULTS

Sixty articles met the eligibility criteria and were included in the narrative synthesis. Fifty-five different instruments to assess patient preferences, based on 24 different elicitation methods, were identified. The most commonly applied preference measurement techniques were "medication willingness" (description of a specific medication with inquiry of the participant's willingness to take it), discrete choice experiments, Likert scale-based questionnaires, and rank prioritization. The majority of the instruments were created for disease-specific or context-specific settings. Only three instruments (Outcome Prioritization Tool, a complex intervention, "MediMol" questionnaire) dealt with the broader issue of geriatric multimorbidity. Only seven of the identified tools showed somewhat favorable characteristics for a potential use of the respective method in the context of polypharmacy.

CONCLUSION

Up to now, few instruments have been specifically designed for the assessment of medication preferences in older patients with multimorbidity. To facilitate valid preference elicitation in the context of geriatric polypharmacy, future research should focus on suitable characteristics of existing techniques to develop new measurement approaches for this increasingly relevant population.

Patient Perceptions of Diabetes Guideline Frameworks for Individualizing Glycemic Targets

IMPORTANCE

Diabetes guidelines recommend considering specific factors, such as diabetes duration and life expectancy, to individualize treatment in older adults. These individualized glycemic targets inform decisions on whether to intensify or deintensify medication treatment plans. How older adults with diabetes perceive these factors used to individualize glycemic targets is unknown.

OBJECTIVES

To examine how older adults perceive factors used in diabetes guidelines for individualizing glycemic targets.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional national survey was conducted from December 13, 2018, to January 3, 2019, of a nationally representative, probability-based online survey panel (KnowledgePanel). A total of 1364 KnowledgePanel members who were 65 years or older and had type 2 diabetes were invited to participate in the survey; 836 (61.3%) responded, and 818 (60.0%) completed the survey.

MAIN OUTCOMES AND MEASURES

The study randomized participants to 2 vignettes: one about adding and the other about removing diabetes medications from treatment plans. Participants rated the importance of 7 factors (diabetes duration, established diabetes complications, other health conditions, life expectancy, risk of adverse effects, cost, and treatment effort) in these treatment decisions using binary (yes/no) responses and the best-worst scaling method to quantify the factors' relative importance. All participants then answered questions on how different levels of each factor were associated with aggressiveness of diabetes treatment.

RESULTS

The sample included 818 participants (mean [SD] age, 74.0 [6.8] years; 469 [53.7%] male; and 668 [67.7%] white). A total of 410 participants answered questions about adding medicine, whereas 408 participants answered questions about stopping medicine. Of the 7 factors to consider for adding a diabetes medication to the treatment plan, the number who deemed each factor important ranged from 197 (45.6%) to 263 (62.8%). In contrast, these same factors were considered important by only 29 (8.4%) to 146 (37.7%) of participants when deciding to stop use of a diabetes medication. In both decisions, participants perceived the risk of adverse effects as the most important factor (relative importance was 22.8 for adding a medicine and 25.0 for stopping a medicine on a ratio scale in which, for each decision, the relative importance of the 7 factors adds up to 100, with 0 indicating complete indifference and 100 complete priority). In contrast to current guideline recommendations, most participants believed that patients with longer disease duration (498 [60.1%]), more established complications (632 [75.6%]), and greater number of other health conditions (545 [67.5%]) should receive more aggressive diabetes treatment.

CONCLUSIONS AND RELEVANCE

Many older adults do not place high importance on factors recommended by guidelines to individualize diabetes treatment, especially when deciding to stop use of diabetes medications. Moreover, when considering treatment aggressiveness, many older adults weighted several factors in the opposite direction than suggested by the guidelines. Individualizing diabetes care in older adults will require effective communication regarding the benefits and consequences of making changes to treatment plans.

Deprescribing as a Clinical Improvement Focus

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.

How many older adults receive drugs of questionable clinical benefit near the end of life? A cohort study

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.

Decision-Making Preferences and Deprescribing: Perspectives of Older Adults and Companions About Their Medicines

Objectives

Polypharmacy in the older population is increasing-and can be harmful. It can be safe to reduce or carefully cease medicines (deprescribing) but a collaborative approach between patient and doctor is required. This study explores decision-making about polypharmacy with older adults and their companions.

Method

Semi-structured interviews were conducted with 30 older people (aged 75+ years, taking multiple medicines) and 15 companions. Framework analysis was used to identify qualitative themes.

Results

Participants varied considerably in attitudes towards medicines, preferences for involvement in decision-making, and openness to deprescribing. Three types were identified. Type 1 held positive attitudes towards medicines, and preferred to leave decisions to their doctor. Type 2 voiced ambivalent attitudes towards medicines, preferred a proactive role, and were open to deprescribing. Type 3 were frail, perceived they lacked knowledge about medicines, and deferred most decisions to their doctor or companion.

Discussion

This study provides a novel typology to describe differences between older people who are happy to take multiple medicines, and those who are open to deprescribing. To enable shared decision-making, prescribers need to adapt their communication about polypharmacy based on their patients' attitudes to medicines and preferences for involvement in decisions.

Attitudes towards deprescribing and the influence of health literacy among older Australians

Aim

This study aimed to explore attitudes, beliefs and experiences regarding polypharmacy and discontinuing medications, or deprescribing, among community living older adults aged ≥65 years, using ≥5 medications. It also aimed to investigate if health literacy capabilities influenced attitudes and beliefs towards deprescribing.

Background

Polypharmacy use is common among Australian older adults. However, little is known about their attitudes towards polypharmacy use or towards stopping medications. Previous studies indicate that health literacy levels tend to be lower in older adults, resulting in poor knowledge about medications.

Methods

A self-administered survey was conducted using two previously validated tools; the Patients’ Attitude Towards Deprescribing (PATD) tool to measure attitudes towards polypharmacy use and deprescribing and the All Aspects of Health Literacy Scale (AAHLS) to measure functional, communicative and critical health literacy. Descriptive statistical analysis was conducted.

Findings

The 137 responses showed that 80% thought all their medications were necessary and were comfortable with the number taken. Wanting to reduce the number of medications taken was associated with concerns about the amount taken (P<0.001), experiencing side effects (P<0.001), or believing that one or more medications were no longer needed (P<0.000). Those who were using ten or more medications were more likely to want to reduce the number taken (P=0.019). Most (88%) respondents would be willing to stop medication/s in the context of receiving this advice from their doctor. Willingness to consider stopping correlated with higher scores on the critical health literacy subscale (P<0.021) and overall AAHLS score (P<0.009). Those with higher scores on the overall AAHLS measure were more likely to report that they understood why their medications were prescribed (P<0.000) and were more likely to participate in decision-making (P=0.027). Opportunities to proactively consider deprescribing may be missed, as one third of the respondents could not recall a recent review of their medications.

Deprescribing in the context of multiple providers: understanding patient preferences

OBJECTIVES

Deprescribing could reduce the risk of harm from inappropriate medications. We characterized patients' acceptance of deprescribing recommendations from pharmacists, primary care providers (PCPs), and specialists relative to the original prescriber's professional background.

STUDY DESIGN

Secondary analysis of national Patient Perceptions of Discontinuation survey responses from Veterans Affairs (VA) primary care patients with 5 or more prescriptions.

METHODS

We created 4 relative deprescribing authority (RDA) outcome groups from responses to 2 yes/no (Y/N) items: (1) "Imagine…a specialist…prescribed a medicine. Would you be comfortable if your PCP told you to stop...it?" and (2) "Imagine…your VA PCP prescribed a medicine. Would you be comfortable if a VA clinical pharmacist [Pharm] told you to stop…it?" Multinomial regression associated patient factors with RDA.

RESULTS

Respondents (n = 803; adjusted response rate, 52%) were predominantly men (85%) and older than 65 years (60%). A total of 281 (38%) respondents said no to both questions (PCP-N/Pharm-N) and 146 (20%) said yes to both (PCP-Y/Pharm-Y). A total of 155 (21%) said no to a PCP stopping a specialist's medicine but yes to a pharmacist stopping a PCP's (PCP-N/Pharm-Y). A total of 153 (21%) said that a PCP could stop a specialist's medication but a pharmacist could not stop a PCP's (PCP-Y/Pharm-N). In adjusted models (reference, PCP-N/Pharm-N), those with greater medication concerns were more likely to respond PCP-Y/Pharm-Y (odds ratio [OR], 1.45; 95% CI, 1.09-1.92). Those with more interest in shared decision making were more likely to respond PCP-N/Pharm-Y (OR, 1.41; 95% CI, 1.04-1.92). Those with greater trust in their PCP were less likely to respond PCP-N/Pharm-Y (OR, 0.52; 95% CI, 0.34-0.81) but more likely to respond PCP-Y/Pharm-N (OR, 2.16; 95% CI, 1.31-3.56) or PCP-Y/Pharm-Y (OR, 1.83; 95% CI, 1.13-2.98).

CONCLUSIONS

Understanding patient preferences of RDA can facilitate effective design and implementation of deprescribing interventions.

A patient-centered deprescribing intervention for hospitalized older patients with polypharmacy: rationale and design of the Shed-MEDS randomized controlled trial

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.

Willingness to Change Medications Linked to Increased Fall Risk: A Comparison between Age Groups

OBJECTIVE

To describe and compare two age groups' knowledge of medications linked to falls and willingness to change these medications to reduce their fall risk.

METHOD

We analyzed data from community-dwelling adults age 55 and older (n = 1812): 855 adults aged 55 to 64 years and 957 older adults (65 and older) who participated in the 2016 summer wave of the ConsumerStyles survey, an annual Web-based survey. The data are weighted to match the US Current Population Survey proportions on nine US Census Bureau demographic characteristics.

MEASUREMENTS

Survey respondents were asked about medication use, knowledge of side effects, their willingness to change their medications to reduce fall risk, communication in the previous year about fall risk with their healthcare provider, and their comfort in discussing fall risk with their healthcare provider. All data were weighted to match the 2016 population estimates. Descriptive statistics and χ² (p ≤ .05) were used to identify differences between the two age groups.

RESULTS

About one-fifth of all respondents reported using at least one class of medication that increases fall risk. Older adults were less likely to report using medications for mood or sadness, less likely to report knowing the side effects of pain medications, and more willing to change their sleep medications compared with their younger counterparts. Among all respondents using these medication classes, less than one-third knew the potential fall-related side effects. However, most of them expressed willingness to change their medication if advised by their healthcare provider.

CONCLUSION

Most older adults were unaware of potential fall risks associated with medications prescribed to address pain, difficulty sleeping, mood or sadness, and anxiety- or nervousness-related health issues. However, most were willing to change their medication if recommended by a healthcare provider. J Am Geriatr Soc 67:527-533, 2019.

The deprescribing rainbow: a conceptual framework highlighting the importance of patient context when stopping medication in older people

The area of "deprescribing" has rapidly expanded in recent years as a positive intervention to reduce inappropriate polypharmacy and improve health outcomes for (older) people with multimorbidity. While our understanding of deprescribing as a process has greatly improved and existing approaches all have patient-centered elements, there is still limited literature exploring the importance of the individual patient context in deprescribing decision-making. This is clearly an important consideration to ensure that any deprescribing approach is ethical, respectful, and successful. To address this gap in the literature, we have developed a conceptual framework in the form of a rainbow - with five different deprescribing determinants - and place the person at the center of the deprescribing process. This framework is informed by literature on patient-centered care for older people and people with multimorbidity. We illustrate the potential application of this framework to a complex patient case to highlight the importance of the different clinical, psychological, social, financial and physical deprescribing determinants, and how this approach could be adopted by those working in clinical practice.

Missed opportunities: unnecessary medicine use in patients with lung cancer at the end of life - an international cohort study

AIMS

The aims of the current study were: (i) to examine the prescribing of preventative medication in a cohort of people with advanced lung cancer on hospital admission and discharge across different healthcare systems; and (ii) to explore the factors that influence preventative medication prescribing at hospital discharge.

METHODS

A retrospective cohort study was conducted across two centres in the UK and the US. The prescribing of preventative medication was examined at hospital admission and discharge for patients who died of lung cancer. A zero-inflated negative binomial regression model was used to examine the association between preventative medications at discharge and patient- and hospital-based factors. The classes of preventative medication prescribed included were: vitamins and minerals, and antidiabetic, antihypertensive, antihyperlipidaemic and antiplatelet medications.

RESULTS

In the UK site (n = 125), the mean number of preventative medications prescribed was 1.9 [standard deviation (SD) 1.7) on admission, and 1.7 (SD 1.7) on discharge, and in the US site (n = 191) the mean was 2.6 (SD 2.2) on admission and 1.9 (SD 2.2) on discharge. The model found a significant association between the number of preventative drugs prescribed on admission and the number on discharge; it also found a significant association between the total number of drugs prescribed on discharge and the number of preventative medications on discharge. Other indicators related to patient and hospital factors were not significantly associated with the number of preventative medications supplied on discharge.

CONCLUSIONS

The use of preventative medication was common in lung cancer patients, despite undergoing discharge. Patient- and hospital-based factors did not influence the prescribing of preventative medication.

Clinical Intentions of Antibiotics Prescribed Upon Discharge to Hospice Care

OBJECTIVES

To better understand the clinical intentions for antibiotic prescribing upon discharge from acute care to hospice care.

DESIGN

Retrospective cohort study.

SETTING

Five hundred forty-four-bed academic, acute-care, tertiary referral hospital in Portland, Oregon.

PARTICIPANTS

Adults (≥18) who received an outpatient prescription for antibiotics on discharge from an acute care hospital to hospice care between January 1, 2009 and December 31, 2011 (N = 149).

MEASUREMENTS

We determined whether antibiotics were indicated for treatment of an active infection, palliative treatment, prophylaxis, or prescribed according to family or participant preference.

RESULTS

Antibiotics were prescribed to 17.6% (n = 149) of individuals discharged to hospice care over the 3-year study period. Antibiotics were most frequently prescribed for pneumonia (19.5%), urinary tract infections (18.9%), and gastrointestinal tract infections (17.0%). The explicit rationale for antibiotic prescription was documented for only 72 prescriptions (45.3%). For 84 (52.8%) participants, antibiotics were used to treat an active infection in the hospital. Of prescriptions with a documented rationale, 37.5% indicated that the intent was curative, 26.4% prophylaxis, and 22.2% to suppress an infection. For 19.4% of prescriptions, participants or their family members specifically wanted to be treated with antibiotics. Only 9.7% of prescriptions specifically indicated that antibiotics were prescribed for palliative reasons.

CONCLUSION

Antibiotics were frequently prescribed for treatment of active infection in individuals discharged to hospice care. Further research is needed to document antibiotic benefits and risks and optimize medication management at the end of life.