Deprescribing in older people

Medicines Regimens Charted for Older People Living in Residential Aged Care: A Repeated Cross-Sectional Study Describing the Number of Medicines, Regimen Complexity, High-Risk Prescribing, and Potential Underprescribing

OBJECTIVE

We aimed to explore medicines regimens charted for older people living in residential aged care facilities (RACFs).

DESIGN

Repeated cross-sectional study using routinely collected data sampled in a cross-sectional manner at 11 time points (day of admission, then at 1, 3, 7, 14, and 30 days, and 3, 6, 12, 18, and 24 months post admission).

SETTING AND PARTICIPANTS

The cohort is set in 34 RACFs managed by a single Australasian provider. People aged ≥65 years admitted to permanent care between January 1, 2017, and October 1, 2021, with medicines charted on the date of admission.

METHODS

Medicines charted were evaluated for potentially suboptimal prescribing including number of medicines, high-risk prescribing (eg, potentially inappropriate medicines, anticholinergic burden), and potential underprescribing.

RESULTS

The 3802 residents in the final cohort had a mean age of 84.9 ± 7.2 years at admission. At least 1 example of suboptimal prescribing was identified in 3479 (92%) residents at admission increasing to 1410 (97%) at 24 months. The number of medicines charted for each resident increased over time from 6.0 ± 3.8 regular and 2.8 ± 2.7 as required medicines at admission to 8.9 ± 4.1 regular and 8.1 ± 3.7 as required medicines at 24 months. Anticholinergic drug burden increased from 1.6 ± 2.4 at admission to 3.0 ± 2.8 at 24 months. Half the residents (2173; 57%) used at least 1 potentially inappropriate medicine at admission, which rose to nearly three-quarters (1060; 73%) at 24 months admission.

CONCLUSION AND IMPLICATIONS

The total number of medicines charted for older adults living in RACFs increases with length of stay, with charted as required medicines nearly tripling. Effective interventions to optimize medicines use in this vulnerable population are required.

Medications and cognitive risk in Aboriginal primary care: a cross-sectional study

BACKGROUND

Aboriginal and Torres Strait Islander people are ageing with high rates of comorbidity, yet little is known about suboptimal prescribing in this population.

AIM

The prevalence of potentially suboptimal prescribing and associated risk factors were investigated among older patients attending primary care through Aboriginal Community Controlled Health Services (ACCHSs).

METHODS

Medical records of 420 systematically selected patients aged ≥50 years attending urban, rural and remote health services were audited. Polypharmacy (≥ 5 prescribed medications), potentially inappropriate medications (PIMs) as per Beers Criteria and anticholinergic burden (ACB) were estimated and associated risk factors were explored with logistic regression.

RESULTS

The prevalence of polypharmacy, PIMs and ACB score ≥3 was 43%, 18% and 12% respectively. In multivariable logistic regression analyses, polypharmacy was less likely in rural (odds ratio (OR) = 0.43, 95% confidence interval (CI) = 0.24-0.77) compared to urban patients, and more likely in those with heart disease (OR = 2.62, 95% CI = 1.62-4.25), atrial fibrillation (OR = 4.25, 95% CI = 1.08-16.81), hypertension (OR = 2.14, 95% CI = 1.34-3.44), diabetes (OR = 2.72, 95% CI = 1.69-4.39) or depression (OR = 1.91, 95% CI = 1.19-3.06). PIMs were more frequent in females (OR = 1.88, 95% CI = 1.03-3.42) and less frequent in rural (OR = 0.41, 95% CI = 0.19-0.85) and remote (OR = 0.58, 95% CI = 0.29-1.18) patients. Factors associated with PIMs were kidney disease (OR = 2.60, 95% CI = 1.37-4.92), urinary incontinence (OR = 3.00, 95% CI = 1.02-8.83), depression (OR = 2.67, 95% CI = 1.50-4.77), heavy alcohol use (OR = 2.83, 95% CI = 1.39-5.75) and subjective cognitive concerns (OR = 2.69, 95% CI = 1.31-5.52). High ACB was less common in rural (OR = 0.10, 95% CI = 0.03-0.34) and remote (OR = 0.51, 95% CI = 0.25-1.04) patients and more common in those with kidney disease (OR = 3.07, 95% CI = 1.50-6.30) or depression (OR = 3.32, 95% CI = 1.70-6.47).

CONCLUSION

Associations between potentially suboptimal prescribing and depression or cognitive concerns highlight the importance of considering medication review and deprescribing for these patients.

Proactive Polypharmacy Management Using Large Language Models: Opportunities to Enhance Geriatric Care

Polypharmacy remains an important challenge for patients with extensive medical complexity. Given the primary care shortage and the increasing aging population, effective polypharmacy management is crucial to manage the increasing burden of care. The capacity of large language model (LLM)-based artificial intelligence to aid in polypharmacy management has yet to be evaluated. Here, we evaluate ChatGPT's performance in polypharmacy management via its deprescribing decisions in standardized clinical vignettes. We inputted several clinical vignettes originally from a study of general practicioners' deprescribing decisions into ChatGPT 3.5, a publicly available LLM, and evaluated its capacity for yes/no binary deprescribing decisions as well as list-based prompts in which the model was prompted to choose which of several medications to deprescribe. We recorded ChatGPT responses to yes/no binary deprescribing prompts and the number and types of medications deprescribed. In yes/no binary deprescribing decisions, ChatGPT universally recommended deprescribing medications regardless of ADL status in patients with no overlying CVD history; in patients with CVD history, ChatGPT's answers varied by technical replicate. Total number of medications deprescribed ranged from 2.67 to 3.67 (out of 7) and did not vary with CVD status, but increased linearly with severity of ADL impairment. Among medication types, ChatGPT preferentially deprescribed pain medications. ChatGPT's deprescribing decisions vary along the axes of ADL status, CVD history, and medication type, indicating some concordance of internal logic between general practitioners and the model. These results indicate that specifically trained LLMs may provide useful clinical support in polypharmacy management for primary care physicians.

Cost-Consequence Analysis of Deprescribing to Optimize Health Outcomes for Frail Older People: A Within-Trial Analysis

OBJECTIVES

The structured, clinically supervised withdrawal of medicines, known as deprescribing, is one strategy to address inappropriate polypharmacy. This study aimed to evaluate the costs and consequences of deprescribing in frail older people living in residential aged care facilities (RACFs) in Australia.

DESIGN

A within-trial cost-consequence analysis of a deprescribing intervention-Opti-Med. The Opti-Med double-blind randomized controlled trial of deprescribing included 3 groups: blinded control, blinded intervention, and an open intervention group.

SETTING AND PARTICIPANTS

Seventeen RACFs in Western Australia and New South Wales. Participants were 303 older people living in participating RACFs from March 2014 to February 2019.

METHODS

Analysis was conducted from the health sector perspective. Health economic outcomes assessed include cost saved from deprescribed medicines and the incremental quality-adjusted life-years. Costs were presented in 2022 Australian dollars.

RESULTS

The total cost of the Opti-Med intervention was $239.13 per participant. The costs saved through deprescribed medicines over 12 months after adjusting for mortality within the trial period was $328.90 per participant in the blinded intervention group and $164.00 per participant in the open intervention group. On average, the cost of the intervention was more than offset by the cost saved from deprescribed medicines. Extrapolating these findings to the Australian population suggests a potential net cost saving of about $1 to $16 million per annum for the health system nationally. The incremental quality-adjusted life-years were very similar across the 3 groups within the trial period.

CONCLUSIONS AND IMPLICATIONS

Deprescribing for frail older people living in RACFs can be a cost-saving intervention without reducing the quality of life. Systemwide implementation of deprescribing across RACFs in Australia has the potential to improve health care delivery through the cost savings, which could be reapplied to further optimize care within RACFs.

Deprescribing in Older Poly-Treated Patients Affected with Dementia

Polypharmacy is an important issue in older patients affected by dementia because they are very vulnerable to the side effects of drugs'. Between October 2021 and September 2022, we randomly assessed 205 old-aged outpatients. The study was carried out in a Center for Dementia in collaboration with a university center. The primary outcomes were: (1) deprescribing inappropriate drugs through the Beers and STOPP&START criteria; (2) assessing duplicate drugs and the risk of iatrogenic damage due to drug-drug and drug-disease interactions. Overall, 69 men and 136 women (mean age 82.7 ± 7.4 years) were assessed. Of these, 91 patients were home care patients and 114 were outpatient. The average number of the drugs used in the sample was 9.4 drugs per patient; after the first visit and the consequent deprescribing process, the average dropped to 8.7 drugs per patient (p = 0.04). Overall, 74 potentially inappropriate drugs were used (36.1%). Of these, long half-life benzodiazepines (8.8%), non-steroidal anti-inflammatory drugs (3.4%), tricyclic antidepressants (3.4%), first-generation antihistamines (1.4%), anticholinergics (11.7%), antiplatelet drugs (i.e., ticlopidine) (1.4%), prokinetics in chronic use (1.4%), digoxin (>0.125 mg/day) (1.4%), antiarrhythmics (i.e., amiodarone) (0.97%), and α-blockers (1.9%) were included. The so-called "duplicate" drugs were overall 26 (12.7%). In total, ten potentially dangerous prescriptions were found for possible interactions (4.8%). We underline the importance of checking all the drugs taken periodically and discontinuing drugs with the lowest benefit-to-harm ratio and the lowest probability of adverse reactions due to withdrawal. Computer tools and adequately trained teams (doctors, nurses, and pharmacists) could identify, treat, and prevent possible drug interactions.

The role of pharmacists in deprescribing benzodiazepines: A scoping review

Background

Polypharmacy can increase the risk of adverse drug events, hospitalisation, and unnecessary healthcare costs. Evidence indicates that discontinuing certain medications, such as benzodiazepines, can improve health outcomes, by resolving adverse drug effects. This scoping review aims to explore the pharmacists' role in deprescribing benzodiazepines.

Method

A scoping review has been conducted to distinguish and map the literature, discover research gaps, and focus on targeted areas for future studies and research. A systematic search strategy was conducted to identify relevant studies from PubMed, Medline, and EMBASE databases. The eligibility criteria involved studies that focused on the role of pharmacists in benzodiazepine deprescribing, quantitative and qualitative studies conducted in humans, full-text articles published in English.

Results

Twenty studies were identified, revealing three themes: 1) pharmacists' involvement in benzodiazepine deprescribing, 2) the impact of their involvement, and 3) obstacles impeding the process. Pharmacists involved in deprescribing procedures, mainly through completing medication reviews, collaborative work with other healthcare providers, and education. Pharmacists' involvement in benzodiazepine deprescribing intervention led to better health and economic outcomes. Withdrawal symptoms after medication discontinuation, dependence on medication, and lack of time and guidelines were identified in the literature as barriers to deprescribing.

Conclusion

Pharmacists' involvement in deprescribing benzodiazepines is crucial for optimizing medication therapy. This scoping review examines the pharmacists' role in benzodiazepine deprescribing. The findings contribute to enhancing healthcare outcomes and guiding future research in this area.

Pharmacist-led medication review in a residential in-reach service leads to deprescribing

OBJECTIVE

To examine the effect of a pharmacist-led medication review on deprescribing medications in a Residential In-Reach (RIR) service which provides acute care substitution to residential aged care residents.

METHODS

A pre-post observational study was conducted. Patient characteristics and admission and discharge medications were collected over two 3-month phases before (prephase) and after (postphase) the introduction of a pharmacist who performed a comprehensive medication review and provided deprescribing recommendations. The Screening Tool of Older Persons' Prescriptions (STOPP) version 2 was used to identify potentially inappropriate medications (PIMs). The Drug Burden Index (DBI) was used to measure cumulative anticholinergic and sedative medication burden. Outcome of deprescribing was measured by the reduction in the number of PIMs, DBI scores and proportion of polypharmacy from admission to discharge.

RESULTS

The prephase included 59 patients (mean age 87.3 years, 63% female), and the postphase included 88 patients (mean age 87.3 years, 63% female). There was a significant reduction in the mean number of PIMs (pre +0.05 ± 2.59 vs. post -0.78 ± 2.32, p = 0.04) and median DBI (pre -0.004 ± 0.17 vs. post -0.07 ± 0.2, p = 0.03) in postphase compared to prephase. The proportion of polypharmacy at discharge was reduced in the postphase (pre-100% vs. post-90%, p = 0.01). The most deprescribed PIMs as measured by STOPP in postphase were drugs without indication, cardiovascular system drugs and gastrointestinal system drugs.

CONCLUSIONS

The introduction of a pharmacist-led medication review in RIR service was associated with a significant reduction in the mean number of PIMs, median DBI and polypharmacy. Future studies are needed to determine whether deprescription is sustained to examine correlations to long-term patient outcomes.

Polypharmacy and malnutrition in older people: A narrative review

Polypharmacy is the simultaneous use of multiple medicines, usually more than five. Polypharmacy is highly prevalent among older individuals and is associated with several adverse health outcomes, including frailty. The role of polypharmacy in nutritional status seems to be crucial: although a clear association between polypharmacy and malnutrition has been widely reported in older people, the magnitude of the effect of increased number of drugs in combination with their type on the risk for malnutrition remains to be largely explored. Therefore, this review aims to discuss the association between polypharmacy and malnutrition in older people and to provide suggestions for its management. Polypharmacy is prevalent among malnourished frail patients, and the relative contribution of comorbidities and polypharmacy to malnutrition is difficult to be determined. Several mechanisms by which commonly used medications have the potential to affect nutritional status have been identified and described. Deprescribing (i.e., a systematic process of identification and discontinuation of drugs or a reduction of drug regimens) could be an essential step for minimizing the effects of polypharmacy on malnutrition. In this regard, the literature suggests that in older patients taking several medications, the best method to solve this problem is the comprehensive geriatric assessment, based on a holistic approach, including drug review, to find potential unnecessary and inappropriate medications. Nutritional and deprescribing interventions must be tailored to patient needs and to the local context to overcome barriers when applied in different settings.

Deprescribing to optimise health outcomes for frail older people: a double-blind placebo-controlled randomised controlled trial-outcomes of the Opti-med study

BACKGROUND

potentially harmful polypharmacy is very common in older people living in aged care facilities. To date, there have been no double-blind randomised controlled studies of deprescribing multiple medications.

METHODS

three-arm (open intervention, blinded intervention and blinded control) randomised controlled trial enrolling people aged over 65 years (n = 303, noting pre-specified recruitment target of n = 954) living in residential aged care facilities. The blinded groups had medications targeted for deprescribing encapsulated while the medicines were deprescribed (blind intervention) or continued (blind control). A third open intervention arm had unblinded deprescribing of targeted medications.

RESULTS

participants were 76% female with mean age 85.0 ± 7.5 years. Deprescribing was associated with a significant reduction in the total number of medicines used per participant over 12 months in both intervention groups (blind intervention group -2.7 medicines, 95% CI -3.5, -1.9, and open intervention group -2.3 medicines; 95% CI -3.1, -1.4) compared with the control group (-0.3, 95% CI -1.0, 0.4, P = 0.053). Deprescribing regular medicines was not associated with any significant increase in the number of 'when required' medicines administered. There were no significant differences in mortality in the blind intervention group (HR 0.93, 95% CI 0.50, 1.73, P = 0.83) or the open intervention group (HR 1.47, 95% CI 0.83, 2.61, P = 0.19) compared to the control group.

CONCLUSIONS

deprescribing of two to three medicines per person was achieved with protocol-based deprescribing during this study. Pre-specified recruitment targets were not met, so the impact of deprescribing on survival and other clinical outcomes remains uncertain.

Patient-Reported Barriers and Enablers to Deprescribing Recommendations During a Clinical Trial (Shed-MEDS)

BACKGROUND AND OBJECTIVES

Effective deprescribing requires shared decision making between a patient and their clinician, and should be used when implementing evidence-based deprescribing conversations. As part of the Shed-MEDS clinical trial, this study assessed barriers and enablers that influence patient decision making in deprescribing to inform future implementation efforts and adaptations.

RESEARCH DESIGN AND METHODS

Shed-MEDS, a randomized controlled deprescribing trial, included hospitalized older adults discharging to post-acute care facilities. A trained clinician reviewed each participant's medical history and medication list to identify medications with potential for deprescribing. The study clinician then conducted a semistructured patient-centered deprescribing interview to determine patient (or surrogate) concerns about medications and willingness to deprescribe. Reeve et al.'s (2013) framework was used to categorize barriers and enablers to deprescribing from the patient's perspective, including "appropriateness of cessation," "fear," "dislike of a medication," "influences," and "process of cessation."

RESULTS

Overall, participants/surrogates (N = 177) agreed with 63% (883 total medications) of the study clinician's deprescribing recommendations. Thematic analysis revealed that "appropriateness" of a medication was the most common barrier (88.2%) and enabler (67.3%) to deprescribing. Other deprescribing enablers were in the following domains: "influences" (22.7%), "process" (22.5%), "pragmatic" (19.4%), and "dislike" (5.3%).

DISCUSSION AND IMPLICATIONS

Use of a semistructured deprescribing interview conversation tool allowed study clinicians to elicit individual barriers and enablers to deprescribing from the patient's perspective. Participants in this study expressed more agreement than disagreement with study clinicians' deprescribing recommendations. These results should inform future implementation efforts that incorporate a patient-centered framework during deprescribing conversations.

CLINICAL TRIALS REGISTRATION NUMBER

NCT02979353.

What types of information do pharmacists include in comprehensive medication management review reports? A qualitative content analysis

BACKGROUND

Comprehensive medication management reviews are an established intervention to identify medication-related problems, such as the prescribing of potentially inappropriate medications, and under- and over-prescribing. However, the types of information included in written reports of comprehensive medication management reviews, beyond types of medication-related problems, are unknown.

AIM

This study aimed to explore the types of information Australian pharmacists include in their written reports following comprehensive medication management reviews.

METHOD

Australian consultant pharmacists were invited to upload their 10 most recent written reports of their domiciliary-based comprehensive medication management reviews. A random selection of the reports, stratified by each pharmacist, were included for qualitative content analysis.

RESULTS

Seventy-two de-identified reports from eight consultant pharmacists located in five of the eight Australian States and Territories were included for analysis. From the evaluated reports, four major categories of information were identified: (1) patient details such as date of interview (n = 72, 100%) and medicine history (n = 70, 97%); (2) pharmacist assessment including assessment of the patient (n = 70, 97%), medicines management (n = 68, 94%) and medicine-related issues (n = 60, 83%); (3) pharmacist recommendations, specifically pharmacological recommendations (n = 67, 93%); and (4) patient-centred experiences such as perspectives on medicines (n = 56, 78%). Reporting of patient-centred experiences appeared most variably in the included reports, including patient concerns (n = 38, 53%), willingness for change (n = 27, 38%), patient preferences (n = 13, 18%), and patient goals (n = 7, 10%).

CONCLUSION

Pharmacists within our study included a wide variety of information in their comprehensive medication management review reports. Aside from medication-related problems, pharmacists commonly provided a holistic assessment of the patients they care for. However, variability across reports has the potential to impact consistent service delivery.

Clinical pharmacists' reported approaches and processes for undertaking Home Medicines Review services: A national survey

INTRODUCTION

Comprehensive medicines reviews are a strategy to reduce medicines-related harm. In Australia, Home Medicines Review services (HMRs) are provided by consultant pharmacists to community-dwelling consumers, on referral from the consumer's medical practitioner. Limited research exists on the processes undertaken by consultant pharmacists when delivering HMRs, particularly as it relates to the information types received, collected, and reported.

OBJECTIVE

Describe the types of information consultant pharmacists report receiving in HMR referrals, collect before and during consumer consultations, and include in their written reports.

MATERIALS AND METHODS

We conducted a national online survey of Australian consultant pharmacists who deliver HMRs. Participants were recruited using a broad advertising strategy, including social and traditional media platforms, and snowballing. Data were analysed descriptively.

RESULTS

Of the 248 eligible participants, 179 (72%) completed the survey. The most commonly included information in the referral was medication list (97%), the least were details of hospitalisations (8%) and specialist letters (5%). Information pertaining to hospitalisation and specialist letters were collected by 20% of participants prior to the consultation. Details of, and history from, community pharmacy was the most sought information prior to consultations. Less than a quarter of participants 'most of the time' or 'always' formally assess adherence using a validated instrument during the consultation. Participants commonly (80%) report consumer concerns in the written report.

CONCLUSIONS

Consultant pharmacists collect a broad variety of information, beyond medicines-related content. Written HMR reports by consultant pharmacists were often reported to be consumer-centric.

Polypharmacy and medicine regimens in older adults in residential aged care

OBJECTIVE

To describe medicines regimens used by older people living in residential aged care facilities (RACFs).

MATERIALS AND METHODS

This cross-sectional study presents baseline data from a randomised controlled trial in seventeen Australian RACFs that recruited residents aged 65 years and older at the participating facilities. The main outcome measures were to evaluation of medicines utilisation, including the number of medicines, medicine regimen complexity, potential under-prescribing and high-risk prescribing (prescribing cascades, anticholinergic or sedative medicines or other potentially inappropriate medicines) with data analysed descriptively.

RESULTS

Medicines regimens were analysed for 303 residents (76% female) with a mean age of 85.0 ± 7.5 years, of whom the majority were living with dementia (72%). Residents were prescribed an average of 10.3 ± 4.5 regular medicines daily. Most participants (85%) had highly complex regimens. Most residents (92%) were exposed to polypharmacy (five or more medicines). Nearly all, 302 (98%) residents had at least one marker of potentially suboptimal prescribing. At least one instance of potential under-prescribing was identified in 86% of residents. At least one instance of high-risk prescribing was identified in 81% of residents including 16% of participants with at least one potential prescribing cascade.

CONCLUSION(S)

Potentially suboptimal prescribing affected almost all residents in this study, and most had highly complex medicines regimens. If generalisable, these findings indicate most older people in RACFs may be at risk of medicines-related harm from suboptimal prescribing, in addition to the burden of administration of complex medicines regimens for facility staff and residents.

Mapping the methodological diversity of published drug discontinuation studies-a scoping review of study topics, objectives, and designs

BACKGROUND

Trials evaluating drug discontinuation (drug discontinuation trials, DDTs) show a broad methodological spectrum. There are several specific methodological aspects in drug discontinuation trials (e.g., determination of research question; configuration of intervention; definition of outcomes). To verify this specifies, we did a scoping review about the study designs of drug discontinuation trials.

METHODS

A systematic literature search in Medline (PubMed), The Cochrane Library, EMBASE, CINAHL, Web of Science, and PsycINFO was performed. In a two-step selection process, we identified DDTs, which evaluate the discontinuation of one or more long-term medication as the investigated intervention, by two independent reviewers. Besides bibliographic data, we extracted several parameters to describe the used study design of the included DDTs: motivation for DDT, initially treatment aim of the discontinued medication, study design, methods of discontinuation, follow-up times, number of study participants, and outcome parameter.

RESULTS

Out of 12,132 records, we included 581 DDTs. The most common motivation for doing a DDT were expected side effects (48.8%), the motivation of proving the efficacy of medication (21.6%), or doubts on the expected benefit of the used medication (13.8%). The majority of the discontinued medication was initially prescribed to improve the prognosis of a chronic disease (60.4%) or to relieve symptoms (31%). The study designs of the trials showed a broad methodological spectrum. The minority of the drug discontinuation trials were randomized controlled trials (34%).

CONCLUSION

The results of this scoping review illustrates the need for an evidence-based methodological standard for planning and conducting drug discontinuation trials.

Prescribing and deprescribing in very old age: perceptions of very old adults, caregivers and health professionals

BACKGROUND

although they are major consumers of medications, there is little evidence-based data to guide prescribing and deprescribing of medications for very old adults (80+ years).

OBJECTIVES

to discover the perceptions of very old adults, caregivers and health professionals in order to further examine the clinical and ethical issues raised by prescribing and deprescribing in very old age.

METHODS

individual interviews were conducted with very old adults (n = 10) and caregivers (n = 6), whereas group interviews were conducted with health professionals (n = 11). The themes covered included perceptions of medication use, polypharmacy, deprescribing and patient-health professional relationships. Thematic analysis was used to identify areas of convergence and divergence.

RESULTS

very old adults are satisfied with the medications they are taking, do not see the need to reduce their medication use and consider their doctor as the expert who should make the decisions regarding treatment. The perceptions of caregivers are similar to those of older adults, whereas health professionals believe that very old adults take a lot of inappropriate medications and list multiple barriers to deprescribing. All participants describe a normalisation of medication use with ageing.

CONCLUSION

there is a dichotomy between the perception of the very old adults/caregivers and that of health professionals regarding the safety of medication in very old age. A cultural change regarding medication use seems essential to optimise therapy and support deprescribing in clinical practice since the potential issues raised by researchers do not resonate with the main stakeholders.

The patterns and implications of potentially suboptimal medicine regimens among older adults: a narrative review

In the context of an ageing population, the burden of disease and medicine use is also expected to increase. As such, medicine safety and preventing avoidable medicine-related harm are major public health concerns, requiring further research. Potentially suboptimal medicine regimens is an umbrella term that captures a range of indicators that may increase the risk of medicine-related harm, including polypharmacy, underprescribing and high-risk prescribing, such as prescribing potentially inappropriate medicines. This narrative review aims to provide a background and broad overview of the patterns and implications of potentially suboptimal medicine regimens among older adults. Original research published between 1990 and 2021 was searched for in MEDLINE, using key search terms including polypharmacy, inappropriate prescribing, potentially inappropriate medication lists, medication errors, drug interactions and drug prescriptions, along with manual checking of reference lists. The review summarizes the prevalence, risk factors and clinical outcomes of polypharmacy, underprescribing and potentially inappropriate medicines. A synthesis of the evidence regarding the longitudinal patterns of polypharmacy is also provided. With an overview of the existing literature, we highlight a number of key gaps in the literature. Directions for future research may include a longitudinal investigation into the risk factors and outcomes of extended polypharmacy, research focusing on the patterns and implications of underprescribing and studies that evaluate the applicability of tools measuring potentially inappropriate medicines to study settings.

Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis

BACKGROUND

Tackling problematic polypharmacy requires tailoring the use of medicines to individual needs and circumstances. This may involve stopping medicines (deprescribing) but patients and clinicians report uncertainty on how best to do this. The TAILOR medication synthesis sought to help understand how best to support deprescribing in older people living with multimorbidity and polypharmacy.

OBJECTIVES

We identified two research questions: (1) what evidence exists to support the safe, effective and acceptable stopping of medication in this patient group, and (2) how, for whom and in what contexts can safe and effective tailoring of clinical decisions related to medication use work to produce desired outcomes? We thus described three objectives: (1) to undertake a robust scoping review of the literature on stopping medicines in this group to describe what is being done, where and for what effect; (2) to undertake a realist synthesis review to construct a programme theory that describes 'best practice' and helps explain the heterogeneity of deprescribing approaches; and (3) to translate findings into resources to support tailored prescribing in clinical practice.

DATA SOURCES

Experienced information specialists conducted comprehensive searches in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (targeted searches).

REVIEW METHODS

The scoping review followed the five steps described by the Joanna Briggs Institute methodology for conducting a scoping review. The realist review followed the methodological and publication standards for realist reviews described by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) group. Patient and public involvement partners ensured that our analysis retained a patient-centred focus.

RESULTS

Our scoping review identified 9528 abstracts: 8847 were removed at screening and 662 were removed at full-text review. This left 20 studies (published between 2009 and 2020) that examined the effectiveness, safety and acceptability of deprescribing in adults (aged ≥ 50 years) with polypharmacy (five or more prescribed medications) and multimorbidity (two or more conditions). Our analysis revealed that deprescribing under research conditions mapped well to expert guidance on the steps needed for good clinical practice. Our findings offer evidence-informed support to clinicians regarding the safety, clinician acceptability and potential effectiveness of clinical decision-making that demonstrates a structured approach to deprescribing decisions. Our realist review identified 2602 studies with 119 included in the final analysis. The analysis outlined 34 context-mechanism-outcome configurations describing the knowledge work of tailored prescribing under eight headings related to organisational, health-care professional and patient factors, and interventions to improve deprescribing. We conclude that robust tailored deprescribing requires attention to providing an enabling infrastructure, access to data, tailored explanations and trust.

LIMITATIONS

Strict application of our definition of multimorbidity during the scoping review may have had an impact on the relevance of the review to clinical practice. The realist review was limited by the data (evidence) available.

CONCLUSIONS

Our combined reviews recognise deprescribing as a complex intervention and provide support for the safety of structured approaches to deprescribing, but also highlight the need to integrate patient-centred and contextual factors into best practice models.

FUTURE WORK

The TAILOR study has informed new funded research tackling deprescribing in sleep management, and professional education. Further research is being developed to implement tailored prescribing into routine primary care practice.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018107544 and PROSPERO CRD42018104176.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 32. See the NIHR Journals Library website for further project information.

Frailty in older adults with heart disease

BACKGROUND

Heart failure prevalence will double in the next 40 years and affects more than 10% of persons over the age of 70 years in an age-dependent manner. Frailty is an age-associated clinical syndrome defined as a decrease in physiological reserve in situations of stress, such as operations, infections and acute illness based on a state of higher vulnerability. The prevalence is up to 74% in older individuals over the age of 80 years or those over 70 years old with a high burden of comorbidities and chronic diseases. This geriatric syndrome is associated with a worse clinical outcome and higher morbidity and mortality in acute and chronic disease than in age-matched cohorts without this syndrome.

METHODS

In this brief review, the scientific evidence of appropriate tools for diagnosis of frailty in heart failure patients is addressed. Heart failure management in this special group of patients requires a holistic care planning presented here in accordance with pathophysiologic particularities. A literature search in PubMed using the terms "heart failure" and "frailty" was carried out and a further search in the references based on the findings.

CONCLUSION

The diagnosis of frailty should influence the intensity of further diagnostic investigations and medical treatment based on the personal wishes of the patient, reduced organ reserves and general prognosis. The prognosis of heart failure patients remains poor, partially due to the intertwining with frailty. A clear statement for the use of an appropriate diagnostic tool for frailty and heart failure and specific therapeutic recommendations are presented based on clinical evidence.

Applicability of explicit potentially inappropriate medication lists to the Australian context: A systematic review

OBJECTIVES

To determine i) the similarity of potentially inappropriate medications specified in and between existing explicit lists and ii) the availability in Australia of medications included on existing lists to determine their applicability to the Australian context.

METHODS

This systematic review identified explicit potentially inappropriate medication lists that were published on EMBASE (1974 - April 2021), MEDLINE (1946 - April 2021) and Elsevier Scopus (2004 - April 2021). The reference lists of seven previously published systematic reviews were also manually reviewed. Lists were included if they were explicit, and the most recent version and the complete list were published in English. Lists based on existing lists were excluded if no new items were added. Potentially inappropriate medications identified on each list were extracted and compared to the medications available on the Australian Register of Therapeutic Goods and Australian Pharmaceutical Benefits Schemes.

RESULTS

Thirty-five explicit published lists were identified. A total of 645 unique potentially inappropriate medications were extracted, of which 416 (64%) were available in Australia and 262 (41%) were subsided by the general Pharmaceutical Benefits Scheme. Applicability of each explicit list ranged from 50-96% according to medications available in Australia and 25-83% according to medications available under subsidy.

CONCLUSIONS

Pooling data from different lists may help to identify potentially inappropriate medications that may be applicable to local settings. However, if selecting a list for use in the Australian context, consideration should also be given to the intended purpose and setting for application.

Effect of deprescribing in elderly patients with type 2 diabetes: iDegLira might improve quality of life

Older people with type 2 diabetes (T2D) often have several comorbidities and take multiple drugs. This study tested a deprescribing strategy in older T2D patients, replacing a hypoglycemic therapeutic scheme with a single drug combination (iDegLira). In this 6-month, real-world, single-arm, open interventional study, we enrolled patients ≥ 75 years with T2D taking ≥ 2 medications for diabetes. Patients on a basal-bolus insulin regimen (n = 13), on a basal-insulin regimen plus oral glucose-lowering drugs (n = 9), and those on oral glucose-lowering drugs (n = 18) were switched to daily iDegLira. The primary clinical endpoint of the study was an improvement in CASP-19 and/or DTSQ score after 6 months. We also evaluated changes in glucose metabolism, depression, cognitive function, level of independence, and markers of inflammation. Thirty-five patients (12 women, mean age=81.4 y) completed the protocol. Results shown here are given as estimated mean difference (95%CI). DTSQ score improved [11.08 (7.13/15.02); p = 0.0001], whereas CASP-19 did not after 6 months of iDegLira treatment. We observed reductions in BMI [- 0.81 (- 1.27/0.35); p < 0.001], fasting glucose [- 52.07 (- 77.26/26.88); p < 0.001], HbA1c [- 0.58 (- 1.08/0.08); p < 0.05], and TNF-α [- 1.83 (- 3.12/- 0.54); p = 0.007]. Activities of daily living and cognitive function score increased [p = 0.006 and p = 0.02], whereas depression score significantly decreased [p = 0.02]. Notably, no patient reported episodes of severe hypoglycemia after initiation of iDegLira treatment. Among older patients with T2D, deprescribing using a single dose of iDegLira resulted in a greater likelihood of improving health and quality of life. Although our data indicate the effectiveness and safety of this approach, it must be confirmed in larger studies.

An Interprofessional Student-Run Medication Review Program: The Clinical STOPP/START-Based Outcomes of a Controlled Clinical Trial in a Geriatric Outpatient Clinic

As the population ages, more people will have comorbid disorders and polypharmacy. Medication should be reviewed regularly in order to avoid adverse drug reactions and medication‐related hospital visits, but this is often not done. As part of our student‐run clinic project, we investigated whether an interprofessional student‐run medication review program (ISP) added to standard care at a geriatric outpatient clinic leads to better prescribing. In this controlled clinical trial, patients visiting a memory outpatient clinic were allocated to standard care (control group) or standard care plus the ISP team (intervention group). The medications of all patients were reviewed by a review panel (“gold standard”), resident, and in the intervention arm also by an ISP team consisting of a group of students from the medicine and pharmacy faculties and students from the higher education school of nursing for advanced nursing practice. For both groups, the number of STOPP/START‐based medication changes mentioned in general practitioner (GP) correspondence and the implementation of these changes about 6 weeks after the outpatient visit were investigated. The data of 216 patients were analyzed (control group = 100, intervention group = 116). More recommendations for STOPP/START‐based medication changes were made in the GP correspondence in the intervention group than in the control group (43% vs. 24%, P = < 0.001). After 6 weeks, a significantly higher proportion of these changes were implemented in the intervention group (19% vs. 9%, P = 0.001). The ISP team, in addition to standard care, is an effective intervention for optimizing pharmacotherapy and medication safety in a geriatric outpatient clinic.

Functional Status among Polymedicated Geriatric Inpatients at Discharge: A Population-Based Hospital Register Analysis

This study explored and compared the functional status of polymedicated and non-polymedicated geriatric inpatients at hospital discharge. We used a cross-sectional registry of geriatric patients' hospital records from a multi-site public hospital center in Switzerland. The analysis included all inpatients aged 65 years old or more admitted between 1 January 2015 and 31 December 2017 (n = 53,690), of whom 67.5% were polymedicated at hospital discharge, 52.1% were women (n = 18,909), and 42.7% were 75-84 years old (n = 15,485). On average, the polymedicated patients' hospital lengths of stay were six days longer, they presented with more than three comorbidities, and they were prescribed more than nine medications at hospital discharge (p < 0.001). They showed more frequent general mobility decline (43.2% vs. 41.9%), gait disorders (46.2% vs. 43%), fatigue (48.6% vs. 43.4%) and dependence on lower-body care (49.7% vs. 47.6%), and presented a higher malnutrition risk (OR = 1.411; 95%CI 1.263-1.577; p < 0.001). However, the non-polymedicated inpatients had proportionally more physical and cognitive impairments. The comparison of the functional status of polymedicated and non-polymedicated geriatric inpatients at hospital discharge is important for clinicians trying to identify and monitor those who are most vulnerable to functional decline, and to design targeted strategies for the prevention of functional impairment and related adverse health outcomes.

No impact of a prescription booklet on medication consumption in nursing home residents from 2011 to 2014: a controlled before-after study

Background

Older persons are particularly exposed to adverse events from medication. Among the various strategies to reduce polypharmacy, educational approaches have shown promising results. We aimed to evaluate the impact on medication consumption, of a booklet designed to aid physicians with prescriptions for elderly nursing home residents.

Methods

Among 519 nursing homes using an electronic pill dispenser, we recorded the daily number of times that a drug was administered for each resident, over a period of 4 years. The intervention group comprised 113 nursing homes belonging to a for-profit geriatric care provider that implemented a booklet delivered to prescribers and pharmacists and specifically designed to aid with prescriptions for elderly nursing home residents. The remaining 406 nursing homes where no such booklet was introduced comprised the control group. Data were derived from electronic pill dispensers. The effect of the intervention on medication consumption was assessed with multilevel regression models, adjusted for nursing home status. The main outcomes were the average daily number of times that a medication was administered and the number of drugs with different presentation identifier codes per resident per month.

Results

96,216 residents from 519 nursing homes were included between 1 January 2011 and 31 December 2014. The intervention group and the control group both decreased their average daily use of medication (− 0.05 and − 0.06). The booklet did not have a statistically significant effect (exponentiated difference-in-differences coefficient 1.00, 95% confidence interval 0.99–1.02, P = .45).

Conclusion

We observed an overall decrease in medication consumption in both the control and intervention groups. Our analysis did not provide any evidence that this reduction was related to the use of the booklet. Other factors, such as national policy or increased physician awareness, may have contributed to our findings.

Electronic supplementary material

The online version of this article (10.1007/s40520-020-01670-5) contains supplementary material, which is available to authorized users.

Prevalence and association of continuous polypharmacy and frailty among older women: A longitudinal analysis over 15 years

OBJECTIVES

This study aimed to determine the prevalence of continuous polypharmacy and hyperpolypharmacy, determine medications that contribute to continuous polypharmacy, and examine the association between frailty and continuous polypharmacy.

STUDY DESIGN

A prospective study using data from the Australian Longitudinal Study on Women's Health. Women aged 77-82 years in 2003, and 91-96 years in 2017 were analysed, linking the Pharmaceutical Benefits Scheme data to participants' survey data.

MAIN OUTCOME MEASURES

The association between frailty and continuous polypharmacy was determined using generalised estimating equations for log binomial regressions, controlling for confounding variables. Descriptive statistics were used to determine the proportion of women with polypharmacy, and medications that contributed to polypharmacy.

RESULTS

The proportion of women with continuous polypharmacy increased over time as they aged. Among participants who were frail (n = 833) in 2017, 35.9 % had continuous polypharmacy and 1.32 % had hyperpolypharmacy. Among those who were non-frail (n = 1966), 28.2 % had continuous polypharmacy, and 1.42 % had hyperpolypharmacy. Analgesics (e.g. paracetamol) and cardiovascular medications (e.g. furosemide and statins) commonly contributed to continuous polypharmacy among frail and non-frail women. Accounting for time and other characteristics, frail women had an 8% increased risk of continuous polypharmacy (RR 1.08; 95 % CI 1.05, 1.11) compared to non-frail women.

CONCLUSIONS

Combined, polypharmacy and frailty are key clinical and public health challenges. Given that one-third of women had continuous polypharmacy, monitoring and review of medication use among older women are important, and particularly among women who are frail.

Risk management strategy for preventing the reduced treatment effectiveness from the position of drug interactions and polypharmacy in patients with coronary heart disease

Introduction: In modern clinical practice, various drug combinations are widely used, especially in cardiological patients. The existing clinical recommendations necessitate using organ protective agents, especially with a patient having a comorbid pathology and with an ineffective monotherapy. In some cases, drug interaction decreases the effectiveness of pharmacotherapy and increases the risk of developing adverse events (AE).

The purpose of the study was to analyze the modern pharmacotherapy of patients with coronary heart disease (CHD), identify polypharmacy of treatment, evaluate its significance for the treatment process, and determine ways to solve the problem of using a multi-component system of pharmacotherapy risk management.

Materials and methods: The study involved 156 patients with CHD, among whom 39 received more than 8 drugs at a time.

Results and discussion: In these patients, the evaluation of drug interactions revealed 580 variants (48 were dangerous, 428 – significant, 104 – insignificant). The administration of a therapy to comorbid patients, taking into account possible changes in the activity of cytochrome P450 isoenzymes, is one of the promising ways to improve the safety of a combined pharmacotherapy.

Conclusion: It was revealed that with a mutated cytochrome P450 most of processes of drug biotransformation occurs. And there is a greater risk of developing AE against the background of polypragmasia in polymorbid patients, which makes it possible to individually adjust the dose of beta-blockers, thus affecting the frequency of their development. The choice of management measures should be determined considering all the areas of personalized medicine, including pharmacogenetic predictors, pharmacoepidemiological data, pharmacoeconomic effectiveness, the development of adverse reactions, polypragmasia, and medical and social risk factors.

Electronic Medication Management System Introduction and Deprescribing Practice in Post-Acute Care

OBJECTIVE

To determine the effect of introducing an electronic medication management system (EMMS) on deprescribing practice in a post-acute hospital setting.

DESIGN

This study used a before-after study design.

SETTING AND PARTICIPANTS

This study examined the admission and discharge medications prescribed to patients admitted to an Australian post-acute hospital before and after the introduction of an EMMS.

METHODS

Data were collected over a 1-month period before and after the introduction of an EMMS and included summary measures of drug burden including Potentially Inappropriate Medications and the Drug Burden Index. We calculated and compared admission and discharge medication prescription as well as change in medication use before and after the introduction of an EMMS.

RESULTS

Medication prescription data were available for 121 people before and 107 people after EMMS introduction. In both phases, when compared with admission, those discharged were prescribed fewer medications (mean reduction pre-EMMS = 2.9, P < .001, post-EMMS = 2.6, P < .001), fewer Potentially Inappropriate Medications (mean reduction pre-EMMS = 0.4, P < .001, post-EMMS = 0.6, P < .001) and had lower Drug Burden Index (mean reduction pre-EMMS = 0.1, P < .001, post-EMMS = 0.2, P < .001). The degree of reduction in each measure was similar before and after EMMS introduction.

CONCLUSIONS AND IMPLICATIONS

The introduction of an EMMS did not affect deprescribing practice in a post-acute hospital setting. Future work is required to explore the potential for clinical decision support within an EMMS to further improve the safety and effectiveness of deprescribing within post-acute care.

Barriers to effective prescribing in older adults: applying the theoretical domains framework in the ambulatory setting - a scoping review

BACKGROUND

As the population ages, potentially inappropriate prescribing (PIP) in the older adults may become increasingly prevalent. This undermines patient safety and creates a potential source of major morbidity and mortality. Understanding the factors that influence prescribing behaviour may allow development of interventions to reduce PIP. The aim of this study is to apply the Theoretical Domains Framework (TDF) to explore barriers to effective prescribing for older adults in the ambulatory setting.

METHODS

A scoping review was performed based on the five-stage methodological framework developed by Arksey and O'Malley. From 30 Aug 2018 to 5 Sep 2018, we conducted our search on PubMed, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews, and Web of Science. We also searched five electronic journals, Google and Google Scholar to identify additional sources and grey literature. Two reviewers applied eligibility criteria to the title and abstract screening, followed by full text screening, before systematically charting the data.

RESULTS

A total of 5731 articles were screened. Twenty-nine studies met the selection criteria for qualitative analysis. We mapped our results using the 14-domain TDF, eventually identifying 10 domains of interest for barriers to effective prescribing. Of these, significant domains include physician-related factors such as "Knowledge", "Skills", and "Social/Professional Role and Identity"; issues with "Environmental Context and Resources"; and the impact of "Social Influences" and "Emotion" on prescribing behaviour.

CONCLUSION

The TDF elicited multiple domains which both independently and collectively lead to barriers to effective prescribing for older adults in the ambulatory setting. Changing the prescribing climate will thus require interventions targeting multiple stakeholders, including physicians, patients and hospital/clinic systems. Further work is needed to explore individual domains and guide development of frameworks to aid guide prescribing for older adults in the ambulatory setting.

Generic instruments for drug discontinuation in primary care: A systematic review

Aims

The aim of this systematic review was to identify generic instruments for drug discontinuation in patients with polypharmacy in the primary care setting.

Methods

We systematically searched PubMed and EMBASE, 8 guideline databases (AWMF, NICE, NGC, SIGN, NHMRC, CPG, KCE), the Cochrane Library and grey literature (Google) in 2016 and 2017. Two independent researchers screened and analysed data. The drug discontinuation instruments of the included publications were described and classified.

Results

We identified 16 relevant publications. Here we found complex algorithms as well as instruments composed of distinct sequential steps. Two guidelines are constructed as electronic web‐applications. Instruments revealed diverging emphases on the stages of deprescribing, i.e. preparation, drug evaluation, decision‐making and implementation. Accordingly, 3 types of instruments emerged: general frameworks, detailed drug assessment tools and comprehensive discontinuation guidelines.

Conclusion

Diverse generic instruments exist for different areas of applications in regard to drug discontinuation. However, there is still a need for practical and user‐friendly tools that support physicians in communicational aspects, visualise trade‐offs and also enhance patient involvement.

An Interprofessional Workshop to Enhance De-prescribing Practices Among Health Care Providers

INTRODUCTION

De-prescribing is a complex behavior that benefits from a multifaceted approach to learning. We sought to create and deliver a 1-day interprofessional workshop to enhance de-prescribing knowledge and skills among health care professionals.

METHODS

Workshop development was based on the Adult Learning Theory and the Theoretical Domains Framework. The workshop addressed provider-related barriers, was created and delivered by an interprofessional team, and combined didactic and active learning techniques. Targeted participants included physicians, advanced practice providers (nurse practitioners and physician's assistants), pharmacists, and clinic staff. Interprofessional workgroups were created a priori. Participants were asked to complete a postprogram evaluation, including whether they would implement changes to practice, teaching, research, or administrative duties after participation.

RESULTS

We created an in-person, 5.5 credit hour, interprofessional de-prescribing workshop that comprised six sessions: (1) polypharmacy and de-prescribing overview; (2) identification of potentially inappropriate medications; (3) prioritization of medications for de-prescribing; (4) design and implementation of a de-prescribing plan; (5) principles for a patient-centered approach; and (6) suggestions for successful collaboration. Forty-one participants attended the workshop, and 38 (92.7%) completed the postprogram assessment. Participants felt they were likely to implement changes in practice, teaching, research, or administrative duties, rating themselves with a mean of 9.2 (SD = 1.06) on a 1 to 10 scale. Ultimately, 96.6% would recommend the workshop to others.

DISCUSSION

Based on participant feedback, the workshop catalyzed intention to change practice, teaching, research, or administrative duties. Other institutions seeking to change the complex behavior of de-prescribing may wish to model this development and delivery strategy.

Polypharmacy Among Home-Dwelling Older Adults: The Urgent Need for an Evidence-Based Medication Management Model

Ageing populations with multiple chronic conditions challenge low-, middle-, and high-income countries. Older adults frequently depend on complex medication regimens and polypharmacy, both of which can lead to potentially devastating and debilitating medication-related problems and to subsequent far-reaching public health, social, and economic effects. This perspectives article provides an overview of the current state of medication management, reflects on its relevance among polymedicated home-dwelling older adults living with multiple chronic conditions, and proposes patient-centered approaches for optimizing medication management and preventing medication-related problems.

Deprescribing: Polypharmacy management in older adults with comorbidities

In today's clinical landscape, the simultaneous use of multiple drugs to treat a single condition has become a major patient safety issue. Recent evidence suggests a need to identify deprescribing opportunities in the management of polypharmacy. NPs, as clinical gatekeepers, are in a key position to spearhead deprescribing best practices, specifically as they relate to older adults with multiple medication regimens.

Evaluation of a Pharmacist-Managed Antidiabetic Deprescribing Program in an Integrated Health Care System

BACKGROUND

In the elderly, use of medications may increase the propensity for adverse drug events due to alterations in pharmacokinetic and pharmacodynamic profiles from normal aging processes. Deprescribing is the planned and supervised process of dose reduction or discontinuation of medications that may lead to harm or are no longer beneficial. While there are studies detailing strategies to deprescribe medications such as benzodiazepines and antipsychotics in nursing homes or for patients with dementia, there is a lack of guidance to safely deprescribe chronic medications, such as antidiabetics, for older patients in the community setting.

OBJECTIVE

To evaluate the risk of hypoglycemia and other outcomes of pharmacist-managed deprescribing on selected antidiabetic medications under the guidance of a standardized program compared with usual care within an integrated health care system.

METHODS

This was a retrospective propensity score-matched cohort study. The pharmacist-managed deprescribing group included patients who were enrolled in the deprescribing program between July 1, 2016, and June 30, 2017. The usual care group included eligible patients who did not receive the deprescribing intervention and were matched to the deprescribing group using propensity score matching (PSM). Baseline demographics and clinical variables were used for matching. Patients were followed for 6 months or the end of membership or death, whichever occurred first. Primary outcome was the risk of hypoglycemia. Secondary outcomes included risk of hyperglycemia, proportion of patients at goal (A1c), change in A1c, change in monthly antidiabetic drug cost, and all-cause mortality. Outcomes were analyzed using descriptive statistics and multivariant regression or Cox proportional hazard models when appropriate.

RESULTS

After PSM, 685 patients in the deprescribing group and 2,055 patients in the usual care group were similar in age, gender, weight, and comorbidity burden (mean [SD] age 82.4 [5.4] years, 48% female, mean [SD] weight 81.7 [19.2] kg, mean [SD] Charlson Comorbidity Index score 3.2 [1.6]). Compared with the usual care group, the deprescribing group had a lower risk of hypoglycemia (1.5% vs. 3.1%, P < 0.02; adjusted odds ratio 0.42, P < 0.01). As for the secondary outcomes, the deprescribing group had a greater change (SD) in A1c (0.3 [0.6] vs. 0.2 [0.7] P < 0.01) and lower all-cause mortality (2.3% vs 5.6%, P < 0.01; adjusted hazard ratio 0.35, P < 0.01). There were no differences observed in the risk of hyperglycemia, proportion of patients at goal A1c < 7%, and change in monthly antidiabetic drug costs between the 2 groups.

CONCLUSIONS

There are currently no studies to our knowledge that evaluate the outcomes of a pharmacist-managed deprescribing program targeting antidiabetic medications. The results of our study showed that deprescribing of selected antidiabetics reduced the risk of hypoglycemia and may have mortality benefit in elderly patients with well-controlled type 2 diabetes, who are taking medications that can cause hypoglycemia. Further and longer studies are needed to validate these benefits.

DISCLOSURES

No outside funding was provided to support this research study. The authors of this study have no actual or potential conflicts of interest to report. Parts of this study were presented in a nonreviewed resident poster at the Academy of Managed Care Pharmacy Managed Care and Specialty Pharmacy Annual Meeting; April 23-26, 2018; Boston, MA.

Health professionals' and researchers' opinions on conducting clinical deprescribing trials

While clinical deprescribing trials are increasingly being performed, there is no guidance on the optimum conduction of such studies. The aim of this survey was to explore the perspectives, attitudes, interests, barriers, and enablers of conducting clinical deprescribing trials among health professionals and researchers. An anonymous survey was developed, reviewed, and piloted by all investigators and informed by consultation with experts, as well as current deprescribing guidelines. The questions were formulated around current clinical trial frameworks and incorporated identified enablers and barriers of performing deprescribing studies. The survey was sent to members of Australian and international deprescribing, pharmacological, and pharmacy organizations, and other researchers published in deprescribing. A total of 96 respondents completed the survey (92.3% completion rate). Respondents indicated the main deprescribing trial rationale is to generate evidence to optimize patient-centered outcomes (79.2%). Common barriers identified included the time and effort required (18.2%), and apprehension of health professionals involved in trials (17.1%). Studies are enabled by positive attitudes toward deprescribing of treating prescribers (24.4%) and patients (20.9%). Classical randomized controlled trials (RCTs) were deemed the most appropriate methodology (93.2%). Sixty percent of participants indicated a good clinical practice framework is required to guide the conduct of deprescribing trials. There were no significant differences in responses based on previous experience in conducting clinical deprescribing trials. In conclusion, clinical deprescribing trials should be conducted to investigate whether deprescribing medications improves patient care. A future deprescribing trial framework should use classical RCTs as a model, ensure participant safety, and target patient-centered outcomes.

Medication Management Models for Polymedicated Home-Dwelling Older Adults With Multiple Chronic Conditions: Protocol of a Systematic Review

Background

Older adults with multiple chronic diseases commonly require complex medication regimes. When combined with frailty, cognitive impairment, and changing pharmacological prescriptions, older adults’ polymedication regimes increase the risk of medication-related problems (MRPs) and hospitalization. Effective, well-organized medication management could avoid MRPs and their clinical outcomes.

Objective

Identify medication management models and analyze their impact on managing and preventing MRPs for polymedicated, home-dwelling older adults.

Methods

We will conduct a systematic review of published articles in relevant professional scientific journals from inception until March 31, 2019, in the following electronic databases,: Embase; Medline OvidSP; PubMed (NOT Medline[sb]); Cumulative Index to Nursing and Allied Health Literature (CINAHL) EBSCO; PsycINFO OvidSP; Cochrane Library, Wiley; and Web of Science. We will also hand search the bibliographies of all the relevant articles found and search for unpublished studies. We will consider publications in English, French, German, Spanish, Italian, and Portuguese. Retrieved articles will be screened for eligibility. Statistical analyses will be conducted following the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) statements. Data will be analyzed using SPSS Statistics for Windows, version 25.0 (IBM Corp), and Review Manager, version 5.5 (The Nordic Cochrane Centre, The Cochrane Collaboration).

Results

A preliminary search in Embase delivered 3272 references. This preliminary search allows us to complete our research strategy with equation development and to search the other databases. Relevant articles identified will allow for searching the reference lists for unpublished studies. The inclusion and exclusion criteria will be rigorously respected in the study selection. The entire study is expected to be completed by January 2020.

Conclusions

This review will provide an exhaustive view of medication management models that could be effective for polymedicated, home-dwelling older adults and will allow us to analyze their impact on managing and preventing MRPs.

Trial Registration

PROSPERO CRD42018117287; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=117287 (Archived by WebCite at http://www.webcitation.org/77fCfbCjT)

International Registered Report Identifier (IRRID)

DERR1-10.2196/13582

Approaches to managing older people using opiates and their risk of dependence

There is little doubt that opiates have transformed healthcare, particularly in relation to pain management. However, many patients prescribed this type of drug develop problems such as dependency. Although we do not know how many older people have developed such problems due to opiate use we know that some will. It is important for nurses to understand the context in which opiates are used, as well as the specific needs of older people and how to respond to them.

Reducing inappropriate prescribing for older adults with advanced frailty: A review based on a survey of practice in four countries

The management of medications in persons with frailty presents challenges. There is evidence of inappropriate prescribing and a lack of consensus among healthcare professionals on the judicious use of medications, particularly for patients with more severe frailty. This study reviews the evidence on the use of commonly prescribed pharmacological treatments in advanced frailty based on a questionnaire of prescribing practices and attitudes of healthcare professionals at different stages in their careers, in different countries. A convenience sample of those attending hospital grand rounds in Ireland, Canada and Australia/New Zealand (ANZ) were surveyed on the management of 18 medications in advanced frailty using a clinical vignette (man with severe dementia, Clinical Frailty Scale 7/9). Choices were to continue or discontinue (stop now or later) medications. In total, 298 respondents from Ireland (n = 124), Canada (n = 110), and ANZ (n = 64) completed the questionnaire, response rate 97%, including 81 consultants, 40 non-consultant hospital doctors, 134 general practitioners and 43 others (nurses, pharmacists, and medical students). Most felt that statins (88%), bisphosphonates (77%) and cholinesterase inhibitors (76%) should be discontinued. Thyroid replacement (88%), laxatives (83%) and paracetamol (81%) were most often continued. Respondents with experience in geriatric, palliative and dementia care were significantly more likely to discontinue medications. Age, gender and experience working in nursing homes did not contribute to the decision. Reflecting the current literature, there was no clear consensus on inappropriate prescribing, although respondents preferentially discontinued medications for secondary prevention. Experience significantly predicted the number and type discontinued, suggesting that education is important in reducing inappropriate prescribing for people in advanced states of frailty.

Medication-related quality of life among Ethiopian elderly patients with polypharmacy: A cross-sectional study in an Ethiopia university hospital

Polypharmacy among older patients has been associated with a decline in their quality of life. We aimed to assess the medication-related quality of life (MRQOL) among older patients with polypharmacy at Gondar University Hospital, Gondar, Ethiopia. A prospective cross-sectional study was carried out among 150 elder patients who had visited the internal medicine ward and ambulatory ward of Gondar referral hospital from March 25 to May 15, 2017, using a validated scale, Medication-Related Quality of Life Scale version 1.0 (MRQoLS-v1.0). A total of 150 older patients with polypharmacy participated in the study with a mean age of 70.06±5.12, andtwo-thirds of the participants (67.3%) were female. The overall prevalence of poor quality of life due to polypharmacy in the current study was found to be three fourth (75.3%) of the participants. Regarding the severity of impairment in MRQoL, Univariate analysis revealed that frequency of hospital visits (COR = 1.34, 95% CI, 1.02–1.77) and medication number (COR = 1.94, 95% CI, 1.33, 2.8) had a statistically significant positive association with the likelihood of having a severe impairment.The multivariate analysis also showed that one unit increase in the number of hospital visits (AOR = 1.45, 95% CI, 1.040–2.024) and medications greater than 5 (AOR = 1.91, 95% CI, 1.29, 2.84) increases 1.45 and 1.91 times the likely hood of posing severe impairment of MRQoL, respectively. As far as poor MRQoL quality of life is concerned, multivariate analysis did not show any significant association between the poor MRQoL;and Sociodemographic and clinical data of patients. The poor QoL associated with medication was very high in this study. Deprescribing should be sought by the health care providers to optimize drug therapy and minimize the polypharmacy related poor quality of life.

Achieving appropriate medication for older adults: A multidimensional perspective

Achieving appropriate medication is a multidimensional process. Current research on polypharmacy mainly focuses on drug appropriateness, but little is devoted to what determines the ongoing challenge. The authors, with their diverse clinical, pharmaceutical and regulatory backgrounds, offer a narrative review on the causes of inappropriate polypharmacy and how to avoid it. Inappropriate polypharmacy may stem from the systematic exclusion of frail older patients from landmark randomised controlled trials, which has prevented the accurate establishment of the clinical benefits of a drug for that ever-growing group of patients. Nonetheless, what may determine the usefulness of a drug in a specific patient cohort is its design. Patient-centric drug product development must, therefore, account for older people's characteristics, so that drugs are better formulated from their inception. This novel drug development process has significant implications for industry and requires adequate regulation. Clinicians must understand and be part of drug development. Explicit criteria such as STOPP/START provide guidance on identifying opportunities and circumstances to review medication but achieving appropriateness is far more complicated. New healthcare technology may pave the way to better-tailored interventions at a healthcare system level, but patient and advocate voices, as well as communication and continuity of care, must remain at the core. In conclusion, inappropriate polypharmacy results from the combination of multiple factors. Achieving appropriate medication for older adults requires merging different disciplines and a focus on patients' needs and expectations.

Undiagnosing to prevent overprescribing

Health care focuses on controlling symptoms and managing risk factors to improve survival by avoiding future complications. Diagnoses describe a group of signs and symptoms, often implying specific aetiologies and underlying pathophysiological disease processes. The diagnosis provides a tool for the health professional to conceptualise and classify a presentation, and thus manage the condition, and can provide the patient with an explanation or validation of their experience. Not every diagnosis holds significant clinical implications. There are diagnosed conditions that do not require treatment and, moreover, where treatment has the potential for harm without the potential for benefit. Promoting investigations and diagnoses can lead to overdiagnosis related to vested interests in increased services, use of devices or therapeutics. Multiple factors drive this issue, including broadening disease definitions and cultural factors that encourage tests and treatments, as well as medicolegal factors. While the traditional medicine review process typically involved cross-referencing medicines used with current diagnoses, a more sophisticated version of this process critically reviews the medicines and associated diagnosis, giving less emphasis to diagnoses that are no longer relevant. Known as undiagnosis, this process facilitates the withdrawal of corresponding medicines used to manage those conditions. Systematically reviewing diagnoses regularly and the associated medicine management strategies could reduce prescribing. The novel ERASE process can help clinicians Evaluate diagnoses to consider Resolved conditions, Ageing normally and Selecting appropriate targets to Eliminate unnecessary diagnoses and their corresponding medicines.

Drugs in fall versus non-fall accidents with major trauma - A population-based clinical and medico-legal autopsy study

BACKGROUND

The main aim of the present population-based study was to compare drugs in fall versus non-fall accidents causing major trauma, including both clinical and medico-legal autopsy data.

METHODS

All individuals with accidents resulting in major trauma, a new injury severity score (NISS)>15 or lethal outcome was identified at hospital and/or the Department of Forensic Medicine between 2011 and 2013. Modified Downton Fall Risk Index ranged from 0 to 7, and was based on specific pharmaceuticals (max 5 points), previous fall (1 point) and cognitive impairment (1 point).

RESULTS

One hundred and four individuals with major traumatic accidents were identified, 38 (36.5%) died. The median modified Downton Fall Risk Index was 2 for fall accidents and 0 for non-fall accidents (p < 0.001). Modified Downton Fall Risk Index was an age-independent factor associated with fall accident (p < 0.001). The medico-legal autopsy rate for in-hospital patients was 50% (6/12) for fatal fall accidents in comparison with 92.3% (12/13) for fatal non-fall accidents (p = 0.03). In individuals undergoing medico-legal autopsy, the proportion of individuals with any detected drug was 77% in fall accidents compared to 39% in non-fall accidents (p = 0.036). The presence of sedatives (p = 0.002) and bensodiazepines (p = 0.023) were higher for fall accidents compared to non-fall accidents.

CONCLUSION

This population-based study on accidents with major trauma showed that drugs had high impact on fall accidents with major trauma. It seems warranted from a public health perspective to study if implementation of medication review guidelines at hospital managing polypharmacy issues may prevent fall accident recidivism.

International Group for Reducing Inappropriate Medication Use & Polypharmacy (IGRIMUP): Position Statement and 10 Recommendations for Action

Globally, the number of drug prescriptions is increasing causing more adverse drug events, which is now a significant cause of mortality, morbidity, and disability that has reached epidemic proportions. The risk of adverse drug events is correlated to very old age, multiple co-morbidities, dementia, frailty, and limited life expectancy, with the major contributor being polypharmacy. Each characteristic alters the risk-benefit balance of medications, typically reducing anticipated benefits and amplifying risk. Current clinical guidelines are based on evidence proven in younger/healthier adult populations using a single disease model and their application to older adults with multimorbidity, in whom testing has not been conducted, yields a different risk-benefit prospect and makes inappropriate medication use and polypharmacy inevitable. Applying inappropriate clinical practice guidelines to older adults is antithetical to good healthcare, is likely to increase health inequity, and is associated with substantial negative clinical, economic, and social implications for health systems. The casualties are on the scale of a war or epidemic, yet are usually invisible in measures of healthcare quality and formal recommendations. Radical and rapid action is required to achieve a better quality of life for older populations and to remain true to the principles of medical professionalism and evidence-based medicine that place patients' interests and autonomy at the fore. This first International Group for Reducing Inappropriate Medication Use & Polypharmacy position statement briefly details the causes, consequences, and extent of inappropriate medication use and polypharmacy. This article outlines current strategies to reduce inappropriate medication use, provides evidence for their effect, and then proposes recommendations for moving forward with 10 recommendations for action and 12 recommendations for research. We conclude that an urgent integrated effort to reduce inappropriate medication use and polypharmacy should be a leading global target of the highest priority. The cornerstone of this position statement from the International Group for Reducing Inappropriate Medication Use & Polypharmacy is the understanding that without evidence of definite relevant benefit, when it comes to prescribing, for many older patients 'less is more'. This approach differs from most other current recommendations and guidance in medical care, as the focus is on what, when, and how to stop, rather than on when to start medications/interventions. Disrupting the framework that indiscriminately applies standard guidelines to older adults requires a new approach that better serves patients with multimorbidity. This transition requires a shift in medical education, research, and diagnostic frameworks, and re-examination of the measures used as quality indicators. In achieving this objective, we promote a return to some of the original concepts of evidence-based medicine: which considers scientific data (where it exists), clinical judgment, patient/family preference, and context. A shift is needed: from the current model that focuses on single conditions to one that simultaneously considers multiple conditions and patient priorities. This approach reframes the clinician's role as a professional providing care, rather than a disease technician.

Analysis of clinical pharmacist interventions in the neurology unit of a Brazilian tertiary teaching hospital

It is estimated that around five to 10.0% of hospital admissions occur due to clinical conditions resulting from pharmacotherapy. Clinical pharmacist's activity can enhance drug therapy's effectiveness and safety through pharmacotherapy interventions (PIs), thus minimizing drug-related problems (DRPs) and optimizing the allocation of financial resources associated with health care. This study aimed to estimate the DRPs prevalence, evaluate PI which were performed by clinical pharmacists in the Neurology Unit of a Brazilian tertiary teaching hospital and to identify factors associated with the occurrence of PI-related DRP. A single-arm trial included adults admitted in the referred Unit from 2012 July to 2015 June. Patients were evaluated during their hospitalization period and PIs were performed based on trigger DRPs that were detected in medication reconciliation (admission or discharge) or during inpatient follow-up. Student's t-test, Chi-square test, Pearson and Multiple logistic regression models to analise the association among age, number of drugs, hospitalization period, and number of diagnoses with occurrence of DRPs. Analyses level of significance was 5%. In total 409 inpatients were followed up [51.1% male, mean age of 49.1 (SD 16.5)]. Patients received, on average, 11.9 (SD 5.8) drugs, ranging from two to 38 drugs per patient, and 54.3% of the sample presented at least one DRP whose most frequent description was "untreated condition". From all 516 performed PIs that resulted from DRPs, 82.8% were accepted and the majority referred to "drug introduction" (27.5%). Multiple logistic regression showed that age, length of hospital stay, number of drugs used, diagnosis of epilepsy, multiple sclerosis and myasthenia gravis would be clinical variables associated with DRP (p < 0,05). Monitoring the use of drugs allowed the clinical pharmacist to detect DRPs and to suggest interventions that promote rational pharmacotherapy.

Deprescribing interventions and their impact on medication adherence in community-dwelling older adults with polypharmacy: a systematic review

BACKGROUND

Polypharmacy, and the associated adverse drug events such as non-adherence to prescriptions, is a common problem for elderly people living with multiple comorbidities. Deprescribing, i.e. the gradual withdrawal from medications with supervision by a healthcare professional, is regarded as a means of reducing adverse effects of multiple medications including non-adherence. This systematic review examines the evidence of deprescribing as an effective strategy for improving medication adherence amongst older, community dwelling adults.

METHODS

A mixed methods review was undertaken. Eight bibliographic database and two clinical trials registers were searched between May and December 2017. Results were double screened in accordance with pre-defined inclusion/exclusion criteria related to polypharmacy, deprescribing and adherence in older, community dwelling populations. The Mixed Methods Appraisal Tool (MMAT) was used for quality appraisal and an a priori data collection instrument was used. For the quantitative studies, a narrative synthesis approach was taken. The qualitative data was analysed using framework analysis. Findings were integrated using a mixed methods technique. The review was performed in accordance with the PRISMA reporting statement.

RESULTS

A total of 22 original studies were included, of which 12 were RCTs. Deprescribing with adherence as an outcome measure was identified in randomised controlled trials (RCTs), observational and cohort studies from 13 countries between 1996 and 2017. There were 17 pharmacy-led interventions; others were led by General Practitioners (GP) and nurses. Four studies demonstrated an overall reduction in medications of which all studies corresponded with improved adherence. A total of thirteen studies reported improved adherence of which 5 were RCTs. Adherence was reported as a secondary outcome in all but one study.

CONCLUSIONS

There is insufficient evidence to show that deprescribing improves medication adherence. Only 13 studies (of 22) reported adherence of which only 5 were randomised controlled trials. Older people are particularly susceptible to non-adherence due to multi-morbidity associated with polypharmacy. Bio-psycho-social factors including health literacy and multi-disciplinary team interventions influence adherence. The authors recommend further study into the efficacy and outcomes of medicines management interventions. A consensus on priority outcome measurements for prescribed medications is indicated.

TRIAL REGISTRATION

PROSPERO number CRD42017075315.

Identification of behaviour change techniques in deprescribing interventions: a systematic review and meta-analysis

AIMS

Deprescribing interventions safely and effectively optimize medication use in older people. However, questions remain about which components of interventions are key to effectively reduce inappropriate medication use. This systematic review examines the behaviour change techniques (BCTs) of deprescribing interventions and summarizes intervention effectiveness on medication use and inappropriate prescribing.

METHODS

MEDLINE, EMBASE, Web of Science and Academic Search Complete and grey literature were searched for relevant literature. Randomized controlled trials (RCTs) were included if they reported on interventions in people aged ≥65 years. The BCT taxonomy was used to identify BCTs frequently observed in deprescribing interventions. Effectiveness of interventions on inappropriate medication use was summarized in meta-analyses. Medication appropriateness was assessed in accordance with STOPP criteria, Beers' criteria and national or local guidelines. Between-study heterogeneity was evaluated by I-squared and Chi-squared statistics. Risk of bias was assessed using the Cochrane Collaboration Tool for randomized controlled studies.

RESULTS

Of the 1561 records identified, 25 studies were included in the review. Deprescribing interventions were effective in reducing number of drugs and inappropriate prescribing, but a large heterogeneity in effects was observed. BCT clusters including goals and planning; social support; shaping knowledge; natural consequences; comparison of behaviour; comparison of outcomes; regulation; antecedents; and identity had a positive effect on the effectiveness of interventions.

CONCLUSIONS

In general, deprescribing interventions effectively reduce medication use and inappropriate prescribing in older people. Successful deprescribing is facilitated by the combination of BCTs involving a range of intervention components.

Potentially Inappropriate Medications in Older Adults: Deprescribing with a Clinical Pharmacist

OBJECTIVES

To compare the effects of a Geriatric Patient-Aligned Care Team (GeriPACT) on deprescribing of potentially inappropriate medications (PIMs) in individuals aged 80 and older with usual care (UC) in the Veterans Affairs setting.

DESIGN

Retrospective cohort study.

SETTING

Veterans Affairs Medical Center in Lexington, Kentucky.

PARTICIPANTS

Individuals aged 80 and older who filled a PIM at least 90 days before a GeriPACT or primary care appointment between January 1, 2015, and September 6, 2017 (N = 568).

MEASUREMENTS

The primary outcome was to determine whether an interdisciplinary team (IDT) including a clinical pharmacy specialist (CPS) resulted in greater deprescribing of PIMs for older adults than UC.

RESULTS

One hundred twenty-one (26.8%) PIMs were deprescribed in GeriPACT, compared with 73 (16.1%) in UC (p = <.001). Of PIMs not deprescribed, 9.7% (n = 32) were dose reduced in GeriPACT, versus 2.8% (n = 11) in UC (p < .001). Documentation of risk versus benefit discussion between a provider and participant or pharmacist and participant occurred with 65.2% (n = 215) of PIMs not deprescribed in GeriPACT and 0.003% (n = 1) in UC (p < .001).

CONCLUSION

An IDT that included a CPS led to significantly more deprescribing of PIMs in older veterans. Including a CPS on an IDT for the management of older adults can decrease PIM use in our rapidly growing aging population. J Am Geriatr Soc 67:115-118, 2019.