Consumer Attitudes Towards Deprescribing: A Systematic Review and Meta-Analysis

Consumer and multidisciplinary clinician experiences after implementation of the Drug Burden Index intervention bundle to facilitate deprescribing in older inpatients: A mixed method study

RATIONALE

The Drug Burden Index (DBI) measures exposure to anticholinergic and sedative drugs, which are associated with harm in older adults. To facilitate deprescribing in older Australian inpatients, we piloted an intervention bundle integrating the DBI in Electronic Medical Records, clinician deprescribing guides, consumer information leaflets and a stewardship pharmacist.

OBJECTIVES

To understand (i) hospital clinician experiences of using the bundle and (ii) consumer (patient and carer) and General Practitioner (GP) experiences of in-hospital deprescribing, following bundle implementation.

METHODS

Hospital clinicians from target services (General and Geriatric Medicine) at an Australian metropolitan tertiary-referral hospital, were invited to complete surveys, including the System Usability Scale (SUS), and interviews. Patients aged ≥75 years with high DBI (DBI ≥1) were admitted to target services, and their carers, received interview invitations. Consenting patients' GPs received surveys. Qualitative data was thematically analysed. Hospital clinician interviews were mapped to the Human Organisation Technology-fit Framework. Patient interviews were mapped to an adaptation of the National Health Service Patient Experience Framework.

RESULTS

Seventeen hospital clinicians (n = 15 medical, n = 2 pharmacists) and four GPs completed surveys. Eight hospital clinicians (n = 7 medical, n = 1 pharmacist), seven patients and two carers completed interviews. Hospital clinicians reported good usability (SUS score 71.5 ± 12.5). Most themes were around system use and user satisfaction. They reported the intervention was useful for medication review, identified challenges from pre-existing heavy workload and suggested further integration into workflows. Patients and carers reported themes around information, communication and education. Patients reported feeling better or no different post-deprescribing. Patients, carers and GPs described poor communication regarding in-hospital medication changes and their rationale.

CONCLUSIONS

The intervention was well accepted by hospital clinicians. The bundle requires further integration into workflows for sustainability and assessment of generalisability in other health services. Given patients, carers and GPs reported poor medication-related communication, future interventions may target this.

Behavioral Determinants of Older Adults' and Caregivers' Willingness to Deprescribe: A Systematic Review

BACKGROUND

Deprescribing is a strategy to optimize medication use and to prevent medication harm. Despite the fact that behavioral theories have been shown to be useful in explaining health behaviors, the literature on deprescribing relies almost exclusively on attitudes as an explanatory factor for deprescribing behavior. This study systematically reviews the literature that made explicit use of the constructs included in health behavior theories (HBTs) to explain older adults' and informal caregivers' deprescribing behavior and outcomes.

METHODS

Studies were screened from five electronic databases by two reviewers. Quantitative interventional and non-interventional studies applying at least one HBTs or construct from these theories to older adults' or informal caregiver' intention or behavior to deprescribe, were included. Studies that used the patients' attitudes toward deprescribing (PATD) questionnaire or its revised version were excluded.

RESULTS

A total of 11 non-interventional studies and 11 interventional studies were identified, seven of which applied HBTs, and the other 15 used constructs from the HBTs. Health literacy and locus of control were identified as moderator variables. Only two studies targeted informal caregivers' deprescribing intentions or behavior.

CONCLUSIONS

HBTs are not systematically used. However, combining the main HBT constructs reported in the literature offers a better explanation of the (intention to) engage in deprescribing.

TRAIL REGISTRATION

The study protocol (ID: CRD42022378157) was published on PROSPERO.

Communication as a key component of deprescribing: Conceptual framework and review of the literature

BACKGROUND

Deprescribing, the process of identifying and discontinuing potentially harmful or unnecessary medications, is a key component of caring for older persons. Communication is central to deprescribing. This study's objectives were to create a conceptual framework for deprescribing communication and to apply the framework to evaluate current and potential uses of communication in deprescribing.

METHODS

The consensus development working group comprises an international set of 14 experts in geriatrics, clinical pharmacology, communication, community outreach, and care partner stakeholders. Critical literature reviews describe (a) components of communication used in deprescribing randomized clinical trials (RCTs) and (b) the content of studies examining deprescribing communication, knowledge, attitudes, and values.

RESULTS

The framework demonstrates that communication extends beyond interactions between clinicians and patients. Communication can occur at the health system level, involving methods such as patient-specific feedback materials and academic detailing. Communication can also occur at the community level, involving entities such as pharmaceutical companies, the internet, community groups, and guidelines. Evaluation of the summary of RCTs against the framework demonstrates that intervention studies overwhelmingly focus on communication in individual clinical and health system-based encounters. Evaluation of the summary of observational studies demonstrates that there has been little study of the communication methods and styles themselves.

CONCLUSIONS

Potentially untapped opportunities exist to expand the use of different approaches for communication in deprescribing interventions, particularly in the community setting. More studies are required to elucidate and personalize the best content and style of deprescribing communication.

Deprescribing Cardiovascular Medications in Older Adults Living with Frailty

Certain medications have shown significant effectiveness in reducing the incidence of cardiovascular events and mortality, leading them to be among those that are prescribed most commonly for Canadian seniors. However, polypharmacy, which disproportionately affects older adults, is particularly concerning for frail individuals who are at higher risk for adverse medication-related events. The deprescribing process is the discontinuation, either immediate or gradual, of inappropriate medications, to address polypharmacy and improve outcomes. Nonetheless, the incorporation of deprescribing principles into clinical practice present challenges, including the limited amount of data available on the clinical benefits of deprescription, and a lack of consensus on how to deprescribe. The current narrative review explores frailty as a basis for deciding to deprescribe medication. The evidence regarding the benefits of use of medications prescribed for common cardiovascular conditions (including acetylsalicylic acid, statins, and antihypertensives) in older adults with frailty is reviewed. The review also examines the issue of who should initiate the deprescribing process, and the associated psychological implications. Although no one-size-fits-all approach to deprescription is available, patient goals should be prioritized. For older adults with frailty, healthcare professionals must consider carefully whether the benefits of use of a cardiovascular medication outweighs the potential harms. Ideally, the deprescribing process should involve shared decision-making among physicians, other health professionals, and patients and/or their substitute decision-makers, with the common goal of improving patient outcomes.

Exploring GP and patient attitudes towards the use and deprescribing of dietary supplements: a survey study in Switzerland

BACKGROUND

Dietary supplements are commonly used by older adults, but their inappropriate use may lead to adverse events. To optimise medication use, general practitioners (GPs) ideally are aware of all substances that patients use, including supplements. This cross-sectional study explored the use of dietary supplements by older patients with polypharmacy, the rate at which they disclosed this use to their GPs, and compared patients' and GPs' attitudes towards discontinuing dietary supplements.

METHODS

Ten GPs in Swiss primary care recruited five to ten of their older patients taking ≥ 5 regular medications. Both GPs and their patients completed a survey on patients' use of dietary supplements and attitudes towards deprescribing those. We described and compared their responses. We assessed the association of supplement disclosure with patient characteristics using multilevel logistic regression analysis.

RESULTS

Three out of ten GPs (30%) were female, and GPs' average age was 52 years (SD = 8). 45% of patients were female (29/65). Most patients (n = 45, 70%) were taking ≥ 1 supplement. On average, patients reported to be using three supplements (SD = 2). In 60% (n = 39) of patients, GPs were unaware of ≥ 1 supplement used. We did not find evidence for an association between supplement disclosure to GPs and patient characteristics. Only 8% (n = 5) of patients and 60% (n = 6) of GPs reported ≥ 1 supplement they would be willing to deprescribe and none of the supplements reported by GPs and patients to deprescribe matched.

CONCLUSION

Swiss GPs were unaware of many dietary supplements used by their older patients, which may affect medication optimisation efforts.

Active deprescribing attitudes and practices in a large regional tertiary health service: a mixed methods study

In this pilot study, we explored current attitudes and deprescribing practices of clinicians in a large regional health service through a mixed methods approach. Respondents included doctors, pharmacists and nurse practitioners, who outlined three themes including professional and organisational contexts, disconnect between goals and practices and factors influencing deprescribing.

An Internationally Derived Process of Healthcare Professionals' Proactive Deprescribing Steps and Constituent Activities

Proactive deprescribing is the process of tapering or stopping a medicine before harm occurs. This study aimed to specify and validate, with an international sample of healthcare professionals, a proactive deprescribing process of steps and constituent activities. We developed a proactive deprescribing process framework of steps which we populated with literature-derived activities required to be undertaken by healthcare professionals. We distributed a survey to healthcare professionals internationally, requesting for each activity the frequency of its occurrence in practice and whether it was important. Extended response questions investigated barriers and enablers to deprescribing. The 263 survey respondents were from 25 countries. A proactive deprescribing process was developed comprising four steps: (1) identify a patient for potential stop of a medicine, (2) evaluate a patient for potential stop of a medicine, (3) stop a medicine(s), and (4) monitor after a medicine has been stopped, and 17 activities. All activities were considered important by ≥70% of respondents. Nine activities required healthcare professionals to undertake in direct partnership with the patient and/or caregiver, of which seven were only sometimes undertaken. Deprescribing interventions should include a focus on addressing the barriers and enablers of healthcare professionals undertaking the activities that require direct partnership with the patient and/or caregiver.

Factors influencing deprescribing in primary care for those towards the end of life: A qualitative interview study with patients and healthcare practitioners

BACKGROUND

For people with limited lifetime expectancy, the benefit of many medications may be outweighed by their potential harms. Despite the relevance of reducing unnecessary medication use, deprescribing is poorly enacted in primary care practice.

AIM

This study aims to describe factors, as identified by primary care professionals and patients, that influence deprescribing in the last phase of life.

DESIGN

Semi-structured interviews were conducted and analysed using a thematic approach.

SETTING/PARTICIPANTS

This study was performed in primary care settings, including general practices, hospices and community care teams in The Netherlands. Purposefully identified primary care professionals (general practitioners, pharmacists, nurses) and patients with limited lifetime expectancy due to advanced chronic illness or cancer and their caretakers were interviewed.

RESULTS

Three themes emerged detailing factors influencing deprescribing in the last phase of life in primary care: (1) non-maleficence, the wish to avoid additional psychological or physical distress; (2) reactive care, the lack of priority and awareness of eligible patients; and (3) discontinuity of care within primary care and between primary care and specialty care.

CONCLUSIONS

Deprescribing is an incremental process, complicated by the unpredictability of life expectancy and attitudes of patients and health care professionals that associate continued medication use with clinical stability. Opportunities to facilitate the deprescribing process and its acceptance include the routinely systematic identification of patients with limited life expectancy and potentially inappropriate medications, and normalisation of deprescribing as component of regular primary care, occurring for all patients and continuing into end-of-life care.

Perspectives on deprescribing in older people with type 2 diabetes and/or cardiovascular conditions: challenges from healthcare provider, patient and caregiver perspective, and interventions to support a proactive approach

INTRODUCTION

For people with type 2 diabetes and/or cardiovascular conditions, deprescribing of glucose-lowering, blood pressure-lowering and/or lipid-lowering medication is recommended when they age, and their health status deteriorates. So far, deprescribing rates of these so-called cardiometabolic medications are low. A review of challenges and interventions addressing these challenges in this population is pertinent.

AREAS COVERED

We first provide an overview of relevant deprescribing recommendations. Next, we review challenges for healthcare providers (HCPs) to deprescribe cardiometabolic medication and provide insight in the patient and caregiver perspective on deprescribing. We summarize findings from research on implementing deprescribing of cardiometabolic medication and reflect on strategies to enhance deprescribing. We have used a combination of methods to search for relevant articles.

EXPERT OPINION

There is a need for rigorous development and evaluation of intervention strategies aimed at proactive deprescribing of cardiometabolic medication. To address challenges at different levels, these should be multifaceted interventions. All stakeholders must become aware of the relevance of deintensifying medication in this population. Education and training for HCPs and patients should support patient-centered communication and shared decision-making. Development of procedures and tools to select eligible patients and conduct targeted medication reviews are important for implementation of deprescribing in routine care.

'Troubling' medication reviews in the context of polypharmacy and ageing: A linguistic ethnography

Healthy ageing is a global priority. Polypharmacy (the use of 5+ medicines) amongst older people is increasing, with over one-third of adults in England, aged 80-89, prescribed at least eight medications. Although sometimes necessary, polypharmacy can be harmful; the risk of harm increases with age and number of medicines prescribed. Medication reviews are recommended as one way of reducing the potential harms of polypharmacy although evidence of clinically significant benefit of medication reviews as currently delivered is limited. What happens in medication reviews in practice is poorly understood. We used a linguistic ethnography approach to explore how medication reviews proceed and what is accomplished during these consultations. We studied 18 video-recorded medication review consultations from three general practices in England. The consultations involved patients aged 65 or older, prescribed 10+ medications ('higher risk' polypharmacy), and primary care clinicians (general practitioner or clinical pharmacist). Video-recordings were gathered as part of a wider ethnographic study investigating practices of polypharmacy in primary care between 2017 and 2021. We conducted microanalysis of consultation data, drawing on our ethnographic knowledge of the organisational, institutional and domestic contexts of polypharmacy to inform our interpretation of these interactions. Consultations were time-consuming and involved lengthy stretches of interactional trouble: non-understandings; misunderstandings; misalignments. These stretches revealed profound uncertainties as to the effectiveness of medicines in the context of multimorbidity and polypharmacy. These uncertainties seeped further into 'troubles talk' concerning patients' existential concerns relating to enduring illness, ageing and mortality. Although these existential concerns were partially articulated, clinicians and patients left such troubles talk unelaborated, unresolved and unfinished. Participants succeeded in smoothing over interactional difficulties and maintaining respectful relationships but often fell short of addressing problematic polypharmacy more directly.

Deprescribing in older adults in a French community: a questionnaire study on patients' beliefs and attitudes

BACKGROUND

General practitioners (GPs) have a central role to play on reduction of polypharmacy and deprescribing. This study aimed to assess beliefs and attitudes towards deprescribing in patients, aged 65 years or older in primary care, and to identify factors associated with deprescribing and their willingness to stop medication.

METHODS

A questionnaire study was performed between 23 May and 29 July 2022 on patients aged 65 years or older attending a GP's surgery in a French area. We used the French version of the revised Patients' Attitudes Towards Deprescribing self-report questionnaire (rPATD), which measures four subscales ("Burden", "Appropriateness", "Concerns about stopping" and, "Involvement"), patients' willingness to stop one of their regular medicines, and patients' satisfaction with their current medicines.

RESULTS

The study enrolled 200 patients. Median age was 76 years old (IQR 71-81), 55% were women, and 42.5% took 5 or more medications per day. Although most patients (92.5%) were satisfied with their current medicines, 35% were reluctant to stop medications they had been taking for a long time, and 89.5% were willing to stop medication if asked to by their GP. Patients aged less than 75 years old reported more concerns about stopping. Women and patients with higher educational attainment showed significantly higher involvement in medication management.

CONCLUSIONS

The majority of older adults were willing to stop one or more of their regular medicines if asked to do so by their GP. GPs should address deprescribing into their current practice.

Deprescribing: An umbrella review

This umbrella review examined systematic reviews of deprescribing studies by characteristics of intervention, population, medicine, and setting. Clinical and humanistic outcomes, barriers and facilitators, and tools for deprescribing are presented. The Medline database was used. The search was limited to systematic reviews and meta-analyses published in English up to April 2022. Reviews reporting deprescribing were included, while those where depre-scribing was not planned and supervised by a healthcare professional were excluded. A total of 94 systematic reviews (23 meta--analyses) were included. Most explored clinical or humanistic outcomes (70/94, 74 %); less explored attitudes, facilitators, or barriers to deprescribing (17/94, 18 %); few focused on tools (8/94, 8.5 %). Reviews assessing clinical or humanistic outcomes were divided into two groups: reviews with deprescribing intervention trials (39/70, 56 %; 16 reviewing specific deprescribing interventions and 23 broad medication optimisation interventions), and reviews with medication cessation trials (31/70, 44 %). Deprescribing was feasible and resulted in a reduction of inappropriate medications in reviews with deprescribing intervention trials. Complex broad medication optimisation interventions were shown to reduce hospitalisation, falls, and mortality rates. In reviews of medication cessation trials, a higher frequency of adverse drug withdrawal events underscores the importance of prioritizing patient safety and exercising caution when stopping medicines, particularly in patients with clear and appropriate indications.

Deprescribing in older adults with polypharmacy

Polypharmacy is common in older adults and is associated with adverse drug events, cognitive and functional impairment, increased healthcare costs, and increased risk of frailty, falls, hospitalizations, and mortality. Many barriers exist to deprescribing, but increased efforts have been made to develop and implement deprescribing interventions that overcome them. This narrative review describes intervention components and summarizes findings from published randomized controlled trials that have tested deprescribing interventions in older adults with polypharmacy, as well as reports on ongoing trials, guidelines, and resources that can be used to facilitate deprescribing. Most interventions were medication reviews in primary care settings, and many contained components such as shared decision making and/or a focus on patient care priorities, training for healthcare professionals, patient facing education materials, and involvement of family members, representing great heterogeneity in interventions addressing polypharmacy in older adults. Just over half of study interventions were found to perform better than usual care in at least one of their primary outcomes, and most study interventions were assessed over 12 months or less.

Reducing potentially inappropriate polypharmacy at a national and international level: the impact of deprescribing networks

INTRODUCTION

Over the past decade, polypharmacy has increased dramatically. Measurable harms include falls, fractures, cognitive impairment, and death. The associated costs are massive and contribute substantially to low-value health care. Deprescribing is a promising solution, but there are barriers. Establishing a network to address polypharmacy can help overcome barriers by connecting individuals with an interest and expertise in deprescribing and can act as an important source of motivation and resources.

AREAS COVERED

Over the past decade, several deprescribing networks were launched to help tackle polypharmacy, with evidence of individual and collective impact. A network approach has several advantages; it can spark interest, ideas and enthusiasm through information sharing, meetings and conversations with the public, providers, and other key stakeholders. In this special report, the details of how four deprescribing networks were established across the globe are detailed.

EXPERT OPINION

Networks create links between people who lead existing and/or budding deprescribing practices and policy initiatives, can influence people with a shared passion for deprescribing, and facilitate sharing of intellectual capital and tools to take initiatives further and strengthen impact.This report should inspire others to establish their own deprescribing networks, a critical step in accelerating a global deprescribing movement.

Influence of chronic medical conditions on older patients' willingness to deprescribe medications: a cross-sectional study

BACKGROUND

Aging correlates with a heightened prevalence of chronic diseases, resulting in multimorbidity affecting 60% of those aged 65 or older. Multimorbidity often leads to polypharmacy, elevating the risk of potentially inappropriate medication (PIM) use and adverse health outcomes. To address these issues, deprescribing has emerged as a patient-centered approach that considers patients' beliefs and attitudes toward medication and reduces inappropriate polypharmacy in older adults. Our study aims to investigate whether certain chronic medical conditions are associated with older patients' willingness to deprescribe medications.

METHODS

A cross-sectional study enrolled 192 community-dwelling individuals aged 65 or older taking at least one regular medication. Data included demographics, clinical characteristics, and responses to the Portuguese revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. Descriptive statistics characterized participants, while multiple binary logistic regression identified associations between chronic medical conditions and willingness to deprescribe.

RESULTS

Among the participants (median age: 72 years, 65.6% female), 91.6% had multimorbidity. The analysis revealed that willingness to deprescribe significantly increased with the presence of gastric disease (adjusted odds ratio [aOR] = 4.123; 95% CI 1.221, 13.915) and age (aOR = 1.121; 95% CI 1.009, 1.246). Conversely, prostatic pathology (aOR = 0.266; 95% CI 0.077, 0.916), higher scores in the rPATD appropriateness factor (aOR = 0.384; 95% CI 0.190, 0.773), and rPATD concerns about stopping factor (aOR = 0.450; 95% CI 0.229, 0.883) diminished patients' willingness to deprescribe.

CONCLUSIONS

This study highlights the intricate relationship between older patients' attitudes toward deprescribing and chronic medical conditions. We found that gastric disease was associated with an increased willingness to deprescribe medications, while prostate disease was associated with the opposite effect. Future research should explore how patients with specific diseases or groups of diseases perceive deprescribing of medications general and for specific medications, aiding in the development of targeted interventions.

Deprescribing potential of commonly used medications among community-dwelling older adults: insights from a pharmacist's geriatric assessment

Pharmacist's geriatric assessment can provide valuable insights into potential deprescribing targets, while including important information on various health-related domains. Data collected from a geriatric assessment questionnaire, for 388 patients, from the Croatian cohort of the EuroAgeism H2020 ESR 7 international project, along with guideline-based deprescribing criteria, were used to analyse potentially inappropriate prescribing of four medication groups (benzodiazepines (BZN), proton pump inhibitors (PPI), opioids, and non-steroidal anti-inflammatory drugs (NSAID)), and to assess the deprescribing potential. Binary logistic regression was used to explore the effects of age, gender, number of medicines and diagnoses, self-reported health, frailty score, and healthcare utilization on the likelihood of needing deprescribing. More than half of participants (n = 216, 55.2%) are candidates for deprescribing, with 31.1% of PPI, 74.8% of NSAID, 75% of opioid, and 96.1% of BZN users meeting at least one criterion. Most common criteria for deprescribing were inappropriately long use and safety concerns. Women (aOR = 2.58; p < 0.001), those reporting poor self-reported health (aOR = 5.14; p < 0.001), and those exposed to polypharmacy (aOR = 1.29; p < 0.001) had higher odds of needing to have medicines deprescribed. The high rate of deprescribing potential warrants prompt action to increase patient safety and decrease polypharmacy. Pharmacist's geriatric assessment and deprescribing-focused medication review could be used to lead a personalised approach.

Older adults' adherence to medications and willingness to deprescribe: A substudy of a randomized clinical trial

Our study investigated the association between patients' willingness to have medications deprescribed and medication adherence. This longitudinal substudy of the 'Optimizing PharmacoTherapy In the Multimorbid Elderly in Primary CAre' (OPTICA) trial, a cluster randomized controlled trial, took place in Swiss primary care settings. Participants were aged ≥65 years and over, with ≥3 chronic conditions and ≥5 regular medications. At baseline, the 'revised Patient Attitudes Towards Deprescribing' (rPATD) questionnaire was measured. The A14-scale measured adherence (self-report) at the 12-month follow-up. Multilevel linear regression analyses adjusted for baseline variables were performed. Of the 298 participants, 45% were women, and the median age was 78. Participants reported a high level of adherence and willingness to have medications deprescribed. We did not find evidence for an association between patients' willingness to deprescribe and medication adherence. Further research is needed to explore the relationship between these concepts and to inform collaborative decisions about medicines in the context of polypharmacy.

Does missing data matter in the revised Patients' Attitudes Towards Deprescribing questionnaire? A systematic review and two case analyses

BACKGROUND

The revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire was developed to capture beliefs and perceptions of patients about deprescribing. In general, handling of missing data is underreported in survey studies. Underlying mechanisms related to missing data may impact the findings from survey studies.

OBJECTIVES

The aim of this study was to assess the missing data in studies using the rPATD questionnaire through a systematic review and datasets from two studies.

METHODS

First, this review updated a systematic review on the rPATD (and other versions). We searched Medline via OVID, EMBASE, Scopus, Web of Science until 31st January 2023. Missing data reporting and methods to handle them were collected. Second, data from two deprescribing studies were analyzed using three methods of missing data handling: complete case analysis, personal mean substitution, and multiple imputation. We compared the scores from each domain and the associations of the domains with two questions from the rPATD to highlight how using different methods can influence the interpretation of study findings.

RESULTS

We identified 49 studies: 31 (63 %) from this study and 18 (37 %) from the original systematic review. The question or domain with the most missing data could be identified in 9 studies (18.4 %). Missing data management was reported in 19 studies (38.8 %). In one case analysis, the "Burden" domain was significantly associated with the question "I would like to try stopping one of my medicines to see how I feel without it" using complete case analysis (p = 0.044) or multiple imputation (p = 0.038), but not when using personal mean substitution (p = 0.057).

CONCLUSIONS

Missing data and methods used to handle missing data were underreported in studies using the rPATD questionnaire. The methods should be chosen carefully as our analyses from two distinct studies suggest that they may impact the interpretation of the findings from the questionnaire.

Polypharmacy and Deprescribing in Older Adults

Older adults commonly end up on many medications. Deprescribing is an important part of individualizing care for older adults. It is an opportunity to discuss treatment options and revisit medications that may not have been reassessed in many years. A large evidence base exists in the field, suggesting that deprescribing is feasible and safe, though questions remain about the potential clinical benefits. Deprescribing research faces a myriad of challenges, such as identifying and employing the optimal outcome measures. Further, there is uncertainty about which deprescribing approaches are likely to be most effective and in what contexts. Evidence on barriers and facilitators to deprescribing has underscored how deprescribing in routine clinical practice can be complex and challenging. Thus, finding practical, sustainable ways to implement deprescribing is a priority for future research in the field.

Older adults' attitudes towards deprescribing and medication changes: a longitudinal sub-study of a cluster randomised controlled trial

OBJECTIVE

To investigate the association between older patients' willingness to have one or more medications deprescribed and: (1) change in medications, (2) change in the appropriateness of medications and (3) implementation of prescribing recommendations generated by the electronic decision support system tested in the 'Optimising PharmacoTherapy In the Multimorbid Elderly in Primary CAre' (OPTICA) trial.

DESIGN

A longitudinal sub-study of the OPTICA trial, a cluster randomised controlled trial.

SETTING

Swiss primary care settings.

PARTICIPANTS

Participants were aged ≥65 years, with ≥3 chronic conditions and ≥5 regular medications recruited from 43 general practitioner (GP) practices.

EXPOSURES

Patients' willingness to have medications deprescribed was assessed using three questions from the 'revised Patient Attitudes Towards Deprescribing' (rPATD) questionnaire and its concerns about stopping score.

MEASURES/ANALYSES

Medication-related outcomes were collected at 1 year follow-up. Aim 1 outcome: change in the number of long-term medications between baseline and 12 month follow-up. Aim 2 outcome: change in medication appropriateness (Medication Appropriateness Index). Aim 3 outcome: binary variable on whether any prescribing recommendation generated during the OPTICA medication review was implemented. We used multilevel linear regression analyses (aim 1 and aim 2) and multilevel logistic regression analyses (aim 3). Models were adjusted for sociodemographic variables and the clustering effect at GP level.

RESULTS

298 patients completed the rPATD, 45% were women and 78 years was the median age. A statistically significant association was found between the concerns about stopping score and the change in the number of medications over time (per 1-unit increase in the score the average number of medications use was 0.65 higher; 95% CI: 0.08 to 1.22). Other than that we did not find evidence for statistically significant associations between patients' agreement with deprescribing and medication-related outcomes.

CONCLUSIONS

We did not find evidence for an association between most measures of patient agreement with deprescribing and medication-related outcomes over 1 year.

TRIAL REGISTRATION NUMBER

NCT03724539.

Attitudes towards deprescribing in geriatric psychiatry: A survey among older psychiatric outpatients

Understanding the patient perspective is a significant part of the deprescribing process. This study aimed to explore the attitudes of older patients with psychiatric disorders towards deprescribing. A total of 72 of psychiatric outpatients (68% women; median age 76 years) completed the validated Danish version of the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. Patients used a median of eight medications (interquartile range 6-12), with 88%, 49% and 24% using antidepressants, antipsychotics and anxiolytics, respectively. Fifty-one percent of patients reported an intrinsic desire to stop one of their medications, while 92% would be willing to stop one on their physician's advice. Seventy-five percent of patients would be worried about missing out on future benefits following deprescribing and 37% had previous bad deprescribing experiences. Use of ≥8 regular medications was associated with more concerns about stopping medication and greater perceived burden of using medication, while use of antipsychotics was not associated with any differences in rPATD factor scores. It is crucial for health care professionals to be aware of patients' specific concerns and past experiences to promote a patient-centred deprescribing approach that takes into account the needs and preferences of older patients with psychiatric disorders.

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.

The Patient Typology about deprescribing and medication-related decisions: A quantitative exploration

This study aimed to test the adequacy of a quantitative measure of our qualitatively developed Patient Typology-categories of older adults' attitudes towards medicines and medicine decision-making-and identify characteristics associated with each Typology. We conducted secondary data analyses of a subset of survey item measures of adults (≥65 years) who were members of online survey panels in Australia, the United Kingdom, the United States and the Netherlands (n = 4688). Multinomial logistic regression analyses assessed associations between demographic, psychosocial and medication-related measures. Mean age was 71.5 (5), and 47.5% of participants were female. Factors associated with an increased likelihood of identifying with Typology 1 'Attached to medicines' over Typology 2 'Open to deprescribing' were higher positive attitude towards polypharmacy (RRR = 1.12, p = <0.001) and higher need for certainty (RRR = 1.11, p = 0.039). Factors associated with an increased likelihood of identifying with Typology 3 'Defers (medication decision-making) to others' over Typology 2 were older age (RRR = 1.47 per 10-year age increase, p = <0.001) and a decreased likelihood of prior deprescribing experience (RRR = 0.73, p = 0.033). This study provides validation of the Typology with large samples from four countries, with the quantitatively-measured typologies generally aligning with the qualitatively derived categories. Our Patient Typology measure provides a succinct way researchers can assess attitudes towards deprescribing.

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 in a multimorbid older adult: A case vignette study among community pharmacists and primary care physicians

Collaborative deprescribing can include pharmacists' medication review with identification and suggestion of potential deprescribing targets to physicians. Case vignettes can be a valuable method for researching variations in clinical decision making, especially in settings unaccustomed to newer clinical approaches such as deprescribing. This study aimed to explore if pharmacists can identify deprescribing targets and if physicians would accept pharmacist's deprescribing rationales. A cross-sectional study was performed using an online case vignette based on a real-life elderly patient. Pharmacists were asked to indicate which medicines they would recommend deprescribing, alongside a rationale. Physicians were asked to state their acceptance of the proposed pharmacist's deprescribing suggestion. Pharmacists gave 1275 deprescribing rationales, and most were given for deprescribing opioids, NSAID and diuretics. Physicians would accept rationales to deprescribe a median of 10 medicines, while pharmacist would recommend deprescribing a median of six medicines. Most difference lays in deprescribing of preventative medicines. Healthcare providers share agreement on deprescribing targets, but pharmacists show hesitancies in making recommendations that could hamper potential collaboration. Action is needed to improve pharmacists' skills in recognizing deprescribing targets and confidence in making suggestions, which could lead to opening of possibilities for joint patient care.

Predictors of older patients' willingness to have medications deprescribed: A cross-sectional study

BACKGROUND

Deprescribing is a complex process requiring a patient-centred approach. One frequently expressed deprescribing barrier is patients' attitudes and beliefs towards deprescribing. This study aimed to identify the predictors of patients' willingness to have medications deprescribed.

METHODS

A cross-sectional study was conducted with community-dwelling patients aged ≥65 who are taking at least one regular medication. Data collection included patients' demographic and clinical characteristics and the Portuguese revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. Descriptive statistics were used to present the patients' characteristics. Multiple binary logistic regression analysis was performed to identify the predictors of the patients' willingness to have medications deprescribed.

RESULTS

One hundred ninety-two participants (median age 72 years; 65.6% female) were included. Most (83.33%) were willing to have medications deprescribed, and the predictors were age (adjusted odds ratio [aOR] = 1.136; 95% CI 1.026, 1.258), female sex (aOR = 3.036; 95% CI 1.059, 8.708) and the rPATD concerns about stopping factor (aOR = 0.391; 95% CI 0.203, 0.754).

CONCLUSIONS

Most patients were willing to have their medications deprescribed if it is recommended by their doctors. Older age and female sex increased the odds of willingness to deprescribe; higher concerns about stopping medications decreased the odds. These findings suggest that addressing patients' concerns about stopping their medicines may contribute to deprescribing success.

Association between patient attitudes towards deprescribing and subsequent prescription changes

Deprescribing is an essential component of safe prescribing, especially for people with higher levels of polypharmacy. Identifying individuals prepared to consider medicine changes may facilitate deprescribing-orientated reviews. We aimed to explore the relationship between revised patients' attitudes towards deprescribing (rPATD) scores and medication changes in older people prescribed ≥15 medicines. A secondary analysis of rPATD scores and prescription data from a cluster randomised controlled trial of a GP-delivered, deprescribing-orientated medication review was conducted. The association between number of medicines stopped, started and changed and baseline rPATD scores was assessed using Poisson regression, adjusting for patient age, gender, study group allocation, baseline number of medicines and effects of clustering. Participants (n = 404) had a mean age of 76.4 years and were prescribed a mean of 17.1 medicines at baseline. Willingness to stop a medicine was associated with higher rates of both deprescribing (IRR: 1.40; 95% CI: 1.06-1.84) and initiating medicines (IRR: 1.43; 95% CI: 1.09-1.88). Satisfaction with current medicines was associated with a lower rate of deprescribing (IRR: 0.69; 95% CI: 0.57-0.85). The rPATD questionnaire could be used as part of a deprescribing intervention to identify participants who may be prepared to engage in deprescribing, enabling more efficient use of clinician time during complex consultations.

Translation, cultural adaptation and validation of the revised patients' attitudes towards deprescribing (rPATD) questionnaire in Romanian older adults

BACKGROUND

Deprescribing is part of ensuring appropriate medication use and may reduce medication-related harm. Capturing the beliefs and attitudes of patients towards deprescribing by using a validated tool may support optimizing medication use in practice.

OBJECTIVES

To translate, culturally adapt and validate the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire in Romanian and to investigate the attitudes and beliefs of older adults towards deprescribing.

METHODS

The rPATD questionnaire was translated using forward-backward translation into Romanian and culturally adapted. The psychometric properties were evaluated in older adults ≥65 years of age. Structural validity was assessed by item load on factors using an exploratory factor analysis (EFA) which was compared to the original English version and the internal consistency by Cronbach's alpha. Construct validity was evaluated by calculating the Spearman's rank correlation coefficients between the factor scores obtained using the revised version of the Romanian rPATD and scores on the Beliefs about Medicines Questionnaire (BMQ) Specific Concerns Romanian version. Floor and ceiling effect were also examined.

RESULTS

We translated the questionnaire and administered it to 224 participants (median age 72 years [interquartile range: 68.0; 77.0]). In the EFA individual items loaded onto 4 factors, grouped similarly to the English version (Involvement, Burden, Appropriateness, Concerns about Stopping factors). Two items from each of the Involvement and Appropriateness factors were removed to improve factor loading and avoid cross-loading. The Cronbach's alpha values for the 4 factors ranged between 0.522 and 0.773. The scores for Burden and Concerns about Stopping factors were found to be positively correlated with BMQ Specific Concerns score. We identified a ceiling effect for one of the four factors (Involvement) and no floor effects.

CONCLUSIONS

The Romanian rPATD was validated in 4 factor structure similar to the original English questionnaire. The Romanian version of the questionnaire may support the health care professionals in Romania to initiate and support patient-centered deprescribing.

Factors Important to Older Adults Who Disagree With a Deprescribing Recommendation

Importance

Little is known about why older adults decline deprescribing recommendations, primarily because interventional studies rarely capture the reasons.

Objective

To examine factors important to older adults who disagree with a deprescribing recommendation given by a primary care physician to a hypothetical patient experiencing polypharmacy.

Design, Setting, and Participants

This online, vignette-based survey study was conducted from December 1, 2020, to March 31, 2021, with participants 65 years or older in the United Kingdom, the US, Australia, and the Netherlands. The primary outcome of the main study was disagreement with a deprescribing recommendation. A content analysis was subsequently conducted of the free-text reasons provided by participants who strongly disagreed or disagreed with deprescribing. Data were analyzed from August 22, 2022, to February 12, 2023.

Main Outcomes and Measures

Attitudes, beliefs, fears, and recommended actions of older adults in response to deprescribing recommendations.

Results

Of the 899 participants included in the analysis, the mean (SD) age was 71.5 (4.9) years; 456 participants (50.7%) were men. Attitudes, beliefs, and fears reported by participants included doubts about deprescribing (361 [40.2%]), valuing medications (139 [15.5%]), and a preference to avoid change (132 [14.7%]). Valuing medications was reported more commonly among participants who strongly disagreed compared with those who disagreed with deprescribing (48 of 205 [23.4%] vs 91 of 694 [13.1%], respectively; P < .001) or had personal experience with the same medication class as the vignette compared with no experience (93 of 517 [18.0%] vs 46 of 318 [12.1%], respectively; P = .02). Participants shared that improved communication (225 [25.0%]), alternative strategies (138 [15.4%]), and consideration of medication preferences (137 [15.2%]) may increase their agreement with deprescribing. Participants who disagreed compared with those who strongly disagreed were more interested in additional communication (196 [28.2%] vs 29 [14.2%], respectively; P < .001), alternative strategies (117 [16.9%] vs 21 [10.2%], respectively; P = .02), or consideration of medication preferences (122 [17.6%] vs 15 [7.3%], respectively; P < .001).

Conclusions and Relevance

In this survey study, older adults who disagreed with a deprescribing recommendation were more interested in additional communication, alternative strategies, or consideration of medication preferences compared with those who strongly disagreed. These findings suggest that identifying the degree of disagreement with deprescribing could be used to tailor patient-centered communication about deprescribing in older adults.

Ethical Aspects of Physician Decision-Making for Deprescribing Among Older Adults With Dementia

Importance

Physicians endorse deprescribing of risky or unnecessary medications for older adults (aged ≥65 years) with dementia, but there is a lack of information on what influences decisions to deprescribe in this population.

Objective

To understand how physicians make decisions to deprescribe for older adults with moderate dementia and ethical and pragmatic concerns influencing those decisions.

Design, Setting, and Participants

A cross-sectional national mailed survey study of a random sample of 3000 primary care physicians from the American Medical Association Physician Masterfile who care for older adults was conducted from January 15 to December 31, 2021.

Main Outcomes and Measures

The study randomized participants to consider 2 clinical scenarios in which a physician may decide to deprescribe a medication for older adults with moderate dementia: 1 in which the medication could cause an adverse drug event if continued and the other in which there is no evidence of benefit. Participants ranked 9 factors related to possible ethical and pragmatic concerns through best-worst scaling methods (from greatest barrier to smallest barrier to deprescribing). Conditional logit regression quantified the relative importance for each factor as a barrier to deprescribing.

Results

A total of 890 physicians (35.0%) returned surveys; 511 (57.4%) were male, and the mean (SD) years since graduation was 26.0 (11.7). Most physicians had a primary specialty in family practice (50.4% [449 of 890]) and internal medicine (43.5% [387 of 890]). A total of 689 surveys were sufficiently complete to analyze. In both clinical scenarios, the 2 greatest barriers to deprescribing were (1) the patient or family reporting symptomatic benefit from the medication (beneficence and autonomy) and (2) the medication having been prescribed by another physician (autonomy and nonmaleficence). The least influential factor was ease of paying for the medication (justice).

Conclusions and Relevance

Findings from this national survey study of primary care physicians suggests that understanding ethical aspects of physician decision-making can inform clinician education about medication management and deprescribing decisions for older adults with moderate dementia.

Deprescribing Anticholinergic and Sedative Drugs to Reduce Polypharmacy in Frail Older Adults Living in the Community: A Randomized Controlled Trial

BACKGROUND

Polypharmacy is associated with poor outcomes in older adults. Targeted deprescribing of anticholinergic and sedative medications may improve health outcomes for frail older adults. Our pharmacist-led deprescribing intervention was a pragmatic 2-arm randomized controlled trial stratified by frailty. We compared usual care (control) with the intervention of pharmacists providing deprescribing recommendations to general practitioners.

METHODS

Community-based older adults (≥65 years) from 2 New Zealand district health boards were recruited following a standardized interRAI needs assessment. The Drug Burden Index (DBI) was used to quantify the use of sedative and anticholinergic medications for each participant. The trial was stratified into low, medium, and high-frailty. We hypothesized that the intervention would increase the proportion of participants with a reduction in DBI ≥ 0.5 within 6 months.

RESULTS

Of 363 participants, 21 (12.7%) in the control group and 21 (12.2%) in the intervention group had a reduction in DBI ≥ 0.5. The difference in the proportion of -0.4% (95% confidence interval [CI]: -7.9% to 7.0%) provided no evidence of efficacy for the intervention. Similarly, there was no evidence to suggest the effectiveness of this intervention for participants of any frailty level.

CONCLUSION

Our pharmacist-led medication review of frail older participants did not reduce the anticholinergic/sedative load within 6 months. Coronavirus disease 2019 (COVID-19) lockdown measures required modification of the intervention. Subgroup analyses pre- and post-lockdown showed no impact on outcomes. Reviewing this and other deprescribing trials through the lens of implementation science may aid an understanding of the contextual determinants preventing or enabling successful deprescribing implementation strategies.

Preferences for deprescribing antihypertensive medications amongst clinicians, carers and people living with dementia: a discrete choice experiment

BACKGROUND

Optimal management of hypertension in people with dementia may involve deprescribing antihypertensives. Understanding differing treatment priorities is important to enable patient-centred care. This study explored preferences for antihypertensive deprescribing amongst people living with dementia, carers and clinicians.

METHODS

Discrete choice experiments (DCEs) are a stated preference survey method, underpinned by economic theory. A DCE was conducted, and respondents completed 12 labelled choice-questions, each presenting a status quo (continuing antihypertensives) and antihypertensive deprescribing option. The questions included six attributes, including pill burden, and event risks for stroke, myocardial infarction, increased blood pressure, cognitive decline, falls.

RESULTS

Overall, 112 respondents (33 carers, 19 people living with dementia, and 60 clinicians) completed the survey. For people with dementia, lower pill burden increased preferences for deprescribing (odds ratio (OR) 1.95, 95% confidence interval (95% CI) 1.08-3.52). Increased stroke risk (for each additional person out of 100 having a stroke) decreased the likelihood of deprescribing for geriatricians (OR 0.71, 95% CI 0.55-0.92) and non-geriatrician clinicians (OR 0.62, 95% CI 0.45-0.86), and carers (OR 0.71, 95% CI 0.58-0.88). Increased myocardial infarction risk decreased preferences for deprescribing for non-geriatricians (OR 0.81, 95% CI 0.69-0.95) and carers (OR 0.84, 95% CI 0.73-0.98). Avoiding cognitive decline increased preferences for deprescribing for geriatricians (OR 1.17, 95% CI 1.03-1.33) and carers (OR 1.27, 95% CI 1.09-1.48). Avoiding falls increased preferences for deprescribing for clinicians (geriatricians (OR 1.20, 95% CI 1.11-1.29); non-geriatricians (OR 1.16, 95% CI 1.07-1.25)). Other attributes did not significantly influence respondent preferences.

CONCLUSIONS

Antihypertensive deprescribing preferences differ amongst people with dementia, carers and clinicians. The study emphasises the importance of shared decision-making within the deprescribing process.

Attitudes of Older Adult Patients and Caregivers Towards Deprescribing of Medications in Ethiopia

Background

Deprescribing is essential for reducing inappropriate medication use and polypharmacy. For a holistic approach, it is essential to know how older adult patients and their caregivers perceive deprescribing.

Objective

To assess the attitude of older adult patients and caregivers towards deprescribing medication at Ambo University Referral Hospital.

Methodology

Institutional-based cross-sectional study was conducted using the revised Patients' Attitude Towards Deprescribing tool (rPATD). The data was analyzed using the SPSS-25 software. Backward linear regression and logistic regression were used to measure association between outcome and determinant variables. The two-sided P-value ≤0.05 with 95% confidence interval was utilized for reporting significant factors.

Results

One hundred fifty-six (81.3%) of the respondents (ie, 85.0% of older adult and 77.2% of caregivers) agreed to stop one or more of their regular medications if the physician said it was possible despite 98 (51.0%) of them (ie, 49.0% of older adult and 53.3% of caregivers) being satisfied with their/their care recipient's medications. On the overall aggregate mean score, the respondents had a neutral position (2.6-3.59) regarding the burden and concerns of stopping medications whereas the majority of them disagree (1.0-2.59) with the inappropriateness of the medication they were taking and agreed (3.6-5.0) with the need for their involvement in treatment decision making. Concerns about stopping medicine scores (AOR = 0.440, 95% CI = 0.262-0.741, P = 0.035) and perceived levels of medication inappropriateness (AOR = 0.653, 95% CI = 0.456-0.936, P = 0.020) was significantly associated with the willingness to discontinue and overall satisfaction with their medicine regimen respectively.

Conclusion

The majority of older adult patients and caregivers would like to deprescribe if the physicians recommended it. The perceived concerns of stopping and inappropriateness of the medicines were associated with the willingness to deprescribe and overall satisfaction with their medicine respectively. Healthcare providers should prompt the deprescribing process with older adult patients and caregivers by addressing their concerns about stopping medications.

Harm and Medication-Type Impact Agreement with Hypothetical Deprescribing Recommendations: a Vignette-Based Experiment with Older Adults Across Four Countries

BACKGROUND

Little is known about what factors are important to older adults when deciding whether to agree with a recommendation to deprescribe.

OBJECTIVE

To explore the extent to which medication type and rationale for potential discontinuation influence older adults' acceptance of deprescribing.

DESIGN

Cross-sectional 2 (drug: lansoprazole - treat indigestion; simvastatin - prevent cardiovascular disease) by 3 (deprescribing rationale: lack of benefit; potential for harm; both) experimental design.

PARTICIPANTS

Online panelists aged ≥65 years from Australia, the Netherlands, the United Kingdom, and the United States INTERVENTIONS: Participants were presented with a hypothetical patient experiencing polypharmacy whose PCP discussed stopping a medication. We randomized participants to receive one of six vignettes.

MAIN MEASURES

We measured agreement with deprescribing (6-point Likert scale, "Strongly disagree (1)" and "Strongly agree (6)") for the hypothetical patient as the primary outcome. We also measured participants' personality traits, perceptions of risk and uncertainty, and attitudes towards polypharmacy and deprescribing.

KEY RESULTS

Among 5311 participants (93.3% completion rate), the mean (M) agreement with deprescribing for the hypothetical patient was 4.71 (95% confidence interval (CI): 4.67, 4.75). Participants reported higher agreement with stopping lansoprazole (n=2656) (M=4.90, 95% CI: 4.85, 4.95) compared to simvastatin (n=2655) (M=4.53, 95% CI: 4.47, 4.58), P<.001. Participants who received the combination rationale (n=1786) reported higher agreement with deprescribing (M=4.83, 95% CI: 4.76, 4.89) compared to those who received the rationales on lack of benefit (n=1755) (M=4.66, 95% CI: 4.60, 4.73) or potential for harm (n=1770) (M=4.65, 95% CI 4.58, 4.72). In adjusted regression analyses (n=5062), participants with a higher desire to engage in health promotion behaviors (b=0.08, 95% CI 0.02, 0.13) or need for certainty (b=0.12, 95% CI 0.04, 0.20) reported higher agreement with deprescribing.

CONCLUSIONS

Older adults across four countries were accepting of deprescribing in the setting of polypharmacy. The medication type and rationale for discontinuation were important factors in the decision-making process.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT04676282, https://clinicaltrials.gov/ct2/show/NCT04676282?term=vordenberg&draw=2&rank=1.

Supporting conversations about medicines and deprescribing: GPs' perspectives on a Medicines Conversation Guide

OBJECTIVES

To explore GP perspectives on a Medicines Conversation Guide to support deprescribing communication.

METHODS

Semistructured interviews with GPs from Australia (n = 32). Participants were purposively sampled with varying experiences and locations. Transcribed audio recordings of interviews were coded using framework analysis.

KEY FINDINGS

Most GPs stated they would use the Guide in consultation with an older patient to discuss medications. The strengths of the Guide included empowering the patient voice on an important topic. Limitations included time and complex concepts.

CONCLUSIONS

Overall, the Medicines Conversation Guide was perceived by GPs to be a useful communication tool to support discussions about deprescribing with patients.

Deprescribing Medications Among Older Adults From End of Hospitalization Through Postacute Care: A Shed-MEDS Randomized Clinical Trial

Importance

Deprescribing is a promising approach to addressing the burden of polypharmacy. Few studies have initiated comprehensive deprescribing in the hospital setting among older patients requiring ongoing care in a postacute care (PAC) facility.

Objective

To evaluate the efficacy of a patient-centered deprescribing intervention among hospitalized older adults transitioning or being discharged to a PAC facility.

Design, Setting, and Participants

This randomized clinical trial of the Shed-MEDS (Best Possible Medication History, Evaluate, Deprescribing Recommendations, and Synthesis) deprescribing intervention was conducted between March 2016 and October 2020. Patients who were admitted to an academic medical center and discharged to 1 of 22 PAC facilities affiliated with the medical center were recruited. Patients who were 50 years or older and had 5 or more prehospital medications were enrolled and randomized 1:1 to the intervention group or control group. Patients who were non-English speaking, were unhoused, were long-stay residents of nursing homes, or had less than 6 months of life expectancy were excluded. An intention-to-treat approach was used.

Interventions

The intervention group received the Shed-MEDS intervention, which consisted of a pharmacist- or nurse practitioner-led comprehensive medication review, patient or surrogate-approved deprescribing recommendations, and deprescribing actions that were initiated in the hospital and continued throughout the PAC facility stay. The control group received usual care at the hospital and PAC facility.

Main Outcomes and Measures

The primary outcome was the total medication count at hospital discharge and PAC facility discharge, with follow-up assessments during the 90-day period after PAC facility discharge. Secondary outcomes included the total number of potentially inappropriate medications at each time point, the Drug Burden Index, and adverse events.

Results

A total of 372 participants (mean [SD] age, 76.2 [10.7] years; 229 females [62%]) were randomized to the intervention or control groups. Of these participants, 284 were included in the intention-to-treat analysis (142 in the intervention group and 142 in the control group). Overall, there was a statistically significant treatment effect, with patients in the intervention group taking a mean of 14% fewer medications at PAC facility discharge (mean ratio, 0.86; 95% CI, 0.80-0.93; P < .001) and 15% fewer medications at the 90-day follow-up (mean ratio, 0.85; 95% CI, 0.78-0.92; P < .001) compared with the control group. The intervention additionally reduced patient exposure to potentially inappropriate medications and Drug Burden Index. Adverse drug event rates were similar between the intervention and control groups (hazard ratio, 0.83; 95% CI, 0.52-1.30).

Conclusions and Relevance

Results of this trial showed that the Shed-MEDS patient-centered deprescribing intervention was safe and effective in reducing the total medication burden at PAC facility discharge and 90 days after discharge. Future studies are needed to examine the effect of this intervention on patient-reported and long-term clinical outcomes.

Trial Registration

ClinicalTrials.gov Identifier: NCT02979353.

Attitudes towards deprescribing and patient-related factors associated with willingness to stop medication among older patients with type 2 diabetes (T2D) in Indonesia: a cross-sectional survey study

BACKGROUND

Deprescribing of preventive medication is recommended in older patients with polypharmacy, including people with type 2 diabetes (T2D). It seems that many patients in low-middle-income countries are not willing to have their medicines deprescribed. This study aims to assess attitudes of Indonesian patients with T2D towards deprescribing in general and regarding specific cardiometabolic medicines, and factors influencing their willingness to stop medicines.

METHODS

Primary care patients with T2D of ≥60 years in Indonesia completed the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. Attitudes in general and for cardiometabolic medicines were reported descriptively. Proportions of patients willing to stop one or more medicines when recommended by different healthcare professionals were compared with Chi-square test. Multiple regression analysis was used to analyse the influence between patient-related factors and the willingness to stop medicines.

RESULTS

The survey was completed by 196 participants (median age 69 years, 73% female). The percentages willing to stop medicines were 69, 67, and 41%, when the general practitioner (GP), the specialist, or the pharmacist initiates the process (p-value < 0.001). Higher perceived burden of medicines (p-value = 0.03) and less concerns about stopping (p-value < 0.001) were associated with a higher willingness to stop medicines if proposed by the GP. Patients using multiple glucose-regulating medicines were less willing to stop (p-value = 0.02). Using complementary or alternative medicines was not associated with the willingness to stop. If proposed by their pharmacist, patients without substantial education were more willing to stop than educated patients.

CONCLUSIONS

Only two-thirds of older people with T2D in Indonesia were willing to stop one or more of their medicines if the GP or specialist recommended this, and even less when the pharmacist proposed this. Attention should be given to concerns about stopping specific medicines, especially among patients using multiple glucose-lowering medicines, who may be more eligible but were less willing to accept deprescribing.

Willingness of older people living with dementia and mild cognitive impairment and their caregivers to have medications deprescribed

BACKGROUND

people living with cognitive impairment commonly take multiple medications including potentially inappropriate medications (PIMs), which puts them at risk of medication related harms.

AIMS

to explore willingness to have a medication deprescribed of older people living with cognitive impairment (dementia or mild cognitive impairment) and multiple chronic conditions and assess the relationship between willingness, patient characteristics and belief about medications.

METHODS

cross-sectional study using results from the revised Patients' Attitudes Towards Deprescribing questionnaire (rPATDcog) collected as baseline data in the OPTIMIZE study, a pragmatic, cluster-randomised trial educating patients and clinicians about deprescribing. Eligible participants were 65+, diagnosed with dementia or mild cognitive impairment, and prescribed at least five-long-term medications.

RESULTS

the questionnaire was mailed to 1,409 intervention patients and 553 (39%) were returned and included in analysis. Participants had a mean age of 80.1 (SD 7.4) and 52.4% were female. About 78.5% (431/549) of participants said that they would be willing to have one of their medications stopped if their doctor said it was possible. Willingness to deprescribe was negatively associated with getting stressed when changes are made and with previously having a bad experience with stopping a medication (P < 0.001 for both).

CONCLUSION

most older people living with cognitive impairment are willing to deprescribe. Addressing previous bad experiences with stopping a medication and stress when changes are made to medications may be key points to discuss during deprescribing conversations.

Understanding older patients' willingness to have medications deprescribed in primary care: a protocol for a cross-sectional survey study in nine European countries

INTRODUCTION

To reduce inappropriate polypharmacy, deprescribing should be part of patients' regular care. Yet deprescribing is difficult to implement, as shown in several studies. Understanding patients' attitudes towards deprescribing at the individual and country level may reveal effective ways to involve older adults in decisions about medications and help to implement deprescribing in primary care settings. In this study we aim to investigate older adults' perceptions and views on deprescribing in different European countries. Specific objectives are to investigate the patients' willingness to have medications deprescribed by medication type and to have herbal or dietary supplements reduced or stopped, the role of the Patient Typology (on medication perspectives), and the impact of the patient-GP relationship in these decisions.

METHODS AND ANALYSIS

This cross-sectional survey study has two parts: Part A and Part B. Data collection for Part A will take place in nine countries, in which per country 10 GPs will recruit 10 older patients (≥65 years old) each (n = 900). Part B will be conducted in Switzerland only, in which an additional 35 GPs will recruit five patients each and respond to a questionnaire themselves, with questions about the patients' medications, their willingness to deprescribe those, and their patient-provider relationship. For both Part A and part B, a questionnaire will be used to assess the willingness of older patients with polypharmacy to have medications deprescribed and other relevant information. For Part B, this same questionnaire will have additional questions on the use of herbal and dietary supplements.

DISCUSSION

The international study design will allow comparisons of patient perspectives on deprescribing from different countries. We will collect information about willingness to have medications deprescribed by medication type and regarding herbal and dietary supplements, which adds important information to the literature on patients' preferences. In addition, GPs in Switzerland will also be surveyed, allowing us to compare GPs' and patients' views and preferences on stopping or reducing specific medications. Our findings will help to understand patients' attitudes towards deprescribing, contributing to improvements in the design and implementation of deprescribing interventions that are better tailored to patients' preferences.

Factors which influence the deprescribing decisions of community-living older adults and GPs in Australia

Deprescribing aims to reduce polypharmacy and inappropriate medication use. Both General Practitioners (GPs) and older adults have expressed a willingness to consider deprescribing. However, deprescribing is often deferred in practice. The aim of this study was to identify factors which influence GP and older adult decisions about deprescribing in primary care. Semi-structured interviews were used in this qualitative study, conducted in a regional area in Australia. Participants included GPs and adults aged 65 years or older, using five or more medications and living independently in the community. Data were collected between January 2018 and May 2019. Thematic analysis was used to analyse the verbatim transcribed interviews using NVivo 12. A total of 41 interviews were conducted, 25 with older adults and 16 with GPs. Four key themes influenced deprescribing decisions: views of ageing, shared decision-making, attitudes toward medication use and characteristics of the health care environment. Discussions of deprescribing were limited by the influence of negative stereotypes toward age and ageing, a lack of older adult participation in shared decision-making, a positive attitude towards ongoing medication use and perception of the normality of using medications in older age. Time constraints, poor communication about prescribing information and unclear roles regarding responsibility for deprescribing also prevented discussions. Continuity of care, involvement of older adults in medication reviews and GPs who asserted their generalist role were the main factors which promoted discussion of deprescribing. GPs are well placed to discuss deprescribing with their older patients because they are trusted and can provide continuity of care. Actively encouraging and involving older adults in medication reviews in order to understand their preferences, supports shared decision-making about deprescribing. Active involvement may also reduce the influence of negative views of ageing held by both older adults and GPs.

Enhancing deprescribing: A qualitative understanding of the complexities of pharmacist-led deprescribing in care homes

The English National Overprescribing Review identified that older people often take eight or more medicines a day. The report recommended pharmacists in primary care should take responsibility for addressing polypharmacy. Overprescribing is a safety concern in care homes as approximately half of older care home residents are prescribed at least one medicine that is unnecessary or now harmful. This predisposes them to adverse outcomes including hospitalisation and mortality. Deprescribing is the planned activity of stopping or reducing a medicine that may no longer be appropriate. Deprescribing, when performed by a pharmacist, is a multidisciplinary activity requiring close communication with general practitioners (GPs) and care home staff. A recently completed trial that integrated pharmacists with prescribing rights into older peoples' care homes found significant variation in proactive deprescribing activity. The aim of the current study was to specifically explore beliefs and practices of deprescribing in care homes. A qualitative approach was adopted to examine individual, social and contextual factors that acted as enablers and barriers to pharmacist deprescribing in care homes. Semi-structured interviews were conducted with participants of the previous study (16 pharmacists, 6 GPs and 7 care home staff from Northern Ireland, Scotland and England). Using thematic analysis, we identified two themes: (a) Structures and systems affecting deprescribing, that is the context in which deprescribing happened, including team involvement and routine practices in GP surgeries and care homes; (b) Balancing risks when deprescribing, that is the perception of individual risk and social barriers were mitigated by understanding the medical background of residents. This supported the clinical understanding that risks from overprescribing were greater than risks from deprescribing. While deprescribing can involve all health professionals in the primary care team, these results suggest the pharmacist is well placed to lead the process; by having both clinical competence and professional willingness to drive this activity forward.

N-of-1 trials to facilitate evidence-based deprescribing: Rationale and case study

Deprescribing has emerged as an important aspect of patient-centred medication management but is vastly underutilized in clinical practice. The current narrative review will describe an innovative patient-centred approach to deprescribing-N-of-1 trials. N-of-1 trials involve multiple-period crossover design experiments conducted within individual patients. They enable patients to compare the effects of two or more treatments or, in the case of deprescribing N-of-1 trials, continuation with a current treatment versus no treatment or placebo. N-of-1 trials are distinct from traditional between-patient studies such as parallel-group or crossover designs which provide an average effect across a group of patients and obscure differences between individuals. By generating data on the effect of an intervention for the individual rather than the population, N-of-1 trials can promote therapeutic precision. N-of-1 trials are a particularly appealing strategy to inform deprescribing because they can generate individual-level evidence for deprescribing when evidence is uncertain, and can thus allay patient and physician concerns about discontinuing medications. To illustrate the use of deprescribing N-of-1 trials, we share a case example of an ongoing series of N-of-1 trials that compare maintenance versus deprescribing of beta-blockers in patients with heart failure with preserved ejection fraction. By providing quantifiable data on patient-reported outcomes, promoting personalized pharmacotherapy, and facilitating shared decision making, N-of-1 trials represent a potentially transformative strategy to address polypharmacy.

Multimorbidity, polypharmacy and inappropriate prescribing in elderly patients with atrial fibrillation: A report from the China Atrial Fibrillation Registry Study

Background

Multimorbidity, polypharmacy and inappropriate prescribing is common in elderly patients worldwide. We aimed to explore the current status of multimorbidity, polypharmacy and the appropriateness of pharmacological therapy among elderly patients with atrial fibrillation (AF) in China.

Materials and methods

We randomly selected 500 patients aged 65 years or older from the China AF Registry study. Multimorbidity was defined as ≥2 comorbidities and polypharmacy was defined as ≥5 long-term prescribed drugs. Appropriateness of prescribing was evaluated using the Screening Tool of Older People’s Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) criteria version 2. Patients’ attitudes toward polypharmacy were evaluated by the Patients’ Attitudes Towards Deprescribing (PATD) questionnaire.

Results

Among the 500 patients included (mean age 75.2 ± 6.7 years, 49.0% male), 98.0% had multimorbidity and 49.4% had polypharmacy. The prevalence of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) was 43.6% (n = 218) and 71.6% (n = 358), respectively. Traditional Chinese medicine attributed largely to PIMs. Anticoagulants were the most common PPOs. Many clinical factors increased the risk of PIMs and PPOs. However, polypharmacy increased the risk of PIMs (OR 2.70, 95%CI 1.78–4.11; p &lt; 0.0001), but not PPOs. In addition, 73.7% patients with polypharmacy were willing to have one or more of their medications prescribed if advised by their doctor.

Conclusion

Multimorbidity and polypharmacy were highly prevalent in elderly patients with AF in China. A high prevalence of inappropriate prescribing was also observed. Therefore, much more attention should be paid to the serious health problem in the elderly population.