Qualitative insights into general practitioners views on polypharmacy

Designing and validating a clinical decision support algorithm for diabetic nephroprotection in older patients

BACKGROUND

Older patients with diabetic kidney disease (DKD) often do not receive optimal pharmacological treatment. Current clinical practice guidelines (CPGs) do not incorporate the concept of personalised care. Clinical decision support (CDS) algorithms that consider both evidence and personalised care to improve patient outcomes can improve the care of older adults. The aim of this research is to design and validate a CDS algorithm for prescribing renin-angiotensin-aldosterone system inhibitors (RAASi) for older patients with diabetes.

METHODS

The design of the CDS tool included the following phases: (1) gathering evidence from systematic reviews and meta-analyses of randomised clinical trials to determine the number needed to treat (NNT) and time-to-benefit (TTB) values applicable to our target population for use in the algorithm. (2) Building a list of potential cases that addressed different prescribing scenarios (starting, adding or switching to RAASi). (3) Reviewing relevant guidelines and extracting all recommendations related to prescribing RAASi for DKD. (4) Matching NNT and TTB with specific clinical cases. (5) Validating the CDS algorithm using Delphi technique.

RESULTS

We created a CDS algorithm that covered 15 possible scenarios and we generated 36 personalised and nine general recommendations based on the calculated and matched NNT and TTB values and considering the patient's life expectancy and functional capacity. The algorithm was validated by experts in three rounds of Delphi study.

CONCLUSION

We designed an evidence-informed CDS algorithm that integrates considerations often overlooked in CPGs. The next steps include testing the CDS algorithm in a clinical trial.

Patient-centered care in diabetes care-concepts, relationships and practice

We still do not have comprehensive knowledge of which framework of patient-centered care (PCC) is appropriate for diabetes care, which elements of PCC are evidence-based, and the mechanism by which PCC elements are associated with outcomes through mediators. In this review, we elaborate on these issues. We found that for diabetes care, PCC elements such as autonomy support (patient individuality), cooperation and collaboration (system-level approach), com-munication and education (behavior change techniques), emotional support (biopsychosocial approach), and family/other involvement and support are critically important. All of these factors are directly associated with different patient outcomes and indirectly associated with outcomes through patient activation. We present the practical implications of these PCC elements.

Assessing deprescribing tools for implementation in care homes: A qualitative study of the views of care home staff

BACKGROUND

Care home residents often experience polypharmacy (defined as taking five or more regular medicines). Therefore, we need to ensure that residents only take the medications that are appropriate or provide value (also known as medicines optimisation). To achieve this, deprescribing, or the reduction or stopping of prescription medicines that may no longer be providing benefit, can help manage polypharmacy and improve outcomes. Various tools, guides, and approaches have been developed to help support health professionals to deprescribe in regular practice. Little evaluation of these tools has been conducted and no work has been done in the care home setting.

OBJECTIVE

This qualitative study aimed to assess distinct types of deprescribing tools for acceptability, feasibility, and suitability for the care home setting.

METHODS

Cognitive (think-aloud) interviews with care home staff in England were conducted (from December 2021 to June 2022) to assess five different deprescribing tools. The tools included a general deprescribing guidance, a generic (non-drug specific) deprescribing framework, a drug-specific deprescribing guideline/guide, a tool for identifying potentially inappropriate medications, and an electronic clinical decision support tool. Participants were recruited via their participation in another deprescribing study. The Consolidated Framework for Implementation Research informed the data collection and analysis.

RESULTS

Eight care home staff from 7 different care homes were interviewed. The five deprescribing tools were reviewed and assessed as not acceptable, feasible, or suitable for the care home setting. All would require significant modifications for use in the care home setting (e.g., language, design, and its function or use with different stakeholders).

CONCLUSIONS

As none of the tools were deemed acceptable, feasible, and suitable, future work is warranted to develop and tailor deprescribing tools for the care home setting, considering its specific context and users. Deprescribing implemented safely and successfully in care homes can benefit residents and the wider health economy.

Antidepressant deprescribing: State of the art and recommendations-A literature overview

INTRODUCTION

In recent years, the consumption of antidepressants has arisen. However, deprescribing antidepressant therapy is very complicated. The aim of this study was to implement practical recommendations for the development of guidelines to be used for antidepressant deprescription in clinical practice.

MATERIALS AND METHODS

The literature search has been conducted on March 13, 2023, using Scopus and PubMed databases. The following search string has been used: "antidepressants AND (deprescribing OR deprescription)". All studies reporting a deprescribing intervention for antidepressant medication, regardless of the study design, have been included. Studies that did not report antidepressant drug deprescription interventions and non-English-language papers have been excluded.

RESULTS

From the literature search, a total of 230 articles have been extracted. Applying the exclusion criteria, 26 articles have been considered eligible. Most of the analyzed studies (16, 61%) have been carried out in the real world, 3 (11%) were RCTs, 5 (19%) were qualitative studies, in particular expert opinions, 1 (4%) was a literature review, and 1 (4%) was a post-trial observational follow-up of an RCT. In 8 out of 26 studies (31%), the analyzed antidepressants have been specified: 2 (8%) focused on anticholinergics, 2 (8%) on SSRIs, 3 (11%) on tricyclic antidepressants, and 1 (4%) on esketamine. Nineteen out of 26 studies (73%) did not stratify antidepressants by therapeutic class. The sample sizes analyzed in the studies ranged from a minimum of 4 patients to a maximum of 113,909, and 12 studies included geriatric age as an inclusion criterion. A patient's therapy review has been the main deprescribing intervention, and it has been identified in 14 (54%) articles. Interventions have been carried out by clinicians in 4 (15%) studies, general practitioners in 5 (19%) studies, nurses in 2 (8%) studies, pharmacists in 4 (15%) studies, multidisciplinary teams in 10 (38%) studies, and patients in 1 (4%) study.

CONCLUSIONS

From the literature review, it emerged that there is no clear evidence useful to support clinicians in antidepressant deprescribing interventions.

Determinants of implementing deprescribing for older adults in English care homes: a qualitative interview study

OBJECTIVES

To explore the factors that may help or hinder deprescribing practice for older people within care homes.

DESIGN

Qualitative semistructured interviews using framework analysis informed by the Consolidated Framework for Implementation Research (CFIR).

SETTING

Participants were recruited from two care home provider organisations (a smaller independently owned organisation and a large organisation) in England.

PARTICIPANTS

A sample of 23 care home staff, 8 residents, 4 family members and 1 general practitioner were associated with 15 care homes.

RESULTS

Participants discussed their experiences and perceptions of implementing deprescribing within care homes. Major themes of (1) deprescribing as a complex process and (2) internal and external contextual factors influencing deprescribing practice (such as beliefs, abilities and relationships) were interrelated and spanned several CFIR constructs and domains. The quality of local relationships with and support from healthcare professionals were considered more crucial factors than the type of care home management structure.

CONCLUSIONS

Several influencing social and contextual factors need to be considered for implementing deprescribing for older adults in care homes. Additional training, tools, support and opportunities need to be made available to care home staff, so they can feel confident and able to question or raise concerns about medicines with prescribers. Further work is warranted to design and adopt a deprescribing approach which addresses these determinants to ensure successful implementation.

A health-system-embedded deprescribing intervention targeting patients and providers to prevent falls in older adults (STOP-FALLS trial): study protocol for a pragmatic cluster-randomized controlled trial

BACKGROUND

Central nervous system (CNS) active medications have been consistently linked to falls in older people. However, few randomized trials have evaluated whether CNS-active medication reduction reduces falls and fall-related injuries. The objective of the Reducing CNS-active Medications to Prevent Falls and Injuries in Older Adults (STOP-FALLS) trial is to test the effectiveness of a health-system-embedded deprescribing intervention focused on CNS-active medications on the incidence of medically treated falls among community-dwelling older adults.

METHODS

We will conduct a pragmatic, cluster-randomized, parallel-group, controlled clinical trial within Kaiser Permanente Washington to test the effectiveness of a 12-month deprescribing intervention consisting of (1) an educational brochure and self-care handouts mailed to older adults prescribed one or more CNS-active medications (aged 60 + : opioids, benzodiazepines and Z-drugs; aged 65 + : skeletal muscle relaxants, tricyclic antidepressants, and antihistamines) and (2) decision support for their primary health care providers. Outcomes are examined over 18-26 months post-intervention. The primary outcome is first incident (post-baseline) medically treated fall as determined from health plan data. Our sample size calculations ensure at least 80% power to detect a 20% reduction in the rate of medically treated falls for participants receiving care within the intervention (n = 9) versus usual care clinics (n = 9) assuming 18 months of follow-up. Secondary outcomes include medication discontinuation or dose reduction of any target medications. Safety outcomes include serious adverse drug withdrawal events, unintentional overdose, and death. We will also examine medication signetur fields for attempts to decrease medications. We will report factors affecting implementation of the intervention.

DISCUSSION

The STOP-FALLS trial will provide new information about whether a health-system-embedded deprescribing intervention that targets older participants and their primary care providers reduces medically treated falls and CNS-active medication use. Insights into factors affecting implementation will inform future research and healthcare organizations that may be interested in replicating the intervention.

TRIAL REGISTRATION

ClinicalTrial.gov NCT05689554. Registered on 18 January 2023, retrospectively registered.

A GP's clinical reasoning in the context of multimorbidity: beyond the perception of an intuitive approach

INTRODUCTION

GP's clinical reasoning processes in the context of patients suffering from multimorbidity are often a process which remains implicit. Therefore, the goal of this case study analysis is to gain a better understanding of the processes at play in the management of patients suffering from multimorbidity.

METHODS

A case study analysis, using a qualitative thematic analysis was conducted. This case follows a 54-year-old woman who has been under the care of her GP for almost 10 years and suffers from a number of chronic conditions. The clinical reasoning of an experienced GP who can explicitly unfold his processes was chosen for this case analysis.

RESULTS

Four main themes emerged from this case analysis: The different roles that GPs have to manage; the GP's cognitive flexibility and continual adaptation of their clinical reasoning processes, the patient's empowerment, and the challenges related to the collaboration with specialists and healthcare professionals.

CONCLUSION

This could help GPs gain a clearer understanding of their clinical reasoning processes and motivate them to communicate their findings with others during clinical supervision or teaching. Furthermore, this may emphasize the importance of valuing the role of the primary care physician in the management of multimorbid patients.

Medication Review and Enhanced Information Transfer at Discharge of Older Patients with Polypharmacy: a Cluster-Randomized Controlled Trial in Swiss Hospitals

BACKGROUND

Medication safety in patients with polypharmacy at transitions of care is a focus of the current Third WHO Global Patient Safety Challenge. Medication review and communication between health care professionals are key targets to reduce medication-related harm.

OBJECTIVE

To study whether a hospital discharge intervention combining medication review with enhanced information transfer between hospital and primary care physicians can delay hospital readmission and impact health care utilization or other health-related outcomes of older inpatients with polypharmacy.

DESIGN

Cluster-randomized controlled trial in 21 Swiss hospitals between January 2019 and September 2020, with 6 months follow-up.

PARTICIPANTS

Sixty-eight senior physicians and their blinded junior physicians included 609 patients ≥ 60 years taking ≥ 5 drugs.

INTERVENTIONS

Participating hospitals were randomized to either integrate a checklist-guided medication review and communication stimulus into their discharge processes, or follow usual discharge routines.

MAIN MEASURES

Primary outcome was time-to-first-readmission to any hospital within 6 months, analyzed using a shared frailty model. Secondary outcomes covered readmission rates, emergency department visits, other medical consultations, mortality, drug numbers, proportions of patients with potentially inappropriate medication, and the patients' quality of life.

KEY RESULTS

At admission, 609 patients (mean age 77.5 (SD 8.6) years, 49.4% female) took a mean of 9.6 (4.2) drugs per patient. Time-to-first-readmission did not differ significantly between study arms (adjusted hazard ratio 1.14 (intervention vs. control arm), 95% CI [0.75-1.71], p = 0.54), nor did the 30-day hospital readmission rates (6.7% [3.3-10.1%] vs. 7.0% [3.6-10.3%]). Overall, there were no clinically relevant differences between study arms at 1, 3, and 6 months after discharge.

CONCLUSIONS

The combination of a structured medication review with enhanced information transfer neither delayed hospital readmission nor improved other health-related outcomes of older inpatients with polypharmacy. Our results may help researchers in balancing practicality versus stringency of similar hospital discharge interventions.

STUDY REGISTRATION

ISRCTN18427377, https://doi.org/10.1186/ISRCTN18427377.

Nurses' Experiences Concerning Older Adults with Polypharmacy: A Meta-Synthesis of Qualitative Findings

Polypharmacy is an increasing health concern among older adults and results in many health risks. Nurses have an important role to play in supporting medication management and promoting medication safety across different settings. This study aims to provide a meta-synthesis of qualitative studies investigating the perceptions and experiences of nurses in caring for older adults with polypharmacy. Electronic databases including PsycArticles, CINAHL Complete, MEDLINE, and ERIC were searched between September 2001 and July 2022. Potential studies were checked against inclusion and exclusion criteria. We included peer-reviewed studies reporting data on the experiences of nursing staff across different settings. Studies unitizing any qualitative approach were included, and the included studies were reviewed and analyzed using a thematic synthesis approach. Study quality was examined using the Critical Appraisal Skills Programme checklist for qualitative research. A total of nine studies with 91 nurses were included. Four major themes emerged: older adults suffering from polypharmacy, the importance of multidisciplinary teams, nursing roles in caring for older adults, and the complexity and barriers of implementing polypharmacy management. Healthcare professionals should pay attention to the impacts of polypharmacy in older adults' lives and should acknowledge the importance of team-based polypharmacy care in supporting older adults. Nurses play a key role in caring for older adults with polypharmacy, therefore, they should be empowered and be involved in medication management.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

KEY RESULTS

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

CONCLUSION

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

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.

Over- and under-prescribing, and their association with functional disability in older patients at risk of further decline in Germany - a cross-sectional survey conducted as part of a randomised comparative effectiveness trial

Background

Older patients at risk of functional decline are frequently affected by polypharmacy. This is associated with a further loss of independence. However, a relationship between functional disability and medications, such as ‘Potentially Inappropriate Medications’ (PIMs) and ‘Potential Prescribing Omissions’ (PPOs), as itemised for (de) prescribing in practice-orientated medication lists, has yet to be established.

Methods

As part of a randomised comparative effectiveness trial, LoChro, we conducted a cross-sectional analysis of the association between PIMs and PPOs measured using the ‘Screening Tool of Older Persons’ Prescription Criteria / Screening Tool To Alert to Right Treatment’ (STOPP/START) Version 2, with functional disability assessed using the ‘World Health Organization Disability Assessment Schedule 2.0’ (WHODAS). Individuals aged 65 and older at risk of loss of independence were recruited from the inpatient and outpatient departments of the local university hospital. Multiple linear regression analysis was used to model the potential prediction of functional disability using the numbers of PIMs and PPOs, adjusted for confounders including multimorbidity.

Results

Out of 461 patients, both the number of PIMs and the number of PPOs were significantly associated with an increase in WHODAS-score (Regression coefficients B 2.7 [95% confidence interval: 1.5-3.8] and 1.5 [95% confidence interval: 0.2-2.7], respectively). In WHODAS-score prediction modelling the contribution of the number of PIMs exceeded the one of multimorbidity (standardised coefficients beta: PIM 0.20; multimorbidity 0.13; PPO 0.10), whereas no significant association between the WHODAS-score and the number of medications was seen. 73.5 % (339) of the participants presented with at least one PIM, and 95.2% (439) with at least one PPO. The most common PIMs were proton pump inhibitors and analgesic medication, with frequent PPOs being pneumococcal and influenza vaccinations, as well as osteoporosis prophylaxis.

Conclusions

The results indicate a relationship between inappropriate prescribing, both PIMs and PPOs, and functional disability, in older patients at risk of further decline. Long-term analysis may help clarify whether these patients benefit from interventions to reduce PIMs and PPOs.

Integrated Care for Multimorbidity Population in Asian Countries: A Scoping Review

Background:

The complex needs of patients with multiple chronic diseases call for integrated care (IC). This scoping review examines several published Asian IC programmes and their relevant components and elements in managing multimorbidity patients.

Method:

A scoping review was conducted by searching electronic databases encompassing Medline, Embase, Scopus, and Web of Science. Three key concepts – 1) integrated care, 2) multimorbidity, and 3) Asian countries – were used to define searching strategies. Studies were included if an IC programme in Asia for multimorbidity was described or evaluated. Data extraction for IC components and elements was carried out by adopting the SELFIE framework.

Results:

This review yielded 1,112 articles, of which 156 remained after the title and abstract screening and 27 studies after the full-text screening – with 23 IC programmes identified from seven Asian countries. The top 5 mentioned IC components were service delivery (n = 23), workforce (n = 23), leadership and governance (n = 23), monitoring (n = 15), and environment (n = 14); whist financing (n = 9) was least mentioned. Compared to EU/US countries, technology and medical products (Asia: 40%, EU/US: 43%-100%) and multidisciplinary teams (Asia: 26%, EU/US: 50%–81%) were reported less in Asia. Most programmes involved more micro-level elements that coordinate services at the individual level (n = 20) than meso- and macro-level elements, and programmes generally incorporated horizontal and vertical integration (n = 14).

Conclusion:

In the IC programmes for patients with multimorbidity in Asia, service delivery, leadership, and workforce were most frequently mentioned, while the financing component was least mentioned. There appears to be considerable scope for development.

Highlights

Impediments to deprescription in Brazil: overview from a panel of geriatrics experts

Objectives: To identify impediments to deprescription among older adults from the perspective of a panel of Brazilian geriatricians. Methods: The Delphi method was used to obtain a consensus among Brazilian geriatricians about the factors that influence the lack of deprescription for older adults in clinical practice. The study was developed in two stages: (i) a survey and description of potential factors involved in deprescription; and (ii) applying the results of the survey to a panel of experts to obtain a consensus. Results: The deprescription process is influenced by the interaction of three pillars of older adult health care: the prescriber, the patient-family, and the health care system. In the professional and health care systems, professional training and communication skills, prolonged clinical follow-up, access to the multidisciplinary team, medical consultations of an adequate time, and unified electronic health records were identified as facilitators of deprescription. In the patient-family pillar, clear facilitators included health literacy, no sensory or cognitive deficits, and a clinical situation of transitional or palliative care. Conclusions: Deprescription is a complex, multifactorial process that requires attention, time, and specific skills and competencies from the attending physician, but it also requires shared decision-making and a health system compatible with a culture of deprescription.

Expert-based medication reviews to reduce polypharmacy in older patients in primary care: a northern-Italian cluster-randomised controlled trial

BACKGROUND

Evidence regarding clinically relevant effects of interventions aiming at reducing polypharmacy is weak, especially for the primary care setting. This study was initiated with the objective to achieve clinical benefits for older patients (aged 75+) by means of evidence-based reduction of polypharmacy (defined as ≥8 prescribed drugs) and inappropriate prescribing in general practice.

METHODS

The cluster-randomised controlled trial involved general practitioners and patients in a northern-Italian region. The intervention consisted of a review of patient's medication regimens by three experts who gave specific recommendations for drug discontinuation. Main outcome measures were non-elective hospital admissions or death within 24 months (composite primary endpoint). Secondary outcomes were drug numbers, hospital admissions, mortality, falls, fractures, quality of life, affective status, cognitive function.

RESULTS

Twenty-two GPs/307 patients participated in the intervention group, 21 GPs/272 patients in the control group. One hundred twenty-five patients (40.7%) experienced the primary outcome in the intervention group, 87 patients (32.0%) in the control group. The adjusted rates of occurrence of the primary outcome did not differ significantly between the study groups (intention-to-treat analysis: adjusted odds ratio 1.46, 95%CI 0.99-2.18, p = 0.06; per-protocol analysis: adjusted OR 1.33, 95%CI 0.87-2.04, p = 0.2). Hospitalisations as single endpoint occurred more frequently in the intervention group according to the unadjusted analysis (OR 1.61, 95%CI 1.03-2.51, p = 0.04) but not in the adjusted analysis (OR 1.39, 95%CI 0.95-2.03, p = 0.09). Falls occurred less frequently in the intervention group (adjusted OR 0.55, 95%CI 0.31-0.98; p = 0.04). No significant differences were found regarding the other outcomes. Definitive discontinuation was obtained for 67 (16.0%) of 419 drugs rated as inappropriate. About 6% of the prescribed drugs were PIMs.

CONCLUSIONS

No conclusive effects were found regarding mortality and non-elective hospitalisations as composite respectively single endpoints. Falls were significantly reduced in the intervention group, although definitive discontinuation was achieved for only one out of six inappropriate drugs. These results indicate that (1) even a modest reduction of inappropriate medications may entail positive clinical effects, and that (2) focusing on evidence-based new drug prescriptions and prevention of polypharmacy may be more effective than deprescribing.

TRIAL REGISTRATION

Current Controlled Trials (ID ISRCTN: 38449870), date: 11/09/2013.

Anticholinergic Burden of Geriatric Ward Inpatients

Background and Objectives: Anticholinergic drug use in the pharmacotherapy of elderly persons is common despite the increased risk of side effects. We examined the prevalence of anticholinergic drug use and total anticholinergic drug burden among patients admitted to an acute care geriatric ward in Poland. Materials and Methods: Cross-sectional study of 329 subjects hospitalized at the geriatric ward. Patient condition was assessed with a comprehensive geriatric assessment. The Anticholinergic Cognitive Burden (ACB) scale was used to estimate the total anticholinergic load. Results: Mean patient age was 79.61 ± 6.82 years. 40.73% of them were burdened with at least one anticholinergic drug. The clinically significant anticholinergic burden was observed in 13.98% of subjects. Patients with dementia, risk of falls, and severe disability had significantly higher total ACB scores compared to other groups. The receiver operating characteristics (ROC) curve revealed that the total ACB score ≥ 1 was significantly associated with dementia and the risk of falls. Total ACB score ≥ 2 was significantly associated with severe disability. Conclusions: Patients admitted to an acute care geriatric ward had an anticholinergic cognitive burden score comparable to other patient populations. We found associations at both low and elevated levels of anticholinergic burden with dementia and risk of falls. At elevated anticholinergic burden levels, we found associations with severe disability. Despite recommendations against the use of anticholinergics in older adults these medications are still commonly prescribed. Further study is necessary to define the characteristics of anticholinergic medication most closely associated with negative outcomes in elderly populations.

Multimorbidity and clinical reasoning through the eyes of GPs: a qualitative study

Objectives

Despite the high prevalence of patients suffering from multimorbidity, the clinical reasoning processes involved during the longitudinal management are still sparse.

This study aimed to investigate what are the different characteristics of the clinical reasoning process clinicians use with patients suffering from multimorbidity, and to what extent this clinical reasoning differs from diagnostic reasoning.

Design

Given the exploratory nature of this study and the difficulty general practitioners (GPs) have in expressing their reasoning, a qualitative methodology was therefore, chosen. The Clinical reasoning Model described by Charlin et al was used as a framework to describe the multifaceted processes of the clinical reasoning.

Setting

Semistructured interviews were conducted with nine GPs working in an ambulatory setting in June to September 2018, in Geneva, Switzerland.

Participants

Participants were GPs who came from public hospital or private practice. The interviews were transcribed verbatim and a thematic analysis was conducted.

Results

The results highlighted how some cognitive processes seem to be more specific to the management reasoning.

Thus, the main goal is not to reach a diagnosis, but rather to consider several possibilities in order to maintain a balance between the evidence-based care options, patient’s priorities and maintaining quality of life. The initial representation of the current problem seems to be more related to the importance of establishing links between the different pre-existing diseases, identifying opportunities for actions and trying to integrate the new elements from the patient’s context, rather than identifying the signs and symptoms that can lead to generating new clinical hypotheses. The multiplicity of options to resolve problems is often perceived as difficult by GPs. Furthermore, longitudinal management does not allow them to achieve a final resolution of problems and that requires continuous review and an ongoing prioritisation process.

Conclusion

This study contributes to a better understanding of the clinical reasoning processes of GPs in the longitudinal management of patients suffering from multimorbidity. Through a practical and accessible model, this qualitative study offers new perspectives for identifying the components of management reasoning. These results open the path to new research projects.

Deprescribing practice in a resource-limited setting: Healthcare providers' insights

AIMS

Inappropriate polypharmacy poses risks of adverse drug events, high healthcare costs and mortality. Deprescribing could minimise inappropriate polypharmacy and the consequences thereof. The aim of this study was to evaluate healthcare providers' (HCPs') attitudes toward and experiences with deprescribing practice in Ethiopia.

METHODS

We conducted an institution-based cross-sectional survey among HCPs at the University of Gondar Comprehensive Specialized Hospital, Ethiopia. We used a validated questionnaire developed by Linsky et al. The tool included questions that explore medication characteristics, current patient clinical factors, predictions of future health states, patients' resources to manage their own health and education and experience. One-way ANOVA was used to test the association between sociodemographic variables and their perception of deprescribing decisions.

RESULTS

Of 85 HCPs approached, about 82 HCPs completed the survey, giving a response rate of 96.5%. Most of the participants (n = 73, 89%) have scored less than 1.5 points showing they are reluctant to proactively deprescribe. Physicians seem to be affected by the significant physical health conditions (mean = 1.68) and clinical endpoint like blood pressure (mean = 1.5) to make deprescribing decisions. According to the post hoc analysis of one-way ANOVA, clinical pharmacists seemed to have a better attitude toward deprescribing decisions compared with physicians (P = .025).

CONCLUSION

HCPs' decision to discontinue a medication could be multifactorial. Physicians could be influenced by physical health condition and clinical endpoints for deprescribing decision. Future studies should emphasise on barriers and facilitators to deprescribing practice specific to the context in Ethiopia.

Barriers to appropriate prescribing in older adults with multimorbidity: A modified Delphi study

OBJECTIVES

We aimed to understand the barriers experienced by physicians when prescribing for older adults with multimorbidity in specialist outpatient clinics in Singapore.

METHODS

A modified Delphi study was conducted via email with 20 panel experts in the field of geriatric medicine. Barriers identified from an earlier scoping review were presented as statements to the panel.

RESULTS

Eleven barrier statements reached consensus with high importance according to the Delphi panel. Of these statements, seven (64%) belong to the domain of Environmental context and resources in the Theoretical Domains Framework (TDF), while the remaining barriers belong to the domains of skills, knowledge, intentions, and professional/social role and identity. The barriers are further linked to intervention functions in the Behaviour Change Wheel (BCW).

CONCLUSION

Linking the TDF domains to intervention functions revealed strategic directions for the development of an intervention to address the barriers and optimize prescribing.

Understanding GPs' clinical reasoning processes involved in managing patients suffering from multimorbidity: A systematic review of qualitative and quantitative research

BACKGROUND

Most consultations in primary care involve patients suffering from multimorbidity. Nevertheless, few studies exist on the clinical reasoning processes of general practitioners (GPs) during the follow-up of these patients. The aim of this systematic review is to summarise published evidence on how GPs reason and make decisions when managing patients with multimorbidity in the long term.

METHODS

A search of the relevant literature from Medline, Embase, PsycINFO, and ERIC databases was conducted in June 2019. The search terms were selected from five domains: primary care, clinical reasoning, chronic disease, multimorbidity, and issues of multimorbidity. Qualitative, quantitative, and mixed-methods studies published in English and French were included. Quality assessment was performed using the Mixed Methods Appraisal Tool.

RESULTS

A total of 2 165 abstracts and 362 full-text articles were assessed. Thirty-two studies met the inclusion criteria. Results showcased that GPs' clinical reasoning during the long-term management of multimorbidity is about setting intermediate goals of care in an ongoing process that adapts to the patients' constant evolution and contributes to preserve their quality of life. In the absence of guidelines adapted to multimorbidity, there is no single correct plan, but competing priorities and unavoidable uncertainties. Thus, GPs have to consider and weigh multiple factors simultaneously. In the context of multimorbidity, GPs describe their reasoning as essentially intuitive and seem to perceive it as less accurate. These clinical reasoning processes are nevertheless more analytical as they might think and rooted in deep knowledge of the individual patient.

CONCLUSIONS

Although the challenges GPs are facing in the long-term follow-up of patients suffering from multimorbidity are increasingly known, the literature currently offers limited information about GPs' clinical reasoning processes at play. GPs tend to underestimate the complexity and richness of their clinical reasoning, which may negatively impact their practice and their teaching.

GPs' use and understanding of the benefits and harms of treatments for long-term conditions: a qualitative interview study

Background

To support shared decision making and improve the management of polypharmacy, it is recommended that GPs take into account quantitative information on the benefits and harms of treatments (QIRx). Quantitative evidence shows GPs’ knowledge of this is low.

Aim

To explore GPs’ attitudes to and understanding of QIRx for long-term conditions.

Design and setting

Qualitative interview study in UK general practice.

Method

Semi-structured interviews were carried out with 15 GPs. Audiorecordings were transcribed verbatim and a framework approach was used for analysis.

Results

Participants described knowing or using QIRx for only a few treatments. There was awareness of this knowledge deficit coupled with low confidence in statistical terminology. Some GPs perceived an absence of this information as an important barrier to optimal care, while others were content to follow guidelines. In the absence of this knowledge, other strategies were described to individualise treatment decisions. The idea of increasing the use of QIRx appealed to most participants, with imagined benefits for patients and themselves. However, potential barriers were described: a need for accessible information that can be understood and integrated into real-world practice, system factors, and communication challenges.

Conclusion

GPs were aware of their knowledge deficit with regard to an understanding of QIRx. Most participants were positive about the idea of increasing their use of QIRx in practice but described important challenges, which need to be considered when designing solutions.

Primary Care and Mental Health Prescribers, Key Clinical Leaders, and Clinical Pharmacist Specialists' Perspectives on Opioids and Benzodiazepines

OBJECTIVE

Due to increased risks of overdose fatalities and injuries associated with coprescription of opioids and benzodiazepines, healthcare systems have prioritized deprescribing this combination. Although prior work has examined providers' perspectives on deprescribing each medication separately, perspectives on deprescribing patients with combined use is unclear. We examined providers' perspectives on coprescribed opioids and benzodiazepines and identified barriers and facilitators to deprescribing.

DESIGN

Qualitative study using semistructured interviews.

SETTING

One multisite Veterans Affairs (VA) healthcare system in the United States of America.

SUBJECTS

Primary care and mental health prescribers, key clinical leaders, clinical pharmacist specialists (N = 39).

METHODS

Interviews were audio-recorded, transcribed, and analyzed using thematic analysis. Themes were identified iteratively, through a multidisciplinary team-based process.

RESULTS

Analyses identified four themes related to barriers and facilitators to deprescribing: inertia, prescriber self-efficacy, feasibility of deprescribing/tapering, and promoting deprescribing, as well as a fifth theme, consequences of deprescribing. Results highlighted the complexity of deprescribing when multiple prescribers are involved, a need for additional support and time, and concerns about patients' reluctance to discontinue these medications. Facilitators included agreement with the goal of deprescribing and fear of negative consequences if medications are continued. Providers spoke to how deprescribing efforts impaired patient-provider relationships and informed their decisions not to start patients on these medications.

CONCLUSIONS

Although providers agree with the goal, prescribers' belief in a limited deprescribing role, challenges with coordination among prescribers, concerns about insufficient time and patients' resistance to discontinuing these medications need to be addressed for efforts to be successful.

GPs' mindlines on deprescribing antihypertensives in older patients with multimorbidity: a qualitative study in English general practice

Background

Optimal management of hypertension in older patients with multimorbidity is a cornerstone of primary care practice. Despite emphasis on personalised approaches to treatment in older patients, there is little guidance on how to achieve medication reduction when GPs are concerned that possible risks outweigh potential benefits of treatment. Mindlines — tacit, internalised guidelines developed over time from multiple sources — may be of particular importance in such situations.

Aim

To explore GPs’ decision-making on deprescribing antihypertensives in patients with multimorbidity aged ≥80 years, drawing on the concept of mindlines.

Design and setting

Qualitative interview study set in English general practice.

Method

Thematic analysis of face-to-face interviews with a sample of 15 GPs from seven practices in the East of England, using a chart-stimulated recall approach to explore approaches to treatment for older patients with multimorbidity with hypertension.

Results

GPs are typically confident making decisions to deprescribe antihypertensive medication in older patients with multimorbidity when prompted by a trigger, such as a fall or adverse drug event. GPs are less confident to attempt deprescribing in response to generalised concerns about polypharmacy, and work hard to make sense of multiple sources (including available evidence, shared experiential knowledge, and non-clinical factors) to guide decision-making.

Conclusion

In the absence of a clear evidence base on when and how to attempt medication reduction in response to concerns about polypharmacy, GPs develop ‘mindlines’ over time through practicebased experience. These tacit approaches to making complex decisions are critical to developing confidence to attempt deprescribing and may be strengthened through reflective practice.

Understanding stakeholders’ perspectives on implementing deprescribing for older people living in long-term residential care homes: the STOPPING study protocol

Background

Older people with multimorbidity often experience polypharmacy. Taking multiple medicines can be beneficial; however, some older adults are prescribed multiple medicines when they are unlikely to improve clinical outcomes and may lead to harm. Deprescribing means reducing or stopping prescription medicines which may no longer be providing benefit. While appropriate deprescribing may usually be safely undertaken, there is a lack of guidance about how to implement it in practice settings such as care homes. Implementing deprescribing in care homes is often challenging, due to differing concerns of residents, staff, clinicians, friends/family members and carers along with differences in care home structures. The STOPPING study will support the development of better deprescribing practice in care homes, considering different views and environments. This paper aims to introduce the research protocol.

Methods

We will use qualitative approaches informed by the widely accepted Consolidated Framework for Implementation Research (CFIR) to aid analysis. To understand the barriers, facilitators, and contextual factors influencing deprescribing in care homes, we will employ individual interviews with care home residents and family members, focus groups with care home staff and healthcare professionals, and observations from care homes. Then, we will examine acceptability, feasibility, and suitability of existing deprescribing approaches using cognitive interviews with care home staff and healthcare professionals. Lastly, we will use narrative synthesis to integrate findings and develop guidance for implementing a deprescribing approach for care homes.

Discussion

This research will support the development of implementable approaches to deprescribing in care homes. The insights from this project will be shared with various stakeholders: care home residents, staff, pharmacists, general practitioners, nurses, and other health professionals, carers, researchers, and the public. This work will support deprescribing to be implemented effectively in care homes to benefit residents and the wider health economy.

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.

Barriers and facilitators to deprescribing in primary care: a systematic review

BACKGROUND

Managing polypharmacy is a challenge for healthcare systems globally. It is also a health inequality concern as it can expose some of the most vulnerable in society to unnecessary medications and adverse drug-related events. Care for most patients with multimorbidity and polypharmacy occurs in primary care. Safe deprescribing interventions can reduce exposure to inappropriate polypharmacy. However, these are not fully accepted or routinely implemented.

AIM

To identify barriers and facilitators to safe deprescribing interventions for adults with multimorbidity and polypharmacy in primary care.

DESIGN & SETTING

A systematic review of studies published from 2000, examining safe deprescribing interventions for adults with multimorbidity and polypharmacy.

METHOD

A search of electronic databases: MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature (CINHAL), Cochrane, and Health Management Information Consortium (HMIC) from inception to 26 Feb 2019, using an agreed search strategy. This was supplemented by handsearching of relevant journals, and screening of reference lists and citations of included studies.

RESULTS

In total, 40 studies from 14 countries were identified. Cultural and organisational barriers included: a culture of diagnosing and prescribing; evidence-based guidance focused on single diseases; a lack of evidence-based guidance for the care of older people with multimorbidities; and a lack of shared communication, decision-making systems, tools, and resources. Interpersonal and individual-level barriers included: professional etiquette; fragmented care; prescribers' and patients' uncertainties; and gaps in tailored support. Facilitators included: prudent prescribing; greater availability and acceptability of non-pharmacological alternatives; resources; improved communication, collaboration, knowledge, and understanding; patient-centred care; and shared decision-making.

CONCLUSION

A whole systems, patient-centred approach to safe deprescribing interventions is required, involving key decision-makers, healthcare professionals, patients, and carers.

Role of nurses in supporting proactive deprescribing

Deprescribing is the term used to describe the discontinuation of medicines. It can be either 'reactive', for example in response to an adverse event or therapeutic failure, or 'proactive', when the prescriber and patient decide to discontinue the medicine because its future benefits no longer outweigh its potential for harm. At present, there is a limited amount of proactive deprescribing activity in primary and secondary care. This article provides the rationale for increasing proactive deprescribing activity, lists the medicines this relates to, identifies the barriers and enablers to its implementation, and describes the potential role of the nurse in this process.

Appropriateness of Medications in Older Adults Living With Frailty: Impact of a Pharmacist-Led Structured Medication Review Process in Primary Care

Background: Older persons with frailty take multiple medications and are vulnerable to inappropriate prescribing. Objective: This study assesses the impact of a team-based, pharmacist-led structured medication review process in primary care on the appropriateness of medications taken by older adults living with frailty. Methods: This was a quasi-experimental pretest-posttest design in 6 primary care practices within an academic clinic in Edmonton, Alberta, Canada. We enrolled community dwelling older adults 65 years and older with frailty who have polypharmacy and/or 2 or more chronic conditions (ie, high-risk group for drug-related issues). The intervention was a structured pharmacist-led medication review using evidence-based explicit criteria (ie, Beers and STOPP/START criteria) and implicit criteria (ie, pharmacist expertise) for potentially inappropriate prescribing, done in the context of a primary care team-based seniors’ program. We measured the changes in the number of medications pre- and postmedication review, number of medications satisfying explicit criteria of START and STOPP/Beers and determined the association with frailty level. Data were analyzed using descriptive and inferential statistics (a priori significance level of P < .05). Results: A total of 54 participants (61.1% females, mean age 81.7 years [SD = 6.74]) enrolled April 2017 to May 2018 and 52 participants completed the medication review process (2 lost to hospitalization). Drug-related problems noted on medication review were untreated conditions (61.1%), inappropriate medications (57.4%), and unnecessary therapy (40.7%). No significant changes in total number of medications taken by patients before and after, but the intervention significantly decreased number of inappropriate medications (1.15 meds pre to 0.9 meds post; P = .006). Conclusion: A pharmacist-led medication review is a strategy that can be implemented in primary care to address inappropriate medications.

Teaching physicians the GPGP method promotes deprescribing in both inpatient and outpatient settings

Background

In complex older patients, inappropriate medication use and polypharmacy (IMUP) are commonplace and increasing exponentially. Reducing IMUP is a challenge in multiple clinical contexts, including acute admission and family practice, due to several key barriers. In the global effort against this epidemic, educational programs geared toward changing physicians’ prescribing patterns represent an important means of promoting deprescribing.

Methods

This is a nonrandomized, controlled interventional study investigating polypharmacy outcomes and prescribing patterns in patients whose physicians were trained in the Good Palliative-Geriatric Practice (GPGP) method, an algorithm for the reduction of polypharmacy, with patients whose physicians were not. Training involved a one-time, full-day workshop led by a senior geriatrician. Two separate settings were examined. In the inpatient setting, one internal medicine ward was trained and compared with another ward which was not trained. In the family practice setting, 28 physicians were trained and compared with practices of 15 physicians not trained. Patients were above the age of 70, representative of the general geriatric population, and not terminally ill.

Results

In the inpatient arm, the intervention group (n = 100) experienced a decrease in medications prescribed from admission to discharge of 18.5%, compared with a decrease of 1.9% in the control group (n = 100, difference between groups p < 0.0001). In the outpatient arm, the intervention group (n = 100) experienced a decrease in medication number of 6.1% compared with 0.07% in the control group (n = 100, difference between groups p = 0.001) over a 6-month period. Preferential decreases in specific drug classes were observed in both groups, including benzodiazepines, psychotropics, and antihypertensives.

Conclusions

A one-time educational intervention based on GPGP can change prescribing patterns in both outpatient and inpatient settings leading to a moderate reduction in polypharmacy. Future work should focus on longitudinal interventions, and longer-term clinical outcomes such as morbidity, mortality, and quality of life.

Deprescribing for older adults in Australia: factors influencing GPs

Polypharmacy is increasing among older Australians, raising their risk of experiencing medication-related harm. As part of the prescribing continuum, deprescribing is a strategy proposed to reduce inappropriate polypharmacy. This study explored factors that influence deprescribing among Australian GPs using a new 21-item survey to measure GP attitudes and practices. The 85 GP responses indicated that many factors are supportive of deprescribing. GPs suggest that they are willing to explore their older patients' deprescribing preferences; they believe that they have enough information about the potential harms and benefits of medication to inform their deprescribing decisions and are confident to communicate this information to their patients. GPs did not consider their patients would interpret deprescribing as being 'given up on'. Limited time to review medications, poor communication between prescribers and a perception that other prescribers do not respect their role as overall coordinators of their older patients' medications were considered by respondents to be unsupportive of deprescribing. Overall, despite GPs reporting many supportive factors for deprescribing, the influence of unsupportive factors appears to remain strong, as deprescribing is not routinely considered in practice.

Health care professionals' attitudes towards deprescribing in older patients with limited life expectancy: A systematic review

AIMS

The aim of this systematic review was to explore health care professionals' attitudes towards deprescribing in older people with limited life expectancy.

METHODS

A systematic literature search was conducted from inception to December 2017 using MEDLINE, EMBASE and CINAHL. Studies were included if they specifically concerned older people (≥65 years) with limited life expectancy, including those residing in any type of aged care facility, or were based on representative patient profiles. Results were analyzed inspired by the Joanna Briggs Institute's method for synthesis of qualitative data. Studies were characterized using a checklist for reporting of qualitative research.

RESULTS

Eight studies were included. Six studies explored health care professionals' views on deprescribing in general, and two studies focused specifically on psychotropic agents. All eight studies explored the views of physicians, mostly general practitioners, while three studies also considered other health care professionals. Four themes related to health care professionals' attitudes towards deprescribing were identified: (i) patient and relative involvement; (ii) the importance of teamwork; (iii) health care professionals' self-assurance and skills; and (iv) the impact of organizational factors. Within each of these themes, 3-4 subthemes were identified and analysed.

CONCLUSIONS

Our results suggest that health care professionals' decisions to engage in deprescribing activities with older people with limited life expectancy depend on multiple factors which are highly interdependent. Consequently, there is an urgent need for more research on how to approach deprescribing in clinical practice within this population.

Improving inappropriate medication and information transfer at hospital discharge: study protocol for a cluster RCT

BACKGROUND

Inappropriate medication and polypharmacy increase morbidity, hospitalisation rate, costs and mortality in multimorbid patients. At hospital discharge of elderly patients, polypharmacy is often even more pronounced than at admission. However, the optimal discharge strategy in view of sustained medication appropriateness remains unclear. In particular, unreflectingly switching back to the pre-hospitalisation medication must be avoided. Therefore, both the patients and the follow-up physicians should be involved in the discharge process. In this study, we aim to test whether a brief medication review which takes the patients' priorities into account, combined with a standardised communication strategy at hospital discharge, leads to sustained medication appropriateness and extends readmission times among elderly multimorbid patients.

METHODS

The study is designed as a two-armed, double-blinded, cluster-randomised trial, involving 42 senior hospital physicians (HPs) with their junior HPs and 2100 multimorbid patients aged 60 years or older. Using a randomised minimisation strategy, senior HPs will be assigned to either intervention or control group. Following instructions of the study team, the senior HPs in the intervention group will teach their junior HPs how to integrate a simple medication review tool combined with a defined communication strategy into their ward's discharge procedure. The untrained HPs in the control group will provide data on usual care, and their patients will be discharged following usual local routines. Primary outcome is the time until readmission within 6 months after discharge, and secondary outcomes cover readmission rates, number of emergency and GP visits, classes and numbers of drugs prescribed, proportions of potentially inappropriate medications, and the patients' quality of life after discharge. Additionally, the characteristics of both the HPs as well as the patients will be collected before the intervention. Process evaluation outcomes will be assessed parallel to the ongoing core study using qualitative research methods.

DISCUSSION

So far, interventions to reduce polypharmacy are still scarce at the crucial interface between HPs and GPs. To our knowledge, this trial is the first to analyse the combination of a brief deprescribing intervention with a standardised communication strategy at hospital discharge and in the early post-discharge period.

TRIAL REGISTRATION

ISRCTN, ISRCTN18427377 . Registered 11 January 2018.

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

OBJECTIVE

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

METHOD

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

MEASUREMENTS

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

RESULTS

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

CONCLUSION

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

General practitioners' and nurses' views on medication reviews and potentially inappropriate medicines in elderly patients - a qualitative study of reports by educating pharmacists

OBJECTIVE

The aim with this study was to understand more about how general practitioners (GPs) and nurses in primary care experience their work with medication reviews in elderly patients.

DESIGN

This qualitative study was nested within a cluster randomised trial and analysed narrative and unstructured diaries written by two pharmacists who performed academic detailing, i.e. educational outreach visits in primary care. The educational sessions dealt with potentially inappropriate medicines, and stimulated interprofessional dialogue in relation to medication reviews. The purpose of the diaries was to document and structure the pedagogical process of academic detailing and contained quotes from 194 GP and 113 nurse participants in the sessions, and the pharmacists' reflections. The data was explored using thematic analysis.

SETTING

Thirty-three primary care practices in Stockholm, Sweden.

SUBJECTS

GPs and nurses working in primary care.

MAIN OUTCOME MEASURES

Thematic descriptions of academic detailing by pharmacists.

RESULTS

Five themes were identified: 1) Complexity in 3 'P': patients, pharmacotherapy, and primary care; 2) What, when, who? Clash between GPs' and nurses' experiences and guidelines; 3) Real-world problems and less-than-ideal solutions; 4) Eureka? Experiences with different steps during a medication review; and 5) Threats to GP autonomy.

CONCLUSION

GPs and nurses should participate in the construction and release of guidelines in order to increase their usability in clinical practice. Future research should analyse if alternative strategies such as condensed medical reviews and feedback on prescribing are easier to implement in primary care. Key points Complex medication reviews have been introduced on a large scale in Swedish primary care, but knowledge on GPs' and nurses' views on such reviews is lacking. In the context of primary care alternative strategies such as condensed medication reviews and feedback on prescribing may be more applicable than medication reviews according to guidelines. GPs and nurses should make contributions to the development of guidelines on medication reviews in order to increase their usability in clinical practice.

Primary Care Provider Counseling Practices about Adverse Drug Reactions and Interactions in Croatia

BACKGROUND

Prescribing medications is one of the most common medical decisions that is made by primary care providers (PCPs). In the Republic of Croatia, PCPs hold a key position in prescribing and evaluating the medications that are provided for patients. Accordingly, providing advice for patients regarding the potential adverse drug reactions (ADRs) and drug-drug interactions (DDIs) is frequently the responsibility of the PCPs. The aim of the current study was to assess the knowledge, attitudes, and counseling practices of PCPs regarding drug interactions and adverse effects.

METHODS

After enrolling 195 PCPs that were selected at random, a survey was conducted while using an anonymous questionnaire that was created based on previously published studies, adjusted in a way that includes the most commonly prescribed medications in Croatia.

RESULTS

Of the 10 questions on knowledge about DDIs and ADRs, the median number of correct responses by PCPs was 5 (interquartile range 4 to 7). More than half of respondents (56%) agreed with the claim that knowledge of drug side effects facilitated their work in family medicine. Almost all of the respondents (92.8%) explained side effects and drug interactions to special groups of patients (pregnant women, elderly patients etc.).

CONCLUSION

The results show a need for additional education in the field of drug prescribing. However, PCPs were aware of the importance of counseling practices about adverse drug reactions and interactions and counseling practices among special patients populations are satisfactory.

German healthcare professionals' perspective on implementing recommendations about polypharmacy in general practice: a qualitative study

BACKGROUND

Key recommendations for the management of patients with polypharmacy are structured medication counselling (SMC), medication lists and systematic medication reviews.

OBJECTIVE

The aim of this study was to identify determinants (hindering and facilitating factors) for the implementation of the recommendations in general practice.

METHODS

This study was linked to a tailored intervention aimed at improving the implementation of the recommendations in German general practice. Interviews and focus groups with different healthcare professionals were carried out in the design phase and after delivery of the intervention. The material from both data collections was analysed separately in a content analytical approach resulting in two sets of categories. For this study, the subcategories of both sets were assigned to the Tailoring Interventions for Chronic Diseases (TICD) checklist, a comprehensive framework of determinants of practice.

RESULTS

Interviews with 24 general practitioners (GPs), 4 other medical specialists, 1 pharmacist, 3 nurses and 6 medical assistants as well as 2 mixed focus groups with 17 professionals were conducted. We identified 93 determinants: 29 referred to medication counselling, 21 to the use of medication lists, 20 to medications reviews and 23 to all recommendations. The determinants were related to all 7 main domains and to 25 of the 57 subdomains on the TICD checklist including guideline factors, patient factors, individual healthcare professional factors, social, political and legal factors, incentives and resources, and capacity for organizational change.

CONCLUSION

While many interventions to improve polypharmacy focus on the provision of pharmacological knowledge, a much wider range of domains need to be addressed, such as communication skills, patient involvement and practice organization.

Reduction of inappropriate medication in older populations by electronic decision support (the PRIMA-eDS study): a qualitative study of practical implementation in primary care

BACKGROUND

Within the EU-funded project PRIMA-eDS (Polypharmacy in chronic diseases: Reduction of Inappropriate Medication and Adverse drug events in older populations by electronic Decision Support) an electronic decision support tool (the "PRIMA-eDS-tool") was developed for general practitioners (GPs) to reduce inappropriate medication in their older polypharmacy patients. After entering patient data relevant to prescribing in an electronic case report form the physician received a comprehensive medication review (CMR) on his/her screen displaying recommendations regarding missing indications, necessary laboratory tests, evidence-base of current medication, dose adjustments for renal malfunction, potentially harmful drug-drug interactions, contra-indications, and possible adverse drug events. We set out to explore the usage of the PRIMA-eDS tool and the adoption of the recommendations provided by the CMR to optimise the tool and prepare it for its future implementation.

METHODS

In a qualitative study carried out in North Rhine-Westphalia, Germany, 21 GPs using the PRIMA-eDS tool within the PRIMA-eDS study were interviewed. Interviews encompassed the GPs' attitudes regarding use of the electronic case report form and the CMR, their response to the recommendations, and the implementation of the tool into daily practice routine. The collected data were analysed applying thematic qualitative text analysis.

RESULTS

GPs found the patient data entry into the electronic case report form to be inconvenient and time-consuming. The CMR was conducted often outside practice hours and without the patient present. GPs found that the PRIMA-eDS CMR provided relevant information for and had several positive effects on the caring process. However, they encountered several barriers when wanting to change medication.

CONCLUSIONS

It is unlikely that the PRIMA-eDS CMR will be used in the future as it is now as patient data entry is too time-consuming. Several barriers towards deprescribing medications were found which are common in deprescribing studies. Given the positive attitude towards the CMR, a new way of entering patient data into the PRIMA-eDS tool to create the CMR needs to be developed.

Deprescribing medications for older adults in the primary care context: A mixed studies review

AIMS

This review investigates the factors that influence deprescribing of medications in primary care from the perspective of general practitioners (GPs) and community-living older adults.

METHODS

A mixed studies review structure was adopted searching Scopus, CINAHL, PsychINFO, ProQuest, and PubMed from January 2000 to December 2017. A manual search of reference lists was also conducted. Studies were included if they were original research available in English and explored general deprescribing rather than deprescribing of a specific class of medications. The Mixed Methods Assessment Tool was used to assess the quality of studies, and content analysis generated common categories across studies.

RESULTS

Thirty-eight articles were included, and 7 key categories were identified. The review found that the factors that influence deprescribing are similar across and within health systems and mostly act as barriers. These factors remained unchanged across the review period. The structural organisation of health systems remains poorly suited to facilitate deprescribing. Individual knowledge gaps of both GPs and older adults influence practices and attitudes towards deprescribing, and significant communication gaps occur between GPs and specialists and between GPs and older adults. As a result, deprescribing decision making is characterised by uncertainty, and deprescribing is often considered only when medication problems have already arisen. Trust plays a complex role, acting as both a barrier and facilitator of deprescribing.

CONCLUSIONS

Deprescribing is influenced by many factors. Despite recent interest, little change has occurred. Multilevel strategies aimed at reforming aspects of the health system and managing uncertainty at the practice and individual level, notably reducing knowledge limitations and closing communications gaps, may achieve change.

[Not Available]

Objectif

Formuler des lignes directrices fondées sur les données probantes visant à aider les cliniciens à décider du moment et de la façon sécuritaire de réduire la dose des agonistes des récepteurs des benzodiazépines (BZRA) pour mettre fin au traitement; se concentrer sur le niveau le plus élevé des données disponibles et obtenir les commentaires des professionnels de première ligne durant le processus de rédaction, de révision et d’adoption des lignes directrices.

Méthodes

L’équipe comptait 8 cliniciens (1 médecin de famille, 2 psychiatres, 1 psychologue clinique, 1 pharmacologue clinique, 2 pharmaciennes cliniques et 1 gériatre) et une spécialiste de la méthodologie; les membres ont divulgué tout conflit d’intérêts. Nous avons eu recours à un processus systématique, y compris l’approche GRADE (Grading of Recommendations Assessment, Development and Evaluation) pour formuler les lignes directrices. Les données ont été générées par une revue systématique d’études portant sur la déprescription des BZRA contre l’insomnie, de même que par une revue des revues sur les torts liés à la poursuite du traitement par BZRA et des synthèses narratives sur les préférences des patients et les répercussions sur les ressources. Ces données et le score GRADE de qualité des données ont servi à formuler les recommandations. L’équipe a peaufiné le texte sur le contenu et les recommandations des lignes directrices par consensus et a synthétisé les considérations cliniques afin de répondre aux questions des cliniciens de première ligne. Une version préliminaire des lignes directrices a été révisée par les cliniciens et les intervenants.

Recommandations

Nous recommandons d’offrir la déprescription (réduction lente de la dose) des BZRA à tous les patients âgés (≥ 65 ans) sous un BZRA, sans égard à la durée de l’usage, et suggérons d’offrir la déprescription (réduction lente de la dose) à tous les adultes de 18 à 64 qui prennent un BZRA depuis plus de 4 semaines. Ces recommandations visent les patients qui prennent un BZRA contre l’insomnie seule (insomnie primaire) ou l’insomnie comorbide lorsque les comorbidités sous-jacentes sont efficacement prises en charge. Ces lignes directrices ne visent pas les personnes atteintes d’autres troubles non traités du sommeil ou d’anxiété, de dépression, ou d’autres troubles physiques ou de santé mentale pouvant causer ou aggraver l’insomnie.

Conclusion

Les agonistes des récepteurs des benzodiazépines sont liés à des torts, et leur effet thérapeutique serait bref. La réduction graduelle de la dose de BZRA améliore le taux d’abandon comparativement aux soins habituels, et ce, sans causer de torts graves. Les patients seraient plus ouverts à une conversation sur la déprescription s’ils comprennent le pourquoi (potentiel de torts), participent à l’élaboration du plan de réduction de la dose et reçoivent des conseils en matière de comportement. Les présentes lignes directrices émettent des recommandations pour décider du moment et de la façon de réduire la dose de BZRA pour mettre fin au traitement. Elles visent à contribuer au processus de décision conjointement avec le patient et non à le dicter.

Deprescribing benzodiazepine receptor agonists: Evidence-based clinical practice guideline

OBJECTIVE

To develop an evidence-based guideline to help clinicians make decisions about when and how to safely taper and stop benzodiazepine receptor agonists (BZRAs); to focus on the highest level of evidence available and seek input from primary care professionals in the guideline development, review, and endorsement processes.

METHODS

The overall team comprised 8 clinicians (1 family physician, 2 psychiatrists, 1 clinical psychologist, 1 clinical pharmacologist, 2 clinical pharmacists, and 1 geriatrician) and a methodologist; members disclosed conflicts of interest. For guideline development, a systematic process was used, including the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence was generated by conducting a systematic review of BZRA deprescribing trials for insomnia, as well as performing a review of reviews of the harms of continued BZRA use and narrative syntheses of patient preferences and resource implications. This evidence and GRADE quality of evidence ratings were used to generate recommendations. The team refined guideline content and recommendations through consensus and synthesized clinical considerations to address front-line clinician questions. The draft guideline was reviewed by clinicians and stakeholders.

RECOMMENDATIONS

We recommend that deprescribing (tapering slowly) of BZRAs be offered to elderly adults (≥ 65 years) who take BZRAs, regardless of duration of use, and suggest that deprescribing (tapering slowly) be offered to adults aged 18 to 64 who have used BZRAs for more than 4 weeks. These recommendations apply to patients who use BZRAs to treat insomnia on its own (primary insomnia) or comorbid insomnia where potential underlying comorbidities are effectively managed. This guideline does not apply to those with other sleep disorders or untreated anxiety, depression, or other physical or mental health conditions that might be causing or aggravating insomnia.

CONCLUSION

Benzodiazepine receptor agonists are associated with harms, and therapeutic effects might be short term. Tapering BZRAs improves cessation rates compared with usual care without serious harms. Patients might be more amenable to deprescribing conversations if they understand the rationale (potential for harm), are involved in developing the tapering plan, and are offered behavioural advice. This guideline provides recommendations for making decisions about when and how to reduce and stop BZRAs. Recommendations are meant to assist with, not dictate, decision making in conjunction with patients.

Evaluation of the impact of telementoring using ECHO© technology on healthcare professionals' knowledge and self-efficacy in assessing and managing pain for people with advanced dementia nearing the end of life

Background

Pain assessment and management in advanced and end-stage dementia are challenging; patients are at risk of under-diagnosis, under-assessment and under-treatment. Previous research has highlighted the importance of needs-driven training and development in this area for physicians, nurses and healthcare assistants (HCAs) across specialties, disciplines and care settings. This study used teleconferencing technology to connect healthcare professionals across multiple settings and disciplines in real-time clinics, based on the Project ECHO© model. This paper reports the evaluation of the clinics by physicians, nurses and HCAs, including their knowledge and self-efficacy in pain assessment and management for patients with advanced and end-stage dementia.

Methods

A mixed method evaluation comprising quantitative survey of self-reported knowledge and self-efficacy pre- and post-ECHO clinic participation, and qualitative exploration of experiences of the clinics using focus group interviews. A census approach to sampling was undertaken. Pre- and post-ECHO evaluations were administered electronically using Survey Monkey software. Mann-Whitney U tests were used to explore differences in knowledge and self-efficacy scores pre- and post-ECHO clinic participation. Statistical significance was set a-priori at p = 0.05. Focus groups were video- and audio-recorded, transcribed verbatim and analysed using Braun & Clarke’s model of thematic analysis.

Results

Eighteen healthcare professionals [HCPs] (physicians [n = 7], nurses [n = 10], HCA [n = 1]) and twenty HCPs (physicians [n = 10], nurses [n = 10]) completed pre- and post-ECHO evaluations respectively, reporting improvements in knowledge and self-efficacy on participation in ECHO clinics and perceived utility of the clinics. Seven HCPs (physicians [n = 2], nurses [n = 5]) participated in two focus groups. Four themes emerged: knowledge and skills development and dissemination; protected time; areas for improvement; and the future of ECHO.

Conclusions

Telementoring clinics for HCP education and training in pain assessment and management in advanced and end-stage dementia demonstrate a positive impact on knowledge and self-efficacy of HCPs and highlight the value of a cross-specialty network of practice which spans across disciplines/HCP types, care settings and geographical areas. Further development of ECHO services in this and in other clinical areas, shows significant potential to support delivery of high-quality care to complex patient populations.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3032-y) contains supplementary material, which is available to authorized users.

A Province-wide, Cross-sectional Study of Demographics and Medication Use of Patients in Hemodialysis Units Across Ontario

Background:

Hemodialysis patients are at an increased risk of polypharmacy as they have the highest pill burden of all chronically ill patient populations, with an estimated average of 12 medications per day.

Objectives:

The aim of this study was to evaluate prescribing patterns of outpatient medications in patients receiving in-center hemodialysis. This was done to identify potential candidate medications for future quality improvement initiations to optimize prescribing.

Design:

We conducted a descriptive retrospective cross-sectional study in the province of Ontario, Canada, using several linked health care databases housed at the Institute for Clinical Evaluative Sciences (ICES).

Setting:

We considered outpatient medications dispensed to patients eligible for the Ontario Drug Benefit program.

Patients:

Patients were receiving chronic in-center hemodialysis at one of the 69 facilities in the province of Ontario, Canada as of October 1, 2013.

Measurements:

We assessed whether any of our 28 study medications of interest were recently dispensed (within the prior 120 days), the type of prescribing physician, and the associated medication costs. The 28 included medications of interest (ie, proton pump inhibitors, benzodiazepines) were selected because they may not have a true indication for dialysis patients and/or there are safety concerns with their use in this population. Results are presented as median (25th, 75th percentile).

Methods:

We conducted this study at ICES according to a prespecified protocol approved by the Research Ethics Board at Sunnybrook Health Sciences Centre (Toronto, Ontario).

Results:

A total of 3094 patients on chronic in-center hemodialysis received a study drug of interest (age: 76.5 years [SD: 7.3]), 44% women). Patients were dispensed 11 (8, 14) unique medication products with more than two-thirds of patients dispensed 9 or more different medications. The median number of annual health care visits was 7 (3-15) with more than half the cohort receiving prescriptions from 3 or more specialists. The 10 most commonly dispensed study medications cost more than 3 million dollars in direct costs in 1 year.

Limitations:

Our study was also subjected to some limitations of health care databases.

Conclusions:

Polypharmacy is frequent in in-center hemodialysis patients. To decrease polypharmacy and its associated negative outcomes, health care providers need to implement tools to optimize medication use and deprescribe medications that lack evidence for efficacy and safety in hemodialysis patients. Therefore, strategies to improve prescribing and discontinue ineffective medications warrant testing for better patient outcomes and reduced health care costs.

Effectiveness of a complex intervention on Prioritising Multimedication in Multimorbidity (PRIMUM) in primary care: results of a pragmatic cluster randomised controlled trial

OBJECTIVES

Investigate the effectiveness of a complex intervention aimed at improving the appropriateness of medication in older patients with multimorbidity in general practice.

DESIGN

Pragmatic, cluster randomised controlled trial with general practice as unit of randomisation.

SETTING

72 general practices in Hesse, Germany.

PARTICIPANTS

505 randomly sampled, cognitively intact patients (≥60 years, ≥3 chronic conditions under pharmacological treatment, ≥5 long-term drug prescriptions with systemic effects); 465 patients and 71 practices completed the study.

INTERVENTIONS

Intervention group (IG): The healthcare assistant conducted a checklist-based interview with patients on medication-related problems and reconciled their medications. Assisted by a computerised decision support system, the general practitioner optimised medication, discussed it with patients and adjusted it accordingly. The control group (CG) continued with usual care.

OUTCOME MEASURES

The primary outcome was a modified Medication Appropriateness Index (MAI, excluding item 10 on cost-effectiveness), assessed in blinded medication reviews and calculated as the difference between baseline and after 6 months; secondary outcomes after 6 and 9 months' follow-up: quality of life, functioning, medication adherence, and so on.

RESULTS

At baseline, a high proportion of patients had appropriate to mildly inappropriate prescriptions (MAI 0-5 points: n=350 patients). Randomisation revealed balanced groups (IG: 36 practices/252 patients; CG: 36/253). Intervention had no significant effect on primary outcome: mean MAI sum scores decreased by 0.3 points in IG and 0.8 points in CG, resulting in a non-significant adjusted mean difference of 0.7 (95% CI -0.2 to 1.6) points in favour of CG. Secondary outcomes showed non-significant changes (quality of life slightly improved in IG but continued to decline in CG) or remained stable (functioning, medication adherence).

CONCLUSIONS

The intervention had no significant effects. Many patients already received appropriate prescriptions and enjoyed good quality of life and functional status. We can therefore conclude that in our study, there was not enough scope for improvement.

TRIAL REGISTRATION NUMBER

ISRCTN99526053. NCT01171339; Results.

Deprescribing antipsychotics for behavioural and psychological symptoms of dementia and insomnia: Evidence-based clinical practice guideline

OBJECTIVE

To develop an evidence-based guideline to help clinicians make decisions about when and how to safely taper and stop antipsychotics; to focus on the highest level of evidence available and seek input from primary care professionals in the guideline development, review, and endorsement processes.

METHODS

The overall team comprised 9 clinicians (1 family physician, 1 family physician specializing in long-term care, 1 geriatric psychiatrist, 2 geriatricians, 4 pharmacists) and a methodologist; members disclosed conflicts of interest. For guideline development, a systematic process was used, including the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence was generated from a Cochrane systematic review of antipsychotic deprescribing trials for the behavioural and psychological symptoms of dementia, and a systematic review was conducted to assess the evidence behind the benefits of using antipsychotics for insomnia. A review of reviews of the harms of continued antipsychotic use was performed, as well as narrative syntheses of patient preferences and resource implications. This evidence and GRADE quality-of-evidence ratings were used to generate recommendations. The team refined guideline content and recommendation wording through consensus and synthesized clinical considerations to address common front-line clinician questions. The draft guideline was distributed to clinicians and stakeholders for review and revisions were made at each stage.

RECOMMENDATIONS

We recommend deprescribing antipsychotics for adults with behavioural and psychological symptoms of dementia treated for at least 3 months (symptoms stabilized or no response to an adequate trial) and for adults with primary insomnia treated for any duration or secondary insomnia in which underlying comorbidities are managed. A decision-support algorithm was developed to accompany the guideline.

CONCLUSION

Antipsychotics are associated with harms and can be safely tapered. Patients and caregivers might be more amenable to deprescribing if they understand the rationale (potential for harm), are involved in developing the tapering plan, and are offered behavioural advice or management. This guideline provides recommendations for making decisions about when and how to reduce the dose of or stop antipsychotics. Recommendations are meant to assist with, not dictate, decision making in conjunction with patients and families.

Déprescription des antipsychotiques pour les symptômes comportementaux et psychologiques de la démence et l’insomnie

Objectif

Élaborer un guide de pratique clinique fondé sur des données probantes pour aider les cliniciens à prendre des décisions quant au moment et à la façon de réduire et de cesser les antipsychotiques en toute sécurité; insister sur les données les plus probantes et solliciter les contributions des professionnels des soins primaires pour l’élaboration, la révision et l’approbation des lignes directrices.

Méthodologie

L’équipe comptait 9 cliniciens (1 médecin de famille, 1 médecin de famille spécialisée en soins de longue durée, 1 psychiatre gériatrique, 2 gériatres, 4 pharmaciens) et une spécialiste en méthodologie; les membres ont divulgué leurs conflits d’intérêts. Un processus systématique a été utilisé pour l’élaboration du guide de pratique, y compris le protocole GRADE (Grading of Recommendations Assessment, Development and Evaluation). Les données probantes ont été tirées d’une revue systématique de Cochrane portant sur des études sur la déprescription des antipsychotiques pour les symptômes comportementaux et psychologiques de la démence. Nous avons effectué une revue systématique pour évaluer les données probantes étayant les bienfaits de l’utilisation des antipsychotiques pour traiter l’insomnie. Nous avons examiné les revues portant sur les torts associés à l’utilisation des antipsychotiques sur une base continue, et nous avons fait une synthèse narrative des préférences des patients et des répercussions sur le plan des ressources. Ces données probantes, de même que l’évaluation de la qualité des données selon GRADE, ont été utilisées pour produire les recommandations. L’équipe a peaufiné le contenu du guide de pratique et le libellé des recommandations, et elle a résumé les considérations d’ordre clinique pour répondre aux questions courantes des cliniciens de première ligne. Une ébauche du guide de pratique a été distribuée à des cliniciens et à des intervenants aux fins d’examen. Des révisions ont été apportées au texte à chaque étape.

Recommandations

Nous recommandons la déprescription des antipsychotiques chez les adultes ayant des symptômes comportementaux et psychologiques de démence traités depuis au moins 3 mois (symptômes stabilisés ou sans réponse après un essai adéquat) et chez les adultes souffrant d’insomnie primaire, quelle que soit la durée du traitement, ou d’une insomnie secondaire lorsque les comorbidités sous-jacentes sont prises en charge. Un algorithme décisionnel accompagne le guide de pratique clinique.

Conclusion

Les antipsychotiques sont associés à des préjudices et il est possible de procéder à un sevrage en toute sécurité. Les patients et leurs aidants peuvent être plus réceptifs à la déprescription s’ils comprennent ce qui la justifie (potentiel de préjudices), s’ils participent à l’élaboration du plan de sevrage et si on leur offre des conseils ou une prise en charge quant aux comportements. Le présent guide de pratique clinique offre des recommandations pour décider du moment et de la façon de réduire la dose d’antipsychotiques ou de les cesser complètement. Les recommandations servent à aider à prendre les décisions conjointement avec les patients et leur famille plutôt qu’à les dicter.