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Kucukdagli P, Bahat G, Bay I, Kilic C, Oren MM, Turkmen BO, Karan MA. The relationship between common geriatric syndromes and potentially inappropriate medication use among older adults. Aging Clin Exp Res 2020; 32:681-7. [PMID: 31190200 DOI: 10.1007/s40520-019-01239-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 06/01/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND/AIM Polypharmacy and inappropriate medication use in older adults is a major public health problem associated with morbidity and mortality. Aging is associated with metabolic changes and decreased drug clearance, increased drug-drug interactions, prescribing cascades, and potentially inappropriate medication (PIM) use. The purpose of this study was to evaluate the association between a common geriatric syndromes and PIM use among older adults. METHODS Study participants were recruited among patients admitted to Istanbul Medical School Geriatrics outpatient clinic between June 2000 and June 2014 and were evaluated retrospectively by a geriatrician using the patients' records according to Beers 2012 criteria. RESULTS Among the 667 enrolled patients, 421 (63.1%) were women and 246 (36.9%) were men. The use of PIM was not associated with age or sex. Polypharmacy (OR 4.86, 95% CI 3.25-7.27, p < 0.001), malnutrition (OR 2.69, 95% CI 1.52-4.76, p = 0.001), depression (OR 2.61, 95% CI 1.7-3.95, p < 0.001), presence of fall in the previous year (OR 2.24, 95% CI 1.51-3.32, p < 0.001), and dementia (OR 1.69, 95% CI 1.08-2.65, p = 0.021) were independently associated with the use of PIM. DISCUSSION/CONCLUSIONS The results of our study suggest that PIM use is independently associated with presence of polypharmacy, malnutrition, depression, falls and dementia in older outpatients. Identifying the association of inappropriate medication use with common geriatric syndromes in older people can help to prevent, delay, and reduce PIM use and related adverse health outcomes.
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Bahat G, Ilhan B, Erdogan T, Halil M, Savas S, Ulger Z, Akyuz F, Bilge AK, Cakir S, Demirkan K, Erelel M, Guler K, Hanagasi H, Izgi B, Kadioglu A, Karan A, Kulaksizoglu IB, Mert A, Ozturk S, Satman I, Sever MS, Tukek T, Uresin Y, Yalcin O, Yesilot N, Oren MM, Karan MA. Turkish inappropriate medication use in the elderly (TIME) criteria to improve prescribing in older adults: TIME-to-STOP/TIME-to-START. Eur Geriatr Med 2020; 11:491-498. [PMID: 32297261 PMCID: PMC7280176 DOI: 10.1007/s41999-020-00297-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/04/2020] [Indexed: 01/30/2023]
Abstract
Aim To meet the current need in different European countries for improving prescribing in older adults, we aimed to create an update screening tool getting origin from the two user friendly criterion sets: the STOPP/STARTv2 criteria and CRIME criteria. Findings Based on thorough literature review, 55 criteria were added, 17 criteria were removed, and 60 criteria were modified. As a result, 153 TIME criteria composed of 112 TIME-to-STOP and 41 TIME-to-START criteria were introduced. Message TIME criterion set is an update screening tool reported from Eastern Europe that included experts from geriatrics and other specialties frequently giving care to older adults and some additional practical explanations for clinical use. Electronic supplementary material The online version of this article (10.1007/s41999-020-00297-z) contains supplementary material, which is available to authorized users. Purpose To improve prescribing in older adults, criterion sets have been introduced from different countries. While current criterion sets are useful to some extent, they do not meet the need in some European countries. Turkish inappropriate medication use in the elderly (TIME) criteria was planned to meet this need. Methods In phase 1, the user friendly sets: STOPP/START version2 and CRIME criteria were combined. National experts composed of geriatricians and non-geriatricians were invited to review and comment. In phase 2, thorough literature review was performed and reference-based revisions, omissions, and additions were made. Explanatory additions were added to some criteria to improve application in practice. In phase 3, all working group members reviewed the criteria/explanations and agreed on the final content. Results Phase 1 was performed by 49 expert academicians between May and October 2016. Phase 2 was performed by 23 working group academicians between October 2016 and November 2018 and included face-to-face interviews between at least two geriatrician members and one criterion-related specialist. Phase 3 was completed between November 2018–March 2019 with review and approval of all criteria by working group academicians. As a result, 55 criteria were added, 17 criteria were removed, and 60 criteria were modified from the first draft. A total of 153 TIME criteria composed of 112 TIME-to-STOP and 41 TIME-to-START criteria were introduced. Conclusion TIME criteria is an update screening tool that differs from the current useful tools by the interactive study of experts from geriatrics and non-geriatrics, inclusion of practical explanations for some criteria and by its eastern European origin. TIME study respectfully acknowledges its roots from STOPP/START and CRIME criteria. Studies are needed whether it would lead improvements in older adults’ health. Electronic supplementary material The online version of this article (10.1007/s41999-020-00297-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gulistan Bahat
- Division of Geriatrics, Department of Internal Medicine, Istanbul Medical School, Istanbul University, Capa, 34390, Istanbul, Turkey.
| | - Birkan Ilhan
- Division of Geriatrics, Department of Internal Medicine, Istanbul Medical School, Istanbul University, Capa, 34390, Istanbul, Turkey
| | - Tugba Erdogan
- Division of Geriatrics, Department of Internal Medicine, Istanbul Medical School, Istanbul University, Capa, 34390, Istanbul, Turkey
| | - Meltem Halil
- Division of Geriatric Medicine, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Sumru Savas
- Division of Geriatrics, Department of Internal Medicine, Ege University Faculty of Medicine, Izmir, Turkey
| | - Zekeriya Ulger
- Department of Internal Medicine, Kirikkale University Medical School, Kirikkale, Turkey
| | - Filiz Akyuz
- Division of Gastroenterology, Department of Internal Medicine, Istanbul University Istanbul Medical School, Istanbul, Turkey
| | - Ahmet Kaya Bilge
- Department of Cardiology, Istanbul University Istanbul Medical School, Istanbul, Turkey
| | - Sibel Cakir
- Department of Psychiatry, Istanbul University Istanbul Medical School, Istanbul, Turkey
| | - Kutay Demirkan
- Department of Clinical Pharmacy, Hacettepe University Faculty of Pharmacy, Ankara, Turkey
| | - Mustafa Erelel
- Department of Pulmonary Medicine, Istanbul University Istanbul Medical School, Istanbul, Turkey
| | - Kerim Guler
- Department of Internal Medicine, Istanbul University Istanbul Medical School, Istanbul, Turkey
| | - Hasmet Hanagasi
- Department of Neurology, Istanbul University Istanbul Medical School, Istanbul, Turkey
| | - Belgin Izgi
- Department of Ophthalmology, Istanbul University Istanbul Medical School, Istanbul, Turkey
| | - Ates Kadioglu
- Department of Urology, Istanbul University Istanbul Medical School, Istanbul, Turkey
| | - Ayse Karan
- Department of Physical Therapy and Rehabilitation, Istanbul University Istanbul Medical School, Istanbul, Turkey
| | | | - Ali Mert
- Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Savas Ozturk
- Department of Nephrology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Ilhan Satman
- Division of Endocrinology, Department of Internal Medicine, Istanbul University Istanbul Medical School, Istanbul, Turkey
| | - Mehmet Sukru Sever
- Division of Nephrology, Department of Internal Medicine, Istanbul University Istanbul Medical School, Istanbul, Turkey
| | - Tufan Tukek
- Department of Internal Medicine, Istanbul University Istanbul Medical School, Istanbul, Turkey
| | - Yagiz Uresin
- Department of Pharmacology, Istanbul University Istanbul Medical School, Istanbul, Turkey
| | - Onay Yalcin
- Department of Obstetrics and Gynecology, Istanbul University Istanbul Medical School, Istanbul, Turkey
| | - Nilufer Yesilot
- Department of Neurology, Istanbul University Istanbul Medical School, Istanbul, Turkey
| | - Meryem Merve Oren
- Department of Public Health, Istanbul University Istanbul Medical School, Istanbul, Turkey
| | - Mehmet Akif Karan
- Division of Geriatrics, Department of Internal Medicine, Istanbul Medical School, Istanbul University, Capa, 34390, Istanbul, Turkey
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Edey R, Edwards N, Von Sychowski J, Bains A, Spence J, Martinusen D. Impact of deprescribing rounds on discharge prescriptions: an interventional trial. Int J Clin Pharm 2019; 41:159-66. [PMID: 30478496 DOI: 10.1007/s11096-018-0753-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 11/08/2018] [Indexed: 12/14/2022]
Abstract
Background Successful deprescribing practices are required to address issues associated with polypharmacy but are hindered by minimal interprofessional collaboration, time constraints, concern for negative outcomes, and absence of a systematic and evidence-based approach. Objective Determine the impact of pharmacist-led deprescribing rounds within a clinical teaching unit (CTU) the number of home medications discontinued upon hospital discharge. Setting Canadian tertiary care hospital. Methods Prospective, dual-arm, interventional study conducted in a single centre, from November 23rd, 2015 to August 30th, 2016. All patients ≥ 19 years old admitted under the CTU were considered for enrolment if on medication(s) prior to admission and patients were excluded if not taking any medications. Study arm allocation alternated daily between the two teams. The control arm operated as per standard whereas the intervention arm's pharmacist used a deprescribing guide and medication review to identify medications eligible for discontinuation prior to discussing during daily rounds. Discharge documents communicated medication changes to patient and primary healthcare providers. The study was sufficiently powered. Main outcome measure The difference of number of home medications discontinued at discharge between the intervention and control groups. Results 171 and 187 patients were allocated to the intervention and control arms, respectively. No significant differences of baseline characteristics existed between groups. Main outcome measure results showed that deprescribing rounds resulted in significantly more medications deprescribed compared to control (65% vs. 38%; p = 0.001). The rates of readmission and emergency department visits were reduced in the intervention arm. Conclusions Incorporating deprescribing rounds into routine care led to significantly greater discontinuation of medications without increasing rate of emergency department visits or hospital admissions.Trial registration ISRCTN11751440.
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Wilchesky M, Mueller G, Morin M, Marcotte M, Voyer P, Aubin M, Carmichael PH, Champoux N, Monette J, Giguère A, Durand P, Verreault R, Arcand M, Kröger E. The OptimaMed intervention to reduce inappropriate medications in nursing home residents with severe dementia: results from a quasi-experimental feasibility pilot study. BMC Geriatr 2018; 18:204. [PMID: 30180821 PMCID: PMC6123948 DOI: 10.1186/s12877-018-0895-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 08/27/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Medication regimens in nursing home (NH) residents with severe dementia should be frequently reviewed to avoid inappropriate medication, overtreatment and adverse drug events, within a comfort care approach. This study aimed at testing the feasibility of an interdisciplinary knowledge exchange (KE) intervention using a medication review guidance tool categorizing medications as either "generally", "sometimes" or "exceptionally" appropriate for NH residents with severe dementia. METHODS A quasi-experimental feasibility pilot study with 44 participating residents aged 65 years or over with severe dementia was carried out in three NH in Quebec City, Canada. The intervention comprised an information leaflet for residents' families, a 90-min KE session for NH general practitioners (GP), pharmacists and nurses focusing on the medication review guidance tool, a medication review by the pharmacists for participating residents with ensuing team discussion on medication changes, and a post-intervention KE session to obtain feedback from team staff. Medication regimens and levels of pain and of agitation of the participants were evaluated at baseline and at 4 months post-intervention. A questionnaire for team staff explored perceived barriers and facilitators. Statistical differences in measures comparing pre and post-intervention were assessed using paired t-tests and Cochran's-Q tests. RESULTS The KE sessions reached 34 NH team staff (5 GP, 4 pharmacists, 6 heads of care unit and 19 staff nurses). Forty-four residents participated in the study and were followed for a mean of 104 days. The total number of regular medications was 372 pre and 327 post-intervention. The mean number of regular medications per resident was 7.86 pre and 6.81 post-intervention. The odds ratios estimating the risks of using any regular medication or a "sometimes appropriate" medication post-intervention were 0.81 (95% CI: 0.71-0.92) and 0.83 (95% CI: 0.74-0.94), respectively. CONCLUSION A simple KE intervention using a medication review guidance tool categorizing medications as being either "generally", "sometimes" or "exceptionally" appropriate in severe dementia was well received and accompanied by an overall reduction in medication use by NH residents with severe dementia. Levels of agitation were unaffected and there was no clinically significant changes in levels of pain. Staff feedback provided opportunities to improve the intervention.
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Affiliation(s)
- Machelle Wilchesky
- Department of Family Medicine and Division of Geriatric Medicine, McGill University, 5858, Chemin de la Côte-des-Neiges, Montreal, Quebec, H3S 1Z1, Canada.,Donald Berman Maimonides Centre for Research in Aging, 5795 Caldwell Avenue, Montreal, Quebec, H4W 1W3, Canada
| | - Gerhard Mueller
- Department of Nursing Science and Gerontology, UMIT-The Health & Life Sciences University, Eduard-Wallnoefer-Zentrum 1, A-6060, Hall in Tyrol, Tyrol, Austria
| | - Michèle Morin
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, 1050, Chemin Ste-Foy, room L2-30, Quebec City, Quebec, G1S 4L8, Canada.,Laval University, 1050, avenue de la Médecine, Quebec City, Quebec, G1V 0A6, Canada
| | - Martine Marcotte
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, 1050, Chemin Ste-Foy, room L2-30, Quebec City, Quebec, G1S 4L8, Canada
| | - Philippe Voyer
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, 1050, Chemin Ste-Foy, room L2-30, Quebec City, Quebec, G1S 4L8, Canada.,Laval University, 1050, avenue de la Médecine, Quebec City, Quebec, G1V 0A6, Canada
| | - Michèle Aubin
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, 1050, Chemin Ste-Foy, room L2-30, Quebec City, Quebec, G1S 4L8, Canada
| | - Pierre-Hugues Carmichael
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, 1050, Chemin Ste-Foy, room L2-30, Quebec City, Quebec, G1S 4L8, Canada
| | - Nathalie Champoux
- Faculté de médecine, Université de Montréal, 2900 Boulevard Edouard-Montpetit, Montreal, Quebec, H3T 1J4, Canada
| | - Johanne Monette
- Division of Geriatric Medicine, McGill University, Jewish General Hospital, 3755 Côte-Ste-Catherine, Montreal, Quebec, H3T 1E2, Canada
| | - Anik Giguère
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, 1050, Chemin Ste-Foy, room L2-30, Quebec City, Quebec, G1S 4L8, Canada.,Laval University, 1050, avenue de la Médecine, Quebec City, Quebec, G1V 0A6, Canada
| | - Pierre Durand
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, 1050, Chemin Ste-Foy, room L2-30, Quebec City, Quebec, G1S 4L8, Canada.,Laval University, 1050, avenue de la Médecine, Quebec City, Quebec, G1V 0A6, Canada
| | - René Verreault
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, 1050, Chemin Ste-Foy, room L2-30, Quebec City, Quebec, G1S 4L8, Canada.,Laval University, 1050, avenue de la Médecine, Quebec City, Quebec, G1V 0A6, Canada
| | - Marcel Arcand
- Centre de recherche sur le vieillissement, affilié à l'Université de Sherbrooke, 1036, rue Belvédère Sud, Sherbrooke, Quebec, J1H 4C4, Canada
| | - Edeltraut Kröger
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, 1050, Chemin Ste-Foy, room L2-30, Quebec City, Quebec, G1S 4L8, Canada. .,Laval University, 1050, avenue de la Médecine, Quebec City, Quebec, G1V 0A6, Canada.
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Ramsey CM, Gnjidic D, Agogo GO, Allore H, Moga D. Longitudinal patterns of potentially inappropriate medication use following incident dementia diagnosis. Alzheimers Dement (N Y) 2017; 4:1-10. [PMID: 29296658 PMCID: PMC5738721 DOI: 10.1016/j.trci.2017.10.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Potentially inappropriate medication (PIM) use in older adults with dementia is an understudied area. We assessed longitudinal changes in PIM exposure by dementia type following dementia diagnosis. METHODS We followed 2448 participants aged ≥65 years (52% women, 85.5% Caucasian, mean age 80.9 ± 7.5 years) diagnosed with dementia after enrollment in the National Alzheimer's Coordinating Center (2005-2014). We estimated the association between dementia type and PIM annually for 2 years after diagnosis, using Generalized Estimating Equations. RESULTS Participants with Lewy body dementia had more PIM use, and participants with frontotemporal dementia had less PIM use than participants with Alzheimer's disease. In the first year following diagnosis, total number of medications increased, on average, by 10% for Alzheimer's disease and 15% for Lewy body dementia (P < .05 for both). DISCUSSION A tailored approach aimed at optimizing drug therapy is needed to mitigate PIM exposure to improve medical care for individuals with dementia.
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Affiliation(s)
- Christine M. Ramsey
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Corresponding author. Tel.: +610 613 6745; Fax: +203 785 4823.
| | - Danijela Gnjidic
- Faculty of Pharmacy and Charles Perkins Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - George O. Agogo
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Heather Allore
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Daniela Moga
- Department of Pharmacy Practice and Science, University of Kentucky, College of Pharmacy, Lexington, KY, USA
- Department of Epidemiology, University of Kentucky, College of Public Health, Lexington, KY, USA
- University of Kentucky, Sanders-Brown Center on Aging, Lexington, KY, USA
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Reeve E, Thompson W, Farrell B. Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. Eur J Intern Med 2017; 38:3-11. [PMID: 28063660 DOI: 10.1016/j.ejim.2016.12.021] [Citation(s) in RCA: 166] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 12/21/2016] [Accepted: 12/25/2016] [Indexed: 12/17/2022]
Abstract
Deprescribing can be defined as the process of withdrawal or dose reduction of medications which are considered inappropriate in an individual. The aim of this narrative review is to provide an overview of "deprescribing"; firstly discussing the potential benefits and harms followed by the barriers to and enablers of deprescribing. We also provide practical recommendations to recognise opportunities and strategies for deprescribing in practice. Studies focused on minimizing polypharmacy indicate that deprescribing may be associated with potential benefits including resolution of adverse drug reactions, improved quality of life and medication adherence and a reduction in drug costs. While the data on the benefits is inconsistent, deprescribing appears to be safe. There are, however, potential harms including return of medical conditions or symptoms and adverse drug withdrawal reactions which emphasise the need for the process to be supervised and monitored by a health care professional. Taking action on deprescribing can be facilitated by knowledge of potential barriers, implementing a deprescribing process (utilising developed tools and resources) and identifying opportunities for deprescribing through engaging with patients and caregivers and other health care professionals and considering deprescribing in a variety of populations. Important areas for future research include the suitability of deprescribing of certain medications in specific populations, how to implement deprescribing processes into clinical care in a feasible and cost effective manner and how to engage consumers throughout the process to achieve positive health and quality of life outcomes.
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Affiliation(s)
- Emily Reeve
- NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Northern Clinical School, Faculty of Medicine, University of Sydney, NSW, Australia; Geriatric Medicine Research, Faculty of Medicine, Dalhousie University and Capital Health, Nova Scotia Health Authority, NS, Canada.
| | - Wade Thompson
- Bruyère Research Institute, Ottawa, ON, Canada; School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, ON, Canada
| | - Barbara Farrell
- Bruyère Research Institute, Ottawa, ON, Canada; Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada; School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
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Abstract
Deprescribing is the term used to describe the process of withdrawal of an inappropriate medication supervised by a clinician. This article presents a discussion of how the Four Principles of biomedical ethics (beneficence, non-maleficence, autonomy, and justice) that may guide medical practitioners' prescribing practices apply to deprescribing medications in older adults. The view of deprescribing as an act creates stronger moral duties than if viewed as an omission. This may explain the fear of negative outcomes which has been reported by prescribers as a barrier to deprescribing. Respecting the autonomy of older adults is complex as they may not wish to be active in the decision-making process; they may also have reduced cognitive function and family members may therefore have to step in as surrogate decision-makers. Informed consent is intended as a process of information giving and reflection, where consent can be withdrawn at any time. However, people are rarely updated on the altered risks and benefits of their long-term medications as they age. Cessation of inappropriate medication use has a large financial benefit to the individual and the community. However, the principle of justice also dictates equal rights to treatment regardless of age.
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Affiliation(s)
- Emily Reeve
- Ageing and Pharmacology, Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Sydney Medical School, University of Sydney, Level 12 Kolling building, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia.
| | - Petra Denig
- Faculty of Medical Sciences, Clinical Pharmacy & Pharmacology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, Netherlands
| | - Sarah N Hilmer
- Departments of Aged Care and Clinical Pharmacology, Royal North Shore Hospital and Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Sydney Medical School, University of Sydney, Level 12 Kolling building, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
| | - Ruud Ter Meulen
- Centre for Ethics in Medicine, School of Social and Community Medicine, University of Bristol, Office Room G.04b, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
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