ORCID Profile
0000-0002-1405-999X
Current Organisations
Monash University
,
University of South Australia
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Publisher: Informa UK Limited
Date: 02-11-2021
DOI: 10.1080/17425255.2021.1839413
Abstract: Age-associated physiological changes can alter the disposition of drugs, however, pathophysiological changes associated with geriatric syndromes in older adults may lead to even greater heterogeneity in pharmacokinetics. Geriatric syndromes are common health problems in older adults which have multifactorial causes and do not fit into distinct organ-based disease categories. With older adults being the greatest users of medications, understanding both age- and geriatric syndrome-related changes is important clinically to ensure safe and effective medication use. This review provides an overview of current evidence regarding pharmacokinetic alterations that occur with aging and in common geriatric syndromes, including frailty, sarcopenia, dementia, polypharmacy and enteral feeding. The evidence is presented according to the four primary pharmacokinetic processes (Absorption, Distribution, Metabolism and Excretion). There is some evidence to inform our understanding of the impact of chronological aging and various geriatric syndromes on drug disposition. However, many areas require more research, including drug induced inhibition and induction of cytochrome P450 enzymes and the clinical utility of emerging methods for estimating renal function. There is a need to develop tools to predict alterations in drug disposition in subgroups of older adults, particularly where the currently available clinical information is sparse.
Publisher: Elsevier BV
Date: 09-2022
DOI: 10.1016/J.SAPHARM.2022.03.002
Abstract: Understanding the perspective of health care professionals (HCPs) is significant to the implementation of deprescribing in older adults with limited life expectancy (LLE) but a tool to assess this is lacking. This study aimed to develop and validate a survey tool for assessing HCPs attitudes towards deprescribing (HATD) in older adults with LLE. An online survey was used to collect data to determine the psychometric properties of a 49-item questionnaire generated from literature review, expert opinion and pretesting. 108 HCPs (doctors, nurses and pharmacists) with experience or interest in palliative care or a member of a palliative care team/organisation completed the survey. Principal component analysis of the participants' data resulted in a 23-item questionnaire structured in five factors, named HATD tool. The factors were related to concerns about deprescribing (7 items), perceived burden of medications on patients (7 items), organisational support for deprescribing (4 items), assurance to deprescribing (2 items) and perceived involvement of patients in medication management (3 items). The HATD tool had valid descriptive statistics (Kaiser-Meyer-Olkin measure: 0.708 Bartlett's test of sphericity: p 0.05: 39%). The reliability statistics of all the factors were ≥0.750 for both Cronbach's alpha (α) and composite reliability (CR) except for the patient-involvement factor (α = 0.644 but CR = 0.787). The 23-itemed HATD tool is a valid and reliable tool to assess the attitudes and beliefs of HCPs towards deprescribing in older adults with LLE in the Australian setting.
Publisher: Bristol University Press
Date: 08-2022
DOI: 10.1332/174426421X16141831484350
Abstract: Deprescribing, the process of dose reduction or stopping of medication(s) that may no longer be required, may improve medication use and patient outcomes. A collaborative interprofessional deprescribing research team was formed in 2017 in Nova Scotia (NS), Canada with the goal of investigating potential deprescribing initiatives which could be translated to primary healthcare in NS. The knowledge-to-action framework, which includes knowledge exchange, was used to guide the work of this team. Preliminary work involved knowledge inquiry and synthesis through a scoping review of deprescribing strategies in primary healthcare, a qualitative study to understand influences on deprescribing by local practitioners, and an analysis that combined the two. To describe and reflect on how an interactive knowledge exchange event strategy was used to (1) share the results, including knowledge tools, of previously conducted deprescribing research with stakeholders (2) identify priorities for the development and implementation of collaborative deprescribing strategies in primary healthcare in NS. The knowledge exchange event strategy utilised in this project achieved the planned objectives of sharing research results, raising awareness about deprescribing, and providing direction for future initiatives. The successful implementation of the knowledge exchange event hinged on many factors such as hiring a research coordinator limiting the in-person event to one half-day and using a variety of strategies for participant engagement both before and after the event. Other research teams could adopt a similar knowledge exchange event process as an approach for sharing research results and identifying future research and translation priorities.
Publisher: Wiley
Date: 31-05-2017
DOI: 10.1002/PRP2.321
Publisher: AMPCo
Date: 16-02-2019
DOI: 10.5694/MJA2.50015
Abstract: Cholinesterase inhibitors (ChEIs) and memantine are medications used to treat the symptoms of specific types of dementia. Their benefits and harms can change over time, particularly during long term use. Therefore, appropriate use of ChEIs and memantine involves both prescribing these medications to in iduals who are likely to benefit, and deprescribing (withdrawing) them from in iduals when the risks outweigh the benefits. We recently developed an evidence-based clinical practice guideline for deprescribing ChEIs and memantine, using robust international guideline development processes. Our recommendations aim to assist clinicians to: identify in iduals who may be suitable for a trial of deprescribing ChEIs and memantine (such as those who do not have an appropriate indication, those who have never experienced a benefit, those who appear to be no longer benefitting, and those who have severe or end-stage dementia) and taper treatment and monitor in iduals during the deprescribing process. Deprescribing ChEIs and memantine through shared decision making with in iduals and their caregivers by: ▶determining their treatment goals ▶discussing benefits and harms of continuing and ceasing medication, from the start of therapy and throughout and ▶engaging them in monitoring after discontinuation, while informing carers that the in idual will continue to decline after discontinuation. This approach may reduce adverse drug reactions and medication burden, leading to improved quality of life in people with dementia.
Publisher: Springer Science and Business Media LLC
Date: 03-08-2013
DOI: 10.1007/S40266-013-0106-8
Abstract: Inappropriate medication use is common in the elderly and the risks associated with their use are well known. The term deprescribing has been utilised to describe the complex process that is required for the safe and effective cessation of inappropriate medications. Given the primacy of the consumer in health care, their views must be central in the development of any deprescribing process. The aim of this study was to identify barriers and enablers that may influence a patient's decision to cease a medication. A systematic search of MEDLINE, International Pharmaceutical Abstracts, EMBASE, CINAHL, Informit and Scopus was conducted and augmented with a manual search. Numerous search terms relating to withdrawal of medications and consumers' beliefs were utilised. Articles were included if the barriers or enablers were directly patient/carer reported and related to long-term medication(s) that they were currently taking or had recently ceased. Determination of relevance and data extraction was performed independently by two reviewers. Content analysis with coding was utilised for synthesis of results. Twenty-one articles met the criteria and were included in the review. Three themes, disagreement/agreement with 'appropriateness' of cessation, absence resence of a 'process' for cessation, and negative ositive 'influences' to cease medication, were identified as both potential barriers and enablers, with 'fear' of cessation and 'dislike' of medications as a fourth barrier and enabler, respectively. The most common barrier/enabler identified was 'appropriateness' of cessation, with 15 studies identifying this as a barrier and 18 as an enabler. The decision to stop a medication by an in idual is influenced by multiple competing barriers and enablers. Knowledge of these will aid in the development of a deprescribing process, particularly in approaching the topic of cessation with the patient and what process should be utilised. However, further research is required to determine if the proposed patient-centred deprescribing process will result in improved patient outcomes.
Publisher: Springer Science and Business Media LLC
Date: 30-04-2017
DOI: 10.1007/S00228-017-2257-8
Abstract: Benzodiazepines are effective medicines for insomnia and anxiety but are commonly used beyond recommended treatment time frames, which may lead to adverse drug events. The aim of this systematic review was to critically evaluate the success of interventions used to reduce benzodiazepines and 'Z-drug' use, and the impact of these interventions on clinical outcomes in older adults. A search was conducted in PubMed, Embase, Informit, International Pharmaceutical Abstracts, Scopus, PsychINFO, Cochrane Central Register of Controlled Trials (CENTRAL) and CINAHL. Studies conducted in older adults (≥65 years) and published between January 1995 and July 2015 were included. Two authors independently reviewed all articles for eligibility and extracted the data. Seven studies of benzodiazepines and Z-drug withdrawal were identified. Benzodiazepine discontinuation rates were 64.3% in one study that employed pharmacological substitution with melatonin and 65.0% in a study that employed general practitioner-targeted intervention. Mixed interventions including patient education and tapering (n = 2), pharmacological substitution with psychological support (n = 1) and tapering with psychological support (n = 1) yielded discontinuation rates between 27.0 and 80.0%. Five studies measured clinical outcomes following benzodiazepine discontinuation. Most (n = 4) observed no difference in prevalence of withdrawal symptoms or sleep quality, while one study reported decline in quality of life in those who continued taking benzodiazepine vs. those who discontinued over 8 months. Current evidence shows that benzodiazepine withdrawal is feasible in the older population, but withdrawal rates vary according to the type of intervention. As the benefits and sustainability of these interventions are unclear, further studies should be conducted to assess this.
Publisher: Elsevier BV
Date: 04-2019
DOI: 10.1016/J.THERAP.2018.10.006
Abstract: Knowledge of the benefit/risk ratio of drugs in older adults is essential to optimise medication use. While randomised controlled trials are fundamental to the process of drug development and bringing new drugs to the market, they often exclude older adults, especially those suffering from frailty, multimorbidity and/or receiving polypharmacy. Therefore, it is generally unknown whether the benefits and harms of drugs established through pre-marketing clinical trials are translatable to the real-word population of older adults. Pharmacoepidemiology can provide real-world data on drug utilisation and drug effects in older people with multiple comorbidities and polypharmacy and can greatly contribute towards the goal of high quality use of drugs and well-being in older adults. A wide variety of pharmacoepidemiology studies can be used and exciting progress is being made with the use of novel and advanced statistical methods to improve the robustness of data. Coordinated and strategic initiatives are required internationally in order for this field to reach its full potential of optimising drug use in older adults so as to improve health care outcomes.
Publisher: Elsevier BV
Date: 11-2023
Publisher: Wiley
Date: 12-12-2023
DOI: 10.1111/JGS.18148
Abstract: Polypharmacy is common in older adults with cognitive impairment and multiple chronic conditions, increasing risks of adverse drug events, hospitalization, and death. Deprescribing, the process of reducing or stopping potentially inappropriate medications, may improve outcomes. The OPTIMIZE pragmatic trial examined whether educating and activating patients, family members and clinicians about deprescribing reduces number of chronic medications and potentially inappropriate medications. Acceptability and challenges of intervention delivery in cognitively impaired older adults are not well understood. We explored mechanisms of intervention implementation through post hoc qualitative interviews and surveys with stakeholder groups of 15 patients, 7 caregivers, and 28 clinicians. We assessed the context in which the intervention was delivered, its implementation, and mechanisms of impact. Acceptance of the intervention was affected by contextual factors including cognition, prior knowledge of deprescribing, communication, and time constraints. All stakeholder groups endorsed the acceptability, importance, and delivery of the intervention. Positive mechanisms of impact included patients scheduling specific appointments to discuss deprescribing and providers being prompted to consider deprescribing. Recollection of intervention materials was inconsistent but most likely shortly after intervention delivery. Short visit times remained the largest provider barrier to deprescribing. Our work identifies key learnings in intervention delivery that can guide future scaling of deprescribing interventions in this population. We highlight the critical roles of timing and repetition in intervention delivery to cognitively impaired populations and the barrier posed by short consultation times. The acceptability of the intervention to patients and family members highlights the potential to incorporate deprescribing education into routine clinical practice and expand proven interventions to other vulnerable populations.
Publisher: American Board of Family Medicine (ABFM)
Date: 05-2019
Publisher: Wiley
Date: 06-10-2016
DOI: 10.1002/JPPR.1249
Publisher: Springer Science and Business Media LLC
Date: 10-2015
DOI: 10.1007/S40266-015-0302-9
Abstract: A significant proportion of older people are prescribed statins and are also exposed to polypharmacy, placing them at increased risk of statin-drug interactions. To describe the prevalence rates of potential and clinically relevant statin-drug interactions in older inpatients according to frailty status. A cross-sectional study of patients aged ≥65 years who were prescribed a statin and were admitted to a teaching hospital between 30 July and 10 October 2014 in Sydney, Australia, was conducted. Data on socio-demographics, comorbidities and medications were collected using a standardized questionnaire. Potential statin-drug interactions were defined if listed in the Australian Medicines Handbook and three international drug information sources: the British National Formulary, Drug Interaction Facts and Drug-Reax(®). Clinically relevant statin-drug interactions were defined as interactions with the highest severity rating in at least two of the three international drug information sources. Frailty was assessed using the Reported Edmonton Frail Scale. A total of 180 participants were recruited (median age 78 years, interquartile range 14), 35.0% frail and 65.0% robust. Potential statin-drug interactions were identified in 10% of participants, 12.7% of frail participants and 8.5% of robust participants. Clinically relevant statin-drug interactions were identified in 7.8% of participants, 9.5% of frail participants and 6.8% of robust participants. Depending on the drug information source used, the prevalence rates of potential and clinically relevant statin-drug interactions ranged between 14.4 and 35.6% and between 14.4 and 20.6%, respectively. In our study of frail and robust older inpatients taking statins, the overall prevalence of potential statin-drug interactions was low and varied significantly according to the drug information source used.
Publisher: AMPCo
Date: 10-2014
DOI: 10.5694/MJA13.00200
Abstract: Deprescribing is the process of trial withdrawal of inappropriate medications. Currently, the strongest evidence for benefit of deprescribing is from cohort and observational studies of withdrawal of specific medication classes that have shown better patient outcomes, mainly through resolution of adverse drug reactions. Additional potential benefits of deprescribing include reduced financial costs and improved adherence with other medications. The harms of ceasing medication use include adverse drug withdrawal reactions, pharmacokinetic and pharmacodynamic changes and return of the medical condition. These can be minimised with proper planning (ie, tapering), monitoring after withdrawal, and reinitiation of the medication if the condition returns. More evidence is needed regarding negative, non-reversible effects of ceasing use of certain classes of medication, such as acetylcholinesterase inhibitors. Cessation of use has not been studied for many medication classes, and large-scale randomised controlled trials of systematic deprescribing are required before the true benefits and harms can be known.
Publisher: Informa UK Limited
Date: 27-02-2020
Publisher: American Medical Association (AMA)
Date: 05-2022
Publisher: Elsevier BV
Date: 02-2022
Publisher: Wiley
Date: 19-09-2014
DOI: 10.1111/BCP.12386
Publisher: Elsevier BV
Date: 08-2021
Publisher: Springer Science and Business Media LLC
Date: 24-09-2015
Publisher: Wiley
Date: 13-06-2019
DOI: 10.1111/JGS.16012
Publisher: Wiley
Date: 26-08-2013
DOI: 10.1111/JGS.12418
Abstract: To capture people's attitudes, beliefs, and experiences regarding the number of medications they are taking and their feelings about stopping medications. Administration of a validated questionnaire. Multidisciplinary ambulatory consulting service at the Royal Adelaide Hospital. Participants were in iduals aged 18 and older (median 71.5) taking at least one regular prescription medication 100 participants completed all items of the questionnaire, 65 of whom were aged 65 and older. Participants were administered the 15-item Patients' Attitudes Towards Deprescribing (PATD) questionnaire. Participants were taking an average of 10 different prescription and nonprescription (including complementary), regular and as-needed medications. More than 60% felt that they were taking a "large number" of medications, and 92% stated that they would be willing to stop one or more of their current medications if possible. Number of regular medications, age, and number of medical conditions were not found to be correlated with willingness to stop a medication. The findings were similar in older and younger participants. This study has shown that a cohort of mostly older adults were largely accepting of a trial of cessation of medication(s) that their prescriber deemed to be no longer required. Because few factors were associated with willingness to cease medications, all patients should be in idually evaluated for deprescribing.
Publisher: Wiley
Date: 13-02-2019
DOI: 10.1111/JGS.15804
Abstract: Use of harmful and/or unnecessary medications in older adults is common. Understanding older adult and caregiver attitudes toward deprescribing will contribute to medication optimization in practice. The aims of this study were to capture the attitudes and beliefs of older adults and caregivers toward deprescribing and determine what participant characteristics and/or attitudes (if any) predicted reported willingness to have a medication deprescribed. Self-completed questionnaire. Australia. Older adults (n = 386), 65 years or older, taking one or more regular prescription medications and caregivers of older adults (n = 205) who could self-complete a written questionnaire in English. Older adult and caregiver versions of the validated revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire were completed. The rPATD includes two global questions and four factors: perceived burden of medications, belief in appropriateness of medications, concerns about stopping, and involvement in medication management. Participant characteristics, self-rated health, trust in physician, and health autonomy were also collected. Older adult participants had a median age of 74 years (interquartile range [IQR] = 70-81 y), and caregivers were aged 67 years (IQR = 59-76) and were caring for a person aged 81 years (IQR = 75-86.25 y). Most of both older adults (88%) and caregivers (84%) agreed or strongly agreed that they would be willing to stop one or more of their or their care recipient's medications if their or their care recipient's doctor said it was possible. In a binary logistic regression model, a low concern about stopping factor score was the strongest predictor of willingness to have a medication deprescribed in older adults (odds ratio [OR] = 0.12 95% confidence interval [CI] = 0.04-0.34). Excellent/good rating of physical health was the strongest predictor in caregivers (OR = 3.71 95% CI = 1.13-12.23). Most older adults and caregivers are willing to have one of their or their care recipient's medication deprescribed, although different predictors (characteristics/attitudes) of this willingness were identified in these two groups.
Publisher: Wiley
Date: 15-04-2023
DOI: 10.1111/BCPT.13862
Publisher: Springer Science and Business Media LLC
Date: 31-10-2018
DOI: 10.1007/S40266-018-0604-9
Abstract: The Canadian Emergency Team Initiative (CETI) cohort showed that minor injuries like sprained ankles or small fractures trigger a downward spiral of functional decline in 16% of independent seniors up to 6 months post-injury. Such seniors frequently receive medications with sedative or anticholinergic properties. The Drug Burden Index (DBI), which summarises the drug burden of these specific medications, has been associated with decreased physical and cognitive functioning in previous research. We aimed to assess the contribution of the DBI to functional decline in the CETI cohort. CETI participants were assessed physically and cognitively at baseline during their consultations at emergency departments (EDs) for their injuries and up to 6 months thereafter. The medication data were used to calculate baseline DBI and functional status was measured with the Older Americans Resources and Services (OARS) scale. Multivariate linear regression models assessed the association between baseline DBI and functional status at 6 months, adjusting for age, sex, baseline OARS, frailty level, comorbidity count, and mild cognitive impairment. The mean age of the 846 participants was 77 years and their mean DBI at baseline was 0.24. Complete follow-up data at 3 or 6 months was available for 718 participants among whom a higher DBI at the time of injury contributed to a lower functional status at 6 months. Each additional point in the DBI lead to a loss of 0.5 points on the OARS functional scale, p < 0.001. Among those with a DBI ≥ 1, 27.4% were considered 'patients who decline' at 3 or 6 months' follow-up, compared with 16.0% of those with a DBI of 0 (p = 0.06). ED visits are considered missed opportunities for optimal care interventions in seniors Identifying their DBI and adjusting treatment accordingly may help limit functional decline in those at risk after minor injury.
Publisher: American Chemical Society (ACS)
Date: 21-09-2023
DOI: 10.1021/JACS.3C06371
Publisher: Elsevier BV
Date: 07-2021
Publisher: SAGE Publications
Date: 2020
Abstract: Deprescribing is a complex process requiring consideration of behavior change theory to improve implementation and uptake. The aim of this study was to describe the knowledge, attitudes, beliefs, and behaviors that influence deprescribing for primary healthcare providers (family physicians, nurse practitioners (NPs), and pharmacists) within Nova Scotia using the Theoretical Domains Framework version 2 (TDF(v2)) and the Behavior Change Wheel. Interviews and focus groups were completed with primary care providers (physicians, NPs, and pharmacists) in Nova Scotia, Canada. Coding was completed using the TDF(v2) to identify the key influencers. Subdomain themes were also identified for the main TDF(v2) domains and results were then linked to the Behavior Change Wheel—Capability, Opportunity, and Motivation components. Participants identified key influencers for deprescribing including areas related to Opportunity, within TDF(v2) domain Social Influences, such as patients and other healthcare providers, as well as Physical barriers (TDF(v2) domain Environmental Context and Resources), such as lack of time and reimbursement. Our results suggest that a systematic approach to deprescribing in primary care should be supported by opportunities for patient and healthcare provider collaborations, as well as practice and system level enhancements to support sustainability of deprescribing practices.
Publisher: Wiley
Date: 28-08-2022
DOI: 10.5694/MJA2.51686
Publisher: Springer Science and Business Media LLC
Date: 06-06-2015
DOI: 10.1007/S11096-015-0147-7
Abstract: Deprescribing is the process of medication withdrawal with the aims of reducing the harms of potentially inappropriate medication use and improving patient outcomes. Deprescribing of statins may be indicated for some older people, because the evidence for benefit in primary prevention of cardiovascular disease is limited and there is an increased risk of side effects in old age. To determine older peoples' attitudes and beliefs regarding medication use and their willingness to have regular medications, particularly statins, deprescribed. Setting An Australian acute-care hospital. A cross-sectional study of patients admitted to a teaching hospital in Sydney, Australia, aged ≥65 years and taking a statin was conducted. Attitudes and beliefs regarding medication use and willingness to have medications or statins deprescribed were captured using the validated Patients' Attitudes Towards Deprescribing questionnaire, supplemented with additional statin-specific questions. Older inpatients' attitudes and perspectives towards stopping medications, in particular statins. Overall, 180 participants were recruited, with a median age of 78 years, (interquartile range 71-85). Eighty-nine percent (95% CI 84.4-93.6) of participants reported that they would be willing to stop one or more of their regular medications if their doctor said it was possible. Ninety-five percent (95% CI 91.8-98.2) agreed that they would be willing to have a statin deprescribed. Moreover, 94% (95% CI 90.5-97.5) of participants expressed concern regarding the potential side effects of taking a statin. The majority of older inpatients using statins are willing to have one or more of their current medications, including statins, deprescribed. These findings can be used to inform clinical practice and interventional statin deprescribing studies to optimise medication use in older adults.
Publisher: Wiley
Date: 27-02-2020
DOI: 10.1111/AJAG.12783
Publisher: Elsevier BV
Date: 10-2020
Publisher: Wiley
Date: 02-11-2021
DOI: 10.1111/BCP.14557
Publisher: Elsevier BV
Date: 03-2022
DOI: 10.1016/J.PEC.2021.06.021
Abstract: To examine older adults' perceptions and identify barriers and enablers to initiating a conversation about stopping medication(s) with their healthcare provider. We conducted one focus group (n = 3) and in-depth, face-to-face, in idual interviews (n = 6) using an interview guide. Older adults aged ≥65 years in a retirement community who were taking ≥5 medications were recruited. Focus groups and interviews were audio-recorded and transcribed verbatim. Both a deductive analysis, informed by the Theoretical Domains Framework, and an inductive analysis were conducted. Five themes and fourteen sub-themes were identified. Theme 1, 'older adult-related barriers', discusses limited or varying self-efficacy, past unsuccessful deprescribing experiences and limited familiarity with medications/deprescribing. Theme 2, 'provider-related barriers', discusses trust, short office visits, lack of communication and multiple providers. Theme 3, 'environmental/social-related barriers', involves limited availability of resources and access to telehealth/internet. The remaining themes (Themes 4-5) identified enablers including strategies to promote older adults' self-efficacy and improved healthcare communication. Consumer-centric tools could improve older adults' self-efficacy to initiate deprescribing conversations. Removing barriers and implementing enablers may empower older adults to initiate deprescribing conversations with providers to take fewer medications. Ultimately, this could be a catalyst for increased translation of deprescribing in practice.
Publisher: Wiley
Date: 02-2017
DOI: 10.1111/BCP.13222
Publisher: Springer Science and Business Media LLC
Date: 11-2012
Publisher: Wiley
Date: 04-10-2022
Publisher: American Medical Association (AMA)
Date: 05-2015
DOI: 10.1001/JAMAINTERNMED.2015.0324
Abstract: Inappropriate polypharmacy, especially in older people, imposes a substantial burden of adverse drug events, ill health, disability, hospitalization, and even death. The single most important predictor of inappropriate prescribing and risk of adverse drug events in older patients is the number of prescribed drugs. Deprescribing is the process of tapering or stopping drugs, aimed at minimizing polypharmacy and improving patient outcomes. Evidence of efficacy for deprescribing is emerging from randomized trials and observational studies. A deprescribing protocol is proposed comprising 5 steps: (1) ascertain all drugs the patient is currently taking and the reasons for each one (2) consider overall risk of drug-induced harm in in idual patients in determining the required intensity of deprescribing intervention (3) assess each drug in regard to its current or future benefit potential compared with current or future harm or burden potential (4) prioritize drugs for discontinuation that have the lowest benefit-harm ratio and lowest likelihood of adverse withdrawal reactions or disease rebound syndromes and (5) implement a discontinuation regimen and monitor patients closely for improvement in outcomes or onset of adverse effects. Whereas patient and prescriber barriers to deprescribing exist, resources and strategies are available that facilitate deliberate yet judicious deprescribing and deserve wider application.
Publisher: Springer Science and Business Media LLC
Date: 17-11-2014
DOI: 10.1007/S11096-013-9871-Z
Abstract: Deprescribing is a holistic process of medication cessation that encompasses gaining a comprehensive medication list, identifying potentially inappropriate medications, deciding if the identified medication can be ceased, planning the withdrawal regimen and monitoring, support and follow-up. It is currently being investigated as a mechanism to reduce unnecessary or redundant medications. However, given the systematic and patient-centred nature of the deprescribing process, it is possible that it may also confer additional benefits such as improving adherence to medications, even if there is no net reduction in overall medication use. Specifically, deprescribing may improve adherence via reducing polypharmacy, reducing the financial costs associated with medication taking, increasing the patient's medication knowledge through education, increasing patient engagement in medication management and resolution of adverse drug reactions. More research into deprescribing must be conducted to establish if these potential benefits can be realised, in addition to establishing any negative consequences.
Publisher: Bentham Science Publishers Ltd.
Date: 20-08-2015
DOI: 10.2174/157488471003150820150330
Abstract: Older adults with dementia commonly have multiple chronic conditions that prompt clinicians to prescribe medications. While dementia is a life-limiting disease, progression from mild cognitive impairment to end stage dementia is a process that can occur over many years and may not take a predetermined course. Therefore aligning pharmacological treatment with changing goals of care can be challenging. The aim of this narrative review was to explore barriers to optimising prescribing and deprescribing (withdrawing) of medications as the goal of care shifts from prolonging life to optimising quality of life. Optimising pharmacological treatment to help people with dementia achieve their goals of care often requires deprescribing of medications that are inappropriate, as well as initiating appropriate medications. Medical practitioner, system, patient and carer related barriers to optimisation of medications in older adults with multiple morbidities have been identified including: inadequate guidelines, incomplete medical histories, lack of time, avoidance of negative consequences, established beliefs in the benefits and harms of medication use and others. Optimising prescribing for older people with dementia is further complicated by diminished decision making capacity, difficulties with comprehension and communication, increasing involvement of carers and difficulties establishing goals of care. Further research is required into the attitudes, beliefs and preferences of people with dementia and their carers regarding prescribing and deprescribing.
Publisher: Oxford University Press (OUP)
Date: 2023
Abstract: people living with cognitive impairment commonly take multiple medications including potentially inappropriate medications (PIMs), which puts them at risk of medication related harms. to explore willingness to have a medication deprescribed of older people living with cognitive impairment (dementia or mild cognitive impairment) and multiple chronic conditions and assess the relationship between willingness, patient characteristics and belief about medications. cross-sectional study using results from the revised Patients’ Attitudes Towards Deprescribing questionnaire (rPATDcog) collected as baseline data in the OPTIMIZE study, a pragmatic, cluster-randomised trial educating patients and clinicians about deprescribing. Eligible participants were 65+, diagnosed with dementia or mild cognitive impairment, and prescribed at least five-long-term medications. the questionnaire was mailed to 1,409 intervention patients and 553 (39%) were returned and included in analysis. Participants had a mean age of 80.1 (SD 7.4) and 52.4% were female. About 78.5% (431/549) of participants said that they would be willing to have one of their medications stopped if their doctor said it was possible. Willingness to deprescribe was negatively associated with getting stressed when changes are made and with previously having a bad experience with stopping a medication (P & 0.001 for both). most older people living with cognitive impairment are willing to deprescribe. Addressing previous bad experiences with stopping a medication and stress when changes are made to medications may be key points to discuss during deprescribing conversations.
Publisher: Wiley
Date: 04-05-2023
DOI: 10.1111/BCPT.13877
Publisher: Elsevier BV
Date: 04-2020
Publisher: SAGE Publications
Date: 10-11-2015
Abstract: Background: Proton pump inhibitors (PPIs) are inappropriately prescribed in up to 50% of users. Systematic medication review and cessation of inappropriate medications or deprescribing may improve patient outcomes and reduce costs. Objective: The aim of this study was to assess the feasibility of a patient-centered deprescribing process in a population of adults with complex polypharmacy. Methods: This was a prospective feasibility study. Participants were recruited from hospital outpatient clinics. The patient-centered deprescribing process consisted of 5 steps: comprehensive medication history, identification of potentially inappropriate medications, determining if the medication can be ceased, planning the withdrawal regimen (eg, tapering where necessary), and provision of monitoring, support, and documentation. Feasibility was determined by assessing time taken to complete the different steps of the deprescribing process and participant feedback. Results: In all, 57 PPI users were recruited participants were 70 ± 14 years old and took 14 ± 6 medications. The indication for PPI use was verified in 43 participants and judged as potentially inappropriate in 19 (44%) 8 were suitable for trial withdrawal, and 6 consented. All 6 successfully ceased (n = 3) or reduced (n = 3) their PPI use, and this was sustained at 6 months postintervention in 4 participants. Conclusions: The patient-centered deprescribing process can safely reduce inappropriate PPI prescribing in a small proportion of people. Although the process was acceptable to participants, difficulties in accessing complete medical histories, time limitations, and minimal evidence to support effectiveness in certain indications were barriers to implementation of the process in clinical practice.
Publisher: Elsevier BV
Date: 03-2017
DOI: 10.1016/J.EJIM.2016.12.021
Abstract: Deprescribing can be defined as the process of withdrawal or dose reduction of medications which are considered inappropriate in an in idual. 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.
Publisher: SAGE Publications
Date: 2019
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2015
Publisher: American Medical Association (AMA)
Date: 03-10-2023
Publisher: Springer Science and Business Media LLC
Date: 09-10-2013
DOI: 10.1007/S11096-012-9704-5
Abstract: There is a large amount of research into and promotion of rational prescribing, but there is a comparative lack of investigation into deprescribing. The success of deprescribing is likely to be dependent on both medical and patient factors. The aim of this study was to develop and validate a tool to capture the views and beliefs of patients regarding cessation of medications. Setting Participants were recruited from a multidisciplinary clinic at the Royal Adelaide Hospital and H stead Rehabilitation Centre. The patients' attitudes towards deprescribing (PATD) questionnaire was developed through expert opinion and piloting. Psychometric testing included face, content and criterion validity, sensitivity and test-retest reliability. A final 15 item questionnaire was produced. Through piloting, expert review and gamma rank correlation with the previously validated beliefs about medicines questionnaire, the PATD was determined to be valid. Test-retesting resulted in a total concordance of 71.3 % (95 % confidence interval, 64.1-78.5 %). The PATD has acceptable psychometric properties and has potential for future use in research and practice to not only determine patients' willingness towards deprescribing, but also uncover what beliefs may influence this.
Publisher: Wiley
Date: 27-02-2017
Publisher: Wiley
Date: 25-06-2023
DOI: 10.5694/MJA2.52002
Abstract: Long term opioids are commonly prescribed to manage pain. Dose reduction or discontinuation (deprescribing) can be challenging, even when the potential harms of continuation outweigh the perceived benefits. The Evidence‐based clinical practice guideline for deprescribing opioid analgesics was developed using robust guideline development processes and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, and contains deprescribing recommendations for adults prescribed opioids for pain. Eleven recommendations provide advice about when, how and for whom opioid deprescribing should be considered, while noting the need to consider each person's goals, values and preferences. The recommendations aim to achieve: implementation of a deprescribing plan at the point of opioid initiation initiation of opioid deprescribing for persons with chronic non‐cancer or chronic cancer‐survivor pain if there is a lack of overall and clinically meaningful improvement in function, quality of life or pain, a lack of progress towards meeting agreed therapeutic goals, or the person is experiencing serious or intolerable opioid‐related adverse effects gradual and in idualised deprescribing, with regular monitoring and review consideration of opioid deprescribing for in iduals at high risk of opioid‐related harms avoidance of opioid deprescribing for persons nearing the end of life unless clinically indicated avoidance of opioid deprescribing for persons with a severe opioid use disorder, with the initiation of evidence‐based care, such as medication‐assisted treatment of opioid use disorder and use of evidence‐based co‐interventions to facilitate deprescribing, including interdisciplinary, multidisciplinary or multimodal care. To our knowledge, these are the first evidence‐based guidelines for opioid deprescribing. The recommendations intend to facilitate safe and effective deprescribing to improve the quality of care for persons taking opioids for pain.
Publisher: Springer Science and Business Media LLC
Date: 27-10-2016
DOI: 10.1007/S40266-016-0410-1
Abstract: Knowledge of consumer (patient and caregiver) attitudes is essential for conducting medication optimization in practice. The aim of this study was to develop and validate a questionnaire to capture older adults' and caregivers' beliefs and attitudes towards deprescribing. The previously validated Patients' Attitudes Towards Deprescribing (PATD) questionnaire was expanded based on literature review, expert opinion and focus groups, and a caregivers' version was developed. The revised questionnaire was piloted and then distributed for self-completion to older adults (≥65 years of age), taking at least one regular medication and caregivers of older adults. Psychometric validity and reliability were examined. Responses to questions that were identified to group into a specific factor were combined to produce a score. A total of 383 consumer questionnaires and 200 caregiver questionnaires were completed and included in analysis. Exploratory factor analysis revealed four factors in both versions of the questionnaire (with four to five questions retained in each factor). The factors relate to the perceived burden of medication taking, belief in appropriateness of medication use (harms and benefits), concerns about stopping the medication, and level of involvement/knowledge of medications. Internal consistency of all factors was acceptable with Cronbach's alpha >0.6. In both the older adults' and caregivers' versions, the burden score was inversely associated with the appropriateness score (p < 0.001 both versions). Factor scores between administration times (test-retest reliability) were statistically significantly correlated (p = 0.000), with gamma values ranging between 0.57 and 0.89. The revised PATD questionnaire had acceptable validity and reliability. This newly validated questionnaire may provide insight into in iduals' willingness for/barriers to deprescribing, with applications in practice and research.
Publisher: Wiley
Date: 2021
DOI: 10.1111/IMJ.15155
Publisher: Springer Science and Business Media LLC
Date: 18-06-2020
DOI: 10.1186/S13063-020-04482-0
Abstract: Most in iduals with dementia or mild cognitive impairment (MCI) have multiple chronic conditions (MCC). The combination leads to multiple medications and complex medication regimens and is associated with increased risk for significant treatment burden, adverse drug events, cognitive changes, hospitalization, and mortality. Optimizing medications through deprescribing (the process of reducing or stopping the use of inappropriate medications or medications unlikely to be beneficial) may improve outcomes for MCC patients with dementia or MCI. With input from patients, family members, and clinicians, we developed and piloted a patient-centered, pragmatic intervention (OPTIMIZE) to educate and activate patients, family members, and primary care clinicians about deprescribing as part of optimal medication management for older adults with dementia or MCI and MCC. The clinic-based intervention targets patients on 5 or more medications, their family members, and their primary care clinicians using a pragmatic, cluster-randomized design at Kaiser Permanente Colorado. The intervention has two components: a patient/ family component focused on education and activation about the potential value of deprescribing, and a clinician component focused on increasing clinician awareness about options and processes for deprescribing. Primary outcomes are total number of chronic medications and total number of potentially inappropriate medications (PIMs). We estimate that approximately 2400 patients across 9 clinics will receive the intervention. A comparable number of patients from 9 other clinics will serve as wait-list controls. We have 80% power to detect an average decrease of − 0.70 ( 1 medication). Secondary outcomes include the number of PIM starts, dose reductions for selected PIMs (benzodiazepines, opiates, and antipsychotics), rates of adverse drug events (falls, hemorrhagic events, and hypoglycemic events), ability to perform activities of daily living, and skilled nursing facility, hospital, and emergency department admissions. The OPTIMIZE trial will examine whether a primary care-based, patient- and family-centered intervention educating patients, family members, and clinicians about deprescribing reduces numbers of chronic medications and PIMs for older adults with dementia or MCI and MCC. NCT03984396 . Registered on 13 June 2019
Publisher: Elsevier BV
Date: 11-2019
Publisher: Wiley
Date: 02-2020
DOI: 10.1002/JPPR.1626
Publisher: Informa UK Limited
Date: 11-02-2019
DOI: 10.1080/17425255.2017.1325873
Abstract: The number of people with dementia internationally is increasing. Older adults with dementia are prescribed multiple medications, both to treat dementia symptoms and to manage their other medical conditions. Dementia is correlated with increasing age and frailty this provides insight into how the efficacy and toxicity of medications may be altered in people with dementia. Areas covered: This review discusses the current evidence of the alterations in pharmacokinetics that can occur with aging, frailty and in people with dementia. The evidence is presented via the four primary pharmacokinetic processes (absorption, distribution, metabolism and elimination). Additionally, distribution into the brain, sex considerations and potential pharmacodynamic alterations in older people with dementia are discussed. Expert opinion: While the evidence is limited, people with dementia appear to be at a higher risk of toxicity of some medications due to altered pharmacokinetic processes and pharmacodynamics. There are a number of limitations to the research and there are still significant gaps in knowledge in this field. Proactive, ongoing review of the appropriateness of choice of medication, dose and whether or not a medication is required at all is necessary for achieving quality use of medications in people living with dementia.
Publisher: Elsevier BV
Date: 08-2022
DOI: 10.1016/J.SAPHARM.2021.12.001
Abstract: Polypharmacy is a major global problem. Evidence in primary care shows deprescribing can be beneficial. Behaviour change theories such as the Theoretical Domains Framework (TDF) and the Behaviour Change Wheel (BCW) can help develop successful implementation of deprescribing initiatives. To link locally identified deprescribing influencers with components of successfully trialed deprescribing strategies, with the aim of informing the development of local deprescribing initiatives. Two background studies were completed. A qualitative study of interviews and focus groups identified influencers of deprescribing from local primary care physicians, nurse practitioners, and pharmacists. Transcripts were coded using the TDF and mapped to the Intervention Functions of the BCW. A scoping review identified studies that investigated primary care deprescribing strategies, which were mapped to the BCW Intervention Functions and the Behaviour Change Techniques (BCTs). For this analysis, six main TDF domains from the qualitative study were linked to the BCTs identified in the scoping review through the Intervention Functions of the BCW. Within the BCW component Capability, one TDF domain identified in the qualitative study, Memory, Attention and Decision Process, was linked to strategies like academic detailing from the scoping review. For the Opportunity component, two TDF domains, Social Influences and Environmental Context and Resources, were linked to strategies such as pharmacist medication reviews, providing patient information leaflets, and evidence-based deprescribing tools. For the Motivation component, three TDF domains, Social/Professional Role and Identity, Intentions, and Beliefs about Consequences, were linked to strategies such as sending deprescribing information to prescribers, using tools to identify eligible patients, and having patients report adverse events of medications. This analysis identified deprescribing strategies that can be used to address influencers related to behaviour change from the perspective of primary care providers, and to assist with future deprescribing initiative development and implementation in the local context.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2015
DOI: 10.1002/CHP.21269
Abstract: We investigated whether using an audience response system (ARS) as part of continuing education (CE) activities enhances immediate and long-term knowledge acquisition or learner reactions. A multicenter single-blinded controlled trial involving pharmacists at 2 metropolitan teaching hospitals was used for this investigation. Pharmacists were allocated to either (a) an interactive presentation incorporating multiple-choice questions (MCQs) answered using an ARS, or (b) the same, but noninteractive, presentation using summary points instead of MCQs. Baseline knowledge was evaluated using a 10-item questionnaire, which was also used to evaluate immediate and long-term (6 weeks later) knowledge acquisition. Learner reactions were evaluated through feedback questionnaires. The control and ARS intervention presentations were attended by 44 and 35 pharmacists, respectively. The 6-week follow-up questionnaire was completed by 35 control (80%) and 27 (77%) ARS group participants. Baseline knowledge was similar across groups (5.0 ± 1.6 SD vs 5.2 ± 1.6 p = .44) with no differences in immediate (8.3 ± 1.5 vs 7.9 ± 1.5 p = 0.30) or long-term (7.0 ± 1.6 vs 7.0 ± 1.5 p = 0.93) knowledge acquisition. Feedback regarding the use of an ARS was overwhelmingly positive, with participants feeling more strongly that the ARS enabled them to compare knowledge to that of their peers (p < .001). There was no observed benefit of an ARS in relation to immediate or long-term knowledge acquisition. The use of an ARS, however, appeared to facilitate enhanced interactivity and participant self-reflection of knowledge, with strong participant desire to continue their use in future CE activities.
Publisher: Elsevier BV
Date: 07-2017
DOI: 10.1016/J.SAPHARM.2016.08.006
Abstract: While there is evidence that supervised withdrawal of inappropriate medications might be beneficial for in iduals with polypharmacy, little is known about their attitudes towards deprescribing. This study aimed to describe the situation among older community-dwelling Canadians. A self-administered survey was adapted from the Patients' Attitudes Towards Deprescribing questionnaire and distributed to 10 community pharmacies and 2 community centers. The participants rated their agreement on statements about polypharmacy/deprescribing on a 5-point, Likert-type scale. Correlations between the desire to have medications deprescribed and survey items were evaluated using Spearman's Rho and Goodman and Kurska's gamma rank correlations. From the 129 participants, 63% were women [median age: 76 (IQR:71-80) median number medication: 6 (IQR: 3-8)]. A proportion of 50.8% (95%CI: 41.6%-60.0%) expressed the desire to reduce their number of medications. This desire was strongly correlated with the in iduals' feeling of taking a large number of medications and moderately correlated with the belief that some of the medications were no longer needed or that they were experiencing side effects. The results show that older in iduals in the community are eager to undertake deprescribing, especially if they have a large number of medications, are experiencing side effects or feel some medications are no longer necessary.
Publisher: Elsevier BV
Date: 04-2021
Publisher: Informa UK Limited
Date: 02-11-2022
DOI: 10.1080/14740338.2022.2147923
Abstract: Over 4 billion prescriptions are dispensed each year to patients in the United States, with the number of prescriptions continuing to increase. There is a growing recognition of pharmacists' potential in improving medication safety in community settings, in collaboration with primary care providers (PCPs). However, the nature of collaboration has not been well defined, and barriers and strategies are not articulated. For this narrative review, published studies were retrieved from PubMed between January 2000 and December 2020. Search terms included "patient safety," "medication safety," "collaboration," "primary care physician," and "community pharmacy." Resulting articles were categorized as follows: defining collaboration, types of collaboration, and barriers and solutions to collaboration. It is important to understand the factors within a community pharmacy setting that limit or facilitate community pharmacists' participation in medication safety activities. Strategies such as medication review are a common form of collaboration. Barriers to collaboration include misconceptions regarding roles and differences in access to clinical information and community pharmacy practice variability. Future recommendations include increasing training and utilization of pharmacists/PCP teams, increasing community pharmacists' practice in emerging roles, and expanding the community pharmacist role in transitions of care from the hospital to the community.
Publisher: Oxford University Press (OUP)
Date: 30-04-2021
Publisher: Elsevier BV
Date: 03-2022
DOI: 10.1016/J.SAPHARM.2021.04.004
Abstract: Unnecessary polypharmacy continues to be a problem among older adults. The field of deprescribing (planned, supervised process of medication discontinuation) aims to address this problem. Deprescribing is a relatively new field despite having grown substantially in recent years. Much of the early research in this area focused on identifying barriers to and facilitators of deprescribing in clinical practice, which contributed to a large body of work on this topic. However, with continuing research around barriers and facilitators, we need to be mindful to undertake research that builds on existing knowledge, addresses known gaps, and advances the field. Additionally, there is a need in deprescribing research to shift focus to developing ways to address known barriers and harness knowledge of facilitators. That is, translating existing knowledge into strategies and tools that can impact clinical practice and lead to practical and sustained deprescribing efforts.
Publisher: Royal College of General Practitioners
Date: 06-06-2016
Publisher: Wiley
Date: 17-08-2023
DOI: 10.1111/BCP.15864
Abstract: Deprescribing aims to address the problem of medication overuse in older adults. There has been an increasing number of systematic reviews of ‘deprescribing’. We aimed to describe the categories of trials included in recent systematic reviews, and to make recommendations for future research. We categorized 122 trials included in eight recent deprescribing systematic reviews into: discontinuation, deprescribing implementation, medication optimisation (including medication initiation) and non‐initiation trials. We identified heterogeneity and inconsistency in the categories of trials included in deprescribing systematic reviews. For ex le, 39 trials (32.0%) involved medication initiation in addition to the deprescribing component. It is now time for international researchers to develop and validate terminology used for trials involving discontinuation/deprescribing of medications, and to provide recommendations for evidence synthesis that will better inform future research, and translation into practice and policy.
Publisher: American Medical Association (AMA)
Date: 12-2018
Publisher: Elsevier BV
Date: 06-2019
Publisher: Elsevier BV
Date: 06-2019
DOI: 10.1016/J.SAPHARM.2018.08.010
Abstract: Deprescribing is a clinically important and feasible innovation that ensures medication efficacy, reduces harms, and mitigates polypharmacy. It involves reducing doses or stopping medications that are not useful, no longer needed, or which may be causing harm. It may also involve changing to a safer agent or using non-pharmacological approaches for care instead. Clinical guidelines combined with behaviour changes (of health care providers (HCPs), the public, and health care decision-makers) are needed to integrate deprescribing into routine practice. Using rigorous international standards, the Bruyère Research Institute Deprescribing Guidelines research team validated a ground-breaking deprescribing guideline methodology and developed or co-developed 5 evidence-based deprescribing guidelines. In March 2018, the team hosted an international symposium convening HCPs, researchers, public agencies, policymakers, and patient advocates in Ottawa, Ontario, Canada. This 3-day symposium aimed to facilitate knowledge exchange amongst guideline developers, users, and the public initiate partnerships and collaborations for new deprescribing guideline recommendations and effectiveness research and to continue work on HCP deprescribing education activities. An interprofessional planning committee developed an overall agenda, and small groups worked on session objectives and formats for different components: methods for rigorous deprescribing guideline development, implementation experiences, research/evaluation experiences and educational needs. Through a series of keynote speakers, panel discussions, and small working groups, the symposium provided a forum for participants to meet one another, learn about their different experiences with deprescribing guidelines, and develop collaborations for future initiatives. One hundred thirty participants, from 10 countries and representing over 100 institutions and organizations took part. Symposium proceedings are presented in this issue of RSAP for sharing with the wider community engaged in the care of patients with problematic polypharmacy.
Publisher: Cambridge University Press (CUP)
Date: 09-03-2017
DOI: 10.1017/S1041610216002180
Abstract: Online tools can be used by people with dementia and their caregivers to self-identify and track troubling symptoms, such as verbal repetition. We aimed to explore verbal repetition behaviors in people with dementia. Participants were recruited via an online resource for people with dementia and their caregivers. Respondents were instructed to complete information about symptoms that are most important to them for tracking over time. In this cross-sectional study, we analyzed data pertaining to in iduals with dementia who had at least three symptoms selected for tracking. Of the 3,573 participants who began a user profile, 1,707 fulfilled criteria for analysis. Verbal repetition was identified as a treatment target in 807 respondents (47.3%). Verbal repetition was more frequent in in iduals with mild dementia compared to those with moderate and severe dementia (57.2% vs. 36.0% and 39.9%, p 0.01) and in those with Alzheimer's disease versus other dementias (65.2% vs. 29.7%, p 0.001). Repetitive questioning was the most frequent type of verbal repetition (90.5% of in iduals with verbal repetition). Verbal repetition was most strongly associated with difficulties operating gadgets/appliances (OR 3.65, 95%CI: 2.82–4.72), lack of interest and/or initiative (3.52: 2.84–4.36), misplacing or losing objects (3.25: 2.64–4.01), and lack of attention and/or concentration (2.62: 2.12–3.26). Verbal repetition is a common symptom in people at all stages of dementia but is most commonly targeted for monitoring and treatment effects in its mild stage. Much research is required to further elucidate the underlying mechanisms and the effect of different treatment strategies.
Publisher: Springer International Publishing
Date: 2020
Publisher: Springer Science and Business Media LLC
Date: 22-06-2021
DOI: 10.1186/S12875-021-01488-8
Abstract: Recruiting general practitioners (GPs) and their multimorbid older patients for trials is challenging for multiple reasons (e.g., high workload, limited mobility). The comparability of study participants is important for interpreting study findings. This manuscript describes the baseline characteristics of GPs and patients participating in the ‘Optimizing PharmacoTherapy in older multimorbid adults In primary CAre’ (OPTICA) trial, a study of optimization of pharmacotherapy for multimorbid older adults. The overall aim of this study was to determine if the GPs and patients participating in the OPTICA trial are comparable to the real-world population in Swiss primary care. Analysis of baseline data from GPs and patients in the OPTICA trial and a reference cohort from the FIRE (‘Family medicine ICPC Research using Electronic medical records’) project. Primary care, Switzerland. Three hundred twenty-three multimorbid (≥ 3 chronic conditions) patients with polypharmacy (≥ 5 regular medications) aged ≥ 65 years and 43 GPs recruited for the OPTICA trial were compared to 22,907 older multimorbid patients with polypharmacy and 227 GPs from the FIRE database. We compared the characteristics of GPs and patients participating in the OPTICA trial with other GPs and other older multimorbid adults with polypharmacy in the FIRE database. We described the baseline willingness to have medications deprescribed of the patients participating in the OPTICA trial using the revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire. The GPs in the FIRE project and OPTICA were similar in terms of sociodemographic characteristics and their work as a GP (e.g. aged in their fifties, ≥ 10 years of experience, ≥ 60% are self-employed, ≥ 80% work in a group practice). The median age of patients in the OPTICA trial was 77 years and 45% of trial participants were women. Patients participating in the OPTICA trial and patients in the FIRE database were comparable in terms of age, certain clinical characteristics (e.g. systolic blood pressure, body mass index) and health services use (e.g. selected lab and vital data measurements). More than 80% of older multimorbid patients reported to be willing to stop ≥ 1 of their medications if their doctor said that this would be possible. The characteristics of patients and GPs recruited into the OPTICA trial are relatively comparable to characteristics of a real-world Swiss population, which indicates that recruiting a generalizable patient s le is possible in the primary care setting. Multimorbid patients in the OPTICA trial reported a high willingness to have medications deprescribed. Clinicaltrials.gov ( NCT03724539 ), KOFAM (Swiss national portal) ( SNCTP000003060 ), Universal Trial Number (U1111-1226-8013)
Publisher: Informa UK Limited
Date: 06-11-2017
DOI: 10.1080/14740338.2018.1397625
Abstract: As with prescribing or continuing medications, deprescribing brings with it the potential for harm as well as benefit. Uncertainty and avoidance of harm has been reported as a barrier to deprescribing in practice and may contribute to continuation of inappropriate medications. This narrative review covers four main safety concerns otential harms of deprescribing in older adults: adverse drug withdrawal events, return of medical condition(s), reversal of drug-drug interactions and damage to the doctor-patient relationship. These are discussed in relation to medications in general, with some ex les of medication classes used to illustrate the potential safety concerns. The majority of these harms can be minimized or even prevented by using a patient-centered, structured deprescribing process with planning, tapering and close monitoring during, and after medication withdrawal. More research is needed into the safety concerns of deprescribing, however, avenues exist during drug development and post-marketing surveillance to gain knowledge on this topic. Questions remain about when it is suitable to discontinue certain medications/medication classes and there is uncertainty about the harms and benefits of both medication continuation and discontinuation in complex older adults.
Publisher: Oxford University Press (OUP)
Date: 16-01-2015
DOI: 10.1111/IJPP.12111
Publisher: BMJ
Date: 02-2020
DOI: 10.1136/BMJOPEN-2019-035656
Abstract: Polypharmacy and potentially inappropriate medication use is common in older adults and is associated with adverse outcomes such as falls and hospitalisations. This study is a pharmacist-led medication optimisation initiative using an electronic tool (the Drug Burden Index (DBI) Calculator) in four hospital sites in the Canadian province of Nova Scotia. The study aims to enrol 160 participants between the preintervention and intervention groups. The Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT 2013 checklist) was used to develop the protocol for this prospective interventional implementation study. A preintervention retrospective control cohort and a multiple case study analysis will also be used to assess the effect of intervention implementation. Statistical analysis will involve change in DBI scores and assessment of clinical outcomes, such as rehospitalisation and mortality using appropriate statistical tests including t-test, χ 2 , analysis of variance and unadjusted and adjusted regression methods. Ethics approval has been granted by the Nova Scotia Health Authority Research Ethics Board. The findings of this study will be published in peer-reviewed journals and presented at local, national and international conferences. NCT03698487 .
Publisher: Wiley
Date: 26-08-2020
DOI: 10.1111/BCP.14525
Publisher: The Royal Australian College of General Practitioners
Date: 11-2022
Publisher: Springer Science and Business Media LLC
Date: 09-05-2023
Publisher: Springer Science and Business Media LLC
Date: 12-02-2020
DOI: 10.1186/S12877-020-1442-2
Abstract: Older people living in the community have a high prevalence of polypharmacy and are vulnerable to adverse drug events. Home Medicines Review (HMR) is a collaborative medication review service involving general practitioners (GPs), accredited clinical pharmacists (ACPs) and patients, which aims to prevent medication-related problems. This study aims to evaluate the implementation of a Computerised Clinical Decision Support System (CCDSS) called G-MEDSS© (Goal-directed Medication Review Electronic Decision Support System) in HMRs to deprescribe anticholinergic and sedative medications, and to assess the effect of deprescribing on clinical outcomes. This study consists of 2 stages: Stage I – a two-arm parallel-group cluster-randomised clinical trial, and Stage II – process evaluation of the CCDSS intervention in HMR. Community-dwelling older adults living with and without dementia who are referred for HMR by their GP and recruited by ACPs will be included in this study. G-MEDSS is a CCDSS designed to provide clinical decision support for healthcare practitioners when completing a medication review, to tailor care to meet the patients’ goals and preferences. The G-MEDSS contains three tools: The Goals of Care Management Tool, The Drug Burden Index (DBI) Calculator©, and The revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire. The G-MEDSS produces patient-specific deprescribing reports, to be included as part of the ACPs communication with the patient’s GP, and patient-specific reports for the patient (or carer). ACPs randomised to the intervention arm of the study will use G-MEDSS to create deprescribing reports for the referring GP and for their patient (or carer) when submitting the HMR report. ACPs in the comparison arm will provide the usual care HMR service (without the G-MEDSS). The primary outcome is reduction in DBI exposure 3 months after HMR ± G-MEDSS intervention between comparison and intervention groups. The secondary outcomes include changes in clinical outcomes (physical and cognitive function, falls, institutionalisation, GP visits, medication adherence and mortality) 3-months after HMR. This study is expected to add to the evidence that the combination of CCDSS supporting medication review can improve prescribing and clinical outcomes in older adults. The trial was registered on the Australian New Zealand Clinical Trials Registry ACTRN12617000895381 on 19th June 2017.
Publisher: Wiley
Date: 08-09-2023
DOI: 10.1111/BCPT.13938
Publisher: Elsevier BV
Date: 09-2016
DOI: 10.1016/J.SAPHARM.2015.12.004
Abstract: There has been recent interest in deprescribing, particularly among older people. No previous studies have assessed whether residents of aged care facilities are willing to have their medications deprescribed. Understanding residents' attitudes toward deprescribing is important for developing deprescribing interventions. To investigate residents' willingness to have their medications deprescribed. This was a cross-sectional survey of 232 residents aged ≥65 years from six residential aged care facilities (RACFs) across metropolitan and regional South Australia. Overall, 163 of the 232 residents (70.3%) took ≥9 regular medications. All participants completed the 10-item Patients' Attitudes Towards Deprescribing (PATD) questionnaire. Overall, 40.5% of residents reported a desire to stop taking one or more of their medications. If their doctor said it was possible, 78.9% of residents were willing to have one or more of their medications deprescribed. Residents taking ≥9 medications were more likely to feel that they were taking a large number of medications compared to residents taking <9 medications (50.3% vs 14.5%, P < 0.01), and were more likely to believe one or more of their medications was causing side effects (14.7% vs 10.1%, P = 0.02). However, residents taking ≥9 regular medications were not significantly more likely to want to reduce their number of medications than residents taking <9 medications. Deprescribing interventions are likely to be acceptable to residents' of RACFs, with a high willingness to discontinue medicines if doctors say it is possible. This highlights the importance of the proactive involvement of health care professionals in an in idualized deprescribing process.
Publisher: Wiley
Date: 04-2021
DOI: 10.1002/JPPR.1725
Publisher: Authorea, Inc.
Date: 20-02-2023
Publisher: BMJ
Date: 19-06-2014
Publisher: Springer Science and Business Media LLC
Date: 07-03-2016
DOI: 10.1007/S11096-016-0279-4
Abstract: From 20 to 65 % of older adults receiving polypharmacy take at least one potentially inappropriate medication (PIM), leading to a high risk of adverse drug reactions. The term deprescribing was coined to describe a process of optimization of drug regimens through the withdrawal of PIMs. There is a paucity of evidence on the attitudes, beliefs and willingness of hospitalized patients towards deprescribing. To measure at hospital discharge inpatients' attitudes and beliefs towards polypharmacy and the potential withdrawal of one or more of their medications using the PATD (Patients' Attitudes Towards Deprescribing) questionnaire and determine if they are associated with participant characteristics. Geriatric and internal medicine wards in an Italian teaching hospital. Administration of the PATD questionnaire (developed and validated in an Australian outpatient setting, translated and adapted to the Italian setting for this study) to a consecutive s le of 100 older (aged ≥65 years) inpatients with polypharmacy who were interviewed by a nurse or pharmacist at the time of hospital discharge. Older patients' attitudes and beliefs towards reducing medications and participant characteristics. Eighty-nine percent of patients surveyed would like to reduce the number of daily medications. The desire for deprescribing was not associated with age, sex or number of medications or medical conditions older patients were less aware of the reasons for taking medications. The majority of hospitalized older adults with polypharmacy think they are taking a lot of drugs and would like to reduce this number. Older adults should not be considered a major limitation on deprescribing interventions. Future research should examine this issue with qualitative studies in order to gain a more in-depth understanding and explore how these findings can be translated into a multidisciplinary deprescribing process.
Publisher: Informa UK Limited
Date: 19-01-2015
DOI: 10.1517/17425255.2015.1004310
Abstract: The worldwide population is aging, and several age-associated physiological and pathophysiological changes can affect drug disposition. This is particularly important in view of the extensive medication prescribing and exposure in older adults. Using a framework of the four primary pharmacokinetic processes (Absorption, Distribution, Metabolism and Elimination), this review discusses the current evidence of the pharmacokinetic changes that occur with aging, particularly 'healthy aging,' focusing on developments in this field over the last 10 years. A substantial amount of work has been conducted to address whether advancing age significantly affects drug disposition in humans. Despite significant advances in the field, particularly regarding drug metabolism and elimination, a number of issues remain unsolved. In particular, lack of inclusion of older adults with multimorbidity and those aged > 80 and minimal evidence in relation to new drugs limits the applicability of findings to current clinical practice.
Publisher: Springer Science and Business Media LLC
Date: 29-07-2020
Publisher: Wiley
Date: 04-11-2015
DOI: 10.1111/BCP.12732
Abstract: The aim of this study was to identify what definitions have been published for the term 'deprescribing', and determine whether a unifying definition could be reached. A secondary aim was to uncover patterns between the published definitions which could explain any variation. Systematic literature searches were performed (earliest records to February 2014) in MEDLINE, Embase, CINAHL, Informit, Scopus and Google Scholar. The terms deprescrib* or de-prescrib* were employed as a keyword search in all fields. Conventional content analysis and word frequencies were used to identify characteristics of the definitions. Network analysis was conducted to visualize characteristic distribution across authors and articles. Following removal of duplicates, 231 articles were retrieved, 37 of which included a definition. Eight characteristics of the definitions were identified: use of the term stop/withdraw/cease/discontinue (35 articles), aspect of prescribing included e.g. long term therapy/inappropriate medications (n = 18), use of the term 'process' or 'structured' (n = 13), withdrawal is planned/supervised/judicious (n = 11), involving multiple steps (n = 7), includes dose reduction/substitution (n = 7), desired goals/outcomes described (n = 5) and involves tapering (n = 4). Network analysis did not reveal patterns responsible for variations in previously used definitions. These findings show that there is lack of consensus on the definition of deprescribing. This article proposes the following definition: 'Deprescribing is the process of withdrawal of an inappropriate medication, supervised by a health care professional with the goal of managing polypharmacy and improving outcomes'. This definition has not yet been externally validated and further work is required to develop an internationally accepted and appropriate definition.
Publisher: Elsevier BV
Date: 07-2022
DOI: 10.1016/J.SAPHARM.2021.09.004
Abstract: 1) To understand and investigate the experiences of accredited clinical pharmacists (ACP) using computerised clinical decision support systems (CCDSS) during medication reviews for older people, including those living with dementia 2) To design, develop, validate, and evaluate a CCDSS that incorporates pharmacological and other deprescribing tools to aid person-centred management of high-risk medications in older adults living with and without dementia. This study consisted of three phases and was designed on scenario-based methodology: a) the development phase, which included an exploratory survey and prototype building b) the validation phase, which included qualitative data collection and usability testing with ACPs, general practitioners (GPs) and carers for people living with dementia and c) the evaluation phase, using mixed-methods analyses. The exploratory survey found that ACPs required a flexible, and reliable CCDSS to support them with clinical decisions regarding high-risk medication use in older adults. The Goal-directed Medication review Electronic Decision Support System (G-MEDSS)© was developed and validated using quantitative and qualitative feedback received from ACPs, GPs and carers for people with dementia. The mean (SD) System Usability Scale score was 69.0 (12.9), which indicated fair-good usability. Involving end-users in the design process refined and improved the design of G-MEDSS, allowing for a person-centred and goal-directed delivery of pharmaceutical care. G-MEDSS allows healthcare practitioners conducting medication reviews for older adults living with and without dementia to tailor pharmaceutical care to meet their goals and preferences. Future studies may explore integration of G-MEDSS with prescribing or dispensing software.
Publisher: BMJ
Date: 09-2019
DOI: 10.1136/BMJOPEN-2019-031080
Abstract: Multimorbidity and polypharmacy are major risk factors for potentially inappropriate prescribing (eg, overprescribing and underprescribing), and systematic medication reviews are complex and time consuming. In this trial, the investigators aim to determine if a systematic software-based medication review improves medication appropriateness more than standard care in older, multimorbid patients with polypharmacy. Optimising PharmacoTherapy In the multimorbid elderly in primary CAre is a cluster randomised controlled trial that will include outpatients from the Swiss primary care setting, aged ≥65 years with ≥three chronic medical conditions and concurrent use of ≥five chronic medications. Patients treated by the same general practitioner (GP) constitute a cluster, and clusters are randomised 1:1 to either a standard care sham intervention, in which the GP discusses with the patient if the medication list is complete, or a systematic medication review intervention based on the use of the 'Systematic Tool to Reduce Inappropriate Prescribing'-Assistant (STRIPA). STRIPA is a web-based clinical decision support system that helps customise medication reviews. It is based on the validated ‘Screening Tool of Older Person’s Prescriptions’ (STOPP) and ‘Screening Tool to Alert doctors to Right Treatment’ (START) criteria to detect potentially inappropriate prescribing. The trial’s follow-up period is 12 months. Outcomes will be assessed at baseline, 6 and 12 months. The primary endpoint is medication appropriateness, as measured jointly by the change in the Medication Appropriateness Index (MAI) and Assessment of Underutilisation (AOU). Secondary endpoints include the degree of polypharmacy, overprescribing and underprescribing, the number of falls and fractures, quality of life, the amount of formal and informal care received by patients, survival, patients’ quality adjusted life years, patients’ medical costs, cost-effectiveness of the intervention, percentage of recommendations accepted by GPs, percentage of recommendation rejected by GPs and patients’ willingness to have medications deprescribed. The ethics committee of the canton of Bern in Switzerland approved the trial protocol. The results of this trial will be published in a peer-reviewed journal. Swiss National Science Foundation, National Research Programme (NRP 74) ‘Smarter Healthcare’. Clinicaltrials.gov ( NCT03724539 ), KOFAM (Swiss national portal) (SNCTP000003060), Universal Trial Number (U1111-1226-8013).
Publisher: Springer Science and Business Media LLC
Date: 09-2021
Abstract: We measure the branching fractions and CP asymmetries for the singly Cabibbo-suppressed decays D 0 → π + π − η , D 0 → K + K − η , and D 0 → ϕη , using 980 fb − 1 of data from the Belle experiment at the KEKB e + e − collider. We obtain $$ {\\displaystyle \\begin{array}{c}\\mathcal{B}\\left({D}^0\\to {\\pi}^{+}{\\pi}^{-}\\eta \\right)=\\left[1.22\\pm 0.02\\left(\\mathrm{stat}\\right)\\pm 0.02\\left(\\mathrm{syst}\\right)\\pm 0.03\\left({\\mathcal{B}}_{\\mathrm{ref}}\\right)\\right]\\times {10}^{-3},\\\\ {}\\mathcal{B}\\left({D}^0\\to {K}^{+}{K}^{-}\\eta \\right)=\\left[{1.80}_{-0.06}^{+0.07}\\left(\\mathrm{stat}\\right)\\pm 0.04\\left(\\mathrm{syst}\\right)\\pm 0.05\\left({\\mathcal{B}}_{\\mathrm{ref}}\\right)\\right]\\times {10}^{-4},\\\\ {}\\mathcal{B}\\left({D}^0\\to \\phi \\eta \\right)=\\left[1.84\\pm 0.09\\left(\\mathrm{stat}\\right)\\pm 0.06\\left(\\mathrm{syst}\\right)\\pm 0.05\\left({\\mathcal{B}}_{\\mathrm{ref}}\\right)\\right]\\times {10}^{-4},\\end{array}} $$ B D 0 → π + π − η = 1.22 ± 0.02 stat ± 0.02 syst ± 0.03 B ref × 10 − 3 , B D 0 → K + K − η = 1.80 − 0.06 + 0.07 stat ± 0.04 syst ± 0.05 B ref × 10 − 4 , B D 0 → ϕη = 1.84 ± 0.09 stat ± 0.06 syst ± 0.05 B ref × 10 − 4 , where the third uncertainty ( $$ \\mathcal{B} $$ B ref ) is from the uncertainty in the branching fraction of the reference mode D 0 → K − π + η . The color-suppressed decay D 0 → ϕη is observed for the first time, with very high significance. The results for the CP asymmetries are $$ {\\displaystyle \\begin{array}{c}{A}_{CP}\\left({D}^0\\ {\\pi}^{+}{\\pi}^{-}\\eta \\right)=\\left[0.9\\pm 1.2\\left(\\mathrm{stat}\\right)\\pm 0.5\\left(\\mathrm{syst}\\right)\\right]\\%,\\\\ {}{A}_{CP}\\left({D}^0\\to {K}^{+}{K}^{-}\\eta \\right)=\\left[-1.4\\pm 3.3\\left(\\mathrm{stat}\\right)\\pm 1.1\\left(\\mathrm{syst}\\right)\\right]\\%,\\\\ {} ACP\\ \\left({D}^0\\to \\phi \\eta \\right)=\\left[-1.9\\pm 4.4\\left(\\mathrm{stat}\\right)\\pm 0.6\\left(\\mathrm{syst}\\right)\\right]\\%.\\end{array}} $$ A CP D 0 π + π − η = 0.9 ± 1.2 stat ± 0.5 syst % , A CP D 0 → K + K − η = − 1.4 ± 3.3 stat ± 1.1 syst % , ACP D 0 → ϕη = − 1.9 ± 4.4 stat ± 0.6 syst % . The results for D 0 → π + π − η are a significant improvement over previous results. The branching fraction and A CP results for D 0 → K + K − η , and the ACP result for D 0 → ϕη , are the first such measurements. No evidence for CP violation is found in any of these decays.
Publisher: Public Library of Science (PLoS)
Date: 26-10-2020
Publisher: SAGE Publications
Date: 06-2016
Abstract: Background: Anticholinergic and sedative (ACh-Sed) medications are commonly prescribed for older adults and are associated with adverse events. Objectives: (1) To investigate perspectives of health care practitioners (HCPs) surrounding deprescribing (withdrawal) of ACh-Sed medications in older adults (2) to assess HCPs’ perspectives on the design and implementation of a report on a patient’s exposure to ACh-Sed medications using the Drug Burden Index (DBI) pharmacological tool. Methods: This was a qualitative study using focus groups with purposive s les of accredited pharmacists (APs), general practitioners (GPs), and specialist physicians (SPs). Participants were also asked to comment on a s le DBI report of a hypothetical patient and its potential role in practice. The discussions were audiorecorded, transcribed verbatim, and thematically analyzed to derive conceptual domains. QSR NVivo Version 10 was used for data management. Results: Several barriers and enablers to deprescribing ACh-Sed medications in older adults were identified. The most noteworthy barrier to deprescribing related to devolving responsibility. Predominantly, APs expressed frustration surrounding disregard by GPs of their recommendations to deprescribe medications. GPs expressed that deprescribing should be conducted by SPs and vice versa. The DBI report supported and addressed some of the identified barriers to deprescribing ACh-Sed medications in older adults. The HCPs also identified several opportunities and considerations for implementing the DBI report in practice, mainly highlighting that ACh-Sed medications are not the only high-risk medications for older people. Conclusions: Although HCPs recognize the harms associated with ACh-Sed medication use, they devolve prescribing and management responsibility to other groups of HCPs.
Publisher: Wiley
Date: 12-06-2023
DOI: 10.1002/ACR.25141
Abstract: Methotrexate (MTX) is effective in controlling disease activity in rheumatoid arthritis (RA). Parenteral MTX may have benefits over oral MTX, but it is rarely used in practice. To better understand this low usage rate, it is necessary to explore the barriers and enablers of therapy from the perspective of RA patients. The objectives of this scoping review were to describe RA patients’ perspectives on the barriers and enablers in the use of parenteral MTX and to identify the research gaps in this field. The search was performed in Medline, Embase, Scopus, and Cochrane Library from inception to May 2021. Data synthesis was conducted using the Theoretical Framework of Acceptability. This scoping review included any type of study that explored the use of parenteral MTX by adult RA patients from the patients’ perspective, written in English. Fifteen studies were included findings related to the constructs “affective attitude,” “burden,” “intervention coherence,” and “self‐efficacy” were explored the most, while some were rarely (“opportunity cost” and “perceived effectiveness”) or not (“ethicality”) reported. RA patients were generally satisfied with MTX injections (“affective attitude”). From the burden construct, the requirement for dexterity for administering MTX by injection was considered a barrier, whereas the lack of significant pain from MTX injection was considered an enabler. The findings suggested that patients generally preferred parenteral MTX formulations with attributes that facilitate self‐administration. However, much of the identified research focused on prefilled pen devices, and significant gaps were identified, such as a lack of qualitative research. image
Publisher: Oxford University Press (OUP)
Date: 22-01-2020
Abstract: Knowledge of decision-making preference of patients and caregivers is needed to facilitate deprescribing. This study aimed to assess the perspectives of caregivers and older adults towards deprescribing in an Asian population. Secondary objectives were to identify and compare characteristics associated with these attitudes and beliefs. A cross-sectional survey of two groups of participants was conducted using the Revised Patients’ Attitudes Towards Deprescribing questionnaire. Descriptive results were reported for participants’ characteristics and questionnaire responses from four factors (belief in medication inappropriateness, medication burden, concerns about stopping, and involvement) and two global questions. Correlation between participant characteristics and their responses was analyzed. A total of 1,057 (615 older adults 442 caregivers) participants were recruited from 10 institutions in Singapore. In which 511 (83.0%) older adults and 385 (87.1%) caregivers reported that they would be willing to stop one or more of their medications if their doctor said it was possible, especially among older adults recruited from acute-care hospitals (85.3%) compared with older adults in community pharmacies (73.6%). In iduals who take more than five medications and those with higher education were correlated with greater agreement in inappropriateness and involvement, respectively. Clinicians should consider discussing deprescribing with older adults and caregivers in their regular clinical practice, especially when polypharmacy is present. Further research is needed into how to engage older adults and caregivers in shared decision making based on their attitudes toward deprescribing.
Publisher: Wiley
Date: 06-08-2018
DOI: 10.1111/AJAG.12576
Abstract: (i) To develop a version of the revised Patients' Attitude Towards Deprescribing (rPATD) questionnaire for people with mild cognitive impairment (MCI) and mild-to-moderate dementia (rPATDcog) and (ii) to capture the beliefs and attitudes of this population and their carers about deprescribing through a pilot study. First, the rPATDcog was modified from the rPATD and tested in a small group of participants with MCI or mild dementia, and then, we conducted a pilot study of the rPATDcog and the carers' rPATD. Twenty-one participants with cognitive impairment and 11 carer participants (forming dyads) participated in this study. Eighty-one per cent (17/21) of participants said that they would stop one or more of their medications if their doctor said it was possible. There was an excellent agreement of corresponding questions between dyads. The rPATDcog was feasible to administer in this study. Further work is required to provide generalisable results and determine utility in practice.
Publisher: Springer Science and Business Media LLC
Date: 14-07-2016
DOI: 10.1007/S11673-016-9736-Y
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 in idual and the community. However, the principle of justice also dictates equal rights to treatment regardless of age.
Publisher: Springer Science and Business Media LLC
Date: 20-01-2016
DOI: 10.1007/S00228-016-2011-7
Abstract: Statins are among the most frequently prescribed medications internationally. Older people are commonly prescribed multiple medications and are at an increased risk of drug-drug interactions, including statin-drug interactions. The aim of this study was to conduct a systematic review of current evidence on the prevalence of statin-drug interactions in older people. A systematic search of observational studies in Embase, Medline, and PubMed was conducted. Articles were included if they were published in English during the period July 2000-July 2014 and reported on the prevalence of statin-drug interactions in people over 65 years of age. Two reviewers independently assessed the articles for eligibility and extracted the data. The search returned 1556 eligible articles. A total of 19 articles met the inclusion criteria. In studies (n = 7) that focused on statin users only, the prevalence of potential statin-drug interactions assessed using different measures ranged from 0.19 to 33.0 %. In studies that examined drug interactions across a population of both statin users and non-users (n = 12), the prevalence of potential statin-drug interactions ranged from 0.1 to 7.1 % (n = 8), and the prevalence of clinically relevant statin-drug interactions ranged from 1.5 to 4 % (n = 4). Current published evidence suggests substantial variations in the prevalence of statin-drug interactions and their clinical relevance. Further studies are necessary to provide a better understanding of the prevalence of clinically significant statin-drug interactions, the medications most frequently contributing to statin-drug interactions, and impact on relevant clinical outcomes in older people.
Publisher: Wiley
Date: 24-02-2017
DOI: 10.1002/JPPR.1264
Publisher: SAGE Publications
Date: 12-09-2018
Abstract: The aim of this study was (1) to apply the current United Kingdom (UK) National Institute for Health and Care Excellence (NICE) clinical practice guidelines to a hypothetical older patient with multimorbidity and life-limiting illness (2) consider how treatment choices could be influenced by NICE guidance specifically related to multimorbidity and, (3) ascertain if such clinical practice guidelines describe how and when medication should be reviewed, reduced and stopped. Based upon common long-term conditions in older people, a hypothetical older patient was constructed. Relevant NICE guidelines were applied to the hypothetical patient to determine what medication should be initiated in three treatment models: a new patient model, a treatment-resistant model, and a last-line model. Medication complexity for each model was assessed according to the medication regimen complexity index (MRCI). The majority of the guidelines recommended the initiation of medication in the hypothetical patient if the initial treatment approach was unsuccessful, each guideline advocated the use of more medication, with the regimen becoming increasingly complex. In the new patient model, 4 separate medications (9 dosage units) would be initiated per day for the treatment-resistant model, 6 separate medications (15 dosage units) and, for the last-line model, 11 separate medications (20 dosage units). None of the guidelines used for the hypothetical patient discussed approaches to stopping medication. In a UK context, disease-specific clinical practice guidelines routinely advocate the initiation of medication to manage long-term conditions, with medication regimens becoming increasingly complex through the different steps of care. There is often a lack of information regarding specific treatment recommendations for older people with life-limiting illness and multimorbidity. While guidelines frequently explain how and when a medication should be initiated, there is often no information concerning when and how the medications should be reduced or stopped.
Publisher: Springer Science and Business Media LLC
Date: 22-03-2017
Publisher: Springer Science and Business Media LLC
Date: 07-01-2021
DOI: 10.1186/S12877-020-01953-6
Abstract: General practitioners (GPs) should regularly review patients’ medications and, if necessary, deprescribe, as inappropriate polypharmacy may harm patients’ health. However, deprescribing can be challenging for physicians. This study investigates GPs’ deprescribing decisions in 31 countries. In this case vignette study, GPs were invited to participate in an online survey containing three clinical cases of oldest-old multimorbid patients with potentially inappropriate polypharmacy. Patients differed in terms of dependency in activities of daily living (ADL) and were presented with and without history of cardiovascular disease (CVD). For each case, we asked GPs if they would deprescribe in their usual practice. We calculated proportions of GPs who reported they would deprescribe and performed a multilevel logistic regression to examine the association between history of CVD and level of dependency on GPs’ deprescribing decisions. Of 3,175 invited GPs, 54% responded ( N = 1,706). The mean age was 50 years and 60% of respondents were female. Despite differences across GP characteristics, such as age (with older GPs being more likely to take deprescribing decisions), and across countries, overall more than 80% of GPs reported they would deprescribe the dosage of at least one medication in oldest-old patients ( 80 years) with polypharmacy irrespective of history of CVD. The odds of deprescribing was higher in patients with a higher level of dependency in ADL (OR =1.5, 95%CI 1.25 to 1.80) and absence of CVD (OR =3.04, 95%CI 2.58 to 3.57). The majority of GPs in this study were willing to deprescribe one or more medications in oldest-old multimorbid patients with polypharmacy. Willingness was higher in patients with increased dependency in ADL and lower in patients with CVD.
Publisher: Elsevier BV
Date: 03-2022
DOI: 10.1016/J.SAPHARM.2021.05.018
Abstract: Implementation science may address some of the limitations that impede the translation of deprescribing recommendations into practice and policy. Application of principles and standard terminologies from implementation science could improve understanding and interpretation of deprescribing research findings. As such, in this commentary we propose three main avenues to help achieve this. These include: The application of these concepts derived from implementation science could help inform future deprescribing needs for clinicians and researchers. Ultimately, this could help ensure the quality use of medications and examination of meaningful outcomes in deprescribing studies. This could result in more consistent and widespread translation of deprescribing evidence into practice and policy across various healthcare settings.
No related grants have been discovered for Emily Reeve.