Case Report: The Complexities of Managing Medications and the Importance of Deprescribing Anticholinergics in Older Adults.
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SUBMITTER: Elliott T
PROVIDER: S-EPMC8087073 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Background/objectivesGuideline-based management of cardiovascular disease often involves prescribing multiple medications, which contributes to polypharmacy and risk for adverse drug events in older adults. Deprescribing is a potential strategy to mitigate these risks. We sought to characterize and compare clinician perspectives regarding deprescribing cardiovascular medications across three specialties.DesignNational cross-sectional survey.SettingAmbulatory.ParticipantsRandom sample of geriatricians, general internists, and cardiologists from the American College of Physicians.MeasurementsElectronic survey assessing clinical practice of deprescribing cardiovascular medications, reasons and barriers to deprescribing, and choice of medications to deprescribe in hypothetical clinical cases.ResultsIn each specialty, 750 physicians were surveyed, with a response rate of 26% for geriatricians, 26% for general internists, and 12% for cardiologists. Over 80% of respondents within each specialty reported that they had recently considered deprescribing a cardiovascular medication. Adverse drug reactions were the most common reason for deprescribing for all specialties. Geriatricians also commonly reported deprescribing in the setting of limited life expectancy. Barriers to deprescribing were shared across specialties and included concerns about interfering with other physicians' treatment plans and patient reluctance. In hypothetical cases, over 90% of physicians in each specialty chose to deprescribe when patients experienced adverse drug reactions. Geriatricians were most likely and cardiologists were least likely to consider deprescribing cardiovascular medications in cases of limited life expectancy (all P < .001), such as recurrent metastatic cancer (84% of geriatricians, 68% of general internists, and 45% of cardiologists), Alzheimer dementia (92% of geriatricians, 81% of general internists, and 59% of cardiologists), or significant functional impairment (83% of geriatricians, 68% of general internists, and 45% of cardiologists).ConclusionsWhile barriers to deprescribing cardiovascular medications are shared across specialties, reasons for deprescribing, especially in the setting of limited life expectancy, varied. Implementing deprescribing will require improved processes for both physician-physician and physician-patient communication. J Am Geriatr Soc 68:78-86, 2019.
| S-EPMC7061460 | biostudies-literature
Project description:BackgroundDeprescribing interventions delivered through the electronic medical record have not significantly reduced the use of high-risk anticholinergics in prior trials. Pharmacists have been identified as ideal practitioners to conduct deprescribing; however, little experience beyond collaborative consult models has been published.ObjectiveTo evaluate the impact of two pilot pharmacist-based advanced practice models nested within primary care.MethodsPilot studies of a collaborative clinic-based pharmacist deprescribing intervention and a telephone-based pharmacist deprescribing intervention were conducted. Patients receiving the clinic-based pharmacy model were aged 55 years and older and referred for deprescribing at a specialty clinic. Patients receiving the telephone-based pharmacy model were aged 65 years and older and called by a clinical pharmacist for deprescribing without referral. Deprescribing was defined as a discontinuation or dose reduction reported either in clinical records or through self-reporting.ResultsThe 18 patients receiving clinic-based deprescribing had a mean age of 68 years and 78% were female. Among 24 medications deemed eligible for deprescribing, 23 (96%) were deprescribed. The clinic-based deprescribing model resulted in a 93% reduction in median annualized total standardized dose (TSD), 56% lowered their annualized exposure below a cognitive risk threshold, and 4 (17%) of medications were represcribed within 6 months. The 24 patients receiving telephone-based deprescribing had a mean age of 73 years and 92% were female. Among 24 medications deemed eligible for deprescribing, 12 (50%) were deprescribed. There was no change in the median annualized TSD, the annualized TSD was lowered below a cognitive risk threshold in 46%, and no medications were represcribed within 6 months. Few withdrawal symptoms or adverse events were reported in both groups.ConclusionsPharmacist-based deprescribing successfully reduced exposure to high-risk anticholinergics in primary care older adults, yet further work is needed to understand the impact on clinical outcomes.
| S-EPMC9796793 | biostudies-literature
Project description:AimsThis review investigates the factors that influence deprescribing of medications in primary care from the perspective of general practitioners (GPs) and community-living older adults.MethodsA mixed studies review structure was adopted searching Scopus, CINAHL, PsychINFO, ProQuest, and PubMed from January 2000 to December 2017. A manual search of reference lists was also conducted. Studies were included if they were original research available in English and explored general deprescribing rather than deprescribing of a specific class of medications. The Mixed Methods Assessment Tool was used to assess the quality of studies, and content analysis generated common categories across studies.ResultsThirty-eight articles were included, and 7 key categories were identified. The review found that the factors that influence deprescribing are similar across and within health systems and mostly act as barriers. These factors remained unchanged across the review period. The structural organisation of health systems remains poorly suited to facilitate deprescribing. Individual knowledge gaps of both GPs and older adults influence practices and attitudes towards deprescribing, and significant communication gaps occur between GPs and specialists and between GPs and older adults. As a result, deprescribing decision making is characterised by uncertainty, and deprescribing is often considered only when medication problems have already arisen. Trust plays a complex role, acting as both a barrier and facilitator of deprescribing.ConclusionsDeprescribing is influenced by many factors. Despite recent interest, little change has occurred. Multilevel strategies aimed at reforming aspects of the health system and managing uncertainty at the practice and individual level, notably reducing knowledge limitations and closing communications gaps, may achieve change.
| S-EPMC6266366 | biostudies-literature
Project description:BackgroundDifficulty managing medicines and finances becomes increasingly common with advanced age, and compromises the ability to live safely and independently. Remarkably little is known how often this occurs.ObjectivesTo provide population-based estimates of the risk of developing incident difficulty managing medications and finances in older adults.DesignA prospective cohort study.SettingThe Health and Retirement Study (HRS), a nationally representative study of older adults.Participants9,434 participants aged 65 and older who did not need help in managing medications or managing finances in 2002. Follow-up assessments occurred every 2 years until 2012.MeasurementsThe primary outcomes were time to difficulty managing medications and time to difficulty managing finances. Risk factors such as demographics, comorbidities, functional status, and cognitive status were assessed at baseline. Hazard models that considered the competing risk of death were used to estimate both the cumulative incidence of developing difficulty managing medications and finances and to identify potential risk factors. Analyses were adjusted for age, gender, race, marital status, wealth and education.ResultsThe 10 years incidence of difficulty increased markedly with age, ranging from 10.3% (95% CI 9.3-11.6) for managing medications and 23.1% (95% CI 21.6-24.7) for managing finances in those aged 65-69, to 38.2% (95% CI 33.4-43.5) for medicines and 69% (95% CI 63.7-74.3) for finances in those over age 85. Women had a higher probability of developing difficulty managing medications and managing finances than men.ConclusionThis study highlights the importance of preparing older adults for the likelihood they will need assistance with managing their medicines and finances as the risk for having difficulty with these activities over time is substantial.
| S-EPMC5580243 | biostudies-literature
Project description:Deprescribing, an integral component of a continuum of good prescribing practices, is the process of medication withdrawal or dose reduction to correct or prevent medication-related complications, improve outcomes, and reduce costs. Deprescribing is particularly applicable to the commonly encountered multimorbid older adult with cardiovascular disease and concomitant geriatric conditions such as polypharmacy, frailty, and cognitive dysfunction-a combination rarely addressed in current clinical practice guidelines. Triggers to deprescribe include present or expected adverse drug reactions, unnecessary polypharmacy, and the need to align medications with goals of care when life expectancy is reduced. Using a framework to deprescribe, this review addresses the rationale, evidence, and strategies for deprescribing cardiovascular and some noncardiovascular medications.
| S-EPMC6724706 | biostudies-literature
Project description:ObjectivesTo examine older adults' perspectives regarding managing sleep problems through selection and use of non-prescription sleep aids, and the role of pharmacists.MethodsTelephone interviews were conducted from May to June 2015 with 116 individuals aged ≥60 years in Pittsburgh, Pennsylvania. Participants reported in a previous survey to have used at least one non-prescription sleep aid in the past 30 days and were willing to participate in a follow-up interview. Interview guides were designed to elicit perspectives of sleep problems, selection and use of non-prescription sleep aids, and consultation with healthcare professionals. Interview transcripts underwent content analysis.Key findingsFour themes emerged as follows: experiences with sleep problems, selection of non-prescription sleep aids, non-prescription sleep aid use and interactions with healthcare professionals. Over half of participants reported using a non-prescription sleep aid for >1 year, were satisfied with its use and perceived it improved sleep quality. Participants commonly used an antihistamine-only sleep aid; 36% of participants self-recommended their sleep aid; and 16% of participants consulted healthcare professionals. Few participants read medication dosage labels (22%), side effects or warnings (19%), and many reported they disregarded directions. Participants did not typically consult pharmacists about sleep problems (65%) but perceived that they could assist with medication concerns.ConclusionsAlthough most participants had favourable perceptions of non-prescription sleep aids, older adults may be inappropriately using non-prescription sleep aids to self-manage sleep problems by frequently disregarding medication labels and directions for safe use. Also, few older adults are discussing their sleep aid selection and use with pharmacists.
| S-EPMC5724494 | biostudies-literature
Project description:Purpose of reviewThe population of older adults 60-79 years globally is projected to double from 800 million to 1.6 billion between 2015 and 2050, while adults ≥ 80 years were forecast to more than triple from 125 to 430 million. The risk for cardiovascular events doubles with each decade of aging and each 20 mmHg increase of systolic blood pressure. Thus, successful management of hypertension in older adults is critical in mitigating the projected global health and economic burden of cardiovascular disease.Recent findingsWomen live longer than men, yet with aging systolic blood pressure and prevalent hypertension increase more, and hypertension control decreases more than in men, i.e., hypertension in older adults is disproportionately a women's health issue. Among older adults who are healthy to mildly frail, the absolute benefit of hypertension control, including more intensive control, on cardiovascular events is greater in adults ≥ 80 than 60-79 years old. The absolute rate of serious adverse events during antihypertensive therapy is greater in adults ≥ 80 years older than 60-79 years, yet the excess adverse event rate with intensive versus standard care is only moderately increased. Among adults ≥ 80 years, benefits of more intensive therapy appear non-existent to reversed with moderate to marked frailty and when cognitive function is less than roughly the twenty-fifth percentile. Accordingly, assessment of functional and cognitive status is important in setting blood pressure targets in older adults. Given substantial absolute cardiovascular benefits of more intensive antihypertensive therapy in independent-living older adults, this group merits shared-decision making for hypertension targets.
| S-EPMC10904451 | biostudies-literature
Project description:Background:Polypharmacy is common in hospitalized older adults. Deprescribing interventions are not well described in the acute-care setting. The objective of this study was to describe a hospital-based, patient-centered deprescribing protocol (Shed-MEDS) and report pilot results. Methods:This was a pilot study set in one academic medical center in the United States. Participants consisted of a convenience sample of 40 Medicare-eligible, hospitalized patients with at least five prescribed medications. A deprescribing protocol (Shed-MEDS) was implemented among 20 intervention and 20 usual care control patients during their hospital stay. The primary outcome was the total number of medications deprescribed from hospital enrollment. Deprescribed was defined as medication termination or dose reduction. Enrollment medications reflected all prehospital medications and active in-hospital medications. Baseline characteristics and outcomes were compared between the intervention and usual care groups using simple logistic or linear regression for categorical and continuous measures, respectively. Results:There was no significant difference between groups in mean age, sex or Charlson comorbidity index. The intervention and control groups had a comparable number of medications at enrollment, 25.2 (±6.3) and 23.4 (±3.8), respectively. The number of prehospital medications in each group was 13.3 (±4.6) and 15.3 (±4.6), respectively. The Shed-MEDS protocol compared with usual care significantly increased the mean number of deprescribed medications at hospital discharge and reduced the total medication burden by 11.6 versus 9.1 (p = 0.032) medications. The deprescribing intervention was associated with a difference of 4.6 [95% confidence interval (CI) 2.5-6.7, p < 0.001] in deprescribed medications and a 0.5 point reduction (95% CI -0.01 to 1.1) in the drug burden index. Conclusions:A hospital-based, patient-centered deprescribing intervention is feasible and may reduce the medication burden in older adults.
| S-EPMC6116773 | biostudies-literature
Project description:BackgroundGeneral 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.MethodsIn 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.ResultsOf 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).InterpretationThe 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.
| S-EPMC7792080 | biostudies-literature
Project description:ObjectivesTo determine older adults' awareness of the concept of medication-induced harm and their familiarity with the term "deprescribing." Secondary objectives were to ascertain determinants of self-initiated deprescribing conversations and to identify how older adults seek information on medication harms.DesignCross-sectional population-based household telephone survey using random-digit dialling.SettingCanada.ParticipantsCommunity-dwelling adults aged 65 and older (N = 2,665; n = 898 men, n = 1,767 women, mean age 74.9 ± 7.2, range 65-100).MeasurementsInformation was gathered on age; sex; awareness of the term "deprescribing"; knowledge and information-seeking behaviors related to medication harms; and previous initiation of a deprescribing conversation with a healthcare professional. Three targeted classes of potentially inappropriate prescriptions were asked about: sedative-hypnotics, glyburide, and proton pump inhibitors. Descriptive statistics and regression analyses were used to quantify associations.ResultsTwo-thirds (65.2%, 95% confidence interval (CI) = 63.4-67.0%) of participants were familiar with the concept of medication-induced harms. Only 6.9% (95% CI = 5.9-7.8%) recognized the term deprescribing; 48% (95% CI = 46-50%) had researched medication-related harms. Older adults most commonly sought information from the Internet (35.5%, 95% CI = 33.4-37.6%), and from health care professionals (32.2%, 95% CI = 30.1-34.3%). Patient-initiated deprescribing conversations were associated with awareness of medication harms (odds ratio (OR) = 1.74, 95% CI = 1.46-2.07), familiarity with the term deprescribing (OR = 1.55, 95% CI = 1.13-2.12), and information-seeking behaviors (OR = 4.57, 95% CI = 3.84-5.45), independent of age and sex.ConclusionHealthcare providers can facilitate patient-initiated deprescribing conversations by providing information on medication harms and using the term "deprescribing."
| S-EPMC5763385 | biostudies-literature