Case Report: The Complexities of Managing Medications and the Importance of Deprescribing Anticholinergics in Older Adults.
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ABSTRACT:
SUBMITTER: Elliott T
PROVIDER: S-EPMC8087073 | biostudies-literature | 2021
REPOSITORIES: biostudies-literature
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Case Report: The Complexities of Managing Medications and the Importance of Deprescribing Anticholinergics in Older Adults.
Elliott Taylor T Eckmann Lynne L Moga Daniela C DC
Frontiers in pharmacology 20210416
Potentially inappropriate anticholinergic medications (including over-the-counter products), polypharmacy, and the existence of communication barriers among members of the interprofessional team frequently contribute to clinical complexity in older adults. We present the case of a frail 86-year old female from the perspective of a community pharmacist managing outpatient medications and transitions of care. CD's past medical history is significant for dementia, multiple falls, recurrent urinary ...[more]
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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:ObjectiveWe sought to characterize caregiver medication assistance for older adults with multiple chronic conditions.DesignSemi-structured qualitative interviews.SettingCommunity and academic-affiliated primary care practices.ParticipantsA total of 25 caregivers to older adults participating in an ongoing cohort study with ≥3 chronic conditions.MeasurementsA semi-structured interview guide, informed by the Medication Self-Management model, aimed to understand health-related and medication-specific assistance caregivers provided.ResultsThree typologies of caregiver assistance with medications emerged: Actively Involved, Peripherally Involved, and Not Involved. A total of 10 caregivers were Actively Involved, which was defined as when the caregiver perceived a need for and offered assistance, and the patient accepted the assistance. Peripherally Involved (n = 6) was defined as when the caregiver perceived a need and offered assistance; however, the patient rejected this assistance, yet relied on the caregiver as a backup in managing his or her medications. To combat resistance from the patient, caregivers in this typology disguised assistance and deployed workaround strategies to monitor medication-taking behaviors to ensure safety. Lastly, nine caregivers were classified as Not Involved, defined as when the caregiver did not perceive a need to offer assistance with medications, and the patient managed his or her medicines independently. A strong preference toward autonomy in medication management was shared across all three typologies.ConclusionThese findings suggest that caregivers value independent medication management by their care recipient, up until safety is seriously questioned. Clinicians should not assume caregivers are actively and consistently involved in older adults' medication management; instead, they should initiate conversations with patients and caregivers to better understand and facilitate co-management responsibilities, especially among those whose assistance is rejected by older adults.
| S-EPMC8497389 | 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:Pharmacist's geriatric assessment can provide valuable insights into potential deprescribing targets, while including important information on various health-related domains. Data collected from a geriatric assessment questionnaire, for 388 patients, from the Croatian cohort of the EuroAgeism H2020 ESR 7 international project, along with guideline-based deprescribing criteria, were used to analyse potentially inappropriate prescribing of four medication groups (benzodiazepines (BZN), proton pump inhibitors (PPI), opioids, and non-steroidal anti-inflammatory drugs (NSAID)), and to assess the deprescribing potential. Binary logistic regression was used to explore the effects of age, gender, number of medicines and diagnoses, self-reported health, frailty score, and healthcare utilization on the likelihood of needing deprescribing. More than half of participants (n = 216, 55.2%) are candidates for deprescribing, with 31.1% of PPI, 74.8% of NSAID, 75% of opioid, and 96.1% of BZN users meeting at least one criterion. Most common criteria for deprescribing were inappropriately long use and safety concerns. Women (aOR = 2.58; p < 0.001), those reporting poor self-reported health (aOR = 5.14; p < 0.001), and those exposed to polypharmacy (aOR = 1.29; p < 0.001) had higher odds of needing to have medicines deprescribed. The high rate of deprescribing potential warrants prompt action to increase patient safety and decrease polypharmacy. Pharmacist's geriatric assessment and deprescribing-focused medication review could be used to lead a personalised approach.
| S-EPMC10940601 | biostudies-literature
Project description:ImportanceDeprescribing is a promising approach to addressing the burden of polypharmacy. Few studies have initiated comprehensive deprescribing in the hospital setting among older patients requiring ongoing care in a postacute care (PAC) facility.ObjectiveTo evaluate the efficacy of a patient-centered deprescribing intervention among hospitalized older adults transitioning or being discharged to a PAC facility.Design, setting, and participantsThis randomized clinical trial of the Shed-MEDS (Best Possible Medication History, Evaluate, Deprescribing Recommendations, and Synthesis) deprescribing intervention was conducted between March 2016 and October 2020. Patients who were admitted to an academic medical center and discharged to 1 of 22 PAC facilities affiliated with the medical center were recruited. Patients who were 50 years or older and had 5 or more prehospital medications were enrolled and randomized 1:1 to the intervention group or control group. Patients who were non-English speaking, were unhoused, were long-stay residents of nursing homes, or had less than 6 months of life expectancy were excluded. An intention-to-treat approach was used.InterventionsThe intervention group received the Shed-MEDS intervention, which consisted of a pharmacist- or nurse practitioner-led comprehensive medication review, patient or surrogate-approved deprescribing recommendations, and deprescribing actions that were initiated in the hospital and continued throughout the PAC facility stay. The control group received usual care at the hospital and PAC facility.Main outcomes and measuresThe primary outcome was the total medication count at hospital discharge and PAC facility discharge, with follow-up assessments during the 90-day period after PAC facility discharge. Secondary outcomes included the total number of potentially inappropriate medications at each time point, the Drug Burden Index, and adverse events.ResultsA total of 372 participants (mean [SD] age, 76.2 [10.7] years; 229 females [62%]) were randomized to the intervention or control groups. Of these participants, 284 were included in the intention-to-treat analysis (142 in the intervention group and 142 in the control group). Overall, there was a statistically significant treatment effect, with patients in the intervention group taking a mean of 14% fewer medications at PAC facility discharge (mean ratio, 0.86; 95% CI, 0.80-0.93; P < .001) and 15% fewer medications at the 90-day follow-up (mean ratio, 0.85; 95% CI, 0.78-0.92; P < .001) compared with the control group. The intervention additionally reduced patient exposure to potentially inappropriate medications and Drug Burden Index. Adverse drug event rates were similar between the intervention and control groups (hazard ratio, 0.83; 95% CI, 0.52-1.30).Conclusions and relevanceResults of this trial showed that the Shed-MEDS patient-centered deprescribing intervention was safe and effective in reducing the total medication burden at PAC facility discharge and 90 days after discharge. Future studies are needed to examine the effect of this intervention on patient-reported and long-term clinical outcomes.Trial registrationClinicalTrials.gov Identifier: NCT02979353.
| S-EPMC9989899 | biostudies-literature
Project description:There is paucity of studies focused on the enablers and barriers to community pharmacists' readiness to deprescribe inappropriate medications for older adults in developing settings. The current study assessed the enablers and barriers to community pharmacists' readiness to implement deprescribing of inappropriate medications for older adults. A cross-sectional survey of 252 community pharmacists was conducted in Qatar with a pre-tested 24-item questionnaire developed with the theory of domain framework. Information about perceived enablers and barriers were elicited with a 5-point Likert-type scale. The response rate was 79.4% (200/252). The majority of the community pharmacists were females (54.5%), within the age range of 20-40 years (88.0%), had BSc / BPharm as the highest educational qualification (70.5%), were full-time employee (97.0%). The top-ranked enablers of community pharmacists' readiness to implement deprescribing were exposure to CPD on the use of deprescribing toolkits and algorithm (66%), interprofessional collaboration with physicians (60.5%) and shared electronic patient record (59.5%), and improved remuneration / re-imbursement 58%). The top-ranked barriers were lack of access to patient records (70.5%), ineffective collaboration with physicians (66.5%), lack of time due to heavy workload (65%), regulatory framework that limit expansion of clinical roles (51%) and intense focus on sales target (49%). The top-ranked enablers of community pharmacists' readiness to implement deprescribing were exposure to CPD on the use of deprescribing toolkits and algorithm, interprofessional collaboration with physicians and shared electronic patient record. These findings bode well for the implementation of community pharmacists-led deprescribing of inappropriate medications for older adults in Qatar. However, a number of critical barriers were identified, and these will require institutional, regulatory and organizational interventions to improve readiness.
| S-EPMC11781633 | 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 healthcare provider-related perceptions toward deprescribing inappropriate medications among older adults.MethodsA cross-sectional, correlational study used a convenience sample of outpatient older adults to measure their perception toward deprescribing using a Patient's Perceptions of Deprescribing (PPoD), which include 57 multiple-choice questions related to patients' sociodemographic data, health, medicines, healthcare providers, and experience of care provided by the clinic. Data were collected by a graduate nursing student from one pharmacy in a public hospital, five days per week, via in-person interviews.ResultsData were analyzed for 200 participants. The level of patient collaboration with their primary care providers (PCPs) is linked to their trust in PCPs, beliefs about medication use, PCP knowledge, and medication concerns (p < .0001). Patient involvement in medication deprescribing decision-making is also associated with trust in PCPs and willingness to stop a medication (p < .0001). Additionally, trust in PCPs is related to patient involvement in decision-making, PCP knowledge, general health, collaboration with PCPs, and receiving conflicting information about a medicine (p = .010). Lastly, PCP medication knowledge is associated with trust in PCPs, views on the importance of medicines, medication concerns, seeking help with medicines, interactions with clinical pharmacists, and being advised by a clinical pharmacist to discontinue medication (p < .0001).ConclusionsThe study found that older adults' trust in their PCP, collaboration with their PCP, involvement in the decision-making of deprescribing, and knowledge about medication are associated with clinical and medicine-related factors. Therefore, PCPs should discuss the benefits of deprescribing inappropriate medications to prevent long-term side effects. Future studies should focus on the effectiveness of evidence-based deprescribing protocols for older adults.
| S-EPMC11556697 | biostudies-literature