DEFEAT-polypharmacy:deprescribing anticholinergic and sedative medicines feasibility trial in residential aged care facilities

Background Prolonged use of anticholinergic and sedative medicines is correlated with worsening cognition and physical function decline. Deprescribing is a proposed intervention that can help to minimise polypharmacy whilst potentially improving several health outcomes in older people. Objective This study aimed to examine the feasibility of implementing a deprescribing intervention that utilises a patient-centred pharmacist-led intervention model; in order to address major deprescribing challenges such as general practitioner time constraints and lack of accessible deprescribing guidelines and processes. Setting Three residential care facilities. Methods The intervention involved a New Zealand registered pharmacist utilising peer-reviewed deprescribing guidelines to recommend targeted deprescribing of anticholinergic and sedative medicines to GPs. Main outcome measure The change in the participants' Drug Burden Index (DBI) total and DBI 'as required' (PRN) was assessed 3 and 6 months after implementing the deprescribing intervention. Results Seventy percent of potential participants were recruited for the study (n = 46), and 72% of deprescribing recommendations suggested by the pharmacist were implemented by General Pratitioners (p = 0.01; Fisher's exact test). Ninety-six percent of the residents agreed to the deprescribing recommendations, emphasising the importance of patient centred approach. Deprescribing resulted in a significant reduction in participants' DBI scores by 0.34, number of falls and adverse drug reactions, 6 months post deprescribing. Moreover, participants reported lower depression scores and scored lower frailty scores 6 months after deprescribing. However, cognition did not improve; nor did participants' reported quality of life. Conclusion This patient-centred deprescribing approach, demonstrated a high uptake of deprescribing recommendations and success rate. After 6 months, significant benefits were noted across a range of important health measures including mood, frailty, falls and reduced adverse reactions. This further supports deprescribing as a possible imperative to improve health outcomes in older adults.</p

The Drug Burden Index and Level of Frailty as Determinants of Healthcare Costs in a Cohort of Older Frail Adults in New Zealand

OBJECTIVES: Frailty is common in older people and is associated with increased use of healthcare services and ongoing use of multiple medications. This study provides insights into the healthcare cost structure of a frail group of older adults in Aotearoa, New Zealand. Furthermore, we investigated the relationship between participants' anticholinergic and sedative medication burden and their total healthcare costs to explore the viability of deprescribing interventions within this cohort.METHODS: Healthcare cost analysis was conducted using data collected during a randomized controlled trial within a frail, older cohort. The collected information included participant demographics, medications used, frailty, cost of service use of aged residential care and outpatient hospital services, hospital admissions, and dispensed medications.RESULTS: Data from 338 study participants recruited between 25 September 2018 and 30 October 2020 with a mean age of 80 years were analyzed. The total cost of healthcare per participant ranged from New Zealand $15 (US dollar$10) to New Zealand $270 681 (US dollar$175 943) over 6 months postrecruitment into the study. Four individuals accounted for 26% of this cohort's total healthcare cost. We found frailty to be associated with increased healthcare costs, whereas the drug burden was only associated with increased pharmaceutical costs, not overall healthcare costs.CONCLUSIONS: With no relationship found between a patient's anticholinergic and sedative medication burden and their total healthcare costs, more research is required to understand how and where to unlock healthcare cost savings within frail, older populations.</p

Consumer and Healthcare Professional Led Priority Setting for Quality Use of Medicines in People with Dementia: Gathering Unanswered Research Questions

Background: Historically, research questions have been posed by the pharmaceutical industry or researchers, with little involvement of consumers and healthcare professionals. Objective: To determine what questions about medicine use are important to people living with dementia and their care team and whether they have been previously answered by research. Methods: The James Lind Alliance Priority Setting Partnership process was followed. A national Australian qualitative survey on medicine use in people living with dementia was conducted with consumers (people living with dementia and their carers including family, and friends) and healthcare professionals. Survey findings were supplemented with key informant interviews and relevant published documents (identified by the research team). Conventional content analysis was used to generate summary questions. Finally, evidence checking was conducted to determine if the summary questions were 'unanswered'. Results: A total of 545 questions were submitted by 228 survey participants (151 consumers and 77 healthcare professionals). Eight interviews were conducted with key informants and four relevant published documents were identified and reviewed. Overall, analysis resulted in 68 research questions, grouped into 13 themes. Themes with the greatest number of questions were related to co-morbidities, adverse drug reactions, treatment of dementia, and polypharmacy. Evidence checking resulted in 67 unanswered questions. Conclusion: A wide variety of unanswered research questions were identified. Addressing unanswered research questions identified by consumers and healthcare professionals through this process will ensure that areas of priority are targeted in future research to achieve optimal health outcomes through quality use of medicines

Deprescribing in Older New Zealanders

Polypharmacy, the prescription of five or more medicines, is an emerging worldwide health concern. When older people are prescribed five or more medicines, they are susceptible to a wide variety of negative health consequences, including an increased risk of developing adverse drug events, drug interactions and falling. In specific, medicines with anticholinergic and sedative properties such as sedatives, antidepressants and antipsychotics, have been associated with both the cognitive and physical functioning decline of older people. New Zealand has an exponentially ageing population and therefore issues pertaining to polypharmacy and appropriate prescribing are becoming more imminent. This thesis aims to explore issues related to prescribing in older people from the perspective of health professionals who care for them in everyday clinical practice (i.e. General practitioners and registered nurses). Learning more about the challenges related to prescribing in older people, and administering medicines to older people in the residential care setting would enable us to better understand how to best implement deprescribing, in a safe and efficient manner. Exploring GP and RN perspectives on deprescribing highlighted several existing challenges pertaining to time constraints, healthcare policies, reimbursement schemes and access to easy-to use guidelines that can empower health professionals to stop medicines that they believe are no longer providing benefit to their patient(s). The findings of the pharmacist-led deprescribing feasibility study we implemented supports existing research that deprescribing has many associated benefits and is in fact feasible to implement, within the New Zealand healthcare system. Benefits including a reduction in residents’ pill burden, reported adverse drug events, depression and frailty scores were amongst the noted benefits after six months of deprescribing anticholinergic and sedative medicines. This further solidifies that deprescribing can be an effective and safe way to rationalise and optimise older people’s medication use. Future work is required to determine how deprescribing can be implemented on a larger scale and can be incorporated into existing New Zealand healthcare policies

Deprescribing in Older New Zealanders

Polypharmacy, the prescription of five or more medicines, is an emerging worldwide health concern. When older people are prescribed five or more medicines, they are susceptible to a wide variety of negative health consequences, including an increased risk of developing adverse drug events, drug interactions and falling. In specific, medicines with anticholinergic and sedative properties such as sedatives, antidepressants and antipsychotics, have been associated with both the cognitive and physical functioning decline of older people. New Zealand has an exponentially ageing population and therefore issues pertaining to polypharmacy and appropriate prescribing are becoming more imminent. This thesis aims to explore issues related to prescribing in older people from the perspective of health professionals who care for them in everyday clinical practice (i.e. General practitioners and registered nurses). Learning more about the challenges related to prescribing in older people, and administering medicines to older people in the residential care setting would enable us to better understand how to best implement deprescribing, in a safe and efficient manner. Exploring GP and RN perspectives on deprescribing highlighted several existing challenges pertaining to time constraints, healthcare policies, reimbursement schemes and access to easy-to use guidelines that can empower health professionals to stop medicines that they believe are no longer providing benefit to their patient(s). The findings of the pharmacist-led deprescribing feasibility study we implemented supports existing research that deprescribing has many associated benefits and is in fact feasible to implement, within the New Zealand healthcare system. Benefits including a reduction in residents’ pill burden, reported adverse drug events, depression and frailty scores were amongst the noted benefits after six months of deprescribing anticholinergic and sedative medicines. This further solidifies that deprescribing can be an effective and safe way to rationalise and optimise older people’s medication use. Future work is required to determine how deprescribing can be implemented on a larger scale and can be incorporated into existing New Zealand healthcare policies

Challenges and Enablers of Deprescribing: A General Practitioner Perspective.

AIMS:Deprescribing is the process of reducing or discontinuing medicines that are unnecessary or deemed to be harmful. We aimed to investigate general practitioner (GP) perceived challenges to deprescribing in residential care and the possible enablers that support GPs to implement deprescribing. METHODS:A qualitative study was undertaken using semi-structured, face-to-face interviews from two cities in New Zealand and a purpose-developed pilot-tested interview schedule. Interviews were recorded with permission and transcribed verbatim. Transcripts were read and re-read and themes were identified with iterative building of a coding list until all data was accounted for. Interviews continued until saturation of ideas occurred. Analysis was carried out with the assistance of a Theoretical Domains Framework (TDF) and constant comparison techniques. Several themes were identified. Challenges and enablers of deprescribing were determined based on participants' answers. RESULTS:Ten GPs agreed to participate. Four themes were identified to define the issues around prescribing for older people, from the GPs' perspectives. Theme 1, the 'recognition of the problem', discusses the difficulties involved with prescribing for older people. Theme 2 outlines the identified behaviour change factors relevant to the problem. Deprescribing challenges were drawn from these factors and summarised in Theme 3 under three major headings; 'prescribing factors', 'social influences' and 'policy and processes'. Deprescribing enablers, based on the opinions and professional experience of GPs, were retrieved and summarised in Theme 4. CONCLUSION:The process of deprescribing is laced with many challenges for GPs. The uncertainty of research evidence in older people and social factors such as specialists' and nurses' influences were among the major challenges identified. Deprescribing enablers encompassed support for GPs' awareness and knowledge, improvement of communication between multiple prescribers, adequate reimbursement and pharmacists being involved in the multidisciplinary team

Deprescribing considerations and challenges.

<p>Deprescribing considerations and challenges.</p