Factors Important to Older Adults Who Disagree With a Deprescribing Recommendation.

IMPORTANCE Little is known about why older adults decline deprescribing recommendations, primarily because interventional studies rarely capture the reasons. OBJECTIVE To examine factors important to older adults who disagree with a deprescribing recommendation given by a primary care physician to a hypothetical patient experiencing polypharmacy. DESIGN, SETTING, AND PARTICIPANTS This online, vignette-based survey study was conducted from December 1, 2020, to March 31, 2021, with participants 65 years or older in the United Kingdom, the US, Australia, and the Netherlands. The primary outcome of the main study was disagreement with a deprescribing recommendation. A content analysis was subsequently conducted of the free-text reasons provided by participants who strongly disagreed or disagreed with deprescribing. Data were analyzed from August 22, 2022, to February 12, 2023. MAIN OUTCOMES AND MEASURES Attitudes, beliefs, fears, and recommended actions of older adults in response to deprescribing recommendations. RESULTS Of the 899 participants included in the analysis, the mean (SD) age was 71.5 (4.9) years; 456 participants (50.7%) were men. Attitudes, beliefs, and fears reported by participants included doubts about deprescribing (361 [40.2%]), valuing medications (139 [15.5%]), and a preference to avoid change (132 [14.7%]). Valuing medications was reported more commonly among participants who strongly disagreed compared with those who disagreed with deprescribing (48 of 205 [23.4%] vs 91 of 694 [13.1%], respectively; P < .001) or had personal experience with the same medication class as the vignette compared with no experience (93 of 517 [18.0%] vs 46 of 318 [12.1%], respectively; P = .02). Participants shared that improved communication (225 [25.0%]), alternative strategies (138 [15.4%]), and consideration of medication preferences (137 [15.2%]) may increase their agreement with deprescribing. Participants who disagreed compared with those who strongly disagreed were more interested in additional communication (196 [28.2%] vs 29 [14.2%], respectively; P < .001), alternative strategies (117 [16.9%] vs 21 [10.2%], respectively; P = .02), or consideration of medication preferences (122 [17.6%] vs 15 [7.3%], respectively; P < .001). CONCLUSIONS AND RELEVANCE In this survey study, older adults who disagreed with a deprescribing recommendation were more interested in additional communication, alternative strategies, or consideration of medication preferences compared with those who strongly disagreed. These findings suggest that identifying the degree of disagreement with deprescribing could be used to tailor patient-centered communication about deprescribing in older adults

The Patient Typology about deprescribing and medication-related decisions: A quantitative exploration.

This study aimed to test the adequacy of a quantitative measure of our qualitatively-developed Patient Typology - categories of older adults' attitudes towards medicines and medicine decision-making - and identify characteristics associated with each Typology. We conducted secondary data analyses of a subset of survey item measures of adults (≥65 years) who were members of online survey panels in Australia, the UK, the US, and the Netherlands (n=4,688). Multinomial logistic regression analyses assessed associations between demographic, psychosocial, and medication-related measures. Mean age was 71.5 (5) and 47.5% of participants were female. Factors associated with an increased likelihood of identifying with Typology 1 'Attached to medicines' over Typology 2 'Open to deprescribing' were higher positive attitude towards polypharmacy (RRR=1.12, p =<.001) and higher need for certainty (RRR=1.11, p=.039). Factors associated with an increased likelihood of identifying with Typology 3 'Defers (medication decision-making) to others' over Typology 2 were older age (RRR=1.47 per 10-year age increase, p=<.001) and a decreased likelihood of prior deprescribing experience (RRR=0.73, p=.033). This study provides validation of the Typology with large samples from four countries, with the quantitatively-measured typologies generally aligning with the qualitatively-derived categories. Our Patient Typology measure provides a succinct way researchers can assess attitudes towards deprescribing

Understanding older patients' willingness to have medications deprescribed in primary care: a protocol for a cross-sectional survey study in nine European countries.

INTRODUCTION To reduce inappropriate polypharmacy, deprescribing should be part of patients' regular care. Yet deprescribing is difficult to implement, as shown in several studies. Understanding patients' attitudes towards deprescribing at the individual and country level may reveal effective ways to involve older adults in decisions about medications and help to implement deprescribing in primary care settings. In this study we aim to investigate older adults' perceptions and views on deprescribing in different European countries. Specific objectives are to investigate the patients' willingness to have medications deprescribed by medication type and to have herbal or dietary supplements reduced or stopped, the role of the Patient Typology (on medication perspectives), and the impact of the patient-GP relationship in these decisions. METHODS AND ANALYSIS This cross-sectional survey study has two parts: Part A and Part B. Data collection for Part A will take place in nine countries, in which per country 10 GPs will recruit 10 older patients (≥65 years old) each (n = 900). Part B will be conducted in Switzerland only, in which an additional 35 GPs will recruit five patients each and respond to a questionnaire themselves, with questions about the patients' medications, their willingness to deprescribe those, and their patient-provider relationship. For both Part A and part B, a questionnaire will be used to assess the willingness of older patients with polypharmacy to have medications deprescribed and other relevant information. For Part B, this same questionnaire will have additional questions on the use of herbal and dietary supplements. DISCUSSION The international study design will allow comparisons of patient perspectives on deprescribing from different countries. We will collect information about willingness to have medications deprescribed by medication type and regarding herbal and dietary supplements, which adds important information to the literature on patients' preferences. In addition, GPs in Switzerland will also be surveyed, allowing us to compare GPs' and patients' views and preferences on stopping or reducing specific medications. Our findings will help to understand patients' attitudes towards deprescribing, contributing to improvements in the design and implementation of deprescribing interventions that are better tailored to patients' preferences

Communication and decision-making about medicines and deprescribing: perspectives of older adults, their companions, and clinicians

This thesis aimed to explore communication and decision-making about medicines and deprescribing from the perspectives of older patients, their companions, pharmacists and GPs. A series of qualitative and mixed methods studies provided an in-depth analysis of the attitudes and experiences of key players involved in the deprescribing process in clinical practice. The first study explored decision-making about medicines and deprescribing in healthy and frail older patients and their companions. Study 2 involved the development and feasibility testing of a communication tool to support shared decision making with older patients and accredited pharmacists in the context of Home Medicines Reviews (HMRs), using observations, interviews and surveys. The final study explored GPs’ perspectives on the value of eliciting patient goals and preferences in making decisions about medicines and the utility of medication reviews. This thesis revealed substantial differences between older patients, pharmacists and GPs in their experiences with and attitudes towards medicines discussions. Older patients varied in terms of their attitudes towards medicines, willingness to deprescribe, and decision-making preferences. Pharmacists varied in their approach to HMRs, their communication style and their perceived role in communicating with patients about their goals and preferences. Finally, GPs varied in how important they considered patients’ goals and preferences to be, how they prioritised medicines, their approach to deprescribing, and how they utilised HMRs. Becoming familiar with the differences in these three key players could facilitate medicines optimisation and engaged communication. Indeed, tailoring to these differences could improve interventions such as decision support tools, goal elicitation strategies and conversation guides to support shared decision making about deprescribing

Older adults' adherence to medications and willingness to deprescribe: A sub-study of a randomized clinical trial.

Our study investigated the association between patients' willingness to have medications deprescribed and medication adherence. This longitudinal sub-study of the 'Optimizing PharmacoTherapy In the Multimorbid Elderly in Primary CAre' (OPTICA) trial, a cluster randomized controlled trial, took place in Swiss primary care settings. Participants were aged ≥65 years and over, with ≥3 chronic conditions, and ≥5 regular medications. At baseline the 'revised Patient Attitudes Towards Deprescribing' (rPATD) questionnaire was measured. The A14-scale measured adherence (self-report) at the 12-month follow-up. Multilevel linear regression analyses adjusted for baseline variables were performed. Of the 298 participants, 45% were women and the median age was 78. Participants reported a high level of adherence and willingness to have medications deprescribed. We did not find evidence for an association between patients' willingness to deprescribe and medication adherence. Further research is needed to explore the relationship between these concepts and to inform collaborative decisions about medicines in the context of polypharmacy

Social determinants of antidepressant continuation during pregnancy in the USA: findings from the ABCD cohort study.

PURPOSE Patients and healthcare professionals overestimate the risks of using antidepressants during pregnancy. According to current literature, approximately half of people stop taking an anti-depressant medication when they become pregnant. Discontinuing antidepressants during pregnancy increases risks of postnatal relapses. Factors like socioeconomic status, education, and planned pregnancies play a role in the decision to continue antidepressant medication, which can worsen disparities in maternal and child health. Our aim was to identify the sociodemographic factors associated with antidepressant continuation after awareness of pregnancy. METHODS We used representative data from the Adolescent Brain Cognitive Development (ABCD) study that captures maternal medication during pregnancy. We identified women who used antidepressants before awareness of their pregnancy. We calculated crude and adjusted associations between sociodemographic factors and continuation of antidepressant medication during pregnancy. Our model included age, education, ethnicity, first language, household income, living with a partner, having planned the pregnancy, pregnancy duration and smoking during pregnancy. RESULTS In total, 199 women continued antidepressants and 100 discontinued. The logistic regressions resulted in only one significant factor: first language. Native English speakers were more likely to continue medication than other mothers (adjusted OR = 14.94, 95% CI = [2.40; 291.45], p = .015). CONCLUSIONS Language differences were associated with continuation of antidepressants. Non-native English speakers were more likely to discontinue antidepressants, which may lead to health inequities. This finding should be taken into account to reinforce information about the limited risks of antidepressants among people with non-English speaking backgrounds in the USA

Older adults’ attitudes towards deprescribing and medication changes: a longitudinal sub-study of a cluster randomised controlled trial

Objective To investigate the association between older patients’ willingness to have one or more medications deprescribed and: (1) change in medications, (2) change in the appropriateness of medications and (3) implementation of prescribing recommendations generated by the electronic decision support system tested in the ‘Optimising PharmacoTherapy In the Multimorbid Elderly in Primary CAre’ (OPTICA) trial.Design A longitudinal sub-study of the OPTICA trial, a cluster randomised controlled trial.Setting Swiss primary care settings.Participants Participants were aged ≥65 years, with ≥3 chronic conditions and ≥5 regular medications recruited from 43 general practitioner (GP) practices.Exposures Patients’ willingness to have medications deprescribed was assessed using three questions from the ‘revised Patient Attitudes Towards Deprescribing’ (rPATD) questionnaire and its concerns about stopping score.Measures/analyses Medication-related outcomes were collected at 1 year follow-up. Aim 1 outcome: change in the number of long-term medications between baseline and 12 month follow-up. Aim 2 outcome: change in medication appropriateness (Medication Appropriateness Index). Aim 3 outcome: binary variable on whether any prescribing recommendation generated during the OPTICA medication review was implemented. We used multilevel linear regression analyses (aim 1 and aim 2) and multilevel logistic regression analyses (aim 3). Models were adjusted for sociodemographic variables and the clustering effect at GP level.Results 298 patients completed the rPATD, 45% were women and 78 years was the median age. A statistically significant association was found between the concerns about stopping score and the change in the number of medications over time (per 1-unit increase in the score the average number of medications use was 0.65 higher; 95% CI: 0.08 to 1.22). Other than that we did not find evidence for statistically significant associations between patients’ agreement with deprescribing and medication-related outcomes.Conclusions We did not find evidence for an association between most measures of patient agreement with deprescribing and medication-related outcomes over 1 year.Trial registration number NCT03724539

Does missing data matter in the revised Patients' Attitude Towards Deprescribing questionnaire? A systematic review and two case analyses

International audienc

Reasons why older adults in three countries agreed with a deprescribing recommendation in a hypothetical vignette.

The purpose of this study was to examine factors important to older adults who agreed with a deprescribing recommendation given from a General Practitioner (GP) to a hypothetical patient experiencing polypharmacy. We conducted an online, vignette-based, experimental study in the United Kingdom, United States, and Australia with participants ≥65 years. The primary outcome was agreement with a deprescribing recommendation (6-point Likert scale; 1=strongly disagree and 6=strongly agree). We performed a content analysis of the free text reasons provided by participants who agreed with deprescribing (score of 5 or 6). Among 2,656 participants who agreed with deprescribing, approximately 53.7% shared a preference for following the GP's recommendation or considered the GP the expert. The medication was referred to as a reason for deprescribing by 35.6% of participants. Less common themes included personal experience with the medicine (4.3%) and older age (4.0%). Older adults who agreed with deprescribing in a hypothetical vignette most frequently reported a desire to follow the recommendations given the GP's expertise. Future research should be conducted to help clinicians efficiently identify patients who have a strong desire to follow the doctor's recommendations related to deprescribing as this may allow for a tailored, brief deprescribing conversation