Deprescribing Trials: Methods to Reduce Polypharmacy and the Impact on Prescribing and Clinical Outcomes
Section snippets
The Risks of Polypharmacy
There are many challenges to ensuring good outcomes from the pharmacologic management of older adults. With advancing age, the increased prevalence of diseases promotes high use of medications in older adults and of polypharmacy, commonly defined as the use of 5 or more medications. Further, there is a lack of data to guide the use of medications in older adults. This is because older adults are rarely included in randomized, controlled trials (RCT),1 and most evidence-based clinical guidelines
Challenges of Discontinuing Medications
Before addressing interventions to reduce medications in older adults, it is important to briefly discuss factors that need to be considered during the medication withdrawal process (Fig. 1). There are many barriers to successfully stopping medications in older adults. Health professionals may find it difficult to reduce the dose or to stop the medication once a prescription is initiated. Clinicians might feel uncomfortable with changing or discontinuing a medication prescribed by another
Interventions to Reduce Medications: Impact on Prescribing and Outcomes
A number of clinical controlled studies have been performed to assess the effectiveness of various interventions to reduce medication exposure in older adults (Table 1). These approaches have commonly included medication reviews delivered by clinical pharmacists, prescriber education programs, academic detailing combined with additional strategies, comprehensive geriatric assessments, and multidisciplinary interventions engaging health professionals such as physicians and pharmacists.
Of 4
Deprescribing Trials to Reduce Medications: Impact on Prescribing and Outcomes
The studies described in this section represent those which have employed an RCT design to assess the effects of interventions to reduce medicines in older adults. These trials have been conducted in a range of settings, and have yielded mixed results and are summarized in Table 2.
RCTs involving medication review performed by pharmacists have been utilized in a few studies.36, 37, 38, 39 Although clinical pharmacist-based interventions have resulted in substantial changes in medication regimens
Effectiveness of Trials to Reduce Medication Exposure
Assessing the effectiveness of a range of interventions on prescribing and clinical benefits is challenging because of the range of outcomes measured across studies, as well as differences in the study designs, settings, and types of interventions (Fig. 2). While in some studies the main outcome measure was the surrogate outcome of the change in number of medications, other studies selected more clinically relevant outcomes such as hospitalizations, falls, or mortality. Selecting appropriate
Summary
Different styles of interventions can reduce medication exposure in older adults. However, the evidence for their clinical effectiveness and sustainability is conflicting and lacking. There are some data to guide clinicians on which medicines are more likely to be inappropriate in older people, which medicines are more likely to cause ADWEs, and which medicines should be tapered slowly rather than stopped. To reduce the likelihood of clinically significant adverse events, clinicians should
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Disclosures: The authors gratefully acknowledge the funding support from the Geoff and Elaine Penney Ageing Research Unit and the Ageing and Alzheimer's Research Foundation.