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Wu and colleagues recently did a systemic review of systemic reviews on deprescribing in the elderly (Wu 2021) and it serves as an excellent introduction or primer on the topic. They conclude that the evidence suggests deprescribing is safe and feasible as a management strategy in patients at risk of medication-related problems. The literature shows that deprescribing can reduce the number of potentially inappropriate medications and rarely causes adverse drug withdrawal events. However, the authors note there is actually limited evidence of its effects on global and geriatric outcomes, such as falls, hospitalization, cognitive and physical function decline. Though common sense dictates that patient outcomes will be improved by deprescribing potentially inappropriate drugs in the elderly, studies on deprescribing have been limited by small sample sizes, confounding factors, and the lack of long-term follow up.
The review has a nice table listing the challenges and solutions of implementing deprescribing at the patient, healthcare professional, and health system levels. We just discussed many of those challenges in our June 29, 2021 Patient Safety Tip of the Week Barriers to Deprescribing.
Patient challenges include poor health literacy, reluctance to discontinue medications based on false beliefs, and fact that patients are often not involved in decision making about the use of medications. At the healthcare professional level, time constraints, lack of formal training on deprescribing, and the complexity and multiple comorbidities of the geriatric patient are challenges. At the health system level, fragmentation of care and poor communication between providers is the primary challenge.
They discuss the role of educational solutions at each of those three levels. While educational interventions are necessary, weve always pointed out that they are generally among the weakest solutions to any problem. Wu et al. do note that provision of deprescribing protocols and use of explicit criteria to guide medication review have proven to be effective in achieving deprescribing. And they discuss the role of computer clinical decision support tool, noting that most studies have demonstrated CDS tools do result in reduction of potentially inappropriate medications in the elderly. But, again, even those studies have yet to demonstrate improvement in hard patient outcomes. They also discuss the use of quality indicators, which may be tied to financial incentives, public reporting, accreditation, or continued professional development. However, they note that use of some quality indicators, particularly when tied to financial incentives, may have unintended consequences (such as healthcare providers turning away specific types of patients that might reduce their quality indicator scores). They provide a table with the New South Wales (Australia) Therapeutic Advisory Group (NSW TAG) Polypharmacy Quality Use of Medicines (QUM) Indicators as an example of the kinds of quality indicators you might consider.
The Wu review is a good place to start for those just getting started with deprescribing and has a good bibliography to help you identify relevant studies. It also points out the dearth of research linking results of deprescribing to actual patient outcomes.
We hope youll go back to our June 29, 2021 Patient Safety Tip of the Week Barriers to Deprescribing and the multiple other columns weve done on deprescribing and potentially inappropriate medications in the elderly..
Some of our past columns on deprescribing:
Some of our past columns on Beers List and Inappropriate Prescribing in the Elderly:
Wu H, Kouladjian O'Donnell L, Fujita K, et al. Deprescribing in the Older Patient: A Narrative Review of Challenges and Solutions. International Journal of General Medicine 2021; 14: 3793-3807
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