Patient Safety Tip of the Week Archive

What’s New in the Patient Safety World

September 2021

A Primer on Deprescribing

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, we’ve 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 you’ll go back to our June 29, 2021 Patient Safety Tip of the Week “Barriers to Deprescribing” and the multiple other columns we’ve done on deprescribing and potentially inappropriate medications in the elderly..

Some of our past columns on deprescribing:

March 4, 2014 “Evidence-Based Prescribing and Deprescribing in the Elderly”
September 30, 2014 “More on Deprescribing”
May 2015 “Hospitalization: Missed Opportunity to Deprescribe”
July 2015 “Tools for Deprescribing”
April 4, 2017 “Deprescribing in Long-Term Care”
October 31, 2017 “Target Drugs for Deprescribing”
January 2018 “What Happens After Delirium?”
June 2018 “Deprescribing Benzodiazepine Receptor Agonists”
November 27, 2018 “Focus on Deprescribing”
March 19, 2019 “Updated Beers Criteria”
March 10, 2020 “Medication Harm in the Elderly”
June 2020 “The Antipsychotics in Dementia Conundrum”
June 29, 2021 “Barriers to Deprescribing”

Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:

January 15, 2008 “Managing Dangerous Medications in the Elderly
June 2008 “Potentially Inappropriate Medication Use in Elderly Hospitalized Patients”
October 19, 2010 “Optimizing Medications in the Elderly”
September 22, 2009 “Psychotropic Drugs and Falls in the SNF”
September 2010 “Beers List and CPOE”
June 21, 2011 “STOPP Using Beers’ List?”
December 2011 “Beers’ Criteria Update in the Works”
May 7, 2013 “Drug Errors in the Home”
November 12, 2013 “More on Inappropriate Meds in the Elderly”
January 28, 2014 “Is Polypharmacy Always Bad?”
March 4, 2014 “Evidence-Based Prescribing and Deprescribing in the Elderly”
September 30, 2014 “More on Deprescribing”
February 10, 2015 “The Anticholinergic Burden and Dementia”
May 2015 “Hospitalization: Missed Opportunity to Deprescribe”
July 2015 “Tools for Deprescribing”
November 2015 “Medications Most Likely to Harm the Elderly Are…”
August 2, 2016 “Drugs in the Elderly: The Goldilocks Story”
October 31, 2017 “Target Drugs for Deprescribing”
January 2018 “What Happens After Delirium?”
May 2018 “Antipsychotic Use in Nursing Homes: Progress or Not?”
June 2018 “Deprescribing Benzodiazepine Receptor Agonists”
October 2018 “STOPP/START/STRIP”
November 27, 2018 “Focus on Deprescribing”
March 19, 2019 “Updated Beers Criteria”
March 10, 2020 “Medication Harm in the Elderly”
June 2020 “The Antipsychotics in Dementia Conundrum”
February 2021 “Under the Radar: Muscle Relaxant Use”
April 2021 “Alarming Use of Fall-Prone Medications in 65+ Patients”
June 29, 2021 “Barriers to Deprescribing”

References:

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

https://www.dovepress.com/deprescribing-in-the-older-patient-a-narrative-review-of-challenges-an-peer-reviewed-fulltext-article-IJGM

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