Review Describes Evidence Regarding Deprescribing Interventions for Older Patients

A narrative review published in the International Journal of General Medicine provides an update on current evidence regarding deprescribing and informs and guides clinicians on managing polypharmacy among older populations.

An estimated 15 million Americans aged 65 years are prescribed 5 or more medications, and more are expected to engage in polypharmacy as the population ages. Polypharmacy has been found to be associated with adverse geriatric outcomes like delirium, falls, frailty, cognitive impairment, and hospitalization.

Deprescribing medications for older adults is beneficial in minimizing polypharmacy and reducing the risk of medication-related harms.

The narrative review serves to summarize the literature on the safety and efficacy of deprescribing interventions, synthesize challenges and their solutions for methods of deprescribing in research and practice, and summarize current evidence on 2 emerging solutions in deprescribing research and practice: Computerized Clinical Decision Support Systems (CCDSS) and Quality Indicators (QIs).

Investigators conducted literature searches in Medline and Embase, with an emphasis on systematic reviews published between January 2016 to March 2021 using relevant search terms such as “deprescribing,” “polypharmacy”, and “inappropriate medications”.

Evidence was gleaned from systematic reviews that satisfied the following criteria:

• Included a study population of patients with a median age of 60 years and older.
• Examined the safety and efficacy of deprescribing interventions on potentially inappropriate medications (PIMs) and patient global health outcomes, such as mortality, hospitalization, quality of life and geriatric syndromes.
• Explored challenges of and solutions for deprescribing research and implementation.
• Examined use of CCDS and QIs in deprescribing research.

The authors wrote that their findings indicate that deprescribing was a safe and feasible management strategy in reducing risk of medication-related complications in affected patients. However, small sample sizes, residual confounding by unaccounted factors, and time and cost constraints contribute to limited data on the efficacy of describing interventions. Large randomized controlled multicenter trials are needed to determine the efficacy, benefits on long-term quality of life, and morbidity and geriatric outcomes of deprescribing interventions, as current evidence remains unclear.

To address challenges associated with deprescribing, future deprescribing studies should consider deprescribing outcomes based on both patient and clinician preferences, they noted. Further, evidence suggests that future studies investigate the acceptability and effectiveness of different educational programs on deprescribing and cater these approaches to different patient populations with varying degrees of health literacy, comorbidities, and concurrent medications.

To overcome the lack of assessment regarding the long-term benefits, safety, and sustainability of deprescribing interventions, randomized controlled trials with detailed reporting of the intervention and long-term follow-up of clinical outcomes are needed. Future deprescribing studies should also consider concurrent medications and present chronic conditions among patients to simulate the impacts on different populations with polypharmacy observed in clinical practice.

Collaboration among national and international health care organizations should be practiced to eliminate unnecessary research duplication and promote knowledge sharing, the authors said.

Health care providers should use a patient-centered approach when providing evidence-based advice about patient medications and work towards the improvement of clinical outcomes through goal-directed medication review. A multidisciplinary care approach between general practitioners, physicians, pharmacists, nurses, and allied health professionals is most likely to provide optimal management of patients’ medicine.

Many systematic reviews found that CCDS had the potential to affect deprescribing interventions involving polypharmacy in older populations, but there is no evidence regarding the effect of CCDSS on clinical outcomes, like falls, frailty, quality of life, or mortality.

Polypharmacy contributes to increased morbidity and mortality in older populations but deprescribing interventions can reduce risks associated with inappropriate medication use. Further large multicenter prospective studies are needed to help deprescribing find its place in routine prescribing, authors concluded.

Reference

Wu H, O’Donnell K L, Fujita K, et al. Deprescribing in the older patient: a narrative review of challenges and solutions. Int. J. Med. Published online July 24, 2021. doi:10.2147/IJGM.S253117