Deprescribing, an integral component of a continuum of good prescribing practices, is the process of medication withdrawal or dose reduction to correct or prevent medication-related complications, improve outcomes, and reduce costs. Deprescribing is particularly applicable to the commonly encountered multimorbid older adult with cardiovascular disease and concomitant geriatric conditions such as polypharmacy, frailty, and cognitive dysfunction–a combination rarely addressed in current clinical practice guidelines. Triggers to deprescribe include present or expected adverse drug reactions, unnecessary polypharmacy, and the need to align medications with goals of care when life expectancy is reduced. Using a framework to deprescribe, this review addresses the rationale, evidence, and strategies for deprescribing cardiovascular and some noncardiovascular medications.

Eire frequency is the number of fires experienced by a particular community within a given time period. This concept can potentially be resolved into a number of interacting variables, including: time since the most recent fire, the length of the inter-fire intervals, and the variability of the length of the inter-fire intervals. We estimated the effects of these three variables on the floristic composition of 65 samples from dry sclerophyll vegetation with different fire histories in Brisbane Water, Ku-ring-gai Chase and Royal National Parks near Sydney.Our analyses suggest that fire frequency may account for about 60% of the floristic variation among our samples. They confirm the hypothesis that the recent (<30 years) fire frequency produces effects on floristic composition of fire-prone communities that can recognizably be attributed both to the time since the most recent fire and to the length of the intervals between fires. These effects are equal in magnitude but are different in the nature of the floristic variation they are associated with. Increasing time-since-fire is associated with a decline in the evenness of fire-tolerant species, indicating that fewer of these species come to dominate the community in the prolonged absence of fire. Herbs and small shrubs decrease in abundance, while larger shrubs increase in abundance. Inter-fire intervals of decreasing length are associated with a decrease in the evenness of the fire-sensitive species, particularly those large Proteaceae shrubs that often dominate the community biomass in dry sclerophyll shrublands of southeastern Australia.Furthermore, the variation associated with inter-fire intervals is not necessarily solely related to the shortest inter-fire interval, but is related to combinations of inter-fire intervals through time. Thus, increasing variability of the length of the inter-fire intervals is associated with an increase in the species richness of both fire-sensitive and fire-tolerant species, implying that it may be variation of the inter-fire intervals through time that is primarily responsible for maintaining the presence of a wide variety of plant species in a particular community. Our results also suggest that the floristic variation associated with different inter-fire intervals decreases with increasing time-since-fire.

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BACKGROUND/OBJECTIVES Guideline‐based management of cardiovascular disease often involves prescribing multiple medications, which contributes to polypharmacy and risk for adverse drug events in older adults. Deprescribing is a potential strategy to mitigate these risks. We sought to characterize and compare clinician perspectives regarding deprescribing cardiovascular medications across three specialties. DESIGN National cross‐sectional survey. SETTING Ambulatory. PARTICIPANTS Random sample of geriatricians, general internists, and cardiologists from the American College of Physicians. MEASUREMENTS Electronic survey assessing clinical practice of deprescribing cardiovascular medications, reasons and barriers to deprescribing, and choice of medications to deprescribe in hypothetical clinical cases. RESULTS In each specialty, 750 physicians were surveyed, with a response rate of 26% for geriatricians, 26% for general internists, and 12% for cardiologists. Over 80% of respondents within each specialty reported that they had recently considered deprescribing a cardiovascular medication. Adverse drug reactions were the most common reason for deprescribing for all specialties. Geriatricians also commonly reported deprescribing in the setting of limited life expectancy. Barriers to deprescribing were shared across specialties and included concerns about interfering with other physicians' treatment plans and patient reluctance. In hypothetical cases, over 90% of physicians in each specialty chose to deprescribe when patients experienced adverse drug reactions. Geriatricians were most likely and cardiologists were least likely to consider deprescribing cardiovascular medications in cases of limited life expectancy (all P < .001), such as recurrent metastatic cancer (84% of geriatricians, 68% of general internists, and 45% of cardiologists), Alzheimer dementia (92% of geriatricians, 81% of general internists, and 59% of cardiologists), or significant functional impairment (83% of geriatricians, 68% of general internists, and 45% of cardiologists). CONCLUSIONS While barriers to deprescribing cardiovascular medications are shared across specialties, reasons for deprescribing, especially in the setting of limited life expectancy, varied. Implementing deprescribing will require improved processes for both physician‐physician and physician‐patient communication. J Am Geriatr Soc 68:78–86, 2019

IMPORTANCE Transient elevations of blood pressure (BP) are common in hospitalized older adults and frequently lead practitioners to prescribe more intensive antihypertensive regimens at hospital discharge than the patients were using before hospitalization.OBJECTIVE To investigate the association between intensification of antihypertensive regimens at hospital discharge and clinical outcomes after discharge. DESIGN, SETTING, AND PARTICIPANTSIn this retrospective cohort study, patients 65 years and older with hypertension who were hospitalized in Veterans Health Administration national health system facilities from January 1, 2011, to December 31, 2013, for common noncardiac conditions were studied. Data analysis was performed from October 1, 2018, to March 10, 2019.EXPOSURES Discharge with antihypertensive intensification, defined as receiving a prescription at hospital discharge for a new or higher-dose antihypertensive than was being used before hospitalization. Propensity scores were used to construct a matched-pairs cohort of patients who did and did not receive antihypertensive intensifications at hospital discharge. MAIN OUTCOMES AND MEASURESThe primary outcomes of hospital readmission, serious adverse events, and cardiovascular events were assessed by competing risk analysis. The secondary outcome was the change in systolic BP within 1 year of hospital discharge. RESULTSThe propensity-matched cohort included 4056 hospitalized older adults with hypertension (mean [SD] age, 77 [8] years; 3961 men [97.7%]), equally split between those who did vs did not receive antihypertensive intensifications at hospital discharge. Groups were well matched on all baseline covariates (all standardized mean differences <0.1). Within 30 days, patients receiving intensifications had a higher risk of readmission (hazard ratio [HR], 1.23; 95% CI, 1.07-1.42; number needed to harm [NNH], 27; 95% CI, 16-76) and serious adverse events (HR, 1.41; 95% CI, 1. NNH, 63; 95% CI,. At 1 year, no differences were found in cardiovascular events (HR, 1.18; 95% CI, 0.99-1.40) or change in systolic BP among those who did vs did not receive intensifications (mean BP, 134.7 vs 134.4; difference-in-differences estimate, 0.6 mm Hg; 95% CI, −2.4 to 3.7 mm Hg).CONCLUSIONS AND RELEVANCE Among older adults hospitalized for noncardiac conditions, prescription of intensified antihypertensives at discharge was not associated with reduced cardiac events or improved BP control within 1 year but was associated with an increased risk of readmission and serious adverse events within 30 days.