Deprescribing anticholinergics in primary care older adults: Experience from two models and impact on a continuous measure of exposure

Abstract

Background: Deprescribing interventions delivered through the electronic medical record have not significantly reduced the use of high-risk anticholinergics in prior trials. Pharmacists have been identified as ideal practitioners to conduct deprescribing; however, little experience beyond collaborative consult models has been published.Objective: To evaluate the impact of two pilot pharmacist-based advanced practice models nested within primary care. Methods: Pilot studies of a collaborative clinic-based pharmacist deprescribing intervention and a telephone-based pharmacist deprescribing intervention were conducted. Patients receiving the clinic-based pharmacy model were aged 55 years and older and referred for deprescribing at a specialty clinic. Patients receiving the telephone-based pharmacy model were aged 65 years and older and called by a clinical pharmacist for deprescribing without referral. Deprescribing was defined as a discontinuation or dose reduction reported either in clinical records or through self-reporting. Results:The 18 patients receiving clinic-based deprescribing had a mean age of 68 years and 78% were female. Among 24 medications deemed eligible for deprescribing, 23 (96%) were deprescribed. The clinic-based deprescribing model resulted in a 93% reduction in median annualized total standardized dose (TSD), 56% lowered their annualized exposure below a cognitive risk threshold, and 4 (17%) of medications were represcribed within 6 months. The 24 patients receiving telephone-based deprescribing had a mean age of 73 years and 92% were female. Among 24 medications deemed eligible for deprescribing, 12 (50%) were deprescribed. There was no change in the median annualized TSD, the annualized TSD was lowered below a cognitive risk threshold in 46%, and no medications were represcribed within 6 months.Few withdrawal symptoms or adverse events were reported in both groups.

Impact of medication optimization and recommendations by clinical pharmacists embedded in a memory disorder clinic

“…Study strengths include the use of multiple criteria for PIM identification (Beers, STOPP, and ACB), which allowed for more nuanced PIM recognition. Previous studies utilized only one set of criteria for PIM recognition, potentially limiting PIM identification 15,20,27 . For example, several medications are listed on Beers and STOPP but not the ACB scale, including benzodiazepines and central alpha agonists (e.g., clonidine); while these are not anticholinergic, they can have significant CNS effects and caution should be taken in older adults.…”

“…Reducing PIMs, particularly anticholinergics, may decrease risk of subsequent dementia, but it remains unclear whether this can improve cognitive function in the short‐term. A recent study found that two pharmacist‐led pilot anticholinergic deprescribing programs reduced the number of patients above a predefined “cognitive risk threshold,” but did not assess cognition as an outcome 15 . A review of interventions in patients with dementia concluded that anticholinergics were associated with greater all‐cause mortality, but cognitive effects were inconsistent 16 .…”

“…A recent study found that two pharmacist-led pilot anticholinergic deprescribing programs reduced the number of patients above a predefined "cognitive risk threshold," but did not assess cognition as an outcome. 15 A review of interventions in patients with dementia concluded that anticholinergics were associated with greater all-cause mortality, but cognitive effects were inconsistent. 16 A prospective study found that continuous use of at least one anticholinergic led to significant MMSE score decline at 24 months, but not at 12.…”