Development of a deprescribing manual for frail older people for use in the COFRAIL study and in primary care

Abstract

Introduction: Many older adults are affected by multimorbidity and subsequent polypharmacy which is associated with adverse outcomes. This is especially relevant for frail older patients. Polypharmacy may be reduced via deprescribing. As part of the complex intervention in the COFRAIL study, we developed a deprescribing manual to be used by general practitioners (GPs) in family conferences, in which GPs, patients and caregivers jointly discuss treatments. Methods: We selected indications with a high prevalence in older adults in primary care (e.g. diabetes mellitus, hypertension) and conducted a literature search to identify deprescribing criteria for these indications. We additionally reviewed clinical practice guidelines. Based on the extracted information, we created a deprescribing manual which was then piloted in an expert workshop and in family conferences with volunteer patients according to the inclusion and exclusion criteria of the study protocol. Results: Initially, 13 indications/topics were selected. The literature search identified deprescribing guides, reviews and clinical trials as well as lists of potentially inappropriate medication and systematic reviews on the risk and benefits of specific drugs and drug classes in older patients. After piloting and revisions, the deprescribing manual now covers 11 indications/topics. In each chapter, patient- and medication-related deprescribing criteria, monitoring and communication strategies, and information about concerns related to the use of specific drugs in older patients are provided. Discussion: We found varying deprescribing strategies in the literature, which we consolidated in our deprescribing manual. Whether this approach leads to successful deprescribing in family conferences is being investigated in the cluster-randomised controlled COFRAIL study. Plain Language Summary Development of a manual to help doctors to identify which medications can be withdrawn Many older adults suffer from chronic diseases and take multiple medications concurrently. This can lead to side effects and other undesired events. We developed a manual to help doctors identify which medications can be withdrawn, so that they can discuss this with their patients. This manual was used in the COFRAIL study where doctors, patients and caregivers met in family conferences to discuss their preferences and decide together how future treatments should be handled. The manual contains information on common medications, symptoms and diseases in older patients such as diabetes and high blood pressure. Before the manual was used in the study, it was tested by volunteer patients and their doctors and caregivers to make sure that it is user-friendly.

Stakeholder Perspectives on Factors Related to Deprescribing Potentially Inappropriate Medications in Older Adults Receiving Dialysis

“…41 Decision-making guides, such as decision aids, algorithms, and deprescribing manuals, serve to promote clinician self-efficacy and patient understanding. [42][43][44] The Advancing Kidney Disease through Optimal Medication Management initiative is developing clinician resources relevant for deprescribing. 45 With respect to clinician concern about prescriber boundaries, this concern could be mitigated through improving communication across multiple disciplines and care coordination agreements.…”

Family Conferences to Facilitate Deprescribing in Older Outpatients With Frailty and With Polypharmacy

“…In the joint discussion, GPs were asked to (1) determine the general preferences of the patient, (2) perform a medication check, (3) address further topics from the nonpharmacologic toolbox as needed, and (4) make follow-up appointments. The medication check was to include a review of patient-acquired medication from a pharmacy and, for each medication, an assessment of whether the medication was (still) necessary, whether the risks outweigh the potential benefits, and whether the prescription was consistent with the patient's current treatment preferences . The rationale and development of the COFRAIL intervention, including a deprescribing manual, has been published elsewhere …”

“…The medication check was to include a review of patient-acquired medication from a pharmacy and, for each medication, an assessment of whether the medication was (still) necessary, whether the risks outweigh the potential benefits, and whether the prescription was consistent with the patient's current treatment preferences. 36 The rationale and development of the COFRAIL intervention, including a deprescribing manual, has been published elsewhere. 36 , 37 …”

“… 36 The rationale and development of the COFRAIL intervention, including a deprescribing manual, has been published elsewhere. 36 , 37 …”

Drug safety in older patients with alcohol use disorder: a retrospective cohort study

“…In this regard, PIM classification systems differ from deprescribing tools, which primarily focus on the deliberate discontinuation of drugs with a presumed negative benefit–risk ratio. 13 – 15 In Germany, the PRISCUS (Latin: ancient, venerable) list and the FORTA (Fit fOR The Aged) classification are the preferred PIM evaluation tools, as they specifically take into account German prescribing characteristics and the German pharmaceutical market. 16 , 17 The recently updated PRISCUS list (i.e.…”