Optimising a person-centred approach to stopping medicines in older people with multimorbidity and polypharmacy using the DExTruS framework: a realist review

Abstract

Background Tackling problematic polypharmacy requires tailoring the use of medicines to individual circumstances and may involve the process of deprescribing. Deprescribing can cause anxiety and concern for clinicians and patients. Tailoring medication decisions often entails beyond protocol decision-making, a complex process involving emotional and cognitive work for healthcare professionals and patients. We undertook realist review to highlight and understand the interactions between different factors involved in deprescribing and to develop a final programme theory that identifies and explains components of good practice that support a person-centred approach to deprescribing in older patients with multimorbidity and polypharmacy. Methods The realist approach involves identifying underlying causal mechanisms and exploring how, and under what conditions they work. We conducted a search of electronic databases which were supplemented by citation checking and consultation with stakeholders to identify other key documents. The review followed the key steps outlined by Pawson et al. and followed the RAMESES standards for realist syntheses. Results We included 119 included documents from which data were extracted to produce context-mechanism-outcome configurations (CMOCs) and a final programme theory. Our programme theory recognises that deprescribing is a complex intervention influenced by a multitude of factors. The components of our final programme theory include the following: a supportive infrastructure that provides clear guidance around professional responsibilities and that enables multidisciplinary working and continuity of care, consistent access to high-quality relevant patient contextual data, the need to support the creation of a shared explanation and understanding of the meaning and purpose of medicines and a trial and learn approach that provides space for monitoring and continuity. These components may support the development of trust which may be key to managing the uncertainty and in turn optimise outcomes. These components are summarised in the novel DExTruS framework. Conclusion Our findings recognise the complex interpretive practice and decision-making involved in medication management and identify key components needed to support best practice. Our findings have implications for how we design medication review consultations, professional training and for patient records/data management. Our review also highlights the role that trust plays both as a central element of tailored prescribing and a potential outcome of good practice in this area.

Attitudes of Older Adult Patients and Caregivers Towards Deprescribing of Medications in Ethiopia

“…15 This ensures that taking more medications as per disease-specific guidelines always does not translate to better health for older adult patient. 16 Therefore, devising different preventive strategies, such as deprescription 17 and unorthodox prescriptive interventions like social prescribing, 16 should not be delayed for older adult patients with multimorbidity to minimize the burden of polypharmacy and PIM. 18 Deprescribing is the supervised process of medication's dose reduction and medication/s withdrawal in which its actual or possible risks outweigh existing or potential benefits in the context of an individual patient's treatment goals, the present level of functioning, life expectancy, values, and preferences.…”

“…8 This initiates Turk et al and other authors to outline a person-centered approach such as shared-decision making, continuity of care, the development of trust, monitoring, and a multidisciplinary approach to tackle deprescribing-related challenges. 1,17 Therefore, deprescribing is a patient-centered intervention that requires collaborative decision-making, informed patient consent, and healthcare provider participation. 22 By adhering to a person-centered and multidisciplinary approach, deprescribing is a practical and relatively safe medicine optimization practice.…”

Drivers of unprofessional behaviour between staff in acute care hospitals: A realist review

“…(38). This is done by rst developing an initial programme theory representing how and why an intervention may work, before drawing on a wider body of literature to test and re ne ndings against this initial theory (39,40).…”

Drivers of unprofessional behaviour between staff in acute care hospitals: A realist review

“…[38]. This is done by first developing an ini�al programme theory represen�ng how and why an interven�on may work, before drawing on a wider body of literature to test and refine findings against this ini�al theory [39,40].…”