The value of deprescribing in older adults with dementia: a narrative review

Sawan, Mouna; Moga, Daniela C.; Megan, Jessia Joy; Ng, Joanna; Johnell, Kristina; Gnjidic, Danijela

doi:10.1080/17512433.2021.1961576

Cited by 18 publications

(16 citation statements)

References 88 publications

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“…People living with dementia have greater physical health problems than others of the same age, experience more hospital admissions than other older people, and are at increased risk of delirium and other iatrogenic harms [17]. Achieving quality use of medicines in people living with dementia is complex [18,19]. Most people living with dementia also have other medical conditions, such as cardiovascular disease, depression, and diabetes [20,21].…”

Section: Introductionmentioning

confidence: 99%

Consumer and Healthcare Professional Led Priority Setting for Quality Use of Medicines in People with Dementia: Gathering Unanswered Research Questions

Reeve

Chenoweth

Sawan

et al. 2023

JAD

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Background: Historically, research questions have been posed by the pharmaceutical industry or researchers, with little involvement of consumers and healthcare professionals. Objective: To determine what questions about medicine use are important to people living with dementia and their care team and whether they have been previously answered by research. Methods: The James Lind Alliance Priority Setting Partnership process was followed. A national Australian qualitative survey on medicine use in people living with dementia was conducted with consumers (people living with dementia and their carers including family,and friends) and healthcare professionals. Survey findings were supplemented with key informant interviews and relevant published documents (identified by the research team). Conventional content analysis was used to generate summary questions. Finally, evidence checking was conducted to determine if the summary questions were ‘unanswered’. Results: A total of 545 questions were submitted by 228 survey participants (151 consumers and 77 healthcare professionals). Eight interviews were conducted with key informants and four relevant published documents were identified and reviewed. Overall, analysis resulted in 68 research questions, grouped into 13 themes. Themes with the greatest number of questions were related to co-morbidities, adverse drug reactions, treatment of dementia, and polypharmacy. Evidence checking resulted in 67 unanswered questions. Conclusion: A wide variety of unanswered research questions were identified. Addressing unanswered research questions identified by consumers and healthcare professionals through this process will ensure that areas of priority are targeted in future research to achieve optimal health outcomes through quality use of medicines.

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Section: Introductionmentioning

confidence: 99%

Consumer and Healthcare Professional Led Priority Setting for Quality Use of Medicines in People with Dementia: Gathering Unanswered Research Questions

Reeve

Chenoweth

Sawan

et al. 2023

JAD

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“…Use of polypharmacy and potentially inappropriate medications (PIMs) is common in people living with dementia and can lead to increased risk of harms, such as adverse drug reactions, falls, hospitalization and mortality [ 1–5 ]. Optimising benefit and minimising risk of medication use requires both appropriate prescribing and appropriate deprescribing, i.e.…”

Section: Introductionmentioning

confidence: 99%

“…Optimising benefit and minimising risk of medication use requires both appropriate prescribing and appropriate deprescribing, i.e. discontinuation (or dose reduction) of medications where the harms outweigh the benefits in the individual [ 1 , 6 , 7 ]. The benefits and harms of medications can change over time in an individual, due to addition of new medications, development of new medical conditions and changes in care goals.…”

Section: Introductionmentioning

confidence: 99%

Willingness of older people living with dementia and mild cognitive impairment and their caregivers to have medications deprescribed

et al. 2023

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Background people living with cognitive impairment commonly take multiple medications including potentially inappropriate medications (PIMs), which puts them at risk of medication related harms. Aims to explore willingness to have a medication deprescribed of older people living with cognitive impairment (dementia or mild cognitive impairment) and multiple chronic conditions and assess the relationship between willingness, patient characteristics and belief about medications. Methods cross-sectional study using results from the revised Patients’ Attitudes Towards Deprescribing questionnaire (rPATDcog) collected as baseline data in the OPTIMIZE study, a pragmatic, cluster-randomised trial educating patients and clinicians about deprescribing. Eligible participants were 65+, diagnosed with dementia or mild cognitive impairment, and prescribed at least five-long-term medications. Results the questionnaire was mailed to 1,409 intervention patients and 553 (39%) were returned and included in analysis. Participants had a mean age of 80.1 (SD 7.4) and 52.4% were female. About 78.5% (431/549) of participants said that they would be willing to have one of their medications stopped if their doctor said it was possible. Willingness to deprescribe was negatively associated with getting stressed when changes are made and with previously having a bad experience with stopping a medication (P < 0.001 for both). Conclusion most older people living with cognitive impairment are willing to deprescribe. Addressing previous bad experiences with stopping a medication and stress when changes are made to medications may be key points to discuss during deprescribing conversations.

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“…A recent expert opinion concludes that the next step in the deprescribing field should tailor interventions for home-dwelling PwD while also involving their informal caregivers to identify preferences for medication use and overall health [ 14 ]. Such interventions might be considered complex due to the permitted degree of tailoring or inherent properties of the intervention (e.g., multiple and interacting components) [ 15 ].…”

Section: Introductionmentioning

confidence: 99%

“…Such interventions might be considered complex due to the permitted degree of tailoring or inherent properties of the intervention (e.g., multiple and interacting components) [ 15 ]. Even though complex interventions are essential for changing clinical practices [ 15 ], the best evidence to support deprescribing is for high-risk medications among PwD living in long-term care facilities [ 14 ]. For instance, the WHELD trial demonstrated that antipsychotic drug withdrawal was most beneficial for BPSD and mortality for PwD living in nursing homes when social interactions were promoted in parallel [ 16 ].…”

Section: Introductionmentioning

confidence: 99%

The impact of medication reviews by general practitioners on psychotropic drug use and behavioral and psychological symptoms in home-dwelling people with dementia: results from the multicomponent cluster randomized controlled LIVE@Home.Path trial

Gedde

Husebø

Mannseth

et al. 2022

BMC Med

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Background There is limited knowledge regarding the process of deprescribing psychotropic drugs to people with dementia (PwD) conducted by general practitioners (GP). We investigated the impact of a multicomponent intervention, emphasizing medication reviews, on psychotropic drugs and behavioral and psychological symptoms (BPSD) in home-dwelling PwD and quantified change in patient-GP communication evaluated by their informal caregivers. Methods LIVE@Home.Path is a stepped-wedge closed-cohort cluster randomized controlled trial for people with mild to moderate dementia aged ≥65 and their informal caregivers (dyads) in Norway. Complementary to health care as usual (control condition), municipal coordinators implemented the multicomponent LIVE intervention: Learning, Innovation, Volunteer support, and Empowerment (including medication review by the PwD’s regular GPs). Block-randomization was used to allocate dyads in three groups receiving the intervention sequentially in periods of 6 months duration. Prepandemic data from the first period is reported, resulting in a 1:2 intervention-to-control ratio. Primary outcome was change in psychotropic drug use. Secondary outcomes were changes in BPSD by Neuropsychiatric Inventory and Cornell Scale of Depression in Dementia and patient-GP communication by an adaption of the Clinical Global Impression of Change. Results Four hundred thirty-eight dyads were screened, 280 included, and 237 participated at 6 months (intervention group n=67; control condition n=170). At baseline, 63% used psychotropic medication regularly: antidementia drugs (47%), antidepressants (13%), hypnotics/sedatives (13%), antipsychotics (5%), and anxiolytics (2%). At 6 months, medication reviews were more frequently conducted in the intervention group compared to control (66% vs 42%, P=0.001). We found no differences regarding a change in drug use and BPSD. Patient-GP communication enhanced in the intervention group (mean score 0.95 [standard deviation 1.68] vs 0.41 [1.34], P=0.022). In the intervention group, control group, and overall sample, the informal caregivers of those who had their medications reviewed reported improved patient-GP communication compared to those who did not. Conclusions Change in psychotropic drug use and BPSD did not differ, even though patient-GP communication improved with medication reviews. Restricted psychotropic drug use among PwD likely reflects more judicious prescribing practices in recent years. Nevertheless, medication reviews could be cultivated to optimize pharmacologic treatment for this complex population. Trial registration ClinicalTrials.gov: NCT04043364; registered 15/03/2019.

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The value of deprescribing in older adults with dementia: a narrative review

Cited by 18 publications

References 88 publications

Consumer and Healthcare Professional Led Priority Setting for Quality Use of Medicines in People with Dementia: Gathering Unanswered Research Questions

Consumer and Healthcare Professional Led Priority Setting for Quality Use of Medicines in People with Dementia: Gathering Unanswered Research Questions

Willingness of older people living with dementia and mild cognitive impairment and their caregivers to have medications deprescribed

The impact of medication reviews by general practitioners on psychotropic drug use and behavioral and psychological symptoms in home-dwelling people with dementia: results from the multicomponent cluster randomized controlled LIVE@Home.Path trial

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