Too much medicine in older people? Deprescribing through shared decision making

Abstract

Jansen and colleagues explore the role of shared decision making in tackling inappropriate polypharmacy in older adults Too much medicine is an increasingly recognised problem, 1 2 and one manifestation is inappropriate polypharmacy in older people. Polypharmacy is usually defined as taking more than five regular prescribed medicines.3 It can be appropriate (when potential benefits outweigh potential harms) 4 but increases the risk of older people experiencing adverse drug reactions, impaired physical and cognitive function, and hospital admission. [5][6][7] There is limited evidence to inform polypharmacy in older people, especially those with multimorbidity, cognitive impairment, or frailty.8 Systematic reviews of medication withdrawal trials (deprescribing) show that reducing specific classes of medicines may decrease adverse events and improve quality of life. [9][10][11] Two recent reviews of the literature on deprescribing stressed the importance of patient involvement and shared decision making.12 13 Patients and clinicians typically overestimate the benefits of treatments and underestimate their harms.14 When they engage in shared decision making they become better informed about potential outcomes and as a result patients tend to choose more conservative options (eg, fewer medicines), facilitating deprescribing. 15 However, shared decision making in this context is not easy, and there is little guidance on how to do it. 16 We draw together evidence from the psychology, communication, and decision making literature (see appendix on thebmj.com). For each step of the shared decision making process we describe the unique tasks required for deprescribing decisions; identify challenges for older adults, their companions, and clinicians (figure); give practical advice on how challenges may be overcome; highlight where more work is needed; and identify priorities for future research (table). 17 18 Process for deprescribing with older adultsStep 1: creating awareness that options existThe clinician and patient acknowledge that a decision can be made about continuation or discontinuation of medicines, and that this requires input from both clinician and patient. When to initiate discussions about deprescribingPrescribing new medicines is often straightforward, driven by a new diagnosis, symptom, or test result. When to consider ceasing medicines is less clear.12 Possible triggers include the number of medicines taken (perhaps ≥10); a new symptom that may be an adverse effect of a medicine; identifying high risk, ineffective, or unnecessary medicines; apparent non-adherence; or changed treatment priorities. 19 Most of these situations can be identified only by a medicines review. Reviews can be triggered by important life transitions (such as hospital admission, a new diagnosis, or seeing a new doctor) and can be initiated by the clinician or patient, but they are often Older people's attitudes towards medicineClinicians may be reluctant to initiate discussions about deprescribing with older people, believing tha...

Swimming Against the Tide: Primary Care Physicians’ Views on Deprescribing in Everyday Practice

“…Interventions that have been tried include audit and feedback, education and training, decision support, pharmacist medicines review, and enhancing patient engagement. [15][16][17][18][19][20] Physician input is key to the development of successful interventions. To date, however, there has been relatively little research investigating the views of primary care physicians on deprescribing in everyday practice.…”

A concept analysis of deprescribing medications in older people

“…33 The intervention needs to be undertaken under the supervision of, and in conjunction with a health professional. 26,41 The involvement of a health professional and a patient making the decision together with the goal of improving health outcomes or managing polypharmacy sets deprescribing apart from non-adherence.…”

“…41 Medicolegal concerns are an identified barrier to deprescribing, 42 but this is less significant when undertaken as part of a shared-decision. 41 Deprescribing should be considered from both a patient-centred ethical perspective as well as a clinical perspective. 43 Deprescribing is a variation from the status quo and is thus perceived as an active intervention.…”

“…41 In this review, they outlined the steps A, B and C below, which are needed to discuss deprescribing with consumers to facilitate a shared decision. 41 The combined steps from these papers detail the process.…”

Deprescribing – a valuable practice?

“…Writing in the BMJ, 1 Jansen and col leagues point out: "There is limited evi dence to inform polypharmacy in older people, especially those with multimor bidity, cognitive impairment, or frailty. "…”