Sheehan OC, Gleason KS, Bayliss EA, et al. Intervention design in cognitively impaired populations-Lessons learned from the OPTIMIZE deprescribing pragmatic trial [published online ahead of print, 2022 Dec 12]. J Am Geriatr Soc. 2022;10.1111/jgs.18148. doi:10.1111/jgs.18148
Polypharmacy is a growing concern among older adults, especially those with cognitive impairment and Multiple Chronic Conditions (MCC). Cognitively impaired older adults may face additional challenges with medication management and adherence. While many older adults with cognitive impairment are open to having medications deprescribed, few deprescribing interventions have included this population.
The OPTIMIZE cluster randomized pragmatic trial explored how educating and activating patients, family members, and clinicians about deprescribing affected the number of potentially inappropriate medications and number of chronic medications. The patients were older adults with dementia or mild cognitive impairment (MCI) and MCC. The patient/family caregiver intervention component involved deprescribing brochures that were mailed to patients 2 weeks prior to a primary care visit. The clinician component involved a deprescribing presentation, monthly tip sheets, and electronic notification that the brochure had been mailed to the patient. This paper builds on previously reported findings by presenting intervention fidelity, key learnings, and patient/family/clinician perspectives of the intervention. 15 patients, 7 family caregivers, and 28 Primary Care Providers (PCPs) provided feedback on the intervention.
Patients, family caregivers, and PCPS with prior exposure to deprescribing welcomed the intervention and even felt empowered to discuss medication-related issues. Cognitive impairment hindered several participants’ ability to remember receiving the brochures. Fixed ideas about medications and COVID-related burdens may have dampened the potential impact of this intervention. In addition, providers reported time pressure and competing priorities as barriers to deprescribing.
Most patients favored hard-copy brochures delivered several weeks before an appointment, while providers favored electronic brochures delivered the day of an appointment or immediately before an appointment. Intervention fidelity was high and brochure language was deemed accessible by all patients. Providers found the intervention effective and important to include with other materials that are already provided to patients. Both patients and providers would be open to pharmacy pre-review of medications, which would increase patient awareness and visit efficiency.
Mechanisms of Impact
The majority of patients and family caregivers described the brochure as a reminder or prompt to discuss deprescribing with their providers. Providers reported motivation and openness to deprescribing among patients who received the brochure. Several patients scheduled additional visits to discuss deprescribing with their providers, and many caregivers were inspired to reflect on their own medication decisions.
Although OPTIMIZE did not have a statistically significant effect on PIMs or medication counts, this intervention paved the way for future, larger deprescribing trials, especially those targeting cognitively impaired older adults. Patients, caregivers, and providers alike affirmed the acceptability, importance, and frequency of this intervention.
Primary author Orla C. Sheehan shares her hope for future deprescribing trials:
“Older adults with cognitive impairment are almost universally excluded from clinical trials leaving providers unable to offer evidence-based care to this vulnerable population. The OPTIMIZE trial has clearly demonstrated the feasibility of delivering educational deprescribing interventions to cognitively impaired older adults. In the future I hope that the lessons learned around intervention delivery in OPTIMIZE encourage the inclusion of cognitively impaired older adults across a wide range of drug and intervention trials, expanding the evidence base, providing access to novel interventions and treatments, and improving the quality of care provided to these older adults.”