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

Hall RK, Rutledge J, Lucas A, Liu CK, St Clair Russell J, St Peter W, Fish LJ, Colón-Emeric C. Stakeholder Perspectives on Factors Related to Deprescribing Potentially Inappropriate Medications in Older Adults Receiving Dialysis. Clin J Am Soc Nephrol. 2023 Jul 27. doi: 10.2215/CJN.0000000000000229. Epub ahead of print. PMID: 37499693. The study by Hall et al. was an observational qualitative study conducted in Durham, North Carolina, involving semi-structured interviews and focus groups with key stakeholders. It aimed to understand the perspectives of clinicians and patients regarding deprescribing potentially inappropriate medications in older adults receiving dialysis. The study’s primary objective was to identify factors affecting the integration of deprescribing in dialysis clinics, informing the development of a targeted program. It addressed obstacles including system-level issues, unclear co-management, knowledge gaps, and patient preferences to improve medication management in this healthcare context. The study encompassed 76 participants, with 53 clinicians and 23 patients,

Medication misuse and overuse in community-dwelling persons with dementia

Deardorff WJ, Jing B, Growdon ME, Yaffe K, Boscardin WJ, Boockvar KS, Steinman MA. Medication misuse and overuse in community-dwelling persons with dementia. J Am Geriatr Soc. 2023 Jun 5. doi: 10.1111/jgs.18463. Epub ahead of print. PMID: 37272899. The study by Deardorff et al. investigated medication misuse and overuse within the community-dwelling older adult population affected by dementia. Using Health and Retirement Study (HRS) data from 2008 to 2018, a nationally representative survey of U.S. adults, the main goal was to characterize potentially problematic medication use, covering diabetes and hypertension overtreatment, cognition-impairing drugs, and medications from consensus criteria (2019 Beers and STOPP Version 2). By comparing medication trends between those with and without dementia, it seeks to provide insights into problematic prescribing, highlighting areas for interventions and deprescribing to enhance care quality for individuals with dementia. The study cohort comprised individuals aged 66 years and above, identified as having dementia

Deprescribing to optimise health outcomes for frail older people: a double-blind placebo-controlled randomised controlled trial-outcomes of the Opti-med study

Etherton-Beer C, Page A, Naganathan V, Potter K, Comans T, Hilmer SN, McLachlan AJ, Lindley RI, Mangin D. Deprescribing to optimise health outcomes for frail older people: a double-blind placebo-controlled randomised controlled trial-outcomes of the Opti-med study. Age Ageing. 2023 May 1;52(5):afad081. doi: 10.1093/ageing/afad081. PMID: 37247404; PMCID: PMC10226731. The Opti-med study, conducted between 2014 and 2018, was a double-blind, randomized, placebo-controlled trial conducted across Sydney and Perth. The study’s primary objective was to investigate the effects of deprescribing multiple medications in the target population of older individuals residing in residential aged care facilities (RACFs). The study aimed to assess the impact of deprescribing on survival, quality of life, and clinical outcomes within this population while focusing on reducing medication burden and optimizing medication use. The authors conducted the study with three groups: blinded control, blinded intervention, and open intervention. The intervention in this study involved a structured process of medication

Deprescribing statins, considerations for informed decision making

Thomas C, Ellison H, Taffet GE. Deprescribing statins, considerations for informed decision making. J Am Geriatr Soc. 2023 Apr 21. doi: 10.1111/jgs.18362. Epub ahead of print. PMID: 37082816. To address ongoing uncertainties in deprescribing statins, Thomas et al. authored a commentary that explores key considerations and cautions when stopping these medications. Deprescribing aims to manage risks associated with polypharmacy in older adults. Due to their widespread use, uncertain benefits, and potential adverse effects, statins are a potential target for deprescribing. While statins are effective in reducing cardiovascular events in older patients with preexisting vascular disease, the evidence for primary prevention in older populations is mixed. The decision whether to start a statin is an important one that requires careful consideration.   Thomas et al. highlight the importance of distinguishing between stopping and starting these medications when considering the biologic mechanisms of statin discontinuation. Chronic inhibition of a pathway, as observed with

Frail older adults taking cardiometabolic medications: When less is more

Chaitoff A, Haff N, Lauffenburger JC, Choudhry NK. Medication de-escalation opportunities among frail older adults with strictly-controlled cardiometabolic disease [published online ahead of print, 2023 Apr 4]. J Am Geriatr Soc. 2023;10.1111/jgs.18368. doi:10.1111/jgs.18368 Many patients with hypertension, diabetes, and heart disease benefit from cardiometabolic disease medications. However, the number of medications available and potential downstream complications put patients at risk of polypharmacy. For frail older adults with strictly-controlled cardiometabolic disease, risk-benefit tradeoffs may favor de-escalating medications. A team of researchers at the Center for Healthcare Delivery Sciences at the Brigham and Women’s Hospital set out to clarify potential opportunities to de-escalate medications within this patient population. Using data from the National Health and Nutrition Examination Survey (NHANES) collected between 2005-2018, researchers evaluated adults age 65 and older with frailty. Researchers noted potential opportunity for de-escalating if the patient was taking medication for hypertension, diabetes, or heart disease and exceeded targets

From the hospital to the postacute care facility: How well is Shed-MEDS working?

Vasilevskis EE, Shah AS, Hollingsworth EK, et al. Deprescribing Medications Among Older Adults From End of Hospitalization Through Postacute Care: A Shed-MEDS Randomized Clinical Trial. JAMA Intern Med. 2023;183(3):223-231. doi:10.1001/jamainternmed.2022.6545 Despite the well-known risks of polypharmacy among hospitalized older adults, few deprescribing interventions target initiating deprescribing in the hospital, and to date no deprescribing trial has included older adults transitioning to a post-acute care (PAC) facility. Both acute care and PAC settings provide ample opportunities for deprescribing medications and monitoring deprescribing-related outcomes. To address this gap in deprescribing research, a team of investigators led by USDeN collaborator Eduard E. Vasilevskis conducted a randomized clinical trial of the Shed-MEDS (Best Possible Medication History, Evaluate, Deprescribing Recommendations, and Synthesis) deprescribing intervention between 2016 and 2020. The intervention was carried out by trained research clinicians who began the deprescribing protocol in the hospital and continued to follow up with patients for the duration

How should we better measure the cost-effectiveness of deprescribing interventions? Recommendations for improving value assessment

Hung A, Wang J, Moriarty F, et al. Value assessment of deprescribing interventions: Suggestions for improvement [published online ahead of print, 2023 Feb 21]. J Am Geriatr Soc. 2023;10.1111/jgs.18298. doi:10.1111/jgs.18298 Despite the well-established link between deprescribing interventions and reduced use of potentially inappropriate medications (PIMs), there is little evidence behind the cost-effectiveness of these interventions. Eight members of the USDeN Junior Investigator Intensive (JII) program joined forces to publish a commentary on value assessment of deprescribing interventions, published in the Journal of American Geriatrics Society last month. Authors provide an overview of cost-effectiveness analyses (CEAs), a standard approach to deprescribing value assessment. Most CEAs report value as cost per quality-adjusted life years (QALYs), while some report cost per PIM stopped or per increase in the medication appropriateness index. These approaches are limited by short time windows and their lack of relevance to a variety of patient-centered outcomes. Our JII members

Key learnings from the OPTIMIZE deprescribing pragmatic trial

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

Multiple Comorbidities and Multiple Medications: The Challenges Facing Older Adults with Heart Failure

Kwak MJ, Cheng M, Goyal P, et al. Medication Complexity Among Older Adults with HF: How Can We Assess Better?. Drugs Aging. 2022;39(11):851-861. doi:10.1007/s40266-022-00979-2 Heart failure affects 6 million Americans today, over half of whom are 75 and older. Older adults with heart failure face complex medication regimens that are further complicated by the cognitive, physical, and social challenges of aging. Older adults taking multiple medications are at greater risk of adverse drug events, medication errors, drug-drug or drug-disease interactions, and nonadherence. Few studies, however, have assessed the complexity of medications or clinical outcomes among older adults with heart failure. USDeN Pilot Awardee Dr. Min Ji Kwak led a review of heart failure medication management, covering medication regimen complexity assessment, outcome assessment, and the representation of older adults in the literature. Nine research articles on medication complexity among heart failure patients were included in the literature view. Assessment of Medication

How “age-friendly” are deprescribing interventions?

Wang J, Shen JY, Conwell Y, et al. How “age-friendly” are deprescribing interventions? A scoping review of deprescribing trials [published online ahead of print, 2022 Oct 11]. Health Serv Res. 2022;10.1111/1475-6773.14083. doi:10.1111/1475-6773.14083 The 4Ms (“Medication,” “Mentation,” “Mobility,” and “What Matters Most”) are considered essential components of age-friendly health systems. Age-friendly health systems are better equipped to handle the most pressing health concerns facing older adults. Given that over a third of older adults use potentially inappropriate or unnecessary medications (PIMs), effective, patient-centered deprescribing interventions are expected to incorporate the 4Ms of age-friendly care. After conducting a scoping review of deprescribing trials, a team mentored by USDeN pilot core leaders Amanda Mixon and Sandra Simmons found that “Mentation,” “Mobility,” and “What Matters Most,” are considered to varying degrees in the intervention design and outcome assessment. In this review, 37 studies were selected for their focus on specific deprescribing interventions and inclusion

Deintensifying diabetes medications: Beliefs and misconceptions among older adults

Pilla SJ, Meza KA, Schoenborn NL, Boyd CM, Maruthur NM, Chander G. A Qualitative Study of Perspectives of Older Adults on Deintensifying Diabetes Medications [published online ahead of print, 2022 Sep 29]. J Gen Intern Med. 2022;10.1007/s11606-022-07828-3. doi:10.1007/s11606-022-07828-3 While previous studies have examined the patient perspective on deprescribing, few have explored this topic in relation to diabetes medications. Guidelines recommend deintensification of diabetes medications for older adults with type 2 diabetes who are below glycemic target where it can reduce polypharmacy or the risk of adverse drug effects. In practice, however, diabetes medications are rarely stopped or reduced regardless of glycemic control or health status. In hopes of optimizing deintensification, researchers at Johns Hopkins set out to understand the patient perspective on stopping or reducing diabetes medications. They conducted a qualitative study using individual semi-structured interviews of 24 older adults with medication-treated type 2 diabetes and good glycemic control. Interviewers

Gabapentin as a substitute for opioids: Is the solution creating new problems?

Bongiovanni T, Gan S, Finlayson E, et al. Prolonged use of newly prescribed gabapentin after surgery [published online ahead of print, 2022 Aug 24]. J Am Geriatr Soc. 2022;10.1111/jgs.18005. doi:10.1111/jgs.18005 Postoperative pain management has changed significantly in the last decade. Surgeons have attempted to decrease opioid prescribing by using non-opioid “multimodal” pain regimens, such as gabapentinoids (gabapentin and pregablin). While gabapentinoids are associated with reduced postoperative pain and opioid consumption, they are still included in the AGS Beers Criteria list as potentially inappropriate medications (PIMs) for older adults in certain contexts. In addition, closer attention must be paid to the proper discontinuation of gabapentinoids when they are no longer needed for post-operative pain control. Prolonged use of gabapentinoids carries its own unique risks, from altered mental status to other adverse events and hospitalizations. Researchers from UCSF and Yale investigated the predictors of prolonged gabapentin use through a retrospective cohort study

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