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Pharmacist-led telehealth deprescribing for people living with dementia and polypharmacy in primary care: A pilot study

Green AR, Quiles R, Daddato AE, Merrey J, Weffald L, Gleason K, Xue QL, Swarthout M, Feeser S, Boyd CM, Wolff JL, Blinka MD, Libby AM, Boxer RS. Pharmacist-led telehealth deprescribing for people living with dementia and polypharmacy in primary care: A pilot study. J Am Geriatr Soc. 2024 Mar 15. doi: 10.1111/jgs.18867. Epub ahead of print. PMID: 38488757.

This pilot study, conducted from May 2021 to 2022, assessed the feasibility and effectiveness of a pharmacist-led telehealth intervention called ALIGN. This intervention aimed to optimize medication management for people living with dementia (PLWD) who are dealing with polypharmacy, specifically targeting those on seven or more medications with a care partner involved. The study’s primary goals are to align medication regimens with the patient and care partner’s goals and to reduce medication burden and complexity. 

The study utilized a two-arm randomized design involving PLWD aged 65 or older across primary care clinics in Baltimore and Denver. Following a deprescribing educational brochure, dyads were randomized to receive the telehealth intervention either immediately or after a three-month delay. During telehealth consultations, pharmacists reviewed medications, provided tailored recommendations to primary care providers (PCPs), and made an average of five recommendations per patient, more than the protocol suggested, reflecting personalized care. Outcomes focused on feasibility metrics, like enrollment and completion rates, and efficacy measures, such as the Medication Regimen Complexity Index (MRCI) and the Family Caregiver Medication Administration Hassles Scale (FCMAHS).

The study demonstrated that a pharmacist-led telehealth deprescribing intervention is feasible and may reduce medication burden and complexity for PLWD. Of the 69 dyads enrolled, approximately 80% completed the intervention, with pharmacists receiving high acceptance rates (98%) for their recommendations from primary care providers (PCPs). Notably, 81% of patients in the intervention group had at least one medication discontinued compared to 50% in the control group. Additionally, the intervention group saw a modest reduction in the Medication Regimen Complexity Index (MRCI) and improvements in the Family Caregiver Medication Administration Hassles Scale (FCMAHS) scores. The study’s strengths include active stakeholder involvement, a diverse participant base, a randomized multi-site design, care partner feedback, and a detailed process for ensuring scoring consistency. However, the study acknowledged limitations such as its execution by only two geriatric-trained pharmacists, potentially affecting generalizability and the selection bias towards patients with engaged care partners. Additionally, the absence of data on tolerability and adherence, along with the study’s conduct in settings with already embedded pharmacists, suggests a need for further research in more varied primary care environments.

Author Ariel Green reflects on how lessons learned from the ALIGN pilot study could be used to refine future deprescribing interventions, especially in the context of enhancing patient and care partner education on medication management:

The pilot showed us the importance of focusing on high-priority symptoms and addressing tradeoffs of medication use. Low-touch, pragmatic interventions have an important role, but we will also need future interventions that facilitate meaningful deprescribing conversations. To do this, we will need to incorporate the interdisciplinary team. We need to provide older adults and care partners information about the risks of potentially inappropriate medicines so they are informed while at the same time recognizing that they make tradeoffs involving medicines every day. Some symptoms, such as pain and behavioral symptoms of dementia, are very distressing. We need to offer realistic alternatives, which sometimes include medicines. So, the conversation may not be strictly about stopping medicines; it may be about reducing exposure as much as possible and reducing the overall medication burden to make room for medicines that are helping the patient feel better. We need to make sure we are having these conversations every time we start a new medicine as well.


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