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Background and Objective: As dementia progresses, people living with dementia may take high-risk, unnecessary, or ineffective medicines. Cholinesterase inhibitors (ChEIs) may have benefit in some people with dementia; however, up to one third are continued when no longer necessary or safe. Our aim was to co-design a consult patient decision aid (CPtDA) to support shared decision making between healthcare professionals and consumers about continuing or deprescribing ChEIs. Methods: A systematic process was employed to design and test the CPtDA prototype. First, a steering group composed of healthcare professionals and a consumer representative was assembled. Guided by the International Patient Decision Aids Standards, the steering group defined the CPtDA's purpose, scope, and target audience and drafted the prototype for further testing. Interviews with consumers and healthcare professionals were conducted to gain feedback on the content, format, structure, comprehensibility and usability of the CPtDA prototype. Results: After the steering group developed the CPtDA prototype, interviews were conducted with 11 consumers and six healthcare professionals. The content and format of the decision aid were improved iteratively over three rounds after consolidating the feedback at each round. The main changes included rewording the purpose of the decision aid and simplifying its layout and format. Participants reported that the decision aid is comprehensible and may be useful in practice. Conclusions: Limited available resources guide shared decision making about deprescribing. This study resulted in a co-designed and alpha-tested CPtDA for people living with dementia and carers to help them review the ongoing need for their ChEIs. Further research is needed to explore using the CPtDA in practice to support people living with dementia and their carers engage in the shared decision-making process about continuing or deprescribing their ChEIs. Our co-designed CPtDA could help people living with dementia and their carers review their goals of care alongside their healthcare professional. This may prompt conversations about appropriately using ChEIs and increase the uptake of deprescribing. [ABSTRACT FROM AUTHOR]

With ageing of the population worldwide and discovery of new medications for prevention and management of age-related conditions, there is increasing use of medications by older adults. There are international efforts to increase the representativeness of participants in clinical trials to match the intended real-world users of the medications across a range of characteristics including age, multimorbidity, polypharmacy and frailty. Currently, much of the data on medication-related harm in older adults are from pharmacovigilance studies. New methods in pre-clinical models have allowed for measurement of exposures (such as chronic exposure, polypharmacy and deprescribing) and outcomes (such as health span functional measures and frailty) that are highly relevant to geriatric pharmacotherapy. Here we describe opportunities for design and implementation of pre-clinical models that can better predict drug effects in geriatric patients. This could improve the translation of new drugs from bench to bedside and improve outcomes of pharmacotherapy in older adults. [ABSTRACT FROM AUTHOR]

Aims: Comprehensively investigate prescribing in usual care of hospitalized older people with respect to polypharmacy; potentially inappropriate medications (PIMs) according to Beers criteria; and cumulative anticholinergic and sedative medication exposure calculated with Drug Burden Index (DBI). Specifically, to quantify exposure to these measures on admission, changes between admission and discharge, associations with adverse outcomes and medication costs. Methods: Established new retrospective inpatient cohort of 2000 adults aged ≥75 years, consecutively admitted to 6 hospitals in Sydney, Australia, with detailed information on medications, clinical characteristics and outcomes. Conducted cross‐sectional analyses of index admission data from cohort. Results: Cohort had mean (standard deviation) age 86.0 (5.8) years, 59% female, 21% from residential aged care. On admission, prevalence of polypharmacy was 77%, PIMs 34% and DBI > 0 in 53%. From admission to discharge, mean difference (95% confidence interval) in total number of medications increased 1.05 (0.92, 1.18); while prevalence of exposure to PIMs (−3.8% [−5.4, −2.1]) and mean DBI score (−0.02 [−0.04, −0.01]) decreased. PIMs and DBI score were associated with increased risks (adjusted odds ratio [95% confidence interval]) of falls (PIMs 1.63 [1.28, 2.08]; DBI score 1.21[1.00, 1.46]) and delirium (PIMs 1.76 [1.38, 1.46]; DBI score 1.42 [1.19, 1.71]). Each measure was associated with increased risk of adverse drug reactions (polypharmacy 1.42 [1.19, 1.71]; PIMs 1.87 [1.40, 2.49]; DBI score 1.90 [1.55, 2.15]). Cost (AU$/patient/hospital day) of medications contributing to PIMs and DBI was low ($0.29 and $0.88). Conclusion: In this large cohort of older inpatients, usual hospital care results in an increase in number of medications and small reductions in PIMs and DBI, with variable associations with adverse outcomes. [ABSTRACT FROM AUTHOR]

Background Optimal management of hypertension in people with dementia may involve deprescribing antihypertensives. Understanding differing treatment priorities is important to enable patient-centred care. This study explored preferences for antihypertensive deprescribing amongst people living with dementia, carers and clinicians. Methods Discrete choice experiments (DCEs) are a stated preference survey method, underpinned by economic theory. A DCE was conducted, and respondents completed 12 labelled choice-questions, each presenting a status quo (continuing antihypertensives) and antihypertensive deprescribing option. The questions included six attributes, including pill burden, and event risks for stroke, myocardial infarction, increased blood pressure, cognitive decline, falls. Results Overall, 112 respondents (33 carers, 19 people living with dementia, and 60 clinicians) completed the survey. For people with dementia, lower pill burden increased preferences for deprescribing (odds ratio (OR) 1.95, 95% confidence interval (95% CI) 1.08–3.52). Increased stroke risk (for each additional person out of 100 having a stroke) decreased the likelihood of deprescribing for geriatricians (OR 0.71, 95% CI 0.55–0.92) and non-geriatrician clinicians (OR 0.62, 95% CI 0.45–0.86), and carers (OR 0.71, 95% CI 0.58–0.88). Increased myocardial infarction risk decreased preferences for deprescribing for non-geriatricians (OR 0.81, 95% CI 0.69–0.95) and carers (OR 0.84, 95% CI 0.73–0.98). Avoiding cognitive decline increased preferences for deprescribing for geriatricians (OR 1.17, 95% CI 1.03–1.33) and carers (OR 1.27, 95% CI 1.09–1.48). Avoiding falls increased preferences for deprescribing for clinicians (geriatricians (OR 1.20, 95% CI 1.11–1.29); non-geriatricians (OR 1.16, 95% CI 1.07–1.25)). Other attributes did not significantly influence respondent preferences. Conclusions Antihypertensive deprescribing preferences differ amongst people with dementia, carers and clinicians. The study emphasises the importance of shared decision-making within the deprescribing process. [ABSTRACT FROM AUTHOR]

Introduction: Implementation of the Drug Burden Index (DBI) as a risk assessment tool in clinical practice may facilitate deprescribing. Objective: The purpose of this study is to evaluate how a comprehensive intervention bundle using the DBI impacts (i) the proportion of older inpatients with at least one DBI-contributing medication stopped or dose reduced on discharge, compared with admission; and (ii) the changes in deprescribing of different DBI-contributing medication classes during hospitalisation. Methods: This before-and-after study was conducted in an Australian metropolitan tertiary referral hospital. Patients aged ≥ 75 years admitted to the acute aged care service for ≥ 48 h from December 2020 to October 2021 and prescribed DBI-contributing medication were included. During the control period, usual care was provided. During the intervention, access to the intervention bundle was added, including a clinician interface displaying DBI score in the electronic medical record. In a subsequent 'stewardship' period, a stewardship pharmacist used the bundle to provide clinicians with patient-specific recommendations on deprescribing of DBI-contributing medications. Results: Overall, 457 hospitalisations were included. The proportion of patients with at least one DBI-contributing medication stopped/reduced on discharge increased from 29.9% (control period) to 37.5% [intervention; adjusted risk difference (aRD) 6.5%, 95% confidence intervals (CI) −3.2 to 17.5%] and 43.1% (stewardship; aRD 12.1%, 95% CI 1.0–24.0%). The proportion of opioid prescriptions stopped/reduced rose from 17.9% during control to 45.7% during stewardship (p = 0.04). Conclusion: Integrating a comprehensive intervention bundle and accompanying stewardship program is a promising strategy to facilitate deprescribing of sedative and anticholinergic medications in older inpatients. [ABSTRACT FROM AUTHOR]

Background: Hospitalisation provides an opportunity for medication review and deprescribing. Patient‐reported experience measures (PREM) for deprescribing in older patients in hospital are not well described. Aims: To pilot test and describe PREM for deprescribing in older patients, compare PREM by patient characteristics and investigate patients' awareness of medication changes on hospital discharge. Methods: This prospective, multicentre, observational cohort study at two tertiary hospitals in Sydney, Australia, evaluated the PREM questionnaire developed by the NSW Therapeutic Advisory Group. It was completed by patients (or their next of kin) recruited from acute geriatric medicine and orthogeriatric services. Association with nine patient characteristics was analysed using the Chi‐squared test and multivariable regression. Awareness of medication changes and test–retest reliability were analysed using descriptive statistics. Results: Overall, 201 participants completed the questionnaire, with 170 eligible for analysis; 34 (20%) of 170 were aware of reduction or cessation of their usual medications on discharge and reported involvement in decision‐making and receiving enough information to reduce or stop one or more of their usual medications (positive PREM). Independent predictors of positive PREM included respondent (next of kin), hospital (Hospital 1), language (English) and specialty (acute geriatric medicine). Overall, 92 (59.4%) of 155 patients with medication changes were aware of those changes on hospital discharge. Conclusions: These PREM are a feasible tool to examine older patients' experiences of deprescribing in hospital and might be applied to evaluate interventions to improve awareness, shared decision‐making and provision of information when deprescribing for older patients. [ABSTRACT FROM AUTHOR]

Background potentially harmful polypharmacy is very common in older people living in aged care facilities. To date, there have been no double-blind randomised controlled studies of deprescribing multiple medications. Methods three-arm (open intervention, blinded intervention and blinded control) randomised controlled trial enrolling people aged over 65 years (n  = 303, noting pre-specified recruitment target of n  = 954) living in residential aged care facilities. The blinded groups had medications targeted for deprescribing encapsulated while the medicines were deprescribed (blind intervention) or continued (blind control). A third open intervention arm had unblinded deprescribing of targeted medications. Results participants were 76% female with mean age 85.0 ± 7.5 years. Deprescribing was associated with a significant reduction in the total number of medicines used per participant over 12 months in both intervention groups (blind intervention group −2.7 medicines, 95% CI −3.5, −1.9, and open intervention group −2.3 medicines; 95% CI −3.1, −1.4) compared with the control group (−0.3, 95% CI −1.0, 0.4, P  = 0.053). Deprescribing regular medicines was not associated with any significant increase in the number of 'when required' medicines administered. There were no significant differences in mortality in the blind intervention group (HR 0.93, 95% CI 0.50, 1.73, P  = 0.83) or the open intervention group (HR 1.47, 95% CI 0.83, 2.61, P  = 0.19) compared to the control group. Conclusions deprescribing of two to three medicines per person was achieved with protocol-based deprescribing during this study. Pre-specified recruitment targets were not met, so the impact of deprescribing on survival and other clinical outcomes remains uncertain. [ABSTRACT FROM AUTHOR]

Aging, medication use, and global function are associated with changes in the microbiome. However, their interrelationships and changes over time require further characterization. In a longitudinal aging mouse study, we investigated the effects of aging, chronic polypharmacy with a high Drug Burden Index (DBI, measure of total anticholinergic and sedative medication exposure) and gradual cessation (deprescribing) on the microbiome, further exploring any association with global outcomes. Chronic administration of high DBI polypharmacy attenuated the aging-related reduction in alpha diversity, which was not sustained after deprescribing. Beta diversity and LEfSe (Linear discriminant analysis Effect Size) features varied with age, polypharmacy, and deprescribing. Aging with and without polypharmacy shared decreases in Bifidobacteriaceae , Paraprevotellaceae , Bacteroidaceae , and Clostridiaceae , while only aging with polypharmacy showed increased LEfSe features. Microbiome diversity correlated with frailty, nesting, and open field performance. Polypharmacy deprescribing reversed changes that occurred with treatment. However, the microbiome did not recover to its pretreatment composition at 12 months, nor develop the same aging-related changes from 12 to 24 months as the control group. Overall, aging, chronic polypharmacy, and deprescribing differentially affected the diversity and composition of the gut microbiome, which is associated with frailty and function. [ABSTRACT FROM AUTHOR]

Objectives: Shared decision making is the process in which the person, their representative, and health care professional share information with each other, participate in the decision-making process, and agree on a course of action. At present, very little is known about shared decision making (SDM) in medication management from the perspective of long-term care facility residents. The objective of this study was to identify residents' beliefs, motivation, and aspects of the environment that facilitate or impede SDM.Design: A qualitative study was conducted using face-to-face semi-structured interviews, and data analysis was carried out using a thematic approach.Setting: Six long-term care facilities in Sydney, Australia.Participants: Thirty-one residents.Results: Enablers to resident involvement in SDM were resident beliefs in exercising their right to take part in medication-related decisions, preference to maintain control over decisions, and motivation to raise concern about medication. Residents were not motivated to be involved in SDM if they believed they had no control over life circumstance, perceived that medications were necessary, or experienced no problems with their medications. Participation in SDM was hindered by limitations in opportunities for resident involvement, engagement with staff and primary care physician to discuss issues related to medications, and continuity of care with their regular physician.Conclusion: This study highlights that the residents' beliefs in control over decisions and concerns about medication are a significant function of the SDM process. It is important that residents are given the choice to take part in SDM, their beliefs and values regarding SDM are understood, and the culture of the care facility respects residents' right to participate in SDM. [ABSTRACT FROM AUTHOR]

Deprescribing has emerged as an important aspect of patient‐centred medication management but is vastly underutilized in clinical practice. The current narrative review will describe an innovative patient‐centred approach to deprescribing—N‐of‐1 trials. N‐of‐1 trials involve multiple‐period crossover design experiments conducted within individual patients. They enable patients to compare the effects of two or more treatments or, in the case of deprescribing N‐of‐1 trials, continuation with a current treatment versus no treatment or placebo. N‐of‐1 trials are distinct from traditional between‐patient studies such as parallel‐group or crossover designs which provide an average effect across a group of patients and obscure differences between individuals. By generating data on the effect of an intervention for the individual rather than the population, N‐of‐1 trials can promote therapeutic precision. N‐of‐1 trials are a particularly appealing strategy to inform deprescribing because they can generate individual‐level evidence for deprescribing when evidence is uncertain, and can thus allay patient and physician concerns about discontinuing medications. To illustrate the use of deprescribing N‐of‐1 trials, we share a case example of an ongoing series of N‐of‐1 trials that compare maintenance versus deprescribing of beta‐blockers in patients with heart failure with preserved ejection fraction. By providing quantifiable data on patient‐reported outcomes, promoting personalized pharmacotherapy, and facilitating shared decision making, N‐of‐1 trials represent a potentially transformative strategy to address polypharmacy. [ABSTRACT FROM AUTHOR]

Objectives: 1) To understand and investigate the experiences of accredited clinical pharmacists (ACP) using computerised clinical decision support systems (CCDSS) during medication reviews for older people, including those living with dementia; 2) To design, develop, validate, and evaluate a CCDSS that incorporates pharmacological and other deprescribing tools to aid person-centred management of high-risk medications in older adults living with and without dementia.Methods: This study consisted of three phases and was designed on scenario-based methodology: a) the development phase, which included an exploratory survey and prototype building; b) the validation phase, which included qualitative data collection and usability testing with ACPs, general practitioners (GPs) and carers for people living with dementia; and c) the evaluation phase, using mixed-methods analyses.Results: The exploratory survey found that ACPs required a flexible, and reliable CCDSS to support them with clinical decisions regarding high-risk medication use in older adults. The Goal-directed Medication review Electronic Decision Support System (G-MEDSS)© was developed and validated using quantitative and qualitative feedback received from ACPs, GPs and carers for people with dementia. The mean (SD) System Usability Scale score was 69.0 (12.9), which indicated fair-good usability.Discussion and Conclusions: Involving end-users in the design process refined and improved the design of G-MEDSS, allowing for a person-centred and goal-directed delivery of pharmaceutical care. G-MEDSS allows healthcare practitioners conducting medication reviews for older adults living with and without dementia to tailor pharmaceutical care to meet their goals and preferences. Future studies may explore integration of G-MEDSS with prescribing or dispensing software. [ABSTRACT FROM AUTHOR]

The Frailty Inferred Geriatric Health Timeline (FRIGHT) and Analysis of Frailty and Death (AFRAID) clocks were developed to predict biological age and lifespan, respectively, in mice. Their utility within the context of polypharmacy (≥5 medications), which is very common in older adults, is unknown. In male C57BL/6J(B6) mice administered chronic polypharmacy, monotherapy, and undergoing treatment cessation (deprescribing), we aimed to compare these clocks between treatment groups; investigate whether treatment affected correlation of these clocks with mortality; and explore factors that may explain variation in predictive performance. Treatment (control, polypharmacy, or monotherapy) commenced from age 12 months. At age 21 months, each treatment group was subdivided to continue treatment or have it deprescribed. Frailty index was assessed and informed calculation of the clocks. AFRAID, FRIGHT, frailty index, and mortality age did not differ between continued treatment groups and control. Compared to continued treatment, deprescribing some treatments had inconsistent negative impacts on some clocks and mortality. FRIGHT and frailty index, but not AFRAID, were associated with mortality. The bias and precision of AFRAID as a predictor of mortality varied between treatment groups. Effects of deprescribing some drugs on elements of the clocks, particularly on weight loss, contributed to bias. Overall, in this cohort, FRIGHT and AFRAID measures identified no treatment effects and limited deprescribing effects (unsurprising as very few effects on frailty or mortality), with variable prediction of mortality. These clocks have utility, but context is important. Future work should refine them for intervention studies to reduce bias from specific intervention effects. [ABSTRACT FROM AUTHOR]

Implementation science may address some of the limitations that impede the translation of deprescribing recommendations into practice and policy. Application of principles and standard terminologies from implementation science could improve understanding and interpretation of deprescribing research findings. As such, in this commentary we propose three main avenues to help achieve this. These include: The application of these concepts derived from implementation science could help inform future deprescribing needs for clinicians and researchers. Ultimately, this could help ensure the quality use of medications and examination of meaningful outcomes in deprescribing studies. This could result in more consistent and widespread translation of deprescribing evidence into practice and policy across various healthcare settings. [ABSTRACT FROM AUTHOR]

This commentary looks at the process of conducting a systematic review of surveys and validated questionnaires. Surveys and other questionnaire style tools are often used in the field of social and administrative pharmacy, to capture beliefs, attitudes and experiences of patients and healthcare professionals (including pharmacists). Currently, there is little guidance available on how to conduct a systematic review of these types of studies. Considerations related to the process of a systematic review are highlighted, including identification of articles, data extraction, assessing quality of articles and synthesis and analysis of data. [ABSTRACT FROM AUTHOR]

Background: Targeted deprescribing of anticholinergic and sedative medications in older people may improve their health outcomes. This trial will determine if pharmacist-led reviews lead to general practitioners deprescribing anticholinergic and sedative medications in older people living in the community.Methods and Analysis: The standard protocol items: Recommendations for Interventional Trials (SPIRIT) checklist was used to develop and report the protocol. The trial will involve older adults stratified by frailty (low, medium, and high). This will be a pragmatic two-arm randomized controlled trial to test general practitioner uptake of pharmacist recommendations to deprescribe anticholinergic and sedative medications that are causing adverse side effects in patients.Study Population: Community-dwelling frail adults, 65 years or older, living in the Canterbury region of New Zealand, seeking publicly funded home support services or admission to aged residential care and taking at least one anticholinergic or sedative medication regularly.Intervention: New Zealand registered pharmacists using peer-reviewed deprescribing guidelines will visit participants at home in the community, review their medications, and recommend anticholinergic and sedative medications that could be deprescribed to the participant's general practitioner. The total use of anticholinergic and sedative medications will be quantified using the Drug Burden Index (DBI).Outcomes: The primary outcome will be the change in total DBI between baseline and 6-month follow-up. Secondary outcomes will include entry into aged residential care, prolonged hospitalization, and death.Data Collection Points: Data will be collected at the time of interRAI assessments (T0), at the time of the baseline review (T1), at 6 months following the baseline review (T2), and at the end of the study period, or end of study participation for participants admitted into aged residential care, or who died (T3).Ethics and Dissemination: Ethical approval has been obtained from the Human, Disability and Ethics Committee: ethical number (17CEN265).Trial Registration: ClinicalTrials.gov ACTRN12618000729224 . Registered on May 2, 2018, with the Australian New Zealand Clinical Trials Registry. [ABSTRACT FROM AUTHOR]

Background: Deprescribing, the supervised withdrawal of inappropriate medications, intends to manage polypharmacy, which is prevalent in older patients. Aims: To examine general practitioner (GP) perceptions of communication processes between clinicians in hospital and GP in the community about deprescribing decisions made in hospital. Methods: Focus groups and interviews were held with 15 GP, exploring deprescribing in hospitals, communication of deprescribing information and the format of communications. Sessions were audiotaped, transcribed and analysed using an inductive approach. Results: GP stated that they should be involved in deprescribing decisions, especially for older complex patients, because of their good knowledge of their patients. Barriers to effective communication included the acute nature of hospital stays and lack of time. Facilitators included long‐term relationships of GP with their patients and engaged patients. GP preferred communication of deprescribing decisions to be over the telephone while the patient was still in hospital, and with a concise, electronic discharge summary at the time of discharge. GP indicated that rationale for medication changes and recommended follow‐up actions were crucial in a discharge summary to enable care post‐discharge. Conclusions: GP welcome increased communication with hospital clinicians regarding deprescribing decisions made while patients are in hospital. Communication needs to be timely, transparent, succinct and accessible. Lack of time and difficulties contacting hospital clinicians challenge this process. [ABSTRACT FROM AUTHOR]

Background: Residential aged care facility (RACF) staff are well placed to identify opportunities for more appropriate prescribing. However, little is known about their views of polypharmacy, deprescribing and specific medications. Objective: The objective of this study was to establish the beliefs and attitudes of RACF staff towards polypharmacy and medication use in residents. Methods: A cross-sectional survey was conducted on RACF staff in metropolitan New South Wales, Australia using a self-administered questionnaire. The questionnaire was drafted based on the available literature and research team expertise and then piloted by a mixed group of 13 RACF staff. The final version of the questionnaire consisted of 28 questions. A total of 38 RACFs were contacted about the study. The questionnaire was distributed to eligible RACF staff between October 2017 and October 2019. The RACF staff were eligible if they provided direct patient care to residents or worked as a facility manager. Participants were excluded if they had insufficient English language skills. The results were presented in two groups, the nursing and care staff, using descriptive statistics. Results: A total of 176 individuals from nine RACFs completed the questionnaire of whom 160 were eligible for study inclusion. Most considered polypharmacy to be five or more different tablets and capsules per day (95% nursing and 82% care staff respectively). A wide range of beliefs about medication use and deprescribing that centred on what constitutes appropriate polypharmacy was identified. Most thought that preventive medications were essential for residents. Most nurses agreed that sleeping tablets and pharmacological management of verbal aggression and wandering behaviours should be used less frequently whilst most care staff agreed that medications should be used more frequently to manage physical aggression. Conclusions: To successfully and sustainably optimise medication use in RACF residents, it is important to consider the variation in views of nurses and care staff. [ABSTRACT FROM AUTHOR]

Background/Objectives: Attitudes toward deprescribing could vary among subpopulations. We sought to understand patient attitudes toward deprescribing among patients with heart failure with preserved ejection fraction (HFpEF). Design: Retrospective cohort study. Setting: Academic medical center in New York City. Participants: Consecutive patients with HFpEF seen in July 2018–December 2019 at a program dedicated to providing care to older adults with HFpEF. Measurements: We assessed the prevalence of vulnerabilities outlined in the domain management approach for caring for patients with heart failure and examined data on patient attitudes toward having their medicines deprescribed via the revised Patient Attitudes Toward Deprescribing (rPATD). Results: Among 134 patients with HFpEF, median age was 75 (interquartile range 69–82), 60.4% were women, and 35.8% were nonwhite. Almost all patients had polypharmacy (94.0%) and 56.0% had hyperpolypharmacy; multimorbidity (80.6%) and frailty (78.7%) were also common. Overall, 90.3% reported that they would be willing to have one or more of their medicines deprescribed if told it was possible by their doctors; and 26.9% reported that they would like to try stopping one of their medicines to see how they feel without it. Notably, 91.8% of patients reported that they would like to be involved in decisions about their medicines. In bivariate logistic regression, nonwhite participants were less likely to want to try stopping one of their medicines to see how they feel without it (odds ratio 0.25, 95% confidence interval [0.09–0.62], p = 0.005). Conclusions: Patients with HFpEF contend with many vulnerabilities that could prompt consideration for deprescribing. Most patients with HFpEF were amenable to deprescribing. Race may be an important factor that impacts patient attitudes toward deprescribing. [ABSTRACT FROM AUTHOR]

Polypharmacy is a major challenge in healthcare for older people, and is associated with increased risks of adverse outcomes, such as delirium, falls, frailty, cognitive impairment and hospitalization. There is significant public and professional interest in the role of deprescribing in reducing medication-related harms in older people. We aim to provide a narrative review of 1) the safety and efficacy of deprescribing interventions, 2) the challenges and solutions of deprescribing research and implementation in clinical practice, and 3) the benefits of using Computerized Clinical Decision Support Systems (CCDSS) and Quality Indicators (QIs) in deprescribing research and practice. Deprescribing is an established management strategy to minimize polypharmacy and potentially inappropriate medications. There is limited clinical evidence for its efficacy on global and geriatric outcomes. Various challenges at patient, healthcare professional and healthcare system levels may impact on the success of deprescribing interventions in research and practice. Management strategies that target all levels of the healthcare system are required to overcome these challenges. Future studies may consider large multicenter prospective designs to establish the effects and sustainability of deprescribing interventions on clinical outcomes. [ABSTRACT FROM AUTHOR]

Drugs with anticholinergic effects are known to cause adverse effects such as dry mouth, constipation and urinary retention. In older people drugs with anticholinergic effects may contribute to cognitive decline and a loss of functional capacity. Many drugs that are not in the anticholinergic drug class also have anticholinergic effects. They include antidepressants, antipsychotics and antihistamines. Taking multiple drugs with anticholinergic effects creates an anticholinergic burden. It is important that clinicians identify which patients are at risk. There are several tools to assess the anticholinergic burden. Clinicians can use these tools to make a pharmacological risk assessment when reviewing a patient's medicines. This can assist decisions about continuing or stopping drugs with anticholinergic effects. Deprescribing drugs with anticholinergic effects has several potential benefits in older people. In addition to reversing adverse effects, deprescribing may prevent problems such as falls. [ABSTRACT FROM AUTHOR]

Polypharmacy (use of ≥5 medications) and increasing Drug Burden Index (DBI) score (measure of person's total exposure to anticholinergic/sedative medications) are associated with impaired physical function in observational studies of older adults. Deprescribing, the supervised withdrawal of medications for which harms outweigh benefits for an individual, may be a useful intervention. Current knowledge is limited to clinical observational studies that are unable to determine causality. Here, we establish a preclinical model that investigates the effects of chronic polypharmacy, increasing DBI, and deprescribing on global health outcomes in aging. In a longitudinal study, middle-aged (12 months) male C57BL/6J (B6) mice were administered control feed or feed and/or water containing polypharmacy or monotherapy with different DBI scores. At 21 months, each treatment group was subdivided (stratified by frailty at 21 months) to either continue on treatment for life or to have treatment withdrawn (deprescribed). Frailty and physical function were evaluated at 12, 15, 18, and 24 months, and were analyzed using a mixed modeling approach. Polypharmacy with increasing DBI and monotherapy with citalopram caused mice to become frailer, less mobile, and impaired their strength and functional activities. Critically, deprescribing in old age reversed a number of these outcomes. This is the first preclinical study to demonstrate that chronic polypharmacy with increasing DBI augments frailty and impairs function in old age, and that drug withdrawal in old age reversed these outcomes. It was not the number of drugs (polypharmacy) but the type and dose of drugs (DBI) that caused adverse geriatric outcomes. [ABSTRACT FROM AUTHOR]

Background: Use of high-risk medications is common and associated with adverse effects in older adults, including those living with dementia. A Computerised Clinical Decision Support System (CCDSS) called G-MEDSS© (Goal-directed Medication Review Electronic Decision Support System) contains tools that identify medications with anticholinergic and sedative effects and align older adult's health and medication goals of care with medication management strategies.Objectives: To describe the utility of a CCDSS called G-MEDSS in Home Medicines Review (HMR) by an accredited clinical pharmacist (ACP) using a mixed-methods process evaluation method.Methods: A mixed-methods process evaluation was conducted as part of a nation-wide cluster-randomised clinical trial evaluating the effectiveness of implementing G-MEDSS in HMR. Data were collected from ACPs and HMR recipients (the patient) using a feedback survey (ACPs and HMR recipients) and one-on-one telephone interviews (HMR recipients). Quantitative and qualitative data were combined at the start of analysis. Content analysis of the qualitative data was conducted, and emerging categories were linked to quantitative data.Results: Feedback surveys were completed by eight ACPs and 26 HMR recipients; 11 HMR recipients completed one-on-one telephone interviews. Overall, ACPs and HMR recipients who received the intervention reported a positive attitude towards the utility of G-MEDSS in HMR. ACPs reported that G-MEDSS enhanced their ability to make evidence-based recommendations about anticholinergic and sedative medications, and to better align HMR recommendations with HMR recipients' goals of care. However, ACPs described that it was difficult to obtain goals of care from HMR recipients. HMR recipients gave mixed reports about the ACPs consultations: some HMR recipients reported that they were engaged in discussions about their views on medications, whilst other participants reported that discussions about their concerns towards medications and goals was limited.Conclusions: This study suggests that a CCDSS, such as G-MEDSS, demonstrates good utility to assist ACPs to identify and assess anticholinergic and sedative medications. Given the mixed feedback from the ACPs on the different components of the G-MEDSS, further refinement of these tools and their use in combination in practice may be needed. [ABSTRACT FROM AUTHOR]

A cohesive, national approach is needed to address inappropriate polypharmacy in older adults and promote deprescribing. We describe the dissemination of the Quality Use of Medicines to Optimise Ageing in Older Australians: Recommendations for a National Strategic Action Plan to Reduce Inappropriate Polypharmacy, and the initiatives taken to date that align with, and assist in operationalising this plan. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES: Use of harmful and/or unnecessary medications in older adults is common. Understanding older adult and caregiver attitudes toward deprescribing will contribute to medication optimization in practice. The aims of this study were to capture the attitudes and beliefs of older adults and caregivers toward deprescribing and determine what participant characteristics and/or attitudes (if any) predicted reported willingness to have a medication deprescribed. DESIGN: Self‐completed questionnaire. SETTING: Australia. PARTICIPANTS: Older adults (n = 386), 65 years or older, taking one or more regular prescription medications and caregivers of older adults (n = 205) who could self‐complete a written questionnaire in English. MEASUREMENTS: Older adult and caregiver versions of the validated revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire were completed. The rPATD includes two global questions and four factors: perceived burden of medications, belief in appropriateness of medications, concerns about stopping, and involvement in medication management. Participant characteristics, self‐rated health, trust in physician, and health autonomy were also collected. RESULTS: Older adult participants had a median age of 74 years (interquartile range [IQR] = 70‐81 y), and caregivers were aged 67 years (IQR = 59‐76) and were caring for a person aged 81 years (IQR = 75‐86.25 y). Most of both older adults (88%) and caregivers (84%) agreed or strongly agreed that they would be willing to stop one or more of their or their care recipient's medications if their or their care recipient's doctor said it was possible. In a binary logistic regression model, a low concern about stopping factor score was the strongest predictor of willingness to have a medication deprescribed in older adults (odds ratio [OR] = 0.12; 95% confidence interval [CI] = 0.04‐0.34). Excellent/good rating of physical health was the strongest predictor in caregivers (OR = 3.71; 95% CI = 1.13‐12.23). CONCLUSIONS: Most older adults and caregivers are willing to have one of their or their care recipient's medication deprescribed, although different predictors (characteristics/attitudes) of this willingness were identified in these two groups. [ABSTRACT FROM AUTHOR]

Psychotropic medications have a high risk of serious adverse events and small effect size for changed behaviours for people with dementia. Non-pharmacological approaches are recommended as first-line treatment for changed behaviours, yet psychotropic medications remain highly prevalent in long-term aged care settings. This narrative review describes the current evidence regarding deprescribing psychotropic medications for people with dementia in long-term care. Deprescribing psychotropic medications can be achieved without harm to the person with dementia, and most people experience no withdrawal symptoms. Interventions to deprescribe psychotropic medications should be multifactorial, including lowering the dose of the medication over time, educational interventions and psychological support. However, implementing this is a significant challenge due to the overreliance on psychotropic medications for behavioural management in long-term aged care. Facilitators to deprescribing psychotropic medications in long-term care include multidisciplinary teams with adequate training, education and managerial support, engaging residents and families and change 'champions'. Deprescribing practices should be person-centred, and an individualised deprescribing protocol should be in place, followed by careful monitoring of the individual. The person with dementia and their family, general practitioner, pharmacist, and allied health and direct care staff should all be involved throughout the deprescribing process. Direct care staff need adequate support, education and training, so they can effectively help the individual and implement person-centred approaches in the absence of psychotropic medications. Effective communication between residents and staff and amongst staff is consistently shown to be an important factor for deciding whether deprescribing of a medication should occur and the successful implementation of deprescribing psychotropic medications. [ABSTRACT FROM AUTHOR]

Objectives: (i) To develop a version of the revised Patients' Attitude Towards Deprescribing (rPATD) questionnaire for people with mild cognitive impairment (MCI) and mild‐to‐moderate dementia (rPATDcog); and (ii) to capture the beliefs and attitudes of this population and their carers about deprescribing through a pilot study. Methods: First, the rPATDcog was modified from the rPATD and tested in a small group of participants with MCI or mild dementia, and then, we conducted a pilot study of the rPATDcog and the carers' rPATD. Results: Twenty‐one participants with cognitive impairment and 11 carer participants (forming dyads) participated in this study. Eighty‐one per cent (17/21) of participants said that they would stop one or more of their medications if their doctor said it was possible. There was an excellent agreement of corresponding questions between dyads. Conclusion: The rPATDcog was feasible to administer in this study. Further work is required to provide generalisable results and determine utility in practice. [ABSTRACT FROM AUTHOR]

Benzodiazepines (BZDs; including the related Z-drugs) are frequently targets for deprescribing; long-term use in older people is harmful and often not beneficial. BZDs can result in significant harms, including falls, fractures, cognitive impairment, car crashes and a significant financial and legal burden to society. Deprescribing BZDs is problematic due to a complex interaction of drug, patient, physician and systematic barriers, including concern about a potentially distressing but rarely fatal withdrawal syndrome. Multiple studies have trialled interventions to deprescribe BZDs in older people and are discussed in this narrative review. Reported success rates of deprescribing BZD interventions range between 27 and 80%, and this variability can be attributed to heterogeneity of methodological approaches and limited generalisability to cognitively impaired patients. Interventions targeting the patient and/or carer include raising awareness (direct-to-consumer education, minimal interventions, and ‘one-off’ geriatrician counselling) and resourcing the patient (gradual dose reduction [GDR] with or without cognitive behavioural therapy, teaching relaxation techniques, and sleep hygiene). These are effective if the patient is motivated to cease and is not significantly cognitively impaired. Interventions targeted to physicians include prescribing interventions by audit, algorithm or medication review, and providing supervised GDR in combination with medication substitution. Pharmacists have less frequently been the targets for studies, but have key roles in several multifaceted interventions. Interventions are evaluated according to the Behaviour Change Wheel. Research supports trialling a stepwise approach in the cognitively intact older person, but having a low threshold to use less-consultative methods in patients with dementia. Several resources are available to support deprescribing of BZDs in clinical practice, including online protocols. [ABSTRACT FROM AUTHOR]

Frailty is associated with greater exposure to polypharmacy and medicines with anticholinergic and sedative effects, which may increase the risk of adverse outcomes including falls. People who are frail experience a higher incidence and severity of adverse drug events because of their medicine use and potential changes in pharmacokinetics and pharmacodynamics. Prescribing for these patients requires constant vigilance and review, considering the impact of every medicine, as well as overall drug load, comorbidities, function and goals of care. [ABSTRACT FROM AUTHOR]

Anticholinergic medications are frequently used in older adults to manage a wide range of chronic diseases. Anticholinergic burden associated with the use of multiple medications with anticholinergic effects is cumulative within an individual, and older adults are particularly susceptible to the adverse effects of these medications. These include dry mouth resulting in poor oral health, constipation, urinary retention and confusion. Use of anticholinergic medications has been associated with impaired cognitive and physical function, increased risk of falls, vascular events and hospitalisation. Consideration of anticholinergic burden is an important component of medication management for older adults. Several measures have been developed and validated to quantify anticholinergic burden, such as the Anticholinergic Drug Scale, Anticholinergic Risk Scale and the Anticholinergic Cognitive Burden scale. However, the evidence for translation of these measures into clinical practice is limited. This narrative review provides a brief clinical overview of the pharmacology of anticholinergic medications in the context of older adults, summarises approaches to measure anticholinergic burden, reviews recent evidence of the clinical impact of anticholinergic medications and discusses deprescribing strategies to manage anticholinergic burden for older adults in clinical practice. [ABSTRACT FROM AUTHOR]

Purpose: There has been recent interest in deprescribing, particularly among older people. No previous studies have assessed whether residents of aged care facilities are willing to have their medications deprescribed. Understanding residents' attitudes toward deprescribing is important for developing deprescribing interventions.Objective: To investigate residents' willingness to have their medications deprescribed.Methods: This was a cross-sectional survey of 232 residents aged ≥65 years from six residential aged care facilities (RACFs) across metropolitan and regional South Australia. Overall, 163 of the 232 residents (70.3%) took ≥9 regular medications. All participants completed the 10-item Patients' Attitudes Towards Deprescribing (PATD) questionnaire.Results: Overall, 40.5% of residents reported a desire to stop taking one or more of their medications. If their doctor said it was possible, 78.9% of residents were willing to have one or more of their medications deprescribed. Residents taking ≥9 medications were more likely to feel that they were taking a large number of medications compared to residents taking <9 medications (50.3% vs 14.5%, P < 0.01), and were more likely to believe one or more of their medications was causing side effects (14.7% vs 10.1%, P = 0.02). However, residents taking ≥9 regular medications were not significantly more likely to want to reduce their number of medications than residents taking <9 medications.Conclusions: Deprescribing interventions are likely to be acceptable to residents' of RACFs, with a high willingness to discontinue medicines if doctors say it is possible. This highlights the importance of the proactive involvement of health care professionals in an individualized deprescribing process. [ABSTRACT FROM AUTHOR]

The process of a health professional withdrawing medicines for which the current risk may outweigh the benefit in the individual patient has been given a variety of names including the colloquial ‘geriatrician’s salute’, ‘de-intensification’ and increasingly ‘deprescribing’. The rise of deprescribing as a word with a definition, evidence base and implementation plan, reflects the changing environment in which we practice. In particular, the emphasis on evidence-based medicine and the need to care for our expanding ageing populations, which requires application of components of geriatric evaluation and management by a wider range of health care practitioners. However, there are still significant challenges related to research on the safety, efficacy and implementation of deprescribing. In this commentary, we discuss the current evidence on the effects of deprescribing, emergence of implementation tools to embed deprescribing into the clinical care of older adults, as well as efforts to develop guidelines to improve health care practitioners’ awareness and self-efficacy of deprescribing. Ultimately, judicious prescribing and deprescribing, across a wide range of health care settings, ought to enable older people to use medicines to support their achievable ageing goals. [ABSTRACT FROM AUTHOR]

Anticholinergic and sedative medications are commonly used in older adults and are associated with adverse clinical outcomes. The Drug Burden Index was developed to measure the cumulative exposure to these medications in older adults and its impact on physical and cognitive function. This narrative review discusses the research and clinical applications of the Drug Burden Index, and its advantages and limitations, compared with other pharmacologically developed measures of high-risk prescribing. [ABSTRACT FROM AUTHOR]

Polypharmacy (use of ≥5 concurrent medications) is highly prevalent among older adults to manage chronic diseases and is linked to adverse geriatric outcomes, including physical and cognitive functional impairments, falls, frailty, hospitalization, and mortality. Deprescribing (withdrawal) is a potential strategy to manage polypharmacy. The broad molecular changes by which polypharmacy causes harm and deprescribing may be beneficial are unknown and unfeasible to study rigorously in tissue from geriatric patients. Therefore, in a randomized controlled trial, we administered therapeutic doses of commonly used chronic medications (oxycodone, oxybutynin, citalopram, simvastatin, or metoprolol) as monotherapy or concurrently (polypharmacy) from middle‐age (12 months) to old‐age (26 months) to male C57BL/6J (B6) mice and deprescribed (gradually withdrew) treatments in a subset from age 21 months. We compared drug‐related hepatic effects by applying proteomics along with transcriptomics and histology. We found that monotherapy effects on hepatic proteomics were limited but significant changes were seen with polypharmacy (93% unique to polypharmacy). Polypharmacy altered the hepatic expression of proteins involved in immunity, and in drug, cholesterol, and amino acid metabolism, accompanied by higher serum drug levels than monotherapies. Deprescribing not only reversed some effects but also caused irreversible and novel changes in the hepatic proteome. Furthermore, our study identified several hepatic protein co‐expressed modules that are associated with clinically relevant adverse geriatric outcomes, such as mobility, frailty, and activities of daily living. This study highlights the complex molecular changes following aging, chronic polypharmacy, and deprescribing. Further exploration of these mechanistic pathways may inform management of polypharmacy and deprescribing in older adults. [ABSTRACT FROM AUTHOR]

N-of-1 trials may provide insights into the impact of deprescribing medications in populations where evidence is currently lacking, such as the effect of statins on cognition in people with dementia. For this pilot, N-of-1, double-blinded, deprescribing trial, adults over 80 years of age with dementia taking statins for at least 6-months were recruited from a hospital's geriatric medicine outpatient clinic in Sydney, Australia. Participants discontinued and restarted statins over the study period. At enrolment, the hospital pharmacy—using a random number generator, randomised recruited participants to their usual statin or placebo regimen, with assessment and switching of treatment every 5 weeks from baseline (0-weeks) until Visit 4 (15-weeks). Primary outcome was measured using the rate of change in Alzheimer's Disease Assessment Score-Cognitive Subscale (ADAS-CoG). Over 6-months, 81 participants were screened, 14 were eligible, and four were randomised. One participant (female, 88 years) completed all four assessments with no major harms reported. Cognitive impairment, as measured by ADAS-CoG score, was similar on placebo (15.5/70) compared to statin (15/70). This study suggests there are significant challenges in performing N-of-1 trials and recruiting people with dementia into deprescribing trials from outpatient settings. [ABSTRACT FROM AUTHOR]

Antihypertensive drugs are commonly used by older adults because of the high prevalence of cardiovascular disease and its risk factors, and the increased absolute benefit of blood pressure reduction with increasing age. Clinical trials of blood pressure reduction in older adults have generally excluded older adults with multimorbidity, frailty and limited life expectancy. In this population, the benefit-harm ratio of aggressive blood pressure lowering may become unfavourable; a more relaxed blood pressure target may be appropriate; and deprescribing (cessation or dose reduction) of one or more antihypertensive drugs can be considered. Before deprescribing an antihypertensive drug, it is important to consider other indications for which it may have been prescribed (e.g. heart failure with reduced ejection fraction, diabetic nephropathy, atrial fibrillation). Evidence from randomised controlled deprescribing trials indicates that it is possible to deprescribe antihypertensives in frail older people. However, some patients may experience an increase in blood pressure that warrants restarting the drug. There are limited data on long-term outcomes (follow-up in deprescribing trials ranged from 4 to 56 weeks). The risk of adverse outcomes associated with deprescribing, such as withdrawal effects, can be minimised through appropriate planning, patient engagement, dose tapering and monitoring. [ABSTRACT FROM AUTHOR]

Anticholinergic burden is detrimental to cognitive health. Multiple studies found that a high anticholinergic burden is associated with an increased risk for dementia, changes to the brain structure, function, and cognitive decline. We performed a post hoc analysis of a randomized controlled deprescribing trial. We compared the effect of the intervention on baseline anticholinergic burden across the treatment and control groups and the time of recruitment before and after a lockdown due to the COVID pandemic with subgroup analyses by baseline frailty index. Randomized controlled trial. We analyzed data from a de-prescribing trial of older adults (>65 years) previously conducted in New Zealand that was focused on reducing the Drug Burden Index (DBI). We used the anticholinergic cognitive burden (ACB) to quantify the impact of the intervention on reducing the anticholinergic burden. Participants not taking anticholinergics at the start of the trial were excluded. The primary outcome for this subgroup analysis was a change in ACB, measured with the ĝ Hedges statistic describing the difference in standard deviation units of this change between intervention and control. For this analysis, the trial participants were stratified into low, medium, and high frailty and timing into prior- and post-lockdown (public health measures for COVID-19). Among the 295 participants in this analysis, the median (IQR) age was 79 (74, 85), and 67% were women. For the primary outcome ĝ Hedges = −0.04 (95% CI −0.26 to 0.19) with a −0.23 mean reduction in ACB in the intervention arm and −0.19 in the control arm. Before lockdown ĝ Hedges = −0.38 (95% CI −0.84 to 0.04) and post-lockdown ĝ Hedges = 0.07 (95% CI −0.19 to 0.33). The mean change in ACB for each of the frailty strata was as follows: low frailty (−0.02; 95% CI −0.65 to 0.18); medium frailty (0.05; 95% CI −0.28 to 0.38); high frailty (0.08; 95% CI −0.40 to 0.56). The study did not provide evidence for the effect of pharmacist deprescribing intervention on reducing the anticholinergic burden. However, this post hoc analysis examined the impact of COVID on the effectiveness of the intervention, and further research in this area may be warranted. [ABSTRACT FROM AUTHOR]

The Drug Burden Index (DBI) calculates a person's exposure to anticholinergic and sedative medications. We aimed to review randomized controlled trials (RCTs) of deprescribing interventions that reported the DBI as an outcome, their characteristics, effectiveness in reducing the DBI, and impact on other outcomes. Systematic review with meta-analysis. RCTs of deprescribing interventions where the DBI was measured as a primary or secondary outcome in humans within any setting were included. Electronic databases, citation indexes, and gray literature were searched from April 1, 2007, to September 1, 2023. Quality was assessed using the Cochrane risk-of-bias tool. Of 1721 records identified, 9 met the inclusion criteria. Six interventions were delivered by pharmacists and 3 were delivered by pharmacists/nurses or pharmacists/geriatricians. All interventions required at least intermediate-level skills and involved multiple components and target groups. Studies were conducted in the community (n = 5), nursing homes (n = 2), and hospitals (n = 2). The mean or median age was ≥75 years and most participants were women in all studies. Most (n = 6) studies were underpowered. The follow-up period ranged from 3 to 12 months. Three studies reported a lower DBI in the intervention group compared with control: 1 pharmacist independent prescriber-delivered in nursing homes (adjusted rate ratio, 0.83; 95% CI, 0.74 to 0.92), 1 pharmacist/nurse practitioner-delivered in hospital (adjusted mean difference (MD), −0.28; 95% CI, –0.51 to −0.04), and 1 geriatrician/pharmacist-delivered in hospital (MD, –0.28; 95% CI, –0.52 to −0.04). Meta-analysis showed no difference in the change in DBI between control and intervention groups in the community including nursing homes (MD, −0.03; 95% CI, −0.08 to 0.01) or hospital setting (MD, −0.19; 95% CI, −0.45 to 0.06). Interventions had inconsistent effects on cognition and no effect on other reported outcomes. RCTs of deprescribing interventions had no significant impact on reducing DBI or improving outcomes. Further suitably powered studies are required. [ABSTRACT FROM AUTHOR]

The structured, clinically supervised withdrawal of medicines, known as deprescribing, is one strategy to address inappropriate polypharmacy. This study aimed to evaluate the costs and consequences of deprescribing in frail older people living in residential aged care facilities (RACFs) in Australia. A within-trial cost-consequence analysis of a deprescribing intervention—Opti-Med. The Opti-Med double-blind randomized controlled trial of deprescribing included 3 groups: blinded control, blinded intervention, and an open intervention group. Seventeen RACFs in Western Australia and New South Wales. Participants were 303 older people living in participating RACFs from March 2014 to February 2019. Analysis was conducted from the health sector perspective. Health economic outcomes assessed include cost saved from deprescribed medicines and the incremental quality-adjusted life-years. Costs were presented in 2022 Australian dollars. The total cost of the Opti-Med intervention was $239.13 per participant. The costs saved through deprescribed medicines over 12 months after adjusting for mortality within the trial period was $328.90 per participant in the blinded intervention group and $164.00 per participant in the open intervention group. On average, the cost of the intervention was more than offset by the cost saved from deprescribed medicines. Extrapolating these findings to the Australian population suggests a potential net cost saving of about $1 to $16 million per annum for the health system nationally. The incremental quality-adjusted life-years were very similar across the 3 groups within the trial period. Deprescribing for frail older people living in RACFs can be a cost-saving intervention without reducing the quality of life. Systemwide implementation of deprescribing across RACFs in Australia has the potential to improve health care delivery through the cost savings, which could be reapplied to further optimize care within RACFs. [ABSTRACT FROM AUTHOR]

• Residents in residential aged care facilities are taking unnecessary medications that have the potential to cause harm. • Pharmacists and GPs, as part of a multidisciplinary team, are well-positioned to evaluate polypharmacy and improve patient outcomes through deprescribing to reduce inappropriate polypharmacy. • Pharmacist-led deprescribing recommendations arising from an algorithm-based medication review are acceptable to doctors and can have a significant impact on the number of inappropriate medications consumed by older people. Deprescribing is an intervention to address the high prevalence of inappropriate polypharmacy in older people living in residential aged care facilities (RACFs). Many deprescribing interventions are complex and involve several stages including initial pharmacist recommendation, subsequent acceptance of the recommendations by a prescriber and the patient, and then actual implementation. This study aimed to investigate pharmacist deprescribing recommendations for residents within RACFs, general practitioner (GP) acceptance, and the actual implementation of the accepted recommendations at 12-month. The intervention occurred as part of a randomised controlled trial and comprised a pharmacist-led medication review using an evidence-based algorithm, with the focus on identifying medications to potentially deprescribe. Consent to participate was obtained from residents (or surrogate decision-makers), RACF nursing staff and the resident's GP. Deprescribing recommendations were reviewed by GPs before implementation as part of the intervention and control arms of the trial, although control group participants continued to receive their usual medications in a blinded manner. There were 303 participants enrolled in the study, and 77% (941/1222) of deprescribing recommendations suggested by the pharmacists were accepted by GPs. Of the recommendations accepted by GPs, 74% (692/ 941) were successfully implemented at the end of the follow-up visit at 12 months. The most common reason for deprescribing was because medications were no longer needed (42%, 513/ 1231). Pharmacist-led deprescribing recommendations arising from an algorithm-based medication review are acceptable to doctors and can have a significant impact on reducing the number of inappropriate medications consumed by older people in RACFs. Australian New Zealand Clinical Trials Registry ACTRN12613001204730 [ABSTRACT FROM AUTHOR]