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Background: Motivating patients to discontinue long-term benzodiazepine receptor agonist (BZRA) use for insomnia remains an important challenge in primary care because of the medication's unfavourable risk-benefit profile. Previous studies have shown that understanding the complexity of patients' motivation is crucial to the primary care physician for providing effective interventions efficiently. Theoretical frameworks about behaviour change show that motivation is a multi-layered concept that interacts with other concepts, which aligns with a holistic perspective or implementation of the biopsychosocial model. Aim: Exploring primary care patients’ views and ideas on what factors helped or hindered them in discontinuing long-term BZRA use, in relation to motivation as conceptualised in the Behaviour Change Wheel, and associated domains of the Theoretical Domains Framework. Design and setting: A qualitative study with semi-structured interviews in primary care in Belgium between September 2020 and March 2021. Method: Eighteen interviews with long-term hypnotic users were audio recorded, transcribed and thematically analyzed, using the Framework Method. Results: The success of discontinuation interventions does not solely rely on patients’ spontaneous sense of striving for improvement. Reinforcement and identity were found to be important domains for motivation. Beliefs about personal capabilities, and about consequences of both BZRA intake and discontinuation, differed between previous and current users. Conclusion: Motivation is a multi-layered concept which is not fixed in time. Patient empowerment and goal setting could help long-term BZRA users to lower their intake. As well as public health interventions that might change social attitudes towards the use of hypnotic medication.

Purpose Opportunities exist to meaningfully reduce suboptimal prescription opioid use among older adults. Deprescribing is one possible approach to reducing suboptimal use. Appropriate interventions should outline how to carefully taper opioids, closely monitor adverse events, substitute viable alternative and affordable nonopioid pain treatments, and initiate medications for opioid use disorder to properly manage use disorders, as needed. We sought to document and understand provider perceptions to begin developing effective and safe opioid deprescribing interventions. Methods We conducted 3 semistructured focus groups that covered topics such as participant perspectives on opioid deprescribing in older adults, how to design an ideal intervention, and how to identify potential barriers or facilitators in implementing an intervention. Focus group transcripts were double coded and qualitatively analyzed to identify overarching themes. Results Healthcare providers (n = 17), including physicians, pharmacists, nurses, social workers, and administrative staff, participated in 3 focus groups. We identified 4 key themes: (1) involve pharmacists in deprescribing and empower them as leaders of an opioid deprescribing service; (2) ensure tight integration and close collaboration throughout the deprescribing process from the inpatient to outpatient settings; (3) more expansive inclusion criteria than age alone; and (4) provision of access to alternative pharmacological and nonpharmacological pain management modalities to patients. Conclusion Our findings, which highlight various healthcare provider beliefs about opioid deprescribing interventions, are expected to serve as a framework for other organizations to develop and implement interventions. Future studies should incorporate patients' and family caregivers' perspectives. [ABSTRACT FROM AUTHOR]

Introduction: First-line treatment for behavioral and psychiatric symptoms of dementia is non-pharmacological. Still, psychotropic medication is widely used, despite its limited effect and harmful side-effects. More than half of all nursing home residents with dementia receive antidepressants, even though deprescribing is safe and feasible. Interventions to promote deprescribing of antidepressants in nursing homes are few and complex. To optimize the deprescribing process through an intervention, transparency for the development of the intervention is needed. We aim to describe the steps in the development and tailoring of an intervention targeting GPs, nursing home staff, and relatives to enhance collaboration on reducing the use of antidepressants in institutionalized older persons with dementia in Denmark. Method: A step-wise process guided by the core elements in the Medical Research Council constituted the tailoring process. Five steps were included; 1) a literature search, 2) interviews with stakeholders, 3) drafting the intervention prototype, 4) professionals’ assessment of the intervention, and 5) refinement of the intervention. The steps were conducted from June 2020 to June 2022. Results: Based on the literature search, interviews with stakeholders, and professionals’ assessment of the intervention, four main themes were identified; 1) focusing on antidepressants, 2) importance of professional qualifications, 3) collaboration and communication, and 4) patient and relative involvement. They guided intervention development and refinement of the final intervention, which included 1) a case-based training course and 2) a dialog tool including a symptom assessment scale to be used in a structured consultation at the nursing home. Conclusion: This study presents a detailed account of the tailoring process for a complex intervention to optimize deprescribing of antidepressants for older persons with dementia at nursing homes. By presenting a thorough development process, we expect to achieve increased adherence to the intervention which is currently being tested in an ongoing cluster randomized controlled trial. The transparency of the process will also increase the future development of other similar complex interventions. [ABSTRACT FROM AUTHOR]

Background: Deprescribing, or the intentional discontinuation or dose-reduction of medications, is an approach to reduce harms associated with inappropriate medication use. We sought to determine how direct-to-patient educational materials impacted patient-provider discussion about and deprescribing of potentially inappropriate medications. Methods: We conducted a pre-post pilot trial, using an historical control group, at an urban VA medical center. We included patients in one of two cohorts: 1) chronic proton pump inhibitor users (PPI), defined as use of any dose for 90 consecutive days, or 2) patients at hypoglycemia risk, defined by diabetes diagnosis; prescription for insulin or sulfonylurea; hemoglobin A1c < 7%; and age ≥ 65 years, renal insufficiency, or cognitive impairment. The intervention consisted of mailing medication-specific patient-centered EMPOWER (Eliminating Medications Through Patient Ownership of End Results) brochures, adapted to a Veteran patient population, two weeks prior to scheduled primary care appointments. Our primary outcome – deprescribing – was defined as clinical documentation of target medication discontinuation or dose-reduction. Our secondary outcome was documentation of a discussion about the target medication (yes/possible vs. no/absent). Covariates included age, sex, race, specified comorbidities, medications, and utilization. We used chi-square tests to examine the association of receiving brochures with each outcome. Results: The 348 subjects (253 intervention, 95 historical control) were primarily age ≥ 65 years, white, and male. Compared to control subjects, intervention subjects were more likely to have deprescribing (36 [14.2%] vs. 4 [4.2%], p = 0.009) and discussions about the target medication (31 [12.3%] vs. 1 [1.1%], p = 0.001). Conclusions: Targeted mailings of EMPOWER brochures temporally linked to a scheduled visit in primary care clinics are a low-cost, low-technology method associated with increases in both deprescribing and documentation of patient-provider medication discussions in a Veteran population. Leveraging the potential for patients to initiate deprescribing discussions within clinical encounters is a promising strategy to reduce drug burden and decrease adverse drug effects and harms. [ABSTRACT FROM AUTHOR]

The high prevalence of polypharmacy and potentially inappropriate medications in the elderly makes them a vulnerable group to adverse drug events. Deprescribing is the medication review plus cessation of potentially inappropriate medications with a health professional's help. Several barriers and enablers influence it, and its knowledge can help health professionals. The objective of the study is to understand the Portuguese elderly's attitudes and ideas about polypharmacy and deprescription. We made a qualitative approach through a focus group with elderly patients from an adult daycare center with transcription and codification into themes and subthemes based on previous frameworks. Eleven elderly patients participated in the focus group. The identified elderly's ideas and attitudes could be clustered into five main barriers: appropriateness, process, influences, fear, and habit, and five main enablers: appropriateness, process, influences, dislike, and cost. Although the elderly's strong beliefs regarding medication benefits and necessity prevail, contrary opinions regarding lack of benefit/necessity, drug interaction/side effects, and medication complexity/number may influence their willingness to deprescribe positively. The health professional's influence and the patient's trust in their doctors were perceived essential for decision-making as either a barrier or an enabler. The medication benefit was a big barrier, and side effects/drug interaction experiences are an important enabler. [ABSTRACT FROM AUTHOR]

Abstract Background Deprescribing literature has been increasing rapidly. Our aim was to develop and validate search filters to identify articles on deprescribing in Medline via PubMed and in Embase via Embase.com . Methods Articles published from 2011 to 2020 in a core set of eight journals (covering fields of interest for deprescribing, such as geriatrics, pharmacology and primary care) formed a reference set. Each article was screened independently in duplicate and classified as relevant or non-relevant to deprescribing. Relevant terms were identified by term frequency analysis in a 70% subset of the reference set. Selected title and abstract terms, MeSH terms and Emtree terms were combined to develop two highly sensitive filters for Medline via Pubmed and Embase via Embase.com . The filters were validated against the remaining 30% of the reference set. Sensitivity, specificity and precision were calculated with their 95% confidence intervals (95% CI). Results A total of 23,741 articles were aggregated in the reference set, and 224 were classified as relevant to deprescribing. A total of 34 terms and 4 MeSH terms were identified to develop the Medline search filter. A total of 27 terms and 6 Emtree terms were identified to develop the Embase search filter. The sensitivity was 92% (95% CI: 83–97%) in Medline via Pubmed and 91% (95% CI: 82–96%) in Embase via Embase.com . Conclusions These are the first deprescribing search filters that have been developed objectively and validated. These filters can be used in search strategies for future deprescribing reviews. Further prospective studies are needed to assess their effectiveness and efficiency when used in systematic reviews.

Abstract Background Inappropriately using proton pump inhibitors (PPI) is associated with severe adverse drug reactions and may have major consequences on healthcare costs. Deprescribing (the process by which a healthcare professional supervises the withdrawal of an inappropriate medication, to manage polypharmacy and improve outcomes) should be considered when an inappropriate PPI prescription is identified. Deprescribing interventions directed solely to prescribers have limited efficacy and are rarely targeted to patients. The aim of this trial is to assess the efficacy of a multi-faceted intervention with patients and general practitioners (GPs) to deprescribe PPI. Methods We will conduct a pragmatic, cluster-randomized, population-based, controlled trial in two regions of Western France. GPs with practices with over 100 patients, and their adult patient to whom over 300 defined daily doses (DDD) of PPIs have been dispensed in the year before baseline will be included. A total of 1300 GPs and 33,000 patients will be cluster-randomized by GPs practices. Three arms will be compared: i) a multi-faceted intervention associating a) a patient education brochure about PPI deprescribing sent directly to patients (the brochure was designed using a mixed-methods study), and b) a personalized letter with the Bruyere’s PPI deprescribing algorithm sent to their respective GPs, or ii) a single intervention where only the GPs received the letter and algorithm, or iii) no intervention. The primary outcome will be PPI deprescribing, defined as the proportion of patients achieving at least a 50% decrease in the amount of PPI dispensed to them (DDD/year) at 12 months compared to baseline. Secondary outcomes will include incremental cost-utility ratio (using EQ-5D-5L scale and National Health Insurance’s database), acid rebound (using the Gastroesophageal Reflux Disease Impact Scale), and the patients’ attitudes towards deprescribing (using the French rPATD). Discussion Based on previous trials, we anticipate more than 10% “successful PPI deprescribing” in the multi-faceted intervention compared to the single intervention on GPs and the control arm. The study has been funded through a national grant and will be launched in autumn 2020, for early results by the end of 2022. Trial registration Clinicaltrials.gov NCT04255823 ; first registered on February 5, 2020.

INTRODUCTION:3,4-diaminopyridine has been used to treat Lambert-Eaton myasthenia (LEM) for 30 years despite the lack of conclusive evidence of efficacy. METHODS:We conducted a randomized double-blind placebo-controlled withdrawal study in patients with LEM who had been on stable regimens of 3,4-diaminopyridine base (3,4-DAP) for ≥ 3 months. The primary efficacy endpoint was >30% deterioration in triple timed up-and-go (3TUG) times during tapered drug withdrawal. The secondary endpoint was self-assessment of LEM-related weakness (W-SAS). RESULTS:Thirty-two participants were randomized to continuous 3,4-DAP or placebo groups. None of the 14 participants who received continuous 3,4-DAP had > 30% deterioration in 3TUG time versus 72% of the 18 who tapered to placebo (P

In many jurisdictions pharmacists share prescribing responsibilities with other members of the primary care team. Responsibility for deprescribing, the healthcare professional supervised withdrawal of medications that are no longer needed, has not been assumed by a specific member of the primary care team. In this commentary we describe implementation of pharmacist-led deprescribing in collaborative primary care settings using the seven components of knowledge translation. Patient and stakeholder engagement shaped the deprescribing intervention. The intervention was implemented in three collaborative primary care clinics in two Canadian provinces. The evaluation included measures of medication appropriateness, patient satisfaction, and healthcare professional satisfaction. Pharmacist-led deprescribing in primary care was acceptable to both patients and healthcare professionals and demonstrated a reduction of medications deemed to confer more risk than benefit. Our findings support successes in pharmacist-led deprescribing. Future work is needed to understand how to successfully implement and evaluate pharmacist-led deprescribing more widely. [ABSTRACT FROM AUTHOR]

Most recently, a Canadian cluster RCT enrolled 5698 patients aged 65 years or over who were admitted to 11 hospitals and were taking five or more medications daily.11 Personalised deprescribing suggestions were generated for the hospital physician, community pharmacist and usual attending doctor by a computerised decision tool (MedSafer). Keywords: Deprescriptions; Pharmacoepidemiology; Quality of health care EN Deprescriptions Pharmacoepidemiology Quality of health care 283 286 4 09/20/22 20220915 NES 220915 Ceasing unnecessary medications is a worthy act, but impacts on clinical outcomes are proving elusive The burden and costs of potentially inappropriate medications (PIMs) and polypharmacy are major public health challenges. B Insensitive outcome measures: b While adverse drug events are important, other relevant outcomes such as medication burden may not be reliably measured, and multifactorial outcomes such as quality of life and falls may be insensitive to change by an intervention targeting only one of many contributors. Machine learning applied to large-scale clinical trial or pharmacovigilance data are identifying patient phenotypes at greater risk of medication-specific harm to whom deprescribing interventions could be targeted.21,22 Fourth, sensitive medication-related quality of life measures relevant to both medication class-specific effects and individual goals of care may be better able to detect subtle but important patient-centred outcomes.23 Finally, n-of-1 trials, in which patients act as their own control during randomised cycles of exposure to a drug or placebo, may provide more nuanced assessment of deprescribing effects in individuals. [Extracted from the article]

Background: Older adults commonly experience chronic medical conditions and are at risk of cognitive impairment as a result of age, chronic comorbidity, and medications prescribed to manage multiple chronic conditions. Anticholinergic medications are common treatments for chronic conditions and have been repeatedly associated with poor cognitive outcomes, including delirium and dementia, in epidemiologic studies. However, no study has definitively evaluated the causal relationship between anticholinergics and cognition in a randomized controlled trial design. Utilizing our prior experience in deprescribing anticholinergic medications in various clinical environments, we designed an outpatient deprescribing intervention to prospectively test the potential causal relationship between anticholinergics and cognition in primary care older adults., Methods: This cluster randomized clinical trial will be conducted to evaluate the impact of an anticholinergic deprescribing intervention compared to usual care on outcomes of cognition and safety in primary care older adults. Participants will include those aged 65 years and over, receiving primary care in the greater Indianapolis area, using a strong anticholinergic within the last 2 weeks or with evidence of high-risk exposure in the past year. Those excluded will have a diagnosis of Alzheimer's disease or related dementia, or serious mental illness. The trial plans to enroll 344 participants who will be cluster-randomized at the level of primary care physician to avoid contamination. Participants will complete outcome assessments every 6 months up to 2 years by blinded outcome assessors. The primary outcome of the study is a composite measure of cognition that includes domains assessing executive cognitive function, language, and memory. Secondary outcomes include patient-reported measures of pain intensity, depression, anxiety, sleep disturbance, and health-related quality of life., Discussion: The R2D2 trial will be the largest and longest prospective randomized trial testing the impact of an anticholinergic-specific deprescribing intervention on cognition in primary care older adults. Results could influence deprescribing methodology and provide new insight on the relationship between anticholinergics and cognition., Trial Registration: ClinicalTrials.gov NCT04270474. Registered on February 17, 2020., Competing Interests: Declarations. Ethics approval and consent to participate: All procedures have received and maintained ethical approval from the Institutional Review Board of the Indiana University (IRB# 1811254189; Federal-Wide Assurance Number, FWA00003544). The trial has also been registered at ClinicalTrials.gov (Identifier: NCT04270474). Consent for publication: Not applicable—no identifying images or other personal or clinical details of individual participants are presented here or will be presented in reports of the trial results. The participant information materials and informed consent form are available from the corresponding author on request. Competing interests: Dr. Boustani serves as a Chief Scientific Officer and co-Founder of Blue Agilis; the Chief Health Officer of DigiCare Realized, Inc; and the Chief Health Officer of Mozyne Health, Inc. He has equity interest in Blue Agilis, Inc; DigiCare Realized, Inc; and Mozyne Health, Inc. He sold his equity in Preferred Population Health Management LLC and MyShift, Inc (previously known as RestUp, LLC). He serves as an advisory board member or consultant for Eli Lilly and Co; Eisai, Inc; Merck & Co Inc; Biogen Inc; and Genentech Inc. These conflicts have been reviewed by Indiana University and has been appropriately managed to maintain objectivity. All other authors report no conflicts of interest., (© 2024. The Author(s).)

Objectives: To examine healthcare provider-related perceptions toward deprescribing inappropriate medications among older adults., Methods: A cross-sectional, correlational study used a convenience sample of outpatient older adults to measure their perception toward deprescribing using a Patient's Perceptions of Deprescribing (PPoD), which include 57 multiple-choice questions related to patients' sociodemographic data, health, medicines, healthcare providers, and experience of care provided by the clinic. Data were collected by a graduate nursing student from one pharmacy in a public hospital, five days per week, via in-person interviews., Results: Data were analyzed for 200 participants. The level of patient collaboration with their primary care providers (PCPs) is linked to their trust in PCPs, beliefs about medication use, PCP knowledge, and medication concerns (p < .0001). Patient involvement in medication deprescribing decision-making is also associated with trust in PCPs and willingness to stop a medication (p < .0001). Additionally, trust in PCPs is related to patient involvement in decision-making, PCP knowledge, general health, collaboration with PCPs, and receiving conflicting information about a medicine (p = .010). Lastly, PCP medication knowledge is associated with trust in PCPs, views on the importance of medicines, medication concerns, seeking help with medicines, interactions with clinical pharmacists, and being advised by a clinical pharmacist to discontinue medication (p < .0001)., Conclusions: The study found that older adults' trust in their PCP, collaboration with their PCP, involvement in the decision-making of deprescribing, and knowledge about medication are associated with clinical and medicine-related factors. Therefore, PCPs should discuss the benefits of deprescribing inappropriate medications to prevent long-term side effects. Future studies should focus on the effectiveness of evidence-based deprescribing protocols for older adults., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Rababa, Ghazo. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Source Citation: Phelan EA, Williamson BD, Balderson BH, et al. Reducing central nervous system-active medications to prevent falls and injuries among older adults: a cluster randomized clinical trial. JAMA Netw Open. 2024;7:e2424234. 39052289., Competing Interests: Disclosures: Disclosure forms are available with the article online.

Approximately one in three older adults (aged 65 years and over) experience pain, negatively impacting their quality of life. Opioid analgesics are commonly prescribed to manage pain; however, balancing the benefits and harms of these high-risk analgesics can be challenging for both healthcare professionals and patients. This is particularly true for older adults, as factors such as polypharmacy, age-related physiological changes and cognitive decline may impact upon opioid safety and efficacy. Deprescribing is the patient-centred process of reducing or discontinuing a medication that is no longer appropriate, or where the risks of continuation are deemed to outweigh the anticipated benefits. Opioid deprescribing has been proposed as a mechanism to reduce individual and societal opioid-related harm; however, to date, research has predominantly focused on the general adult population, rather than older adults. This current opinion aims to summarise the existing opioid deprescribing literature, discussing its applicability for older adults. Drawing on a non-systematic review of the literature, it identifies unique challenges and considerations for this population, highlights international initiatives to enhance opioid deprescribing in clinical practice and proposes future directions to advance the field., Competing Interests: Declarations Funding Open Access funding enabled and organized by CAUL and its Member Institutions. Aili V. Langford and Emily Reeve are supported by National Health and Medical Research Council Investigator Grants (2025289, 1195460), Danijela Gnjidic is supported by a University of Sydney Equity Prize - Thompson Fellowship. Author contribution All authors contributed to the conceptualisation of this article. Aili V. Langford wrote the first draft which was refined with critical input from Carl R. Schneider, Emily Reeve and Danijela Gnjidic. Conflicts of interest/competing interests Aili V. Langford, Carl R. Schneider, Emily Reeve and Danijela Gnjidic have no conflicts of interest that are directly relevant to the content of this article. Ethics approval Not applicable. Consent to participate Not applicable. Consent for publication Not applicable. Availability of data and material Not applicable. Code availability Not applicable., (© 2024. The Author(s).)

Abstract: Proton pump inhibitors (PPIs) are widely used for a number of gastric-acid related diseases. Although these agents demonstrate enhanced efficacy and tolerability compared with other acid-suppressive therapies, long-term use is associated with a number of adverse reactions. This article summarizes appropriate indications for short- and long-term use of PPIs and describes deprescribing strategies that clinicians can use to reduce unnecessary PPI use in their patients., (Copyright © 2024 American Academy of Physician Associates.)

Functional neurological disorder (FND) is common among children and adolescents, results in significant impairments in quality of life, and places a substantial burden on healthcare systems. Despite this, there is minimal literature to guide prescribing for this population. The purpose of this article is to provide common sense prescribing recommendations for providers who treat pediatric FND. A narrative review was conducted by searching PubMed using keywords related to FND and pharmacology. The narrative synthesis was guided by the objective of providing evidence for generally accepted practices and highlighting contributions and gaps in the literature. There is a dearth of evidence, and unique challenges exist in prescribing for pediatric patients with FND. Efforts should be made to limit prescribing and to discontinue, or de-prescribe, medications that may contribute to polypharmacy or overmedicalization of functional symptoms. Pediatric patients with FND require a thoughtful, multidisciplinary approach.

Due to the high prevalence of older individuals with multiple morbidities, polypharmacy, and exposed to unnecessary or inappropriate treatments that can cause potentially serious adverse effects, better medication management should be an objective of all health professionals. This is particularly important in older patients with hypertension. Antihypertensive deprescribing and non-pharmacological strategies have been disseminated as viable and safe alternatives for improving the quality of care for hypertension in the older population., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Importance: Antihypertensive medication deprescribing is common among nursing home residents, yet its association with cognitive decline remains uncertain., Objective: To investigate the association of deprescribing antihypertensive medication with changes in cognitive function in nursing home residents., Design, Setting, and Participants: This cohort study using a target trial emulation approach included VA long-term care residents aged 65 years or older with stays of at least 12 weeks from 2006 to 2019. Residents who were not prescribed antihypertensive medication, with blood pressure greater than 160/90 mm Hg, or with heart failure were excluded. Eligible residents with stable medication use for 4 weeks were classified into deprescribing or stable user groups and followed for 2 years or until death or discharge for intention-to-treat (ITT) analysis. Participants switching treatment groups were censored in the per-protocol analysis. Cognitive function measurements during follow-up were analyzed using an ordinal generalized linear mixed model, adjusting for confounders with inverse probability of treatment weighting. Per-protocol analysis included inverse probability of censoring weighting. Data analyses were performed from May 1, 2023, and July 1, 2024., Exposures: Deprescribing was defined as a reduction in the total number of antihypertensive medications or a decrease in medication dosage by 30%, sustained for a minimum of 2 weeks., Main Outcomes and Measures: Cognitive Function Scale (CFS) was classified as cognitively intact (CFS = 1), mildly impaired (CFS = 2), moderately impaired (CFS = 3), and severely impaired (CFS = 4)., Results: Of 45 183 long-term care residents, 12 644 residents (mean [SD] age 77.7 [8.3] years; 329 [2.6%] females and 12 315 [97.4%] males) and 12 053 residents (mean [SD] age 77.7 [8.3] years; 314 [2.6%] females and 11 739 [97.4%] males) met eligibility for ITT and per-protocol analyses, respectively. At the end of the follow-up, 12.0% of residents had a worsened CFS (higher score) and 7.7% had an improved CFS (lower score) with 10.8% of the deprescribing group and 12.1% of the stable user group showing a worsened CFS score. In the per-protocol analysis, the deprescribing group had a 12% reduction in the odds of progressing to a worse CFS category per 12-week period (odds ratio, 0.88; 95% CI, 0.78-0.99) compared to the stable user group. Among residents with dementia, deprescribing was associated with 16% reduced odds of cognitive decline (odds ratio, 0.84; 95% CI, 0.72-0.98). These patterns remained consistent in the ITT analysis., Conclusions and Relevance: This cohort study indicates that deprescribing is associated with less cognitive decline in nursing home residents, particularly those with dementia. More data are needed to understand the benefits and harms of antihypertensive deprescribing to inform patient-centered medication management in nursing homes.

Importance: Patient-directed educational materials are a promising implementation strategy to expand deprescribing reach and adoption, but little is known about the impact across medication groups with potentially different perceived risks., Objective: To examine the impact of a patient-directed education intervention on clinician deprescribing of potentially low-benefit (proton pump inhibitors) or high-risk medications (high-dose gabapentin, diabetes agents with hypoglycemia risks)., Design, Setting, and Participants: This pragmatic multisite nonrandomized clinical trial took place at 3 geographically distinct US Veterans Affairs (VA) medical centers from April 2021 to October 2022. The total study sample was composed of the intervention cohort and the historical control cohort cared for by 103 primary care practitioners (PCPs)., Intervention: The primary intervention component was a medication-specific brochure, mailed during the intervention time frame to all eligible patients 2 to 3 weeks prior to upcoming primary care appointments. Patients seen by the same PCPs at the same sites 1 year prior to the study intervention served as controls., Main Outcome and Measures: The primary binary outcome variable was deprescribing 6 months after the intervention, defined as complete cessation or any dose reduction of the target medication using VA pharmacy dispensing data., Results: The total study sample included 5071 patients. The overall rate of deprescribing among the intervention cohort (n = 2539) was 29.5% compared with 25.8% among the controls (n = 2532). In an unadjusted model, the intervention cohort was statistically significantly more likely to have deprescribing (odds ratio [OR], 1.17 [95% CI, 1.03-1.33]; P = .02). In a multivariable logistic regression model nesting patients within PCPs within sites and controlling for patient and PCP characteristics, the odds of deprescribing in the intervention cohort were 1.21 times that of the control cohort (95% CI, 1.05-1.38; P = .008). The difference in deprescribing prevalence between the intervention and control cohorts (proton pump inhibitors: 29.4% vs 25.4%; gabapentin: 40.2% vs 36.2%; hypoglycemia risk: 27.3% vs 25.1%) did not statistically significantly differ by medication group (P = .90)., Conclusion and Relevance: This nonrandomized clinical trial found that patient-directed educational materials provided prior to scheduled primary care appointments can effectively promote deprescribing for potentially low-benefit and high-risk medication groups., Trial Registration: ClinicalTrials.gov Identifier: NCT0429490.

Context: Medications may become inappropriate for patients in the last phase of life and may even compromise their quality of life., Objective: To find consensus on recommendations regarding deprescribing of medications for adult patients with a life expectancy of six months or less., Methods: Experts working in palliative care or other relevant disciplines were asked to participate in this international Delphi study. Existing tools for deprescribing of medication in the last phase of life were integrated in a list of 42 recommendations regarding potential deprescription of various medication types. In two Delphi rounds, experts were asked to rate their agreement with each recommendation on a 5-point Likert-scale (strongly agree-strongly disagree). Recommendations were accepted, if at least 70% of the experts (strongly) agreed, the interquartile range (IQR) was one or less, and less than 10% strongly disagreed., Results: About 47 experts from 10 countries participated (response rate 53%). In most cases (76%), consensus was reached on deprescribing recommendations for patients with a life expectancy of six months or less. The highest level of consensus was reached for recommendations on the deprescription of diuretics in case of decreasing fluid intake or increasing fluid loss, lipid modifying agents if prescribed for primary prevention, and vitamin K antagonists and direct oral anticoagulants in case of high bleeding risk., Conclusion: A high level of consensus was reached on recommendations on potential deprescription of several medications for patients with a life expectancy of six months or less., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Polypharmacy is common among older people and is associated with multiple adverse outcomes. Assessing whether it is appropriate or inappropriate for an individual is more informative than relying on a simple pill count. Modern medicine is based on single disease guidelines that promote prescribing but tend not to have deprescribing criteria. Barriers to deprescribing promote the accumulation of medicines over time. Clinical trial data have limitations due to the selected populations recruited. Some evidence suggests older people with multi-morbidity may benefit less and people with frailty are at increased risk of harm. Prescribing can be inappropriate if it is not evidence-based, harm is likely to exceed the benefit, includes hazardous medications or combinations of medicines, the patient experiences therapeutic burden, there is reduced adherence or prescribing cascades. Medicines optimisation aims to improve prescribing quality for an individual patient and may include deprescribing. It is a complex process that includes shared decision-making, careful follow-up, and communication of any resulting prescription changes.

Background: Despite being cornerstone medications for managing gastrointestinal disorders, proton pump inhibitors (PPI) have raised concerns due to inappropriate prescribing and overutilization, their potential side effects, and interactions with other medications. General practitioners (GPs) provide long-term patient follow-up and are targets to promote PPI deprescribing to reach the widest possible population. GPs practicing in rural settings encounter unique challenges as their numbers dwindle and their workload increases. Hence, targeted educational interventions are crucial to promote appropriate prescribing practices in such underserved areas., Methods: We developed a continuing medical education (CME) program focused on PPI deprescribing for GPs in rural settings. The program comprised of an interactive training session featuring clinical cases, an open discussion, and distribution of educational materials. We assessed the program's effectiveness using a two-level Kirkpatrick model, evaluating participant satisfaction and knowledge levels through pre- and post-course questionnaires., Results: Thirty-three GPs participated, with 61.9% working in semi-rural and 38.1% in rural areas (21 responded to the 1st questionnaire, 14 to the 2nd ). Median medical experience was 6 years, with 61.9% serving as internship supervisors. Despite 95.2% acknowledging PPI overprescription, none had previously participated in dedicated PPI CME programs. The open discussion session provided valuable insights into various topics related to PPI use and gastrointestinal health. Participants expressed high satisfaction with the program (average rating of 9.1/10) and 92.9% reported changes in practice, including increased awareness of inappropriate PPI prescriptions. Indeed, 92.9% of GPs identified inappropriate PPI use following the course. 57.1% of participants utilized the provided educational materials. The main practice changes observed included an increased reassessment rate of PPI indications (71.4% at each renewal after vs. 19% before, 28.6% non-systematically after vs. 66.8% before, 0% rarely after vs. 14.3% before; p = 0.006), the necessity for more than one consultation to deprescribe (64.3% after vs. 23.8% before; p = 0.021), systematic utilization of gradual cessation of PPI (100% vs. 61.9%; p = 0.039) and more frequent use of additional medication (92.9% vs. 57.1%; p = 0.022), primarily antiacids (92.3%)., Conclusions: Our study underscores the effectiveness of targeted CME programs in promoting appropriate prescribing practices and enhancing knowledge among GPs in rural settings. Despite the challenges encountered in deprescribing PPI, the program facilitated proactive approaches in managing treatment discontinuation failures. Tailored educational interventions are essential for mitigating medication prescribing challenges and improving patient outcomes in rural primary care settings., Trial Registrations: Not applicable., (© 2024. The Author(s).)

Introduction: Despite several calls to deprescribe benzodiazepine receptor agonists (BZRA) in older adults, their use among nursing home residents (NHRs) remains high. Therefore, we developed an intervention targeting general practitioners' and healthcare professionals' behaviours regarding BZRA deprescribing in nursing homes (NHs): The END-IT NH (bENzodiazepines Deprescribing InTerventions Nursing homes) 6-component intervention. Before moving on to a large-scale effectiveness and cost-effectiveness evaluation, this feasibility study aims at: (1) assessing the feasibility of the intervention implementation in NHs, (2) assessing the feasibility of conducting a larger-scale evaluation, in terms of recruitment and data collection and (3) conducting an exploratory cost-effectiveness evaluation., Methods and Analysis: We will conduct a cluster-randomised controlled trial in a sample of 6 NHs, with 10-15 NHRs included per NHs. Four NHs will be randomised into the intervention group, and two NHs will deliver usual care (control group). Data collection will occur at baseline, 3, and 6 months (study end). We will collect information to explore implementation fidelity, mechanisms of impact and contextual factors at patient-level, NH-level and healthcare professional-level, using both quantitative and qualitative measures. The feasibility of the study conduction will be assessed by measuring recruitment and attrition rates and completeness of data collection. An exploratory cost-effectiveness evaluation will be conducted based on quality of life and healthcare use and cost data., Ethics and Dissemination: This study protocol received approval from the ethical committee of CHU UCL Namur on the 20 June 2023. All data are confidential and will be anonymised prior to analysis. De-identified data will be shared on a data depository with a 2-year embargo. The results of the study will be disseminated through a scientific paper and will be communicated to local stakeholders and policymakers through a local symposium., Trial Registration Number: NCT05929443., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: The process of identifying and discontinuing medicines in instances in which harms outweigh benefits (deprescribing) can mitigate the negative consequences of problematic polypharmacy. This process should be conducted with a focus on the patient and involve collaborative decision-making. Evidence is needed regarding patients' views on how deprescribing should be safely and routinely implemented in English primary care to improve its application. This study aimed to identify optimal methods of introducing and actioning deprescribing from the patient's perspective., Methods: Participants in England aged 65 and above who were taking five or more medicines and residing in their own homes were recruited through social media and service user groups. An interview guide was created from deprescribing literature and input from patients and the public, guided by the Normalisation Process Theory (NPT). The interviews were held online using Microsoft Teams ® or via phone, recorded, and then transcribed. The data was analysed using the Framework analysis., Results: Twenty patients (mean age of 74.5, SD = 6.93), with 75% being female, were enrolled in the study. Three main themes emerged: (1) 'Why deprescribe now?' emphasised the significance of explaining the reasons behind deprescribing; (2) 'Monitoring and follow-up' underscored the necessity of safety measures during deprescribing and patients' willingness to self-monitor post-intervention; (3) 'Roles and relationships' explored patient perceptions of various healthcare professionals involved in deprescribing and the essential interpersonal skills for fostering therapeutic relationships., Conclusion: Optimal methods of introducing deprescribing included communicating a convincing rationale for stopping medicines and preparing patients for deprescribing conversations. Patients required support from a range of healthcare professionals with whom they had an existing therapeutic relationship. Whilst patients were motivated to self-monitor unwanted/unexpected effects post-deprescribing, timely support was required. The nature of such bolstered collective action and cognitive participation within NPT enhances the normalisation potential of deprescribing. These findings highlight the significance of considering the content and process of deprescribing consultations to enhance normalisation and tackle problematic polypharmacy. This provides a deeper understanding of patients' needs for implementing safe and routine deprescribing in primary care, which should be considered when designing medication review and deprescribing services., (© 2024. The Author(s).)

Over-prescribing of proton-pump inhibitors (PPIs) is widely observed in older patients. Clinical findings have showed that deprescribing service significantly decreased inappropriate PPIs utilization. We aimed to examine the cost-effectiveness of PPI deprescribing service from the perspective of Hong Kong public healthcare provider. A decision-analytic model was constructed to examine the clinical and economic outcomes of PPI deprescribing service (deprescribing group) and usual care (UC group) in a hypothetical cohort of older PPI-users aged ≥65 years in the ambulatory care setting. The model inputs were retrieved from literature and public data. The model time-frame was one-year. Base-case analysis and sensitivity analysis were performed. Primary model outcomes were direct medical cost and quality-adjusted life-years (QALYs) loss. In base-case analysis, the deprescribing service (versus UC) reduced total direct medical cost by USD235 and saved 0.0249 QALY per PPI user evaluated. The base-case results were robust to variation of all model inputs in one-way sensitivity analysis. In probabilistic sensitivity analysis, the deprescribing group was accepted as cost-effective (versus the UC group) in 100% of the 10,000 Monte Carlo simulations. In conclusion, the PPI deprescribing service saved QALYs and reduced total direct medical cost in older PPIs users, and showed a high probability to be accepted as the cost-effective option from the perspective of public healthcare provider in Hong Kong., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Xie, You. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Dietary supplements are commonly used by older adults, but their inappropriate use may lead to adverse events. To optimise medication use, general practitioners (GPs) ideally are aware of all substances that patients use, including supplements. This cross-sectional study explored the use of dietary supplements by older patients with polypharmacy, the rate at which they disclosed this use to their GPs, and compared patients' and GPs' attitudes towards discontinuing dietary supplements., Methods: Ten GPs in Swiss primary care recruited five to ten of their older patients taking ≥ 5 regular medications. Both GPs and their patients completed a survey on patients' use of dietary supplements and attitudes towards deprescribing those. We described and compared their responses. We assessed the association of supplement disclosure with patient characteristics using multilevel logistic regression analysis., Results: Three out of ten GPs (30%) were female, and GPs' average age was 52 years (SD = 8). 45% of patients were female (29/65). Most patients (n = 45, 70%) were taking ≥ 1 supplement. On average, patients reported to be using three supplements (SD = 2). In 60% (n = 39) of patients, GPs were unaware of ≥ 1 supplement used. We did not find evidence for an association between supplement disclosure to GPs and patient characteristics. Only 8% (n = 5) of patients and 60% (n = 6) of GPs reported ≥ 1 supplement they would be willing to deprescribe and none of the supplements reported by GPs and patients to deprescribe matched., Conclusion: Swiss GPs were unaware of many dietary supplements used by their older patients, which may affect medication optimisation efforts., (© 2024. The Author(s).)

Introduction: The importance of deprescribing in clinical practice is growing, particularly in aging populations with polypharmacy scenarios, making it a crucial matter in Portugal, one of Europe's most aged nations. The aim of this study was to investigate deprescribing awareness, training, attitudes, and practices among Portuguese physicians to inform future healthcare strategies., Methods: A cross-sectional study using an anonymous online questionnaire was disseminated through the Portuguese Medical Association. It gathered sociodemographic and professional data, and insights into deprescribing awareness, attitudes, training, and practices. Descriptive statistics were summarized as frequencies, percentages, medians, and interquartile ranges. For inferential analysis, the Chi-square test and Fisher's exact test were used to evaluate categorical variables, and the Mann-Whitney U test was used for continuous variables. The significance level was set at p < 0.05., Results: A total of 425 valid questionnaires were included. The participants were mostly women (61.6%), with a median age of 45 (IQR 34 - 42). General practice/family medicine (34.1%) and internal medicine (16.2%) were the most common medical specialties. While 81.2% of the respondents were familiar with the term 'deprescribing', 55.4% reported no training. A vast majority (91.9%) reported practicing deprescribing, but a smaller fraction employed specific methodologies to deprescribe (39.8%) and criteria for identifying potentially inappropriate medications (38.7%). Training in deprescribing was significantly associated with higher deprescribing awareness (p < 0.001), the use of specific deprescribing methods (p < 0.001), the use of criteria to identify potentially inappropriate medications (p < 0.001) and having certification in geriatrics by the Portuguese Medical Association (p = 0.006). Family physicians showed higher familiarity with and training in deprescribing than hospital-based specialists (p < 0.001). Deprescribing methodologies were adopted more often by family physicians than by hospital-based specialists (p = 0.004)., Conclusion: This study highlights widespread deprescribing awareness among Portuguese physicians, while simultaneously uncovering considerable gaps in training and inconsistencies in its application. These findings highlight the pressing need for targeted educational initiatives that could contribute to medication optimization for older adults in the national healthcare system. Furthermore, these findings emphasize the importance of policy development and medical education in promoting safe deprescribing.

Background: Benzodiazepines and z-drugs increase the fall risk in older adults. There is a lack of real-world data examining the association between falls and deprescribing medications., Objective: In a retrospective cohort study of older adults with chronic benzodiazepine or z-drug use receiving care at an academic health system from January 2017 to December 2020, we explored the association between medication discontinuation and falls., Methods: Chronic use was defined as ≥ 3 medication dispensings and cumulative days' supply ≥ 45 days within 100 days in 2018. Discontinuation was defined as a dispensing gap of ≥ 180 days within 1 year of chronic use eligibility, with a secondary definition requiring a gap of ≥ 90 days. Non-discontinuers (n = 524) were matched 4:1 to discontinuers (n = 131) if they had a fill in the same month as the matched discontinuation index date. The association between discontinuation and a fall during 2.25-year follow-up was assessed using Cox proportional hazards models. The analysis was repeated using a gap of ≥ 90 days (n = 279 discontinuers; 1116 matched non-discontinuers)., Results: The cumulative incidence of falls-related acute visits was 6.9% for discontinuers and 9.7% for non-discontinuers [adjusted hazard ratio (HR) 0.65, 95% confidence interval (CI) 0.31-1.31]. Using the 90-day-gap definition, the cumulative incidence was 9.3% for discontinuers and 8.5% for non-discontinuers (HR 1.12, 95% CI 0.70-1.77)., Conclusion: Benzodiazepine/z-drug discontinuation was not associated with reduced risk of falls. However, the relationship between discontinuation and falls varies depending on the definitions used. It is essential to examine different discontinuation definitions in larger studies while considering other relevant clinical outcomes., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

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., (© 2024. The Author(s).)

In this pilot study, we explored current attitudes and deprescribing practices of clinicians in a large regional health service through a mixed methods approach. Respondents included doctors, pharmacists and nurse practitioners, who outlined three themes including professional and organisational contexts, disconnect between goals and practices and factors influencing deprescribing., (© 2024 The Author(s). Internal Medicine Journal published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Physicians.)

Competing Interests: Conflict of interest The authors declare they have no conflict of interest.

Aims: Previous systematic reviews suggest that deprescribing may improve survival, particularly in frail older people. Evidence is rapidly accumulating, suggesting a need for an updated review of the literature., Methods: We updated a 2016 systematic review and meta-analysis to include studies published from inception to 26 April 2024 from specified databases. Studies in which older people had at least one medication deprescribed were included and grouped by study designs and targeted medications. The risk of bias was assessed using the Cochrane tool and the Newcastle-Ottawa tool. Odds ratios (OR) or mean differences were calculated as the effect measures using either the Mantel-Haenszel or generic inverse-variance method with fixed- or random-effects meta-analyses. The primary outcome was mortality. Secondary outcomes were adverse drug withdrawal events, physical health, cognitive function, quality of life and effect on medication regimen. Subgroup analyses were performed based on age and intervention types., Results: A total of 259 studies (reported in 286 papers) were included in this updated review. Deprescribing polypharmacy did not result in a significant reduction in mortality in both randomized (OR 0.96, 95% confidence interval [CI] 0.84-1.09) and non-randomized studies (OR 0.70, 95% CI 0.36-1.38). Further subgroup analyses of randomized studies on deprescribing polypharmacy demonstrated a significant reduction in mortality in the young old (aged 65-79) (OR 0.71, 95% CI 0.51-0.99) and when patient-specific interventions were applied (OR 0.79, 95% CI 0.63-0.99)., Conclusions: Deprescribing can be achieved with potentially important benefits in terms of improved survival, particularly when patient-specific interventions are applied and initiated early in the young old., (© 2024 The Author(s). British Journal of Clinical Pharmacology published by John Wiley & Sons Ltd on behalf of British Pharmacological Society.)

Background: Polypharmacy is a primary risk factor for the prescription of potentially inappropriate medications (PIMs), drug-drug interactions (DDIs), and ultimately, adverse drug reactions (ADRs). Medication review and deprescribing represent effective strategies to simplify therapeutic regimens, minimize risks, and reduce PIM prescriptions. This systematic review and meta-analysis of experimental and observational studies aimed to evaluate the impact of different medication review and deprescribing interventions in hospitalized older patients., Methods: Experimental and observational prospective cohort studies evaluating the clinical effects of medication review and deprescribing strategies in older hospitalized patients were searched in the bibliographic databases, PubMed, Embase, and Scopus, from inception until January 8, 2024. A narrative synthesis of the results was provided, along with a meta-analysis of dichotomous data (i.e., re-hospitalizations and mortality)., Results: Overall, 21 randomized controlled trials, 7 non-randomized interventional studies, and 2 prospective cohort studies were included in the systematic review. Of these, 14 (46.7%) assessed medication appropriateness as the primary outcome, while the remaining evaluated clinical outcomes (e.g., length of hospital stay, hospital readmissions, emergency department visits, and incidence of ADRs) and/or quality of life. The meta-analysis revealed a slight but statistically significant 8% reduction in hospital readmissions (HR: 0.92; 95% CI: 0.85-0.99) following medication review and deprescribing, but no significant impact on mortality (HR: 0.98; 95% CI: 0.96-1.00). Of the 30 included studies, 21 were considered at high risk of bias, mostly due to potential deviations from intended interventions and randomization processes. The remaining nine studies had "some concerns" (eight studies) or were considered at "low" risk of bias (one study)., Conclusion: Medication review and deprescribing are associated with potential benefits in reducing hospital readmission rates among hospitalized older patients, particularly through the reduction of PIM prescriptions. The integration of thorough medication review and deprescribing protocols in hospital settings may improve post-discharge outcomes and reduce overall healthcare costs., (© 2024 The Author(s). Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.)

Background: The Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy (STOPPFrail) criteria aim to reduce inappropriate/unnecessary medications in frail older adults, which should minimise adverse drug events and additional healthcare expenditure. Little is known about the economic outcomes of applying these criteria as an intervention., Aim: To evaluate cost avoidance of pharmacist-led application of STOPPFrail to frail older nursing home residents with limited life expectancy., Method: Pharmacist-identified STOPPFrail-defined potentially inappropriate medications that were deprescribed by patients' general practitioners were assigned a rating by a multidisciplinary panel, i.e. the probability of an adverse drug event occurring if the medication was not deprescribed. The intervention's net cost benefit and cost-benefit ratio were then determined by factoring in adverse drug event cost avoidance (calculated from probability of adverse drug event ratings), direct cost savings (deprescribed medication costs/reimbursement fees), and healthcare professionals' salaries., Results: Of the 176 potentially inappropriate medications deprescribed across 69 patients, 65 (36.9%) were rated as having a medium or high probability of an adverse drug event occurring if not deprescribed. With €27,162 for direct cost savings, €61,336 for adverse drug event cost avoidance, and €2,589 for healthcare professionals' salary costs, there was a net cost benefit of €85,909 overall. The cost-benefit ratio was 33.2 and remained positive in all scenarios in sensitivity analyses., Conclusion: Pharmacist-led application of STOPPFrail to frail older nursing home residents is associated with significant cost avoidance. Wider implementation of pharmacist interventions in frail older nursing home residents should be considered to reduce potentially inappropriate medications and patient harm, alongside substantial cost savings for healthcare systems., (© 2024. The Author(s).)

Background: Electronic consultations (eConsults) enable asynchronous consultation between primary care providers (PCPs) and specialists. eConsults have been used successfully to manage a variety of conditions and have the potential to help PCPs manage polypharmacy and promote deprescribing., Objective: To elicit clinician perspectives on barriers/facilitators of using eConsults for deprescribing among older adults within a university health network., Design: Semi-structured interviews., Participants: PCPs, geriatricians, and pharmacists., Approach: We used the COM-B (Capability, Opportunity, Motivation, and Behavior) model to structure the interview guide and qualitative analysis methods to identify barriers/facilitators of (1) deprescribing and (2) use of eConsults for deprescribing., Key Results: Of 28 participants, 19 were PCPs (13 physicians, 4 residents, 2 nurse practitioners), 7 were geriatricians, and 2 were pharmacists. Barriers and facilitators to deprescribing: PCPs considered deprescribing important but identified myriad barriers (e.g., time constraints, fragmented clinical care, lack of pharmacist integration, and patient/family resistance). Use of eConsults for deprescribing: Both PCPs and geriatricians highlighted the limits of contextual information available through electronic health record (vs. face-to-face) to render specific and actionable eConsults (e.g., knowledge of prior deprescribing attempts). Participants from all groups expressed interest in a targeted process whereby eConsults could be offered for select patients based on key factors (e.g., polypharmacy or certain comorbidities) and accepted or declined by PCPs, with pithy recommendations delivered in a timely manner relative to patient appointments. This was encapsulated by one PCP: "they need to be crisp and to the point to be helpful, with specific suggestions of something that could be discontinued or switched…not, 'hey, did you know your patient is on over 12 medicines?'"., Conclusions: Clinicians identified multifaceted factors influencing the utility of eConsults for deprescribing among older adults in primary care. Deprescribing eConsult interventions should be timely, actionable, and mindful of limitations of electronic chart review., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: We aimed to identify the target of deprescribing, i.e. the 24-hour SBP increase needed to achieve the greatest reduction of SBP drops., Method: Forty hypertensive patients (mean age 73.6 ± 9.3 years, 26 females) with reflex syncope and SBP drops on a screening ABPM were advised to withdraw or to reduce their therapy. The study objective was the reduction of SBP drops <90 mmHg and <100 mmHg on a second ABPM performed within 3 months., Results: Out of a total of 98 drugs taken during ABPM 1, 44 were withdrawn, 16 had a dose reduction and 38 remained unchanged at the time of ABPM 2. 24-hour SBP increased from 119.7 ± 10.1 mmHg to 129.4 ± 13.2 mmHg during ABPM2. Total disappearance of daytime SBP drops <100 mmHg was achieved in 20 (50 %) patients who had 24-hour SBP of 134±13 mmHg and an increase from ABPM 1 of 12 (IQR 5-20) mmHg. Compared with the 20 patients who had persistence of drops, these patients had a greater reduction of the number of hypotensive drugs (67 % versus 19 %, p = 0.002) and a greater rate of withdrawals (62 % versus 29 %, p = 0.003)., Conclusion: In hypertensive patients with reflex syncope, an increase of 12 mmHg and an absolute value of 24-hour SBP of 134 mmHg appear to represent the optimal goals aimed to prevent SBP drops. Drugs withdrawal, rather than simply dose reduction, is mostly required to achieve the above target., Competing Interests: Declaration of competing interest The authors declare they have no conflict of interest., (Copyright © 2024 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Background: Patients in palliative care are often treated with antithrombotics, even in the late stages of disease. Clear guidelines regarding deprescribing are lacking. Objective: The aims of this study were to investigate bleeding as a side effect of antithrombotic treatments the last year in life and map the timing of deprescribing. Methods: A retrospective cohort study was performed. All medical records were screened for deceased patients admitted to a palliative care unit in Stockholm, Sweden, over a 3-year period. Patients with antithrombotics were identified; data on bleeding, and on side effects due to deprescribing, were extracted from the medical records. Log-binomial models were used to explore factors associated with bleeding. Results: Of 1501 patients, 897 were treated with antithrombotics during the last year of life (mean age 75 years, 41% women). Of these, 56% continued treatment up until the last 3 days of life. Of the 897 patients, 144 (16%) had at least one bleeding during the treatment. The risk for bleeding was significantly higher for men with prostate cancer compared to other cancer forms, adjusted relative risk 1.9 (95% CI 1.1-3.2). No difference in risk for bleeding was found between sex, age groups, type of antithrombotics, or indication. Two patients (0.2%) developed strokes after antithrombotics were deprescribed. Conclusions: Treatment with antithrombotics during the last year of life is associated with a high risk of bleeding. In this cohort, men with prostate cancer seemed to have more side effects of bleeding than other groups. Few experienced side effects from deprescribing.

Background: Antidepressants have a pivotal role in the treatment of many psychiatric disorders, but there are concerns about long-term use and adverse effects. The objectives of this study were (1) to examine time trends in antidepressant use, (2) to estimate the prevalence of long-term and potential high-risk antidepressant use, and (3) to examine patient characteristics associated with potential deprescribing indications (PDIs) (i.e., simultaneous long-term and potential high-risk antidepressant use)., Methods: Repeated population-based cross-sectional study for all 609,299 people aged ≥ 18 years resident in the Tayside or Fife regions of Scotland. The prevalence of antidepressant use was examined on June 30th (index date) of each year from 2012 to 2019, while the prevalence of long-term and potential high-risk use as well as PDIs was assessed and compared on the same dates in 2012 and 2019. Binary logistic regression modeling was used to examine patient characteristics associated with PDIs., Results: Antidepressant use increased by 27% from 12.0 to 15.3% among adult residents between 2012 and 2019. While the proportion of antidepressants users dispensed ≥ 1 antidepressant for > 2 years increased from 54.3 to 61.9% between 2012 and 2019, the proportion of antidepressant users triggering ≥ 1 indicator of potential high-risk use decreased slightly from 37.9 to 34.7%. In 2019, potential high-risk use most commonly related to indicators targeting fall risk (16.0%), cardiovascular risks (14.1%), insomnia (10.6%), and risk of orthostatic hypotension (8.6%). More than 1 in 4 (25.8%) antidepressant users had PDIs. The main risk factors associated with PDIs included increasing age (65-79, adjusted OR 14.12; 95% CI, 13.15-15.17), increasing number of drugs taken concomitantly (≥ 15 drugs, adjusted OR 7.37; 95% CI, 6.71-8.10), use of tricyclic antidepressants (≥ 50 mg) (adjusted OR 5.49; 95% CI, 5.02-6.01), and concomitant use of ≥ 2 antidepressants (adjusted OR 5.52; 95% CI, 5.20-5.85)., Conclusions: Long-term and potential high-risk use of antidepressants is widespread, and potential deprescribing indications (PDIs) are increasing, suggesting the need for a critical review of their ongoing use by clinicians. If deemed necessary, future deprescribing interventions may use the criteria applied here for identification of patients with PDIs and for evaluating intervention effectiveness., (© 2024. The Author(s).)

Background: Deprescribing of potentially inappropriate medications is recommended for older adults and may improve health outcomes and quality of life in persons living with Parkinson disease (PD). Patient attitudes, beliefs, and preferences play a crucial role in the success of deprescribing interventions. We aimed to examine the attitudes and beliefs about medication burden and deprescribing among persons living with PD., Methods: We administered a survey to participants of Fox Insight, a prospective longitudinal study of persons living with PD. The survey included the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire and additional questions about adverse drug effects. We used logistic regression models to explore potential predictors of treatment dissatisfaction and willingness to deprescribe., Results: Of the 4945 rPATD respondents, 31.6% were dissatisfied with their current medications, and 87.1% would be willing to deprescribe medications. Male sex was associated with a greater willingness to deprescribe (adjusted odds ratio [aOR] 1.62, 95% confidence interval [CI] 1.37-1.93). A greater belief that the medication burden was high or that some medications were inappropriate was associated with treatment dissatisfaction (aORs 3.74, 95% CI 3.26-4.29 and 5.61, 95% CI 4.85-6.50), and more willingness to deprescribe (aORs 1.74, 95% CI 1.47-2.06 and 2.87, 95% CI 2.41-3.42). Cognitive impairment was the adverse drug effect participants were most concerned about when prescribed new medications to treat nonmotor symptoms., Conclusions: Persons with PD are often dissatisfied with their overall medication load and are open to deprescribing. Medications that are associated with cognitive impairment might be prioritized targets for deprescribing interventions in this population., (© 2024. The Author(s).)

Background: Deprescribing has been defined as the planned process of reducing or stopping medications that may no longer be beneficial or are causing harm, with the goal of reducing medication burden while improving patient quality of life. At present, little is known about the specific challenges of decision-making to support deprescribing for patients who are accessing palliative care. By exploring the perspectives of healthcare professionals, this qualitative study aimed to address this gap, and explore the challenges of, and potential solutions to, making decisions about deprescribing in a palliative care context., Methods: Semi-structured interviews were conducted with healthcare professionals in-person or via video call, between August 2022 - January 2023. Perspectives on approaches to deprescribing in palliative care; when and how they might deprescribe; and the role of carers and family members within this process were discussed. Interviews were audio-recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes. QSR NVivo (Version 12) facilitated data management. Ethical approval was obtained from the NHS Health Research Authority (ref 305394)., Results: Twenty healthcare professionals were interviewed, including: medical consultants, nurses, specialist pharmacists, and general practitioners (GPs). Participants described the importance of deprescribing decision-making, and that it should be a considered, proactive, and planned process. Three themes were developed from the data, which centred on: (1) professional attitudes, competency and responsibility towards deprescribing; (2) changing the culture of deprescribing; and (3) involving the patient and family/caregivers in deprescribing decision-making., Conclusions: This study sought to explore the perspectives of healthcare professionals with responsibility for making deprescribing decisions with people accessing palliative care services. A range of healthcare professionals identified the importance of supporting decision-making in deprescribing, so it becomes a proactive process within a patient's care journey, rather than a reactive consequence. Future work should explore how healthcare professionals, patients and their family can be supported in the shared decision-making processes of deprescribing., Trial Registration: Ethical approval was obtained from the NHS Health Research Authority (ref 305394)., (© 2024. The Author(s).)

Introduction: Deprescribing fall-risk increasing drugs (FRIDs) is promising for reducing the risk of falling in older adults. Applying appropriate deprescribing in practice can be difficult due to the outcome uncertainties associated with stopping FRIDs. The ADFICE&#95;IT intervention addresses this complexity with a clinical decision support system (CDSS) that facilitates optimum deprescribing of FRIDs by using a fall-risk prediction model, aggregation of deprescribing guidelines, and joint medication management., Methods: The development process of the CDSS is described in this paper. Development followed a user-centered design approach in which users and experts were involved throughout each phase. In phase I, a prototype of the CDSS was developed which involved a literature and systematic review, European survey (n = 581), and semi-structured interviews with clinicians (n = 19), as well as the aggregation and testing of deprescribing guidelines and the development of the fall-risk prediction model. In phase II, the feasibility of the CDSS was tested by means of two usability testing rounds with users (n = 11)., Results: The final CDSS consists of five web pages. A connection between the Electronic Health Record allows for the retrieval of patient data into the CDSS. Key design requirements for the CDSS include easy-to-use features for fast-paced clinical environments, actionable deprescribing recommendations, information transparency, and visualization of the patient's fall-risk estimation. Key elements for the software include a modular architecture, open source, and good security., Conclusion: The ADFICE&#95;IT CDSS supports physicians in deprescribing FRIDs optimally to prevent falls in older patients. Due to continuous user and expert involvement, each new feedback round led to an improved version of the system. Currently, a cluster-randomized controlled trial with process evaluation at hospitals in the Netherlands is being conducted to test the effect of the CDSS on falls. The trial is registered with ClinicalTrials.gov (date; 7-7-2022, identifier: NCT05449470)., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Groos et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Proton pump inhibitors (PPIs) are frequently overprescribed and maintained without clear indication, leading to significant clinical and economic consequences. Deprescribing, which involves discontinuing or reducing the dose of a medication, lacks clear guidelines for PPIs, despite various approaches being described. Gradual tapering of PPIs appears to be an effective strategy, especially when combined with non-pharmacological measures and multimodal interventions. Additionally, it is crucial to involve the patient in the discussion and ensure a post-tapering follow-up plan., Competing Interests: Le Pr Omar Kherad est membre de l’assemblée « smartermedicine Choosing Wisely Switzerland » et président du groupe de travail « Choosing wisely » au sein de la fédération européenne de médecine interne. Les autres auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Polypharmacy is the concurrent use of five or more drugs per day. It is common in old age because of multimorbidity. The prevalence of polypharmacy is increasing as the number of old people is increasing worldwide. The proliferation of clinical guidelines and wider availability of preventive and curative medicines are important causes of polypharmacy. Appropriate polypharmacy is beneficial to the patients. However, polypharmacy may be inappropriate, causing adverse effects, drug interactions (DI), poor treatment efficacy, hospitalizations, and high healthcare costs. Prescribing cascade and legacy prescribing add to the burden of inappropriate polypharmacy. Inappropriate polypharmacy can be prevented or managed by medication optimization through medication review, deprescription, ensuring adherence, and patient education. Deprescription includes the removal of risky, unnecessary, and duplicate drugs, replacement with efficacious drugs, and relaxation of tight control as per life expectancy. Several deprescription tools (both explicit and implicit) exist for helping physicians to decide when to deprescribe or to add medicines, especially in old age. Care should be taken during deprescription to prevent unjustified omission, reduction to subtherapeutic dose, and onset of withdrawal features. Age and disease-related changes in pharmacokinetics and pharmacodynamics of drugs should be considered during the optimization of pharmacotherapy., (© Journal of the Association of Physicians of India 2024.)

Background: For people with limited lifetime expectancy, the benefit of many medications may be outweighed by their potential harms. Despite the relevance of reducing unnecessary medication use, deprescribing is poorly enacted in primary care practice., Aim: This study aims to describe factors, as identified by primary care professionals and patients, that influence deprescribing in the last phase of life., Design: Semi-structured interviews were conducted and analysed using a thematic approach., Setting/participants: This study was performed in primary care settings, including general practices, hospices and community care teams in The Netherlands. Purposefully identified primary care professionals (general practitioners, pharmacists, nurses) and patients with limited lifetime expectancy due to advanced chronic illness or cancer and their caretakers were interviewed., Results: Three themes emerged detailing factors influencing deprescribing in the last phase of life in primary care: (1) non-maleficence, the wish to avoid additional psychological or physical distress; (2) reactive care, the lack of priority and awareness of eligible patients; and (3) discontinuity of care within primary care and between primary care and specialty care., Conclusions: Deprescribing is an incremental process, complicated by the unpredictability of life expectancy and attitudes of patients and health care professionals that associate continued medication use with clinical stability. Opportunities to facilitate the deprescribing process and its acceptance include the routinely systematic identification of patients with limited life expectancy and potentially inappropriate medications, and normalisation of deprescribing as component of regular primary care, occurring for all patients and continuing into end-of-life care., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.