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Introduction: Cholinesterase inhibitors (ChEIs) and memantine are medications used to treat the symptoms of specific types of dementia. Their benefits and harms can change over time, particularly during long term use. Therefore, appropriate use of ChEIs and memantine involves both prescribing these medications to individuals who are likely to benefit, and deprescribing (withdrawing) them from individuals when the risks outweigh the benefits. We recently developed an evidence-based clinical practice guideline for deprescribing ChEIs and memantine, using robust international guideline development processes.Main Recommendations: Our recommendations aim to assist clinicians to: identify individuals who may be suitable for a trial of deprescribing ChEIs and memantine (such as those who do not have an appropriate indication, those who have never experienced a benefit, those who appear to be no longer benefitting, and those who have severe or end-stage dementia); and taper treatment and monitor individuals during the deprescribing process.Changes in Management AsA Result Of the Guideline: Deprescribing ChEIs and memantine through shared decision making with individuals and their caregivers by: ▶determining their treatment goals; ▶discussing benefits and harms of continuing and ceasing medication, from the start of therapy and throughout; and ▶engaging them in monitoring after discontinuation, while informing carers that the individual will continue to decline after discontinuation. This approach may reduce adverse drug reactions and medication burden, leading to improved quality of life in people with dementia. [ABSTRACT FROM AUTHOR]

OBJECTIVES To summarize available tools that can assist clinicians in identifying and reducing or stopping (deprescribing) potentially inappropriate medications and that specifically consider frailty or limited life expectancy. DESIGN Systematic review and narrative synthesis. SETTING We searched MEDLINE (via Ovid SP), EMBASE (via Ovid SP), and CINAHL from inception to December 2017, along with grey literature. We included articles that described a tool to guide deprescribing of medications. PARTICIPANTS Frail older persons and older persons with limited life expectancy. MEASUREMENTS Narrative description of tools. RESULTS: We identified 15 tools and organized them into three main categories: tools (n = 2) that described a model or framework for approaching deprescribing, tools (n = 9) that outlined a deprescribing approach for the entire medication list, and tools (n = 4) that provided medication‐specific advice. The complexity of the tools ranged from simple lists to detailed, step‐wise protocols. The development methodology varied widely, and the methods used to synthesize the tools were generally not well described. Most tools were based on expert opinion. Only four of the 15 tools have been tested in clinical practice (in very low‐quality studies). CONCLUSION: Tools exist to help clinicians deprescribe in frail older persons and those with limited life expectancy. These tools may assist clinicians at various stages in the deprescribing process. However, it remains to be investigated whether use of such tools in practice is likely to improve clinical outcomes or reduce inappropriate medication use. J Am Geriatr Soc 67:172–180, 2019. [ABSTRACT FROM AUTHOR]

The article presents a study which developed and tested a consultant patient decision aid (PtDA) aimed at continuation or deprescribing of proton pump inhibitor (PPI) therapy. Topics discussed include information on PtDAs, challenges in the implementation of the tool, and possibility for pharmacists to take the lead on shared decision-making on continuation or deprescribing of PPIs in primary care clinics.

The article discusses the issue of polypharmacy and its negative health outcomes, particularly among older adults in Canada. It introduces the Canadian Medication Appropriateness and Deprescribing Network (CADeN) and describes the goals and outcomes of the CADeN 2023 National Meeting, which focused on strengthening relationships, sharing resources, and informing policy. The meeting emphasized equity, diversity, and inclusion, as well as the importance of indigenous perspectives in healthcare. Initiatives and research on medication appropriateness and deprescribing were discussed, along with strategies to reduce medication overload. The meeting highlighted the need for health policy reforms, equitable access to medications, patient engagement, and collaboration within the healthcare system. The CADeN network plans to continue its efforts to promote medication appropriateness in Canada. [Extracted from the article]

In this systematic review, we report on the effects of diuretic deprescribing compared to continued diuretic use. We included clinical studies reporting on outcomes such as mortality, heart failure recurrence, tolerability and feasibility. We assessed risk of bias and certainty of the evidence using the GRADE framework. We included 25 publications from 22 primary studies (15 randomized controlled trials; 7 nonrandomized studies). The mean number of participants in the deprescribing groups was 35, and median/mean age 64 years. In patients with heart failure, there was no clear evidence that diuretic deprescribing was associated with increased mortality compared to diuretic continuation (low certainty evidence). The risk of cardiovascular composite outcomes associated with diuretic deprescribing was inconsistent (studies showing lower risk for diuretic deprescribing, or comparable risk with diuretic continuation; very low certainty evidence). The effect on heart failure recurrence after diuretic deprescribing in patients with diuretics for heart failure, and of hypertension in patients with diuretics for hypertension was inconsistent across the included studies (low certainty evidence). In patients with diuretics for hypertension, diuretic deprescribing was well tolerated (moderate certainty evidence), while in patients with diuretics for heart failure, deprescribing diuretics can result in complaints of peripheral oedema (very low certainty evidence). The overall risk of bias was generally high. In summary, this systematic review suggests that diuretic discontinuation could be a safe and feasible treatment option for carefully selected patients. However, there isa lack of high‐quality evidence on its feasibility, safety and tolerability of diuretic deprescribing, warranting further research. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions Clinicians and patients often face a decision to continue or discontinue statins. We examined the impact of discontinuation of statins compared with continuation on clinical outcomes (all‐cause mortality, cardiovascular [CV] mortality, CV events, and quality of life).We conducted a systematic review. Randomized controlled trials (RCTs), cohort studies, case–control studies, and quasi‐randomized studies among people ≥18 years were eligible. We searched MEDLINE, Embase, and Cochrane Central Registry (inception to August 2023). Two independent reviewers performed screening and extracted data. Quality assessment was performed by one author and verified by another. We summarized results narratively, performed meta‐analysis for a subset of studies, and used GRADE to assess certainty of evidence. We summarized findings in the subgroup of persons ≥75 years.We retrieved 8369 titles/abstracts; 37 reports from 36 studies were eligible. This comprised 35 non‐randomized studies (n = 1,708,684) and 1 RCT (n = 381). The 1 RCT was conducted among persons with life expectancy <1 year and showed there is probably no difference in 60‐day mortality (risk difference = 3.5%, 90% CI −3.5 to 10.5) for statin discontinuation compared with continuation. Non‐randomized studies varied in terms of population and setting, but consistently suggested that statin discontinuation might be associated with a relative increased risk of mortality (hazard ratio (HR) 1.92, 95% CI 1.52 to 2.44, nine studies), CV mortality (HR 1.63, 95% CI 1.27 to 2.10, five reports), and CV events (HR 1.31, 95% CI 1.23 to 1.39, eight reports). Findings in people ≥75 years were consistent with main results. There was a high degree of uncertainty in findings from non‐randomized studies due to methodological limitations.Statin discontinuation does not appear to affect short‐term mortality near end‐of‐life based on one RCT. Outside of this population, findings from non‐randomized studies consistently suggested statin discontinuation may be associated with worse outcomes, though this is uncertain. [ABSTRACT FROM AUTHOR]

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 FROM AUTHOR]

A discussion of life expectancy allows patients to make choices that fit with their health context.[1],[2] Our recently published systematic review on patient preferences for discussing life expectancy found that, in 24 out of 31 of the included studies, the majority of patients (>=50%) reported a positive attitude towards discussing life expectancy.[3] Previous studies have focused mostly on patients with cancer, while few have focused on older adults with frailty.[3] We examined Danish geriatric outpatients' preferences for discussing life expectancy with a physician. This is consistent with previous studies among similar patient groups.[4]-[6] However, a survey conducted among 878 older persons, using an online hypothetical patient scenario,[6] found that most people unwilling to discuss their life expectancy did also not find it appropriate for a patient to even be offered a discussion on the topic. The outcome of interest was patients' willingness to discuss life expectancy with a physician, defined as: I not willing at all i , I to a low degree i , I to a medium degree i , or I to a high degree. i We reported results using descriptive statistics. [Extracted from the article]

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).)

Competing Interests: Intérêts concurrents :: Lisa McCarthy mentionne recevoir des subventions de l’organisme Trillium Health Partners (Partenaires de santé Trillium), du University of Toronto, de Santé Canada ainsi qu’un soutien financier additionnel des Centres d’apprentissage, de recherche et d’innovation en soins de longue durée de l’Ontario à l’Institut de recherche Bruyère. Elle obtient aussi un soutien financier pour ses frais de déplacement de l’Initiative consensuelle de la International Geriatric Diabetes Society Deprescribing Consensus Initiative (Société internationale du diabète chez la population gériatrique), indépendamment des travaux soumis. Mme McCarthy siège au comité de direction du Réseau canadien pour l’usage approprié des médicaments et la déprescription et au comité directeur du groupe de travail pour les foyers de soins de longue durée de Choisir avec soin. En appui à l’élaboration du présent manuscrit, Iliana Lega et Lisa McCarthy mentionnent avoir reçu la subvention no PJT 186203 des Instituts de recherche en santé du Canada (IRSC). Wade Thompson déclare recevoir des subventions de la Fondation Michael-Smith pour la recherche en santé de la Colombie-Britannique, du National Institute on Aging (Institut national sur le vieillissement) et de Santé Canada. Il a obtenu une rémunération de la revue Pharmacy Practice Plus pour un article portant sur la déprescription, le tout indépendamment des travaux soumis. Iliana Lega signale avoir obtenu la subvention no PJT 159472 des Instituts de recherche en santé du Canada, versée à l’Institut de recherche de l’Hôpital Women’s College. La Dre Lega a aussi obtenu un soutien financier de Diabète Canada pour ses déplacements.

In this systematic review, we report on the effects of diuretic deprescribing compared to continued diuretic use. We included clinical studies reporting on outcomes such as mortality, heart failure recurrence, tolerability and feasibility. We assessed risk of bias and certainty of the evidence using the GRADE framework. We included 25 publications from 22 primary studies (15 randomized controlled trials; 7 nonrandomized studies). The mean number of participants in the deprescribing groups was 35, and median/mean age 64 years. In patients with heart failure, there was no clear evidence that diuretic deprescribing was associated with increased mortality compared to diuretic continuation (low certainty evidence). The risk of cardiovascular composite outcomes associated with diuretic deprescribing was inconsistent (studies showing lower risk for diuretic deprescribing, or comparable risk with diuretic continuation; very low certainty evidence). The effect on heart failure recurrence after diuretic deprescribing in patients with diuretics for heart failure, and of hypertension in patients with diuretics for hypertension was inconsistent across the included studies (low certainty evidence). In patients with diuretics for hypertension, diuretic deprescribing was well tolerated (moderate certainty evidence), while in patients with diuretics for heart failure, deprescribing diuretics can result in complaints of peripheral oedema (very low certainty evidence). The overall risk of bias was generally high. In summary, this systematic review suggests that diuretic discontinuation could be a safe and feasible treatment option for carefully selected patients. However, there isa lack of high-quality evidence on its feasibility, safety and tolerability of diuretic deprescribing, warranting further research., (© 2024 The Author(s). British Journal of Clinical Pharmacology published by John Wiley & Sons Ltd on behalf of British Pharmacological Society.)