A Systematic Review of the Evidence for Deprescribing Interventions Among Older People Living With Frailty

Abstract

Background: Older people living with frailty are often exposed to polypharmacy and potential harm from medications. Targeted deprescribing in this population represents an important component of optimizing medication. This systematic review aims to summarise the current evidence for deprescribing among older people living with frailty.Methods: The literature was searched using Medline, Embase, CINAHL, PsycInfo, Web of Science, and the Cochrane library up to May 2020. Studies with any design or setting were included if they reported deprescribing interventions among people aged 65+ who live with frailty identified using reliable measures. The primary outcome was safety of deprescribing; whereas secondary outcomes included clinical outcomes, medication-related outcomes, feasibility, acceptability and cost-related outcomes. Narrative synthesis was used to summarise findings and study quality was assessed using Joanna Briggs Institute checklists.Results: 2322 articles were identified and six (two randomised controlled trials) were included with 53 participants in total (mean age range 79–87 years). Studies were heterogenous in their designs, settings and outcomes. Deprescribing interventions were pharmacist-led (n=3) or multidisciplinary team-led (n=3). Frailty was identified using several measures and deprescribing was implemented using either explicit or implicit tools or both. Three studies reported safety outcomes and showed no significant changes in adverse events, hospitalisation or mortality rates. Three studies reported positive impact on clinical outcomes including depression, mental health status, function and frailty; with mixed findings on falls and cognition; and no significant impact on quality of life. All studies described medication-related outcomes and reported a reduction in potentially inappropriate medications and total number of medications per-patient. Feasibility of deprescribing was reported in four studies which showed that 72-91% of recommendations made were implemented. Two studies evaluated and reported the acceptability of their interventions and further two described cost saving. Conclusion: There is a paucity of research about the impact of deprescribing in older people living with frailty. However, included studies suggest that deprescribing could safe, feasible, well tolerated and can lead to important benefits. Research should now focus on understanding the impact of deprescribing on frailty status in high risk populations. Trial registration: the review was registered on the international prospective register of systematic reviews (PROSPERO) ID number: CRD42019153367.

Interventions to improve medicines optimisation in frail older patients in secondary and acute care settings: a systematic review of randomised controlled trials and non-randomised studies

“…One study in this review examined the impact of deprescribing on medication costs and demonstrated a significant reduction [43]. This is in line with the findings of a previous systematic review and interventional studies conducted in different healthcare settings including nursing homes, intermediate and acute care settings, which found that medication review and deprescribing among older people generated substantial cost savings and a reduction in medication costs [33,[77][78][79][80][81][82][83][84][85][86]. However, the cost-effectiveness of medicines optimisation is still unclear and many reviews have highlighted the paucity of evidence regarding the economic impact of these interventions [87][88][89].…”

“…Two of the included studies reported that deprescribing reduced the number of regular medicines and PIMs consumed by frail older people [42,43], and one reported that deprescribing did not adversely affect the rate of hospitalisation or mortality [43]. This reflects similar findings reported in a recent systematic review of deprescribing for frail older people in all types of healthcare settings, which demonstrated the feasibility, safety, tolerability and effectiveness of deprescribing in reducing the number of prescribed medications and number of PIMs [33]. These findings are also consistent with the findings of several other systematic reviews that examine the impact of deprescribing among older people in primary and secondary care settings as well as community-dwelling older adults [66][67][68].…”

“…It encompasses medication withdrawal and reduction of medication dose and frequency [28][29][30][31][32]. A recent systematic review demonstrated that deprescribing among older people living with frailty in all types of healthcare settings significantly reduced the number of prescribed medications and PIMs [33]. However, little work has been conducted in hospitalised frail older patients to examine the impact of medicines optimisation interventions in secondary and acute care settings.…”

Key concepts in medication management in older persons for pharmacists practicing in non‐geriatric specialties

“…23 The safety of deprescribing has been explored in two systematics reviews. 24,25 Both reported that deprescribing was safe and not associated with increased hospitalisations, adverse events or mortality. Deprescribing was associated with a positive impact on a range of clinical outcomes including depression, function and frailty but did not impact quality of life.…”

“…Deprescribing was associated with a positive impact on a range of clinical outcomes including depression, function and frailty but did not impact quality of life. 25 While deprescribing should be an integral part of the medication review process for all people, it is even more critical for older persons due to age-related changes increasing the risk of medication-related harms, alongside changing patient treatment goals and preferences that may occur over time. A recent overview of tools and resources to support deprescribing in clinical practice, published in this journal, provides pharmacists caring for older persons with practical guidance for incorporation into daily practice.…”