Clinical practice guidelines for older people with multimorbidity and life-limiting illness: what are the implications for deprescribing?

Okeowo, Daniel; Patterson, Alastair; Boyd, Cynthia M.; Reeve, Emily; Gnjidic, Danijela; Todd, Adam

doi:10.1177/2042098618795770

Cited by 22 publications

(15 citation statements)

References 41 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…The evidence suggests that deprescribing is widely acceptable to patients and carers [23–25], yet geriatricians and pharmacists believe there to be resistance. An intervention should therefore target “Social influences” to address this misalignment between the evidence and practitioners’ beliefs.…”

Section: Discussionmentioning

confidence: 99%

Development of a hospital deprescribing implementation framework: A focus group study with geriatricians and pharmacists

et al. 2019

View full text Add to dashboard Cite

Background over 50% of older people in hospital are prescribed a pre-admission medicine that is potentially inappropriate; however, deprescribing by geriatricians and pharmacists is limited. This study aimed to characterise geriatricians’ and pharmacists’ barriers and enablers to deprescribing in hospital. It also intended to develop a framework of intervention components to facilitate implementation of hospital deprescribing. Methods fifty-four geriatricians and pharmacists representing four UK hospitals attended eight focus groups. We designed a topic guide to invite discussions about barriers and enablers to deprescribing. After thematic analysis, themes were mapped to the theoretical domains framework (TDF), enabling prioritisation of domains for behaviour change. We then identified evidence-based intervention components for changing behaviour within prioritised TDF domains. Results geriatricians and pharmacists described several deprescribing enablers in the hospital setting including alignment with their role and generalist knowledge, and routine patient monitoring. Five prioritised TDF domains represent the key barriers and enabler: patient and caregiver attachment to medication (social influence); perceptions that deprescribing is riskier than continuing to prescribe (beliefs about consequences); pharmacists’ working patterns limiting capacity to support deprescribing (environmental context and resources); deprescribing being a low hospital priority (goals) and incentives to deprescribe (reinforcement). Prioritised TDF domains aligned with 44 evidence-based intervention components to address the barriers and enabler to hospital deprescribing. Conclusion the behavioural determinants and their associated intervention components provide a hospital deprescribing implementation framework (hDIF). Intervention components should be selected from the hDIF to provide a theory and evidence-based intervention tailored to hospital contexts.

show abstract

Section: Discussionmentioning

confidence: 99%

Development of a hospital deprescribing implementation framework: A focus group study with geriatricians and pharmacists

et al. 2019

View full text Add to dashboard Cite

show abstract

“…highlights just how skewed current systems are towards initiating and multiplying treatments with an inexorable progression of cumulative complexity. 21 They found few if any supports for thinking about the appropriateness of stopping, let alone when and how to do so. Against this background the challenge is likely to be drowned out in the noise of a system that places multiple demands on clinicians and patients who are working in funding frameworks that constrain time.…”

Section: For the International Group For Reducing Inappropriate Medicmentioning

confidence: 99%

Foreword to the first special collection: Addressing the invisible iatrogenic epidemic: the role of deprescribing in polypharmacy and inappropriate medication use

Mangin

Garfinkel

2019

Therapeutic Advances in Drug Safety

View full text Add to dashboard Cite

The role of de-prescribing in polypharmacy and inappropriate medication use For the International Group for Reducing Inappropriate Medication Use and Polypharmacy The issues around inappropriate medication use and polypharmacy (IMUP) for individual patients are well known: associations with harmful physical and psychological effects, negative implications for mobility and social interactions as well as the opportunity costs of the sheer burden of treatment. The effect of this problem at the population level is massive. Nearly one-half of older adults take five or more medications, and as many as one in five of these prescriptions is potentially inappropriate. 1,2 Older adults prescribed more medications are more likely to be hospitalized for an adverse drug reaction. 3 Moreover, adverse drug events account for more morbidity and mortality than most chronic diseases, 4,5 with death rates higher than many common cancers. 6,7 The prescribing cascade often attached to inappropriate medication use and polypharmacy drives overdiagnosis and overtreatment, escalating the cost of drugs and hospitalizations.

show abstract

“…Whereas seminal cardiovascular disease research and related CPGs have traditionally focused on single disease specific paradigms, this overlooks the fact that cardiovascular disease rarely presents as an isolated problem in old age. Providers adhering strictly to CPGs in patients with multimorbidity can potentially exacerbate risks associated with concurrent diseases (for example, aspirin increasing bleeding risk), contradict an older adult’s therapeutic goals (for example, prescribing additional drugs in a patient wanting to be on as few pills as possible), or both 34. However, as data are limited, little assistance is available to guide clinicians caring for older adults with multimorbidity.…”

Section: Geriatric Conditions In Older Adults With Cardiovascular Diseasementioning

confidence: 99%

“…Cardiovascular care is well known for its large clinical trials and evidence based clinical practice guidelines (CPGs), usually followed by cardiologists and non-cardiologists as a standard of excellence. Although CPGs largely achieve superior outcomes for the general population, including many older adults, following such recommendations can be less reliable in older adults, for whom clinical complexities associated with aging are more likely to confound standard precepts 345. Geroscience is a burgeoning field that explores the intersection of aging biology and disease.…”

Section: Introductionmentioning

confidence: 99%

Cardiovascular care of older adults

Oneill

Forman

2021

BMJ

View full text Add to dashboard Cite

Age is an independent risk factor for cardiovascular disease. With the accelerated growth of the population of older adults, geriatric and cardiac care are becoming increasingly entwined. Although cardiovascular disease in younger adults often occurs as an isolated problem, it is more likely to occur in combination with clinical challenges related to age in older patients. Management of cardiovascular disease is transmuted by the context of multimorbidity, frailty, polypharmacy, cognitive dysfunction, functional decline, and other complexities of age. This means that additional insight and skills are needed to manage a broader range of relevant problems in older patients with cardiovascular disease. This review covers geriatric conditions that are relevant when treating older adults with cardiovascular disease, particularly management considerations. Traditional practice guidelines are generally well suited for robust older adults, but many others benefit from a relatively more personalized therapeutic approach that allows for a range of medical circumstances and idiosyncratic goals of care. This requires weighing of risks and benefits amidst the patient’s aggregate clinical status and the ability to communicate effectively about this with patients and, where appropriate, their care givers in a process of shared decision making. Such a personalized approach can be particularly gratifying, as it provides opportunities to optimize an older patient’s function and quality of life at a time in life when these often become foremost therapeutic priorities.

show abstract

Clinical practice guidelines for older people with multimorbidity and life-limiting illness: what are the implications for deprescribing?

Cited by 22 publications

References 41 publications

Development of a hospital deprescribing implementation framework: A focus group study with geriatricians and pharmacists

Development of a hospital deprescribing implementation framework: A focus group study with geriatricians and pharmacists

Foreword to the first special collection: Addressing the invisible iatrogenic epidemic: the role of deprescribing in polypharmacy and inappropriate medication use

Cardiovascular care of older adults

Contact Info

Product

Resources

About