Deprescribing in Older People Approaching End of Life: A Randomized Controlled Trial Using STOPPFrail Criteria

Abstract

OBJECTIVES Older people approaching end of life are commonly prescribed multiple medications, many of which may be inappropriate or futile. Our objective was to examine the effect of applying the STOPPFrail, a recently developed deprescribing tool, to the medication regimens of older patients with advanced frailty. DESIGN Randomized controlled trial. SETTING Two acute hospitals in Ireland. PARTICIPANTS Adults 75 years or older (n = 130) with advanced frailty and polypharmacy (five or more drugs), transferring to long‐term nursing home care. INTERVENTION A STOPPFrail‐guided deprescribing plan was presented to attending physicians who judged whether or not to implement recommended medication changes. MEASUREMENTS The primary outcome was the change in the number of regular medications at 3 months. Secondary outcomes included unscheduled hospital presentations, falls, quality of life, monthly medication costs, and mortality. RESULTS Intervention (n = 65) and control group (n = 65) participants were prescribed a mean (plus or minus standard deviation [SD]) of 11.5 (±3.0) and 10.9 (±3.5) medications, respectively, at baseline. The mean (SD) change in the number of medications at 3 months was −2.6 (±2.73) in the intervention group and −.36 (±2.60) in the control group (mean difference = 2.25 ± .54; 95% confidence interval [CI] = 1.18‐3.32; P < .001). The mean change in monthly medication cost was –$74.97 (±$148.32) in the intervention group and –$13.22 (±$110.40) in the control group (mean difference $61.74 ± $26.60; 95% CI = 8.95‐114.53; P = .02). No significant differences were found between groups for any of the other secondary outcomes. CONCLUSION STOPPFrail‐guided deprescribing significantly reduced polypharmacy and medication costs in frail older people. No significant differences between groups were observed with regard to falls, hospital presentations, quality of life, and mortality, although the trial was likely underpowered to detect differences in these outcomes. J Am Geriatr Soc 68:762–769, 2020

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

“…Several tools and algorithms were used to guide deprescribing. Two studies used explicit criteria (lists of drug names targeted); one used only the STOPP criteria [36], one used the STOPPFrail tool [34]. Two studies utilised implicit criteria (lists of evaluative questions or a process) developed by the research teams themselves including the Gar nkel algorithm for concurrent deprescribing of multiple medications [38], and guidelines for targeted deprescribing of anticholinergic and sedative medicines [35].…”

“…In addition, adverse effects of psychotropic medications decreased signi cantly by a mean difference of 1.8 (95%, CI; p < 0.05) three months after deprescribing, and by a mean difference of 2.24 (95%, CI; p < 0.05) after six months of deprescribing. One RCT in hospital reported that 88% of deprescribing recommendations based on STOPPFrail were accepted and implemented and no adverse events were reported of MDT-led deprescribing during three months follow-up [34].…”

“…Two MDT-led deprescribing studies in hospital and community showed no signi cant differences in unplanned hospitalisation and mortality [34,38]. The RCT in hospital showed no statistically signi cant differences between the intervention and control groups for three months unscheduled hospital presentations [0.14 intervention vs 0.08 control, 95% CI, P=0.27] and mortality [ 0.18 vs 0.28, 95% CI; P=0.22] [34] .…”

“…Two MDT-led deprescribing studies in hospital and community showed no signi cant differences in unplanned hospitalisation and mortality [34,38]. The RCT in hospital showed no statistically signi cant differences between the intervention and control groups for three months unscheduled hospital presentations [0.14 intervention vs 0.08 control, 95% CI, P=0.27] and mortality [ 0.18 vs 0.28, 95% CI; P=0.22] [34] . Similarly a longitudinal cohort study in community reported that the incidence of hospitalizations per patient per year (0.39 intervention vs 1.02 comparator, p= 0.1006) and survival (77% intervention vs 67% comparator group, p=0.026) was comparable between the groups after three years [38].…”

“…All six studies reported medication-related outcomes [33][34][35][36][37][38]. Four studies reported a signi cant reduction in the number of medications taken by patients living with frailty after implementing deprescribing, ranging from a mean of 2-3 medicines stopped per patient [33][34][35] across the different settings to unsurprisingly 7 medications per patient when poly-deprescribing of three or more drugs was implemented in people's home [38].…”