Implementation considerations of deprescribing interventions: A scoping review

Abstract

Over half of older adults experience polypharmacy, including medications that may be inappropriate or unnecessary. Deprescribing, which is the process of discontinuing or reducing inappropriate and/or unnecessary medications, is an effective way to reduce polypharmacy. This review summarizes (1) the process of deprescribing and conceptual models and tools that have been developed to facilitate deprescribing, (2) barriers, enablers, and factors associated with deprescribing, and (3) characteristics of deprescribing interventions in completed trials, as well as (4) implementation considerations for deprescribing in routine practice. In conceptual models of deprescribing, multilevel factors of the patient, clinician, and health‐care system are all related to the efficacy of deprescribing. Numerous tools have been developed for clinicians to facilitate deprescribing, yet most require substantial time and, thus, may be difficult to implement during routine health‐care encounters. Multiple deprescribing interventions have been evaluated, which mostly include one or more of the following components: patient education, medication review, identification of deprescribing targets, and patient and/or provider communication about high‐risk medications. Yet, there has been limited consideration of implementation factors in prior deprescribing interventions, especially with regard to the personnel and resources in existing health‐care systems and the feasibility of incorporating components of deprescribing interventions into the routine care processes of clinicians. Future trials require a more balanced consideration of both effectiveness and implementation when designing deprescribing interventions.

Antipsychotic use among older patients with dementia receiving home health care services: Prevalence, predictors, and outcomes

“…Prescribers, HHC clinicians, and family caregivers should pay attention to inappropriate use of antipsychotics, regularly monitor patient symptoms and potential side effects on outcomes. Serving over 3.3 million Medicare beneficiaries every year, 34,35 HHC is a leading provider of home‐based care for older adults, 36 including home medication review and reconciliation, 19,37 making them an invaluable source for identifying antipsychotic use. Moreover, HHC clinicians should play a bigger role in deprescribing antipsychotics as they can help meet the underlying needs that cause BPSD, 14 such as by assessing and managing pain, 38,39 monitoring symptom changes in medical conditions, 40 removing stressors in the home (e.g., noise, temperature, light), and educating the patients and caregivers, as well as providing social contact.…”

“…HHC nurses typically start by reviewing the patient's written prescriptions (scheduled and pro‐re‐nata) from the referring provider (e.g., the prescription list upon hospital discharge or from the primary care provider). The patient's home is then visually inspected to identify medications not listed on the prescription list, such as over‐the‐counter drugs, nutritional supplements, and prescriptions from other providers 19 . Once every medicine has been identified, HHC nurses ask the patient/caregiver if the patient takes it regularly (e.g., more than 1 day a week).…”

The Barriers to Deprescription in Older Patients: A Survey of Spanish Clinicians

“…Although it is clear that all barriers, in one way or another, can influence the deprescription process, the appearance of certain barriers in the process affects the feasibility of implementing this activity [ 15 ]. The difficulty of modifying prescriptions made by other professionals and the resistance to withdrawal by the patient or caregiver are related to the degree of acceptance of the recommendations by the clinician, a variable highly evaluated in feasibility studies [ 17 , 18 , 19 ].…”

Determinants of implementing deprescribing for older adults in English care homes: a qualitative interview study

“…The National Institute for Health and Care Excellence (NICE) recommends deprescribing as part of the comprehensive medication review of a person with multiple long-term conditions 16–18. While appropriate deprescribing is usually commended and may be cautiously undertaken to good effect,15 there is a lack of information about how to implement it safely and appropriately 19. Recommendations overlook the specific contextual factors and various stakeholder views of care homes 20.…”

“…Considering these findings, the present study investigated the process of implementing deprescribing and these contextual factors in English care homes, including the roles and relationships of different stakeholders, which influence it. Furthermore, implementation activities of deprescribing in care homes are typically not well described and poorly understood 19 31. A better understanding of how contextual factors facilitate or hinder deprescribing, informed by an implementation framework, is needed to support the translation of deprescribing recommendations into practice 32 33…”