Deprescribing of Problematic Polypharmacy

A special issue of Pharmacy (ISSN 2226-4787).

Deadline for manuscript submissions: closed (15 August 2019) | Viewed by 30038

Special Issue Editor


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Guest Editor
School of Pharmacy, University of Bradford, Bradford, England, UK
Interests: deprescribing in frail older people; patient involvement in shared-decision making; implementing of prescribing guidelines through behaviour change; use of anticoagulation to reduce strokes in atrial fibrillation

Special Issue Information

Dear Colleagues,

The population of most countries in getting older and patients now commonly live with multimorbidity, which in turn is treated with increasing amounts of repeat prescriptions (polypharmacy). In addition, the increase in polypharmacy for older people is also fueled by the perceived need of prescribers to follow national guidance which encourage prescribing. Whilst prescribing may have benefits that outweigh risks, as patients become older and frailer it may be that some prescribing is no longer appropriate. As a consequence, health commissioners, practitioners and researchers are encouraging a focus on deprescribing of medicines that are no longer suitable, unlikely to provide benefit or are causing, or could cause, more harm than benefit.

However there remain many unanswered questions about deprescribing that are barriers to implementing change in practice. For example, how harmful is polypharmacy in frail older people? Which medicines are safe to deprescribe and for which medical conditions? How should individual medicines be reduced and stopped? What are the medico-legal considerations of deprescribing and how can the risks of litigation be minimised? How do patients feel about having their long-term medicines stopped and how would they like to be involved in decisions to reduce or stop their medicines? And what terminology should we be using in patient consultations to describe “deprescribing”?

The scope of this Special Issue is to share learning on these questions and the broader subject of deprescribing, especially for, but not restricted to, the frail elderly population. I encourage you to present your research, reviews and quality improvement work on the topic of deprescribing.

Dr. Duncan Petty
Guest Editor

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Keywords

  • Deprescribing
  • Polypharmacy
  • Medication review
  • Patient participation
  • Frailty

Published Papers (6 papers)

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Research

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9 pages, 445 KiB  
Article
The Use of Primary Care Electronic Health Records for Research: Lipid Medications and Mortality in Elderly Patients
by Adam J. Hodgkins, Judy Mullan, Darren J. Mayne and Andrew Bonney
Pharmacy 2019, 7(3), 134; https://doi.org/10.3390/pharmacy7030134 - 18 Sep 2019
Cited by 1 | Viewed by 3210
Abstract
General practice electronic health record (EHR) data have significant potential for clinical research. This study demonstrates the feasibility of utilising longitudinal EHR data analysis to address clinically relevant outcomes and uses the relationship between lipid medication prescription and all-cause mortality in the elderly [...] Read more.
General practice electronic health record (EHR) data have significant potential for clinical research. This study demonstrates the feasibility of utilising longitudinal EHR data analysis to address clinically relevant outcomes and uses the relationship between lipid medication prescription and all-cause mortality in the elderly as an exemplar for the validity of this methodology. EHR data were analysed to describe the association of lipid medication use, non-use or cessation with all-cause mortality in patients aged ≥75 years. Survival analysis with Cox regression was used to calculate hazard ratios, which were adjusted for confounders. There was no significant difference in all-cause mortality among patients according to their use, non-use, or cessation of lipid medications. The outcomes of this study correlate well with the results of other research works. This single-practice study demonstrates the feasibility and potential of analysing EHR data to address important clinical issues such as the relationship between all-cause mortality and lipid medication prescription in the elderly. Full article
(This article belongs to the Special Issue Deprescribing of Problematic Polypharmacy)
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10 pages, 1003 KiB  
Article
Deprescribing: Practical Ways to Support Person-Centred, Evidence-Based Deprescribing
by Katherine Le Bosquet, Nina Barnett and John Minshull
Pharmacy 2019, 7(3), 129; https://doi.org/10.3390/pharmacy7030129 - 3 Sep 2019
Cited by 15 | Viewed by 6157
Abstract
Deprescribing is complex and multifactorial with multiple approaches described in the literature. Internationally, there are guidelines and tools available to aid clinicians and patients to identify and safely withdraw inappropriate medications, post a shared decision-making medicines optimisation review. The increase in available treatments [...] Read more.
Deprescribing is complex and multifactorial with multiple approaches described in the literature. Internationally, there are guidelines and tools available to aid clinicians and patients to identify and safely withdraw inappropriate medications, post a shared decision-making medicines optimisation review. The increase in available treatments and use of single disease model guidelines have led to a healthcare system geared towards prescribing, with deprescribing often seen as a separate activity. Deprescribing should be seen as part of prescribing, and is a key element in ensuring patients remain on the most appropriate medications at the correct doses for them. Due to the complex nature of polypharmacy, every patient experience and relationship with medications is unique. The individual’s history must be incorporated into a patient-centred medication review, in order for medicines to remain optimal through changes in circumstance and health. Knowledge of the law and appropriate recording is important to ensure consent is adequately gained and recorded in line with processes followed when initiating a medication. In recent years, with the increase in interested clinicians globally, a number of prominent networks have grown, creating crucial links for both research and sharing of good practice. Full article
(This article belongs to the Special Issue Deprescribing of Problematic Polypharmacy)
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16 pages, 659 KiB  
Communication
Person-Centred Care Including Deprescribing for Older People
by Heather Smith, Karen Miller, Nina Barnett, Lelly Oboh, Emyr Jones, Carmel Darcy, Hilary McKee, Jayne Agnew and Paula Crawford
Pharmacy 2019, 7(3), 101; https://doi.org/10.3390/pharmacy7030101 - 25 Jul 2019
Cited by 11 | Viewed by 7787
Abstract
There is concern internationally that many older people are using an inappropriate number of medicines, and that complex combinations of medicines may cause more harm than good. This article discusses how person-centred medicines optimisation for older people can be conducted in clinical practice, [...] Read more.
There is concern internationally that many older people are using an inappropriate number of medicines, and that complex combinations of medicines may cause more harm than good. This article discusses how person-centred medicines optimisation for older people can be conducted in clinical practice, including the process of deprescribing. The evidence supports that if clinicians actively include people in decision making, it leads to better outcomes. We share techniques, frameworks, and tools that can be used to deprescribe safely whilst placing the person’s views, values, and beliefs about their medicines at the heart of any deprescribing discussions. This includes the person-centred approach to deprescribing (seven steps), which incorporates the identification of the person’s priorities and the clinician’s priorities in relation to treatment with medication and promotes shared decision making, agreed goals, good communication, and follow up. The authors believe that delivering deprescribing consultations in this manner is effective, as the person is integral to the deprescribing decision-making process, and we illustrate how this approach can be applied in real-life case studies. Full article
(This article belongs to the Special Issue Deprescribing of Problematic Polypharmacy)
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14 pages, 254 KiB  
Article
Polypharmacy in African American Adults: A National Epidemiological Study
by Shervin Assari, Hamid Helmi and Mohsen Bazargan
Pharmacy 2019, 7(2), 33; https://doi.org/10.3390/pharmacy7020033 - 29 Mar 2019
Cited by 20 | Viewed by 3859
Abstract
Background: Despite the association between polypharmacy and undesired health outcomes being well established, very little is known about epidemiology of polypharmacy in the African American community. We are not aware of any nationally representative studies that have described the socioeconomic, behavioral, and health [...] Read more.
Background: Despite the association between polypharmacy and undesired health outcomes being well established, very little is known about epidemiology of polypharmacy in the African American community. We are not aware of any nationally representative studies that have described the socioeconomic, behavioral, and health determinants of polypharmacy among African Americans. Aims: We aimed to investigate the socioeconomic and health correlates of polypharmacy in a national sample of African American adults in the US. Methods: The National Survey of American Life (NSAL, 2003–2004) included 3,570 African American adults. Gender, age, socioeconomic status (SES; education attainment, poverty index, and marital status), access to the healthcare system (health insurance and having a usual source of care), and health (self-rated health [SRH], chronic medical disease, and psychiatric disorders) in addition to polypharmacy (5 + medications) as well as hyper-polypharmacy (10 + medications) were measured. Logistic regressions were applied for statistical analysis. Results: that About 9% and 1% of all African American adults had polypharmacy and hyper-polypharmacy, respectively. Overall, higher age, higher SES (education and poverty index), and worse health (poor SRH, more chronic medical disease, and psychiatric disorders) were associated with polypharmacy and hyper-polypharmacy. Individuals with insurance and those with a routine place for healthcare also had higher odds of polypharmacy and hyper-polypharmacy. Conclusions: Given the health risks associated with polypharmacy, there is a need for systemic evaluation of medication use in older African Americans with multiple chronic conditions. Such policies may prevent medication errors and harmful drug interactions, however, they require effective strategies that are tailored to African Americans. Full article
(This article belongs to the Special Issue Deprescribing of Problematic Polypharmacy)

Review

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14 pages, 476 KiB  
Review
Polypharmacy Definitions for Multimorbid Older Adults Need Stronger Foundations to Guide Research, Clinical Practice and Public Health
by Caroline Sirois, Nelia Sofia Domingues, Marie-Laure Laroche, Arsène Zongo, Carlotta Lunghi, Line Guénette, Edeltraut Kröger and Valérie Émond
Pharmacy 2019, 7(3), 126; https://doi.org/10.3390/pharmacy7030126 - 29 Aug 2019
Cited by 38 | Viewed by 5961
Abstract
There are numerous definitions of polypharmacy to describe the use of many medications among older adults, but there is a need to clarify if they are purposive and meaningful. By means of a systematic review, we identified definitions of polypharmacy used in multimorbid [...] Read more.
There are numerous definitions of polypharmacy to describe the use of many medications among older adults, but there is a need to clarify if they are purposive and meaningful. By means of a systematic review, we identified definitions of polypharmacy used in multimorbid older adults (≥65 years). We evaluated if the definitions align among the domains of research, clinical practice, and public health and appraised whether concepts of polypharmacy are based on strong foundations. More than 46 definitions of polypharmacy were retrieved from 348 publications (research: n = 243; clinical practice: n = 88; public health: n = 17). Several thresholds based on the number of medications were mentioned. The majority of the publications (n = 202, 58%) used a minimal threshold of five medications. Heterogeneous qualitative definitions were identified, mostly stating that polypharmacy is “more drugs than needed”. There was no significant divergence between domains as to the type of definitions used, although qualitative definitions were more common in clinical practice. Nearly half (n = 156, 47%) of the publications provided no justification for the polypharmacy definition used. The wide variety of definitions for polypharmacy precludes comparisons, appropriate identification and management of polypharmacy in multimorbid older adults. Standardized definitions would allow more coherent judgments regarding the individual and collective stakes of polypharmacy. Full article
(This article belongs to the Special Issue Deprescribing of Problematic Polypharmacy)
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Other

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7 pages, 169 KiB  
Discussion
Deprescribing: Fashion Accessory or Fig Leaf?
by Arnold G. Zermansky
Pharmacy 2019, 7(2), 49; https://doi.org/10.3390/pharmacy7020049 - 23 May 2019
Cited by 1 | Viewed by 2552
Abstract
Deprescribing is the general practice fashion accessory that no prescriber can be seen without. However, it is in danger of becoming a “fig leaf” substitute for the entire medication review suite. Full article
(This article belongs to the Special Issue Deprescribing of Problematic Polypharmacy)
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