Evidence-Based Practice Proposal – Final Paper

Age and Ageing 2018; 47: 638–640 doi: 10.1093/ageing/afy014 Published electronically 23 February 2018

© The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: [email protected]

COMMENTARIES

Deprescribing: the emerging evidence for and the practice of the ‘geriatrician’s salute’

SARAH N. HILMER1, DANIJELA GNJIDIC2

1Kolling Institute of Medical Research, Sydney Medical School, Sydney University and Royal North Shore Hospital, St Leonards, New South Wales 2065, Australia 2Faculty of Pharmacy and Charles Perkins Centre, University of Sydney, New South Wales 2006, Australia

Address correspondence to: S. N. Hilmer. Tel: +612 9926 4481; Fax: +612 9926 4053. Email: [email protected]

Abstract

The process of a health professional withdrawing medicines for which the current risk may outweigh the benefit in the indi- vidual patient has been given a variety of names including the colloquial ‘geriatrician’s salute’, ‘de-intensification’ and increas- ingly ‘deprescribing’. The rise of deprescribing as a word with a definition, evidence base and implementation plan, reflects the changing environment in which we practice. In particular, the emphasis on evidence-based medicine and the need to care for our expanding ageing populations, which requires application of components of geriatric evaluation and manage- ment by a wider range of health care practitioners. However, there are still significant challenges related to research on the safety, efficacy and implementation of deprescribing. In this commentary, we discuss the current evidence on the effects of deprescribing, emergence of implementation tools to embed deprescribing into the clinical care of older adults, as well as efforts to develop guidelines to improve health care practitioners’ awareness and self-efficacy of deprescribing. Ultimately, judicious prescribing and deprescribing, across a wide range of health care settings, ought to enable older people to use medicines to support their achievable ageing goals.

Keywords: deprescribing, prescribing, geriatric evaluation and management, older people

Judicious, frequent, goal-oriented medication review is a core component of the practice of geriatric medicine. As geriatricians, we ensure that our patients are not denied treatments that may help them because they are considered ‘too old’, while minimising iatrogenesis, which includes adverse effects of medicines. One way to achieve this is by ceasing medicines for which the current risk is thought to outweigh the benefit in the individual patient. This process has been given a variety of names: the colloquial ‘geriatri- cian’s salute’, ‘de-intensification’ and increasingly ‘depre- scribing’, which is defined in the literature as, ‘the process of withdrawal of an inappropriate medication, supervised by a health care professional with the goal of managing polypharmacy and improving outcomes’ [1].

The rise of deprescribing as a word with a definition, evidence base and implementation plan, reflects the chan- ging environment in which we practice. Geriatricians cannot possibly evaluate and manage every older person in our ageing population. Therefore, we need to objectively define and describe some of our strategies, including medication

review, so that they can be performed by other health care practitioners, reserving our face to face clinical expertise for the most complex patients. Emergence of evidence-based medicine to guide prescribing has resulted in calls for comparable evidence to guide deprescribing. As evidence on the effects of deprescribing grows, tools of implementation science for behaviour change are simultaneously being applied to embed deprescribing into the routine clinical care of older adults.

In the era of evidence-based medicine, clinicians report that a lack of evidence of the safety and efficacy of deprescrib- ing is a major barrier to practicing deprescribing [2] and there are significant efforts to address this. Systematic reviews sug- gest that deprescribing certain medication classes may reduce adverse events and improve quality of life [3]. Deprescribing has been consistently shown to be safe: it appears to improve survival in non-randomised studies and does not reduce sur- vival in randomised studies [4]. While there is high-grade evidence that deprescribing of psychotropics reduces falls [4], there is limited evidence of the impact of deprescribing targeting polypharmacy in general on global health outcomes

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that are critical for successful ageing, such as physical and cognitive function. This is also the case for most prescribing interventions. While there is an absence of evidence at pre- sent, it is plausible that deprescribing, which tackles only one part of geriatric evaluation and management, may not have a big impact on multifactorial geriatric syndromes. However, since adverse effects of medications are one of the most reversible causes of geriatric syndromes, it is important that they are addressed.

Research on how to deprescribe is emerging concurrently with the evidence on its safety and efficacy. Enablers and bar- riers to deprescribing have been described for practitioners [2] and for patients [5]. For practitioners, in addition to lack of evidence, these include problem awareness, inertia because of lower perceived value of stopping than continuing medicines, self-efficacy and feasibility [2]. Key factors identified by patients are the appropriateness of cessation, the need for a process for cessation, previous experiences, influence of health care practitioners, family and friends, fear of cessation and dis- like of medications [5]. Researchers are striving to define and test a ‘deprescribing process’ for routine care to address polypharmacy, including the five step patient-centred depre- scribing process, the CEASE protocol (Current medications, Elevated risk, Assess, Sort, Eliminate), and the Good Palliative-Geriatric Practice algorithm [6]. A number of clin- ical trials have assessed the feasibility of deprescribing benzo- diazepines in older patients and have yielded success rates between 27% and 80% targeting patients and/or different health care practitioners in a range of settings [7]. While most studies demonstrate that benzodiazepine withdrawal is feasible and safe in the older population, the clinical impact and sus- tainability of various interventions is yet to be established. Similarly, a recent Cochrane review which assessed the benefits and harms of deprescribing long-term proton pump inhibitor therapy in adults reported a reduction in pill burden, an increase in gastro intestinal symptoms and insufficient evi- dence in relation to long-term benefits and harms [8].

Guidelines are being developed that aim to improve health care practitioners’ awareness and self-efficacy of deprescribing. However, while rigorous methodology has been developed and utilised to generate the guidelines [9], the recommenda- tions are rarely supported by a strong evidence base because of the limited evidence on safety and efficacy of deprescribing. The Deprescribing Guidelines in the Elderly group, based in Canada have developed evidence-based deprescribing guidelines for a range of medication classes including proton pump inhi- bitors (PPIs), benzodiazepines, antipsychotics, cholinesterase inhibitors and memantine, with tools to support implementa- tion. While preliminary evidence suggests the guidelines and tools may reduce the use and cost of certain medication such us proton pump inhibitors [10], no randomised trial to date has assessed impact of rolling out guidelines on a population level on prescribing, patient-centred or clinical outcomes.

Other tools have been developed to facilitate deprescrib- ing in practice. Implementation of deprescribing is greatly assisted by access to non-pharmacological therapies. Efforts

are being made internationally to consolidate the evidence for and improve the availability of these therapies, through projects such as the European Union funded SENATOR- ONTOP (Optimal Evidence-Based Non-drug Therapies in Older People) series. A wide range of tools to help identify medications that are likely to be candidates for deprescrib- ing have been developed and validated, such as the STOPP criteria, Beers criteria and Drug Burden Index [6]. Most recently computerised decision support systems have been developed to facilitate using these tools to identify medica- tions for which risk is likely to outweigh benefit and prompt deprescribing in practice [11]. Use of the tools, and collab- oration between medical practitioners, pharmacists and nurses [12] may enable wider deprescribing practice and reach a broader group of older people than those who can access geriatricians.

Deprescribing occurs most often in patients during their last year of life, as it becomes clearer that a person’s care goals focus on comfort, and the time to benefit from most pre- ventative medications is limited. For example, it has been demonstrated that withdrawal of statins in patients with life limiting illness is safe [13], and analysis of national data from New Zealand found that statins were discontinued in the last year of life in 70.4% of people with cancer [14]. There are also efforts to apply deprescribing to specific patient populations such as people with chronic kidney disease [15].

There are opportunities for deprescribing across all health care settings where a comprehensive and, where pos- sible, multidisciplinary review can be performed. These include on admission to hospital where a new diagnosis or change in prognosis may become apparent, on transition to a nursing home, and during regular review by a practitioner who knows the patient well in the community. Healthcare for older people is frequently fragmented between settings and practitioners, and rather than ‘passing the buck’ for the responsibility of medication review, a collaborative approach with excellent communication is required [12]. The patient’s goals and priorities are central to deprescribing, and the vast majority of patients report that they would like to stop a medicine if their doctor said that they could [5].

Despite increasing international efforts, clinicians and researchers still face significant challenges in relation to depre- scribing research to generate evidence on safety, efficacy and implementation. We need to move away from conducting pilot deprescribing studies, which test feasibility in relation to pre- scribing outcomes, but are not powered to evaluate clinical outcomes. In addition, the choice of study design and interven- tion needs to be carefully selected to ensure that outcomes of deprescribing trials are reproducible, beneficial to patients and cost effective. The optimal study design will depend on the study population, outcomes of interest (e.g. short versus long- term), setting and health care system. Improving the evidence base for deprescribing, educating health care practitioners, and increasing public awareness are essential for application of deprescribing to clinical care and translation to policy. The ultimate aim is that through careful, informed prescribing and

Deprescribing: the emerging evidence for and the practice of the ‘geriatrician’s salute’

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deprescribing, across a wide range of health care settings, older people will use medicines to support their achievable ageing goals.

Key points

• Judicious, frequent, goal-oriented medication review is a core component of the practice of geriatric medicine.

• Deprescribing is the process of supervised withdrawal of a medication that aims to improve patient outcomes.

• Research on how to deprescribe is emerging concurrently with the evidence on its safety and efficacy.

Conflict of interest

None declared.

Funding

D.G. is supported by the Australian National Health and Medical Research Council Dementia Leadership Fellowship (1136849).

References

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Received 2 January 2018; editorial decision 4 January 2018

S. N. Hilmer and D. Gnjidic

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