Tools for Deprescribing in Frail Older Persons and Those With Limited Life Expectancy

A Systematic Review

Wade Thompson, PharmD, MSc; Carina Lundby, MScPhm; Trine Graabæk, MScPhm, PhD; Dorthe S. Nielsen, RN, MHS, PhD; Jesper Ryg, MD, PhD; Jens Søndergaard, MD, PhD; Anton Pottegård, MScPhm, PhD

Disclosures

J Am Geriatr Soc. 2019;67(1):172-180. 

In This Article

Abstract and Introduction

Abstract

Objectives: To summarize available tools that can assist clinicians in identifying and reducing or stopping (deprescribing) potentially inappropriate medications and that specifically consider frailty or limited life expectancy.

Design: Systematic review and narrative synthesis.

Setting: We searched MEDLINE (via Ovid SP), EMBASE (via Ovid SP), and CINAHL from inception to December 2017, along with grey literature. We included articles that described a tool to guide deprescribing of medications.

Participants: Frail older persons and older persons with limited life expectancy.

Measurements: Narrative description of tools.

Results: We identified 15 tools and organized them into three main categories: tools (n = 2) that described a model or framework for approaching deprescribing, tools (n = 9) that outlined a deprescribing approach for the entire medication list, and tools (n = 4) that provided medication-specific advice. The complexity of the tools ranged from simple lists to detailed, step-wise protocols. The development methodology varied widely, and the methods used to synthesize the tools were generally not well described. Most tools were based on expert opinion. Only four of the 15 tools have been tested in clinical practice (in very low-quality studies).

Conclusion: Tools exist to help clinicians deprescribe in frail older persons and those with limited life expectancy. These tools may assist clinicians at various stages in the deprescribing process. However, it remains to be investigated whether use of such tools in practice is likely to improve clinical outcomes or reduce inappropriate medication use.

Introduction

Older persons often take many medications[1] and are more susceptible to the adverse effects of medications compared to younger persons.[2,3] Polypharmacy has been defined as concomitant use of multiple medications (often arbitrarily defined as use of ≥5 or ≥10 medications), use of medications that are not indicated, or use of medications for which harms outweigh benefits.[4,5] Regardless of the definition, the prevalence of polypharmacy is increasing in older persons,[6] and it is associated with an increased risk of adverse health outcomes such as falls, adverse drug events, and hospitalizations, even after accounting for comorbidities.[4,7] In frail older persons and those with limited life expectancy, there is also a lack of evidence of benefit from some common treatments[8] (e.g., statins or intensive blood glucose control in type 2 diabetes mellitus). However, these individuals sometimes continue on such treatments[9] without reassessment when the potential for harm may outweigh the potential for benefit. Older persons may also be started on medications for which the known time to benefit exceeds life expectancy.[10,11] Finally, goals of drug treatment may shift from reducing risk of disease and prolonging life to maintaining quality of life and reducing treatment burden.[8]

When medications are potentially inappropriate for the reasons outlined above, patients and prescribers may be interested in reducing or stopping them. Deprescribing is the planned, supervised dose reduction or stopping of a medication.[12] Prescribers sometimes view deprescribing as challenging because of lack of time and resources as well as low self-efficacy,[13,14] but some resources are available to help clinicians with deprescribing decisions. These include resources focusing on screening for potentially inappropriate medications (e.g., Beers criteria, Screening Tool of Older People's Prescriptions (STOPP) criteria), providing a general framework for the deprescribing process, and giving medication-specific guidance.[15]

The range of tools available to support deprescribing was summarized in 2012[15] and 2017 (search conducted December 2015),[16] but neither review focused specifically on frail older persons or those with limited life expectancy. Although deprescribing is important to consider at all stages of medical care, it is particularly important in frail older adults and those with limited life expectancy for the reasons outlined above. Thus, it will be helpful for clinicians to be aware of and use the deprescribing tools that are most applicable to this population.

With this systematic review, we aimed to identify and describe tools focused on deprescribing medications in frail older persons and those with limited life expectancy. We wanted to provide an overview of tools that clinicians can use to manage polypharmacy in this population and identify what is needed from future studies within the field.

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