Deprescribing in Older People Approaching End of Life

A Randomized Controlled Trial Using STOPPFrail Criteria

Denis Curtin, MB; Emma Jennings, MB; Ruth Daunt, MB; Sara Curtin, MSc; Mary Randles, MB; Paul Gallagher, PhD; Denis O'Mahony, MD

Disclosures

J Am Geriatr Soc. 2020;68(4):762-769. 

In This Article

Abstract and Introduction

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.

Introduction

Nursing home residents are among the greatest consumers of prescription medications.[1] This is important for several reasons. First, polypharmacy in this population is strongly associated with an increased risk of adverse drug events.[2,3] Second, many older people entering the nursing home environment have markedly reduced life expectancy. In the United States, the median length of stay in a nursing home before death is 5 months; in the United Kingdom, the median length of stay is 15 months.[4,5] In this context, patients frequently do not live long enough to realize the benefit of some of their prescribed medicines, and, indeed, the consumption of multiple pills may be physically and emotionally burdensome. Finally, there is an opportunity cost to prescribing inappropriate medications that could be measured as the health benefits that would have been achieved had the money been spent on alternative interventions or programs (eg, improving the social environment of the nursing home, specialist palliative care services).[6]

Functional decline during an acute hospital admission is often the trigger for admission to long-term care facilities. Indeed, most patients who transfer to nursing homes come from the hospital setting.[7] Therefore, there is an opportunity, before this transition, to conduct a formal medication review while the patient is under medical supervision in the hospital environment. When life expectancy is likely to be limited, an approach focused on enhancing quality of life should be prioritized over long-term preventive strategies or achieving strict chronic disease management targets. The term deprescribing refers to the process of withdrawing potentially inappropriate medications, supervised by healthcare professionals, with the goal of managing polypharmacy and improving patient outcomes.[8] A 2018 systematic review by Thillainadesan et al that evaluated randomized controlled trials of deprescribing interventions in hospitalized older adults found that potentially inappropriate medications could be successfully withdrawn without compromising patient safety or well-being.[9]

Many of the deprescribing interventions included in the review by Thillainadesan et al involved a pharmacist and/or a physician conducting a formal medication review. Identifying deprescribing targets in frail multimorbid older people is clearly complex, and healthcare professionals are likely to vary in their assessment of the importance and appropriateness of medications.[10,11] Evidence indicates that hospital physicians commonly forgo the opportunity to deprescribe because of fear of negative consequences such as symptom relapse, clinical deterioration, litigation, or increased workload.[12] Therefore, structured interventions, which can be reproduced in different settings by clinicians of different specialties, may be preferable.[13]

STOPPFrail criteria were recently developed to assist clinicians with deprescribing decisions in older people approaching end of life (Table 1).[14] The criteria consist of 27 indicators that highlight instances of potentially inappropriate prescribing in this particular population of older patients. STOPPFrail-guided deprescribing was shown to have substantial interrater reliability among clinicians of different specialities, and it may be a reasonable and potentially efficient alternative to a specialist medication review where this is unavailable.[15,16]

The primary aim of the present study was to examine whether STOPPFrail-guided deprescribing could reduce the number of medications taken by frail older people transferring from the hospital to nursing home care compared with usual pharmaceutical care alone. Secondary aims were to determine the effect of this intervention on unscheduled hospital admissions, falls, fractures, antipsychotic prescribing, monthly medication costs, quality of life, and mortality.

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