Attitudes Toward Deprescribing Among Older Adults With Dementia in the United States

Matthew E. Growdon MD, MPH; Edie Espejo MA; Bocheng Jing MS; W. John Boscardin PhD; Andrew R. Zullo PharmD, PhD; Kristine Yaffe MD; Kenneth S. Boockvar MD, MS; Michael A. Steinman MD

Disclosures

J Am Geriatr Soc. 2022;70(6):1764-1773. 

In This Article

Abstract and Introduction

Abstract

Background: People with dementia (PWD) take medications that may be unnecessary or harmful. This problem can be addressed through deprescribing, but it is unclear if PWD would be willing to engage in deprescribing with their providers. Our goal was to investigate attitudes toward deprescribing among PWD.

Methods: This was a cross-sectional study of 422 PWD aged ≥65 years who completed the medications attitudes module of the National Health and Aging Trends Study (NHATS) in 2016. Proxies provided responses when a participant was unable to respond due to health or cognitive problems. Attitudinal outcomes comprised responses to two statements from the patients' attitudes toward deprescribing questionnaire and its revised version (representing belief about the necessity of one's medications and willingness to deprescribe); another elicited the maximum number of pills that a respondent would be comfortable taking.

Results: The weighted sample represented over 1.8 million PWD; 39% were 75 to 84 years old and 38% were 85 years or older, 60% were female, and 55% reported six or more regular medications. Proxies provided responses for 26% of PWD. Overall, 22% believed that they may be taking one or more medicines that they no longer needed, 87% were willing to stop one or more of their medications, and 50% were uncomfortable taking five or more medications. Attitudinal outcomes were similar across sociodemographic and clinical factors. PWD taking ≥6 medications were more likely to endorse a belief that at least one medication was no longer necessary compared to those taking <6 (adjusted probability 29% [95% confidence interval (CI), 22%–38%] vs. 13% [95% CI, 8%–20%]; p = 0.004); the same applied for willingness to deprescribe (92% [95% CI, 87%–95%] vs. 83% [95% CI, 76%–89%]; p = 0.04).

Conclusions: A majority of PWD are willing to deprescribe, representing an opportunity to improve quality of life for this vulnerable population.

Introduction

People with dementia (PWD) have a higher prevalence of polypharmacy than those without dementia and in many cases receive medications that may be unnecessary, discordant with goals of care, or harmful.[1,2] A large body of research has demonstrated that polypharmacy in older adults increases the risk of exposure to potentially inappropriate medications and is associated with a higher likelihood of adverse drug reactions, drug–drug interactions, falls, cognitive decline, and even mortality.[3–5] Given that PWD are particularly vulnerable to the occurrence and adverse outcomes of polypharmacy and potentially inappropriate prescribing,[6] current efforts are underway to develop and implement deprescribing interventions in this population.[7–9]

Deprescribing refers to the clinically supervised process of tapering or stopping drugs, with the goal of minimizing inappropriate polypharmacy and improving patient outcomes.[10] Successful approaches to deprescribing are grounded in a shared decision-making process with patient involvement; in caring for adults with dementia, this process necessarily includes caregivers in many cases.[8,11] As such, attaining an understanding of the views and attitudes of PWD and their caregivers is critical to the ongoing development of deprescribing interventions for PWD.

Prior work has underscored that older adults in the U.S. hold skeptical attitudes toward some medications and welcome deprescribing efforts.[12] Additionally, qualitative studies have elucidated the importance of culturally competent approaches to deprescribing among PWD from diverse communites[13] and the importance of ensuring robust non-pharmacologic strategies and caregiver supports when addressing medications used for symptom management in dementia.[14] However, the broad attitudes toward medications and deprescribing of PWD and/or their caregivers remain undocumented in a widely generalizable U.S. sample. With the goal of aiding efforts to identify PWD and caregivers particularly amenable to reductions in medication usage, we described attitudes toward medications and deprescribing among PWD in a nationally representative sample and elucidated factors associated with these attitudes.

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