Pulling Back the Curtain on Deprescribing Interventions

Abstract

Older adults living with dementia commonly experience polypharmacy and exposure to high-risk medications [1, 2]. According to findings from the National Health and Aging Trends Study, among people with dementia, 1 in 5 believe that they may be taking one or more medicines they no longer need, nearly 9 in 10 are willing to stop one or more of their medications, and half are uncomfortable taking five or more medications [3]. This underscores the need for tailored medication optimization strategies, including carefully designed, evidence-based deprescribing interventions.

ALIGN (Aligning Medications with What Matters Most) was a pragmatic, pharmacist-led telehealth deprescribing pilot study to support primary care providers in addressing polypharmacy in people living with dementia, who were age ≥ 65 and who were prescribed > 7 medications [4, 5]. The intervention consisted of a deprescribing educational brochure, a telehealth visit by a pharmacist with the patient-care partner dyad to discuss the patient's medications in the context of their goals and preferences, and deprescribing recommendations from the pharmacist conveyed to the primary care provider via the electronic health record. The primary goal of the intervention was to reduce total medication burden and regimen complexity by focusing on what matters most to patients and care partners. With the primary care provider's approval, the pharmacist was able to implement recommended medication changes. The intervention pharmacists held PharmD degrees with board certification in Geriatric Pharmacy. Pharmacist recommendations could include both stopping medications and starting medications; 73% of patients received a recommendation to stop a medication, or reduce the dose or frequency, while 42% received a recommendation to start a medication, or increase the dose or frequency.

In this issue of the Journal of the American Geriatrics Society, Green and colleagues complement the findings of the ALIGN study by reporting on an analysis of audio-recorded conversations between the intervention pharmacists and the patient-care partner dyads [5]. By characterizing these conversations, the authors aimed to provide new insights to guide the future development of deprescribing interventions. This qualitative study specifically focused on how elicitation of medication-related priorities from people with dementia and their care partners shaped discussions with the pharmacists.

Importantly, the investigator team has described what actually happened during the telehealth visits with patients and their care partners, including the actual language used by the pharmacists to explain their recommendations. This is a refreshing step forward beyond the usual “sterile” results reported out from most deprescribing intervention trials, which rarely ever extend beyond tables and figures summarizing mean total numbers of medications in the intervention versus control groups [6], or the proportion who were deprescribed a targeted medication class [7, 8].

In their paper, Green and colleagues highlight the important role and influence that pharmacists have in deprescribing interventions; in only four instances were the recommendations of pharmacists declined by the patient-care partner dyad. In addition, the study highlights the realities, practicalities, and challenges of carrying out broad-based deprescribing interventions directed at complex older patients with complicated medication regimens and polypharmacy. Patients participating in the study were taking an average of 13 medications.

In this study, there was no prioritization of which medication classes warranted the most attention. Such decisions were left up to the individual clinical pharmacist. The absence of a strategy to target specific high priority medication classes for deprescribing (e.g., those considered high-risk in people with dementia or cognitive impairment [9]) and of a consistent, evidence-based, and systematic deprescribing approach had important implications. For example, clinical pharmacists most frequently picked the lowest hanging (and least impactful) “fruit” (e.g., vitamins and supplements) for deprescribing, in preference to addressing substantially more challenging deprescribing situations, such as the use of antipsychotics in people with dementia.

As mentioned above, the intervention prioritized the preferences of care partners and patients. In theory, this is exactly what should happen, but perhaps with consideration of the risks associated with a particular drug therapy, and the possible availability of nonpharmacologic alternatives. For example, in the case of antipsychotics for behavioral symptoms of dementia, sometimes it seemed as if the only recommendation available was to continue the antipsychotic. Yet, there is considerable evidence supporting nonpharmacological interventions to address behavioral symptoms in persons living with dementia and associated care partner stress [10], but these strategies fell outside the scope of the intervention.

Understandably, the clinical pharmacists felt an obligation to try to do something to address high-priority symptoms, such as pain. Sometimes that led to recommendations to start a new medication or to increase the dose of an existing medication, even if evidence for effectiveness was questionable. Examples of non-evidence-based recommendations included increasing the dose of gabapentin for back pain, and starting a buprenorphine patch to treat pain relating to neuropathy.

There were also missed deprescribing opportunities and some possible inconsistencies regarding recommendations, as in the case of statin therapy, with one pharmacist quoted as saying to the care partner, “The estimator says that there is about a one in five chance of a heart attack or stroke within the next 10 years …. That leans me toward saying it's worth staying on cholesterol medicine to prevent that.” However, in the case of another patient, the advice was exactly the opposite: “We're now at the point where we don't need to be worrying about heart attack or stroke happening 15 years from now.”

The practicalities of spreading and scaling the intervention also deserve mention. The visits with pharmacists were time-consuming; over 90% of the visits took over 20 min, and for the majority, multiple follow-up interactions were required. The intensity of the intervention, and the associated personnel costs, could pose a challenge to widespread adoption.

In summary, Green and colleagues are to be commended for “pulling back the curtain” on this pharmacist-led deprescribing intervention. As the investigators acknowledge, “an unexpected finding was that the elicitation of people with dementia and care partner priorities often led to continuation of potentially inappropriate medications or the addition of medications that were not evidence-based.” Such insights are extraordinarily valuable in guiding future deprescribing efforts focused on these complex patients.

As in the case of any good study, we are left with lingering questions that lay the groundwork for future research. Among them: (1) Should deprescribing interventions address the entire pharmacopeia or be more narrowly focused on a limited number of high-priority, high-risk medication classes?; (2) What is the right thing to do when the goals and preferences of patients and care partners (“what matters most”) conflict with the available evidence regarding the safety and effectiveness of a drug therapy?; (3) How should the varied experiences and practice styles of individual pharmacists factor into the delivery of an intervention that should be evidence-based and consistently applied?; (4) Should a deprescribing intervention be limited solely to deprescribing or should it be broadened to encompass overall medication optimization, including the addition of new medications to the patient's regimen, as appropriate?; and (5) How do we empower pharmacists to apply their expertise and experience relating to non-pharmacologic strategies to further success in deprescribing?

To paraphrase W. Edwards Deming, “All [deprescribing interventions] are perfectly designed to get the results they get.” Green and colleagues have shown us just how true that is. Through their efforts we are a bit closer to being able to develop and implement medication optimization strategies that can truly enhance the lives of people living with dementia.

Jerry H. Gurwitz prepared the manuscript.

Dr. Jerry H. Gurwitz serves as a consultant to United Healthcare.

This publication is linked to a related article by Green et al. To view this article, visit https://doi.org/10.1111/jgs.19379.