Analysis

Too much medicine in older people? Deprescribing through shared decision making

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2893 (Published 03 June 2016) Cite this as: BMJ 2016;353:i2893
  1. Jesse Jansen, senior research fellow1 2,
  2. Vasi Naganathan, geriatrician and associate professor3,
  3. Stacy M Carter, associate professor4,
  4. Andrew J McLachlan, professor of pharmacy3 5,
  5. Brooke Nickel, PhD candidate1 2,
  6. Les Irwig, professor of epidemiology1,
  7. Carissa Bonner, senior research officer1 2,
  8. Jenny Doust, GP and professor of clinical epidemiology6,
  9. Jim Colvin, health consumer representative7,
  10. Aine Heaney, manager program design at NPS MedicineWise8,
  11. Robin Turner, biostatistician9,
  12. Kirsten McCaffery, professorial research fellow1 2
  1. 1Screening and Test Evaluation Program, Sydney School of Public Health, University of Sydney, NSW 2006, Australia
  2. 2Centre for Medical Psychology and Evidence Based Decision Making, University of Sydney
  3. 3Centre for Education and Research on Ageing, Ageing and Alzheimer’s Institute, Concord Hospital, University of Sydney
  4. 4Centre for Values, Ethics and the Law in Medicine, University of Sydney
  5. 5Faculty of Pharmacy, University of Sydney
  6. 6Centre for Research in Evidence Based Practice, Bond University, Queensland, Australia
  7. 7Health Consumers New South Wales, Australia
  8. 8NPS MedicineWise, Surry Hills, NSW, Australia
  9. 9School of Public Health and Community Medicine, University of New South Wales, Australia
  1. Correspondence to: J Jansen jesse.jansen{at}sydney.edu.au

Jansen and colleagues explore the role of shared decision making in tackling inappropriate polypharmacy in older adults

Too much medicine is an increasingly recognised problem,1 2 and one manifestation is inappropriate polypharmacy in older people. Polypharmacy is usually defined as taking more than five regular prescribed medicines.3 It can be appropriate (when potential benefits outweigh potential harms)4 but increases the risk of older people experiencing adverse drug reactions, impaired physical and cognitive function, and hospital admission.5 6 7 There is limited evidence to inform polypharmacy in older people, especially those with multimorbidity, cognitive impairment, or frailty.8 Systematic reviews of medication withdrawal trials (deprescribing) show that reducing specific classes of medicines may decrease adverse events and improve quality of life.9 10 11

Two recent reviews of the literature on deprescribing stressed the importance of patient involvement and shared decision making.12 13 Patients and clinicians typically overestimate the benefits of treatments and underestimate their harms.14 When they engage in shared decision making they become better informed about potential outcomes and as a result patients tend to choose more conservative options (eg, fewer medicines), facilitating deprescribing.15 However, shared decision making in this context is not easy, and there is little guidance on how to do it.16

We draw together evidence from the psychology, communication, and decision making literature (see appendix on thebmj.com). For each step of the shared decision making process we describe the unique tasks required for deprescribing decisions; identify challenges for older adults, their companions, and clinicians (figure); give practical advice on how challenges may be overcome; highlight where more work is needed; and identify priorities for future research (table).17 18

Schematic representation of challenges for clinicians and older patients associated with each step of the process of shared decision …

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