Too much medicine in older people? Deprescribing through shared decision makingBMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2893 (Published 03 June 2016) Cite this as: BMJ 2016;353:i2893
All rapid responses
I welcome Jansen and colleagues' article about deprescribing in older people (1). As a palliative medicine consultant, I often see examples of patients on inappropriate primary prevention medications, even as they approach the end of their life. Often these medications can be harmful at worst, and add to unnecessary medication burden at best. A prime example is statins at the end of life. Evidence shows that stopping statins in the context of advanced illness can improve quality of life (2).
A particular challenge for those attempting medication rationalisation at the end of life can be the previous information given to patients, and all clinicians should be aware of this. Some of my patients have previously declined to stop their statins because clinicians have told them they "should be on them for the rest of their life". Whilst well meaning at the initiation of therapy, a more realistic comment when starting new, long term therapies, with the aim to encourage compliance but also enlighten patients that there may come a sensible time to stop medications, might be "continue this until you and your doctor agree it is no longer helpful."
1) Jansen and Colleagues. Deprescribing in older people. BMJ 2016;353:i2893
2) Kutner et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life limiting illness: A randomised clinical trial. JAMA Intern Med 2015; 175(5): 691-700
Competing interests: No competing interests
A new and exciting development in anaesthesia is that all anaesthetists are now to be trained in perioperative medicine, with the goal of delivering high quality care for the full patient journey from decision to operate, to complete recovery. In this new role anaesthetists would seem ideally placed to identify de-prescribing opportunities and initiate withdrawal of medicines. However, this approach without the involvement and agreement of the general practitioner runs the risk of creating confusion, of disrupting carefully considered management strategies, and of causing more harm than good. Perhaps patients might best be served by close collaboration between the Royal College of Anaesthetists and the Royal College of General Practitioners in order that strategies for safe and effective de-prescribing during the perioperative period can be identified.
Competing interests: No competing interests
Poor uptake and targeting of interdisciplinary medicines reviews for older people: a barrier to deprescribing
To the editor,
In the recent article by Jansen and colleagues about deprescribing through shared decision making (1), the point is made that many of the triggers for deprescribing can be identified only by a medicines review, and that a medicines review can be triggered by important ‘life transitions’. These transitions include hospital admission, residential care admission, referral to an aged care assessment service (ACAS) due to functional decline, or referral to a community nursing service for medicines management support.
But is there evidence that these transitions currently lead to a medicines review? In Australia, publicly funded interdisciplinary medicines reviews, known as Home Medicine Reviews (HMR), have been available for 15 years (2). However studies of HMR uptake have found that only 5-10% of older people discharged from hospital, referred to an ACAS or community nursing service or residing in supported accommodation receive a HMR (3-7).
Many barriers to the use of HMR have been identified, but most have not been resolved (8,9). New approaches to improve access to interdisciplinary medicines review within the primary care are needed to facilitate deprescribing. These include simplification and improved targeting of the HMR model, along with implementation of new collaborative care models that integrate pharmacists into general practice clinics, ACAS teams and community nursing services (2,6,8,10,11).
Rohan A Elliott, clinical senior lecturer(a) and senior aged care pharmacist(b); Cik Yin Lee, research fellow(a,c)
a. Centre for Medicine Use and Safety, Monash University, Melbourne, Victoria, Australia
b. Pharmacy Department, Austin Health, Melbourne, Victoria, Australia
c. Royal District Nursing Service (RDNS) Institute, Melbourne, Victoria, Australia
1. Jansen J, Naganathan V, Carter SM, McLachlan AJ, Nickel B, Irwig L, et al. Too much medicine in older people? Deprescribing through shared decision making. BMJ 2016; 353: i2893
2. Rigby D. Collaboration between doctors and pharmacists in the community. Aust Prescriber 2010; 33: 191-3
3. Bollella G, Angley MT, Pink JA, Caird CJ, Goldsworthy SJ. Optimal level of liaison pharmacist intervention to facilitate a post-discharge Home Medicines Review. J Pharm Pract Res 2008; 38: 107-10
4. Lee CY, George J, Elliott RA, Stewart K. Prevalence of medication-related risk factors among retirement village residents: a cross-sectional survey. Age Ageing 2010; 39: 581-87
5. Lee CY, George J, Elliott RA, Chapman CB, Stewart K. Exploring medication risk among older residents in supported residential services: a cross-sectional study. J Pharm Pract Res 2011; 41: 98-101
6. Elliott RA, Martinac G, Campbell S, Thorn J, Woodward MC. Pharmacist-led medication review to identify medication-related problems in older people referred to an Aged Care Assessment Team: a randomized comparative study. Drugs Aging 2012; 29: 593-605
7. Elliott RA, Lee CY, Beanland C, Vakil K, Goeman D. Medicines management, medication errors and adverse medication events in older people referred to a community nursing service: a retrospective observational study. Drugs - Real World Outcomes 2016; 3: 13-24
8. Lee CY, George J, Elliott RA, Stewart K. Exploring stakeholder perspectives on medication review services for older residents in retirement villages. Int J Pharm Pract 2012; 20: 249-58
9. Swain L, Barclay L. Medication reviews are useful, but the model needs to be changed: Perspectives of Aboriginal Health Service health professionals on Home Medicines Reviews. BMC Health Serv Res 2015; 15: 366
10. Angley M, Ponniah AP, Spurling LK, Sheridan L, Colley D, Nooney VB, et al. Feasibility and timeliness of alternatives to post-discharge home medicines reviews for high-risk patients. J Pharm Pract Res 2011; 41: 27-32
11. Petrie N, Petrie B, Elliott R, Lee CY, Beanland C, Goeman D. A new role for clinical pharmacists: working within a community nursing service. Aust Pharm 2016(May): 24-5
Competing interests: No competing interests
Obviously we agree with deprescribing through shared decision making, topic of this interesting paper, in almost all old patients. However, as founders of the Single Patient Based Medicine (1-3), first of all, we must consider the necessity to bedside assess both structure and function of old patient biological systems. Doing so we can be able to monitoring the prescribed treatment, conditio sine qua non of a personalized therapy. In other words, doctors need to know when to start therapy, but also when to reduce it, modifying it or stop it, at the bedside, i.e., using a simple stethoscope (4, 5).
1) Stagnaro Sergio. Single Patient Based Medicine: its paramount role in Future Medicine. Public Library of Science. http://medicine.plosjournals.org/perlserv/?request=read-response
2) Stagnaro S., Stagnaro-Neri M., Le Costituzioni Semeiotico-Biofisiche.Strumento clinico fondamentale per la prevenzione primaria e la definizione della Single Patient Based Medicine. Travel Factory, Roma, 2004. http://www.travelfactory.it/libro_costituzionisemeiotiche.htm
3) Stagnaro S., Stagnaro-Neri M., Single Patient Based Medicine.La Medicina Basata sul Singolo Paziente: Nuove Indicazioni della Melatonina. Travel Factory, Roma, 2005. http://www.travelfactory.it/libro_singlepatientbased.htm
4) Caramel S., Marchionni M., Stagnaro S. Morinda citrifolia Plays a Central Role in the Primary Prevention of Mitochondrial-dependent Degenerative Disorders. Asian Pac J Cancer Prev. 2015;16(4):1675. http://www.ncbi.nlm.nih.gov/pubmed/25743850 [MEDLINE]
5) Marco Marchionni, Simone Caramel, Sergio Stagnaro. The Role of ‘Modified Mediterranean Diet’ and Quantum Therapy In Alzheimer’s Disease Primary Prevention. Letter to the Editor, The Journal of Nutrition, Health & Aging, Volume 18, Number 1, 2014, Springer Ed. http://link.springer.com/article/10.1007/s12603-013-0435-7 [MEDLINE]
Competing interests: No competing interests
This was a very interesting article especially for persons like myself who are involved in providing care for the mentally ill. The title, “Too much medicine in older people? De-prescribing through shared decision making,” as presented by Jansen et al., 2016 captivated my attention. Yes, this is an initiative that needs to be examined and implemented, not just in older people, but especially for clients who are living with a mental illness!
As a primary care mental health practitioner I have seen multiple cases of poly-pharmacy. Similarly, one-third of the clients visiting outpatient psychiatric departments are being treated with three or more psychotropic drugs (Mojtabai & Olfson, 2010). Which leaves me asking the question; what is the role of the patient in decision making regarding medication management? Self-determination within mental health services is increasingly recognized as an ethical imperative, (Stanhope, Barrenger, Salzer & Marcus, 2013). Clients need to be invited to, and supported in expressing treatment preferences. Furthermore, this should take place within the context of a strong therapeutic relationship (Klingaman et al., 2013).
My interaction with clients has alerted me to adherence issues, as well as clients’ reluctance to be “dictated to”, and instead request to be “consulted” in the decision making process in relation to their medication management. There are, however, stereotyping and stigmatizing issues related to clients’ decision making and mental illness. As a result, when working with patients exhibiting poor insight, practitioners may use authoritative decision-making styles despite the patient's desire to participate (Grim, Rosenberg, Svedberg, & Schön, 2016). Krumholz (2010) posits that people want to be involved in understanding evidence and making decisions about their care.
I must agree, that forming a “…therapeutic alliance” towards reducing symptoms and improving functioning (Stanhope et al., 2013), while engaging clients in treatment decisions, not only provides clients’ with needed information and treatment options, but it allows them to feel actively involved in the treatment process thus increasing compliance rates (Klingaman et al., 2015).
While we seek to engage in shared decision making, there is one question that demands an answer. Are we as health practitioners treating the client, the disorder or the symptom (Kukreja, Kalra, Shah, & Shrivastava, 2013)?
Grim, K., Rosenberg, D., Svedberg, P., & Schön, U. (2016). Shared decision-making in mental health care - A user perspective on decisional needs in community-based services. International Journal Of Qualitative Studies On Health And Well-Being, 11. doi:http://dx.doi.org/10.3402/qhw.v11.30563
Jansen, J., Nagathan, V., Carter, S. M., McLachlan, A. J., Nickel, B., Irwig, L. et al. (2016). Too much medicine in older people? Deprescribing through shared decision making. British Medical Journal, 2016;353:i2893
Klingaman, E. A., Medoff, D. R., Park, S. G., Brown, C. H., Fang, L., Dixon, L. B., Hack, S. M., Tapscott, S. L., Walsh, M. B., Kreyenbuhl, J. A. (2015). Consumer satisfaction with psychiatric services: The role of shared decision making and the therapeutic relationship. Psychiatric Rehabilitation Journal, Vol 38(3), 242-248. http://dx.doi.org/10.1037/prj0000114
Krumholz, H. M. (2010). Informed Consent to Promote Patient-Centered Care.
The Journal of the American Medical Association, 303(12):1190-1191. doi:10.1001/jama.2010.309.
Kukreja, S., Kalra, G., Shah, N., & Shrivastava, A. (2013). Polypharmacy In Psychiatry: A Review. Mens Sana Monographs, 11(1), 82–99. http://doi.org/10.4103/0973-1229.104497
Mojtabai, R. & Olfson, M. (2010). National trends in psychotropic medication polypharmacy in office-based psychiatry. Archives of General Psychiatry, 67(1):26-36.
Stanhope, V., Barrenger, S. L., Salzer, M. S., Marcus, S. C. (2013). Examining the Relationship between Choice, Therapeutic Alliance and Outcomes in Mental Health Services. Journal of Personalized Medicine, 3, 191-202; doi:10.3390/jpm3030191
Competing interests: No competing interests
Jansen and colleagues approach deprescribing in older people methodically and sensitively, deconstructing and analysing the process and some of its pitfalls. (1) Any intervention to reduce the total medication burden in the very old, in whom the potential benefits of many medicines are doubtful and the potential for harm increased by their creaking metabolic status, is to be welcomed.
Their four stage process underestimates its complexity though, since they only reach the point where the joint decision is agreed in principle. Then the clinician needs to plan and execute the withdrawal. First there may be a decision about the order of withdrawal of several drugs. Each may involve a gradual reduction in dosage, monitoring of biological variables as well as of withdrawal symptoms, some of which may be temporary, but some due to a recurrence of the original disorder. The most important requirement with all but the most innocuous of medicines is how soon to review the patient to assess the outcome of the process. This re-review is not necessarily easy. It requires a judgment by the prescriber, but also by the patient (and/or carer), as to whether any change was caused by the withdrawal. This may in turn lead to the reinstatement of the medicine, even sometimes when the pharmacological justification for so doing is dubious.
People become attached to their medicines, as they often do to their illnesses. Sometimes the medicine is a symbol of an unstated collusion between patient and prescriber. The medicine allows the patient to maintain a “peaceful but distant” relationship with the prescriber that endorses the patient’s ongoing sickness without interference. Back in the 1960s Balint and his colleagues explored this phenomenon in some depth. They concluded that “in an established repeat prescription regime the drug has become representative of the ‘something’ that the patient so badly needs. It must therefore be respected, and the repeat prescription cannot be simply taken away without replacing it with something equally valuable.” (2) It is therefore important not to regard repeat medication as just a pharmacological or logistic issue. There is a major psychological dimension of many treatments, some of which are the archaeological remnant of a distant but often still sensitive life event. Interfering with such a treatment can be perilous and lead to unexpected consequences.
(1) Jansen and Colleagues. Deprescribing in older people. BMJ 2016;353:i2893
(2) Balint M, Hunt J, Joyce D, Marinker M and Woodcock J. (1970) in Treatment or Diagnosis. A Study of Repeat Prescriptions in General Practice. Tavistock London.
Competing interests: I am a member of a research group looking at medication review of nursing home patients.
Jansen’s paper, How to reduce medicines for older people, is badly needed, and it makes some good points. Regrettably the main recommendations are dependent on an essential component in shortest supply in the NHS, time for communication in the consultation. Unfortunately it is always easier and quicker to prescribe an extra medication than to take a patient off a medication!
In UK literally millions of elderly patients are on numerous medications. Michael Holden previously chief executive of the National Pharmacy Association stated that nearly half of all medicines for long term conditions in elderly patients are not used as they should be. There is a huge amount of waste.1
It is widely recognised that all elderly patients who are on four or more medications long-term should have a “medicines review” regularly, about every six months. This requires timetabling and proper financial provision. Only then will practitioners make the time for the necessary discussions, explore preferences and make decisions about stopping medicines. Such reviews should be part of regular good practice and make economic sense.
Every decision about prescribing or deprescribing needs to be discussed with and explained to the patient. This education time is essential. Often an older patient will not take in instructions with one hasty telling. Feed-back time is necessary in order to test the patient and see if he or she understands the change in medication. Other obvious improvements include large print and simple instructions.
A significant proportion of the elderly patients have early dementia. For them understanding and making decisions is difficult. Joint consultations with the patient’s carer are essential if the medicine is to be used correctly.
Some of the education about use of medications can be given effectively by Pharmacists. In some chemist shops Pharmacists really check that patients understand how to use the medicines prescribed. Some GP practices, mainly for financial economy, insist that all patients get their medicines from their in-house dispensaries run by the practice “Dispensers”. This means that patients and their carers, when they collect their medications, never see a pharmacist trained to instruct about medicines.
William Cutting retired Consultant, counselor on health and wellbeing of the elderly, Oxford.
1. Cutting WAM. Seniors, Make the Most of the Health You Have. Face the Future, Book 3. 2015; O&U, Leatherhead; ISBN:978-1-910197-13-4
Competing interests: No competing interests
We thank Jansen and colleagues for this paper on shared decision making related to deprescribing. Discussions surrounding deprescribing can be difficult to have. We agree there is a clear need for patient-friendly deprescribing resources that facilitate discussions surrounding continuation of a medication versus trying deprescribing, and foster shared, informed decisions that are consistent with patient values.
Our research group believes that patient decision aids (PtDAs) can address this gap. PtDAs are structured tools that outline different treatment options (i.e. the decision to continue or have a medication deprescribed), quantify the benefits and harms of outcomes, and allow patients to rate how important outcomes are to them [1,2]. They can be delivered on their own or in consultation with a clinician (called a consult PtDA). PtDAs increase knowledge surrounding a decision, help patients have realistic expectations of different options and reduce decisional conflict .
In recognizing the potential of PtDAs to facilitate these discussions, our group has developed a consult PtDA surrounding the decision to continue a proton pump inhibitor (PPI) at the same dose or try deprescribing . Our tool outlines the benefits and harms of options and allows patients to clarify values. Content is based on an evidence-based PPI deprescribing guideline and support tool developed by our research team [Farrell B, Pottie K, Thompson W, et al. Deprescribing proton-pump inhibitors: an evidence based clinical practice guideline. Unpublished manuscript (submitted to PLOS ONE March 2016)]. The consult PtDA describes the rationale for considering the decision to continue a PPI at the same dose or have it deprescribed, and also what to do if symptoms come back – both of these areas have been described as barriers to deprescribing [6,7]. Our PtDA was developed by physicians, pharmacists and patients and is currently being piloted in Ottawa, Canada.
Our consult PtDA operationalizes the framework Jansen and colleagues outline, and provides a practical tool to facilitate discussions surrounding continuation versus deprescribing of medications. We aim to demonstrate that consult PtDAs can support clinicians in having these discussions and hope other PtDAs can be developed for different medication classes to help engage and foster shared, informed decision making.
For more about our deprescribing guidelines research: http://www.open-pharmacy-research.ca/research-projects/emerging-services...
Wade Thompson BScPhm and Barbara Farrell BScPhm PharmD
Bruyère Research Institute, Ottawa, Ontario, Canada
1. Ottawa Hospital Research Institute. Patient Decision Aids [Internet]. 2015 [cited 2016 Jun 6]. Available: https://decisionaid.ohri.ca/
2. Coulter A, Stilwell D, Kryworuchko J, Mullen PD, Ng CJ, van der Weijden T. A systematic development process for patient decision aids. BMC Med Inform Decis Mak 2013;13 Suppl 2:S2.
3. Stacey D, Légaré F, Col NF, Bennet CL, Barry MJ, Eden KB, et al. Decision aids for people facing health treatment or screening decisions ( Review ). Cochrane Database Sys Rev 2014;(1):CD001431.
4. ClinicalTrials.gov. Should I Continue Taking My Acid Reflux Medication? Development and Pilot Testing of a Patient Decision Aid. In: ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 2015 [cited 2016 Jun 6]. Available: https://clinicaltrials.gov/ct2/show/NCT02558049
5. Farrell B, Pottie K, Thompson W, Boghossain T, Pizzola L, Rashid J, et al. Proton pump inhibitor deprescribing algorithm [Internet]. 2015 [cited 2016 Jun 6]. Available: http://www.open-pharmacy-research.ca/wordpress/wp-content/uploads/ppi-de...
6. Reeve E, To J, Hendrix I, Shakib S, Roberts MS, Wiese MD. Patient barriers to and enablers of deprescribing: a systematic review. Drugs Aging 2013;30(10):793–807.
7. Smeets HM, De Wit NJ, Delnoij DMJ, Hoes AW. Patient attitudes towards and experiences with an intervention programme to reduce chronic acid-suppressing drug intake in primary care. Eur J Gen Pract 2009;15: 219–225.
Competing interests: Dr. Farrell declares that she has received research funding from the Government of Ontario for the purposes of developing deprescribing guidelines; received financial payments from Institute for Healthcare Improvement and Commonwealth Fund for deprescribing guidelines summary and from Ontario Pharmacists Association and Canadian Society of Hospital Pharmacists for speaking engagements.