Development of a stepwise tool to aide primary health care professionals in the process of deprescribing in older persons

Keywords: Deprescriptions, Polypharmacy, Inappropriate Prescribing, Clinical Decision-Making, Algorithms, Pharmacists, General Practitioners, Geriatricians, Physicians, Family, Consensus, Delphi Technique, Validation Studies as Topic, Colombia

Abstract

Objective: The aim of this study was to develop and validate a stepwise tool to aid primary health care professionals in the process of deprescribing potentially inappropriate medication in older persons.

Methods: We carried out a systematic review to identify previously published tools. A composite proposal of algorithm was made by following the steps from clinical experience to deprescribe medications. A 2-round electronic Delphi method was conducted to establish consensus. Eighteen experts from different countries (Colombia, Spain and Argentina) accepted to be part of the panel representing geriatricians, internists, endocrinologist, general practitioners, pharmacologists, clinical pharmacists, family physicians and nurses. Panel members were asked to mark a Likert Scale from 1 to 9 points (1= strongly disagree, 9= strongly agree). The content validity‏ ratio, item-level content validity, and Fleiss’ Kappa statistics was measured to establish reliability. The same voting method was used for round 2.

Results: A 7-question algorithm was proposed. Each question was part of a domain and conduct into a decision. In round 1, a consensus was not reached but statements were grouped and organized. In round 2, the tool met consensus. The inter-rater reliability was between substantial and almost perfect for questions with Kappa=0.77 (95% CI 0.60-0.93), for domains with Kappa= 0.73 (95%CI 0.60-0.86) and for decisions with Kappa= 0.97 (95%CI 0.90-1.00).

Conclusions: This is a novel tool that captures and supports healthcare professionals in clinical decision-making for deprescribing potentially inappropriate medication. This includes patient’s and caregiver’s preferences about medication. This tool will help to standardize care and provide guidance on the prescribing/deprescribing process of older persons’ medications. Also, it provides a holistic way to reduce polypharmacy and inappropriate medications in clinical practice.

Downloads

Download data is not yet available.

References

United Nations. World population ageing 2019: Highlights. Available at: https://www.un.org/en/development/desa/population/publications/pdf/ageing/WorldPopulationAgeing2019-Highlights.pdf (accessed Nov 4, 2020).

Sera LC, McPherson ML. Pharmacokinetics and pharmacodynamic changes associated with aging and implications for drug therapy. Clin Geriatr Med. 2012;28(2):273-286. https://doi.org/10.1016/j.cger.2012.01.007

Farrell B, Pottie K, Rojas-Fernandez CH, Bjerre LM, Thompson W, Welch V. Methodology for Developing Deprescribing Guidelines: Using Evidence and GRADE to Guide Recommendations for Deprescribing. PLoS One. 2016;11(8):e0161248. https://doi.org/10.1371/journal.pone.0161248

Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, Meinow B, Fratiglioni L. Aging with multimorbidity: a systematic review of the literature. Ageing Res Rev. 2011;10(4):430-439. https://doi.org/10.1016/j.arr.2011.03.003

Patterson SM, Hughes C, Kerse N, Cardwell CR, Bradley MC. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2012;(5):CD008165. https://doi.org/10.1002/14651858.cd008165.pub2

Qato DM, Wilder J, Schumm LP, Gillet V, Alexander GC. Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults in the United States, 2005 vs 2011. JAMA Intern Med. 2016;176(4):473-482. https://doi.org/10.1001/jamainternmed.2015.8581

Ahmed B, Nanji K, Mujeeb R, Patel MJ. Effects of polypharmacy on adverse drug reactions among geriatric outpatients at a tertiary care hospital in Karachi: a prospective cohort study. PLoS One. 2014;9(11):e112133. https://doi.org/10.1371/journal.pone.0112133

Richardson K, Bennett K, Kenny RA. Polypharmacy including falls risk-increasing medications and subsequent falls in community-dwelling middle-aged and older adults. Age Ageing. 2015;44(1):90-96. https://doi.org/10.1093/ageing/afu141

Dhalwani NN, Fahami R, Sathanapally H, Seidu S, Davies MJ, Khunti K. Association between polypharmacy and falls in older adults: a longitudinal study from England. BMJ Open. 2017;7(10):e016358. https://doi.org/10.1136/bmjopen-2017-016358

Abe T, Tamiya N, Kitahara T, Tokuda Y. Polypharmacy as a risk factor for hospital admission among ambulance-transported old-old patients. Acute Med Surg. 2015;3(2):107-113. https://doi.org/10.1002/ams2.153

Roulet L, Ballereau F, Hardouin JB, Chiffoleau A, Potel G, Asseray N. Adverse drug event nonrecognition in emergency departments: an exploratory study on factors related to patients and drugs. J Emerg Med. 2014;46(6):857-864. https://doi.org/10.1016/j.jemermed.2013.11.124

Shehab N, Lovegrove MC, Geller AI, Rose KO, Weidle NJ, Budnitz DS. US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA. 2016;316(20):2115-2125. https://doi.org/10.1001/jama.2016.16201

Tamura BK, Bell CL, Inaba M, Masaki KH. Outcomes of polypharmacy in nursing home residents. Clin Geriatr Med. 2012;28(2):217-236. https://doi.org/10.1016/j.cger.2012.01.005

Woodward MC. Deprescribing: Achieving Better Health Outcomes for Older People through Reducing Medications. J Pharm Pract Res. 2003;33(4):323-328. https://doi.org/10.1002/jppr2003334323

Hardy JE, Hilmer SN. Deprescribing in the last year of life. Review. J Pharm Pract Res. 2011;41(2):146-151.

McKean M, Pillans P, Scott IA. A medication review and deprescribing method for hospitalised older patients receiving multiple medications. Intern Med J. 2016;46(1):35-42. https://doi.org/10.1111/imj.12906

Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159-174.

Tristán-López A. [Modification to Lawshe’s quantitative index of content validity for an objective instrument]. Avances en medición. 2008;6(1):37-48.

Garfinkel D, Zur-Gil S, Ben-Israel J. The war against polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people. Isr Med Assoc J. 2007;9(6):430-434.

Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, Janecek E, Domecq C, Greenblatt DJ. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther. 1981;30(2):239-245. https://doi.org/10.1038/clpt.1981.154

Holmes HM, Sachs GA, Shega JW, Hougham GW, Cox Hayley D, Dale W. Integrating palliative medicine into the care of persons with advanced dementia: identifying appropriate medication use. J Am Geriatr Soc. 2008;56(7):1306-1311. https://doi.org/10.1111/j.1532-5415.2008.01741.x

Martin P, Tamblyn R, Benedetti A, Ahmed S, Tannenbaum C. Effect of a Pharmacist-Led Educational Intervention on Inappropriate Medication Prescriptions in Older Adults: The D-PRESCRIBE Randomized Clinical Trial. JAMA. 2018;320(18):1889-1898. https://doi.org/10.1001/jama.2018.16131

Published
2020-12-03
How to Cite
1.
De las Salas R, Eslava-Schmalbach J, Vaca-González C, Rodríguez D, Figueras A. Development of a stepwise tool to aide primary health care professionals in the process of deprescribing in older persons. Pharm Pract (Granada) [Internet]. 2020Dec.3 [cited 2021Jan.24];18(4):2033. Available from: https://pharmacypractice.org/journal/index.php/pp/article/view/2033
Section
Original Research

Most read articles by the same author(s)