A Delphi process to address medication appropriateness for older persons with multiple chronic conditions.

Terri R Fried,Mary K Goldstein,Kristina Niehoff,Jennifer Tjia,Nancy Redeker

doi:10.1186/s12877-016-0240-3

Abstract

BackgroundFrameworks exist to evaluate the appropriateness of medication regimens for older patients with multiple medical conditions (MCCs). Less is known about how to translate the concepts of the frameworks into specific strategies to identify and remediate inappropriate regimens.MethodsModified Delphi method involving iterative rounds of input from panel members. Panelists (n = 9) represented the disciplines of nursing, medicine and pharmacy. Included among the physicians were two geriatricians, one general internist, one family practitioner, one cardiologist and two nephrologists. They participated in 3 rounds of web-based anonymous surveys.ResultsThe panel reached consensus on a set of markers to identify problems with medication regimens, including patient/caregiver report of non-adherence, medication complexity, cognitive impairment, medications identified by expert opinion as inappropriate for older persons, excessively tight blood sugar and blood pressure control among persons with diabetes mellitus, patient/caregiver report of adverse medication effects or medications not achieving desired outcomes, and total number of medications. The panel also reached consensus on approaches to address these problems, including endorsement of strategies to discontinue medications with known benefit if necessary because of problems with feasibility or lack of alignment with patient goals.ConclusionsThe results of the Delphi process provide the basis for an algorithm to improve medication regimens among older persons with MCCs. The algorithm will require assessment not only of medications and diagnoses but also cognition and social support, and it will support discontinuation of medications both when risks outweigh benefits and when regimens are not feasible or do not align with goals.

Highlights

Frameworks exist to evaluate the appropriateness of medication regimens for older patients with multiple medical conditions (MCCs)
The panel considered the fact that time to benefit is a very useful concept for improving decision making around cancer screening and diabetes management, but discussed the lack of evidence regarding the time to benefit for commonly used medications, such as antihypertensives and statins, for other chronic conditions
The results of the Delphi process used in this study provide specific strategies for identifying problems with medications, including recognition when medication regimens are not feasible, are associated with an excess risk of harm, and when they are not meeting the patient’s goals

Summary

Introduction

Frameworks exist to evaluate the appropriateness of medication regimens for older patients with multiple medical conditions (MCCs). A growing body of evidence describes a number of problems with current patterns of prescribing for older persons with multiple chronic conditions (MCCs) These patients are underrepresented in randomized controlled trials providing the data underlying many disease management guidelines, and they may derive less benefit from and be at increased risk of harm from guideline-. Recognizing that additional factors affect the appropriateness of medication prescribing for the complex older patient, a number of investigators have expanded the basis for implicit medication review by proposing conceptual frameworks to evaluate appropriateness [3, 13,14,15] and to deprescribe medications [16, 17] These frameworks include the concepts of evaluating time-to-benefit, patients’ preferences and goals and individually tailored benefits and harms or burdens. These frameworks provide a general description of the concepts without more specific strategies for applying these concepts to individual patients and regimens

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