Problematic Polypharmacy Research Articles

The patient’s perspectives of safe and routine proactive deprescribing in primary care for older people living with polypharmacy: a qualitative study

BackgroundThe process of identifying and discontinuing medicines in instances in which harms outweigh benefits (deprescribing) can mitigate the negative consequences of problematic polypharmacy. This process should be conducted with a focus on the patient and involve collaborative decision-making. Evidence is needed regarding patients’ views on how deprescribing should be safely and routinely implemented in English primary care to improve its application. This study aimed to identify optimal methods of introducing and actioning deprescribing from the patient’s perspective.MethodsParticipants in England aged 65 and above who were taking five or more medicines and residing in their own homes were recruited through social media and service user groups. An interview guide was created from deprescribing literature and input from patients and the public, guided by the Normalisation Process Theory (NPT). The interviews were held online using Microsoft Teams® or via phone, recorded, and then transcribed. The data was analysed using the Framework analysis.ResultsTwenty patients (mean age of 74.5, SD = 6.93), with 75% being female, were enrolled in the study. Three main themes emerged: (1) ‘Why deprescribe now?’ emphasised the significance of explaining the reasons behind deprescribing; (2) ‘Monitoring and follow-up’ underscored the necessity of safety measures during deprescribing and patients’ willingness to self-monitor post-intervention; (3) ‘Roles and relationships’ explored patient perceptions of various healthcare professionals involved in deprescribing and the essential interpersonal skills for fostering therapeutic relationships.ConclusionOptimal methods of introducing deprescribing included communicating a convincing rationale for stopping medicines and preparing patients for deprescribing conversations. Patients required support from a range of healthcare professionals with whom they had an existing therapeutic relationship. Whilst patients were motivated to self-monitor unwanted/unexpected effects post-deprescribing, timely support was required. The nature of such bolstered collective action and cognitive participation within NPT enhances the normalisation potential of deprescribing. These findings highlight the significance of considering the content and process of deprescribing consultations to enhance normalisation and tackle problematic polypharmacy. This provides a deeper understanding of patients’ needs for implementing safe and routine deprescribing in primary care, which should be considered when designing medication review and deprescribing services.

"How well do we know our patients?": Further validation of a complexity rating scale for HIV.

Despite advances in the management and treatment of HIV, identifying risks for disengagement are essential to maximize positive outcomes. The current study investigated the validity of the Clinical Complexity Rating Scale for HIV (CCRS-HIV), a risk-prediction tool, by assessing agreement between patient and clinician scores of patient complexity. 207 patients completed the patient version of the CCRS-HIV (CCRS-HIVP), and six Attending Medical Officers (AMOs) caring for those individuals completed the original clinician version (CCRS-HIVC). Kappa statistics, sensitivity and specificity were used to assess patient-clinician agreement. Patient-clinician agreement was highest for problematic crystal methamphetamine use (86%), polypharmacy (84%) and other physical health concerns (67%). Cut-offs of 40 and 45 for the total CCRS-HIV score were identified as most appropriate, with high sensitivity (79.31% and 76.0% respectively). Overall agreement between the clinician and patient complexity scores was high. These findings provide further evidence of the validity of the scale. The study demonstrates that the unique role of AMOs at the center contributes to them knowing their patients well, allowing them to manage and refer when required for interdisciplinary care which likely contributes to their ongoing engagement in care and may account for the high level of agreement.

2300 A survey on the underlying knowledge of doctors’ in conducting polypharmacy review and medication optimisation in older adults.

Abstract Introduction Polypharmacy is common among older adults and could result in adverse outcomes if not reviewed and optimised regularly (Davies et al, 2020). The aim of this survey is to assess and report on the variation in doctors’ understanding of medication reviews at Maidstone and Tunbridge Wells hospitals (MTW). Method A short, anonymised, online questionnaire was circulated to all current doctors at MTW via email and WhatsApp groups. Results 38 doctors of different grades (Foundation Year One-Consultant) from a variety of medical and surgical specialties responded. Of these, 41% could correctly define appropriate polypharmacy, but only 6% could define problematic polypharmacy. Most respondents (59.5%) had not received any training on structured medication reviews (SMR). 51.4% were not aware of any tools used in medication optimisation. 43% said they ‘always carry out’ medication reviews in clinical practice and 8.3% said that they never do. Less than half (38%) felt confident in completing SMR. The main barriers to routine implementation of SMR identified by the respondents were: lack of confidence (27%), time pressures (26%), senior clinicians not giving importance to SMR (16%), 3% felt it was not the doctor’s responsibility. Most respondents (91.7%) said that they would benefit from further training in SMR. Conclusions The results show that there is a wide variation in the respondents’ understanding and practice of medication reviews. Also, that there is a clear and well- founded demand for training. Once training has been formulated and delivered a follow up survey of those attending should be used to help gauge its effectiveness. The small sample size is a limitation of this study affecting its generalisability as is the fact that it was a self-selected group completing the survey.

Protocol for the development and validation of a Polypharmacy Assessment Score

BackgroundAn increasing number of people are using multiple medications each day, named polypharmacy. This is driven by an ageing population, increasing multimorbidity, and single disease-focussed guidelines. Medications carry obvious benefits, yet polypharmacy is also linked to adverse consequences including adverse drug events, drug-drug and drug-disease interactions, poor patient experience and wasted resources. Problematic polypharmacy is ‘the prescribing of multiple medicines inappropriately, or where the intended benefits are not realised’. Identifying people with problematic polypharmacy is complex, as multiple medicines can be suitable for people with several chronic conditions requiring more treatment. Hence, polypharmacy is often potentially problematic, rather than always inappropriate, dependent on clinical context and individual benefit vs risk. There is a need to improve how we identify and evaluate these patients by extending beyond simple counts of medicines to include individual factors and long-term conditions.AimTo produce a Polypharmacy Assessment Score to identify a population with unusual levels of prescribing who may be at risk of potentially problematic polypharmacy.MethodsAnalyses will be performed in three parts:1. A prediction model will be constructed using observed medications count as the dependent variable, with age, gender and long-term conditions as independent variables. A ‘Polypharmacy Assessment Score’ will then be constructed through calculating the differences between the observed and expected count of prescribed medications, thereby highlighting people that have unexpected levels of prescribing.Parts 2 and 3 will examine different aspects of validity of the Polypharmacy Assessment Score:2. To assess ‘construct validity’, cross-sectional analyses will evaluate high-risk prescribing within populations defined by a range of Polypharmacy Assessment Scores, using both explicit (STOPP/START criteria) and implicit (Medication Appropriateness Index) measures of inappropriate prescribing.3. To assess ‘predictive validity’, a retrospective cohort study will explore differences in clinical outcomes (adverse drug reactions, unplanned hospitalisation and all-cause mortality) between differing scores.DiscussionDeveloping a cross-cutting measure of polypharmacy may allow healthcare professionals to prioritise and risk stratify patients with polypharmacy using unusual levels of prescribing. This would be an improvement from current approaches of either using simple cutoffs or narrow prescribing criteria.

Stakeholder perceptions of and attitudes towards problematic polypharmacy and prescribing cascades: a qualitative study

Stakeholder perceptions of and attitudes towards problematic polypharmacy and prescribing cascades: a qualitative study

‘Troubling’ medication reviews in the context of polypharmacy and ageing: A linguistic ethnography

Healthy ageing is a global priority. Polypharmacy (the use of 5+ medicines) amongst older people is increasing, with over one-third of adults in England, aged 80–89, prescribed at least eight medications. Although sometimes necessary, polypharmacy can be harmful; the risk of harm increases with age and number of medicines prescribed. Medication reviews are recommended as one way of reducing the potential harms of polypharmacy although evidence of clinically significant benefit of medication reviews as currently delivered is limited. What happens in medication reviews in practice is poorly understood.We used a linguistic ethnography approach to explore how medication reviews proceed and what is accomplished during these consultations. We studied 18 video-recorded medication review consultations from three general practices in England. The consultations involved patients aged 65 or older, prescribed 10+ medications (‘higher risk’ polypharmacy), and primary care clinicians (general practitioner or clinical pharmacist). Video-recordings were gathered as part of a wider ethnographic study investigating practices of polypharmacy in primary care between 2017 and 2021. We conducted microanalysis of consultation data, drawing on our ethnographic knowledge of the organisational, institutional and domestic contexts of polypharmacy to inform our interpretation of these interactions.Consultations were time-consuming and involved lengthy stretches of interactional trouble: non-understandings; misunderstandings; misalignments. These stretches revealed profound uncertainties as to the effectiveness of medicines in the context of multimorbidity and polypharmacy. These uncertainties seeped further into ‘troubles talk’ concerning patients' existential concerns relating to enduring illness, ageing and mortality. Although these existential concerns were partially articulated, clinicians and patients left such troubles talk unelaborated, unresolved and unfinished. Participants succeeded in smoothing over interactional difficulties and maintaining respectful relationships but often fell short of addressing problematic polypharmacy more directly.

Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scoping review

IntroductionPolypharmacy and multimorbidity pose escalating challenges. Despite numerous attempts, interventions have yet to show consistent improvements in health outcomes. A key factor may be varied approaches to targeting patients for...

Managing polypharmacy through medication review tools - pros and cons.

Inappropriate polypharmacy is a common occurrence in elderly patients, resulting in increased adverse drug reactions, nonadherence, and increased healthcare costs. Medication review and deprescribing are the primary strategies described in the literature for dealing with problematic polypharmacy. To effectively carry out the medication review, various tools have been developed. These tools can support medication review in a variety of ways. Some tools include a list of medications requiring detailed attention, while others guide medical professionals with principles and algorithms for reviewing and prescribing medicines. A third category of tools focuses on tracking and identifying symptoms that may be due to drug-related problems.

2052 Polypharmacy reviews in outpatient clinics - beginning the structured medication review in bone health clinic

Abstract Introduction Inappropriate polypharmacy is recognised as a contributing factor towards adverse outcomes in frail patients. Current efforts at national level are centred around primary care initiatives in completing structured medication reviews (SMR) where shared decision making takes place with open discussion around risks and benefits of treatments. The aim of this review was to assess whether recommendations for discussion in SMR have been adopted for patients attending frailty bone health clinic led by Consultant Pharmacist, in hospital outpatient setting. Method Retrospective analysis of notes was undertaken in a sample of 30 patients reviewed in clinic in the period 01.09.22-28.02.23 who were on at least five medications, were still alive six months post review and where suggestions with regards to actions to discuss during a structured medication review were made. Results Average age of patients sampled was 79 years with average CFS of 5.75. Number of medicines documented at outpatient appointment was on average 10.6 which reduced to 9.95 at review six months after the appointment. Around a third of recommendations were adapted fully, with another third partially completed and a third not completed. Interventions included review of falls risk increasing drugs (FRIDs), reduction of anticholinergic load, identification of possible prescribing cascades, review of opioid medication in chronic pain context and review of medicines where benefit may no longer be derived due to frailty progression. In cases where review of medication with high anticholinergic load was advised, an average reduction of -3 was achieved at six-month review. Conclusion(s) Starting a structured medication review in outpatient clinic has the potential to reduce the risk of adverse events and improve outcomes for patients. Further work will be undertaken to ascertain reasons for not adopting the recommendations and continuous collaboration with primary care colleagues will continue to address problematic polypharmacy.

261 Perceptions of and attitudes towards problematic polypharmacy and prescribing cascades in older adults: a stakeholder analysis

Abstract Background Research to date on appropriate prescribing in older adults has focused on characterising inappropriate prescribing using explicit prescribing indicator tools. Less is known about other causes of problematic polypharmacy such as prescribing cascades. Prescribing cascades occur when a medication is prescribed to treat or to prevent the symptoms of an adverse drug reaction and may be characterised as intentional or unintentional, as well as appropriate or inappropriate. Prescribing cascades, therefore, represent an important and under-researched area of problematic polypharmacy. The aim of this study was to conduct a stakeholder analysis (patients with polypharmacy; carers; General Practitioners [GPs]; hospital doctors; community pharmacists; professional organisation representatives and policymakers) to elicit perceptions of and attitudes towards problematic polypharmacy, with a focus on prescribing cascades. Methods Qualitative one-to-one semi-structured interviews were conducted. Participants were recruited via a gatekeeper approach. Interview duration ranged from 58 to 80 minutes. Interviews were analysed thematically. Results Thirty-one participants (six patients, two carers, seven GPs, eight community pharmacists, four hospital doctors, two professional organisation representatives, and two policy makers) were interviewed. The challenges of communication at the interface of primary and secondary care were outlined, including the lack of clear ownership of drug monitoring. The community pharmacist and, at times, the patient were relied upon to fill in these gaps in communication. Patients discussed the burden of taking multiple medications. GPs described the importance of ‘mindful prescribing’ to avoid, where possible, unintentional prescribing cascades. The need for further education for health care professionals and patients on prescribing cascades was highlighted, as was the importance of improved collaboration between health care professionals. Conclusion Understanding the perceptions of different stakeholders towards problematic polypharmacy and prescribing cascades is key to the development of effective tools or resources to improve patient care.

‘Really putting a different slant on my use of a glass of wine’: patient perspectives on integrating alcohol into Structured Medication Reviews in general practice

Background Alcohol is often overlooked in primary care even though it has wide-ranging impacts. The Structured Medication Review (SMR) in England is a new ‘holistic’ service designed to tackle problematic polypharmacy, delivered by clinical pharmacists in a general practice setting. Implementation has been protracted owing to the COVID-19 pandemic. This study explores early patient experiences of the SMR and views on the acceptability of integrating clinical attention to alcohol as another drug linked to their conditions and medicines, rather than as a standalone ‘healthy living’ or ‘lifestyle’ question. Method Semi-structured interviews with a sample of 10 patients who drank alcohol twice or more each week, recruited to the study by five clinical pharmacists during routine SMR delivery. Results SMRs received were remote, brief, and paid scant attention to alcohol. Interviewees were interested in the possibility of receiving integrated attention to alcohol within a SMR that was similar to the service specification. They saw alcohol inclusion as congruent with the aims of a holistic medicines review linked to their medical history. For some, considering alcohol as a drug impacting on their medications and the conditions for which they were prescribed, introduced a new frame for thinking about their own drinking. Conclusions Including alcohol in SMRs and changing the framing of alcohol away from a brief check with little meaningful scope for discussion, toward being fully integrated within the consultation, was welcomed as a concept by participants in this study. This was not their current medication review experience.

Managing problematic polypharmacy: GP trainee perspectives on their role in deprescribing.

Problematic polypharmacy is an increasingly common clinical scenario in part due to increasing multimorbidity and application of multiple single condition guidelines. It is a challenging problem requiring a multifaceted management approach. This includes deprescribing, which is the structured dose reduction or stopping of medications. Qualified GPs struggle with deprescribing due to existing barriers, but little is known about how trainee GPs feel about this skill. To explore and understand the perspectives of GP trainees in managing problematic polypharmacy. A qualitative approach with focus groups using a novel love and breakup letter methodology. Purposive sampling of final year GP trainees led to two focus groups. Data from the groups were subjected to thematic analysis. Four key themes emerged: value in deprescribing, requiring a generalist skillset, undermined trainee identity, and educational barriers. Trainees recognised a value in deprescribing and the importance of tackling problematic polypharmacy using this skill. They identified key skills to facilitate this but barriers that prevented them from doing so. They also described how some aspects of the hidden curriculum and 'imposter syndrome' impact on their ability to develop confidence in these skills. Barriers within their training programme were also recognised. This study explored the complex area of problematic polypharmacy and deprescribing as relating to final year GP trainees. It identified key skills that trainees feel they need to manage this task in practice. Importantly, it also recognises barriers to be overcome before confident deprescribing can be performed. Potential improvements in training are identified with suggestions for educational opportunities.

495 Developing deprescribing resources for older people with polypharmacy living in primary care: using co-design and logic modelling

Abstract Introduction Proactive deprescribing – identifying and discontinuing medicines where harms outweigh benefits (1) – can minimise problematic polypharmacy, but it has not been routinely implemented into practice and can have risks. There are complex barriers and facilitators to deprescribing, however there is little evidence about how to overcome such barriers or promote facilitators and what resources are needed to safely and routinely implement deprescribing in primary care. Aim To co-design deprescribing resources that aid the implementation of safe and routine deprescribing in primary care. Methods Community-dwelling patients aged ≥65 years taking ≥5 medicines, community pharmacists, primary care pharmacists and GPs were invited to co-design workshops conducted in July 2022. Participants were recruited through social media and research networks. This project did not require formal ethical approval as it was a service improvement initiative. Two online workshops were facilitated using Microsoft Teams and Miro boards and were supported by a Patient and Public Involvement representative. The first workshop comprised a briefing about findings from a scoping review, systematic review and interview study with patients and healthcare professionals about deprescribing implementation, followed by idea generation through group activities. Potential resources identified were collated and, through discussions with the wider research team, two were prioritised to be further developed. The second workshop used storyboards to further understand and add detail to how the resources chosen would aid the implementation of routine and safe deprescribing in primary care. A logic model was then developed for the resource developed in the workshop. Results Five patients, two GPs, one primary care pharmacist and one community pharmacist took part. In the first workshop, participants identified:(a) patients were suitable advocates for their own health and could initiate conversations about medicines necessity but may need prompts or suggested questions to do so; and (b) community pharmacist follow-up with patients post-deprescribing could help ensure safe deprescribing and facilitate appraisal of deprescribing for future learning. In the second workshop, five questions patients could ask healthcare professionals during everyday interactions and two questions patients could ask during a medication review were developed to stimulate conversations on the necessity of medicines. A storyboard about how community pharmacy could act as a safety net post-deprescribing was developed and refined, following the workshop, into a Real World Logic Model (2) to explain how this safety net could work, the safety net context, and the anticipated outcomes. Conclusion Patients may be able to stimulate conversations on medicine necessity leading to routine deprescribing, whilst community pharmacists could potentially help ensure deprescribing safety. Questions were developed to empower patients to raise the issue of medicines necessity, and a logic model demonstrating community pharmacists as a deprescribing safety net were developed to aid safe and routine deprescribing in primary care. The co-participation of patients and healthcare professionals ensured that both groups’ values and priorities informed intervention development. However, the acceptability and usability of the co-designed interventions cannot be known until feasibility testing has been conducted.

463 Understanding the role of nurses in deprescribing medicines for older people: A systematic review

Abstract Introduction It is predicted that by 2035, two-thirds of people aged over 65 in the UK will be living with multiple health conditions requiring a life-long intake of multiple medicines (1). Recent reports suggest that over 8.4 million people take 5+ medicines, and 3.8 million take 8+ medicines (2). Polypharmacy, the concurrent intake of multiple medicines (5+) by one person is not problematic if the multiple medicines are prescribed appropriately to achieve clear therapeutic objectives and minimise harm. However, problematic polypharmacy arises if the risks of medicines exceed their benefits due to drug interactions and adverse drug reactions. Deprescribing is a personalised medicine optimisation intervention to ensure the safe and effective withdrawal of medicines that are no longer appropriate, beneficial or wanted. Several studies explored the role of pharmacists and doctors in deprescribing medicines for older people, and the benefits to patients and the health care system. However, literature on the nurses’ role in this process remains scarce, despite their frequent contact with older people. Aim To review the relevant studies to identify the role nurses play in deprescribing for older people. Methods This is a systematic review of qualitative and quantitative studies, published in Embase, CINHAL, Google Scholar, British Nursing Database and PubMed, between 2012 and 2022. A manual search of reference lists of included studies was also conducted. We used key words such as nurse, nurse prescriber, deprescribing and medication optimisation to search for studies reporting on the role of nurses in deprescribing medicines for older people >65 years of age, in all healthcare settings. The quality of studies was appraised using the Critical Appraisal Skills Programme (CASP) tool. Thematic analysis was used to identify recurrent themes or concepts from the included studies, and these were then synthesised to answer the research question. Results Twelve studies met the inclusion criteria, 11 of which were of qualitative design. All of the included studies were of moderate to high quality. Five critical roles of nurses in deprescribing were identified including: (i) Assessors; (ii) Co-ordinators; (iii) Facilitators, (iv) Communicators; and (v) Educators. Deprescribing requires multidisciplinary collaboration with clear communication between healthcare providers, and nurses are key players through their management of patients and physically effecting prescribing and deprescribing. They also have a role in assessing patients for deprescribing opportunity, coordinating multidisciplinary healthcare professional support, communicating with patients, relatives and other healthcare professionals, and educating nurses and other healthcare professionals on the importance of deprescribing as a discipline. Despite this, deprescribing is not yet integrated into nurse medication administration, prescribing, and initial or continued professional development. Conclusion Evidence on the role of nurses in deprescribing for the older people is limited. However, the studies included in this systematic review highlight the crucial role nurses play in all stages of the process. Further exploration is required to understand the role of the nurse in deprescribing and how their initial and continued professional development can be optimised to support it.

Polypharmacy Among Patients With Major Depressive Disorder and Co-occurring Substance Use Disorders in a Psychiatric Hospital Setting: Prevalence and Risk Factors.

Major depressive disorder (MDD) is common among patients admitted to a psychiatric hospital who frequently present with comorbid conditions such as substance use disorders (up to 50%). Polypharmacy (ie, being prescribed 3 or more medications) may be relatively common in dual-diagnosis patients. This study sought to examine prevalence and risk factors associated with psychotropic polypharmacy in hospitalized patients with MDD and co-occurring SUDs. An electronic chart review was conducted with 1315 individuals admitted to a psychiatric hospital; 505 (38.4%) were identified as having co-occurring MDD + SUD. We examined psychotropic polypharmacy and clinical severity to explore risk for concerning drug interactions. Potentially problematic polypharmacy patterns were identified among those with MDD + SUD and were related to negative clinical outcomes, particularly in terms of increased sedation potential for individuals with an opioid use disorder (OUD). Groups at the highest risk for polypharmacy included patients who were female, older in age, lower in functioning, and presenting with a co-occurring OUD. Having an OUD was associated with particularly risky polypharmacy combinations, while having a cannabis use disorder was associated with the least polypharmacy. Results highlight a high prevalence of polypharmacy among a group that has an elevated risk for negative outcomes. There is a continued need to improve identification of complex patient presentations and adjust medications in a hospital setting to improve treatment outcomes and reduce future mortality.

Reconsidering ‘problematic’ polypharmacy: an opportunity for developing advanced generalist skills

Managing problematic polypharmacy is a complex area of clinical practice and is increasingly recognised as an educational need for newly qualified and experienced GPs. The RCGP curriculum includes this area as a requirement for completion of training, but how this is achieved is devolved to trainers and trainees working in their local training programmes. GPs at all career stages continue to report feeling unconfident in this important, but complex, area of practice. This article aims to address some of these concerns. We will outline the evidence about barriers preventing clinicians from reducing problematic polypharmacy in practice. We will introduce evidence from the Tailor report describing how these barriers can be overcome and focus on the role of trainees and newly qualified GPs in managing problematic polypharmacy. The Tailor report is a recently published synthesis of the evidence surrounding the management of polypharmacy. In particular we will focus on a key output from the report – the DExTruS framework. This has potential applications in GP training and provides a useful structure for developing the skill of deprescribing by AiTs.

Consultation skills development in general practice: findings from a qualitative study of newly recruited and more experienced clinical pharmacists during the COVID-19 pandemic

ObjectiveThe new structured medication review (SMR) service was introduced into the National Health Service in England during the COVID-19 pandemic, following a major expansion of clinical pharmacists within new formations...

DESCRIBING THE EVOLUTION OF MEDICATION USE OVER TIME IN PEOPLE LIVING WITH DEMENTIA USING NETWORK ANALYSIS

Abstract Prescribing for community-dwelling older adults living with dementia is complex. Multiple medications may be used to manage symptoms associated with dementia and/or co-existing chronic conditions, and can lead to problematic polypharmacy. Our objective was to use network analysis, a data science method, to provide a comprehensive description of co-prescribed medications in persons with dementia and describe whether these patterns change over time. We created a population-based cohort of community-dwelling older adults (aged 67+ years) in Ontario, Canada, newly diagnosed with dementia (between April 2014 and January 2019), from health administrative data, and developed medication networks at one year prior to, at, and for up to five years following dementia diagnosis. Among 136,292 individuals newly diagnosed with dementia, the mean age was 82.2 years and 59% were female. The most common medication subclasses dispensed at diagnosis were primarily cardiovascular medications: statins (45.6%), proton pump inhibitors (27.3%), beta-blockers (27.0%), calcium blockers (25.1%), and ACE inhibitors (24.6%). Similar proportions of medication subclasses were found at five years after diagnosis, except cholinesterase inhibitors (34.0% at five years were dispensed cholinesterase inhibitors compared to 16.9% at diagnosis). The most frequent co-prescribed medication pairs at diagnosis included statins and beta-blockers (16.0%), proton pump inhibitors (16.0%), and ace inhibitors (15.4%), respectively. Co-prescription was similar at five years, but also included higher frequency of co-prescribing with cholinesterase inhibitors (e.g., 19.4% were prescribed cholinesterase inhibitors and statins). Network diagrams demonstrate the complexity of prescribing in this population and highlight concurrent prescribing which may require careful monitoring or deprescribing.

Co-designing an intervention to improve the process of deprescribing for older people living with frailty in the United Kingdom.

In older people living with frailty, polypharmacy can lead to preventable harm like adverse drug reactions and hospitalization. Deprescribing is a strategy to reduce problematic polypharmacy. All stakeholders should be actively involved in developing a person-centred deprescribing process that involves shared decision-making. To co-design an intervention, supported by a logic model, to increase the engagement of older people living with frailty in the process of deprescribing. Experience-based co-designis an approach to service improvement, which uses service users and providers to identify problems and design solutions. This was used to create a person-centred intervention with the potential to improve the quality and outcomes of the deprescribing process. A 'trigger film' showing older people talking about their healthcare experiences was created and facilitated discussions about current problems in the deprescribing process. Problems were then prioritized and appropriate solutions were developed. The review located the solutions in the context of current processes and procedures. An ideal care pathway and a complex intervention to deliver better care were developed. Older people living with frailty, their informal carers and professionals living and/or working in West Yorkshire, England, UK. Deprescribing was considered in the context of primary care. The current deprescribing process differed from an ideal pathway. A complex intervention containing seven elements was required to move towards the ideal pathway. Three of these elements were prototyped and four still need development. The complex intervention responded to priorities about (a) clarity for older people about what was happening at all stages in the deprescribing process and (b) the quality of one-to-one consultations. Priorities for improving the current deprescribing process were successfully identified. Solutions were developed and structured as a complex intervention. Further work is underway to (a) complete the prototyping of the intervention and (b) conduct feasibility testing. Older people living with frailty (and their informal carers) have made a central contribution, as collaborators, to ensure that a complex intervention has the greatest possible potential to enhance the experience of deprescribing medicines.

Older people, medication safety, and the role of the community pharmacist: a longitudinal ethnographic study

AbstractBackgroundOlder people with frailty and multimorbidity are at high risk of problematic polypharmacy. Community pharmacists have a key role in medication safety for older people.AimThe aim of this study was to investigate the perspectives of older people with frailty, multimorbidity, and polypharmacy, and their family caregivers or whānau on the role of community pharmacists, including in situ pharmacist care practices.MethodThis study was part of a larger video reflexive ethnography (VRE) study to explore medication safety and wellbeing for older people with frailty across care transitions including hospital, home, aged residential care, primary care, and outpatient care. This paper reports data from the interview, participant observation, and filming phases of the study.ResultsCommunity pharmacists play a significant role in the medication safety of older people with frailty and polypharmacy. Analysis resulted in three main themes: (1) the older person–determined role of the pharmacist, (2) the ‘taken for granted’ safety work of the pharmacist, and (3) collective agency and medication safety.ConclusionIn circumstances where older people and their family caregivers or whānau had a trusted relationship with a community pharmacist, the pharmacist played a key role as mediator of medication safety and was central to older people's care. This key role as a member of the multidisciplinary team in the care of older people with frailty and multimorbidity should be better recognised and legitimised by clinicians and policy makers and resourced accordingly.