Anticholinergic deprescribing: A case report demonstrating improved cognition and function with minimal adverse withdrawal effects.

Anticholinergic-induced cognitive impairment may be partially reversible upon cessation. A barrier to deprescribing of anticholinergics is the unknown risk of anticholinergic adverse drug withdrawal events (ADWE), with only limited information available on the incidence, timing and severity of anticholinergic ADWE. We report the case of a 76-year-old woman who experienced significant cognitive improvement following deprescribing long-term use of a strong anticholinergic drug, doxepin, and dose reduction of another possible anticholinergic agent. The patient decided to abruptly stop taking doxepin, despite a planned careful taper with twice weekly monitoring, but did not experience any severe anticholinergic ADWE and subsequently had significantly improved cognitive function. Future research should focus on better understanding the risk of anticholinergic ADWE so that anticholinergic deprescribing decisions, including how often and by how much to taper, can be made confidently and safely.

Use of antibiotics for urinary tract infections up to and after care home admission in Denmark: a nationwide study.

PURPOSE: Older people have the highest use of antibiotics for acute and chronic urinary tract infection (UTI), despite diagnostic uncertainty and the growing problem of antibiotic resistance. We aim to describe use-patterns of UTI antibiotics two years prior to and following care home admission in Denmark. METHODS: This was a register-based nationwide drug-utilization study. In a cohort comprising all Danish residents admitted into a care home from 2015 to 2021, we described the use of UTI antibiotics, and examined differences between regions and individual care homes in rates of UTI antibiotic use. Further, we described trends in UTI-related contacts with hospitals in the two years prior to and following care home admission. RESULTS: The cohort comprised 101,297 residents (61% female; median age 84 years). UTI antibiotic use doubled from 7 to 14 treatments/100 residents/month two months prior to care home admission and remained at 10 treatments/100 residents/month the following two years. Prescription of pivmecillinam (55%) was most common. Primary care practitioners prescribed the majority (92%) of UTI antibiotics. UTI-related hospital contacts peaked at two months prior to care home admission, with 6 admissions/100 residents/month, subsequently dropping to 2 admission/100 residents/month. We found considerable variation in UTI antibiotic use, with 10% of care homes responsible for 20% of treatments in 2021. CONCLUSION: Use of UTI antibiotics increased prior to and remained at a stable high level following care home admission in Denmark. Despite variation in use across regions and individual care homes, an overall decrease was seen throughout the years 2016-2021.

Measuring Quality of Life in Deprescribing Trials: A Scoping Review.

BACKGROUND: Quality of life (QoL) is an important outcome to capture in clinical trials evaluating deprescribing interventions. OBJECTIVE: We aimed to conduct a scoping review to examine how QoL has been measured in deprescribing trials among older people and identify potentially relevant QoL scales, to better inform QoL measurement in future deprescribing trials. METHODS: We searched MEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled Trials, Google Scholar, Epistemonikos, ClinicalTrials.gov, and reference lists of eligible studies (from inception to October 2023). We included randomized and non-randomized comparative studies with a control group that evaluated deprescribing and polypharmacy reduction interventions in people ≥ 65 years of age and measured QoL as an outcome. We also included studies describing the development and validation of QoL scales related to deprescribing, polypharmacy, or medication burden in adults ≥ 18 years of age. Two independent reviewers screened titles and abstracts, then full texts. Two independent reviewers extracted data from 25% of eligible studies in order to verify agreement, then a single reviewer extracted data from the remaining studies, which a second reviewer cross-checked. We critically appraised scales based on the COSMIN checklist. RESULTS: We retrieved 7290 articles, of which 52 were eligible for inclusion, including 44 deprescribing trials and eight scale development studies. From these studies, we found 21 scales that have been used in the context of deprescribing/polypharmacy (12 generic scales used in clinical trials and nine medication-specific scales). Variations of the generic EQ-5D were the most used scales. The measurement properties of scales for capturing changes in QoL from deprescribing were uncertain. Medication-specific QoL scales have not been employed in deprescribing clinical trials and thus, their performance in this context is also not clear. CONCLUSIONS: Several existing QoL scales have been applied to the context of deprescribing/polypharmacy clinical trials, and new scales specific to the problem have been proposed. If deprescribing does impact QoL, our findings suggest it is uncertain whether existing QoL scales can practically and reliably capture such a change or whether any scale is best. However, this review compares various aspects of the scales that researchers and clinicians can consider in decisions about measuring QoL in deprescribing trials, and in planning future research. PROTOCOL REGISTRATION: Open Science Framework: osf.io/aez6w.

Reducing potentially inappropriate polypharmacy at a national and international level: the impact of deprescribing networks.

INTRODUCTION: Over the past decade, polypharmacy has increased dramatically. Measurable harms include falls, fractures, cognitive impairment, and death. The associated costs are massive and contribute substantially to low-value health care. Deprescribing is a promising solution, but there are barriers. Establishing a network to address polypharmacy can help overcome barriers by connecting individuals with an interest and expertise in deprescribing and can act as an important source of motivation and resources. AREAS COVERED: Over the past decade, several deprescribing networks were launched to help tackle polypharmacy, with evidence of individual and collective impact. A network approach has several advantages; it can spark interest, ideas and enthusiasm through information sharing, meetings and conversations with the public, providers, and other key stakeholders. In this special report, the details of how four deprescribing networks were established across the globe are detailed. EXPERT OPINION: Networks create links between people who lead existing and/or budding deprescribing practices and policy initiatives, can influence people with a shared passion for deprescribing, and facilitate sharing of intellectual capital and tools to take initiatives further and strengthen impact.This report should inspire others to establish their own deprescribing networks, a critical step in accelerating a global deprescribing movement.

Attitudes towards deprescribing in geriatric psychiatry: A survey among older psychiatric outpatients.

Understanding the patient perspective is a significant part of the deprescribing process. This study aimed to explore the attitudes of older patients with psychiatric disorders towards deprescribing. A total of 72 of psychiatric outpatients (68% women; median age 76 years) completed the validated Danish version of the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. Patients used a median of eight medications (interquartile range 6-12), with 88%, 49% and 24% using antidepressants, antipsychotics and anxiolytics, respectively. Fifty-one percent of patients reported an intrinsic desire to stop one of their medications, while 92% would be willing to stop one on their physician's advice. Seventy-five percent of patients would be worried about missing out on future benefits following deprescribing and 37% had previous bad deprescribing experiences. Use of ≥8 regular medications was associated with more concerns about stopping medication and greater perceived burden of using medication, while use of antipsychotics was not associated with any differences in rPATD factor scores. It is crucial for health care professionals to be aware of patients' specific concerns and past experiences to promote a patient-centred deprescribing approach that takes into account the needs and preferences of older patients with psychiatric disorders.

Recommendations on deprescribing of bisphosphonates in osteoporosis guidelines: a systematic review.

PURPOSE: Advancing age, declining health status, and a shift in benefit/risk balance warrant judicious use of preventive medications in older persons, including consideration of deprescribing. Lack of guidance on deprescribing is a major barrier for prescribers to consider deprescribing in daily practice. The aim of this review was to evaluate to what extent osteoporosis guidelines include bisphosphonate deprescribing recommendations. METHODOLOGY: We conducted a systematic review, searching PubMed, Embase, and grey literature. We included guidelines on treatment of osteoporosis with bisphosphonates. Two independent reviewers screened titles, abstracts, and full texts. Recommendations for deprescribing were extracted, and quality of guidelines were assessed. RESULTS: Among 9345 references, 42 guidelines were included. A total of 32 (76%) guidelines included deprescribing recommendations: 29 (69%) guidelines included non-specific deprescribing recommendations framed as a drug holiday, of which 2 (5%) also included specific deprescribing recommendations based on individual health context (e.g. life expectancy, frailty, function, preferences/goals). Twenty-four (57%) guidelines included practical deprescribing recommendations, and 27 (64%) guidelines included recommendations for when deprescribing should not be considered. CONCLUSION: Bisphosphonate deprescribing recommendations in osteoporosis guidelines were primarily framed as drug holidays, with limited guidance on how to make individualized deprescribing decisions based on individual health context. This suggests a need for additional focus on deprescribing in osteoporosis guidelines.

Use of analgesics in Denmark: A national survey.

People suffering from pain constitute a sizeable and heterogeneous patient group. Conventional oral analgesics are considered a cheap and safe first-line treatment. These drugs are used on both a regular and 'as needed' basis and are often obtained over-the-counter (OTC). We explored patient-reported patterns of use and adverse effects of analgesics in a community pharmacy questionnaire. Eight pharmacies invited persons aged ≥18 years requesting analgesics via prescription or OTC to complete an electronic questionnaire. A total of 2410 participants completed the questionnaire (68% female; 50% ≥ 60 years). Most participants filled a prescription for paracetamol (61%; n = 842) and non-steroidal analgesics (n = 363; 26%). Among OTC users, most obtained paracetamol (61%). Among prescription users, 73% (n = 1114) had their analgesic prescribed for daily use; however, of these only 61% (n = 630) reported using it daily, while 35% (n = 363) reported 'as needed' use. Of all prescriptions, 80% (n = 898) were labelled with the standardized indication 'against pain'. Self-reported indications showed that back pain and muscle/joint pain were the most common indications. Among non-new users of OTC analgesics (n = 841), 17% (n = 141) used their medication daily. Finally, 90% (n = 1658) of all participants reported not experiencing adverse effects. Our findings suggest a need for continuous assessment of analgesic patterns of use after treatment initiation to inform counselling in community pharmacies and elsewhere.

[Deprescribing in Danish clinical treatment guidelines].

Lack of clinical guidance constitutes a significant barrier to deprescribing. Within Danish clinical guidelines on treatment of dementia, type 2 diabetes, hypertension, and osteoporosis, only limited attention was given to deprescribing. For dementia, type 2 diabetes, and osteoporosis, guidance was primarily focused on when to consider and implement deprescribing, with limited practical guidance on how to deprescribe. No guidance for deprescribing antihypertensives was identified. This highlights a need to consider deprescribing more broadly when developing and updating clinical guidelines, as argued in this review.

Antihypertensive medication in frail older adults: A narrative review through a deprescribing lens.

Purpose of review: The management of hypertension in frail older adults remains controversial, as these patients are underrepresented in clinical trials and practice guidelines. Overtreatment may cause harm while undertreatment may lead to greater risk of cardiovascular events. Our research aims to examine this controversy and provide guidance regarding deprescribing decisions in frail older adults. Results: Current evidence suggests that there may be minimal cardiovascular benefit and significant harm of antihypertensive medication in the frail older adult population. A minority of hypertension guidelines provide sufficient recommendations for frail older adults, and there are limited tools available to guide clinical decision-making. Conclusion: Randomized controlled trials and well-designed observational studies are needed to confirm the benefit-to-harm relationship of antihypertensive medication in frail older adults. Decision tools that comprehensively address antihypertensive deprescribing would be advantageous to help clinicians with hypertension management in this population. Clinicians should engage in shared decision-making with the patient and family to ensure that decisions regarding antihypertensive deprescribing best meet the needs of all involved.

Patient Preferences for Discussing Life Expectancy: a Systematic Review.

BACKGROUND: Discussing life expectancy helps inform decisions related to preventive medication, screening, and personal care planning. Our aim was to systematically review the literature on patient preferences for discussing life expectancy and to identify predictors for these preferences. METHODS: We searched PubMed, Cochrane Library, Embase, MEDLINE, PsycInfo, and gray literature from inception until 17 February 2021. Two authors screened titles/abstracts and full texts, and extracted data and one author assessed quality. The outcome of interest was the proportion of patients willing to discuss life expectancy. We reported descriptive statistics, performed a narrative synthesis, and explored sub-groups of patients according to patient characteristics. RESULTS: A total of 41 studies with an accumulated population of 27,570 participants were included, comprising quantitative survey/questionnaire studies (n=27) and qualitative interview studies (n=14). Willingness to discuss life expectancy ranged from 19 to 100% (median 61%, interquartile range (IQR) 50-73) across studies, with the majority (77%) reporting more than half of subjects willing to discuss. There was considerable heterogeneity in willingness to discuss life expectancy, even between studies from patients with similar ages, diseases, and cultural profiles. The highest variability in willingness to discuss was found among patients with cancer (range 19-100%, median 61%, IQR 51-81) and patients aged 50-64 years (range 19-97%, median 61%, IQR 45-87). This made it impossible to determine predictors for willingness to discuss life expectancy. DISCUSSION: Most patients are willing to discuss life expectancy; however, a substantial proportion is not. Heterogeneity and variability in preferences make it challenging to identify clear predictors of willingness to discuss. Variability in preferences may to some extent be influenced by age, disease, and cultural differences. These findings highlight the individual and complex nature in which patients approach this topic and stress the importance of clinicians considering eliciting patient's individual preferences when initiating discussions about life expectancy.

Use of sedating medications around nursing home admission in Denmark.

PURPOSE: To examine use of sedating medications around the time of nursing home admission in Denmark. METHODS: We conducted a register-based drug utilization study, describing patterns of commonly used medications with sedative effects leading up to and after nursing home admission using data from 94 Danish nursing homes between 2015 and 2017. RESULTS: We identified 5179 residents (median age 84 years, 63% female) and described monthly incidence and total use of benzodiazepines (BZDs), Z drugs, mirtazapine/mianserin, quetiapine, promethazine, and melatonin. The proportion of unique users of sedating medications was similar before and after admission (42% before vs. 40% after) despite an increase in total use after admission. The overall incidence of sedating medications peaked in the 6 months before and 6 months after admission (peaking at 4.6 per 100 person-months 1 month after admission). The most commonly initiated medications were mirtazapine/mianserin, followed by BZDs and Z drugs. Total use of sedating medications increased leading up to admission (peaking at 1001 defined daily doses per 100 residents per month 1 month after admission) and decreased gradually after admission. CONCLUSIONS: Sedative medication initiation increases sharply leading up to admission in Danish nursing homes. Mirtazapine/mianserin is a commonly used agent in nursing homes, despite limited evidence on benefits and harms. Efforts to promote rational use of these medications in nursing homes remain warranted.

Attitudes towards deprescribing: The perspectives of geriatric patients and nursing home residents.

BACKGROUND/OBJECTIVES: Successful deprescribing requires insight into patients' thoughts about deprescribing. We described attitudes towards deprescribing in a large sample of geriatric patients and nursing home residents. DESIGN: Interview-based questionnaire study. SETTING: Denmark. PARTICIPANTS: Geriatric inpatients (n = 44), geriatric outpatients (n = 94), and nursing home residents (n = 162) with an Orientation-Memory-Concentration score of ≥8. MEASUREMENTS: Participants completed the validated Danish version of the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire by interview. Attitudes were reported descriptively, and rPATD factor scores were compared between participant groups and across participant characteristics. RESULTS: Participants had a median age of 82 years (interquartile range [IQR] 76-89) and used a median of 8 medications (IQR 5-10). Thirty-three percent of participants would like to try stopping one of their medications on their own, while 87% were willing to stop one on their physician's advice. Geriatric inpatients reported slightly greater perceived burden of taking medication compared to geriatric outpatients and nursing home residents (median "burden" score 50 vs 42, p = 0.11), while geriatric outpatients reported slightly more involvement in their medication use compared to nursing home residents (median "involvement" score 80 vs 75, p < 0.05) and geriatric inpatients (median "involvement" score 80 vs 70, p < 0.01). An increasing number of medications was associated with an increased "burden" score (ptrend = 0.001): Those using 1-4 medications daily had a median score of 25 (IQR 17-33) compared to 58 (IQR 42-75) among those using ≥10 medications daily. Similarly, an increasing number of medications was associated with a higher "concerns about stopping" score (ptrend  = 0.001) and a lower "appropriateness" score (ptrend < 0.001), respectively. CONCLUSION: Geriatric patients and nursing home residents are generally open towards deprescribing, particularly if proposed by their physician. Some differences exist between populations and across individual patient characteristics. Clinicians should increase awareness of deprescribing as a possibility in these populations and tailor their deprescribing approach to the individual patient.

"I simply don't know, because I don't know which drugs I get": Perspectives on deprescribing among older adults with limited life expectancy and their relatives.

Use of medications of questionable benefit is common in end of life care. In order to effectively carry out deprescribing, it is important to gain insight into the perspectives of patients and their relatives. Thus, our objective was to explore perspectives on deprescribing among older adults with limited life expectancy and their relatives. We conducted semi-structured interviews with ten nursing home residents and nine relatives. Interviews were analysed using systematic text condensation. Four main themes were identified: "Medication as a necessity and to feel well," "Frailty as a barrier for taking responsibility," "Patient autonomy and faith in authority" and "A wish for being involved." Most participants had not considered the possibility of deprescribing but were open towards medication change if proposed by a healthcare professional. Most participants did not have in-depth knowledge about medication but would like to be informed or involved in decisions. The participants generally had faith in healthcare professionals despite limited contact. Our study implies that older adults with limited life expectancy and their relatives are generally interested in deprescribing activities; however, the initiative of deprescribing lies with the healthcare professionals.

Translation, cross-cultural adaptation, and validation of the Danish version of the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire: Version for older people with limited life expectancy.

BACKGROUND: Knowledge about patients' attitudes towards deprescribing is essential for optimizing medication use. The revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire is a 22-item self-report instrument capturing older patients' beliefs and attitudes towards deprescribing. OBJECTIVES: To translate and cross-culturally adapt the rPATD questionnaire into Danish and subsequently validate it in a cohort of nursing home residents. METHODS: The rPATD questionnaire was translated and cross-culturally adapted during five stages of forward and backward translation. The validation study included 162 Danish nursing home residents (median age 84 years; 67% women). Validity was assessed through exploratory factor analysis (structural validity) and hypothesis testing (construct validity), while reliability was assessed through internal consistency. Floor and ceiling effects were examined. RESULTS: The exploratory factor analysis revealed a 4-factor structure similar to the original rPATD questionnaire, with items loading into four factors related to level of involvement in medication use, perceived burden of taking medication, belief in appropriateness of using medication, and concerns about stopping medication. The questionnaire was adjusted to the Danish nursing home population and health care system by omission of two items, concerning medication expenses and inconvenience of taking medication, which resulted in a model with factor loadings ranging from 0.29 to 0.84 and only minor cross-loading. Construct validity correctly predicted 67% of the hypothesized correlations. Internal consistency of all factors was generally acceptable with Cronbach's α ranging from 0.67 to 0.78. No floor and ceiling effects were identified. CONCLUSIONS: Results suggest that the Danish modified model of the rPATD questionnaire generally has acceptable validity and reliability.

Discussing proton pump inhibitor deprescribing: the views of Danish GPs and older patients.

BACKGROUND: Deprescribing of proton pump inhibitors (PPIs) can be considered in situations where the drug may no longer be necessary; however, this requires a careful discussion between patients and healthcare providers, often general practitioners (GPs). The aim of our study was to explore how GPs discuss PPI deprescribing with patients and compare that to how older patients would like to discuss this decision. METHODS: We conducted a qualitative study using semi-structured interviews with GPs (n = 11) and patients aged ≥65 years who were taking PPIs (n = 4). Analysis of interviews was based on systematic text condensation. RESULTS: We identified four main themes: (1) Reasons PPI deprescribing comes up, (2) Considering PPI deprescribing, (3) Discussion topics, and (4) Incorporating patient preferences into PPI deprescribing decisions. We found that PPI deprescribing often comes up during consultations for other problems or due to concern about medication burden in general. GPs discussed topics related to symptom control, such as the possibility of rebound symptoms, the need to taper PPIs, and what to do if symptoms returned. This aligned with what patients felt was important to discuss. Some GPs routinely incorporated patient preferences into decisions, whereas others did not. CONCLUSION: When discussing PPI deprescribing, the GPs in our study generally focused on topics related to symptom control. There was variability in how and if patient preferences were discussed. Greater focus may be needed on developing mechanisms to elicit and incorporate patient preferences into PPI deprescribing decisions. Future research could also explore more systematic approaches to reassess ongoing PPI use in an effort to curb unnecessary long-term use of PPIs.