Deprescribing bisphosphonates for older adults with dementia: perspectives of caregivers.

Little is known about caregivers' perspectives on deprescribing bisphosphonates for older adults with dementia. Caregivers agreed that fracture prevention was important for maintaining functional independence but acknowledged that changing goals of care may justify deprescribing. Conversations grounded in "what matters most" can align fracture prevention treatment with goals of care. PURPOSE: The long-term fracture prevention benefits of bisphosphonates may begin to be overshadowed by the potential burden of adverse effects and polypharmacy for older adults living with dementia as the disease progresses. We characterized factors that influence caregiver decision-making for continuing versus deprescribing bisphosphonates for persons living with dementia. METHODS: We conducted 11 interviews with family or informal caregivers of older adults living with dementia in the community or in long-term care who had been treated with bisphosphonates. Interviews focused on experiences caring for someone who has experienced a fracture, perceived benefits and harms of bisphosphonates, and experiences with deprescribing. Analyses were conducted using a qualitative framework methodology guided by the Health Belief Model. RESULTS: Most caregivers were male (n = 8), younger than 65 (n = 8) and were an adult child caregiver (n = 8). Three caregivers were Black and five were Latino/a. Attempts to maintain functional independence despite high likelihood of falls was frequently discussed as contributing to fracture risk, in this population. Many caregivers perceived fracture prevention treatment as important, while several noted that it may become less important near the end of life. Perceived benefits of fracture prevention treatment for persons with dementia included improved quality of life and maintaining independence. Although most indicated that bisphosphonates were well tolerated, gastrointestinal adverse effects, preference for fewer treatments, and dementia-related behaviors that interfere with medication administration may be reasons for deprescribing. CONCLUSION: Conversations grounded in caregiver experiences and "what matters most" may help optimize fracture prevention treatment for older adults with dementia.

Patient Perceptions of Opioids and Benzodiazepines and Attitudes Toward Deprescribing.

BACKGROUND: Opioids and benzodiazepines (BZDs) pose a public health problem. Older adults are especially susceptible to adverse events from opioids and BZDs owing to an increased usage of opioids and BZDs, multiple comorbidities, and polypharmacy. Deprescribing is a possible, yet challenging, solution to reducing opioid and BZD use. OBJECTIVE: We aimed to explore older adult patients' knowledge of opioids and BZDs, perceived facilitators and barriers to deprescribing opioids and BZDs, and attitudes toward alternative treatments for opioids and BZDs. METHODS: We conducted 11 semi-structured interviews with patients aged 65+ years with long-term opioid and/or BZD prescriptions. The interview guide was developed by an interprofessional team and focused on patients' knowledge of opioids and BZDs, perceived ability to reduce opioid or BZD use, and attitudes towards alternative treatments. RESULTS: Three patients had taken opioids, either currently or in the past, three had taken BZDs, and five had taken both opioids and BZDs. Generally, knowledge of opioids and BZDs was variable among patients; yet facilitators and barriers to deprescribing both opioids and BZDs were consistent. Facilitators of deprescribing included patient-provider trust and slow tapering of medications, while barriers included concerns about re-emergence of symptoms and a lack of motivation, particularly if medications and symptoms were stable. Patients were generally unenthusiastic about pursuing alternative pharmacologic and non-pharmacologic alternatives to opioids and BZDs for symptom management. CONCLUSIONS: Our findings indicate that patients are open to deprescribing opioids and BZDs under certain circumstances, but overall remain hesitant with a lack of enthusiasm for alternative treatments. Future studies should focus on supportive approaches to alleviate older adults' deprescribing concerns.

Secular Trends in Central Nervous System-Active Polypharmacy Among Serial Cross-Sections of US Adults, 2009-2020.

BACKGROUND: Data comprehensively examining trends in central nervous system (CNS)-active polypharmacy are limited. The objective of this cross-sectional study was to characterize the composition of and trends in CNS-active medication use in US adults. METHODS: We included all participants ≥ 18 years old in the National Health and Nutrition Examination Study (NHANES), 2009-2020. The primary outcome was the percent of adults with CNS-active polypharmacy. This was defined as ≥ 3 medications among antidepressants [tricyclic, selective and serotonin-norepinephrine reuptake inhibitors (SSRIs and SNRIs), opioids, antiepileptics, antipsychotics, benzodiazepines, and nonbenzodiazepine receptor agonists ("Z-drugs")]. Secondary outcomes included prevalence of any CNS-active medication and specific medications and classes over time, and their indications. Percentages were weighted according to NHANES's nationally representative sampling frame. log binomial regressions evaluated the relative risk (RR) for each outcome, comparing the last (2017-2020) versus the first (2010-2011) survey cycle. RESULTS: We included 34,189 adults (18.8% at least 65 years old) from five serial cross-sections (survey cycles). The prevalence of CNS-active polypharmacy was 2.1% in 2009-2010 and 2.6% in 2017-2020 [RR 1.18, 95% confidence interval (CI) 0.94-1.47]. The prevalence of CNS-active polypharmacy did not significantly change within any specific age group (e.g., age at least 65 years: RR 1.29, CI 0.74-2.24). The prevalence of any CNS-active medication was 21.0% in 2009 and 24.6% in 2017-2020 (RR] 1.12, 95% CI 1.02-1.25). A substantial increase occurred for antiepileptics (5.1-8.3%), specifically among participants aged 65 years and older (8.3-13.7%). This was largely driven by increasing gabapentin prevalence (1.4-3.6% overall; 3.3-7.9% age 65 years and older). Anticholinergic, SSRIs/SNRIs, antiepileptics, and benzodiazepines were elevated in most cycles for participants at least 65 years old compared with participants less than 65 years, and opioid use was increased in several cycles for older participants as well. Alprazolam was the most common benzodiazepine and third most common medication for anxiety/depression. Gabapentin was the most common CNS-active medication (3.6% of all participants in 2017-2020), followed by sertraline, citalopram, and acetaminophen-hydrocodone (each ~2%). The most common categories were antidepressants (13.7% in 2017-2020), followed by opioids (5.1% in 2017-2020). CONCLUSIONS: CNS-active medications are increasingly common, particularly gabapentin, and use of any CNS-active medication increased by 12%. Numerous CNS-active classes also increased in older adults throughout the years. Increasing suboptimal medication use highlight the need for further investigation into causes for potentially inappropriate prescribing, particularly for older adults.

Anticholinergic co-prescribing in nursing home residents using cholinesterase inhibitors: Potential deprescribing cascade.

BACKGROUND: Polypharmacy may result from inappropriate prescribing of medications to treat adverse drug reactions (ADRs), i.e., "prescribing cascade." A potentially harmful prescribing cascade affecting those with severe dementia can result when anticholinergics are prescribed to manage side effects of cholinesterase inhibitors (ChEIs). We investigated 1) factors associated with co-prescribing of anticholinergics and ChEIs and 2) whether discontinuation of ChEIs was associated with subsequent discontinuation of anticholinergics-a potentially beneficial reversal or "deprescribing cascade." METHODS: We conducted a retrospective analysis of linked Medicare Part A/B/D claims, Master Beneficiary Summary File, Minimum Data Set, Area Health Resource File, and Nursing Home Compare from 2015 to 2016. Subjects were Medicare beneficiaries residing in nursing homes, ≥65 years old with severe dementia admitted for non-skilled stays, who were prescribed ChEIs. Cross-sectional analysis evaluated factors associated with co-prescribing of anticholinergics with ChEIs. Longitudinal Cox proportional hazards regression examined whether discontinuation of ChEIs was associated with subsequent discontinuation of anticholinergics over a 1-year period. RESULTS: We found 15% of our sample experienced co-prescribing of anticholinergics and ChEIs. Several resident and facility-level factors were associated with co-prescribing anticholinergics. Advancing age, minority race or ethnicity, end-stage renal disease, heart failure, and poor appetite were associated with a decreased likelihood of co-prescribing. Female sex, polypharmacy, and non-geriatric prescriber-type were associated with a higher likelihood of co-prescribing. In longitudinal analyses, we observed that discontinuation of ChEIs was associated with a reduced likelihood (HR 0.58 [95% CI, 0.47-0.71]) of discontinuing any medications with anticholinergic properties, except for bladder antimuscarinics (HR 1.32 [95% CI, 0.83-2.09]). CONCLUSIONS: Younger, healthier older adults with dementia were more likely to experience co-prescribing anticholinergics and ChEIs. Discontinuation of anticholinergics was infrequent. Further research is needed to understand prescribers' ability to recognize and reverse potential prescribing cascades through deprescribing.

Patterns of oral bisphosphonate deprescribing in older nursing home residents with dementia.

In a national sample of Medicare nursing home residents with dementia treated with bisphosphonates, 20% had bisphosphonates deprescribed. Residents with clinical characteristics representing decreased likelihood for long-term benefit were more likely to have bisphosphonates deprescribed. Future studies are needed to evaluate outcomes of deprescribing bisphosphonates in this population. INTRODUCTION: To determine incidence of deprescribing bisphosphonates among nursing home (NH) residents with dementia and identify factors associated with deprescribing. METHODS: 2015-2016 Medicare claims, Part D prescriptions, Minimum Data Set (MDS) 3.0, and Nursing Home Compare for non-skilled NH residents aged 65 + with dementia and prescriptions for oral bisphosphonates overlapping the first 14 days of the stay. Our primary definition for deprescribing was a 90-day gap in medication supply; we also explored the reliability of different deprescribing definitions (30-, 90-, 180-day gaps). We estimated associations of NH, provider, and resident characteristics with deprescribing bisphosphonates using competing risks regression models. RESULTS: Most NH residents with dementia treated with bisphosphonates (n = 5312) were ≥ 80 years old (72%), white (81%), and female (90%); about half were dependent for transfers (50%) or mobility (45%). Using a 90-day gap in supply, the 180-day cumulative incidence of deprescribing bisphosphonates was 14.8%. This increased to 32.1% using a 30-day gap and decreased to 11.7% using a 180-day gap. Factors associated with increased likelihood for bisphosphonate deprescribing were age ≥ 90 years, newly admitted (vs. prevalent stay), dependent for mobility, swallowing difficulty, > 1 hospitalization in the prior year, CCRC facility, and nurse practitioner primary provider (vs. physician). Cancer and western geographic region were associated with reduced likelihood for deprescribing. CONCLUSION: In a national sample of NH residents with dementia, bisphosphonate deprescribing was uncommon, and associated with clinical characteristics signifying poor prognosis and decreased likelihood for long-term benefit. Future studies should evaluate clinical outcomes of deprescribing bisphosphonates in this population.

Incidence and Predictors of Aspirin Discontinuation in Older Adult Veteran Nursing Home Residents at End of Life.

OBJECTIVES: Continuation of aspirin for secondary prevention in persons with limited life expectancy (LLE) is controversial. We sought to determine the incidence and predictors of aspirin discontinuation in veterans with LLE and/or advanced dementia (LLE/AD) who were taking aspirin for secondary prevention at nursing home admission, stratified by whether their limited prognosis (LP) was explicitly documented at admission. DESIGN: Retrospective cohort study using linked Veterans Affairs (VA) and Medicare clinical/administrative data and Minimum Data Set resident assessments. SETTING: All VA nursing homes (referred to as community living centers [CLCs]) in the United States. PARTICIPANTS: Older (≥65 y) CLC residents with LLE/AD, admitted for 7 days or longer in fiscal years 2009 to 2015, who had a history of coronary artery disease and/or stroke/transient ischemic attack, and used aspirin within the first week of CLC admission (n = 13 844). MEASUREMENTS: The primary dependent variable was aspirin discontinuation within the first 90 days after CLC admission, defined as 14 consecutive days of no aspirin receipt. Independent variables included an indicator for explicit documentation of LP, sociodemographics, environment of care characteristics, cardiovascular risk factors, bleeding risk factors, individual markers of poor prognosis (eg, cancer, weight loss), and facility characteristics. Fine and Gray subdistribution hazard models with death as a competing risk were used to assess predictors of discontinuation. RESULTS: Cumulative incidence of aspirin discontinuation was 27% (95% confidence interval [CI] = 26%-28%) in the full sample, 34% (95% CI = 33%-36%) in residents with explicit documentation of LP, and 24% (95% CI = 23%-25%) in residents with no such documentation. The associations of independent variables with aspirin discontinuation differed in residents with vs without explicit LP documentation at admission. CONCLUSION: Just over one-quarter of patients discontinued aspirin, possibly reflecting the unclear role of aspirin in end of life among prescribers. Future research should compare outcomes of aspirin deprescribing in this population. J Am Geriatr Soc 68:725-735, 2020.

Factors Associated With Deprescribing Acetylcholinesterase Inhibitors in Older Nursing Home Residents With Severe Dementia.

BACKGROUND/OBJECTIVE: Uncertainty regarding benefits and risks associated with acetylcholinesterase inhibitors (AChEIs) in severe dementia means providers do not know if and when to deprescribe. We sought to identify which patient-, provider-, and system-level characteristics are associated with AChEI discontinuation. DESIGN: Analysis of 2015 to 2016 data from Medicare claims, Part D prescriptions, Minimum Data Set (MDS), version 3.0, Area Health Resource File, and Nursing Home Compare. Cox-proportional hazards models with time-varying covariates were used to identify patient-, provider-, and system-level factors associated with AChEI discontinuation (30-day or more gap in supply). SETTING: US Medicare-certified nursing homes (NHs). PARTICIPANTS: Nonskilled NH residents, aged 65 years and older, with severe dementia receiving AChEIs within the first 14 days of an MDS assessment in 2016 (n = 37 106). RESULTS: The sample was primarily white (78.7%), female (75.5%), and aged 80 years or older (77.4%). The most commonly prescribed AChEIs were donepezil (77.8%), followed by transdermal rivastigmine (14.6%). The cumulative incidence of AChEI discontinuation was 29.7% at the end of follow-up (330 days), with mean follow-up times of 194 days for continuous users of AChEIs and 105 days for those who discontinued. Factors associated with increased likelihood of discontinuation were new admission, older age, difficulty being understood, aggressive behavior, poor appetite, weight loss, mechanically altered diet, limited prognosis designation, hospitalization in 90 days prior, and northeastern region. Factors associated with decreased likelihood of discontinuation included memantine use, use of strong anticholinergics, polypharmacy, rurality, and primary care prescriber vs geriatric specialist. CONCLUSION: Among NH residents with severe dementia being treated with AChEIs, the cumulative incidence of AChEI discontinuation was just under 30% at 1 year of follow-up. Our findings provide insight into potential drivers of deprescribing AChEIs, identify system-level barriers to deprescribing, and help to inform covariates that are needed to address potential confounding in studies evaluating the potential risks and benefits associated with deprescribing. J Am Geriatr Soc 67:1871-1879, 2019.

Adaptation and Initial Validation of Minimum Data Set (MDS) Mortality Risk Index to MDS Version 3.0.

OBJECTIVES: To evaluate the predictive validity of an adapted version of the Minimum Data Set (MDS) Mortality Risk Index-Revised (MMRI-R) based on MDS version 3.0 assessment items (MMRI-v3) and to compare the predictive validity of the MMRI-v3 with that of a single MDS item indicating limited life expectancy (LLE). DESIGN: Retrospective, cross-sectional study of MDS assessments. Other data sources included the Veterans Affairs (VA) Residential History File and Vital Status File. SETTING: VA nursing homes (NHs). PARTICIPANTS: Veterans aged 65 and older newly admitted to VA NHs between July 1, 2012, and September 30, 2015. MEASUREMENTS: The dependent variable was death within 6 months of admission date. Independent variables included MDS items used to calculate MMRI-v3 scores (renal failure, chronic heart failure, sex, age, dehydration, cancer, unintentional weight loss, shortness of breath, activity of daily living scale, poor appetite, acute change in mental status) and the MDS item indicating LLE. RESULTS: The predictive ability of the MMRI-v3 for 6-month mortality (c-statistic 0.81) is as good as that of the original MMRI-R (c-statistic 0.76). Scores generated using the MMRI-v3 had greater predictive ability than that of the single MDS indicator for LLE (c-statistic 0.76); using the 2 together resulted in greater predictive ability (c-statistic 0.86). CONCLUSION: The MMRI-v3 is a useful tool in research and clinical practice that accurately predicts 6-month mortality in veterans residing in Veterans Affairs NHs. Identification of residents with LLE has great utility for studying palliative care interventions and may be helpful in guiding allocation of these services in clinical practice. J Am Geriatr Soc 66:2353-2359, 2018.

Impact of clinical pharmacist services delivered via telemedicine in the outpatient or ambulatory care setting: A systematic review.

BACKGROUND: Utilization of telemedicine allows pharmacists to extend the reach of clinical interventions, connecting them with patients and providers, but the overall impact of these services is under-studied. OBJECTIVE: Identify the impact of clinical pharmacist telemedicine interventions on clinical outcomes, subsequently defined as clinical disease management, patient self-management, and adherence, in outpatient or ambulatory settings. METHODS: A literature search was conducted from database inception through May 2016 in Medline, SCOPUS, and EMBASE. Broad terms "telemedicine", "telehealth", and "telephone" were used in combination with "pharmacist" or "pharmacy" and "telepharmacy". The search and extraction process followed PRISMA guidelines. Results were screened for pharmacist interventions and reviewed to identify studies in outpatient our ambulatory settings. Studies of non-clinical outcomes (i.e. dispensing or product preparation) and with no comparator were excluded. The final studies were categorized by types of outcomes reported: clinical disease management, patient self-management, and adherence. RESULTS: Only 34 studies measured clinical outcomes against a comparator, consistent with the research question. The majority utilized scheduled models of care (n = 29). Telephone was the most common communication method (n = 25). The most utilized interventions were pharmacist-led telephonic clinics (n = 10). Most studies focused on chronic disease management in adults including hypertension, diabetes, anticoagulation, depression, hyperlipidemia, asthma, heart failure, HIV, PTSD, CKD, stroke, COPD and smoking cessation. Twenty-three studies had a positive impact with one reporting negative results. Higher positive impact rate was observed for scheduled (72.4%, 21/29) and continuous (100%, 2/2) models compared to responsive/reactive (25%, 1/4). CONCLUSIONS: Clinical pharmacy telemedicine interventions in the outpatient or ambulatory setting, primarily via phone, have an overall positive impact on outcomes related to clinical disease management, patient self-management, and adherence in the management of chronic diseases. Commonalities among studies with positive impact included utilization of continuous or scheduled models via telephone, with frequent monitoring and interventions. Studies identified did not evaluate benefits of video capability over telephone or cost-effectiveness, both of which are useful directions for future study.

Deprescribing in Older Nursing Home Patients: Focus on Innovative Composite Measures for Dosage Deintensification.

Deprescribing, which includes stopping or reducing the dosage of medications, is designed to improve safety and prevent adverse drug reactions in older patients. To date, there has been limited work on measuring decreases in dosage intensity, or deintensification, across therapeutic classes of medications. Given the ongoing focus on central nervous system (CNS) medications and the frequency with which providers encounter hypertension and diabetes in older nursing home patients, the objective of this expert review is to describe and critique innovative composite dosage intensity measures that have been, or could be, applied to quantify deintensification within three therapeutic medication targets commonly encountered in nursing home patients: CNS agents, antihypertensive therapy, and antidiabetic therapy and the extent to which they are associated with health outcomes. Composite measures for CNS medication intensity considered dividing a patient's daily dose by defined daily dosage (DDD), or the minimum effective adult or geriatric daily dosage. In contrast, composite measures for antihypertensives used either DDD or maximum recommended daily dosage in the denominator. We were not able to identify any composite measure of intensity for antidiabetic classes. There was a paucity of interventional studies that showed reducing the dosage intensity resulted in improved health outcomes. In conclusion, we identified several innovative composite measures of dosage intensity for CNS and antihypertensive medications, and discussed possible approaches for developing an antidiabetic regimen composite measure. It is critical for future research to compare and contrast various measures and to determine their impact on important clinical outcomes.