To my opinion, there is no evidence for deprescribing for senior population. however there is evidence for appropriate prescribing medication in this population including people with cognitive impairment and this whatever the level of severity.

You can see all paper about the STOPP-START criteria validated in 2008 and more recently the STOPP-START criteria version 2 more recently validated and published in Age and Aging last august 2014. The interest of this set of criteria is, this tool help physician to prescribe properly and this in that way to stop inappropriate treatment in addition to avoid omission prescription of indicated medication and this taking into account drug-drug and drug-dease interaction and potentially adverse side effects. 

Thank you - I am aware of the STOPP START criteria which are very useful. We did a review on intervention to optimize medication use in nursing home residents with advanced dementia, searching criteria and interventions for this particularly vulnerable population. We now want to take this research to ambulatory elderly and are aware of research done in Australia, including a review on patient barriers and facilitators for deprescribing (Drugs Aging. 2013 Oct;30(10):793-807. doi: 10.1007/s40266-013-0106-8. Patient barriers to and enablers of deprescribing: a systematic review.

Reeve E1, To J, Hendrix I, Shakib S, Roberts MS, Wiese MD). I was hoping to find something focussing on older patients in particular.

The following is a useful link to a report on attitudes of Irish physicians towards "Medication use in patients with dementia at the end of life" http://www.cardi.ie/userfiles/Dementia%20medication%20research%20brief.pdf.

I often wonder whether 'deprescribing' is really a helpful phrase.  Every time a prescription sheet or medication list is  updated or rewritten, as is required every few months at least in many countries, the doctor is re-prescribing.  This is not simply a tick-box exercise or administrative chore, although I accept that some doctors and perhaps even more patients and relatives may see it that way.  Instead, the doctor is taking responsibility for that prescription and in effect saying "I believe that all of these medications are required and will benefit this particular patient NOW".  Accepting of course that some medications are associated with withdrawal effects and that gradual discontinuation may be needed, in most cases the fact that a particular drug was indicated previously shouldn't create an automatic bias towards prescribing it again each time. 

Follow Sarah Hilmer from University of Sydney. She is currently working on the deprescribing concept. And Yes, there are evidence available.

Other people who are actively researching deprescribing in older people at the moment include Emily Reeve, Lisa Kouladjian and Danijela Gnjidic from University of Sydney, Kristen Anderson, from University of Queensland, Amy Page, from University of Western Australia, and myself. Most of us are working on projects involving different aspects of deprescribing in older people, some nursing home based, and some community based. Is there something you were specifically after?

Hi Justin, good to hear from you :-)  I already adapted Holmes' criteria regarding appropriate medication for AD patients in NH to our regional context and with a colleague (Caroline Sirois) we are taking this now to ambulatory patients. Caroline is in contact with  Emily Reeve. It is one thing to work on deprescribing with the care providers and another to work with the patients and, especially in AD patients, the families. I know about the review on barriers and facilitators for patients (2013) but was wondering whether anything else, more specific to AD patients ,may have been done. Thank you for your help :-)

Working with the geriatric population every day who have mental health issues I find that the doctors are over prescribing for many of my patients - not only psych meds but pain meds as well.  I am hearing from my patients that they are not being approved for elective surgeries like before as age is a factor now for knee replacements and hip replacements as well as spinal surgeries.  Insurance companies saying NO.

It is important to consider the patient and / or their family / carer when reviewing medication.  The patient / carer / family should be involved in any decision to de-prescribe.

Clinical services and programs and medications prescribed  are often evaluated only on the basis of what matters most to -

physicians -symptom reduction  / control

pharmacists - appropriateness

payers - costs.

What can  matter most to patients/ carers  and families ..................

functioning

quality of life

may not be considered adequately.

This is especially important in relation to vulnerable population groups who experience health inequalities and healthcare inequities.  Vulnerable population groups include people with intellectual disabilities and in particular people with intellectual disabilities and  behaviour disorders.

There seems to be considerable interest in de-prescribing and lots of work happening here in Australia. With 4 million scripts for anti-depressants created in Australia per year for people over 67 years (there are 3.3 million people over 65) we appear to have a problem. Data released a couple of years back showing very high use of anti-psychotics in residential aged care was a wake up call also.

To quote: "A pill for every ill kills". Lots of evidence accumulating that there isn't a lot of efficacy  for many of the drugs prescribed and in fact the risks may outweigh the benefits in older people. Important debate and will be interesting to see how it goes- early days. Education and giving licence to GPs to de-prescribe will be vital so some work in this area would be helpful. A heavy reliance on specialists in Australia doesn't help things. Suspect people's attitudes to polypharmacy and the burden it places on people will influence and possibly drive change.

Exciting !!

Let me know if a poster or any form of abstract becomes available. We did a "medication optimisation" pilot study in 3 QC nursign homes on about 45 seniors with advanced dementia - we are working on the analyses. I now want to take this approach to community living seniors who are in better health but still possibly taking too many meds. I have no experience in quali studies but I doubt whether enough is known on patient and family attitudes and perceptions, barriers and enablers for deprescribing...hence my question :-)

Hello

I came across the following 10 principles for good prescribing from the British Pharmacological Society. Many of the principles could apply to de-prescribing as well as prescribing.

Principle Number 10 below  is   :

Prescribe within the limitations of your knowledge, skills and experience .

In relation to de-prescribing this principle  could read: 

De-prescribe  within the limitations of your knowledge, skills and experience .  This is particularly relevant in the care of vulnerable people such as people with intellectual disabilities.

Best wishes

Bernadette

www.bps.ac.uk

Ten Principles of Good Prescribing

Prescribing is the main approach to the treatment and prevention of disease in modern healthcare. While medicines have the capacity to enhance health, all have the potential to cause harm if used inappropriately. For these reasons the British Pharmacological Society recommends that health-care professionals who prescribe medicines should do so based on the following ten principles, which underpin safe and effective use of medicines.

All prescribers should:

1. Be clear about the reasons for prescribing Establish an accurate diagnosis whenever possible (although this may often be difficult) Be clear in what way the patient is likely to gain from the prescribed medicines

2. Take into account the patient’s medication history before prescribing Obtain an accurate list of current and recent medications (including over-the-counter and alternative medicines); prior adverse drug reactions; and drug allergies from the patient, their carers, or colleagues

3. Take into account other factors that might alter the benefits and risks of treatment Consider other individual factors that might influence the prescription (e.g. physiological changes with age and pregnancy, or impaired kidney, liver or heart function)

4. Take into account the patient’s ideas, concerns, and expectations Seek to form a partnership with the patient when selecting treatments, making sure that they understand and agree with the reasons for taking the medicine

5. Select effective, safe, and cost-effective medicines individualised for the patient The likely beneficial effect of the medicine should outweigh the extent of any potential harms, and whenever possible this judgement should be based on published evidence Prescribe medicines that are unlicensed, ‘off-label’, or outside standard practice only if satisfied that an alternative medicine would not meet the patient's needs (this decision will be based on evidence and/or experience of their safety and efficacy) Choose the best formulation, dose, frequency, route of administration, and duration of treatment

6. Adhere to national guidelines and local formularies where appropriate Be aware of guidance produced by respected bodies (increasingly available via decision support systems), but always consider the individual needs of the patient Select medicines with regard to costs and needs of other patients (health-care resources are finite) Be able to identify, access, and use reliable and validated sources of information (e.g. British National Formulary), and evaluate potentially less reliable information critically

7. Write unambiguous legal prescriptions using the correct documentation Be aware of common factors that cause medication errors and know how to avoid them

8. Monitor the beneficial and adverse effects of medicines Identify how the beneficial and adverse effects of treatment can be assessed Understand how to alter the prescription as a result of this information Know how to report adverse drug reactions (in the UK via the Yellow Card scheme).

9. Communicate and document prescribing decisions and the reasons for them Communicate clearly with patients, their carers, and colleagues Give patients important information about how to take the medicine, what benefits might arise, adverse effects (especially those that will require urgent review), and any monitoring that is required Use the health record and other means to document prescribing decisions accurately

10. Prescribe within the limitations of your knowledge, skills and experience Always seek to keep the knowledge and skills that are relevant to your practice up to date Be prepared to seek the advice and support of suitably qualified professional colleagues Make sure that, where appropriate, prescriptions are checked (e.g. calculations of intravenous doses)

Neat :-))  I will follow up on this and try to keep the thread improving ;-)  Thank you for your input !

Hi all, I am a PhD student looking at inappropriate prescribing and deprescribing specifically in those with a palliative diagnosis. I came across the thread and wondered if could find out how you have got on?

Hi Reine,  we are still writing up the paper from the literature search. You might want to follow Emily Reeve and Justin Turner, both Australia, and check out what they have published  on this issue. Thanx for your interest :-)