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01-12-2020 | Care | Original Research

Designing a Primary Care–Based Deprescribing Intervention for Patients with Dementia and Multiple Chronic Conditions: a Qualitative Study

Authors: Ariel R. Green, MD, MPH, PhD, Cynthia M. Boyd, MD, MPH, Kathy S. Gleason, PhD, Leslie Wright, MA, Courtney R. Kraus, MSPH, Ruth Bedoy, BS, Bianca Sanchez, BS, Jonathan Norton, BS, Orla C. Sheehan, MD, PhD, Jennifer L. Wolff, PhD, Emily Reeve, BPharm(Hons) PhD, Matthew L. Maciejewski, PhD, Linda A. Weffald, PharmD, Elizabeth A. Bayliss, MD, MSPH

Published in: Journal of General Internal Medicine | Issue 12/2020

Abstract

Background

Patients with dementia and multiple chronic conditions (MCC) frequently experience polypharmacy, increasing their risk of adverse drug events.

Objectives

To elucidate patient, family, and physician perspectives on medication discontinuation and recommended language for deprescribing discussions in order to inform an intervention to increase awareness of deprescribing among individuals with dementia and MCC, family caregivers and primary care physicians. We also explored participant views on culturally competent approaches to deprescribing.

Design

Qualitative approach based on semi-structured interviews with patients, caregivers, and physicians.

Participants

Patients aged ≥ 65 years with claims-based diagnosis of dementia, ≥ 1 additional chronic condition, and ≥ 5 chronic medications were recruited from an integrated delivery system in Colorado and an academic medical center in Maryland. We included caregivers when present or if patients were unable to participate due to severe cognitive impairment. Physicians were recruited within the same systems and through snowball sampling, targeting areas with large African American and Hispanic populations.

Approach

We used constant comparison to identify and compare themes between patients, caregivers, and physicians.

Key Results

We conducted interviews with 17 patients, 16 caregivers, and 16 physicians. All groups said it was important to earn trust before deprescribing, frame deprescribing as routine and positive, align deprescribing with goals of dementia care, and respect caregivers’ expertise. As in other areas of medicine, racial, ethnic, and language concordance was important to patients and caregivers from minority cultural backgrounds. Participants favored direct-to-patient educational materials, support from pharmacists and other team members, and close follow-up during deprescribing. Patients and caregivers favored language that explained deprescribing in terms of altered physiology with aging. Physicians desired communication tips addressing specific clinical situations.

Conclusions

Culturally sensitive communication within a trusted patient-physician relationship supplemented by pharmacists, and language tailored to specific clinical situations may support deprescribing in primary care for patients with dementia and MCC.

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Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005;294(6):716-24. https://doi.org/10.1001/jama.294.6.716.CrossRefPubMed

Gray SL, Anderson ML, Dublin S, Hanlon JT, Hubbard R, Walker R et al. Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study. JAMA Intern Med. 2015;175(3):401-7. https://doi.org/10.1001/jamainternmed.2014.7663.CrossRefPubMedPubMedCentral

Castelino RL, Hilmer SN, Bajorek BV, Nishtala P, Chen TF. Drug Burden Index and potentially inappropriate medications in community-dwelling older people: the impact of Home Medicines Review. Drugs Aging. 2010;27(2):135-48. https://doi.org/10.2165/11531560-000000000-00000.CrossRefPubMed

Hill-Taylor B, Sketris I, Hayden J, Byrne S, O’Sullivan D, Christie R. Application of the STOPP/START criteria: a systematic review of the prevalence of potentially inappropriate prescribing in older adults, and evidence of clinical, humanistic and economic impact. J Clin Pharm Ther. 2013;38(5):360-72. https://doi.org/10.1111/jcpt.12059.CrossRefPubMed

Brown JD, Hutchison LC, Li C, Painter JT, Martin BC. Predictive Validity of the Beers and Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP) Criteria to Detect Adverse Drug Events, Hospitalizations, and Emergency Department Visits in the United States. J Am Geriatr Soc. 2016;64(1):22-30. https://doi.org/10.1111/jgs.13884.CrossRefPubMedPubMedCentral

Jansen J, Naganathan V, Carter SM, McLachlan AJ, Nickel B, Irwig L et al. Too much medicine in older people? Deprescribing through shared decision making. BMJ. 2016;353:i2893. https://doi.org/10.1136/bmj.i2893.CrossRefPubMed

Reeve E, Shakib S, Hendrix I, Roberts MS, Wiese MD. Review of deprescribing processes and development of an evidence-based, patient-centred deprescribing process. Br J Clin Pharmacol. 2014;78(4):738-47. https://doi.org/10.1111/bcp.12386.CrossRefPubMedPubMedCentral

Scott IA, Hilmer SN, Reeve E, Potter K, Le Couteur D, Rigby D et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827-34. https://doi.org/10.1001/jamainternmed.2015.0324.CrossRefPubMed

Ostini R, Jackson C, Hegney D, Tett SE. How is medication prescribing ceased? A systematic review. Med Care. 2011;49(1):24-36. https://doi.org/10.1097/MLR.0b013e3181ef9a7e.CrossRefPubMed

10.

Clyne B, Fitzgerald C, Quinlan A, Hardy C, Galvin R, Fahey T et al. Interventions to Address Potentially Inappropriate Prescribing in Community-Dwelling Older Adults: A Systematic Review of Randomized Controlled Trials. J Am Geriatr Soc. 2016;64(6):1210-22. https://doi.org/10.1111/jgs.14133.CrossRefPubMed

11.

Gnjidic D, Le Couteur DG, Kouladjian L, Hilmer SN. Deprescribing trials: methods to reduce polypharmacy and the impact on prescribing and clinical outcomes. Clin Geriatr Med. 2012;28(2):237-53. https://doi.org/10.1016/j.cger.2012.01.006.CrossRefPubMed

12.

Alldred DP, Kennedy MC, Hughes C, Chen TF, Miller P. Interventions to optimise prescribing for older people in care homes. Cochrane Database Syst Rev. 2016;2:CD009095. https://doi.org/10.1002/14651858.CD009095.pub3.CrossRefPubMed

13.

Forsetlund L, Eike MC, Gjerberg E, Vist GE. Effect of interventions to reduce potentially inappropriate use of drugs in nursing homes: a systematic review of randomised controlled trials. BMC Geriatr. 2011;11:16. https://doi.org/10.1186/1471-2318-11-16.CrossRefPubMedPubMedCentral

14.

Child A, Clarke A, Fox C, Maidment I. A pharmacy led program to review anti-psychotic prescribing for people with dementia. BMC Psychiatry. 2012;12:155. https://doi.org/10.1186/1471-244X-12-155.CrossRefPubMedPubMedCentral

15.

Lang PO, Vogt-Ferrier N, Hasso Y, Le Saint L, Drame M, Zekry D et al. Interdisciplinary geriatric and psychiatric care reduces potentially inappropriate prescribing in the hospital: interventional study in 150 acutely ill elderly patients with mental and somatic comorbid conditions. J Am Med Dir Assoc. 2012;13(4):406 e1-7. https://doi.org/10.1016/j.jamda.2011.03.008.CrossRef

16.

Sawan M, Reeve E, Turner J, Todd A, Steinman MA, Petrovic M et al. A systems approach to identifying the challenges of implementing deprescribing in older adults across different health-care settings and countries: a narrative review. Expert Rev Clin Pharmacol. 2020;13(3):233-45. https://doi.org/10.1080/17512433.2020.1730812.CrossRefPubMed

17.

Thompson W, Reeve E, Moriarty F, Maclure M, Turner J, Steinman MA et al. Deprescribing: Future directions for research. Res Social Adm Pharm. 2019;15(6):801-5. https://doi.org/10.1016/j.sapharm.2018.08.013.CrossRefPubMed

18.

Martinez AI, Spencer J, Moloney M, Badour C, Reeve E, Moga DC. Attitudes toward deprescribing in a middle-aged health disparities population. Res Social Adm Pharm. 2020. https://doi.org/10.1016/j.sapharm.2020.02.014.

19.

Primm AB, Cabot D, Pettis J, Vu HT, Cooper LA. The acceptability of a culturally-tailored depression education videotape to African Americans. J Natl Med Assoc. 2002;94(11):1007-16.PubMedPubMedCentral

20.

Sarkisian CA, Brusuelas RJ, Steers WN, Davidson MB, Brown AF, Norris KC et al. Using focus groups of older African Americans and Latinos with diabetes to modify a self-care empowerment intervention. Ethn Dis. 2005;15(2):283-91.PubMed

21.

Carbone ET, Rosal MC, Torres MI, Goins KV, Bermudez OI. Diabetes self-management: perspectives of Latino patients and their health care providers. Patient Educ Couns. 2007;66(2):202-10. https://doi.org/10.1016/j.pec.2006.12.003.CrossRefPubMed

22.

Glaser BG. The discovery of grounded theory: Strategies for qualitative research. In: Strauss AL, editor. Chicago: Aldine Pub. Co.; 1967.

23.

Green AR, Lee P, Reeve E, Wolff JL, Chen CCG, Kruzan R et al. Clinicians’ Perspectives on Barriers and Enablers of Optimal Prescribing in Patients with Dementia and Coexisting Conditions. J Am Board Fam Med. 2019;32(3):383-91. https://doi.org/10.3122/jabfm.2019.03.180335.CrossRefPubMedPubMedCentral

24.

Reeve E, Low LF, Hilmer SN. Beliefs and attitudes of older adults and carers about deprescribing of medications: a qualitative focus group study. Br J Gen Pract. 2016;66(649):e552-60. https://doi.org/10.3399/bjgp16X685669.CrossRefPubMedPubMedCentral

25.

Ashton CM, Haidet P, Paterniti DA, Collins TC, Gordon HS, O’Malley K et al. Racial and ethnic disparities in the use of health services: bias, preferences, or poor communication? J Gen Intern Med. 2003;18(2):146-52.CrossRef

26.

Balkrishnan R, Dugan E, Camacho FT, Hall MA. Trust and satisfaction with physicians, insurers, and the medical profession. Med Care. 2003;41(9):1058-64. https://doi.org/10.1097/01.Mlr.0000083743.15238.9f.CrossRefPubMed

27.

Todd A, Jansen J, Colvin J, McLachlan AJ. The deprescribing rainbow: a conceptual framework highlighting the importance of patient context when stopping medication in older people. BMC Geriatr. 2018;18(1):295. https://doi.org/10.1186/s12877-018-0978-x.CrossRefPubMedPubMedCentral

28.

Kerns JW, Winter JD, Winter KM, Kerns CC, Etz RS. Caregiver Perspectives About Using Antipsychotics and Other Medications for Symptoms of Dementia. Gerontologist. 2017. https://doi.org/10.1093/geront/gnx042.

29.

Steenland K, Goldstein FC, Levey A, Wharton W. A meta-analysis of Alzheimer’s disease incidence and prevalence comparing African-Americans and caucasians. J Alzheimers Dis. 2016;50(1):71-6.CrossRef

30.

Alzheimer’s Association. 2018 Alzheimer’s disease facts and figures. Alzheimers Dement. 2018;14(3):367-429. https://doi.org/10.1016/j.jalz.2018.02.001.CrossRef

31.

Cheng Y, Ahmed A, Zamrini E, Tsuang DW, Sheriff HM, Zeng-Treitler Q. Alzheimer’s Disease and Alzheimer’s Disease-Related Dementias in Older African American and White Veterans. J Alzheimers Dis. 2020. https://doi.org/10.3233/jad-191188.

32.

Lin PJ, Emerson J, Faul JD, Cohen JT, Neumann PJ, Fillit HM et al. Racial and Ethnic Differences in Knowledge About One’s Dementia Status. J Am Geriatr Soc. 2020. https://doi.org/10.1111/jgs.16442.

33.

Kantor ED, Rehm CD, Haas JS, Chan AT, Giovannucci EL. Trends in Prescription Drug Use Among Adults in the United States From 1999-2012. JAMA. 2015;314(17):1818-31. https://doi.org/10.1001/jama.2015.13766.CrossRefPubMedPubMedCentral

34.

Bazargan M, Smith J, Movassaghi M, Martins D, Yazdanshenas H, Salehe Mortazavi S et al. Polypharmacy among underserved older African American adults. J Aging Res. 2017;2017.

35.

Reeve E, Wolff JL, Skehan M, Bayliss EA, Hilmer SN, Boyd CM. Assessment of Attitudes Toward Deprescribing in Older Medicare Beneficiaries in the United States. JAMA Intern Med. 2018. https://doi.org/10.1001/jamainternmed.2018.4720.

36.

Castro FG, Barrera M, Jr., Martinez CR, Jr. The cultural adaptation of prevention interventions: resolving tensions between fidelity and fit. Prev Sci. 2004;5(1):41-5.CrossRef

37.

Chin MH, Walters AE, Cook SC, Huang ES. Interventions to reduce racial and ethnic disparities in health care. Med Care Res Rev. 2007;64(5 Suppl):7S-28S. https://doi.org/10.1177/1077558707305413.CrossRefPubMedPubMedCentral

38.

Coletti DJ, Stephanou H, Mazzola N, Conigliaro J, Gottridge J, Kane JM. Patterns and predictors of medication discrepancies in primary care. J Eval Clin Pract. 2015;21(5):831-9. https://doi.org/10.1111/jep.12387.CrossRefPubMed

39.

Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med. 2014;174(6):890-8. https://doi.org/10.1001/jamainternmed.2014.949.CrossRefPubMed

40.

Patient empowerment--who empowers whom? Lancet. 2012;379(9827):1677. https://doi.org/10.1016/s0140-6736(12)60699-0.

41.

Wolff JL, Roter DL, Boyd CM, Roth DL, Echavarria DM, Aufill J et al. Patient-Family Agenda Setting for Primary Care Patients with Cognitive Impairment: the SAME Page Trial. J Gen Intern Med. 2018;33(9):1478-86. https://doi.org/10.1007/s11606-018-4563-y.CrossRefPubMedPubMedCentral

42.

Gobat N, Kinnersley P, Gregory JW, Robling M. What is agenda setting in the clinical encounter? Consensus from literature review and expert consultation. Patient Educ Couns. 2015;98(7):822-9. https://doi.org/10.1016/j.pec.2015.03.024.CrossRefPubMed

43.

Mossialos E, Courtin E, Naci H, Benrimoj S, Bouvy M, Farris K et al. From “retailers” to health care providers: Transforming the role of community pharmacists in chronic disease management. Health Policy. 2015;119(5):628-39. https://doi.org/10.1016/j.healthpol.2015.02.007.CrossRefPubMed

44.

Reeve E, To J, Hendrix I, Shakib S, Roberts MS, Wiese MD. Patient barriers to and enablers of deprescribing: a systematic review. Drugs Aging. 2013;30(10):793-807. https://doi.org/10.1007/s40266-013-0106-8.CrossRefPubMed

45.

Fixen DR, Linnebur SA, Parnes BL, Vejar MV, Vande Griend JP. Development and economic evaluation of a pharmacist-provided chronic care management service in an ambulatory care geriatrics clinic. Am J Health Syst Pharm. 2018;75(22):1805-11. https://doi.org/10.2146/ajhp170723.CrossRefPubMed

46.

Healey P, Stager ML, Woodmass K, Dettlaff AJ, Vergara A, Janke R et al. Cultural adaptations to augment health and mental health services: a systematic review. BMC Health Serv Res. 2017;17(1):8. https://doi.org/10.1186/s12913-016-1953-x.CrossRefPubMedPubMedCentral

Title: Designing a Primary Care–Based Deprescribing Intervention for Patients with Dementia and Multiple Chronic Conditions: a Qualitative Study
Authors: Ariel R. Green, MD, MPH, PhD
Cynthia M. Boyd, MD, MPH
Kathy S. Gleason, PhD
Leslie Wright, MA
Courtney R. Kraus, MSPH
Ruth Bedoy, BS
Bianca Sanchez, BS
Jonathan Norton, BS
Orla C. Sheehan, MD, PhD
Jennifer L. Wolff, PhD
Emily Reeve, BPharm(Hons) PhD
Matthew L. Maciejewski, PhD
Linda A. Weffald, PharmD
Elizabeth A. Bayliss, MD, MSPH
Publication date: 01-12-2020
Publisher: Springer International Publishing
Keywords: Care
Dementia
Dementia
Published in: Journal of General Internal Medicine / Issue 12/2020
Print ISSN: 0884-8734
Electronic ISSN: 1525-1497
DOI: https://doi.org/10.1007/s11606-020-06063-y

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Designing a Primary Care–Based Deprescribing Intervention for Patients with Dementia and Multiple Chronic Conditions: a Qualitative Study

Abstract

Background

Objectives

Design

Participants

Approach

Key Results

Conclusions

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Conclusions

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