Time to Deprescribe? Some Reasons May Be Nonstarters

When a clinician broaches the idea of stopping a medication with an older patient, pointing out the drug's potential side effects may motivate the patient to discontinue it, results from a new survey suggest.

Other reasons for deprescribing, like doubts about a drug's functional benefits, may be less persuasive, according to a study presented at the American Geriatrics Society (AGS) 2021 Virtual Annual Scientific Meeting and published online in JAMA Network Open.

Ariel R. Green, MD, MPH, PhD, and colleagues analyzed data from 835 adults aged 65 years and older who completed a survey that presented hypothetical scenarios that involved stopping a medication.

In one vignette, a doctor suggests that a patient with functional impairment stop a statin that the patient had been taking for primary prevention. In another scenario, a doctor recommends that an older adult who had been taking zolpidem (Ambien) for insomnia stop taking the sedative-hypnotic.

Respondents were given seven explanations for stopping the medications and picked the ones that were the most and least likely to make them discontinue treatment.

In both scenarios, "the major driver of willingness to deprescribe was side effects," said Green, an assistant professor of medicine at Johns Hopkins University, Baltimore, Maryland.

"This suggests that it is important for clinicians to link deprescribing recommendations to patients' concerns about side effects, or to side effects they may have already experienced such as falls or memory concerns."

Still, the most and least favored reasons for stopping treatment could vary from person to person.

"Even phrases that were most preferred [overall] were also chosen as least preferred by some respondents," Green noted. "This suggests that it is important for clinicians to elicit and understand their patients' priorities and to tailor deprescribing recommendations to those priorities."

In the zolpidem scenario, the least favored phrase by far was "This medicine is unlikely to help you function."

Despite the importance of patient function overall, it is possible that questioning a drug's functional benefits holds limited sway in deprescribing talks, commented Michael Steinman, MD, with the University of California, San Francisco (UCSF) division of geriatrics and the San Francisco VA Medical Center. He highlighted that finding during a presentation about the US Deprescribing Research Network, which funded the study.

"As a geriatrician, I'm all about talking about function and thinking about how important it is. But it is enlightening to realize that using that language for patients in this context might be a nonstarter," Steinman said.

The variation in preferred language was "striking" and "resonates with clinical practice," said Matthew Growdon, MD, MPH, a geriatrician and aging research fellow at UCSF. However, he noted during a question-and-answer session, that he was curious how patients "would respond to these prompts in the context of a real patient–doctor relationship rather than the hypothetical situations."

In the statin scenario, least preferred phrases focused on helping the patient feel better now rather than worrying about preventing future problems, and on reducing burdens associated with taking the medication. "Deprescribing recommendations may be perceived as withdrawal of care or even rationing if not framed as a way of preserving well-being," Green said.

One well-received phrase in the zolpidem scenario indicated that stopping the medicine would be a shared decision made by the patient and doctor and that the doctor would make the change gradually and adjust the plan as needed, Green noted.

Investigators are examining various ways to reduce inappropriate and unnecessary medications in older patients. Results from the survey may help inform future deprescribing interventions, Green said.

Although refining the language used by clinicians in deprescribing discussions with patients may help, other approaches may also be needed. "It is hard to cover the nuanced topic of deprescribing during the already busy primary care visit," Green said. The researchers plan to examine whether a pharmacist's 'pre-review' of medications before a primary care visit may be helpful, for example.

The study was supported by the US Deprescribing Research Network, which is funded by the National Institute on Aging. Green and Growdon have disclosed no relevant financial relationships. Steinman coauthors chapters for UpToDate and is co-principal investigator for the Deprescribing Research Network.

American Geriatric Society 2021 Annual Scientific Meeting: Abstract P-18. Presented May 14, 2021.

JAMA Netw Open. Published online April 5, 2021. Full text

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