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Introduction: There is increasing recognition of the need for deprescribing of inappropriate medications in older adults. However, efforts to encourage implementation of deprescribing in clinical practice have resulted in mixed results across settings and countries.Area covered: Searches were conducted in PubMed, Embase, and Google Scholar in June 2019. Reference lists, citation checking, and personal reference libraries were also utilized. Studies capturing the main challenges of, and opportunities for, implementing deprescribing into clinical practice across selected health-care settings internationally, and international deprescribing-orientated policies were included and summarized in this narrative review.Expert opinion: Deprescribing intervention studies are inherently heterogeneous because of the complexity of interventions employed and often do not reflect the real-world. Further research investigating enhanced implementation of deprescribing into clinical practice and across health-care settings is required. Process evaluations in deprescribing intervention studies are needed to determine the contextual factors that are important to the translation of the interventions in the real-world. Deprescribing interventions may need to be individually tailored to target the unique barriers and opportunities to deprescribing in different clinical settings. Introduction of national policies to encourage deprescribing may be beneficial, but need to be evaluated to determine if there are any unintended consequences.

The aim of this study was to investigate whether interventions to discontinue or down‐titrate heart failure (HF) pharmacotherapy are feasible and associated with risks in older people. A systematic review and meta‐analysis were conducted according to PRISMA 2020 guidelines. Electronic databases were searched from inception to 8 March 2023. Randomized controlled trials (RCTs) and observational studies included people with HF, aged ≥50 years and who discontinued or down‐titrated HF pharmacotherapy. Outcomes were feasibility (whether discontinuation or down‐titration of HF pharmacotherapy was sustained at follow‐up) and associated risks (mortality, hospitalization, adverse drug withdrawal effects [ADWE]). Random‐effects meta‐analysis was performed when heterogeneity was not substantial (Higgins I2 < 70%). Sub‐analysis by frailty status was conducted. Six RCTs (536 participants) and 27 observational studies (810 499 participants) across six therapeutic classes were included, for 3–260 weeks follow‐up. RCTs were conducted in patients presenting with stable chronic HF. Down‐titrating a renin‐angiotensin system inhibitor (RASI) in patients with chronic kidney disease was 76% more likely than continuation (risk ratio [RR] 1.76, 95% confidence interval [CI] 1.14–2.73), with no difference in mortality (RR 0.64, 95% CI 0.30–1.64). Discontinuation of beta‐blockers were feasible compared to continuation in preserved ejection fraction (RR 1.00, 95% CI 0.68–1.47). Participants were 25% more likely to re‐initiate discontinued diuretics (RR 0.75, 95% CI 0.66–0.86). Digoxin discontinuation was associated with 5.5‐fold risk of hospitalization compared to continuation. Worsening HF was the most common ADWE. One observational study measured frailty but did not report outcomes by frailty status. The appropriateness and associated risks of down‐titrating or discontinuing HF pharmacotherapy in people aged ≥75 years is uncertain. Evaluation of outcomes by frailty status necessitates investigation. [ABSTRACT FROM AUTHOR]

Background People living with dementia and their carers often experience difficulties in effectively managing medications and have indicated they lack necessary support, information and guidance. Recognising the medication management information needs of this population is an important first step in addressing these issues. Objectives To identify the priorities for information on medication management expressed by people living with dementia and their carers. Methods A scoping review with systematic search was conducted from inception to 12 May 2023 for any original studies that reported the information needs of people living with dementia and their carers (informal, i.e. unpaid or within an existing relationship) regarding medication management. Two authors independently screened the abstracts, full-texts and extracted data. Study characteristics were described descriptively, and themes of information need were extracted using an iterative approach. Results Of the 11 367 records screened, 35 full-texts were included. All studies (n = 35) involved carers, with 17 also including people living with dementia. Most studies (n = 30) were conducted in the community and used qualitative methods (n = 32). Five major themes of information need were identified: critical medication information; medication effects; medication indication(s); disease progression and impact on medications; and safe and appropriate administration of medications. People living with dementia and their carers indicated they need more medication management information generally and want it simple, tailored and relevant. Conclusions This review highlights the key medication information priorities for people living with dementia and their carers and will help guide the provision of medication management guidance and development of new information resources. [ABSTRACT FROM AUTHOR]

Objectives: Among residents who had a residential medication management review (RMMR), there is a lack of studies assessing exposure to polypharmacy and potentially inappropriate medications (PIMs) in people with dementia. This study compared the exposure to polypharmacy and PIMs in residents with dementia and without dementia receiving RMMR. Methods: A retrospective analysis was performed using data of 16,261 residents living in 343 Australian residential aged care facilities who had an RMMR in 2019. Medication use was assessed as polypharmacy (defined as ≥9 medications) and use of ≥1 PIMs using the 2019 updated Beers criteria. Dementia diagnosis was determined with ICD‐10 coding from medical records. Descriptive analyses reported resident demographics and patterns of medication use. Pearson's χ2 tests and logistic regression analysis were conducted to compare medication exposure between residents with and without dementia. Results: Among 16,261 residents, 6781 (42%) had dementia. Residents with dementia were significantly more likely to be exposed to polypharmacy and PIMs, compared to those without dementia (74% vs. 70% and 83% vs. 73%, p <.001 respectively). Residents with dementia had 1.31 times the odds of exposure to polypharmacy (adjusted OR: 1.31, 95% CI: 1.22–1.41, p <.001) and 1.88 times the odds of being prescribed ≥1 PIMs than people without dementia (adjusted OR: 1.88, 95% CI: 1.73–2.04, p <.001). Conclusions: In a study of residents receiving RMMR, polypharmacy and PIMs were highly common, and those with dementia were more likely to be exposed to inappropriate polypharmacy. There is a need for targeted deprescribing strategies to immediately address inappropriate prescribing in residents, particularly those living with dementia. [ABSTRACT FROM AUTHOR]

Antihypertensive drugs are commonly used by older adults because of the high prevalence of cardiovascular disease and its risk factors, and the increased absolute benefit of blood pressure reduction with increasing age. Clinical trials of blood pressure reduction in older adults have generally excluded older adults with multimorbidity, frailty and limited life expectancy. In this population, the benefit-harm ratio of aggressive blood pressure lowering may become unfavourable; a more relaxed blood pressure target may be appropriate; and deprescribing (cessation or dose reduction) of one or more antihypertensive drugs can be considered. Before deprescribing an antihypertensive drug, it is important to consider other indications for which it may have been prescribed (e.g. heart failure with reduced ejection fraction, diabetic nephropathy, atrial fibrillation). Evidence from randomised controlled deprescribing trials indicates that it is possible to deprescribe antihypertensives in frail older people. However, some patients may experience an increase in blood pressure that warrants restarting the drug. There are limited data on long-term outcomes (follow-up in deprescribing trials ranged from 4 to 56 weeks). The risk of adverse outcomes associated with deprescribing, such as withdrawal effects, can be minimised through appropriate planning, patient engagement, dose tapering and monitoring. [ABSTRACT FROM AUTHOR]

Objective(s): To understand Australian health professionals' perceptions of their knowledge and previous training about frailty, as well as barriers to frailty assessment and management in their practice. Methods: A cross‐sectional online survey was developed and distributed to health professionals (medical, nursing and allied health) engaged in clinical practice in Australia through convenience and snowball sampling techniques from March to May 2022. The survey consisted of five sections: frailty training and knowledge; confidence in recognising and managing adults with frailty; the importance and relevance of frailty; barriers to assessing and managing frailty in practice; and interest in further frailty training. Responses were analysed using descriptive statistics. Results: The survey was taken by 736 health professionals. Less than half of respondents (44%, 321/733) reported receiving any training on frailty, with 14% (105/733) receiving training specifically focussed on frailty. Most respondents (78%, 556/712) reported 'good' or 'fair' understanding of frailty. The majority (64%, 448/694) reported being 'fairly' or 'somewhat' confident with identifying frailty. Almost all respondents (>90%) recognised frailty as having an important impact on outcomes and believed that there are beneficial interventions for frailty. Commonly reported barriers to frailty assessment in practice included 'lack of defined protocol for managing frailty' and 'lack of consensus about which frailty assessment tool to use'. Most respondents (88%, 521/595) were interested in receiving further education on frailty, with a high preference for online training. Conclusions: The findings suggest frailty is important to health professionals in Australia, and there is a need for and interest in further frailty education. [ABSTRACT FROM AUTHOR]

Background: The Drug Burden Index (DBI) measures an individual's total exposure to anticholinergic and sedative medications. This systematic review aimed to investigate the association of the DBI with clinical and prescribing outcomes in observational pharmaco‐epidemiological studies, and the effect of DBI exposure on functional outcomes in pre‐clinical models. Methods: A systematic search of nine electronic databases, citation indexes and gray literature was performed (April 1, 2007–December 31, 2022). Studies that reported primary data on the association of the DBI with clinical or prescribing outcomes conducted in any setting in humans aged ≥18 years or animals were included. Quality assessment was performed using the Joanna Briggs Institute critical appraisal tools and the Systematic Review Centre for Laboratory animal Experimentation risk of bias tool. Results: Of 2382 studies screened, 70 met the inclusion criteria (65 in humans, five in animals). In humans, outcomes reported included function (n = 56), cognition (n = 20), falls (n = 14), frailty (n = 7), mortality (n = 9), quality of life (n = 8), hospitalization (n = 7), length of stay (n = 5), readmission (n = 1), other clinical outcomes (n = 15) and prescribing outcomes (n = 2). A higher DBI was significantly associated with increased falls (11/14, 71%), poorer function (31/56, 55%), and cognition (11/20, 55%) related outcomes. Narrative synthesis was used due to significant heterogeneity in the study population, setting, study type, definition of DBI, and outcome measures. Results could not be pooled due to heterogeneity. In animals, outcomes reported included function (n = 18), frailty (n = 2), and mortality (n = 1). In pre‐clinical studies, a higher DBI caused poorer function and frailty. Conclusions: A higher DBI may be associated with an increased risk of falls and decreased function and cognition. Higher DBI was inconsistently associated with increased mortality, length of stay, frailty, hospitalization or reduced quality of life. Human observational findings with respect to functional outcomes are supported by preclinical interventional studies. The DBI may be used as a tool to identify older adults at higher risk of harm. [ABSTRACT FROM AUTHOR]

Background: Policies, protocols and processes within organisations can facilitate or hinder guideline adoption. There is limited knowledge on the strategies used by organisations to disseminate and implement evidence‐based deprescribing guidelines or their impact. Methods: We aimed to develop an online survey targeting key organisations involved in deprescribing guideline endorsement, dissemination, modification or translation internationally. Survey questions were drafted, mirroring the six components of the reach, effectiveness, adoption, implementation and maintenance (RE‐AIM) framework. Content validation was undertaken and established by a panel of clinicians, researchers and implementation experts. Results: A 52‐item survey underwent two rounds of content validation. The minimum threshold (I‐CVI > 0.78) for relevance and importance was met for 39 items (75%) in the first round and 44 of 48 items (92%) in the second round. The expert panel concluded that the adoption, implementation and effectiveness survey sections were largely relevant and important to this topic, whereas the reach and maintenance sections were harder to understand and may be less pertinent to the research question. Conclusions: A 44‐item survey investigating dissemination and implementation strategies for deprescribing guidelines has been developed and its content validated. Widespread survey distribution may identify effective strategies and inform dissemination and implementation planning for newly developed guidelines. [ABSTRACT FROM AUTHOR]

Background: Deprescribing (reduction or cessation) of prescribed opioids can be challenging for both patients and healthcare professionals. Objective: To synthesize and evaluate evidence from systematic reviews examining the effectiveness and outcomes of patient‐targeted opioid deprescribing interventions for all types of pain. Methods: Systematic searches were conducted in five databases with results screened against predetermined inclusion/exclusion criteria. Primary outcomes were (i) reduction in opioid dose, reported as change in oral Morphine Equivalent Daily Dose (oMEDD) and (ii) success of opioid deprescribing, reported as the proportion of the sample for which opioid use declined. Secondary outcomes included pain severity, physical function, quality of life and adverse events. The certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Findings: Twelve reviews were eligible for inclusion. Interventions were heterogeneous in nature and included pharmacological (n = 4), physical (n = 3), procedural (n = 3), psychological or behavioural (n = 3) and mixed (n = 5) interventions. Multidisciplinary care programmes appeared to be the most effective intervention for opioid deprescribing; however, the certainty of evidence was low, with significant variability in opioid reduction across interventions. Conclusions: Evidence is too uncertain to draw firm conclusions about specific populations who may derive the greatest benefit from opioid deprescribing, warranting further investigation. [ABSTRACT FROM AUTHOR]