Deprescribing in a Frail Older Adult Taking Fourteen Medicines: A Narrative Review of Shared Decision-Making in Polypharmacy
DOI:
https://doi.org/10.5281/zenodo.22236461Keywords:
Deprescribing, Polypharmacy, Frailty, Shared Decision-Making, Medication ReviewAbstract
Every drug on a frail patient's list was started for a reason, usually a good one, usually by someone treating a single condition
correctly. The list is the sum of those decisions, and nobody owns the sum. Deprescribing is the attempt to give it an owner.
Objectives: To review the published evidence on deprescribing in frail older adults with polypharmacy: what structured
medication review achieves in prescribing, what it achieves in outcomes, why those two answers differ, and what shared
decision-making contributes.
Material and Methods: Narrative review of randomised and cluster-randomised trials, Cochrane reviews, meta-analyses,
criteria sets and qualitative studies indexed in PubMed and the major geriatric medicine, clinical pharmacology and general
medical journals. No new patient data were generated; every estimate quoted is one published by the original investigators.
Results: In the largest trial, 2008 hospitalised adults aged 70 or over with multimorbidity and polypharmacy, taking a median of
nine drugs, were cluster-randomised to structured medication review or usual care. At least one recommendation was
implemented in 62.2 per cent of the intervention group. A first drug-related hospital admission occurred in 211 participants (21.9
per cent) against 234 (22.4 per cent), hazard ratio 0.95 (95% CI 0.77 to 1.17). Hazard ratios were 0.96 (0.79 to 1.15) for first fall
and 0.90 (0.71 to 1.13) for death. The intervention reduced inappropriate prescribing without changing any clinical outcome
measured.
Conclusion: The best-powered trial of the intervention is negative, and that should be stated first rather than buried.
Deprescribing remains defensible on other grounds, including patient preference, treatment burden and the incoherence of
applying single-disease guidelines to people with ten conditions, but the claim that it prevents admissions is not currently
supported.
Abbreviations: ADR – Adverse Drug Reaction, DRA – Drug-Related Hospital Admission, HR – Hazard Ratio, ITT – Intention to
Treat, PIP – Potentially Inappropriate Prescribing, STOPP/START – Screening Tool of Older Persons' Prescriptions / Screening
Tool to Alert to Right Treatment.
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