A systems approach to identifying the challenges of implementing deprescribing in older adults across different health-care settings and countries: a narrative review

ABSTRACT

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.

KEYWORDS:

• Deprescribing
• deprescribing in practice
• medication withdrawal
• older adults
• policies
• polypharmacy

Article highlights

• The use of potentially inappropriate medications in older adults is consistently high across different health-care settings and deprescribing is an important step to reduce medication-related harm and improve outcomes in older adults.

• However, the routine implementation of deprescribing interventions in real-world settings is limited which have resulted in mixed outcomes across settings and countries.

• This narrative review identified the unique barriers and opportunities to deprescribing across the four levels of the health-care system and selected countries to identify approaches that may enhance implementation of deprescribing in the real-world.

• Implementation of deprescribing interventions need to be individually tailored to target the unique barriers and opportunities to deprescribing in different clinical settings.

• The knowledge of the efficacy and safety of withdrawing medication is required to inform implementation strategies such as deprescribing interventions across settings.

• Introduction of national policies to encourage deprescribing may be beneficial. However, it would be important to establish the effectiveness of these policies in different contextual settings.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organisation or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript was not funded. Dr Gnjidic is funded by the Australian National Health and Medical Research Council (NHMRC) Dementia Leadership Fellow. Dr. Steinman’s participation was funded by the U.S. National Institute on Aging [grants K24AG049057 and R24AG064025]. Dr Reeve is supported by a National Health and Medical Research Council (NHMRC) Dementia Research Development Fellowship. Dr Turner is supported by a MITACS Elevate Fellowship.