Effectiveness and sustainability of deprescribing for hospitalized older patients near end of life: a systematic review

ABSTRACT

Introduction: Polypharmacy is prevalent in hospitals and deprescribing strategies for older people are strongly promoted. However, evidence of their feasibility and sustainability among patients receiving end of life care is lacking. The objective of this review was to ascertain effectiveness and post-discharge sustainability of hospital-initiated deprescribing strategies in older people near the end of life.

Areas covered: The authors searched for controlled trials, with low risk of bias and measures of effectiveness post-discharge. Intervention description, duration, and healthcare provider engagement were investigated for their impact on reduction of number of medications, proportions of patients prescribed inappropriate medications, returns to emergency, hospital admission and adverse events.

Expert opinion: Limited evidence suggests hospital-initiated deprescribing interventions may reduce prescribing inappropriateness among older terminal patients in the short term, but evidence beyond 3 months is lacking for significant prevention of adverse events or health service utilization. Heterogeneity precluded meta-analysis, and short follow-up periods precluded quantitative assessment of sustainability. Trials of older people with terminal conditions with larger sample sizes and longer follow-up periods are needed to confirm the effectiveness and sustainability of deprescribing at the end of life. Objective tools to reliably identify near end-of-life status would be useful in selecting target groups for these interventions.

KEYWORDS:

• Aged
• controlled trials
• deprescribing
• end-of-life
• polypharmacy

Article highlights

• Older people with progressive multiple comorbidities who are nearing the end of their lives often take multiple non-essential medicines which can impair their cognitive and physical functioning, and are potentially harmful. Medication reviews and deprescribing have been proposed to improve health status and reduce medication-related adverse events and repeat hospitalisations.

• Considerable literature indicates that deprescribing during hospitalization can be achieved, but little published evidence exists about the duration of deprescribed medications following hospital discharge and the long-term benefits until death.

• This review aimed to identify hospital-initiated deprescribing interventions targeting older people in the last year of life and investigate their effectiveness and sustainability beyond 6 months post-discharge. Many articles did not specify terminal status and others excluded people in the terminal phase of illness.

• Studies generally demonstrated reductions in numbers of potentially inappropriate medications within short timeframes (2–3 months) and decrease in drug-related hospitalizations at 12 months. Evidence of longer-term impact on reducing adverse events or mortality, or improving quality of life or physical functioning, was lacking. Small sample sizes, heterogeneity of interventions and outcomes measures, and design flaws precluded definitive evidence of effectiveness.

• Further randomized clinical trials are warranted that have larger samples, longer follow-up periods, and objective classification of people as being in the last year of life.

• This box summarizes key points contained in the article.

Acknowledgments

We thank Associate Professor Mark Jones for his advice on data extraction in the early stages of the project, Dr Alex Bannach-Brown for setting up the risk of bias platform, and the Bond University librarians for their assistance with interlibrary loan acquisitions.

Author contributions

Design and protocol: MC, PS, JC, IS. Searches: JC, MC. Screening: PF, MC, JA, PS, OB, SS. Data extraction: MC, OB, PF. Risk of Bias: PS, OB. Analysis: MC, OB. Interpretation: MC, IS, OB, PS. Manuscript writing: MC, IS, PS, OB. Revisions and approval of last version: All authors.

Reviewer disclosures

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

Declaration of interest

M Cardona previously designed and validated the CriSTAL tool used to identify people at risk of short-term death. She derives no financial or other benefits from the use of the tool in any setting. The authors have no other relevant affiliations or financial involvement with any organization 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.

Supplementary material

Supplemental data for this article can be accessed here.

Additional information

Funding

No funding other than our salaries and in-kind support from medical and pharmacy trainees was available to conduct this review. Salaries of staff involved in this review are paid from the academic or clinical institutions to which they are affiliated.