Background
Methods
Data sources and searches
Study inclusion
Type of studies
Population | Older people (mean age 65+) who live with frailty measured objectively by any reliable tool. |
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Intervention | Studies at any setting and any language that included deprescribing medication review (including tapering/dose reduction, stopping or switching drugs). Deprescribing as the only intervention or part of medication review where deprescribing accounts for at least 50% of changes. |
Comparator | Any, or no, comparator considered |
Outcomes | Primary outcome: safety of deprescribing Secondary outcomes: clinical outcomes, medication-related outcomes, feasibility of deprescribing, acceptability and cost-related outcomes. |
Type of participants
Type of interventions
Type of outcomes
Study selection
Quality assessment
Data abstraction and synthesis
Intervention | Authors and year of publication | Study design | Setting and country | N of Participants (age and gender) | Description of the intervention | medication commonly stopped or reduced | Comparator (if any) | Study Follow up | Frailty tool | Deprescribing tool | Outcome measures | Quality scoring |
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Pharmacists-led medication review | Khera S 2019 [33] | Quasi-experiment (pre- post- comparison) | Primary care Canada | N = 54 Age: 81 ± 6.74 Gender: F 61% | Structured medication review in a primary care team-based seniors’ program. Medication review that included (1) preparing draft medication plan;(2) meet with patient and caregiver; (3) finalise medication plan/report; (4) following up | NR | Pre- and post- intervention | 12 months | Electronic Frailty Index (e-FI) | STOPP/START and Beers criteria in addition to pharmacist’s expertise | Primary outcomes: NA Secondary outcomes Medication-related outcomes: No significant changes in total number (12.1 meds pre to 11.7meds post, P = .254). Significant decrease in number of PIMs (1.15 meds pre to 0.9 meds post; P = .006). A statistically significant correlation between number of PIMs and frailty (r = 0.280, P = .040). Feasibility 72% of the deprescribing recommendations were implemented | 7/9 |
Ailabouni N 2019 [34] | Quasi-experiment (pre- and post- comparison) | Three Residential Care Facilities New Zealand | N = 46 Age: not specified (inclusion ≥65 years old) Gender: F 74% (n = 34) | Patient-centred collaborative pharmacist-led medication review with GPs including (Medical history, initial consultation, deprescribing medication review, development of medication management plan, monitoring and follow up | anticholinergic and sedative medicines (tramadol, codeine, citalopram, Escitalopram, amitriptyline) | Same participants before the intervention (pre-post design) | 6 months | the Edmonton Frailty Scale | peer-reviewed deprescribing guidelines of sedatives and anticholinergic medicines developed by the research team | Primary outcomes: Significant decrease in -adverse drug reactions by a mean difference of 2.8 (95% CI; p < 0.05) and 4.2 (95% CI; p < 0.05) 3 and 6 months after deprescribing -Psychiatric adverse effects decreased by a mean difference of 1.8 (p < 0.05; 95%, CI) and 2.24 (p < 0.05; 95%, CI) after 3 and 6 months Secondary outcomes Clinical outcomes: No significant changes in cognition or QoL 6 months after deprescribing. Significant decrease in -number of falls 6 months post deprescribing. -depression scores (Median difference: − 2; p < 0.05). -frailty scores 6 months after deprescribing (mean difference = 1.35 (p < 0.05,95%, CI). Medication-related outcomes: Significant reduction in: -total N of meds (2.13 medicines per patient) -Drug burden index scores by 0.34 6 months after deprescribing Feasibility 72% of the recommendations agreed and implemented | 6/9 | |
Whitty R 2018 [35] | Prospective interventional cohort study | Hospital (General internal medicine ward) Canada | 104 (Intervention = 53 Control = 51 Age: intervention 79.6 ± 11.7 years control 79.2 ± 13.4 years Gender: intervention F 43% Control F 63% | 1.Medication review by the Medication Rationalization team MERA (pharmacists and physicians) using guideline-based algorithm. 2.Their recommendations to stop, or change dose of medicines then reviewed by the ward pharmacist and physician. | vitamins/minerals, lipid-lowering agents, herbal supplements, proton pump inhibitors, docusate, Antiplatelets Benzodiazepines, Bisphosphonates, Dihydropyridine, Opioids | eligible patients admitted concurrently to general internal medicine wards where the intervention was not delivered | Follow up: 3 months after discharge | Clinical Frailty Score Score ≥ 4 | a guideline- based algorithm based on STOPP guidelines, Beers criteria, Choosing Wisely, and choosing wisely Canada | Primary Outcomes: NA Secondary outcomes Medication-related outcomes: Reduction in number of medications by a mean of 3 per patient, Significant decrease in number PIMs (3.1 intervention v. 0.9 control meds per patient, p < 0.01). Feasibility 81% of total recommendations were accepted by the admitting physician Acceptability 87% participants felt comfortable stopping medications as recommended by the team and only a very small number found the experience stressful or confusing (5 and 11% respectively) Cost-related outcomes: The total direct cost saved of stopped medications was $1508.47, or $94.28 per 100 patient-days. | 6/9 | |
Multidisciplinary team (MDT)-led medication review intervention | Curtin D 2019 [36] | Randomized controlled trial | Hospital (in transition to care homes) Ireland | N = 130 (65 in the intervention group, 65 in the control group) Age = 85.1 (±5.7) Gender = 61% F. | Single pre-discharge STOPPFrail-guided deprescribing. The research Physician recommended a medication withdrawal plan to one of the participant’s attending physicians and also documented in the patient’s medical record. The attending physician judged whether or not to accept the drug withdrawal plan and implement the recommended changes. | Lipid lowering therapies, neuroleptic antipsychotics, proton pump inhibitors, antiresorptive/bone anabolic drugs, calcium supplementation, and multivitamin combination supplements. | Usual pharmaceutical care | 3 months | Clinical Frailty Index (CFS score ≥ 7) | STOPPFrail | Primary outcomes: No significant difference between groups for hospitalisation, mortality Secondary outcomes: Clinical outcomes: No significant differences between the groups in incident of falls or fractures. QoL deteriorated significantly in both the intervention and control groups from baseline to 3-months, but no statistically significant differences were found between the groups Medication-related outcomes Reduction in the number of meds of 2.6 in the intervention group vs 0.36 in the control group (p < 0.001). Cost-related outcomes mean difference in the monthly medications cost of $61.74 ± $26.60; 95% CI; P = 0.02) between the intervention and the control groups. | 10/13 |
Garfinkel D 2017 [37] | A longitudinal, prospective, nonrandomized study | Community dwelling people Israel | 177 (122 in the intervention group and 55 in the comparator group) 64% female) Age: 83.4 ± 5.3 in the PDP group, and 80.8 ± 6.3 in the NR group Gender: F 64% | Medication review performed at home by a geriatrician to implement poly-deprescribing (PDP) of 3 or more drugs in collaboration with GPs. it combines ethics, EBM and clinical judgement while giving the highest priority to patient/ family preferences. | Statins, aspirin, benzodiazepines, proton pump inhibitor, antihypertension drugs, SSRI/SNRIs | The non-response group (NR) including participants who agreed to stop only 2 medication or less | follow up: 3 years | Fried frailty phenotype | concurrent de-prescribing of multiple medications based on the Garfinkel algorithm | Primary Outcomes: The number of major complications was significantly reduced (p < 0.002 in all). The rate of hospitalizations (RR = 0.86, 95% CI: 0.58–1.29) and survival (66.7%} 6.4% for the control group versus 77%} 3.8% for the intervention group) were comparable Secondary outcomes Clinical outcomes The PDP group showed significantly less deterioration (sometimes improvement) in health parameter: functional (OR = 4.63, 95% CI: 2–10.72), mental (OR = 60.41,95% CI: 16.38–222.82) and cognitive status (OR = 4.394, 95% CI: 1.93–9.98) night sleep quality (OR = 10.65, 95% CI: 4.06–27.96), daily alertness (OR = 5.38, 95% CI: 1.95–14.84), appetite (OR = 15.89, 95% CI: 4.91–51.45), and sphincter control (OR = 6.77, 95% CI: 2.54–18.03). Medication-related outcomes: the median number of drugs reduced from 11 to 4 in PDP group (p <0.0001). Feasibility 91% of the recommendations made by a geriatrician were accepted by GPs Acceptability The overall satisfaction of patient/family from the changes was defined as high/very high in 89% (n = 109) | 6/9 | |
O. Dalleur 2014 [38] | Randomised controlled trial | Hospital, Belgium | 146 (intervention = 74, control group = 72) Median age = 85 (IQR 81–88) Gender: F 63% | Medication review on admission using STOPP criteria by inpatient geriatric consultation team (consisting of nurses, geriatricians, a dietician, an occupational therapist, a physiotherapist, a speech therapist, and a psychologist) who makes recommendation to the hospital physician for the discontinuation of PIMs. | Benzodiazepines, antiplatelet, b-blockers, tricyclic antidepressants, and neuroleptics | Non-matched randomised control group (usual care without using STOPP tool) | Follow up: 12 months (only for those with PIMs identified, 50 patients; 26 in intervention group and 24 in the control group) | Identification of Seniors At Risk (ISAR) score of ≥2/6 Median score = 3 | STOPP criteria | Primary outcomes: NA Secondary outcomes Medication-related outcomes At discharge, the reduction in PIMs was twice as high for the intervention group as for the control group (39.7 and 19.3%, respectively; [OR] 2.75 [95% CI = 1.22–6.24]; p = 0.013). PIM discontinuation rate of benzodiazepines tended to be higher in the intervention than in the control group (34.6 vs. 6.7%; p = 0.063) At the patient level, the reduction in the prevalence of PIMs (i.e. patients having one or more PIM) did not differ between the intervention group and the control group (23.1 vs. 16.1%; OR 1.5 [95% CI 0.49–4.89]; p = 0.454). However, the proportion of patients with at least one improvement to their drug treatment was higher for the intervention group than for the control group (25.7 vs. 13.9%; p = 0.034). | 10/13 |