Deprescribing for older adults during acute care admission: a scoping review protocol

Abstract

Objective:

The objective of this scoping review is to understand the current body of knowledge regarding deprescribing in adults aged 60 years or older in acute care settings, including the deprescribing activities that are being undertaken, and the feasibility, challenges, and outcomes of the practice.

Introduction:

Polypharmacy is prevalent amongst older adults, despite risks to patients. Much of the existing research on deprescribing has occurred in the outpatient context, with recent research emerging on the unique opportunity that acute care may provide.

Inclusion criteria:

This review will include deprescribing in adults aged 60 years or older in acute care. It will consider deprescribing occurring during inpatient admission and at the time of discharge from hospital.

Methods:

The JBI method for scoping reviews will guide this review. A search of MEDLINE (Ovid), Scopus, Web of Science Core Collection, CINAHL (EBSCOhost), Embase (Ovid), and the Cochrane Database of Systematic Reviews will be undertaken from inception to present with no language restrictions. Qualitative, quantitative, and mixed method studies, clinical practice guidelines, and opinion papers will be considered for inclusion. Systematic reviews and scoping reviews will be excluded. Google Scholar and a general Google search will be conducted for gray literature. Two reviewers will assess articles for inclusion and any disagreements will be discussed and resolved by discussion or a third reviewer, if required. Findings will be presented in the scoping review using a narrative approach with supporting quantitative data in a tabular format according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist (PRISMA-ScR).

Review registration:

Open Science Framework https://osf.io/pb7aw/

Introduction

Deprescribing is defined as “the planned and supervised process of dose reduction or stopping of medication that might be causing harm, or no longer be of benefit.”^{1 (para.1)} Older adults may benefit from deprescribing as they often experience potentially inappropriate polypharmacy. Recent data from Canada suggest that 36% of older adults met the definition for polypharmacy by taking medications from 5 or more drug classes chronically and up to 25% take medications from 10 or more drug classes.^2,3 Polypharmacy has been associated with a number of negative outcomes in older adults, including adverse drug events, increased frequency of drug interactions, medication non-adherence, decreased functional status, decreased quality of life, cognitive impairment, falls, urinary incontinence, and diminished nutritional status.^4,5

Polypharmacy is also associated with an increased risk of admission to acute care.⁶ Up to 25% of all hospital admissions and visits to emergency departments are associated with a medication adverse event.⁷ Inappropriate prescribing also appears to complicate the hospital course for admitted patients who experience increased lengths of stay as well as a failure to mobilize early postoperatively.⁸ A recent nationwide cohort study in Denmark reported a 3- to 4-fold mortality risk associated with polypharmacy in older adults.⁹ The costs of polypharmacy worldwide have been estimated at 0.3% of the total world health expenditure.¹⁰ Polypharmacy was associated with a near doubling of the total health care expenditure (198%) for patients compared with those not experiencing polypharmacy.¹¹

The incidence of polypharmacy in older adults may increase over time as patients move through the spectrum of the health care system. The Danish study mentioned previously also found that 29% of patients experienced polypharmacy at the time of inclusion, but over 5 years, 47% of the remaining patients transitioned to polypharmacy.⁹ Factors associated with the development of polypharmacy include the complexity of health care settings, multiple clinicians, new treatments becoming available, and the increasing burden of chronic diseases with multi-medication approaches.¹² A lack of accountability for the management of a patient’s medication list or hesitancy by primary care clinicians to discontinue medications initiated by other professionals can contribute to the enduring nature of long medication lists.¹³ As patients age, they often experience an increasing burden of chronic disease. Guideline-directed therapy often leads clinicians toward the addition of medications to manage these conditions.¹⁴ Although these therapies are not necessarily inappropriate, clinicians lack information to guide them through management of multiple chronic diseases with multi-medication approaches, with little evidence-based guidance on when or how to stop therapies.

Primary care providers are often viewed as the main managers of patients’ chronic medications; therefore, it is natural to assume that the most appropriate context for deprescribing medications would be within the ambulatory care setting. Primary care providers cite many barriers to deprescribing in outpatient settings, including problem awareness; low perceived value proposition for discontinuing medications if the patient is not experiencing any obvious adverse effects; professional knowledge gaps in undertaking deprescribing; communication barriers between providers; as well as systemic limitations, such as time and access to other multidisciplinary services within specific health care settings.^15,16 There are also patient-specific barriers to deprescribing in the outpatient setting, including fear of return of a condition, withdrawal effects, and patients’ preference not to deprescribe.¹⁷

Deprescribing during an acute care admission may, at first, seem an unlikely approach, given that patients are acutely ill and often the management of chronic disease states is not a priority of an inpatient stay. The assessment and monitoring of drug therapy may be challenging due to the impact of acute illness as well. Despite this, acute care may offer distinct advantages to overcome some of the barriers to deprescribing identified in the ambulatory setting. Intensive monitoring of patients may alleviate patient fears of enduring drug withdrawal or return of symptoms while at home unattended.¹⁷ In addition, many acute care institutions may offer coordinated access to interdisciplinary professionals with specialized deprescribing knowledge, such as pharmacists and geriatricians to assist in the deprescribing process. Therefore, it is possible that an admission to an inpatient setting may be an ideal opportunity to undertake deprescribing.

We conducted a preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis, and no current or in-progress scoping or systematic reviews on the topic were identified. This initial scan did find publications exploring various aspects of deprescribing in acute care, including studies on deprescribing interventions in hospitals, patient and provider perspectives, and barriers to deprescribing in the hospital, which may inform our proposed review.^18–20

The objectives of the scoping review are 2-fold: to describe the current body of knowledge and to identify gaps in the knowledge base offering potential for future research. A scoping review is the ideal methodology, as the authors anticipate that the body of literature will be heterogeneous in nature. A scoping review will allow for the flexibility to consider all sources of knowledge regarding this emerging topic.

Review questions

What is the current body of knowledge regarding deprescribing in adults, age 60 years or older, in acute care?

Subquestions include:

1. How is deprescribing being undertaken in acute care?

2. What is known about the feasibility of integrating deprescribing activities within the complex acute care environment?

3. What is known regarding the outcomes of deprescribing for older adults in acute care, especially with respect to mitigating the negative outcomes of polypharmacy?

Inclusion criteria

Participants

The scoping review will include sources of evidence reporting on deprescribing in adults aged 60 years or older. The age of 60 was chosen to align with the World Health Organization’s definition of an older adult.²¹ Patients who undergo dosage adjustments and medication cessation in hospital in response to therapeutic drug monitoring of drug levels or as part of oncology management will be excluded, as these activities occur in the context of acute patient management rather than deprescribing. Studies with mixed age populations will be also excluded, as it is possible that deprescribing outcomes vary with age, and the inclusion of patients younger than our target population could introduce bias into the results.

Concept

Reducing the risks of polypharmacy is the main impetus for deprescribing.^4,5 Polypharmacy has many definitions, and a recent systematic review by Masnoon et al. ³ found that many of those definitions are quantitative, stating polypharmacy occurs when a patient is taking 5 or more medications. Polypharmacy can be further categorized as appropriate polypharmacy or inappropriate polypharmacy.³ Implicit lists, including STOPP/START and the BEERS criteria, are widely used to assist clinicians in identifying specific medications as potentially inappropriate. However, defining medication lists as either appropriate or inappropriate is more challenging because optimal medication use is based on a patient-centered, evidence-based approach, which may be unique for each patient.^22–24

The earliest publications on deprescribing focused on stable, community-dwelling adults.²⁵ Subsequent global interest in the topic has amassed a body of research examining a reduction in the burden of chronic medications through drug discontinuation and dose reduction for stable older adults in their home environments.^1,10 Deprescribing has often been assumed to be undertaken by primary care clinicians caring for stable patients, but further studies reveal that deprescribing in the community is fraught with many barriers.^15–17 Challenges to undertaking deprescribing in the hospital also exist, but the concept of deprescribing in various settings goes further than simply sharing the burden of workload between community and acute care clinicians.²⁶ The rationale for considering deprescribing in acute care is 2-fold. Firstly, medication lists are known to be formed and increased across the health care spectrum as patients are treated by multiple providers in various ambulatory and acute care settings.¹² Secondly, if one considers that up to 25% of hospital admissions and emergency room visits can be attributed to a drug-related problem, it highlights that poor outcomes related to polypharmacy are direct reasons for hospital admissions.⁷

Context

The focus of this scoping review is to examine deprescribing occurring specifically in the context of an acute care setting. This includes participants who are inpatients in hospitals due to medical or surgical admissions. The context will be extended to include data that examine deprescribing at discharge from hospital. Studies that describe deprescribing occurring in the emergency room, during an acute inpatient psychiatry admission, in a rehabilitation or transition hospital, or in outpatient chronic care clinics will be excluded, as they do not meet the definition of acute care.

Types of sources

All types of interventional and observational studies, qualitative, and mixed methods studies will be considered for inclusion. Clinical practice guidelines, randomized controlled studies, case-control studies, cohort studies, survey-based studies, and opinion papers will also be assessed for inclusion. Systematic reviews and scoping reviews will be excluded, as they are considered secondary research.

Published and unpublished sources will be searched for in gray literature sources, including, but not limited to, conference notes, guidelines, news articles, dissertations, and textual evidence papers. If necessary, authors will be contacted once via email for further references or information.

Methods

This scoping review will be conducted according to JBI methodology for scoping reviews,^27,28 and will be reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).²⁹

Search strategy

A library scientist will be engaged to assist with locating published and unpublished sources of information. MEDLINE (Ovid) was searched to identify keywords from titles, abstracts and index terms of pertinent articles. From these, a full search strategy was developed, which will be adapted for each database and source utilized (see Appendix I for a full search strategy). A second, broader search will be undertaken utilizing all keywords and index terms across multiple databases including MEDLINE (Ovid), Scopus, Web of Science Core Collection, CINAHL (EBSCOhost), Embase (Ovid), and the Cochrane Library. Databases will be searched without a lower date limit to keep the search as broad as possible. There will be no exclusion of documents in languages other than English. Two validated online language translators, DeepL (DeepL, Cologne, Germany) and Google Translate, will be employed. We will confirm the accuracy of the translation with colleagues who are fluent in the relevant language. A cited reference search of articles selected for data extraction will also occur, in addition to a forward citation search of the articles to ensure all relevant information is retrieved. If prominent author names are identified in the search, their names will be individually searched to ensure any relevant articles are included. If necessary, we will contact these authors directly, once, via email for access to any unpublished information they may possess.

A targeted search of Google and Google Scholar for gray literature will be conducted. We will search the first 200 articles³⁰ listed in Google Scholar for additional sources not obtained in the database search described previously. Selecting the first 200 results from Google Scholar has been demonstrated to be a reasonable number of results to screen.³⁰ In addition, a targeted search of the first 200 results of Google will look for websites related to deprescribing networks, research groups, organizations, and any other relevant sources of information, such as guidance documents, conference notes, opinion articles, and unpublished research not discovered in the original search.

Study selection

Relevant citations will be uploaded to Covidence (Clarivate Analytics, PA, USA) and duplicates removed. Following a successful pilot, where 10 search results will be tested for eligibility for inclusion by 2 reviewers to ensure consistency in the approach, titles and abstracts will be assessed by 2 reviewers independently against the inclusion/exclusion criteria. In the second stage, the full text will again be assessed by 2 reviewers independently. The reason for the exclusion of a study will be noted in the full scoping review. Any disagreements between reviewers at each stage of screening will be resolved through discussion or with a third reviewer, if required. The search and screening process will be presented in detail in a PRISMA flow diagram.³¹

Data extraction

A data extraction tool has been developed and will be pilot tested by 2 reviewers on 3 studies prior to use to ensure the tool consistently captures relevant information.²⁷ The tool aims to identify specific details, including country, participants, context, health care disciplines involved, and key findings (Appendix II). Modifications to the tool may occur throughout the extraction process as necessary and will be reported in the scoping review. Disagreements between reviewers will be resolved through discussion or with a third reviewer. If additional information is required, authors of papers will be contacted once via email. There will be no critical appraisal of individual sources of evidence.

Data analysis and presentation

Data will be presented in a narrative, descriptive style. Where appropriate, descriptive statistics provided in studies will be reported. Information will be presented in response to each review question. If possible, results will be presented using a stratified approach based on findings relevant to the context, such as deprescribing occurring during admission to acute care and at discharge. We expect to present the results in a narrative style with tabular information to support the explanation of how the data collected addresses our review question and objectives.

Acknowledgments

This review will contribute toward a Master of Science degree for ES.

Author contributions

ES, JK, WG, and RT designed the search strategy and analysis. ES, WG, and RT performed the analysis. All authors contributed to the writing and finalizing of the manuscript.

Appendix I: Search strategy

MEDLINE (Ovid)

Date searched: February 17, 2023

#	Query	Results retrieved
1	(deprescri* or de-prescri* or unprescri*).mp.	2714
2	exp Deprescriptions/	939
3	((cease* or ceasing* or cessation* or withdraw* or discontinu* or stop* or intermittent or “on demand” or “as needed” or decreas* or taper* or reduce* or reduction* or reducing) adj4 (medicin* or medication* or drug* or prescription*)).mp.	117,696
4	or/1-3	119,712
5	Emergency Treatment/ or Emergency Medicine/ or Emergency Medical Services/ or Emergency Service, Hospital/ or Trauma Centers/ or Triage/ or exp Evidence-Based Emergency Medicine/ or exp Emergency Nursing/ or Emergencies/ or emergicent*.mp. or casualty department*.mp. or ((emergenc* or ED) adj1 (room* or accident* or ward or wards or unit or units or department* or physician* or doctor* or pharmacist* or nurs* or treatment* or visit*)).mp. or (triage or critical care or (trauma adj1 (cent* or care))).mp.	396,073
6	(acute care or inpatient or in-patient).ti,ab,kf.	199,283
7	hospital*.ti,kf. or hospital*.ab. /freq=2	759,564
8	(intensive care or ICU).ti,ab,kf.	216,803
9	(patient* adj3 discharg*).mp.	86,862
10	or/5-9	1,361,840
11	exp Geriatrics/ or exp Aged/ or Health Services for the Aged/ or (elders or elderly or geriatric* or gerontolog* or “old age” or “senior citizen*“ or (seniors not “high school”) or ((older or mature) adj3 (adult* or person* or people or patient or patients or man or men or woman or women)) or centenarian* or nonagenarian* or octogenarian* or septuagenarian* or sexagenarian* or dottering or decrepit or tottering or overaged or “oldest old” or supercentenarian*).mp.	3,640,923
12	4 and 10 and 11	3339
13	limit 12 to “review articles”	188
14	12 not 13	3151

Appendix II: Draft data extraction tool

Evidence source details and characteristics
Citation details: author/s, date, title, journal, volume, issue, pages
Country
Context (during admission/at discharge)
Participants: characteristics
Study design or description of the information source
Details/results extracted from source of evidence
Description of research question/topic of interest
Key findings of study or topic themes/opinions presented
Health care disciplines involved (if applicable)
Summary data and statistical tests for each group (if reported)

This sample data extraction tool has been adapted from the template data extraction tool developed by JBI.²⁷