Fears about and previous bad experiences with deprescribing may be preventing medication optimisation in people living with cognitive impairment

Dr Emily Reeve is a Senior Research Fellow and NHMRC Emerging Leadership Fellow with the Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences at Monash University. Dr Reeve is also Chair of the Australian Deprescribing Network. They are a pharmacist with a program of research exploring how to optimise deprescribing in older adults and people living with dementia. Follow Emily on Twitter here @Reeve_Research.

Our new research published in Age and Ageing has established that most people living with dementia and mild cognitive impairment and their caregivers are willing to have one of their medications deprescribed (78.5%). Additionally, we found that addressing patient concerns, especially if they have previously had a bad experience when a medication was stopped, or if they get stressed when their medications are changed, may be key to informing productive conversations about deprescribing between healthcare professionals and people living with cognitive impairment and their caregivers.

Use of multiple medications (polypharmacy) and inappropriate medications are far too common in people living with dementia. This leads to medication-related harms such as falls, hospitalisation, and decreased quality of life. Deprescribing is the process of withdrawal (or dose reduction) of inappropriate medications, supervised by a healthcare professional. However, deprescribing does not happen as often as it should, and healthcare professionals have reported that patients and their caregivers are resistant to deprescribing. More knowledge is therefore needed about how to support patient-centred deprescribing in people living with cognitive impairment.

In this study, a validated questionnaire (revised Patients’ Attitudes Towards Deprescribing questionnaire for people living with cognitive impairment; rPATDcog) was used to explore how people living with dementia and mild cognitive impairment feel about their medications and deprescribing. 553 people living in the community in the US completed the questionnaire; they had an average age of 80 years and just over half (52.4%) were female. When asked whether they would be willing to stop one or more of their medications if their doctor said it was possible, about 4 out of 5 responded ‘yes’.

Ours and other studies exploring how patients and caregivers feel about deprescribing have aimed to determine which characteristics are associated with willingness to deprescribe. For example, are older or younger adults more willing? Are those on more medications more willing? A previous systematic review and meta-analysis on this question found that the results were inconsistent between studies, both in whether there was a significant association and even the direction of the relationship. Few previous studies had specifically looked at people living with cognitive impairment. Our recent study (which was among the largest to date) found only the number of chronic medical conditions was associated with willingness to deprescribe.

We also found that people who had a previous bad experience with deprescribing were on more medications and were more likely to be on one or more inappropriate medications. And those who got stressed when changes were made to their medications were also more likely to be on one or more inappropriate medications. Additionally, people who have had a previous bad experience and those who got stressed when changes were made to their medications were less likely to be willing to accept deprescribing.

Therefore, in practice, asking whether people living with cognitive impairment have had a previous bad experience, or if they get stressed with medication changes may be an essential part of a deprescribing conversation. It may be possible to address the cause of the bad experience, e.g. if it had been stopped abruptly and they had experienced a withdrawal reaction. This would then inform developing a plan for tapering and ensuring that they have adequate support for the deprescribing process, such as knowing what to do if symptoms occur.

More research is needed to translate these findings into supporting healthcare professionals and people living with cognitive impairment and their caregivers to have deprescribing conversations.