Discontinuation of medication in older patients with polypharmacy in primary care: development of a complex intervention

• Applicants: Professor Dr. Norbert J. Donner-Banzhoff; Professorin Dr. Ulrike Junius-Walker
• Subject Area: Public Health, Healthcare Research, Social and Occupational Medicine ; Biogerontology and Geriatric Medicine ; Pharmacology
• Term: from 2016 to 2020
• Project identifier: Deutsche Forschungsgemeinschaft (DFG) - Project number 282998937

Polypharmacy, the simultaneous intake of five and more medications, affects nearly every second older person. As chronic diseases increase in ageing people, the medication use rises disproportionally. Several factors promote polypharmacy, such as evidence-based guidelines focusing on single diseases and the traditional format of the consultation, in which patients present complaints in consecutive appointments. This leads to a summation of treatments for patients with multimorbidity. Additional prescriptions by specialists, during hospital stays and further medications to ameliorate drug-induced side-effects result in a prescription cascade. However, polypharmacy is risky. It triggers interactions and adverse drug reactions causing hospital admissions with a potentially lethal outcome. It also leads to a diminished patient compliance and an increase in prescribing errors. Despite these risks there is a lack of consistent practicable and patient-oriented professional approaches on how to discontinue medications. This especially concerns GPs, who are responsible for the continuity of care and the complex medication management in older multimorbid patients. In contrast to starting medications, in which GPs utilize evidence based decision aids, stopping medications usually involves no such established patterns of actions with uncertain consequences. Algorithms for discontinuing medications are being developed and tested in scientific trials, but have not been adopted in practice possible due to issues of practicability and of individual applicability. The aim of this project is to lay the foundations for safe, acceptable and effective deprescribing actions for older patients with multimorbidity. The study design is based on the methodology of a complex intervention design (Campbell, 2007; Craig, 2008). The proposed project contains the first two phases. In the development phase, deprescribing actions are identified and modeled into stepwise deprescribing procedures. For this purpose focus groups are held with health care professionals (doctors, pharmacists) as well as patient interviews to gain insight into the drivers and barriers of deprescribing decisions and treatment priorities as they occur in normal practice. Resultant analytical findings and expert assessments of already existing algorithms are processed via Delphi rounds leading to a specification of a stepwise deprescribing procedure for general practitioners. The Delphi method is also used to reach a consensus on trial outcomes for medication discontinuation procedures. In the phase called testing procedures, experiences/ findings that have been identified during development will be examined as well as acceptability, compliance and delivery of the deprescribing action. Based on these findings the deprescribing procedures will be modified and ready for a pilot test.

• DFG Programme: Research Grants
• Co-Investigators: Professor Dr. Nils Schneider; Dr. Ingrid Schubert; Professor Dr. Dirk O. Stichtenoth