Deprescribing in Frail Older People: A Randomised Controlled Trial

Abstract

Objectives: Deprescribing has been proposed as a way to reduce polypharmacy in frail older people. We aimed to reduce the number of medicines consumed by people living in residential aged care facilities (RACF). Secondary objectives were to explore the effect of deprescribing on survival, falls, fractures, hospital admissions, cognitive, physical, and bowel function, quality of life, and sleep.

Methods: Ninety-five people aged over 65 years living in four RACF in rural mid-west Western Australia were randomised in an open study. The intervention group (n = 47) received a deprescribing intervention, the planned cessation of non-beneficial medicines. The control group (n = 48) received usual care. Participants were monitored for twelve months from randomisation. Primary outcome was change in the mean number of unique regular medicines. All outcomes were assessed at baseline, six, and twelve months.

Results: Study participants had a mean age of 84.3 ± 6.9 years and 52% were female. Intervention group participants consumed 9.6 ± 5.0 and control group participants consumed 9.5 ± 3.6 unique regular medicines at baseline. Of the 348 medicines targeted for deprescribing (7.4 ± 3.8 per person, 78% of regular medicines), 207 medicines (4.4 ± 3.4 per person, 59% of targeted medicines) were successfully discontinued. The mean change in number of regular medicines at 12 months was -1.9 ± 4.1 in intervention group participants and +0.1 ± 3.5 in control group participants (estimated difference 2.0 ± 0.9, 95%CI 0.08, 3.8, p = 0.04). Twelve intervention participants and 19 control participants died within 12 months of randomisation (26% versus 40% mortality, p = 0.16, HR 0.60, 95%CI 0.30 to 1.22) There were no significant differences between groups in other secondary outcomes. The main limitations of this study were the open design and small participant numbers.

Conclusions: Deprescribing reduced the number of regular medicines consumed by frail older people living in residential care with no significant adverse effects on survival or other clinical outcomes.

Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12611000370909.

Conflict of interest statement

Competing Interests: The authors of this manuscript have the following competing interests: KP, CEB, and LF all hold grants from the NHMRC. CEB is a member of a government advisory board (the Pharmaceutical Benefits Advisory Committee - a statutory committee providing independent advice to the Minister under provisions of the National Health Act). KP, CEB, LF and AP have no other competing interests to declare. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1. Deprescribing Algorithm.

Fig 2. Recruitment and Participation.

Fig 3. Deprescribing Outcomes.

“Withdrawal Achieved” means medicine ceased or changed to PRN used less frequently than once per week at the last follow-up assessment point; RN, registered nurse; NOK, next of kin; GP, general practitioner. Percentages for “Withdrawal Failed” and “Withdrawal Achieved” are calculated as a percentage of the “Withdrawal Attempted” total. Italic numbers in () in the two large explanatory boxes refer to number of people.

Fig 4. Change in the mean number of regular medicines per person.

Closed bars are the intervention group. Open bars are the control group. Error bars are 1 SEM.

Fig 5. Kaplan Meier survival plot to 12 months post-randomisation.