Systematic Review and Meta-Analysis: Effectiveness of Deprescribing Interventions for Community-Dwelling Older Adults
BACKGROUND:
More than 40% of people in the United States age ≥ 65 years take five or more prescription medications on a regular basis to control or prevent disease symptoms and complications, and approximately half of older adults take one or more potentially inappropriate medications, which includes duplicative medications and those with known risks or without a clear indication. This systematic review and meta-analysis evaluated the effectiveness, comparative effectiveness, and harms of deprescribing interventions in community-dwelling persons aged 65 or older. Investigators searched OVID Medline, Embase, CINAHL, and the Cochrane Library from 1990 through February 2019 for controlled clinical trials comparing any deprescribing intervention to usual care or another intervention. Of 278 articles with a full text review, 38 low and medium risk of bias trials were included – 12 randomized controlled trials and 26 cluster randomized controlled trails. Primary outcomes were all-cause mortality, hospitalizations, health-related quality of life, and falls. The secondary outcome was the use of potentially inappropriate medications.
FINDINGS:
- In community dwelling people age 65 years and older, medication deprescribing interventions may provide small reductions in mortality and use of potentially inappropriate medications.
- Of the trials included in this review, 22 (low to moderate certainty of evidence) evaluated the effects of comprehensive medication review. Results suggest that such reviews may have reduced all-cause mortality but probably had little to no effect on falls, health-related quality of life, or hospitalizations. Nine of thirteen trials reported fewer inappropriate medications in the intervention group.
- Twelve trials (6 low risk of bias, 6 medium risk) evaluated the effects of various educational initiatives and found that while they may reduce the use of inappropriate medications, the interventions had uncertain effects on quality of life and rates of hospitalizations and falls. Four trials (medium risk of bias) evaluated the effect of computer decision support interventions: two studies reported a significant reduction in inappropriate medications and two studies reported no effect.
- No studies assessed the comparative effectiveness of the different deprescribing approaches.
IMPLICATIONS:
- Future research should include well-designed comparative effectiveness trials conducted in a variety of settings, employing a uniform set of outcome measures and including process evaluations to guide subsequent implementation of effective interventions.
LIMITATIONS:
- This review was limited to the community setting; the effects of deprescribing for people in hospitals or long-term care facilities may differ.
AUTHOR/FUNDING INFORMATION:
This review was funded by HSR&D through its Evidence Synthesis Program (ESP). Drs. Bloomfield and Greer are part of HSR&D’s Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis, MN; Dr. Linsky is with HSR&D’s Center for Healthcare Organization and Implementation Research (CHOIR), Boston and Bedford, MA.
Bloomfield H, Greer N, Linsky A, et al. Deprescribing for Community Dwelling Older Adults: A Systematic Review and Meta-Analysis. Journal of General Internal Medicine. August 20, 2020; Epub ahead of print.
