Multidisciplinary medication reviews and deprescribing in primary care for older people living with frailty

Problem

A third of older people take five or more regular medications (polypharmacy) increasing their risk of adverse events, hospital admission and death, with higher risk among people living with frailty. To address this, medication reviews to identify and stop/reduce inappropriate medications (deprescribing) involving a multidisciplinary approach in primary care are recommended. Aims: To understand what makes multidisciplinary medication review and deprescribingwork in primary care for older people living with frailty.

Approach

An exploratory qualitative study involving focus groups and interviews was conducted with healthcare professionals (HCPs) working in primary care, and interviews with patients aged 65 and over taking 5 or more medicines, and their informal carers. Transcripts were analysed thematically.

Findings

Thirty-six participants were recruited, including 23 HCPs (e.g. GPs, Pharmacists, Advanced Nurse Practitioners) from six practices participating in five focus groups and four individual interviews, ten patients and three carers participating in interviews. Findings highlighted the need for primary care teams to have capacity to undertake both reactive and proactive medication reviews, with the need for systems to identify high-risk patients (e.g. those living with frailty, 10 or more medications). Clinical Pharmacists’ roles are essential and ensuring that Pharmacists are well-integrated into the primary care team can increase confidence to deprescribe amongst the multidisciplinary team (MDT). Clear, defined roles and good communication between members of the MDT was key, facilitated by asynchronous digital communication. Some HCPs identified the need for specific training on deprescribing to increase their confidence in stopping medications safely. Findings identified the need to involve patients and their carers in the deprescribing process, and that patient and carer trust in HCPs and continuity of care are important aspects of this. Reported barriers to deprescribing included unfamiliarity of patients with the role of practice pharmacists, patient’s concerns around stopping medicines viewed as essential to their well-being, and reluctancy to stop medication initiated by a secondary care consultant. Findings suggest that these can be addressed by explaining to patients (and their carers) the rationale for deprescribing, considering their goals and preferences, and involving them in shared decisions about their medications, and having systems in-place for patient monitoring and follow-up. Starting with ‘quick wins’ (whereby HCPs start with a simple deprescribing change that can lead to noticeable improvements in symptoms by patients) and offering deprescribing as a ‘drug holiday’, can also facilitate trust.

Consequences

Good communication and collaboration between an MDT, and in particular the integration of pharmacists are key facilitators for the medication review and deprescribing process. Deprescribing should be approached as a longitudinal process, involving different members of the MDT based on their particular expertise. Involvement and engagement of patients and carers is key, particularly for older people living with frailty.