Deprescribing for frail older adults residing in long-term care facilities: a mixed-methods evaluation

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Heinrich, Clara H.
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University College Cork
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Introduction Globally, the population is ageing and the demand for long-term care (LTC) is increasing. Older adults residing in LTC have a higher degree of physical frailty compared to their community-dwelling counterparts. The physiological changes associated with ageing and frailty can increase the risk of experiencing an adverse event from a medication. Polypharmacy and potentially inappropriate medications (PIMs) are even more of a concern in frail older adults as frailty increases the risk of adverse outcomes. Deprescribing has been shown to reduce PIMs for older adults residing in LTC however, deprescribing is not universally implemented. The aim of this thesis is to develop and test an evidence- and theory-based implementation strategy to support HCPs engage with deprescribing in routine practice for frail older adults residing in LTC. Methods A mixed-methods approach was utilised for this thesis, informed by the Medical Research Council’s framework for designing and evaluating complex interventions. Firstly, the ‘best-fit’ framework method was used to synthesise the qualitative evidence, using the Theoretical Domains Framework. The resulting ‘best-fit’ framework was used to inform a semi-structured interview study of HCPs working in LTC to identify context-specific deprescribing barriers/enablers. A retrospective chart review was conducted in two long-term care facilities (LTCFs) using Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy version 2 (STOPPFrail v2) to identify PIMs. Results supported the design of a deprescribing implementation strategy. The implementation strategy design consisted of 3 phases; a mapping process to identify behaviour change techniques (BCTs) which could form a strategy, a modified online Delphi survey to select feasible BCTs and a roundtable discussion to prioritise barriers/enablers and tailor the proposed strategies for deprescribing in LTC. A feasibility study of the resulting strategy was conducted in two public LTCFs focusing on implementation outcomes whilst collecting intervention data. Results The qualitative evidence synthesis and interview study summarised the deprescribing barriers/enablers in LTC. Barriers included insufficient resources, lack of co-ordination between healthcare settings and negative social influences. Deprescribing enablers included interprofessional support and patient social influence. The retrospective chart review study identified that lack of a documented indication for prescribed medications was the most prevalent PIM criterion, with antihypertensives the largest drug class potentially inappropriately prescribed. The final deprescribing implementation strategy consisted of an education-enhanced 3-monthly multidisciplinary team deprescribing review, led by a nurse, conducted at the LTC site targeting antihypertensives, named the DEFERAL strategy. Of HCPs involved in the feasibility study, the DEFERAL strategy was unanimously considered acceptable and appropriate, with 90% agreeing that it was feasible. Qualitative feedback outlined site-specific modifications for future consideration. Conclusion This thesis has designed and feasibility tested a theory- and stakeholder-informed implementation strategy to support HCPs to engage with deprescribing PIMs prescribed to frail older adults residing in public LTCFs in Ireland. The DEFERAL strategy helped to address a gap reported in the deprescribing literature by incorporating concepts from behavioural and implementation science to target barriers and enablers inherent with the LTC setting and translate deprescribing into routine practice. The strategy was considered acceptable, appropriate and majorly feasible, with modifications reported for consideration in future piloting and effectiveness research.
Deprescribing , Long-term care , Frail older adults , Mixed-methods , Behavioural science , Implementation science
Heinrich, C. H. 2023. Deprescribing for frail older adults residing in long-term care facilities: a mixed-methods evaluation. PhD Thesis, University College Cork.
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