Partnered Pharmacist Medication Deprescribing: a collaborative approach to deprescribing sedatives and anticholinergics

Abstract

Background: Sedative and anticholinergic medications are associated with an increased risk of falls and decreased function and cognition in older patients. These potentially inappropriate medications (PIMs) warrant consideration of deprescribing where potential harm outweighs expected benefits. Pharmacists are well placed to partner with hospital doctors to help identify sedative or anticholinergic PIMs, formulate deprescribing plans, and communicate deprescribing changes and recommendations across transitions of care.

Objective: To test the feasibility of a partnered deprescribing workflow between pharmacists and doctors to identify, action and communicate deprescribing recommendations to reduce sedative and anticholinergic burden.

Method: A partnered deprescribing workflow trial was commenced on two geriatric rehabilitation wards from April 2024. Pharmacists used a locally-developed electronic Deprescribing Opportunity Identification Tool (DO-IT) to identify sedative or anticholinergic PIMs and document deprescribing recommendations. These recommendations were used by doctors to facilitate deprescribing decision-making during ward rounds. Pharmacists also ensured any changes to preadmission medicines were documented in discharge summaries for the general practitioner (GP).

Evaluation: In the first month of feasibility testing, 37 patients with sedative or anticholinergic medications were admitted, then later discharged home. 25/37 (68%) had DO-IT assessments documented by a pharmacist, and 17/25 (68%) assessed patients had at least one PIM identified. Commonly identified PIMs included oxycodone-naloxone, mirtazapine, and pregabalin. 8/22 (36%) identified PIMs were deprescribed in hospital, and 3 PIMs had recommendations for the GP to deprescribe further. 10 of 12 changes to preadmission PIMs were accurately documented in the discharge summary.

Discussion: A partnered deprescribing workflow between pharmacists and doctors facilitates identification and deprescribing of PIMs in hospital and helps to ensure changes to preadmission medicines are documented in discharge summaries. Further work is required to support the routine use of DO-IT during medication reviews and to encourage documentation of deprescribing recommendations for GPs when in-hospital deprescribing is not feasible.