Strategies to Enhance Deprescribing in Long-Term Care Facilities

A new article published in the journal of Exploratory Research in Clinical and Social Pharmacy offers a framework for developing and implementing sustainable deprescribing practices in long-term care facilities (LTCs). Although the study is not specific to psychotropic drug use and polypharmacy in psychiatry, Canadian researchers Lisa M. McCarthy, Barbara Farrell, Pam Howell, and Tammie Quast identified the necessary components, desired behaviors, and supporting actions, of an environment conducive to medication management.

“Many interrelated factors influence deprescribing across care settings with barriers at person, provider, and health system levels. Examples noted in studies of LTC settings include resident and their families’ lack of awareness about indication, potential harms of continuing medication, and deprescribing as an option; prescriber reluctance to change medication therapy; few opportunities or time for collaboration amongst staff, pharmacists, and prescribers; and lack of comprehensive information systems that provide resident health histories. To improve medication experiences for all people living in LTC, a widescale cultural shift is needed,” the researchers write.

Polypharmacy and prolonged use of psychotropic medications have dire and well documented consequences. While the barriers to deprescribing remain abundant, the benefits of tapering and halting psychotropic medications also have documented benefits and are an important role of the care team.

In the current study, in Ontario, Canada from 2018 to 2020, the authors researched for-profit, non-profit, and public LTCs with the intention of understanding the needs of stakeholders to meaningfully begin conversations and dissemination of information concerning deprescribing.

At the beginning of the project, McCarthy and colleagues conducted an environmental scan to build relationships with stakeholders and to better understand the current state of deprescribing across the province. From this scan, a list of key stakeholders influencing the culture of deprescribing was created and informed the two forums that followed.

The first forum, in June of 2019, identified behaviors that needed to change within LTCs to encourage an environment of deprescribing. Participants were chosen for their ability to represent one or more perspectives that influence deprescribing practices in LTCs, such as people living in LTCs and their loved ones, as well as care providers, advocates, and policymakers.

While Forum One identified the behaviors needed to change within LTCs, Forum Two, conducted in January of 2020, was facilitated to create what the authors call “champion-driven implementation plans” or “implementation charters” to support the operationalization and enactment of the behaviors identified in the first. After the second forum, the authors requested that participants respond to Likert-scale feedback concerning their interest in the implementation of deprescribing practices.

After the second forum the authors were able to identify four target behaviors and 14 supporting actions that must be present to foster an environment of deprescribing, as seen in the chart below (the four target behaviors are found in the inner circle and the supporting actions outside the circle). 

The researchers found that:

• People in LTCs, as well as their families/caregivers, should be given full informed consent and allowed to participate in shared decision-making. This means that they should be informed of the risks and benefits of the drugs on offer, as well as other alternatives.
• Everyone on the health care team needs to take part in the conversations about deprescribing.
• All clinical personnel need to be alert for health problems that could be due to medication changes or polypharmacy.
• Prescribing clinicians need to carefully document why each drug is being used, as well as for how long it should be used.

Of their research, the authors write, “Relationship building and attempts to understand local, relevant context were important. Together with stakeholders, we articulated four target behaviours to facilitate deprescribing and 14 evidence-based supporting actions, five of which were prioritized for continued implementation planning.”

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McCarthy, L. M., Farrell, B., Howell, P., & Quast, T. (2022). Supporting deprescribing in long-term care: An approach using stakeholder engagement, behavioural science and implementation planning. Exploratory Research in Clinical and Social Pharmacy, 7,     100168. doi: 10.1016/j.rcsop.2022.100168 (Full text)