Symptom Management Most Important Barrier to Deprescribe Dementia Medications

Physicians who practice patient-centered care may consider deprescribing medications for older adults with dementia when faced with barriers related to beneficence, maleficence, and autonomy. These are the findings of a national survey study published in JAMA Geriatrics.

Between January and December 31, 2021, an academic research team mailed a 24-question survey to 3000 US-based physicians, located via the American Medical Association Physician Masterfile. From these, they collected 689 surveys with sufficient data. The survey questions concerned a hypothetical patient, an older adult with moderate dementia, for whom the respondent might wish to deprescribe a medication. The physicians received, at random, 1 of 2 versions of the survey, differing by rationale for deprescribing. In 1 version, the stated reason was elevated risk for serious adverse drug reaction; in the other version, the reason was lack of evidence of benefit from the drug.

Questions were structured by the best-worst scaling method. Respondents ranked, from most to least important, 9 potential perceived barriers to deprescribing, such as lack of visit time to fully discuss deprescribing, or concern about creating a perception of “giving up” on the patient. Each perceivable barrier, or factor, reflected at least 1 medical ethical principle, ie, justice, autonomy, nonmaleficence, or beneficence.

Physician respondent characteristics included:

• 57% men;
• 93% practiced either internal or family medicine;
• 65% had been in practice for more than 15 years, and 10% for 5 years or less;
• 80% spent the majority of their time providing outpatient care; and
• 23% reported having previously deprescribed a drug for a patient who then had a related adverse event.

Among the 9 perceivable barriers to deprescribing, respondents most frequently ranked the factor “Patient/family reports symptomatic benefit from medication” as being the most important barrier. This was true for both versions of the survey, and reflected the principles of beneficence and autonomy. The barrier, “Medication prescribed by another physician” (ie, autonomy and non-maleficence), received the second highest relative preference ranking. “Ease of [a patient’s] paying for the medication” was most often rated the least important barrier, in both scenarios (the justice principle).

In this regard, the researchers suggested, “Physicians may want to assess their patients’ out-of-pocket costs for their medications before starting a deprescribing conversation so that they can achieve better goal-aligned and person-centered care.”

The researchers noted potential limitations linked to collecting data during the COVID-19 pandemic. This could have introduced bias in characteristics of physicians responding to the survey, and could have colored the physicians’ perspectives on caring for patients with dementias during that period.

They concluded, “Our study highlights that addressing patient preferences (ie, considering autonomy) will be a key factor in the development of deprescribing resources and guidelines … While our study focuses on older adults living with moderate dementia and on deprescribing medications in general, taken together, these findings further support the need for deprescribing guidance for physicians underpinned by ethical principles to support complex decision-making.”

Disclosures: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.