Deprescribing in frail older people: a randomised controlled trial

Withdrawal of multiple medications according to a structured deprescribing protocol. We will record a detailed medical history and conduct a clinical examination of each participant. We will record the generic name, indication, dosage, and frequency of all medications taken by the participant, including all prescribed and over-the-counter medications and any herbal or mineral supplements. We will determine the indication for each medication by discussion with the participant, the participant’s doctor, and, if necessary, by accessing the participant’s medical records. Two investigators will independently review the medication lists and indications and identify target drugs for withdrawal in each participant. Target drugs will be identified using previously published lists of medications considered potentially inappropriate in older people. The list of medications considered for withdrawal will include, but not necessarily be limited to, benzodiazepines, antipsychotics, tricyclic antidepressants, long-acting sulphonylureas, non-steroidal anti-inflammatory drugs, antispasmodics, anticholinergic antihistamines, short-acting calcium channel blockers, stimulant laxatives, muscle relaxants, dipyridamole, nitrofurantoin, ditropan, amiodarone, antihypertensives, statins, potassium supplements, mineral supplements, vitamins, opioid analgesics, inhaled and oral corticosteroids, diuretics, antiemetics, oral and topical oestrogens, digoxin, nitrates, antacids, antireflux medications, iron supplements, herbal remedies, cough suppressants, and nasal decongestants. Each potentially inappropriate medication will be checked against four criteria and if any of the criteria are met in a participant, the medication will be targeted for withdrawal in that participant. The criteria are as follows: 1. Inappropriate prescription (no indication for drug OR clear contraindication) 2. Adverse effects (adverse effects or interactions outweigh any symptomatic benefit OR any future potential benefit) 3. Drug taken for symptom relief AND symptoms stable or absent (determined by reference to a table of pre-defined criteria for assessing symptom stability) 4. Drug taken to prevent future serious events AND patient is experiencing serious adverse effects OR potential future benefit unlikely to be realised due to limited life expectancy. Both investigators will independently determine the order of drug withdrawal. Drugs least likely to cause an adverse drug withdrawal event (ADWE) will be ceased before drugs most likely to cause an ADWE. The investigators will resolve by consensus any differences in the target drugs and withdrawal order. Dose reductions will be made at two weekly intervals by the investigator or the participant's usual treating doctor. Participants will be monitored twice weekly for adverse drug withdrawal effects. If no adverse effects or symptom recurrence are noted, dose reduction and target drug cessation will continue until all target drugs are ceased.