AusTAPER Dem: Team Approach to Polypharmacy Evaluation and Reduction for General Practice patients with dementia: the Australian TAPER Dem study

Intervention (MATCH-D using TAPER App) TAPER is a web-based application (available at eg https://meds.tapermd.org) which can be used as a generic tool for a collaborative medication review between patient, GP and community pharmacist. Intervention: At an initial consultation with the study pharmacist, data will be entered on the participant’s medications, dosages and indications; any reported side effects; the participant’s priorities and preferences for treatment; and medication-related data such as blood pressure and creatinine (if known). Using the medication history, participant’s preferences for care and perceived medical problems, the TAPER App tool performs a ‘machine screen’ comprising ‘machine screen’ comprising i) interaction checker; and ii) listing of potentially inappropriate medicines (including the Screening Tool of Older Person's potentially inappropriate Prescriptions; the Beers List; anticholinergic & serotonergic burden, and QT prolonging drugs). This screen is also linked to existing evidence based tools providing Numbers Needed to Treat/Harm, and decision aids for deprescribing where available, and tapering guidelines. The focus is on maintaining essential drugs while supporting reduction in medicines known to be associated with adverse reactions causing emergency presentation and/ or unplanned admission to hospital, and those in which risk frequently outweighs benefit (eg anticholinergics, sedatives, opiates, proton pump inhibitors). Decisions will be informed by the individual participant’s priorities, including functional and symptom treatment goals. A preliminary plan is produced by TAPER, based on information collected at baseline, and after this initial consultation between the study pharmacist and participant. This plan is then further refined after a consultation between the GP and participant. In this step, the GP may use the TAPER tool to enter new information or modify information already in TAPER. A prioritised medication plan is created at this stage. The emphasis is on ‘pausing and monitoring’ medications with planned follow-up and agreed criteria for restarting medications if necessary. The TAPER medication withdrawal plan is then used to record the planned monitoring parameters and track progress during subsequent follow-up consultations, as a seamless clinical and decision support pathway. Steps in TAPER comprise: 1. Study pharmacist consultation The PWD (and their advocate/ carer) will be engaged in a medication-focused interview with a study pharmacist. This will usually be conducted at the person’s home as this is where people feel most comfortable and the most accurate medication histories are undertaken. If the participant wishes to have a support person present, a relative/person responsible/carer or advocate can be present at this interview. Information will be collected about medications taken, indications for medications and other mediation-related information if available (such as blood pressure creatinine, falls history), prioritised functional and symptom goals for medical treatment, overall preferences for care (using a tool covering 4 domains developed from our systematic review and patient focus group feasibility work), perceived medicine problems or side effects. The medication data and this information will be entered into the TAPER app. Through application of automated filters within the TAPER App., potentially inappropriate medications, medication interactions and warnings will be identified and flag medications which are candidates for discontinuation or dose reduction. The study pharmacist will then carry out a comprehensive medication review focused on medications suitable for discontinuation or dose reduction informed by this list, reported medication-related adverse effects from the participant, and reviewing the participant’s goals for treatment. The study pharmacist will make recommendations based on this review and add these to the TAPER clinical pathway. This information, including all the supporting information and the machine screen dashboard data will be available to the clinic GP for review at their consultation, and will also be cut and pasted into the community pharmacist’s record, to avoid double data entry (TAPER Snapshot). The TAPER Snapshot format is structured to allow for integration into any clinical records software package. 2. GP consultation: Approximately one week (and less than or equal to 2 weeks) after the study pharmacist/participant meeting, the participant will have an extended face-to-face appointment with their GP to discuss medications that may be suitable for a ‘pause and monitor’ trial of discontinuation or dose reduction (the MATCH-D TAPER plan). The GP will have available the pharmacist generated accurate medicine list with flagged recommendations, and evidence and tools to support deprescribing linked to the TAPER App. The GP may modify or add information to the tool if necessary. S/he will discuss the participant’s priorities and preferences for care, and these will inform a prioritised plan for appropriate discontinuations and a template for monitoring frequency, duration and criteria for medicine recommencement. If medications have been prescribed by a specialist, the GP/study pharmacist will follow the their usual clinical process for seeking specialist advice if appropriate. This approach addresses key barriers to deprescribing, such as fears of a return of the original condition and withdrawal effects. Patients report barriers are addressed by knowing about the withdrawal process and understanding they can restart the medication if needed. The participant and their regular dispensing community pharmacy (or pharmacies) will be provided with a copy of the agreed discontinuation and monitoring plan, if changes are recommended. The GP will write scripts for the agreed targets in line with the reduction/cessation plan agreed with the study pharmacist. These scripts will be dispensed as usual by the participant’s regular dispensing community pharmacy/ies. Once a medication is ceased, the GP will no longer need to write a PBS script. • Monitoring Follow-up appointments will be made as clinically indicated by monitoring and follow-up needs of individual participants. It is anticipated these will occur 2 weeks after any new medication changes. If there are no changes being made to a person's medications, then the timing of monitoring visits will be determined by the GP and participant. At each monitoring visit, participants will have a brief GP consultation to review progress with the MATCH-D TAPER plan, and address any concerns (such as perceived Adverse Drug Withdrawal Events) as clinically appropriate.