Lessons learned in intervention design with cognitively impaired populations – The optimize deprescribing intervention

Abstract

Polypharmacy is common in older adults with cognitive impairment and multiple other chronic conditions. Risks of adverse drug events, hospitalization and death are increased by polypharmacy and it leads to higher health care costs. Deprescribing, the process of reducing or stopping potentially inappropriate medications may improve outcomes for those older adults with cognitive impairment and multiple chronic conditions. The OPTIMIZE trial examined whether a primary care-based, patient- and family-centered intervention educating and activating patients, family members, and clinicians about deprescribing reduced numbers of chronic medications and potentially inappropriate medications for older adults with dementia or mild cognitive impairment and multiple chronic conditions. We explored the mechanisms of intervention effectiveness through post hoc qualitative interviews and surveys with 15 patients, 7 family caregivers, and 28 clinicians. The intervention was deemed acceptable by all stakeholder groups. Success of the intervention was affected by contextual factors including patient’s cognition and prognosis as well as patient and provider openness to and knowledge of deprescribing. Positive outcomes included patients and care partners scheduling specific appointments to discuss deprescribing and providers remembering to consider deprescribing in cognitively impaired older adults. Recollection of intervention materials by both patients and providers was inconsistent over time but highest shortly after intervention delivery. The time required to mail intervention materials to patients prior to a scheduled appointment limited the reach of the intervention by excluding persons with rapidly scheduled appointments. Our work identifies key learnings in intervention roll out which can guide future scaling of our intervention and other pragmatic intervention studies in this vulnerable population.