The results showed that a large proportion of older adults (88%) and caregivers (76%) in the four French-speaking countries were open to deprescribing. In addition, both subgroups had moderate concerns about stopping medications and perceived burden of medications. However, certain barriers remain, as 46% of older adults and 46% of caregivers would be reluctant to stop a medication that has been taken for a long time. Furthermore, older adults (92%) and caregivers (76%) were globally satisfied with the current medications and believed strongly in their appropriateness as highlighted by a high appropriateness factor score, which may constitute an important barrier.
Similar positive attitudes towards deprescribing were reported in other countries. A recent meta-analysis of 40 studies conducted in 17 countries showed that 84% (95%CI 81%-88%) of older adults and 80% (95%CI 74%-86%) of caregivers would be willing to stop a medication if the doctor said it was possible . Another meta-analysis involving 29 studies reported similar results, where 87.6% (95%CI 83.3%-91.4%) of older adults expressed the willingness to discontinue medications; but a smaller proportion of willingness to deprescribe care recipients’ medications was found among caregivers (74.8%; 95%CI 49.8%-93.8%) . In addition to this apparent openness to deprescribing, the moderate concerns about stopping medications and perceived burden of medications reported in both older adults and caregivers in our study, as well as the high involvement in medication management may be conducive to deprescribing. Nevertheless, despite these positive attitudes inclined to deprescribing worldwide, some degree of reluctance concerning the cessation of a medication that has been taken for a long time was also found in past studies where 25% and 52% of older adults and 35–54% of caregivers were reluctant to the withdrawal of a medication taken for a long time . Likewise, the high belief in appropriateness of medications in our study, a potential obstacle to deprescribing, was also observed elsewhere, with a significant proportion of participants (older adults and caregivers) who reported a high level of satisfaction with current medications (range: 67–93% for older adults and 79–86% for caregivers) [23, 24]. Of note, higher scores were found in caregivers for the perceived burden of medications and the concerns about stopping medications; this is in line with prior studies .
In our study, the willingness to have a medication deprescribed was significantly associated with two factors: a higher value for the involvement factor for both older adults and caregivers, as well as a low value for the concern about stopping factor, only for older adults. These results were also found in a cross-sectional study conducted in Croatia . Indeed, participants who want to be involved in discussions regarding medication management and who have fewer concerns about drug discontinuation, are probably more likely to be open to deprescribing. In addition, our analyses showed that older adults and caregivers with high belief in the appropriateness of medications were more likely satisfied with medications. In light of these results, targeting the individuals with a high level of involvement in medication management, high concerns about stopping medications and a high degree of belief in the appropriateness of medications may be an optimal way to tackle the barriers of deprescribing, and focus on the levers.
Among patients’ characteristics, older adults living in Switzerland had greater odds of being willing to have a medication deprescribed than those living in Canada. This result may be related to the inclusion of older adults in Switzerland only in institutions (see the Methods section). Indeed, this finding is not surprising given that institutionalized older adults may express general indifference about medications they are taking due to their lack of involvement in the decision-making process and their great trust in healthcare professionals’ decisions regarding medication management [35, 36]. In our study, no significant associations were found with age, number of medications or the level of education. This is consistent with previous research where the willingness to have a medication deprescribed was irrespective of the socio-demographic characteristics of participants and the socioeconomic status of the study country .
Despite their openness to deprescribing when recommended by the physician, older adults and caregivers expressed strong belief in the appropriateness of their medications and their satisfaction. These contradictory beliefs were also observed in past studies . These paradoxical statements illustrate perhaps the influence of a strong professional-patient relationship. Older adults, and more so caregivers, trust the recommendations of prescribers . Deprescribing may be more accepted if the recommendations come from the physician they trust , and this trusting may facilitate the alignment of the deprescribing process with values, goals and preferences of patients; these elements are essential for the implementation of successful deprescribing interventions . In addition, the high involvement factor scores express that older adults and caregivers especially are interested in being involved in medication management. Thus, there is a strong opportunity for healthcare professionals to engage in a collaborative partnership with older patients and families to optimize medication regimen, reduce polypharmacy and deprescribe when it is appropriate.
Interestingly, the moderate burden factor scores indicate that older adults and caregivers did not perceive an important medication-related burden. However, patients may minimize the burden because they view their medication regimen as a necessity, an opinion that was expressed by certain older adults during the recruitment process and outlined in a previous review . This desire to take less medication despite satisfaction and the certain degree of reluctance to stop a medicine that has been taken for a long time in our study, may suggest that some barriers remain to be addressed in order to fully implement successful deprescribing interventions. Reeve et al., suggests that the discussion should not be focusing only on deprescribing but also on medications in general . A study showed that a minority of older adults in Canada were aware of the term “deprescribing”, and suggested that informing patients about the potential harms of medications and using the term “deprescribing” could increase awareness . This lack of awareness was apparent during our recruitment process when individuals appeared uneasy upon hearing the term “deprescribing”. Therefore, further educational interventions from health care providers should be encouraged as outlined in the D-PRESCRIBE trial . Indeed, engaging older adults in the shared decision-making process may lead to the discontinuation of long-term medications .
It should be noted that this widespread willingness towards deprescribing should be put in relation with the effective initiation of a deprescribing conversation in real-life clinical practice, due to the low predictive ability of the rPATD [23, 24, 44]. In this sense, future research is needed into how to optimize the translation of deprescribing in practice, notably identifying factors that influence the initiation of a deprescribing conversation and how tools may be more efficiently used by healthcare professionals to communicate and engage deprescribing in a shared decision-making process.
Strengths and limitations
Thanks to the multicentric design, we were able to recruit a large sample size of participants through different facilities and organizations in four countries allowing for high external validity among French-speaking older adults and caregivers in different contexts. However, there are some limitations in the present study. Older adults and caregivers who have a particular interest in being involved in medication-related decisions may have been more inclined to respond to the questionnaire, leading to a possible volunteer bias. In addition, though the questionnaire has been validated, certain statements may have been interpreted differently which would have influenced the responses. For example, in the statement, I would like to try stopping one of my medicines to see how I feel without it, the person making the decision to stop the medication, the doctor versus the patient themselves, is open to interpretation. We used a conservative definition of deprescribing, considering only withdrawal, but not reduction of the dose, which might also be clinically relevant, especially for patients with the most severe polypharmacy. Finally, a social desirability bias may have occurred particularly in the cases where older adults required assistance to complete the questionnaire.