Barriers to Optimising Prescribing and Deprescribing in Older Adults with Dementia: A Narrative Review
J. Simon Bell,
Sarah N. Hilmer.
Older adults with dementia commonly have multiple chronic conditions that prompt
clinicians to prescribe medications. While dementia is a life-limiting disease, progression from mild
cognitive impairment to end stage dementia is a process that can occur over many years and may
not take a predetermined course. Therefore aligning pharmacological treatment with changing goals of care can be
challenging. The aim of this narrative review was to explore barriers to optimising prescribing and deprescribing
(withdrawing) of medications as the goal of care shifts from prolonging life to optimising quality of life. Optimising
pharmacological treatment to help people with dementia achieve their goals of care often requires deprescribing of
medications that are inappropriate, as well as initiating appropriate medications. Medical practitioner, system, patient and
carer related barriers to optimisation of medications in older adults with multiple morbidities have been identified
including: inadequate guidelines, incomplete medical histories, lack of time, avoidance of negative consequences, established
beliefs in the benefits and harms of medication use and others. Optimising prescribing for older people with dementia is
further complicated by diminished decision making capacity, difficulties with comprehension and communication,
increasing involvement of carers and difficulties establishing goals of care. Further research is required into the attitudes,
beliefs and preferences of people with dementia and their carers regarding prescribing and deprescribing.
Keywords: Cognitive impairment, dementia, deprescribing, goals of care, older adults, quality use of medications, prescribing.
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