It’s another deprescribing super special on today's GeriPal Podcast, where we delve into the latest research on deprescribing medications prescribed to older adults. Today, we explore four fascinating studies highlighting innovative approaches to reducing medication use and improving patient outcomes.

In our first segment, we discuss a study led by Constance Fung and her team, which investigated the use of a masked tapering method combined with augmented cognitive behavioral therapy for insomnia (CBTI) to help patients discontinue benzodiazepines. The study involved 188 middle-aged and older adults who had been using medications like lorazepam, alprazolam, clonazepam, temazepam, and zolpidem for insomnia. The results were impressive: 73% of participants in the masked tapering plus augmented CBTI group successfully discontinued their medication, compared to 59% in the open taper plus standard CBTI group. This significant difference highlights the potential of targeting placebo effect mechanisms to enhance deprescribing efforts.

Next, we turn to Emily McDonald, the director of the Canadian Medication Appropriateness and Deprescribing Network, to discuss her study on the impact of direct-to-consumer educational brochures on gabapentin deprescribing. Patients received brochures detailing the risks of gabapentinoids, nonpharmacologic alternatives, and a proposed deprescribing regimen (see here for the brochure). Additionally, clinicians participated in monthly educational sessions. The intervention group saw a deprescribing rate of 21.1%, compared to 9.9% in the usual care group. This study underscores the power of patient education in promoting safer medication use.

In our third segment, we explore Amy Linsky’s study that examined the effect of patient-directed educational materials on clinician deprescribing of potentially low-benefit or high-risk medications, such as proton pump inhibitors, high-dose gabapentin, or risky diabetes medications. The intervention involved mailing medication-specific brochures to patients before their primary care appointments (click here for the brochure). The results showed a modest but significant increase in deprescribing rates among the intervention group. This approach demonstrates the potential of simple, low-cost interventions to improve medication safety.

Finally, we discuss Michelle Odden’s study, which used a target trial emulation approach to investigate the effects of deprescribing antihypertensive medications on cognitive function in nursing home residents. The study included 12,644 residents and found that deprescribing was associated with less cognitive decline, particularly among those with dementia4. These findings and the two studies Michelle mentions in the podcast (DANTE and OPTIMIZE) suggest that carefully reducing medication use in older adults may help preserve cognitive function. However, the DANTON study adds more questions to that conclusion.

Join us as we dive deeper into these studies and discuss the implications for clinical practice and patient care. Don’t miss this episode if you’re interested in the latest advancements in deprescribing research!

Many older adults lose decision-making capacity during serious illnesses, and a significant percentage lack family or friends to assist with decisions. These individuals may become “unrepresented,” meaning they lack the capacity to make a specific medical decision, do not have an advance directive for that decision, and do not have a surrogate to help.

In today’s podcast, we talk with Joe Dixon, Timothy Farrell, and Yael Zweig, authors of the AGS position statement on making medical treatment decisions for unrepresented older adults. We define “unrepresented” and address the following questions:

• What is the scope of the unrepresented problem?

• Why not use the older term “unbefriended”?

• How should we care for unrepresented individuals in inpatient and outpatient settings?

• What can we do to prevent someone from becoming unrepresented?

Find answers to these questions and more in this week’s podcast. Listen in, and if you’re interested, explore the topic further with the following resources:

• AGS Position statement on making medical treatment decisions for unrepresented older adults

• VA Policy on Advance Care Planning and on Informed Consent

We’ve talked a lot before about integrating psychiatry into palliative care (see here and here for two examples). Still, we haven’t talked about integrating palliative care into psychiatry or in the care of those with severe mental illness.

On this week’s podcast, we talk with two experts about palliative psychiatry. We invited Dani Chammas, a palliative care physician and psychiatrist at UCSF (and a frequent guest to the GeriPal podcast), as well as Brent Kious, a psychiatrist at the Huntsman Mental Health Institute, focusing on the management of severe persistent mental illnesses.

We discuss the following:

• What is Palliative Psychiatry (and how is it different from Palliative Care Psychiatry)?

• What does it look like to take a palliative approach to severe mental illness?

• Is "terminal" mental illness a thing?

• Is hospice appropriate for people with serious mental illness (and does hospice have the skills to meet their needs?)

• Controversy over Medical Aid in Dying for primary psychiatric illness (and for those with serious medical illness who have a comorbid psychiatric illness)

• The level of provider moral distress that can be created in a system not designed to meet the needs of specific populations... and when we are asked to meet a need we don't feel equipped to meet.

Here are a couple of articles if you want to do a deeper dive:

• Dani and colleagues article on “Psychiatry and Palliative Care: Growing the Interface Through Education.”

• Dani and colleagues article on “Palliative Care Psychiatry: Building Synergy Across the Spectrum.”

• Brent’s article on “Physician Aid-in-Dying and Suicide Prevention in Psychiatry: A Moral Crisis?”

• A NY Times article titled “Should Patients Be Allowed to Die From Anorexia?”