Understanding the Landscape of Deprescribing Research
Deprescribing, the process of reducing or stopping medications that may be unnecessary or harmful, is a critical area of focus in modern geriatric medicine. Given the high rates of polypharmacy (taking multiple medications) among older adults, clinical trials focused on deprescribing are vital for improving safety and quality of life. However, these trials face significant recruitment challenges. A study evaluating the reasons older adults decline participation in two deprescribing clinical trials, Shed-MEDS and VA DROP, offers unique insights into these barriers, revealing consistent themes across a large cohort of hospitalized patients.
The Three Core Reasons for Declining Participation
According to the study published in Trials, researchers identified three overarching themes from the 1,226 eligible patients who declined enrollment [1.2, 2.2]:
1. Feeling Overwhelmed by Current Health Status
Many older adults were acutely ill during hospitalization when approached for the study, making trial participation feel like an added burden [1.3, 2.3]. Subthemes included the cognitive load of medical decisions, decision-making fatigue requiring more time, and inconvenient timing during a stressful hospital stay [1.3, 2.3]. Non-Veterans were more likely to cite feeling overwhelmed than Veterans [1.3, 2.3].
2. Lack of Interest or Mistrust of Research
This theme encompassed varied attitudes towards clinical trials and healthcare, being more prevalent in Veterans [1.4, 2.4]. Subthemes included simple disinterest, general mistrust of the healthcare system or research, and reluctance with consent paperwork [1.4, 2.4]. This highlights the need to build trust and effectively communicate trial benefits to older populations [1.4, 2.4].
3. Hesitancy to Participate in a Deprescribing Study
Hesitancy specifically regarding deprescribing was a key finding, suggesting potential enrollment bias [1.5, 2.5]. Concerns included comfort with the current regimen, belief that only their personal doctor should change medications, and negative past experiences with medication changes [1.5, 2.5]. This reveals patient attitudes toward medication changes as a significant barrier [1.5, 2.5].
Comparison of Reasons: Veterans vs. Non-Veterans
| Reason for Declining | Proportion of Non-Veterans | Proportion of Veterans | Insight |
|---|---|---|---|
| Feeling Overwhelmed | 54% | 35% | Non-Veterans were more affected by their current acute health status and the stress of hospitalization [1.6, 2.6]. |
| Lack of Interest/Mistrust | 26% | 42% | Veterans showed a greater degree of mistrust in research, possibly stemming from past experiences [1.6, 2.6]. |
| Hesitancy towards Deprescribing | 23% | 21% | This reason was comparable across both groups, highlighting a shared apprehension [1.6, 2.6]. |
The differences between cohorts emphasize tailoring recruitment strategies to a population's background and concerns [1.6, 2.6].
Moving Forward: Informing Better Research Strategies
To increase older adult representation in clinical research, future deprescribing studies should address identified barriers [1.7, 2.7]. Strategies could include earlier engagement outside acute settings, building trust through community engagement or using patients' own care teams, patient-centered communication on polypharmacy risks and deprescribing benefits, and flexible protocol design [1.7, 2.7]. Understanding these reasons helps create more inclusive, effective clinical trials [1.7, 2.7].
For more detailed information on polypharmacy and deprescribing, you can read the National Institutes of Health's overview of deprescribing to reduce medication harms in older adults, available here.
Conclusion
The analysis of the Shed-MEDS and VA DROP trials reveals key reasons for older adults and surrogates declining research participation: feeling overwhelmed, mistrust of research, and hesitancy toward the intervention [1.8, 2.8]. These findings highlight the need for a more patient-centered approach in research design, recruitment, and communication to improve engagement and the generalizability of clinical evidence for this population [1.8, 2.8].
