VA Healthcare-VISN 4
SAGE QUERI Medications -- EMPOWER
“Medication: If medication is necessary, use Age-Friendly medication that does not interfere with what Matters to the older adult, their mobility or mentation across setting of care.” – IHI Age-Friendly Health System
“Eliminating Medications through Patient OWnership of End Results” (EMPOWER) addresses the Medication component of the Aging-Friendly Health System framework in parallel to Mobility, Mentation, and What Matters. This intervention employs a direct-to veteran brochure meant to educate on potentially inappropriate medications, and empower veterans to make changes aligned with their goals. In collaboration with academic detailers, this intervention takes a wrap around approach to de-implementing medications that pose high-risk for cognition and falls.
Older adults can experience falls, fractures, overdoses, and other harms from medications that affect their Mentation. All of these lead to substantially higher health care utilization and worse patient outcomes.
More than 1 in 10 older Veterans are prescribed high-risk medication(s) by the VA: 1 in 5 is prescribed a high-risk combination of an opioid and a benzodiazepine, and up to 1 in 3 is prescribed an anticholinergic medication known to affect sensorium. In VISN 4, prescription rates for high-risk medications vary up to three-fold across VAMCs.
EMPOWER is a direct-to-patient intervention that employs a mailed brochure to older adults receiving high-risk medications on a chronic basis.
Informed by behavior change theory, the 8-page personalized mailed brochure includes:
- A self-assessment about the risks of the targeted high-risk medication
- Presentation of evidence of harms
- Statements designed to create cognitive dissonance about the safety of the high-risk medication
- Education about dangerous drug-drug interactions
- Peer champion stories of older adults who have successfully switched to safer non-drug alternatives
- Suggestions of safer and effective alternatives
- Stepwise tapering recommendations to discuss with their prescriber.
In two randomized controlled trials (RCTs) including 100 community pharmacies and 800 older adults, researchers found for every 3 brochures distributed, one patient eliminated high-risk medication use for 6 months. This intervention has also been piloted in the VA among older Veterans and showed significant reductions in benzodiazepine use as well. When paired with academic detailing, reductions in use of high-risk medications improves further.
EMPOWER direct-to-consumer booklets have been developed for sedative-hypnotics, anticholinergics, diabetes medications, proton pump inhibitors, opiates, NSAIDs, and gabapentin.
FIND OUT MORE ABOUT EMPOWER
Resource for deprescribing approaches and research:
Additional links to the Evidence:
“Reduction of Inappropriate Benzodiazepine Prescriptions Among Older Adults Through Direct Patient Education”
Tannenbaum, C., Martin, P., Tamblyn, R., Benedetti, A., & Ahmed, S. (2014). Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA internal medicine, 174(6), 890–898. https://doi.org/10.1001/jamainternmed.2014.949
“Academic Detailing to Reduce Sedative-Hypnotic Prescribing in Older Veterans”
Ragan, A. P., Aikens, G. B., Bounthavong, M., Brittain, K., & Mirk, A. (2021). Academic Detailing to Reduce Sedative-Hypnotic Prescribing in Older Veterans. Journal of Pharmacy Practice, 34(2), 287–294. https://doi.org/10.1177/0897190019870949