338 CHAPTER 4.2 Discussion In this study we evaluated older patients’ and their attending hospital physicians’ agreement/disagreement with individualised STOPP/START criteria-based medication optimisation recommendations from a pharmacotherapy team. Overall agreement was 61.6% for STOPP recommendations and 60.7% for START recommendations, after discussion of 371 recommendations with 139 patients and their attending physicians. The most frequently discussed recommendation was ‘no evidence-based clinical indication’ (STOPP A1;33.7% of all recommendations). Highest agreement was found for initiation of osteoporosis agents and discontinuation of drugs for acid related disorders (both 74%). Few studies have explored patients’ or physicians’ agreement with in-hospital pharmacotherapy optimisation recommendations. In a non-randomised study among older patients admitted to a specialist geriatric unit, physicians’ agreements with STOPP recommendations, including benzodiazepines, was 87% compared to 62% in our study, presumably explained by the lack of patient involvement in decision making in contrast to our study [21]. Reasons for disagreement with STOPP/START recommendations in that study were predominantly ‘therapeutic prioritisation’ (STOPP) and ‘severe mental or physical disability’ (START). Differences may be explained by a different study population (mean age 88.5, high prevalence of severe dementia (32%) and high prevalence of severe ADL deficiencies (50%)) compared to our study [21]. In the present study, reasons for disagreement varied between medication groups. Disagreement with stopping of benzodiazepines and Z-drugs was, in 90.9% of instances, due to reluctance to discontinue by the patient (e.g. self-reported dependence, lack of side effects). Low perceived necessity to discontinue medication, as with benzodiazepines in our study, acted as a barrier to agreement with in-hospital medication changes in a qualitative study among older polypharmacy patients [22]. Conversely, the majority of these patients reported acceptance of the hospitalinitiated medication changes with high perceived importance (e.g. usual treatment ineffective or causing side-effects). This could explain our findings that initiation of osteoporosis drugs in patients who experienced a fall in the previous year had significantly higher agreement than in patients with no falls (94.6% versus 51.5%). Research shows that many patients expressed the wish to reduce their daily number of medications [22]. However, patients’ willingness to deprescribe specific medications, like benzodiazepines/Z-drugs, was considerably lower in our study than the hypothetical willingness to discontinue medication reported by other researchers (around 90%), investigating patients’ attitudes, beliefs and willingness related to medication deprescribing through questionnaires [12,23]. This might partly
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