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Medications Safety/Quality Update: Podcast with Nagham Ailabouni

On the one hand, every year we are fortunate to have new medications that help older adults and people living with serious illness.  New treatments for lung cancer with remarkable survival outcomes come to mind, for example.  

On the other hand, the tremendous growth in medications has led to an explosion of prescribing, polypharmacy, with attendant side effects and harms.  

In this week's podcast, we talk with Nagham Ailabouni, a pharmacist and researcher joining us from Australia (song choice: Down Under!) about her review of major articles on medication safety and quality for older adults.  Dr. Ailabouni summarized the top four hardest hitting in a recent publication in the Journal of the American Geriatrics Society, or JAGS.  The four articles are:

  1. Older Medicare Beneficiaries Frequently Continue Medications with Limited Benefit Following Hospice Admission

  2. Prescribing of oral anticoagulants in the emergency department and subsequent long-term use by older adults with atrial fibrillation

  3. Effect of an Electronic Medication Reconciliation Intervention on Adverse Drug Events: A Cluster Randomized Trial

  4. Intensification of older adults' outpatient blood pressure treatment at hospital discharge: national retrospective cohort study

Dr. Ailabouni’s pet peeve medication she sees prescribed to hospice patients?  High dose metformin.  Listen to the podcast for more!



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Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: Today, we are welcoming from the other side of the world and the other hemisphere Nagham Ailabouni who is a Doctor of Clinical Pharmacy and is a Postdoctoral Fellow in Quality of Medications and Pharmacy Research Center at the University of Southern Australia. Welcome to the GeriPal podcast, Nagham.

Nagham: Thank you very much.

Eric: And I am always excited to have a pharmacist on our podcast.

Alex: Right. We we've had Lynn Macpherson, we've had a few and we've had David Currow who is also from Southern Australia. But rarely do we have guests from so far away.

Eric: So big thanks for joining us. We're going to be talking about your recent Jags publication, Medication Use, Quality and Safety in Older Adults, 2019 update, where you talk about four really big articles that came out around medication use and safety. But before we do that, we always ask for a song request. Do you have a song request for Alex?

Nagham: Yeah, it would be great if Alex could play Down Under by Men at Work.

Alex: And why this song? It's maybe obvious.

Nagham: Yeah. Since I'm in Australia. Yeah.

Alex: Right, right. You're down under.

Alex: (singing)

Eric: Nice.

Nagham: That's so good.

Eric: I heard it was also a big day in Australia, you have a new or updated national Anthem, is that right?

Nagham: Yeah, so it seems so it's just in time for Australia Day, which is at the end of the month so that's exciting.

Eric: Wait, what's Australia day?

Nagham: It's on the 26th of January and people usually they go out and they celebrate Australia and everything that's in it and yeah it's people so it's a good day. People are very happy because it's right after the holiday season and everything so.

Eric: Nice. And how are things right now with COVID. Australia and New Zealand feels like they've been doing good things.

Nagham: Right. We're very lucky. We're very lucky, especially in the state in South Australia, we've managed to keep things really under control so can't really complain too much. There are still some restrictions here and there and some of the States are closed off in terms of borders to each other and I'm at Kiwi and I couldn't travel back to New Zealand to see family, but it is what it is and we're very lucky in comparison so yeah. How about you guys?

Eric: Oh, I think it's right now, what day is it today, Alex? I keep on forgetting the day. January 4th for our listeners and we're both in California, but there's a big difference between Northern California and Southern California. Southern California is being hit pretty, pretty, amazingly hard.

Alex: Yeah, Pretty bad.

Eric: And Northern California is just not feeling that same level of surge. I think a lot of has to do with you walk around the city and you see people wearing masks, simple things. But we're not here to talk about COVID, we're here to talk about medications and medication safety. Would you mind just before we talk about the paper in the articles, how did you get interested in this subject?

Nagham: So I'm a pharmacist by background. And when I was practicing as a pharmacist, I usually cared for older adults, some that had dementia and some that didn't but I noticed the overwhelmingly large number of medications that they were prescribed, and that's sort of how I got interested in this topic of rural and then I pursued my PhD at the university of Otago in Dunedin and in Southern Island, New Zealand. And that was around deep prescribing and older and New Zealand is. And then since then I completed a research and teaching fellowship that's specialized and focused on geriatric pharmacy at the university of Washington at the applying center for geriatric pharmacy and this review really was part of one of the projects that I led during that time and its aim was really to succinctly highlight pertinent topics that related to promoting the safe use of medications in older adults and promoting awareness about how do we best optimize medications and remove medications that might potentially have more harm than possible benefit.

Alex: Mm-hmm (affirmative). So this reminds me of something that Eric and Ken lead at the American geriatric society every year and I provide musical comedy for which is a review of articles from the past year that are sort of high hitting. In your case, it's really focused on medication safety and quality and deep prescribing. I don't know that our listeners are going to be super interested in the methods and how you surveyed the literature and all that. So maybe we'll just skip over that.

Nagham: Okay.

Eric: That sounds great [laughter]

Nagham: It's a lot of work but that's usually what happens.

Alex: Should we talk about the first one here?

Eric: Yeah, let's talk about the first one. So the first one was titled the article itself, all their Medicare beneficiaries frequent continued... Wait, that wasn't the article summary. That was the article summary. What article was the first one, again, I'm trying to look down at the...

Nagham: So that was Older Medicare Beneficiaries Frequently Continued Medications with Limited Benefit following Hospice Admission by Zeuger et al.

Eric: And was that in JAGS?

Alex: It was in the Journal of General Internal Medicine.

Eric: Journal of General Internal Medicine. Okay.

Nagham: Correct. So I guess the main points about this article is that as people near the end of life, there are certain medications that could have been initiated in the beginning that were of therapeutic benefit, but as goals of care change as diseases progress and prognosis changes, those medications may become unnecessary or they could be of limited benefit. And so what Zeuger Edel did is that they aim to quantify the prescribing of limited benefit medications in patients who had cancer and non-cancer patients as well after hospice admission. And then they try to look into the factors that could predict why these medications are being continued. And so what they found is that most patients, about 78.7% used at least one limited benefit medication before hospice admission and that that remained after hospice admission in about a third of the patients.

Nagham: And those rates were similar between cancer patients and non cancer patients so perhaps that leads us to believe that that wasn't really a factor that underpinned why these medications were being continued. And what we do know is that they found that anti-dementia medications particularly were continued more frequently whilst anti-osteoporotic medications and anti hyper lipidemic medication such as satins where at least continued post admission. And so that's sort of a main finding that was really interesting is that why were anti dementia medications continued after hospice admission, particularly because given the nature of hospice admission and Eric and Alex, you can comment more about that is that the goals of care is more about comfort and rather than prevention for patients who perhaps have a limited life expectancy.

Eric: Yeah, I was actually somewhat... I thought the numbers would be higher than a third, so in some ways I was a little bit reassured that, hey, when people get admitted to hospice, a significant portion of these medications were discontinued, which was reassuring, but then on the other side, a third are still taking at least one of these medications which is kind of worrisome. How did you think about it as a pharmacist?

Nagham: Right. I mean, I think you make an excellent point, Eric, because I think a lot of the times we can be really harsh on prescribers. And what we know from deep prescribing studies in general is that if we have a third of medications being discontinued, that's actually a really high success rate. And so it's actually pretty positive overall, but it matches research that has been found in other parts of the world such as in England, that approximately a third of cholinesterase inhibitors and amantadine are inappropriately initiated or continued for longer than appropriate in about a third of these situations. And particularly here in Australia, we know that even though we have medication reviews being conducted by pharmacists in the residential care setting, as well as in hospice, these medications are still being continued in about a third of patients as well. So yeah, it's a problem that's being found worldwide.

Alex: Right. Worldwide issue. And so, there's no hard and fast number. It's not that the number should be absolutely zero because some of this depends on patient preferences. And some of it depends on exact clinical circumstances, but one third still seems quite high. What do you think it's going to take, what level are the major interventions needed in order to impact deep prescribing in hospice because you can think of all these different levels, the level of the pharmacist, which you're most familiar with. Is it the level of the hospice nurses talking with patients? Is this the level of the supervising doctor in hospice? Is it the level of patient activation around deep prescribing or all of the above? I don't know. What are your thoughts?

Nagham: Yeah. So, I mean, there was a recently published systematic review in the JCP that was focused around the barriers and facilitators to deep prescribing. And that was in the primary healthcare setting, which is different obviously to hospice. But I think that the same barriers and challenges that face the prescribing exist, and as you very nicely highlighted, Alex, it starts with the patient level, their own patient preferences and values, the family, the care givers, and then it goes into the prescriber factors such as inherited prescribing multiple prescribers and then organizational factors such as fragmentation of healthcare a lot of these people, they're quite vulnerable and they have increasing frailty. And frailty is a hot research topic at the moment because how does that actually stratify how we screen for patients and better deliver medication reviews by pharmacists or other clinicians such as nurse practitioners to really target trying to optimize medication medications being used.

Nagham: But I think when it comes to anti dementia medications there's actually been a deep prescribing guideline that's been developed by my supervisor Dr. Emily reef. And that work was an international collaboration between Australia and Sydney and Canada. And these de-prescribing guidelines, actually, what we're working on at the moment is a consult patient decision aid that's focused on trying to get people with dementia and perhaps, especially in the hospice setting, to think about maybe it's time to review and discontinue the anti dementia medications. So I think more dissemination and development of such decision aids that can be a conversation starter with the clinician is going to be really pivotal and might change things as well as we certainly know a lot about the barriers, but we still don't know a lot about what are some of the things that we can use as strategies in clinical practice to really increase the uptake of deep prescribing guidelines and practice. And so that's something that we're working on at the moment.

Eric: So for our clinicians who are listening to this, whether it be nurses or physicians or pharmacists, let's talk about some of these. If we're admitting somebody to hospice what are some medications that may be of limited benefits? We're talking about dementia medications cholinesterase inhibitors and NMD receptor antagonist. I think in general, they may be of limited benefit, but we have really no studies in people with hospice eligibility advanced dementia that they really do anything.

Alex: Dementia is comorbid diagnosis for people with cancer.

Eric: Yeah. So that's a really good place where we can start as far as stopping medication classes, what other medicines are on that list of yours?

Nagham: So I mean, things like stand-ins, we still see a large number of people who are prescribed things like aspirin. And although there is definitely some benefits that's been demonstrated for aspirin being used for secondary prevention, certainly at that point, you might want to be thinking about taking them off that. And there's still the bisphosphonates that have been on, and that's a large group of medications where there's increasing research that this is a good target for deep prescribing certainly if they haven't been reviewed after the three to five year point. So those are some major medication classes that I can think of.

Nagham: Anticoagulants as well that stand out. Proton pump inhibitors, maybe in some patients it could be of benefit and I think something that I highlighted as a limitation is that certainly, we're looking at this from a data set point of view, but there could have been exceptions to the rule where it was actually appropriate to continue the medication. And those reasons might not have been documented so it's really difficult and it does come down to a conversation with the patient and the caring.

Alex: Yeah, it's hard from these secondary data set analysis to know how much of this continuing the amantadine or whatever dementia medication was due to patient factors, caregiver factors, "What? No, I can't stop that." And how much of it was due to the clinician deep prescribing some things but not recommending deep prescribing others.

Nagham: Correct.

Eric: Yeah. I think one of the challenges that, when I was last on service and we were admitting somebody to the hospice I was thinking about anti-hypertensives, so when is it potentially valuable to continue or what's the indication? I know antihypertensive was on the lists of limited benefit medications in this study, but if they were on it for particular ones for heart failure or for angina, or for a recent EMI or a-fib a flutter that was kind of excluded in this study. I think one of the challenges we often face is for a-fib should we continue their Metoprolol or should we discontinue it? Are they on the Metoprolol because they went rapid and they needed it for rate control and were they symptomatic from it? What are your thoughts on anti-hypertensives?

Nagham: I think that you really hit the nail on the head there because anti-hypertensives is one of those things that we don't know if it's there for heart rate control, we don't know if it's there because of postural hypertension. There's lots of different reasons why people... And it's usually a class of medications where you don't get one medication prescribed from what I could see in clinical practice, right? People are often prescribed multiple and that's actually quite interesting because it ties in with the point of the fourth article in this review, which is that often after hospital admission, these medications are intensified. So it's one of those things that I think is very difficult to develop a broad overview things such as, for example, benzodiazepines and sleeping tablets, where we know that they're just terrible and the number needed to harm is so high in comparison to the number needed to treat. And so I think that's definitely one that really has to go back to a conversation and an individual basis rather than an over all top recommendation.

Eric: And as a geriatric pharmacist, you also must have a pet peeve medicine. Do you have a medicine where you see it in somebody who's being admitted to hospice or has a life limiting diagnosis that just jumps out to you?

Nagham: I really think metformin. When you see really high doses of metformin being prescribed three times a day, I'm like, "What are we doing to this patient and why?" But again, I think that you guys can comment more about this because the journey of one hospice patient in comparison to another could be completely different. And the number of months that they could be in there could differ drastically between one patient and other and so perhaps as well, in some circumstances certain clinicians might've actually tried to take that patient off of the and they're the metformin just didn't cope with it.

Nagham: And so it could be appropriate because it could be easier to help manage the patient as well. So I think it's also important that as pharmacists, looking at the medication list that we don't just always jump to conclusions that, "Oh, this medication definitely shouldn't be there And why is it there? And sort of have the benefit of the doubt.

Alex: Yeah, maybe. Or maybe it's that pharmacists should take a more active role and say to clinicians, "Hey, why is it there?" Because metformin, for example, is designed to reduce blood sugar in people with diabetes, oral and hypoglycemic medication. And it takes about 10 years of preventive treatment with tight blood sugar control to receive benefits in terms of reduced microvascular complications like diabetic retinopathy or nephropathy, 10 years. It's very different from the six month prognosis of people in hospice, six months or less. So it doesn't seem to make a lot of sense. On the other hand, you could say, "Well, if I take them off it, then they'll run high. Maybe they'll be symptomatic, maybe that's the reason.

Alex: But usually people run high and don't get too symptomatic. So there is some accounting for individual circumstances, but certainly not high doses three times a day, that'd be a red flag. So you brought up the Anderson article. So I'm going to jump to your article number four in this paper because you already brought it up which is from JAMA-IM. Includes folks who've been on this podcast before, including Mike Steiman, Charlie Ray on clinical outcomes after intensifying anti-hypertensive medication regimes among older adults after hospital discharge. You want to just give us a little brief what they did in this study?

Nagham: Sure. So as I mentioned before, during hospitalization intensification of older adults, antihypertensive medications could occur and this could actually increase the risk of them developing or experiencing adverse clinical outcomes. And so Anderson at all aimed to investigate is this association between the anti-hypertensive regimen intensification at hospital discharge and clinical health outcomes after. And so what they found is that there was a higher risk of readmission amongst patients who received antihypertensive medication intensification, and then that was not actually associated with any improved blood pressure control or reduction in cardiac events within one year. And in fact, it was associated with an increased risk of readmission and serious adverse events within 30 days which is a major finding.

Nagham: And the strength of this study is that it was really one of the first studies to examine clinical outcomes associated with the intensification of antihypertensives at hospital discharge. And it's something that in clinical practice, I've definitely seen it happening, but when you're working in a hospital setting, it's very difficult to kind of see from the followup point of view, what happens to the patient afterwards unless they're high flyers as we call them here down under, and they always come back into hospital and get readmitted. So yeah, I find it really interesting.

Eric: Yeah. I thought this was fascinating too, that this idea of when people get admitted to the hospital mucking around with medications that are supposed to reduce events over many years, just because their blood pressure was slightly high in the hospital. I think it serves as a good warning that if something takes years to develop a bad outcome, maybe the hospital isn't the best place to be moving around those medications unless their blood pressure is 180, 200 systolic.

Alex: I think we did an article about this. Actually, it was Tim Anderson's first study which documented intensification of blood pressure medicines for older adults admitted to the hospital at one of the AGS reviews of the literature. And the song that went with that one was... you remember, Eric? Let it go, right? Just don't do it. You're so used to as an outpatient doctor, it's like the knee jerk reaction, blood pressure higher than guidelines must treat, must treat, must treat must treat, right? And that's what people do, but they're using outpatient guidelines in the inpatient setting. What I like about this article is it suggests that, "Hey, there aren't really benefits here and there are potentially harms that might be, I'm not still not convinced they're completely tied to the medication intensification, but certainly they're in the setting of few benefits and potential for adverse events associated with intensification. This is a practice that should be stopped.

Nagham: Yeah. And I think that really for my research and my PhD, what I've found is that when I would talk to primary healthcare physicians one of the doctors that I very remember clearly saying in his interview was like, "If we could just stop hospital doctors following these crazy guidelines and prescribing all these medications when the patient goes into hospital, then we would be saving them a lot of harm because what ends up happening is that the patients prescribed all this medication, they go back to the GP or primary healthcare provider and then everything stopped again, and then the same thing happens again and again. So it's a bit of a cycle and so I think improving communication at transfer points of healthcare is really the key that I see helping with reducing this phenomenon from happening.

Eric: I got that the third paper I'm going to bring up is kind of the opposite. There's a lot of discussion around stopping medications that may be inappropriate, but thinking also about starting them and is their role for using the emergency room as a place to think about what medications should people be on. So the next paper was oral anticoagulants prescribed in the ed and long-term use, you want to describe that article really briefly?

Nagham: Sure. So under use of medications is definitely another aspect of sub-optimal prescribing and it's just as harmful. And we know that there are criteria such as the star criteria that focus on medications that could have been helpful, but are limited. And so this is a really good paper that highlights that as an example they found that out of the 2000 or so older adults that met the inclusion criteria, 18.9% were given a prescription for an oral anticoagulant in the ED. And then what they found is that a higher percentage of those patients who received a prescription in the ED for an oral anticoagulant and were alive at six months, built a prescription for an oral anticoagulant in comparison to those who did not receive an oral prescription for an oral anticoagulant.

Nagham: So what we found is that 71.8% of the patients received such as an ED prescription had higher chances of continuing that medication that actually reduces the risk of future strokes and heart attacks. And so what this paper is sort of suggests and the authors is that perhaps this idea of ED physicians prescribing bridging therapy so that they just have default short-term anti-coagulants that would bridge the patient until they're discharged and then suggest a follow up with their GP to discontinue that if they no longer need it. This might be an approach.

Alex: Right. So people come into the emergency department with new onset atrial fibrillation. They're more likely to continue on anticoagulants or be prescribed and fill and continue on anticoagulants if they're prescribed in the emergency department than if they're left to the primary care practitioner or general practitioner, as you say, in Australia and Canada and the UK and the rest of the world so emergency providers should be doing this. It seems very reasonable in order to prevent stroke, which has terrible outcome for older adults. I guess you could argue, well, maybe there was something different about those patients who they deferred to the primary care clinician, but it looks like they did a nice job in this terrific data set. They have wonderful data sets in Canada of accounting for those potentially confounding factors.

Nagham: Yeah. And I mean, there's always going to be other confounding factors because that's just the nature of this type of research. But I think overall what it shows is that typically these medications are not being prescribed in the ED and this is an important consideration that it could actually potentially save a lot of grief later on in terms of adverse drug events that could happen later on in readmission so.

Eric: And then how do you think about this article versus the last one. The last one when we were talking about, "Hey, don't muck around with the antihypertensives if they're admitted to the hospital." But maybe let the primary care provider mock around with it. Once they're out of the hospital, once you see what their blood pressure is when they're not getting poked and prodded, when they're not in pain versus this one, or kind of saying, "Hey, we should be using the emergency room. We should be, we should be discharging people on anticoagulants and then let the primary care provider figure out what to do." How do you think about... Are those opposites in your head? Opposite decisions or how are you thinking about it?

Nagham: Yeah, I mean, I think what's interesting is that now as we're promoting awareness about potentially inappropriate medications, that's a real concern, but I think that when there's an indication medications and there is therapeutic benefit that we want to be encouraging people to prescribe them. And certainly in the case of atrial fibrillation or somebody that has had a DVT, I mean, those are definite indications for starting an anticoagulant and those things should be taken into consideration and people shouldn't be wary or scared of doing that because later on, if they can definitely guarantee that the patient's going to have an outpatient follow-up appointment and that's something perhaps that job for a pharmacist too, once these prescriptions in the ED are being handed out that a pharmacist goes, and I remember as a pharmacist in New Zealand, a big part of my role is to go and talk to any patient that has had a new prescription of an anticoagulant.

Nagham: And we actually used to follow up with them a week after their hospital discharge, just to make sure that they're okay and that if it was meant to be stopped after 10 days, that they have actually stopped jabbing themselves with it and et cetera, et cetera. Yeah. And I mean, I guess that's a difference because there, this paper focuses on morphine and so a comment that we had included is that it could be different given these more contemporary or anticoagulants such as rivaroxaban that are more commonly used now.

Alex: It's good that you're just talking about your own clinical work and interventions. And this is a nice link to the three studies we've talked about so far, have all been observational studies. We're talked about how you have potential for confounding is higher and observational studies, but the last study is a trial, right? This is published in JAMA network open the effect of an electronic medical reconciliation intervention on adverse drug events, a cluster randomized trial by Tamblyn et al. Tell us about this. What is electronic medication reconciliation?

Nagham: Right. So they develop this tool that's the right prescription, right RX, which is really difficult to say it's cluttered tongue twister. But what it allowed or their intervention really focused on retrieval of community drugs that were issued from the provincial insurer and then the intervention involved reconciling that with the in-hospital drugs. And in addition to that reconciliation, it also allowed linkage with the names and the addresses of the community-based physicians and pharmacies, so that there was more communication about drug changes off to discharge. And so it wasn't just a comparison per se, but there was also that communication aspect as well. And then they assessed outcomes after 30 days following hospital discharge.

Nagham: Now they didn't actually find a difference in the ED visits or hospital readmissions, but between the intervention and the control group, but overall, there were less medication discrepancies in the intervention group in comparison to the control group.

Alex: So the meds were more similar in the intervention group to what they were supposed to be in the intervention group, but the outcomes that sort of harder outcomes, I guess you could say didn't really budge. What do you think happened there?

Nagham: So I think that there are factors that we don't yet know about that's at play. And it could be explained partly by the fact that medication discrepancies may not be related to adverse drug event occurrence. Just because there are differences in the medications, both lists could be wrong. The medications in both circumstances might not be optimal for the safety of the person.

Alex: Yeah, that's a good point.

Nagham: Yeah. And so I think that it reaffirms though that if there were the group of patients or the part of the population that are having these multiple medication changes, they're definitely susceptible to be at a higher risk of developing adverse drug events and that's the one thing that we could take away from this paper, but there should be additional strategies to try and mitigate the risk. And I think medication reconciliation from the perspective of pharmacists, it's great. That's one of our core roles in pharmacy in the hospital setting, particularly, but I see it as a first step and it's not really taking it that step further and thinking about the appropriateness of the medication.

Nagham: And that's what we call a medication therapy assessment in this part of the world. It's thinking about taking the time to really nod it out, take a part of the medication list and ask questions about why is this prescribed, how long had they had it for. And I think without that happening, we're not going to be able to really see a major change in adverse drug events. And even then, we need large numbers in these gold-standard RCTs to also show that.

Alex: Mm-hmm (affirmative). Right.

Eric: I feel like if you asked most clinicians about medication reconciliation, their heart rate will increase. Their eyes will narrow, they'll have a mean face because we've all been forced to do medication reconciliation, but not in a good way. It's you have this list of medicines, you have another list there. It's a very bureaucratic form that most of us have to fill out that really does absolutely nothing for the patient, but it's like a documentation that it occurred. And it makes people really probably despise the concept of medication reconciliation rather than thinking of it as a really helpful tool. It's a part that we just don't have a tool yet that actually works for medication reconciliation. I haven't seen right RX. But also, it made me think maybe it was the tool.

Nagham: Yeah, I think so. I think so. I think that's a really good point and that same reaction that clinicians have of sweat rolling off the forehead happens when they see a pharmacist going up to them to talk to them. It's like, "Oh, I did something wrong with my med rec or whatever." I think that there has been something that's an online decision support thing that's been developed called G-meds and that sort of really tries to highlight the high risk drugs which are the drug burden, index drugs. Those are medications that have an anti-cholinergic or sedative property and it works its way through to reconciling them and then thinking about should they still be on them?

Nagham: And then it's more of a communication tool as well and I think that's something that we really need more of. And we need to understand how to better implement such implementation strategies more effectively, both in research studies, as well as clinical practice.

Eric: What's next for you in your research?

Nagham: Yeah. So I'm very interested in improving the knowledge translation of deep prescribing in clinical practice and that's sort of the focus of my fellowship research proposal. So I'm currently trying to develop a tool that helps older adults initiate conversations about deep prescribing with their provider, because we do have some questionnaires that have been trying to gauge how willing people are to deep prescribe their medications. Because usually we know that some patients can be very attached to their medications especially that we've told them to take them for donkey's years. And then they're like you tell them as a clinician or as a healthcare professional, "You don't need to take this anymore," and then they're like, "What do you mean? I've been doing this for 20 years."

Nagham: So it's kind of flipping it around and trying to have this paradigm shift where we activate patients to have more self-efficacy and empower them to ask questions about their medications. So then hopefully that can sort of lead the medication lists to be more aligned with the patient preferences. So that's sort of what I'm working on.

Alex: That's great. Well, we're so happy that you did this study and that you published it in JAGS and that you're continuing in this vein because we need work at all levels at the pharmacist level, as we've talked about, clinician level, patient activation, some of the stuff you're working on. It's not going to be one intervention or the other that really does it, it's going to be all of the above.

Nagham: Right. Thank you very much. It's great to be here.

Eric: Yeah. A big thank you for joining us today. But Alex, can you hear that? Can you hear that thunder?

Alex: I thought you were going to make a Vegemite joke. [laughter]

Eric: I was. I was thinking about Vegemite, should I go for Vegemite? [laughter] You speaking my language or...?

Alex: Okay. I have to admit, I had to get out. I Googled a few of the words in here, like "Kombi". I guess it's some sort of witchcraft or something. And then "chunder", I guess is vomit? [laughter]

Nagham: I don't even know.

Alex: This song is just so silly. It's so ridiculous If you think about the words, but here's a little bit more.

Alex: (singing).

Eric: Do you like Vegemite?

Nagham: No, I'm not one of those Australasians. Yeah. And even in New Zealand, it's marmite and it's just as bad in my eyes, I'm sorry. [laughter]

Alex: Sounds gross. I have a friend who was British growing up. He just tried to get me to eat that at every sleepover.

Nagham: Did it work?

Alex: No, couldn't stand it. It was disgusting [laughter]

Nagham: There's people that love it. They're just like you just need to put butter on it. Just butter it up. And I'm like, still tastes as bad.[laughter]

Alex: You can't cover it up, need to deprescribed.

Eric: Deprescribe the vegemite, the marmite.

Eric: Well, a very big thank you for joining us today. It was really a pleasure having you and we really encourage all of our listeners to check out the JAGS article that was published on this. We'll have a link on our website. Any other plugs that you want to do for deep prescribing websites?

Nagham: Yeah. So there's That's a great one. And then we also have an Australian deprescribing network website that's currently under construction, but that's also something to check out, but we were very active on Twitter so check us out there.

Alex: And there's the US deprescribing network, which Mike Steinman runs. We invited him to be in the podcast. He was unfortunately unable to join due to clinical responsibilities, but I will have him on, in a future date to talk about this issue some more.

Eric: And again, a big thank you to all of our listeners for joining us and supporting the GeriPal podcast. And thank you, Archstone Foundation, for your continued support. Goodnight, everybody.

Alex: Goodnight.