Team Approach to Polypharmacy Reduction to Improve Mobility (TAPER-Mobility): A Pilot Feasibility Study in a Long-Term Care Setting
Conditions: Multi-morbidity, Medication Therapy Management, Polypharmacy
Sponsor: McMaster University

Generated: 2017-11-14 11:00:30 MST 
Mangin, Dee 
 
 
 
CFN File Number: 
CAT2017-20 
Title of CAT Proposal provided 
in Intent to Apply: 
Team Approach to Polypharmacy Reduction in Long-Term Care (TAPER- 
LTC). RCT feasibility study: integrating families’ experiences 
Term of CAT Proposal: 
16 
Budget: 
$100000 
 
Please provide information on the Principal Investigator who will act as Project Leader for 
proposal 
First Name: Dee 
Last 
Name: Mangin 
Designations: MBChB (Otago), DPH 
(Otago), FRNZCGP (NZ) 
 
Email: mangind@mcmaster.ca 
Daytime 
Phone: 
(905) 525- 
9140 ext. 
21685 
Other Phone 
(optional): 
Host Institution that will receive and administer 
funds: McMaster University 
Secondary 
Contact 
Name: 
Larkin Lamarche 
Secondary Telephone 
Number: (905) 525-9140 ext. 21224 
 
Secondary Email: lamarche@mcmaster.ca 
 
CFN Strategic Objective:Empowering, engaging and 
supporting patients and their families/caregivers 
Theme:Optimization of community/residential care 
Setting of Care:Long-term care facility 
Focus of Impact:Patients, their families and informal 
caregivers/support systems (volunteer) 
Knowledge Activities - Indicate the portion of your project that addresses the following activities on the 
knowledge continuum: 
20 % Knowledge synthesis 
70 % Knowledge creation 
10 % Knowledge translation/mobilization 
Ethics/Environmental Assessment 
Please answer the two questions below. 
 
1. Research Ethics: If the proposed research involves biohazards, humans, human embryonic stem cells or animals, AND is funded by CFN, 
certification of approval by your institutional certification committee must be provided to CFN prior to the release of funds 
Yes, I expect that this research will require an ethics review 
2. Environmental Assessment: Does any phase or part of the research described in this proposal a) take place outside an office or laboratory, or 
b) involve an undertaking as described in part 1 of Appendix B of the Natural Sciences and Engineering Research Council of Canada (NSERC) Form 101 
(http://www.nserc-crsng.gc.ca/OnlineServices-ServicesEnLigne/pdf/F101_e.pdf)?. 
No, I do not expect that this research will require an environmental impact review 
 
 
 
 
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2017 Catalyst Grant Competition 
Section 1 - Administrative Information 

  
Mangin, Dee  
 
Funding Priority 
 
CFN Medication Optimization Summit identified research priorities areas for funding. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Provide a non-confidential summary in lay terms of the CAT proposal. A lay summary is an overview of a research project described in a way that can be easily 
understood by those without prior experience of the subject. See Appendix A for CFN’s DRAFT - Guidelines for Writing a Lay Summary 
Polypharmacy (the use of many medications) is associated with poorer health and drug side effects in older  
adults. This makes it a concern in long-term care (LTC).  We  have  developed  a  program  (TAPER)  for  
reducing polypharmacy and drug side effects for older adults living in the community. TAPER combines family 
doctors and clinical pharmacists, with support from the best medical evidence, and patient preferences for 
treatment. In this study, we will test TAPER in LTC residents. Our focus is whether using TAPER can reverse 
medication-related mobility problems and prevent falls. We will also explore family members’ perspectives on   
how best to include their views in the TAPER process. 
 
Study participants from two LTC facilities will be put into either an intervention or comparison group at random. We 
will assess the logistics of the TAPER process in LTC settings as well as patient outcomes including falls, thinking 
ability, quality of life, mobility, as well as hospitalizations and number of medications. These measures   will be 
collected before and after the program to see if there have been changes for those receiving TAPER compared to 
a comparison group. 
 
We will use these results to design and gain funding for a much larger research study to test whether this process 
can improve outcomes for residents when implemented as part of routine care in multiple  settings  across Canada. 
We envision a routine preventive system for screening to reduce polypharmacy and side effects in older adults - 
one that fits alongside immunizations and other screenings. 
 
Provide a non-confidential scientific summary of the CAT proposal, highlighting the hypothesis, study objectives, milestones and deliverables and potential 
socioeconomic impact. (For funded CAT proposals, this summary will be used externally in media releases, communications and posted on the CFN’s website.) 
Our vision is of a routine preventive system in older adults for screening to reduce polypharmacy and adverse  drug 
effects (ADEs). Our previous work in several settings suggest the harms associated with polypharmacy are 
reversible, and we developed a model, TAPER, that engages pharmacists, family physicians and patients in the 
primary care setting for community dwelling older adults. We wish to adapt and test this in a LTC setting to see 
whether, compared to usual care, it could: 
 
Reduce number of medications 
Improve quality of life, physical and functional ability, and falls 
Reduce unplanned healthcare resource utilization 
 
 
 
In this study we will: 
 
 
1. Examine the feasibility and key signals of effectiveness of TAPER in LTC 
2. Talk to families about how best to involve them in this deprescribing process 
3. Test outcome measures and processes to inform a larger trial 
 
 
 
We will spend 4 months finalising processes and training, then 4 months recruiting participants, and randomising to 
TAPER or usual care. By 13 months we will complete follow-up data collection, ready to analyse the data and write 
up results for publication and dissemination to stakeholders in months 14-16. 
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2.1: Lay Summary 
2.2: Scientific Summary 
Section 2 - Proposal Summary 

  
Mangin, Dee  
 
Potential socioeconomic impact 
 
This program will have important impacts for residents on both physical health and the ability to interact socially if  
it can mitigate the functional impairments, reduced quality of life and economic costs of ADEs associated with 
polypharmacy. This scaleable model for sustainable change could substantially reduce the burden on patients, their 
families and the healthcare system. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Provide a comprehensive review of the relevant background literature and identify the knowledge gaps. 
Clearly state the rationale for the project and how the results of this proposal may be used to improve the care of older Canadians living with frailty and 
improve the lives of their family, friends and caregivers. 
 
Polypharmacy, while sometimes beneficial to individuals, continues to cause great concern, especially among the 
elderly who are most likely to have multiple comorbid conditions [1-4]. There are substantial  associations  between 
polypharmacy and reduced function in older adults and frail older adults both in long-term care and in   the 
community. Specific negative effects include poorer quality of life, and reduced function including poorer mobility, 
cognition, and nutrition as well as falls, fatigue and reduced medication adherence [5-8] where complicated 
medication regimes which exceed the patients’ ability to cope [9-19]. Overmedication is not only costly in terms of 
admissions and treatments for adverse drugs effects (ADEs) as well as medication waste [13].  In Canada, ADEs 
cause an estimated 70,000 preventable hospital admissions per year [14]. In Canada, most older adults on multiple 
medications have never had a comprehensive medication review, and ADEs requiring medical care affect a 
substantial proportion of this group (13% of those on ೦5 medications); 1/3 are estimated as preventable [15]. 
 
Polypharmacy and Mobility 
 
Polypharmacy in older adults is associated with mobility-related functional decline, increased falls, hospitalization, 
institutionalization, impaired cognition, and reduced quality of life [10-12]. A higher drug burden has negative 
associations with bathing, dressing, bladder function, transfers, mobility and stair climbing [16]. In Canada, the 
burden of polypharmacy and mobility impairment is much higher in long-term care residents. This group stands to 
gain the most from reduction in polypharmacy. Animal models show polypharmacy affects mobility, balance and 
strength in older frail animals in ways that are not seen with individual drug treatments, nor in younger animals  and 
this appears to be the case with frail older adults. 
 
Canada’s healthcare system lacks a feasible, systematic approach to minimising the negative effects of 
polypharmacy in routine clinical care, yet morbidity and mortality rates from ADEs in seniors are now higher than 
many chronic diseases [17-19]. There is little evidence on whether these associations with poorer function are 
actually reversible if polypharmacy (i.e., the number of medications) is reduced. This is important information, as   it 
determines the type and timing of interventions to address these effects. We propose to test this using an innovative 
model, TAPER (Team Approach to Polypharmacy Evaluation and Reduction) that we have used successfully in 
reducing polypharmacy in community-dwelling adults. 
 
TAPER is a structured clinical pathway aimed at reducing the number of medications. It involves integrating 
evidence tools, an automatic screen for potentially inappropriate medications, and a process developed for 
integrating patient priorities for care. The “Team” engaged in this intervention is the patient/family, the pharmacist 
and the physician. The intervention has been specifically structured to address barriers to deprescribing identified 
in ours and others work with nurses, physicians and patients. (Figure 3 maps TAPER to these identified barriers) 
 
Previous work: Our feasibility study of medication reduction in a cohort of older adults living in the community 
showed improvements in quality of life, mental status and other morbidity indicators, and has been highly cited   [6]. 
Our CIHR funded RCT, based on an initial feasibility randomised controlled trial, is successfully implementing 
TAPER for community-dwelling adults in a primary care clinical setting. We have NIHR funding to trial in a  hospital 
setting in Australia. 
 
Long-term care: Our feasibility study in long-term care focussed on a specific medication area (anticholinergic and 
sedative drugs) showed successful reduction in medication burden, and a statistically significant improvement  in  
the  frailty  score.  [20]  Our  small  pilot  “before  and  after”  study  looking  at  all  medicationPsag,e a
5 onf 2d2 
Section 3 - Scientific Excellence 
3.1: Background, Knowledge Gap(s) and Rationale 

  
Mangin, Dee  
 
aiming to focus in more detail on mobility was carried out in the long-term care facilities selected for this application. 
This has helped us to understand which elements need adjustment for a LTC setting, in particular the need to 
understand how to involve families in the process. The study proposed in this application will test the robustness of 
this signal in improvement of specific functional outcomes and provide the basis for scaling up into   a large 
pragmatic randomized controlled trial if there is a signal of reversibility in this feasibility trial. 
 
 
State the proposed hypothesis and research question(s) to be addressed in the study. 
 
Hypotheses 
 
We hypothesize that over 6 months, compared to the usual care group, participants in TAPER will have: 
 
1. no change/fewer number of medications (primary signal of interest). 
 
2. no change/improvements in quality of life, level of physical functioning and performance, activities of daily  
living, fatigue, sleep, functional ability, and number of falls (secondary outcomes). 
 
3. less healthcare resource utilization. 
 
 
Research Questions 
 
 
 
1. What are the effects of TAPER on numbers/doses of medications and adverse events? 
2. What signals indicate that impairments of function associated with polypharmacy are reversible? 
3. What are the effects on hospitalizations? 
4. How can patient priorities and preferences be successfully integrated in the presence of cognitive impairment 
and family having power of attorney? 
5. What are the experiences of patients and their families undergoing ‘deprescribing’? 
6. What are the key aspects to integrating this model as part of routine practice in long-term care? 
 
 
Describe the overall goal and specific objectives of the study. 
 
We wish to build on our work developing and testing the effectiveness of an intervention in primary care to reduce 
polypharmacy. Our pilot and feasibility studies showed TAPER is suitable for use in routine primary care, scaleable, 
and demonstrated positive health effects of reducing polypharmacy in community dwelling adults [7]. A pilot study 
testing a narrow range of medications suggest positive health effects in frail older adults also. Our overall project 
goal is to adapt, implement and test the TAPER process in LTC. The specific objectives are to: 
 
1. Examine important feasibility measures and extent of implementation of the TAPER polypharmacy 
intervention in 2 LTC facilities 
2. Examine signals of effectiveness of TAPER in LTC 
3. Test measures for use in a larger randomised controlled trial 
4. Collect data from family members to understand how to involve them in the deprescribing process, as well as 
their perspectives on the deprescribing process 
 
 
 
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3.2: Hypothesis and Research Question(s) 
3.3: Overall Goal and Objectives 
3.4: Methodological Approach 

  
Mangin, Dee  
 
 
Describe how this project will be managed overall and who specifically will manage each major aspect of the study. 
Describe the overall study design, approaches, procedures and methods used in the study and why they are appropriate to meet the goals and objectives 
and deliver upon the proposed output(s). 
For example, if relevant, include aspects of participant recruitment, methods and tools used to assess participants for frailty, data collection, statistical 
analysis, etc. 
Note: Study protocols must include frailty assessment of all study participants using a published frailty assessment instrument appropriate for the care 
setting. 
 
Methods 
 
Design 
 
This is a feasibility RCT (1:1 patient randomization to either receive TAPER or usual care). The control group will 
be offered TAPER after 6-month outcomes are collected. In our experience using a randomized design in a full 
feasibility study is essential to ensure subsequent effective implementation in a large multi-site pragmatic RCT. This 
approach enables use of data in subsequent meta-analysis. Detailed testing of the proposed quantitative measures 
in this population is essential as score distributions may be clustered due to population characteristic similarities. In 
order to understand how to incorporate family and patient perspectives in priority setting, our experience with 
developing the approach for integrating patient priorities for TAPER in community-dwelling older adults indicates 
formal qualitative methods are best in developing the approach and producing publishable information for use by 
others working in the area. 
 
We will  randomize  90  patients  (allowing  for  10  dropouts).  Participants  will  be  70  years  or  older  and  on  > 
5 medications. Based on our feasibility RCT in community-dwelling adults, this will provide adequate numbers to test 
feasibility of processes and provide information on outcome measure performance, recruitment rates and sample 
size calculation for a larger trial. 
 
Patients lists (aged 70 or older and on 5 or more medications) residing at each of the LTC facility will be  generated 
by administrative staff. The study team will work with the LTC facility to develop a consent process.  This process 
will include verbally reviewing expectations of participation, written consent, and  confirming  inclusion criteria. For 
those who are unable to provide written consent, consent will be sought by the substitute decision maker. We will 
provide information evenings for families of all residents considering participation. 
 
Intervention 
 
The intervention as a structured medication review through integrated consultations with a pharmacist and then a 
physician. The review is based on patient (or family where appropriate) preferences and priorities for treatment and 
available evidence. A ‘pause and monitor’ plan for medications suitable for discontinuation or dose reduction is 
developed, including agreed criteria for monitoring and for restarting medications (see Figure 1 for TAPER 
diagram). Key aspects of the intervention include: 
 
 
1. Resources, evidence and guidance to support medication discontinuation. A systematic review of 
potentially useful tools has been completed and an eHealth platform (TAPERMD) developed for automatic 
detection of ADEs and screening for potentially inappropriate medications. It combines the Beers  List, STOPP 
criteria, Anticholinergic Burden, hypotension burden, serotonin burden, QT burden and an interaction checker 
as well as deprescribing guidelines and evidence for benefits in older adults. 
2. Formal incorporation of patient priorities to empower patients and clinicians to make choices driven by 
patient’s personal values. A systematic literature review looking for existing tools and approaches and work 
completed with patient focus groups has informed this [21]. This study will seek family members input into how 
best to involve them in this process of priority setting. 
 
 
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3. Collaboration. The pathway supports collaborative review by pharmacists and physician. 
4. Integration of ‘pause and monitor’. Patient priorities, potential medication side effects, eTools, clinical 
consultation record and pause and monitor template plan are integrated in a web-based clinical pathway.  This 
has been piloted with clinicians using a small number of patients in the LTC facilities. 
 
Adverse effects will be addressed within the usual care clinical setting. Clinical follow-up will be determined 
according to the particular drugs discontinued and recorded in the web-based clinical pathway. 
 
Frailty Measure 
 
A validated measure of frailty (Edmonton Frail Scale) will be assessed at baseline and 6-months to determine 
signals of effectiveness of TAPER compared to usual care. We saw signals of improvements following reduction  in 
polypharmacy with a statistically significant difference in the frailty measure, even in our small pilot sample in LTC 
[20] 
 
See Table 1 for a full list of outcomes, timing of data collection and analysis. 
 
Management 
 
We have partnered with 2 LTC facilities in Brampton, Ontario, each supported by in-house primary care clinicians 
and pharmacists. We have an excellent working relationship with these facilities after our pilot study. The Medical 
Director is a co-investigator and key liaison.DM will manage the operation of the study. Regular team meetings with 
the McMaster research team, Medical Director (JV) and involved staff, training pharmacists to  review progress will 
occur. Research staff will help to ensure fidelity of data collection, with double data entry among a random sample 
to test accuracy. Randomization and statistical analysis will be carried out by the Biostatistics  Unit at St Joseph’s 
Healthcare Hamilton (LT). 
 
 
Describe all milestones and anticipated deliverables, outputs and outcomes for the duration of the project. 
Provide a project schedule with dates for all milestones and anticipated deliverables, outputs and outcomes for the duration of the project, including all 
knowledge translation activities. 
Note: The project schedule is mandatory and will be used to track progress of the study. 
Describe how this project will be managed and deliverables tracked. 
 
Demographic information such as age, sex, gender, date of birth, and ethnicity will be self-reported in the  baseline 
data collection session in order to describe the sample. 
 
Feasibility Measures (Research Question 2) 
 
Feasibility measures will be assessed using recommendations of Thabane et al. (2010) [22]. Process, resources, 
management, and scientific areas of feasibility will be assessed through research team  and  administrative records 
for the study, and will include: 
 
 
1. Long-term care recruitment rate 
2. Participant recruitment, retention, refusal rates 
3. Number of cancelled-scheduled appointments 
4. Proportion meeting eligibility criteria from lists generated by administrative personnel (>70 years and 5+ 
medications) 
5. Proportion needing substitute decision maker involvement 
6. Time needed for enrolment target of 80 participants 
 
 
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3.5: Research Outcomes, Deliverables and Milestones 

  
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7. 
Length of time to complete measures 
8. 
Performance of measures, looking for floor and ceiling effects and change over time 
9. Research team’s description of appropriateness of the collection surveys and process of data collection 
10. Changes to process to meet context demands and needs 
 
Study Measures (Research Questions 1,3,4,5) 
 
Main outcome measures will be collected at baseline and 6-months post-intervention. Additional follow-up by the 
research team will occur at 1-week, 3-months, and 6-months after initial appointments to facilitate recall and 
recording of any immediate effects revealed by discontinuation. Study measures include: 
 
 
1. Mean number of medications per participant (primary outcome of interest). 
2. Adverse events will be collected by solicited enquiry as well as spontaneous patient or clinician report, and 
serious adverse events reported as a subgroup. 
3. Quality of life will be measured by the EQ-5D-5L and SF-36 [23]. The EQ5D-5L survey will also be used in 
our economic analysis [7]. 
4. Level of physical functioning impairment will be measured using the Manty. 
5. Timed Up and Go and timed 8-foot walk test will be used as performance measures of physical functioning 
[24]. 
6. Number of falls (minor and those resulting in injury) will be recorded by self-report and from electronic 
medical record review. 
7. Pain will be measured using the Brief Pain Inventory (short-form) [25]. 
8. Performance in activities of daily living (ADL) will be measured using the Barthel Index [26]. 
9. Mobility-related fatigue will be measured by the Avlund Mob-T Scale [27,28]. 
10. Sleep will be measured by a single item on the 15-D quality of life scale [29]. 
11. Grip strength will be assessed using a hand grip dynamometer as per standard testing procedures [30]. 
12. Functional ability will be measured using the Functional Ability Scale for the Elderly [31]. 
13. Frailty will be measured by the Edmonton Frail Scale [32]. 
14. Healthcare resource utilization data will include number of hospitalizations and emergency department and 
urgent care visits, as well as visits to the family physician. 
15. Perceived change in side-effects and medication related symptoms will be self-reported at 1-week,   3-month, 
and 6-month follow-up. 
 
Semi-structured interview (Research Question 6) 
 
Patients and family members will be asked to participated in a semi-structured interview to explore their experience 
with deprescribing, and their views on how to incorporate families’ perspectives into deprescribing   and strategies 
to address polypharmacy in LTC residents 
 
 
 
Data Analysis 
 
Means and standard deviations or proportions will be calculated for demographic information and study outcomes 
where appropriate. Analysis will involve t-tests or Chi-squared statistics where appropriate. Qualitative data will   be 
analyzed by descriptive methods. See Table 1 for a full list of outcomes, timing of data collection and analysis. 
 
 
 
Project Schedule 
 
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The project will be carried out over a 16 month period. All research, analysis and KT activities will be carried out   in 
this time period. The project PI and the Research Associate will oversee all activities and will ensure the project 
schedule is followed (See Figure 2 for the Project Schedule) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Identify all feasibility issues, barriers, challenges and limitations to the successful execution and completion of the study. Specifically address issue   related 
to budget constraints, time constraints, structural issues, and organizational and personnel challenges that may delay or derail timely completion   of the 
study. 
Describe how the investigative team plans on mitigating and overcoming these barriers, challenges and limitations. 
 
We have experience in conducting studies on reducing polypharmacy in community and LTC settings, and have 
chosen an adequate and achievable sample size and time frame to answer the research questions, considering 
expected recruitment rates from our previous studies, and available population. RCTs are complex to implement  in 
community settings, and full feasibility trials such as the one proposed are essential, to ensure success in 
implementation of both the intervention model and the research elements in larger RCTs. Our previous  experience 
in successful conduct of RCTs in the community setting gives us the awareness of the logistics, pragmatism, and 
meticulous attention to detail required.We are aware of the costs, including KT, and have budgeted appropriately, 
and have additional support from students that to ensure adequate study personnel and time to complete the study. 
 
The TAPER intervention model has been specifically designed to address the known barriers to polypharmacy 
reduction: We have mapped this in Figure 3, and we believe the success of our previous feasibility studies  reflects 
this. (see Figure 3 for diagram). 
 
We are currently undertaking a small pilot study in a LTC facility. Our learnings identified several challenges working 
in a long-term care facility that we have put processes in place to mitigate. 
 
Personnel requirements 
 
During the pilot, we found that a dedicated assessor was required for the mobility assessments who is experienced 
in working with with frail older adults and can ensure patients’ safety during physical assessments.  To address this, 
in addition to the research associate and assistant, we propose to hire a trained physiotherapist for physical 
assessments at the LTC sites. We have identified a local physiotherapist who is experienced in working with frail 
older adults, and received training on the study procedures and data collection methods during piloting. This reduces 
time and resources required for specialised training and avoids mileage costs associated with sending a research 
assistant or physiotherapist from McMaster in Hamilton Ontario to Brampton to carry out the assessments. 
 
Partnerships 
 
Finding a long-term care facility willing and able to partner with us was important. We have found and  successfully 
partnered with long-term care facilities in Brampton, Ontario, taking into account the context and needs of the facility 
workflows, and residents needs in designing the trial processes. Key staff have good understanding and experience 
of requirements of a randomized feasibility trial and have worked with the team to develop processes to facilitate 
this. The partnership allows us to have access to a large population of LTC residents when recruiting participants, 
which will provide more than ample sample size given our anticipated response rate. There is no competing research 
at this location and the facility also includes a pharmacy, pharmacists who are interested and engaged with the 
project, and the residents’ primary physicians. As a result, the research team, physiotherapist and the medical team 
will be able to easily and relatively seamlessly communicate and implement the project protocol as evidenced in our 
pilot. 
 
We have piloted several patients through the processes to assess how best to organize processes of the intervention 
and measurement. We discovered that testing needs to be done at a consistent time of day at baseline and 6 
months, as residents tend to fatigue as the day progresses. Consequently, we have idenPtiafgiee1d
1 ofa22 
Section 4 - Project Feasibility 
4.1: Feasibility 

  
Mangin, Dee  
 
2.5 hour morning window for all testing that will ensure residents are not fatigued, data collection is consistent   and 
unbiased, and there is no interference with facility workflows around mealtimes, dressing etc. 
 
The intervention is already designed to partner with patients as an explicit part of the ‘Team’ aspect of the TAPER 
intervention, and this is working successfully in community-dwelling adults. An important partnership in LTC facilities 
is with families, particularly where the resident may have cognitive impairment. Families carry a lot of responsibility 
for overseeing and participating in care decisions for family members in LTC. In order to engage families, to prepare 
for the smooth running of TAPER for the study, and for wider implementation if proven successful, we have planned 
specifically in this feasibility trial to study how best to include families in the process. 
 
Structural issues 
 
Finding space to carry out the assessments in a consistent way, in particular the physical function assessments,  is 
a challenge when working with residents of a long-term care facility. We have scoped and secured a dedicated 
space in the Brampton long-term care facility to carry out the assessments with the residents. The space is within 
the facility, allowing for easy access for the participants. 
 
 
Please describe the expertise and experience of each Principal Investigator, Co-investigator, Partner and other critical team members to demonstrate that 
the team is capable of delivering on the proposed outputs and achieve the goals and objectives of this proposal. 
Please provide an estimate on the number of hours per week (contribution) for each Principal Investigator, Co-investigator, Partner and other critical team 
member that will be working on the study and describe why this is an appropriate level of engagement and/or commitment to deliver the proposed outputs 
and achieve the goals and objectives of this proposal. (Note: All Individuals participating as project team members will also need to be listed in the Project 
Team List document). 
For each Principal Investigator, Co-investigator, Partner and other critical team member please describe why the environment (academic institution   and/or 
other organization) is appropriate to enable the conduct and success of the project. 
 
Our team members have a breadth of experience in various disciplines including pharmacology and therapeutics, 
family medicine, pharmacy, nursing, polypharmacy, epidemiology, sociology, evidence review and synthesis, 
research design, and extensive experience in successful RCT implementation in primary care. Our collaboration 
builds on existing relationships within a team, all committed to the goals of this research. The intervention and 
processes will follow those that were successfully used in our just-completed RCT of antidepressant discontinuation, 
our previously published general medication reduction feasibility study, and our RCT in community-dwelling adults 
as well as our pilot work in LTC. 
 
Our team has a demonstrated track record of collaboration. We have worked collaboratively on Canadian 
Polypharmacy projects and tools including TAPER and MedStopper, and JT, DM, JM and AC specifically have 
collaborated on knowledge translation projects in polypharmacy, and DM PR and LG collaborate in the Canadian 
Longitudinal Study on Aging (CLSA) Medicines Working Group. Our team has also published widely on research 
design (LT), polypharmacy and drug discontinuation (DM JM JH SG), research on how clinical evidence on 
medications gets communicated to policy-makers, prescribers (AC DM) and consumers (AC JT WB DM) and 
effective interventions to change prescribing. 
 
We actively provide consumer medication information through engagement with patient groups, in NGO and internet 
information sites (DM JT), health journalism and books for consumers (AC), translating research for prescribers and 
residency training programs/postgraduate CME (DM AH JL JH JT). Our team is formally linked with national and 
provincial pharmacy organizations through the Ontario Pharmacy Research Collaboration (DM scientific advisory 
board), the Canadian College of Family Physicians leadership (DM SG), and the Medication Leads Group for the 
Integrated Patient Safety Action Plan (Canadian Patient Safety Institute) (JT DM). 
 
Two critical additions to our research team expertise should be highlighted in carrying out this project. First, our 
partnership with DataBasedMedicine has been very effective and efficient in developing the electronic platform 
(TAPERMD) for TAPER in our community-based trial, and they have adapted it for use in Australia as well as for 
this study in LTC setting. The format and function has been extremely well received by clinicians, with rePqaguee12sotfs22 
4.2: Expertise and Experience of Research team 

  
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for access beyond the trial. Second, we have added partners from the LTC facilities, and chosen LTC facilities where 
the director (JV) has academic experience and understanding of the requirements of research, in addition   to 
implementation of new clinical models of care. The integration of expertise in trials focused on specific patient level 
outcomes, in service delivery change models, in sociological perspectives on clinical care  and  health services, in 
the epidemiology of aging within the CLSA, as well as partners in the LTC context makes this a well- informed and 
strongly cohesive team making success of this project likely. 
 
Hours and Roles 
 
See Table 2 for the hours committed to the project and roles for the PI, CO-Is and other team members. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Describe the relevance and the importance of the proposed project to CFN’s mission and strategic research programme goals, priorities, and potential to 
assist CFN in achieving a positive impact on policy and practice. 
Identify how the proposed study meets the specific objectives of the Catalyst Grant Program to foster novel, innovative projects demonstrating potential  
for significant socio-economic benefits related to the care of Canadians living with frailty. 
Describe how sex as a biological variable and/or gender as a social determinant of health have been considered and integrated into the research plan. 
 
This study aligns closely with CFNs strategic priorities and patient-orientated research themes. 
Polypharmacy is associated with poorer quality of life due to adverse drug effects (e.g. falls, cognitive impairment, 
malnutrition), drug interactions, and poorer medication adherence due to inability to manage exhaustive medication 
regimes [9-12]. TAPER is designed to safely reduce polypharmacy, to improve clinical outcomes and care across 
the continuum, and empower and support patients and their families by incorporating their treatment priorities and 
preferences at its core. TAPER was designed with the help of patients, patient groups and caregivers after a 
systematic review failed to show a deprescribing process which formally incorporated patients’ views. 
A key component of this study is input from, and analysis of, families’ experience of deprescribing. This is a  unique 
and important contribution to emerging literature relating to medication burden and will provide unmatched 
qualitative insight. 
 
Additionally, we will determine if introducing TAPER to usual care results in improved clinical outcomes in LTC 
residents. Little is known about structured deprescribing in LTC settings. We know that the majority of LTC residents 
experience multi-morbidity [33]. From 1998-2008 the percentage of Canadian seniors taking >5 prescription 
medications rose from 13% to 30% overall; the percentage for LTC residents is >50%. [34-36]. Canadian seniors 
take a median of 7 regular medications [37,38]. Resulting hospital admissions and other treatments for ADEs are 
costly [13]. 
Our 2 feasibility studies, in primary care and LTC settings, have strongly signaled the beneficial impact on clinical 
outcomes. One of the purposes of this study is to confirm these findings, with a view to upscaling to a large pragmatic 
randomized national trial. Despite increasing morbidity and mortality rates associated with ADEs, Canada’s 
healthcare system currently lacks a feasible, systematic approach to reducing the overmedication [17- 19]. In frail 
older adults, the decision to stop medications may be as important as the decision to start. Our    TAPER approach 
to deprescribing is ready for upscaling, provided the early signals indicating success are confirmed and 
implementation is deemed feasible. We believe TAPER has the potential to transform clinical care  in the LTC setting. 
 
Sex and Gender Considerations 
Women experience more ADEs compared to men, regardless of age and rate of exposure [39]. Women also   have 
a greater risk of certain ADEs. The FDA does not require analysis of sex in terms of efficacy and safety outcomes, 
and women are underrepresented in drug trials [39]. 
Prescribing patterns differ according to gender: on average, US women are prescribed more medications than men 
(5 versus 3.7) [39] and evidence demonstrates certain drugs are prescribed more often to women, especially 
psychotropic and pain medications [39]. 
In this feasibility study, we will describe data on baseline characteristics, clinical outcomes, and patient experiences, 
according to sex and gender. We will not have power in this feasibility study to test hypotheses in subgroups, but 
we plan to use these data to determine power and sample size calculations for sex and gender analyses for the 
larger trial. 
 
 
 
 
 
 
 
Page 14 of 22 
Section 5 - Project Relevance and Impact 

  
Mangin, Dee  
Section 6 - Capacity Building - Highly Qualified Personnel 
 
CFN funded proposals must contribute to the development of Highly Qualified Personnel (HQP) through their inclusion as project team members in a 
meaningful manner. 
Briefly summarize the number and level of HQP required and the experience/expertise afforded by involvement in Network-funded research. 
Specify expected contributions to HQP studies. 
 
Two highly qualified personnel (HQP) will be involved in this study. Alison Ross, a PhD student in sociology will help 
to develop and carry out the semi-structured interviews to explore experiences of deprescribing among  family 
members. Involvement in this study will expand Alison’s knowledge of polypharmacy, a new area for her. Also, this 
involvement will provide her experience working with frail older adults and their family, which will refine her interview 
skills. She will be involved in analysis and write up of the data and in translating the results in adapting the TAPER 
process for long term case based on the findings. Jenna Parascandalo is a Master of Public Health student. She 
will be involved in using this data in the process of adapting TAPER to fit a LTC context as well as the data collection 
for analysis and publication. Her engagement in the process of adapting and implementing TAPER for a LTC setting 
will give her experience in knowledge translation activities and factors involved in scaling up an intervention. Jenna 
will also be involved in translating the results of this study into consumable mediums for a variety of audiences. 
Jenna will be responsible for monitoring our use of the Knowledge-to-Action framework throughout the study. Other 
funds will cover the human resource cost of Alison and Jenna. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Page 15 of 22 

  
Mangin, Dee  
 
 
 
 
 
A funded project must represent a collaborative effort of different Investigators in more than one discipline (e.g., combinations of biomedical science, natural 
sciences and/or the social sciences) and at more than one Institution and with involvement of partners and stakeholders from other sectors. 
Describe the networking and engagement planned for the project across disciplines, research sites (universities, hospitals, institutes) and sectors. 
 
The TAPER team consists of patients, their caregivers, patient advocates, and experienced investigators 
representing multiple disciplines and institutions across several Canadian provinces - Family Medicine (McMaster 
University; University of Alberta; University of British Columbia), Geriatric Medicine (McMaster University;  Geriatric 
Medicine, Kitchener Waterloo), Pharmacy (McMaster Family Health Team; University of British Columbia), 
Sociology (Department of Health, Aging and Society, McMaster University), and Biostatistics and Epidemiology 
(McMaster University/St. Joseph’s Hospital, Hamilton). This project will help evolve this multidisciplinary 
engagement and build on recently-established relationships with caregivers at our Brampton   LTC sites. This project 
will also continue a partnership with Data Based Medicine Americas Ltd. (DBMA) in order  to modify and develop 
our e-tool TAPERMD. DBMA, in partnership with the TAPER team, are committed to the safe and efficient 
incorporation of TAPERMD into the LTC setting. TAPERMD has also been selected by MaRS (MaRS Discovery 
District, Toronto) for development support. We plan to have weekly investigator meetings, with remote members 
attending via Webex and Skype. To date we have found this mode of meeting a successful means of communication 
and collaboration. It is time-efficient and removes necessity of travel for those working remotely (including 
investigators working at the LTC facility). As a team, we are excited about potential TAPER has towards improving 
safe prescription of medications, and overall clinical care, across Canada. 
 
CFN is committed to empowering and engaging older adults living with frailty and their families and caregivers and other knowledge users. 
 
Describe how knowledge users (e.g. patients/families, decision makers, stakeholders, practitioners) will be involved in the research in a meaningful manner. 
For clarity, meaningfully involved participation of knowledge users includes assisting in the planning and execution of the research project and/or in assisting 
in the interpretation and translation/mobilization of research findings. 
 
Johanna Trimble has been a partner in knowledge translation and a key co-investigator in our TAPER program   for 
many years. She is a consumer advocate who has had personal experiences with navigating medications and care 
of frail older adults, and contributes to a number of provincial and national committees working on polypharmacy. 
Her work focuses on the frail elderly, and issues surrounding pharmacology, polypharmacy and medication safety. 
A consumer advisory group lead by Johanna Trimble has been involved in developing the TAPER intervention, and 
will be involved in the planning and execution of this research project. The group is comprised of patients and 
caregivers with lived experience in deprescribing and other aspects of the healthcare system. The group has been 
involved in the development and selection of tools to be used in the data collection for the feasibility study as well 
as knowledge translation of findings, and will continue this role in the RCT  feasibility study. The advisory group will 
meet via skype with the research team once a month to discuss the   study and provide feedback. 
 
Focus groups will be carried out with families and caregivers of participants to gather feedback of their lived 
experience with the study process and gather their input into processes for incorporating their views into the TAPER 
process for their family member. Three focus groups will be held with 7 family members  and/or  caregivers in each 
group. The findings from the focus groups will be used to inform the future RCT. 
 
 
 
 
 
 
 
 
 
Page 16 of 22 
Section 7 - Project Networking and Engagement 
7.1: Project Networking 
7.2: Citizen Engagement 

  
Mangin, Dee  
 
 
 
 
 
Describe the opportunities for knowledge translation and exchange and/or technology transfer or commercialization of the research proposed along a continuum 
leading to social or economic impacts or policy and practice change. If there are specific companies or organizations that will be involved, list in Section 3 
(Partnerships) and ensure that a letter of support is included. 
The project has integrated knowledge translation (KT) at a micro-level with clinicians and consumers participating 
in the design and implementation of the study. They contributed through focus groups and individual comments,  to 
tool development around patients priorities and challenges, and to the web-based evidence support, and pathway. 
This has created a model and tool that is immediately scalable and responsive to emerging evidences. Knowledge 
will be shared at the LTC site level and with the regional network of LTC facilities, with whom we have a close 
collaboration (DM JV and HS) in order to disseminate fundings and initiate processes and policy changes with a 
wider reach. At the macro-level, TAPER investigators work closely with the Canadian National Deprescribing 
Network (CaDeN) to inform development of the national strategy for deprescribing. We will present findings to 
CaDeN to distribute learnings and influence national policy. Study findings will be made available to   the research 
community through open access journal publications and conference presentations. 
 
The team uses social media as part of an integrated KT strategy. Polypharmacy videos describing the rationale, 
and model for TAPER have a high number of views on YouTube (2700 and more recently 700). TAPER is a pathway 
designed so the ‘Team’ stakeholders can initiate the approach to polypharmacy evaluation: we have developed the 
TAPER tool with consumer initiation of the process in mind. A consumer health information site (RxISK.org) has 
been used to disseminate information about polypharmacy [40)], and this will be a vehicle for KT to consumers. The 
website receives >200,000 visits/month. Testing interest with a “Could you be on too many drugs” questionnaire for 
consumers to take to their pharmacist or family physician, generated 1000 completions   in the first month. 
 
Our partnership with DBMA has been very successful. The TAPER tool is designed to easily integrate additional 
evidence resources, as they become available, and designed for seamless scale-up. If successful it is planned to 
progress to commercialisation, in partnership with DBMA, to support scalability and sustainability at provincial 
national and international levels as part of routine clinical care. (support letter attached) 
 
Please identify the KT framework that will be used and how it will be implemented. The framework should be one from the April 2012 Knowledge Translation 
Framework for Ageing and Health from the World Health Organization (http://www.who.int/ageing/publications/knowledge_translation.pdf). 
The Knowledge-to-Action framework will allow us to guide the process of adapting what we already know about 
TAPER in primary care as we move to test its feasibility in a different context, LTC. Tailoring knowledge to a new 
setting is a strength of this framework. Focus of implementing each phase of the framework will occur. 
 
A systematic look at our outcome and process data collected during our feasibility study in primary care will be 
used to help inform how to adapt TAPER to LTC (adapt knowledge to local context). For example, key learnings 
have and will be shared with our partners at the LTC facility with discussion of how to use these learning in the  
LTC setting. Examples of learnings include the best way to support family doctors and pharmacists in using 
TAPERMD: in the primary care setting, partnering during first time use, using peer to peer learning was very 
successful in addition to training sessions. Further, learnings from our feasibility pilot in LTC will also  be  
discussed, assessing feasibility of certain data collection tools and the process of patient consent and family 
engagement. This will provide rich information before implementation of this study in order to assess barriers 
beforehand and develop processes to overcome these barriers (see Section 4.1 for some barriers already 
identified). This ultimately will involve tailoring the intervention to suit the context before implementing the 
intervention. We will also have a process for identifying and addressing barriers online to course-correct the 
intervention as a way to monitor knowledge use. Our plan is to evaluate outcomes at baseline and 6-months as 
well as collate process outcomes at the end of the intervention. We would plan to use these key learnings in 
designing  and  implementing  our  larger  RCT,  using  the  RE-AIM  framework  to  then  study  reach,  effectivPeagnee17sosf 2,2 
adoption, implementation, and maintenance and including a policy environmental assessment of barriers and 
Section 8 - Knowledge Translation 
8.1: Potential for Knowledge Translation/Knowledge Mobilization/Commercialization 
8.2: KT Framework/Platform 

  
Mangin, Dee  
 
facilitators to implementation in routine care. Throughout this process we will leverage the opportunities described 
in section 8.1 to maximise KT. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Page 18 of 22 

  
Mangin, Dee  
 
 
 
Provide tables and figures and a list of references as necessary to support sections above. 
Document appended to the end of the application 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Page 19 of 22 
Section 9 - Supporting Information 

  
Mangin, Dee  
Section 10 - Partnerships & Letters of Support 
 
 
Complete the table below. 
In a single PDF document please provide letters of support for each partner, collaborator etc. Upload this document below. Make sure that each letter of 
support within the PDF is on the organization’s letterhead, detailing the partnership and specifically indicating their cash and/or in-kind contribution. The 
letter should specifically include reference to CFN, the proposed study, and any conditions placed on funding. See Application Instructions for guidance  on 
allowable expenses and eligible partners and contributions. 
Individuals from the partner organizations that will be participating as project team members must be listed in the submitted Project Team Information 
document. 
All financial information provided in the table below must also appear in the submitted budget document. 
Where a researcher has a “financial interest” (as defined by NCE Conflict of Interest Guidelines) in a partner, the potential conflict of interest should be 
declared in the table. This does not preclude the partnership in any way, but provides transparency during the review process. Please see CFN Conflict of 
Interest Policy and Guidelines for additional guidance http://www.cfn-nce.ca/media/23963/cfn-conflict-of-interest-policy.pdf 
 
Partner 
Organization/Research 
Receptor 
Potential 
Conflict of 
Interest 
Role in Project and Specific 
Use of Contribution in 
Project 
Nature of 
Contribution 
Contribution 
Amount (CDN$) 
Data Based Medicine 
Americas Ltd. 
No 
Time, custom web 
development, database 
design, secure platform 
hosting, software licensing, 
and out-of-pocket expenses 
In-Kind 
100000 
 
Download CAT2017-20_Mangin_Partners.pdf 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Page 20 of 22 
Letters of Support 

  
Mangin, Dee  
Section 11 - Other Funding 
 
For all Principal Investigators please provide details on grants currently planned, being applied for, pending and awarded, for the entire period covered by  
this application. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Page 21 of 22 
Status of 
Grant 
Funding 
Source 
Budget 
Amount of 
Grant 
Title of Grant 
% Scientific 
Overlap 
% Financial 
Overlap 
Awarded 
CIHR 
974737 Team Approach to Polypharmacy 
Evaluation and Reduction (TAPER) 
10 
0 
Awarded 
Labarge 
Optimal Aging 
Initiative 
81500 Team Approach to Polypharmacy 
Evaluation and Reduction 
(TAPER)- Long term care (Pilot) 
50 
10 

  
Mangin, Dee  
Supporting Documents 
 
 
 
Download CAT2017-20_Mangin_TeamList.xlsx 
 
Download CAT2017-20_Mangin_Budget.xlsx 
 
Download CAT2017-20_Mangin_PI_CV.pdf 
 
Download CAT2017-20_Mangin_TeamCVs.pdf 
 
Download CAT2017-20_Mangin_Signatures.pdf 
 
Download CAT2017-20_Mangin_REB.pdf 
 
Download CAT2017-20_Mangin_IGH.pdf 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Page 22 of 22 
Project team Information 
Budget 
Principal Investigator CV(s) 
Team Member CVs 
Required Signatures 
Proof of Study Submission to Research Ethics Board 
Proof of Completion of one of CIHR Institute of Gender and Health’s (IGH) online sex- and 
gender-based analysis training modules 

 
Figure 1:  TAPER process 
 

Figure 2: Project Schedule 
 
 
 

Figure 3: Map of barriers 
 
 
 
(1) Reeve E, To J, Hendrix I, Shakib S, Roberts M, Wiese M. Patient Barriers to and Enablers of Deprescribing: a Systematic Review. Drugs & 
Aging [Internet]. 2013;30(10):793-807. Available from: https://link.springer.com/article/10.1007%2Fs40266-013-0106-8 
(2) Dowden A. Deprescribing: reducing inappropriate polypharmacy. Prescriber [Internet]. 2017;28(2):45-49. Available from: 
https://www.ncbi.nlm.nih.gov/pubmed/25798731 
(3) Kesselheim, A., Avorn, J. and Sarpatwari, A. (2016). The High Cost of Prescription Drugs in the United States. JAMA, [online] 316(8), 
p.858. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27552619. 
(4) Reeve, E. and Wiese, M. (2013). Benefits of deprescribing on patients’ adherence to medications. International Journal of Clinical 
Pharmacy, [online] 36(1), pp.26-29. Available at: https://link.springer.com/content/pdf/10.1007/s11096-013-9871-z.pdf. 
(5) Schuling, J., Gebben, H., Veehof, L. and Haaijer-Ruskamp, F. (2012). Deprescribing medication in very elderly patients with 
multimorbidity: the view of Dutch GPs. A qualitative study. BMC Family Practice, [online] 13(1). Available at: 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3391990/. 

 
Figure 4: TAPERMD Screen Shots 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient Priorities and Preferences + 
Screen for potentially 
inappropriate 
medications 
Decision 
support pop up 
Pause and 
Monitor Decision 
Monitoring Plan 
Suggestions for taper rate 
and things to monitor will be 
available where applicable 
Followup notes 

 
Table 1: Summary of proposed data analysis methods for quantitative outcomes 
 
 
 
 
Research question 
Hypothesis 
Outcome 
Outcome 
measure/dat 
a collection 
Timing 
Method 
of 
analysis 
What is the effect of 
a structured 
medication 
discontinuation 
clinical pathway 
designed to reduce 
polypharmacy on 
mean number of 
medications and 
patterns of 
discontinuation 
compared to usual 
practice? 
Reduction in 
mean number 
of medications 
Medication 
from 
reconciliation 
list 
Mean 
number of 
medications 
T0, T6 
t-test 
Proportion 
with 
successful 
reduction in 
medication 
number or 
dose 
T6 
Chi 
Square 
Composite 
variable of 
mean 
number of 
medication 
discontinuati 
ons or dose 
reductions 
T6 
t-test 
What is the effect of 
a structured 
medication 
discontinuation 
clinical pathway 
designed to reduce 
polypharmacy on 
patient quality of 
life, frailty, 
cognition, mobility- 
related fatigue, 
nutritional status, 
physical function 
capacity, pain, sleep, 
patient enablement, 
medication self- 
efficacy, medication 
confusion, grip 
Improved 
frailty, disease 
and treatment 
burden, 
quality of life, 
cognition, 
fatigue, 
nutritional 
status, 
physical 
function 
capacity and 
ability, pain, 
sleep, patient 
enablement, 
medication 
self-efficacy 
and 
Frailty 
Edmonton 
Frail Scale 
T0, T6 
t-test 
Disease burden 
Bayliss 
Disease 
Burden 
T0, T6 
t-test 
Treatment 
burden 
Brief 
Treatment 
Burden 
Scale 
T0, T6 
t-test 
Quality of life 
EQ5D-5L 
(economic 
analysis) 
T0, T6 
t-test for 
all 
Chi 
squared 
for 
proportio 
ns 
SF36v2 
T0, T6 
Cognition 
Mini Mental 
State Exam 
T0, T6 

 
strength, falls and 
adverse events, and 
hospital admissions 
compared to usual 
practice? 
lower/fewer 
falls, 
healthcare 
utilization, 
and adverse 
events will be 
reported in the 
intervention 
arm compared 
to the control 
arm at 6- 
months 
Fatigue 
Avlund 
Mob-T and 
Limb-T 
scale 
T0, T6 
Nutritional 
status 
Mini 
Nutritional 
Assessment 
Short-Form 
T0, T6 
Physical 
function 
capacity and 
ability 
Mänty 
survey 
T0, T6 
Timed up 
and go 
T0, T6 
Global 
rating of 
change 
(balance) 
T0, T6 
Grip 
strength 
T0, T6 
Falls 
Number 
T0, T6 
Pain 
Brief Pain 
Inventory 
T0, T6 
Sleep 
15-D (sleep 
item) 
T0, T6 
Patient 
enablement 
Patient 
Enablement 
Index 
T0, T6 
Medication 
self-efficacy 
Self-efficacy 
for 
appropriate 
medication 
use scale 
T0, T6 
Healthcare 
utilization 
Number of 
hospitalizati 
ons 
T0, T6 
Number of 
ED visits 
T0, T6 
Urgent care 
visits 
T0, T6 
Proportion 
of patients 
with at least 
one 
hospitalizati 
T0, T6 

 
on 
Serious adverse 
events 
Number 
T0, T6 
What is the cost- 
effectiveness of the 
structured 
medication 
discontinuation 
clinical pathway 
designed to reduce 
polypharmacy? 
Not applicable Cost per 
QALY 
Data 
collection 
survey 
developed 
for study, 
EQ5D 
T6 
Cost 
Utility 
Analysis 
What is the 
Not applicable Lived 
Semi- 
T6 
Descripti 
experience of 
experience 
structured 
ve 
patients as they go 
with 
interview/pa 
analysis 
through a structured 
deprescribing 
tient diaries 
medication 
process 
discontinuation 
clinical pathway 
designed to reduce 
polypharmacy? 
Satisfaction 
with the 
intervention 
5-point 
Likert scale 
developed 
for study 
T6 
t-test 
What trajectories do 
patients follow in 
Satisfaction 
5-point 
T0, T6 
t-test 
deprescribing? 
with care 
Likert scale 
around 
developed 
Does deprescribing 
medications 
for study 
transform their 
bio/psycho/social 
Strength and 
weakness of 
intervention 
Open-ended 
question 
T6 
Descripti 
ve 
analysis 
experience of 
chronic disease and 
its management? 
Are there social side 
effects of 
deprescribing? 
What are the 
Not applicable Lived 
Semi- 
T6 
Themati 
experiences of the 
experience 
structured 
c 
pharmacist and 
with 
interview, 
analysis 
family physician of 
deprescribing 
field notes 
managing patients 
process 

 
through the 
Confidence in 
5-point 
T0, T6 
t-test 
deprescribing 
medication 
Likert scale 
process? 
discontinuation developed 
for study 
Five best/worst 
aspects of 
intervention 
Open-ended 
question 
T6 
Descripti 
ve 
analysis 
Implementatio 
NoMAD 
T0, after 
Descripti 
n processes 
3 of 
ve 
their 
analysis 
patients 
have 
reached 
T3 and 
after all 
intervent 
ion 
group 
patients 
have 
complet 
ed T6 
mark T3, 
T6 

 
Table 2: Team contributions 
 
 
Role 
First 
name 
Last Name 
Contribution 
of hours per 
week (based 
on 35hr 
work week) 
Role 
Project Leader 
Dee 
Mangin 
7 
Team lead; co-ordinate 
investigator and steering 
committee meetings; oversee 
the day-to-day operations; 
leading weekly meetings with 
the operational research team; 
supervise the research 
assistants in the day-to-day 
activites with weekly meetings 
including both sites; provide 
input into functional outcomes 
assessment and analysis; lead 
patient/family stakeholder 
engagement in design and KT 
aspects of study 
Co-Investigator 
Gina 
Agarwal 
1.75 
Provide input into functional 
outcomes assessments 
Co-Investigator 
Henry 
Siu 
1.75 
Provide input into functional 
outcomes assessments within 
LTC setting and engagement of 
family members as potential 
substitute decision makers 
Co-Investigator 
Lehana 
Thabane 
3.5 
Provide input into functional 
outcomes assessment and 
analysis; overseeing analysis 
and randomization 

 
Co-Investigator 
Julie 
Richardson 
3.5 
Provide input into functional 
outcomes assessment and 
analysis 
Co-Investigator 
Mat 
Savelli 
1.75 
Lead and oversee the 
qualitative research aspects of 
the study 
Co-Investigator 
Parmind 
er 
Raina 
1.75 
Provide input into functional 
outcomes assessments; provide 
broader context of LTC within 
Canada 
Co-Investigator 
Justin 
Lee 
1.75 
coordinate the expert advisory 
committee of clinical 
pharmacologists, and the 
associated 
geriatric/pharmacologist advice 
service for clinicians 
Co-Investigator 
Jane 
Jurcic-Vrataric 
3.5 Clinical Pharmacist 
Co-Investigator 
Alan 
Cassels 
1.75 
Lead and oversee the 
qualitative research aspects of 
the study; Assist with KT 
activities 
Co-Investigator 
Scott 
Garrison 
1.75 
Assist in analysis and 
randomization 
Co-Investigator 
Anne 
Holbrook 
1.75 
coordinate the expert advisory 
committee of clinical 
pharmacologists, and the 
associated 
geriatric/pharmacologist advice 
service for clinicians; Assist in 
analysis and randomization 

 
Co-Investigator 
Diana 
Sherifali 
1.75 
Provide input into functional 
outcomes assessments 
Co-Investigator 
Cathy 
Risdon 
1.75 
lead patient/family stakeholder 
engagement in design and KT 
aspects of study 
Co-Investigator 
James 
Gillett 
3.5 
Lead and oversee the 
qualitative research aspects of 
the study 
Co-Investigator 
Kiska 
Colwill 
3.5 Clinical Pharmacist 
Co-Investigator 
Joanne 
Ho 
3.5 
coordinate the expert advisory 
committee of clinical 
pharmacologists, and the 
associated 
geriatric/pharmacologist advice 
service for clinicians 
Co-Investigator 
Jobin 
Varughese 
5.25 
lead at LTC sites; oversee 
adapting of TAPER in LTC 
sites; attend weekly operations 
meetings; provide input on 
operational aspects including 
consenting and assessment of 
residents; engagement of KT 
within LTC sites. 
Co-Investigator 
Johanna 
Trimble 
1.75 
lead patient/family stakeholder 
engagement in design and KT 
aspects of study 
Co-Investigator 
Lauren 
Griffith 
1.75 
Provide input into functional 
outcomes assessments 
Co-Investigator 
Kristina 
Frizzle 
3.5 Clinical Pharmacist 

 
Co-Investigator 
James 
McCormack 
1.75 
Provide input into functional 
outcomes assessment and 
analysis 
Collaborator 
Larkin 
Lamarche 
5.25 
Provide input into functional 
outcomes assessments, provide 
support for day-to-day 
operation of study 
HQP 
Alison 
Ross 
3.5 
Assist with the qualitative 
research aspects of the study 
HQP 
Jenna 
Parascandalo 
5.25 
Provide support for operational 
aspects of trial in LTC 
Partner 
Peter 
Wood 
7 
Adapt TAPERMD tool for 
LTC setting 

 
References: 
1. Mangin, D., I. Heath, and M. Jamoulle, Beyond diagnosis: responding to the comorbidity 
challenge British Medical Journal, 2012; 44: e3526. 
2. Tinetti, M.E., S.T. Bogardus, Jr., and J.V. Agostini, Potential Pitfalls of Disease-Specific 
Guidelines for Patients with Multiple Conditions. New England Journal of Medicine, 2004; 
351(27): 2870-2874. 
3. Boyd, C.M., et al., Clinical practice guidelines and quality of care for older patients with 
multiple comorbid diseases: Implications for pay for performance. JAMA, 2005; 294(6): 716- 
724. 
4. Reeve, E., et al., The benefits and harms of deprescribing. Med J Aust, 2014; 201(7): p. 386-9. 
5. Information, C.I.f.H., Drug use among seniors on public drug programs in Canada, 2002 to 
2008.Ottawa: CIHI; 2010 
6. Garfinkel, D. and D. Mangin, Feasibility study of a systematic approach for discontinuation of 
multiple medications in older adults: addressing polypharmacy. Arch Intern Med, 2010; 170(18): 
p. 1648-54. 
7. Rabin, R. and F. de Charro, EQ-5D: a measure of health status from the EuroQol Group. Ann 
Med, 2001; 33(5): 337-43. 
8. Jyrkka, J., et al., Association of polypharmacy with nutritional status, functional ability and 
cognitive capacity over a three-year period in an elderly population. 2011; 20(5):514-22. doi: 
10.1002/pds. 
9. Tinetti, M.E., et al., Antihypertensive medications and serious fall injuries in a nationally 
representative sample of older adults. JAMA Internal Medicine, 2014; 174(4):588-95. doi: 
10.1001/jamainternmed. 
10. Hilmer, S.N. and D. Gnjidic, The effects of polypharmacy in older adults. Clin Pharmacol 
Ther, 2009; 85(1): 86-8. 
11. May, C., V.M. Montori, and F.S. Mair, We need minimally disruptive medicine.2009; 339: 
b2803. 
12. Lu, W.-H., et al., Effect of polypharmacy, potentially inappropriate medications and 
anticholinergic burden on clinical outcomes: a retrospective cohort study. Canadian Medical 
Association Journal. 2015. 
13. Field, T.S., et al., The costs associated with adverse drug events among older adults in the 
ambulatory setting. Med Care, 2005; 43(12): 1171-1176. 
14. Baker, G.R., et al., The Canadian Adverse Events Study: the incidence of adverse events 
among hospital patients in Canada. Canadian Medical Association Journal, 2004; 170(11): 1678- 
1686. 

 
15. CIHI, Seniors and the Health Care System: What Is the Impact of Multiple Chronic 
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