Managing medications in clinically complex elders: "There's got to be a happy medium"

When cardiovascular medicines should be discontinued

An integral component of the practice of medicine is focused on the initiation of medications, based on clinical practice guidelines and underlying trial evidence, which usually test the addition of novel medications intended for life-long use in short-term clinical trials. Much less attention is given to the question of medication discontinuation, especially after a lengthy period of treatment, during which patients age gets older and diseases may either progress or new diseases may emerge. Given the paucity of data, clinical practice guidelines offer little to no guidance on when and how to deprescribe cardiovascular medications. Such decisions are often left to the discretion of clinicians, who, together with their patients, express concern of potential adverse effects of medication discontinuation. Even in the absence of adverse effects, the continuation of medications without any proven effect may cause harm due to drug-drug interactions, the emergence of polypharmacy, and additional preventable spending to already strained health systems. Herein, several cardiovascular medications or medication classes are discussed that in the opinion of this author group should generally be discontinued, either for the prevention of potential harm, for a lack of benefit, or for the availability of better alternatives.

Informatics Tools in Deprescribing and Medication Optimization in Older Adults: Development and Dissemination of VIONE Methodology in a High Reliability Organization

PURPOSE

Polypharmacy is common in older adults, with almost 20% of older adults taking ≥10 medications. They are at great risk for adverse events related to potentially inappropriate medications (PIMs). Although evidence-based methods for deprescribing have been successful at reducing polypharmacy and improving quality of medication use, there are several challenges to implementing these methods on a large scale. VIONE, a medication deprescribing methodology, was developed to reduce polypharmacy and PIMs across the Veterans Health Administration (VHA). (VIONE stands for Vital, Important, Optional, Not indicated, and Every medication has an indication.) This study describes the tools created for implementation of VIONE and the dashboards used to track VIONE implementation and subsequent deprescribing across the VHA; their use and sustainment are examined in a health system-wide adoption of this deprescribing practice in a high reliability organization (HRO).

METHODS

VIONE was disseminated by the VHA via the Diffusion of Excellence Initiative. Dissemination included an implementation toolkit and four dashboards that collect and display data from the electronic medical record to monitor utilization of VIONE, track medication discontinuations, and prospectively identify veterans who may be candidates for deprescribing.

FINDINGS

Between 2016 and the present, VIONE has been adopted at >130 medical centers and influenced almost 700,000 unique patients. In addition, a total of >1.6 million medication orders have been discontinued by >15,000 providers.

IMPLICATIONS

The VIONE methodology and informatics tools were widely disseminated and successfully adopted and sustained nationally in a high reliability organization, leading to a reduction in PIM use by older adults and improved quality and patient safety. Future efforts should continue to consider ways to leverage electronic medical record data and other relevant informatics tools to provide customized clinical decision support to further medication optimization and deprescribing efforts.

Common gastrointestinal drug-drug interactions in geriatrics and the importance of careful planning

INTRODUCTION

Polypharmacy, which uses multiple medications to treat chronic illnesses, is common among elderly patients. However, it can lead to drug interactions, especially with gastrointestinal (GI) medicines that are extensively used. These drug interactions can have severe consequences and pose a significant challenge to healthcare providers. Therefore, it is crucial to identify the underlying mechanisms of these interactions and develop strategies to minimize medication errors.

AREAS COVERED

We analyzed databases on GI illnesses common in older adults, including GERD, peptic ulcer disease, IBS, IBD, constipation, and diarrhea. Our research identified noteworthy drug interactions and utilized major electronic databases such as USFDA, PubMed, Scopus, and Google Scholar until 15 May 202315 May 2023, along with a review of reference lists.

EXPERT OPINION

Aging can affect how the body processes drugs, leading to an increased risk of drug interactions. Therefore, healthcare professionals must carefully evaluate a patient's medical history and health condition to design personalized treatment plans.

A systematic review of randomised-controlled trials on deprescribing outcomes in older adults with polypharmacy

BACKGROUND

Mixed findings about deprescribing impact have emerged from varied study designs, interventions, outcome measures and targeting sub-categories of medications or morbidities. This systematic review controls for study design by reviewing randomised-controlled trials (RCTs) of deprescribing interventions using comprehensive medication profiles. The goal is to provide a synthesis of interventions and patient outcomes to inform healthcare providers and policy makers about deprescribing effectiveness.

OBJECTIVES

This systematic review aims to (1) review RCT deprescribing studies focusing on complete medication reviews of older adults with polypharmacy across all health settings, (2) map patients' clinical and economic outcomes against intervention and implementation strategies and (3) inform research agendas based on observed benefits and best practices.

METHODS

The PRISMA framework for systematic reviews was followed. Databases used were EBSCO Medline, PubMed, Cochrane Library, Scopus and Web of Science. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomised trials.

RESULTS

Fourteen articles were included. Interventions varied in setting, preparation, use of interdisciplinary teams, validated guidelines and tools, patient-centredness and implementation strategy. Thirteen studies (92.9%) found deprescribing interventions reduced the number of drugs and/or doses taken. No studies found threats to patient safety in terms of primary outcomes including morbidity, hospitalisations, emergency room use and falls. Four of five studies identifying health quality of life as a primary outcome found significant effects associated with deprescribing. Both studies with cost as their primary outcome found significant effects as did two with cost as a secondary outcome. Studies did not systematically study how intervention components influenced deprescribing impact. To explore this gap, this review mapped studies' primary outcomes to deprescribing intervention components using the Consolidated Framework for Implementation Research. Five studies had significant, positive primary outcomes related to health-related quality of life (HRQOL), cost and/or hospitalisation, with four reporting patient-centred elements in their intervention.

CONCLUSIONS

RCT primary outcomes found deprescribing is safe and reduces drug number or dose. Five RCTs found a significant deprescribing impact on HRQOL, cost or hospitalisation. Important future research agendas include analysing (1) understudied outcomes like cost, and (2) intervention and implementation components that enhance effectiveness, such as patient-centred elements.

Polypharmacy stewardship: a novel approach to tackle a major public health crisis

With growing global concern regarding medication-related harm, WHO launched a global patient safety challenge, Medication Without Harm, in March, 2017. Multimorbidity, polypharmacy, and fragmented health care (ie, patients attending appointments with multiple physicians in various health-care settings) are key drivers of medication-related harm, which can result in negative functional outcomes, high rates of hospitalisation, and excess morbidity and mortality, particularly in patients with frailty older than 75 years. Some studies have examined the effect of medication stewardship interventions in older patient cohorts, but focused on a narrow spectrum of potentially adverse medication practices, with mixed results. In response to the WHO challenge, we propose the novel concept of broad-spectrum polypharmacy stewardship, a coordinated intervention designed to improve the management of multimorbidities, taking into account potentially inappropriate medications, potential prescribing omissions, drug-drug and drug-disease interactions, and prescribing cascades, aligning treatment regimens with the condition, prognosis, and preferences of the individual patient. Although the safety and efficacy of polypharmacy stewardship need to be tested with well designed clinical trials, we propose that this approach could minimise medication-related harm in older people with multimorbidities exposed to polypharmacy.

Self-Reported Medication Adherence Among Older People Admitted to Hospital: A Descriptive Study

BACKGROUND

Poor medication adherence is prevalent among older people. To optimize therapeutic outcomes, it is crucial to understand the underlying causes and perceptions.

OBJECTIVE

We aimed to investigate the extent of self-reported medication adherence and associated factors among older people admitted to hospital.

METHODS

Individuals living at home aged ≥ 75 years with an emergency admission at a university hospital between September 2018 and September 2021 were included. Participants answered the Medication Adherence Report Scale (MARS-5) questionnaire upon admission regarding their prescribed long-term medications. Participants with a MARS-5 score of 23-25 were defined as adherent and with a score of 5-22 as nonadherent. A multivariable logistic regression analysis was performed to investigate possible factors independently associated with self-reported medication adherence.

RESULTS

A total of 261 individuals were included. The mean age was 84 years (standard deviation 5.7) and the mean MARS-5 score was 23.9 (standard deviation 1.8). Overall, 227 (87%) participants were classified as adherent to their prescribed treatment, while 34 (13%) participants were classified as nonadherent. Participants with cognitive impairment (odds ratio = 0.40, 95% confidence interval 0.18-0.90, p = 0.027) and depression (odds ratio = 0.29, 95% confidence interval 0.10-0.87, p = 0.028) had a lower odds of reporting adherence to their medications.

CONCLUSIONS

The majority of individuals aged ≥ 75 years who were recently hospitalized rated themselves as adherent to their prescribed medications according to MARS-5. Future studies would benefit from adding more possible explanatory factors and combining a self-reported assessment with a more objective measurement of medication adherence.

Research status and hotspots of medication safety in older adults: A bibliometric analysis

Background

Medication safety is a significant concern in healthcare. Research on medication safety for older adults has taken a broad approach, resulting in a range of proposals. At this juncture, it is necessary to identify the main contributors and establish the current developmental status of the principal research topics.

Objective

This study sets out to summarize the state-of-the-art in medication safety for older adults, identifying significant achievements, key topics, and emerging trends.

Methods

The Web of Science Core Collection (WOSCC) database was searched for relevant documentation over the interval 1st January 2000 to 31st December 2021. Annual outputs and citations were identified from the WOS citation reports. CiteSpace and VOSviewer were adopted for bibliometric analysis and visualization that included the distribution of countries/regions, organizations, authors and journals, and an analysis of co-cited references and keywords.

Results

A total of 1,638 documents were retrieved for bibliometric analysis, yielding 34.29 citations per document. Publications have increased over the past two decades, reaching 177 outputs in 2019. Our database encompasses 71 countries/regions, 2,347 organizations, and 7,040 authors. The United States ranks first in terms of scientific activity with 604 publications (36.87%). We have identified the University of Sydney as the most prolific organization (53 publications). J. T. Hanlon, J. H. Gurwitz, D. O'Mahony, and G. Onder are the most influential researchers in terms of publications and citations. The Journal of the American Geriatrics Society ranks first with 89 (5.43%) papers. In terms of major research directions, three topics have been identified from co-cited reference and keyword analysis: (1) estimation of the prevalence and variables associated with polypharmacy and potentially inappropriate medication; (2) analysis of interventions involving pharmacists and the associated impact; (3) patient experience and perception associated with medication use or pharmaceutical care.

Conclusion

Research on medication safety for older adults has progressed significantly over the past two decades. The United States, in particular, has made important contributions to this field. Polypharmacy and potentially inappropriate medication use, interventions involving pharmacists, patient experience and perception represent the current focus of research. Our findings suggest that these directions will continue as research hotspots in the future.

Prolonged use of newly prescribed gabapentin after surgery

BACKGROUND

Surgeons have made substantial efforts to decrease postoperative opioid prescribing, largely because it can lead to prolonged use. These efforts include adoption of non-opioid pain medication including gabapentin. Like opioids, gabapentin use may be prolonged, increasing the risk of altered mental status and even overdose and death when taken concurrently with opioids. However, little is known about postoperative prolonged use of gabapentin in older adults.

METHODS

We merged a 20% sample of Medicare Carrier, MedPAR and Outpatient Files with Part D for 2013-2018. We included patients >65 years old without prior gabapentinoid use who underwent common non-cataract surgical procedures. We defined new postoperative gabapentin as fills for 7 days before surgery until 7 days after discharge. We excluded patients whose discharge disposition was hospice or death. The primary outcome was prolonged use of gabapentin, defined as a fill>90 days after discharge. To identify risk factors for prolonged use, we constructed logistic regression models, adjusted for procedure and patient characteristics, length of stay, disposition location, and care complexity.

RESULTS

Overall, 17,970 patients (3% of all eligible patients) had a new prescription for gabapentin after surgery. Of these, the mean age was 73 years old and 62% were female. The most common procedures were total knee (45%) and total hip (21%) replacements. Prolonged use occurred in 22%. Those with prolonged use were more likely to be women (64% vs. 61%), be non-White (14% vs. 12%), have concurrent prolonged opioid use (44% vs. 18%), and have undergone emergency surgery (8% vs. 4%). On multivariable analysis, being female, having a higher Charlson comorbidity score, having an opioid prescription at discharge and at >90 days and having a higher care complexity were associated with prolonged use of gabapentin.

CONCLUSIONS

More than one-fifth of older adults prescribed gabapentin postoperatively filled a prescription >90 days after discharge, especially among patients with more comorbidities and concurrent prolonged opioid use, increasing the risk of adverse drug events and polypharmacy.

Preferences for pharmacogenomic testing in polypharmacy patients: a discrete choice experiment

Aim: To elicit preferences for pharmacogenomic (PGx) testing in polypharmacy patients. Materials & methods: A face-to-face discrete choice experiment survey was designed and administered to adult polypharmacy patients recruited at a local retail pharmacy in Albuquerque (NM, USA). Results: A total of 128 eligible polypharmacy patients completed the discrete choice experiment survey and significantly preferred a PGx test with lower cost, better confidentiality and higher certainty of identifying best medication/dose and side effects and one that can be used to advocate for their treatment needs (all p < 0.01). Conclusion: This is the first study eliciting preferences for PGx testing among polypharmacy patients. The study found most polypharmacy patients were willing to take a PGx test and their preferences were mostly influenced by test cost.

Patients' attitudes toward deprescribing and their experiences communicating with clinicians and pharmacists

Purpose:

Developing effective deprescribing interventions relies on understanding attitudes, beliefs, and communication challenges of those involved in the deprescribing decision-making process, including the patient, the primary care clinician, and the pharmacist. The objective of this study was to assess patients’ beliefs and attitudes and identify facilitators of and barriers to deprescribing.

Methods:

As part of a larger study, we recruited patients ⩾18 years of age taking ⩾3 chronic medications. Participants were recruited from retail pharmacies associated with the University of Kentucky HealthCare system. They completed an electronic survey that included demographic information, questions about communication with their primary care clinician and pharmacists, and the revised Patients’ Attitudes Toward Deprescribing (rPATD) questionnaire.

Results:

Our analyses included 103 participants (n = 65 identified as female and n = 74 as White/Caucasian) with a mean age of 50.4 years [standard deviation (SD) = 15.5]. Participants reported taking an average of 8.4 daily medications (SD = 6.1). Most participants reported effective communication with clinicians and pharmacists (66.9%) and expressed willingness to stop one of their medications if their clinician said it was possible (83.5%). Predictors of willingness to accept deprescribing were older age [odds ratio (OR) = 2.99, 95% confidence interval (CI) = 1.45–6.2], college/graduate degree (OR = 55.25, 95% CI = 5.74–531.4), perceiving medications as less appropriate (OR = 8.99, 95% CI = 1.1–73.62), and perceived effectiveness of communication with the clinician or pharmacist (OR = 4.56, 95% CI = 0.85–24.35).

Conclusion:

Adults taking ⩾3 chronic medications expressed high willingness to accept deprescribing of medications when their doctor said it was possible. Targeted strategies to facilitate communication within the patient–primary care clinician–pharmacist triad that consider patient characteristics such as age and education level may be necessary ingredients for developing successful deprescribing interventions.

Plain Language Summary

Are patients willing to accept stopping medications?

Sometimes, medicines that a patient takes regularly become inappropriate. In other words, the risks of adverse effects might be greater than a medicine’s potential benefits. The decision to stop such medicines should involve the patient and consider their preferences. We surveyed a group of patients taking multiple medicines to see how they felt about having those medicines stopped. We also asked patients whether and how much they talk to their primary care clinician and pharmacists about their medicines. To qualify for this study, patients had to be at least 18 years old and to take three or more medicines daily; they also needed to speak English. Participants provided demographic information and answered questions about their medicines, their communication with primary care clinicians and pharmacists, and their feelings about having one or more of their medicines stopped. We recruited 107 people and were able to use responses from 103 of them. Their average age was 50 years; 65 of them identified as female, and 75 identified as White/Caucasian. Most of our participants mentioned having conversations with primary care clinicians and pharmacists and said they would be willing to stop a medication if their clinician said it was possible. Older participants, those with more years of education, those who thought their medications might lead to side effects, and those who communicated with their clinician or pharmacists were more willing to have one of their medicines stopped.

Our results indicate that patient characteristics and communication with clinicians and pharmacists are factors to consider when designing interventions to reduce the use of inappropriate medicines.

Multidisciplinary Team Deprescribing Intervention for Polypharmacy in Elderly Orthopedic Inpatients: A Propensity Score-matched Analysis of a Retrospective Cohort Study

Objective This study evaluated the effectiveness of a multidisciplinary team deprescribing intervention to reduce polypharmacy and potentially inappropriate medications (PIMs) in elderly orthopedic inpatients. Methods In this single-center retrospective observational study, orthopedic inpatients ≥75 years old and prescribed ≥6 different medications were enrolled as participants. Interventions comprised multidisciplinary team-led polypharmacy screening and suggestions regarding deprescribing any unnecessary medications during hospital stays. The primary outcome was reduction in the mean number of regular medicines and PIMs. Secondary outcomes included falls, delirium, and other adverse events during hospitalization as well as emergency department visits or unplanned hospital admissions within six months after discharge. Results After propensity score matching, 184 patients (intervention group, n=92; control group, n=92) were included in the analysis. The mean patient age was 83 years old. The mean number of prescribed medications and PIMs at admission were similar in both groups. The mean change in the number of regular medicines was -1.4 [standard deviation (SD), 2.3] in the intervention group and +0.2 (SD, 1.8) in the control group (p<0.001). The mean change in the number of PIMs was -0.5 (SD, 0.9) in the intervention group and +0.1 (SD, 0.8) in the control group (p<0.001). In-hospital adverse events other than falls and delirium were significantly less common in the deprescribing intervention group than in the control group. Conclusion Deprescribing intervention by our multidisciplinary team seems to have been effective in reducing the number of prescribed medicines and PIMs in elderly orthopedic inpatients, with some accompanying reduction in certain adverse events.

Sociodemographic and Health-Related Factors Influencing Drug Intake among the Elderly Population

Excessive drugs intake among the elderly population, including self-medication, constitutes an important public health problem. Polypharmacy may lead to numerous adverse health effects, which become more prevalent when combined with biological changes in seniors. In this cross-sectional study, 500 Polish adults aged ≥60 years (M = 67.9 ± 4.2) were asked to complete a questionnaire via telephone calls, allowing us to identify sociodemographic and health-related factors influencing the daily medications consumption. Our findings revealed that all of the participants were receiving medications; 60.2% of them receive at least 1 to 3 drugs per day (301/500). The most commonly used medications included antihypertensive drugs and analgesics (51.0% and 46.0%, respectively). Taking into account clinical conditions, independent predictors of receiving over 3 medications per day turned out to be (1) coronary artery disease (OR = 6.77; CI 95%, 2.86–16.1), (2) diabetes (OR = 3.23, CI 95%, 1.75–5.95), (3) asthma (OR = 4.87, CI 95%, 2.13–11.1), (4) heart failure (OR = 3.38, CI 95%, 1.59–7.19) and (5) gastroesophageal reflux disease (OR = 1.93, CI 95%, 1.03–3.62). Participants suffering from depression were more likely to take drugs for hypertension (OR = 1.70, CI 95%, 1.04–2.78), while those with anxiety and social loneliness took more painkillers (OR = 2.59, CI 95%, 1.58–4.26 and OR = 2.08, CI 95%, 1.38–3.13, respectively). The most significant sociodemographic factors increasing the drugs intake among the population included in our study were high body mass and subsequent increased BMI values (OR = 2.68, CI 95%, 1.50–4.77). Furthermore, living in a city with over 400,000 inhabitants increased the likelihood of taking antidepressants (OR = 2.18, CI 95%, 1.20–3.94). Our study revealed factors increasing the risk of excessive medications intake and hence, increased susceptibility to some iatrogenic diseases among the elderly population. These factors should be considered by primary care physicians while prescribing appropriate drugs to elderly patients.

Clinical Pharmacist Intervention on Drug-Related Problems among Elderly Patients Admitted to Medical Wards of Northwest Ethiopia Comprehensive Specialized Hospitals: A Multicenter Prospective, Observational Study

Background: Drug therapy in the elderly needs an emphasis on age-related changes in drug pharmacokinetics and pharmacodynamics profile. Hospitalized elderly patients are at risk of more than one disease and polypharmacy associated with these; they are at risk of drug-related problems. This study aimed to assess the role of clinical pharmacy on identifying and resolution of drug-related problems among elderly patients admitted to medical ward of Northwest Ethiopia comprehensive specialized hospitals. Methods: A multicenter prospective observational study was conducted. A systematic sampling technique was used. The identified drug-related problem was recorded and classified using Cipolle, and adverse drug reaction was assessed using Naranjo algorithm of adverse drug reaction probability scale, and Medscape was used for drug-drug interaction. Data were analyzed by using STATA software version 14.1. Logistic regression was used, and results were reported as odds ratios (ORs) with 95% Confidence intervals with $P\text{value}<0.05$ statistically significant. Result: A total of 389 study participants were included in the study. About 266 (68.4%) of the participants had at least a single drug-related problem. About 503 drug-related problems were identified with a mean of 1.32 (CI: 1.27-1.36) drug-related problem per patient. The three-leading categories of drug-related problems were dose too high 108 (21.5%), nonadherence 105 (20.9%), and adverse drug reaction 96 (19.1%). Alcohol use ( $\text{AOR}=2.2$ , 95CI%: 1.23-3.94), source of the drug ( $\text{AOR}=2.85$ , 95CI%: 1.63-4.98), length of hospitalization ( $\text{AOR}=2.32$ , 95CI%: 1.37-3.95), number of comorbidities ( $\text{AOR}=1.48$ , 95CI%: 1.09-1.99), and polypharmacy ( $\text{AOR}=3.06$ , 95CI%: 1.72-5.46) were important risk factors for drug-related problems. From the intervention provided, 84.7% were accepted by prescribers. Among the total drug-related problems 67.4% of the problem was totally solved. Conclusion: This study revealed that DRPs were high among elderly patients admitted to medical ward of Northwest Ethiopia. Comorbidity, length of hospitalization, ploy-pharmacy, payer, and alcohol drinker were more likely to developed drug-related problems. Treatment optimizations were also done by clinical pharmacists and interventions were well accepted by prescribers.

Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis

BACKGROUND

Tackling problematic polypharmacy requires tailoring the use of medicines to individual needs and circumstances. This may involve stopping medicines (deprescribing) but patients and clinicians report uncertainty on how best to do this. The TAILOR medication synthesis sought to help understand how best to support deprescribing in older people living with multimorbidity and polypharmacy.

OBJECTIVES

We identified two research questions: (1) what evidence exists to support the safe, effective and acceptable stopping of medication in this patient group, and (2) how, for whom and in what contexts can safe and effective tailoring of clinical decisions related to medication use work to produce desired outcomes? We thus described three objectives: (1) to undertake a robust scoping review of the literature on stopping medicines in this group to describe what is being done, where and for what effect; (2) to undertake a realist synthesis review to construct a programme theory that describes 'best practice' and helps explain the heterogeneity of deprescribing approaches; and (3) to translate findings into resources to support tailored prescribing in clinical practice.

DATA SOURCES

Experienced information specialists conducted comprehensive searches in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (targeted searches).

REVIEW METHODS

The scoping review followed the five steps described by the Joanna Briggs Institute methodology for conducting a scoping review. The realist review followed the methodological and publication standards for realist reviews described by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) group. Patient and public involvement partners ensured that our analysis retained a patient-centred focus.

RESULTS

Our scoping review identified 9528 abstracts: 8847 were removed at screening and 662 were removed at full-text review. This left 20 studies (published between 2009 and 2020) that examined the effectiveness, safety and acceptability of deprescribing in adults (aged ≥ 50 years) with polypharmacy (five or more prescribed medications) and multimorbidity (two or more conditions). Our analysis revealed that deprescribing under research conditions mapped well to expert guidance on the steps needed for good clinical practice. Our findings offer evidence-informed support to clinicians regarding the safety, clinician acceptability and potential effectiveness of clinical decision-making that demonstrates a structured approach to deprescribing decisions. Our realist review identified 2602 studies with 119 included in the final analysis. The analysis outlined 34 context-mechanism-outcome configurations describing the knowledge work of tailored prescribing under eight headings related to organisational, health-care professional and patient factors, and interventions to improve deprescribing. We conclude that robust tailored deprescribing requires attention to providing an enabling infrastructure, access to data, tailored explanations and trust.

LIMITATIONS

Strict application of our definition of multimorbidity during the scoping review may have had an impact on the relevance of the review to clinical practice. The realist review was limited by the data (evidence) available.

CONCLUSIONS

Our combined reviews recognise deprescribing as a complex intervention and provide support for the safety of structured approaches to deprescribing, but also highlight the need to integrate patient-centred and contextual factors into best practice models.

FUTURE WORK

The TAILOR study has informed new funded research tackling deprescribing in sleep management, and professional education. Further research is being developed to implement tailored prescribing into routine primary care practice.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018107544 and PROSPERO CRD42018104176.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 32. See the NIHR Journals Library website for further project information.

Facing the challenge of polypharmacy when prescribing for older people with cardiovascular disease. A review by the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy

Population ageing has resulted in an increasing number of older people living with chronic diseases (multimorbidity) requiring five or more medications daily (polypharmacy). Ageing produces important changes in the cardiovascular system and represents the most potent single cardiovascular risk factor. Cardiovascular diseases (CVDs) constitute the greatest burden for older people, their caregivers, and healthcare systems. Cardiovascular pharmacotherapy in older people is complex because age-related changes in body composition, organ function, homeostatic mechanisms, and comorbidities modify the pharmacokinetic and pharmacodynamic properties of many commonly used cardiovascular and non-cardiovascular drugs. Additionally, polypharmacy increases the risk of adverse drug reactions and drug interactions, which in turn can lead to increased morbi-mortality and healthcare costs. Unfortunately, evidence of drug efficacy and safety in older people with multimorbidity and polypharmacy is limited because these individuals are frequently underrepresented/excluded from clinical trials. Moreover, clinical guidelines are largely written with a single-disease focus and only occasionally address the issue of coordination of care, when and how to discontinue treatments, if required, or how to prioritize recommendations for patients with multimorbidity and polypharmacy. This review analyses the main challenges confronting healthcare professionals when prescribing in older people with CVD, multimorbidity, and polypharmacy. Our goal is to provide information that can contribute to improving drug prescribing, efficacy, and safety, as well as drug adherence and clinical outcomes.

Estimation of the plasma volume status of elderly patients with acute decompensated heart failure using bedside clinical, biological, and ultrasound parameters

OBJECTIVE

Assessment of intravascular volume status to ensure optimization before hospital discharge could significantly reduce readmissions. It is difficult to evaluate congestion on clinical signs during an episode of acute heart failure (ADHF) in elderly patients.

HYPOTHESIS

There is an association between various volume overload parameters in patients older than 75 years.

METHODS

We performed a single-center prospective longitudinal study of patients older than 75 years hospitalized for acute heart failure. We analyzed the association between congestion assessment based on clinical signs, inferior vena cava (IVC) diameter measured by ultrasound, biological evaluation with N terminal pro brain natriuretic peptide (NT-proBNP), and estimated plasma volume (EPV) during decongestive therapy. We also monitored changes in renal function.

RESULTS

Fifty consecutive ADHF patients (85.2 ± 5.9 years, 68% female) were included in the study. At admission, a dilated, noncompliant IVC was found in all patients. The strongest correlations between different parameters of volume overload estimation were found between IVC and jugular vein distention (r = .8; p < .001), then IVC and oedema (r = .6; p < .001), IVC and crackles (r = .3; p < .036), then IVC and NT-proBNP (r = .3; p = .02). There was no correlation between EPV and signs of congestion. Patients who had no congestive signs on clinical or IVC examination at Day 2, more often presented with acute renal failure.

CONCLUSION

In ADHF patients older than 75 years, clinical and IVC evaluation of intravascular congestion correlate well. The concomitant assessment of clinical signs and IVC may prevent depletion-related renal failure.

Pharmacy students' perceptions on the health and pharmaceutical care needs of older adults

INTRODUCTION

Perceptions of pharmacy students as future health care providers can enhance the health and pharmaceutical care (PC) needs of older adults. The objective of this study was to investigate pharmacy students' awareness and perceptions of the health and PC needs of older adults.

METHODS

A cross-sectional survey was conducted among pharmacy students in Southwest, Nigeria for four weeks using a 39-item structured questionnaire. Unpaired t-tests and one-way analysis of variance were performed. A P < .05 was considered significant.

RESULTS

Based on 422 completed questionnaires, 299 (70.9%) were females, 283 (67.1%) were 20 to 24 years, 123 (29.2%) were in 200 Level, 402 (95.3%) had heard of PC with their first source of information being pharmacy school, 352 (83.4%). Reliability of the instrument was 0.92 (Cronbach's alpha). Mean + SD of pharmacy students' perceived health and PC needs of older adults were 3.73 ± 1.176 and 4.21 ± 1.031, respectively. The majority, 355 (84.2%), agreed on the importance of health care providers understanding their geriatric patients' family circumstances and social environment and 381 (90.3%) perceived that such will strengthen their professional relationship with older adults.

CONCLUSIONS

Pharmacy students were aware of PC and indicated positive attitudes towards caring for older adults but few had provided care. Reinforcement of PC training and emphasis on geriatric topics in pharmacy curriculum are reiterated.

Medications use among women with dementia: a cohort study

BACKGROUND

Older population with dementia use huge range of medications. In this study, we aimed to determine the prevalence of commonly used medications a year before and after first recorded dementia diagnosis among older Australian women.

METHODS

The study utilized Australian Longitudinal Study on Women's Health (ALSWH) data from 2090 women with known dementia, linked with administrative health datasets. The Pharmaceutical Benefits Scheme (PBS) data provided detailed information about prescribed medications. We applied latent class analysis (LCA) to the post-dementia data to identify patterns of medication use. Logistic regression model was used to explore the impact of potential predictors for medication utilization.

RESULTS

Antipsychotic use increased from 5% before dementia to 19% after dementia, while antidementia medication use increased from < 1 to 28%. There was a modest increase in benzodiazepines and antidepressants. Post-dementia, four distinct groups were identified using LCA (names based on probabilities of medications use) as: "High Psychotropic-Low Cardiovascular" (16% of the sample); "Moderate Psychotropic-High Cardiovascular" (12%); "Low Psychotropic-High Cardiovascular" (27%); and "Low Psychotropic-Low Cardiovascular" (45%). Living in Residential Aged Care (RAC) and frailty were associated with increased odds of being in the higher psychotropic use groups.

CONCLUSIONS

Substantial utilization of psychotropic medications by older people with dementia indicates a need for a careful review of the use of these medications. Appropriate alternative approaches to the management of dementia should be practiced with a special focus on RAC residents with frailty.

Gastroesophageal adenocarcinoma in older adults: A comprehensive narrative review of management by the Young International Society of Geriatric Oncology

Gastroesophageal adenocarcinoma is a disease of older adults with very poor survival rates. Its incidence has risen dramatically across the world in recent decades. Current treatment approaches for older adults are based largely on extrapolated evidence from clinical trials conducted in younger and fitter participants than those more commonly encountered in clinical practice. Understanding how to apply available evidence to our patients in the clinic setting is essential given the high morbidity of both curative and palliative treatment. This review aims to use available data to inform the management of an older adult with gastroesophageal adenocarcinoma.

Developing and piloting a self-assessment tool for medication review competence of practicing pharmacists based on nationally set competence criteria

BACKGROUND

New competence requirements have emerged for pharmacists as a result of changing societal needs towards more patient-centred practices. Today, medication review competence can be considered as basic pharmaceutical competence. Medication review specific competence criteria and tools for self-assessing the competence are essential in building competences and a shared understanding of medication reviews as a collaborative practice. The aim of this study was to develop and pilot a self-assessment tool for medication review competence among practicing pharmacists in Finland.

METHODS

The development of the self-assessment tool was based on the national medication review competence criteria for pharmacists established in Finland in 2017 and piloting the tool among practicing pharmacists in a national online survey in October 2018. The pharmacists self-assessed their medication review competence with a five-point Likert scale ranging from 1 for "very poor/not at all" to 5 for "very good".

RESULTS

The internal consistency of the self-assessment tool was high as the range of the competence areas' Cronbach's alpha was 0.953-0.973. The competence areas consisted of prescription review competence (20 items, Cronbach's alpha 0.953), additional statements for medication review competence (11 additional items, Cronbach's alpha 0.963) and medication review as a whole, including both the statements of prescription review and medication review competence (31 items, Cronbach's alpha 0.973). Competence items closely related to routine dispensing were most commonly self-estimated to be mastered by the practicing pharmacists who responded (n = 344), while the more clinical and patient-centred competence items had the lowest self-estimates. This indicates that the self-assessment tool works logically and differentiates pharmacists according to competence. The self-assessed medication review competence was at a very good or good level among more than half (55%) of the respondents (n = 344).

CONCLUSION

A self-assessment tool for medication review competence was developed and validated. The piloted self-assessment tool can be used for regular evaluation of practicing pharmacists' medication review competence which is becoming an increasingly important basis for their contribution to patient care and society.

Abuse/Misuse of Prescription Medications in Older Adults

The world population is aging due to increasing life expectancy. The rate of drug use increases, and inappropriate prescribing is frequently encountered with advancing age. In addition, misuse and abuse of prescription drugs is a serious problem in older adults. It is challenging to detect substance and drug abuse in older patients because it may have fewer consequences in social, legal, and occupational fields. However, there is not enough information about the screening, evaluation, diagnosis, and treatment of abuse. Therefore, the awareness of health care professionals and others involved in older patients' care should be raised about the misuse and abuse of drugs.

Methodological Challenges for Epidemiologic Studies of Deprescribing at the End of Life

Purpose of Review

To describe approaches to measuring deprescribing and associated outcomes in studies of patients approaching end of life (EOL).

Recent Findings

We reviewed studies published through 2020 that evaluated deprescribing in patients with limited life expectancy and approaching EOL. Deprescribing includes reducing the number of medications, decreasing medication dose(s), and eliminating potentially inappropriate medications. Tools such as STOPPFrail, OncPal, and the Unnecessary Drug Use Measure can facilitate deprescribing. Outcome measures vary and selection of measures should align with the operationalized deprescribing definition used by study investigators.

Summary

EOL deprescribing considerations include medication appropriateness in the context of patient goals for care, expected benefit from medication given life expectancy, and heightened potential for medication-related harm as death nears. Additional data are needed on how EOL deprescribing impacts patient quality of life, caregiver burden, and out-of-pocket medication-related costs to patients and caregivers. Investigators should design deprescribing studies with this information in mind.

Shared Medication PLanning In (SIMPLIfy) Home Hospice: An Educational Program to Enable Goal-Concordant Prescribing In Home Hospice

CONTEXT

Simplifying medication regimens by tapering and/or withdrawing unnecessary drugs is important to optimize quality of life and safety for patients with serious illness. Few resources are available to educate clinicians, patients and family caregivers about this process.

OBJECTIVE

To describe the development of an educational program called Shared Medication PLanning In (SIMPLIfy) Home Hospice.

METHODS

An environmental scan identified a state-of-the-art educational program for home hospice deprescribing that we adapted using a stakeholder panel engagement process. The stakeholder panel (two hospice administrators, three nurses, two physicians, two pharmacists, and two former family caregivers) drawn from two geographically diverse hospice agencies reviewed the educational program and recommended additional content.

RESULTS

Iterative rounds of review and feedback resulted in: 1) a three-part clinician educational program (total duration = 1.5 hour) that presents a standardized, goal-concordant, medication review approach to align medications and conversations about regimen simplification with patient and family caregiver goals of care; 2) a patient-family caregiver medication management educational notebook that presents common symptoms, hospice medications, and medication regimen simplification principles; and 3) a brief guide including helpful phrases to use as conversation starters for key steps in the program. A professional designer created thematic coherence for all materials that was well received by stakeholder panelists and hospice staff.

CONCLUSION

Educational materials can support hospice programs' and clinicians' efforts to implement goal-concordant medication simplification that optimizes end-of-life outcomes for patients and family caregivers. Evaluation of outcomes including medication appropriateness and family caregiver medication administration burden are not yet available.

Polypharmacy and Potentially Inappropriate Medication Use in Older Blacks with Diabetes Mellitus Presenting to the Emergency Department

Background: Medication-related problems in older Blacks with diabetes mellitus (DM) are not well established. Objectives: To describe the frequency of medication-related problems in older Blacks with DM presenting to the emergency department (ED). Methods: The study was a cross-sectional analysis of baseline data from a randomized controlled trial evaluating Blacks aged ≥60 years of age presenting to the ED. Polypharmacy, potentially inappropriate medication (PIM) use, and anticholinergic score were evaluated. Results: Of 168 patients (median age = 68, range 60-92), most (n = 164, 98%) were taking ≥5 medications, and 67 (39.9%) were taking a PIM. A majority (n = 124, 74%) were taking a medication with an anticholinergic score ≥1. Number of medications was correlated with number of PIMs (r = .22, p = .004) and anticholinergic score (r = .50, p < .001). Conclusion: Polypharmacy and PIM use was common in older Blacks with DM.

Structured medicines reviews in HIV outpatients: a feasibility study (The MOR Study)

OBJECTIVES

Polypharmacy in people living with HIV (PLWH) increases the risks of medicine-related problems (events or circumstances involving drug therapy that actually or potentially interfere with desired health outcomes). We aimed to examine the feasibility and acceptability of a Medicines Management Optimisation Review (MOR) toolkit in HIV outpatients.

METHODS

This was a multi-centre randomized controlled study across four HIV centres. In all, 200 PLWH on combination antiretroviral therapy, either > 50 years old or < 50 years with other comorbidities, were enrolled to have a MOR or received standard pharmaceutical care. The primary outcome was the difference in the number of medicine-related problems (MRPs) between intervention and standard care groups at baseline and 6 months. Acceptability, cost of the intervention and health-related quality of life were also examined.

RESULTS

In all, 164 patients were analysed: 70 in the intervention group and 94 in the standard care group. A significant number of MRPs were detected in those patients receiving MOR compared with the standard care group at baseline (93 vs. 2; p = 0.001, z = -8.6, r = 0.6) and 6 months (33 vs. 3; p = 0.001, z = -5.7, r = 0.4). A significant reduction in the number of new MRPs at 6 months in the intervention group versus baseline was also observed (p = 0.001, Z = -3.7, r = 0.2); 44% of MRPs were fully resolved at baseline and 51% at 6 months. No changes in health-related quality of life following MOR or between MOR and standard care groups were observed. The MORs were highly acceptable among patients and healthcare professionals.

CONCLUSIONS

The MOR toolkit was feasible and acceptable, suggesting that HIV outpatient services might consider implementing MOR for targeted populations under their care.

Pharmacist-led interventions to improve medication adherence in older adults: A meta-analysis

BACKGROUND/OBJECTIVE

As pharmacists work to ensure reimbursement for chronic disease management services on the national level, evidence of their impact on important health metrics, such as medication adherence, is needed. However, summative evidence is lacking on the effectiveness of pharmacists to improve medication adherence in older adults. The objective was to assess the effectiveness of pharmacist-led interventions on medication adherence in older adults (65+ years).

DESIGN/SETTING/PARTICIPANTS

Using a systematic review and meta-analytic approach, a comprehensive search of publications in PubMed, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar was conducted through April 2, 2020 for randomized clinical trials of pharmacist-led interventions to improve medication adherence in older adults. A standardized mean difference effect size (Cohen's d) was calculated for medication adherence in each study. Study effect sizes were pooled using a random-effects model, with effect sizes weighted by inverse of its total variance.

MEASUREMENTS

Medication adherence using any method of measurement.

RESULTS

Among 40 unique randomized trials of pharmacist-led interventions with data from 8822 unique patients (mean age, range: 65-85 years), the mean effect size was 0.57 (k = 40; 95% Confidence Interval [CI]: 0.38-0.76). When two outlier studies were excluded from the analysis, the mean effect size reduced to 0.41 (k = 38; 95% CI: 0.27-0.54). A sensitivity analysis of medication adherence outcome by time point resulted in a mean effect size of 0.64 at 3 months (k = 12; 95% CI: 0.32-0.97), 0.30 at 6 months (k = 13; 95% CI: 0.11-0.48), 0.22 at 12 months (k = 12; 95% CI: 0.08-0.37), and 0.36 for outcome time points beyond 12 months (k = 5; 95% CI: 0.02-0.70).

CONCLUSION

This meta-analysis found a significant improvement in medication adherence among older adults receiving pharmacist-led interventions. Implementation of pharmacist-led interventions supported by Medicare reimbursement could ensure older adults' access to effective medication adherence support.

Real‑world challenge for clinicians treating advanced gastroesophageal adenocarcinoma (Review)

Gastroesophageal adenocarcinoma (GOA) is a disease of older people. Incidence is rising in the developed world and the majority of patients present with advanced disease. Based on clinical trial data, systemic chemotherapy in the advanced setting is associated with improvements in quality of life and survival. However, there is a recognised mismatch between trial populations and the patients encountered in clinical practice in terms of age, comorbidity and fitness. Appropriate patient selection is essential to safely deliver effective treatment. In this narrative review, we discuss the challenges faced by clinicians when assessing real‑world patients with advanced GOA for systemic therapy. We also highlight the importance of frailty screening and the current available evidence we can use to guide our management.

Impact of pharmacist-led medication therapy management in ambulatory elderly patients with chronic diseases

AIMS

This study aimed to assess the impact of pharmacist-led medication therapy management (MTM) performed on ambulatory elderly patients with chronic diseases.

METHODS

Patients who came to a pharmacist-led outpatient clinic between January 2016 and June 2018 were enrolled in this study. Eligible subjects received MTM services from the pharmacists at least twice a year and the clinical data of these patients were complete. Drug-related problems (DRPs) and recommendations were evaluated using The Pharmaceutical Care Network Europe Classification for Drug related problems V8.03.

RESULTS

A total of 525 DRPs were identified during the study period. Treatment effectiveness (53.71%) was the most common DRP. The most frequently recommended intervention was changing the drug (48.76%). There were 92.38% patients accepting the interventions and 90.48% patients completely implemented. The number of drugs taken was the significant associated factor for DRPs. Postintervention data collection showed lower levels in systolic blood pressure (BP) and diastolic BP compared to the preintervention data collection. There were statistically significant changes in total cholesterol, low-density lipoprotein cholesterol and triglycerides between the pre- and postintervention data collections. The average cost of medications per patient for every month decreased from 387.72 to 355.17 renminbi (P = .009).

CONCLUSION

We confirmed that pharmacists had a valuable role to perform MTM services for ambulatory elderly patients, not only in identifying and solving the DRPs, but also in improving clinical outcomes (BP and lipid level) and cost-saving effect.

Interprofessional medication assessment among home care patients: any impact on functioning? Results from a randomised controlled trial

Background

Multimorbidity and polypharmacy are related to the use of potentially inappropriate medicines and negative clinical outcomes including drug-related adverse events and functional declines. Home care clients are a vulnerable patient group often exposed to these risks. The aim of this study was to examine whether an interprofessional medication assessment can influence the functioning of home care patients.

Methods

The FIMA study was a randomised controlled intervention study comparing a general practitioner-led interprofessional medication assessment conducted at the baseline of the study with usual care with a six-month follow-up. We used linear mixed models (LMM) with a random subject effect to detect differences between the usual care and intervention groups in the following outcome measures; Katz index of Activities of Daily Living (ADL), Lawton and Brody scale of Instrumental Activities of Daily Living, Timed up and go-test (TUG), Mini-Mental State Examination, Geriatric Depression Scale and the 3-level version of EQ-5D.

Results

Home care patients (n = 512) had major disease burdens and functional limitations. Regarding TUG times, the LMM detected a one second improvement in the FIMA group and 2.4 s worsening in the usual care group. However, the result was not statistically significant. The ADL revealed an interaction across time, treatment and sex (p = 0.026). The ADL score decreased in both groups; the decline being the steepest among women in the intervention group.

Conclusions

In general, medication assessments may have limited impact on functioning of older people. Nonetheless, the FIMA intervention may prevent worsening of mobility among older home care patients.

Trial registration

The Interprofessional Medication Assessment for Older Patients, Clinical Trials.gov. NCT02398812. First registration, 26 March 2015. Retrospectively registered.

Challenges in Designing a Fully Autonomous Socially Assistive Robot for People with Parkinson’s Disease

Assistive robots are becoming an increasingly important application platform for research in robotics, AI, and HRI, as there is a pressing need to develop systems that support the elderly and people with disabilities, with a clear path to market. Yet, what remains unclear is whether current autonomous systems are already up to the task or whether additional HRI work is needed to make these systems acceptable and useful.

In this article, we report our efforts of developing and evaluating an architecture for a fully autonomous robot designed to assist older adults with Parkinson’s disease (PD) in sorting their medications. The main goal for the robot is to aid users in a manner that maintains the autonomy of the user by providing cognitive and social support with varying levels of assistance. We first evaluated the robot with subjects drawn from a pool of university students, which is common practice in experimental work in psychology and HRI. As the results were very positive, we followed up with an evaluation using people with Parkinson’s disease, who surprisingly had mostly negative outcomes. We thus report our analysis of the differences in the evaluations and discuss the challenges for HRI posed by the sources of the negative evaluations: (1) designing a robot to adapt to the many routines the participants use at home, (2) unique needs of participants with PD not present in student participants, and (3) the role of familiar technologies in designing and evaluating a new technology. While it is unlikely, given the current state of technology, that fully autonomous assistive robots for older adults will be available in the near term, we believe that our work exposes a critical need in HRI to involve the target population as early as possible in the design process.

Burden of multimorbidity and polypharmacy among cancer survivors: a population-based nested case-control study

PURPOSE

Individuals living with cancer have been shown to have a higher burden of comorbid disease and multimorbidity in comparison to their cancer-free counterparts consequently, leaving them at risk of polypharmacy (i.e., ≥ 5 medications) and its potential negative effects. The primary aim of the current study was to examine the self-reported prevalence of and association between multimorbidity and prescription medication use in a population-based sample of adult cancer survivors (CS).

METHODS

This retrospective, nested case-control study drew participant data from the Atlantic Partnership for Tomorrow's Health cohort. CS (n = 1708) were matched to 4 non-cancer controls (n = 6832) by age and sex. Prevalence of polypharmacy by number of chronic conditions and age was estimated with 95% CI. Logistic regression was used to examine the association between multimorbidity and polypharmacy while adjusting for sociodemographic and lifestyle factors. The comorbidity-polypharmacy score was also calculated as an estimate of disease burden.

RESULTS

Multimorbidity was common in both CS (53%) and non-cancer controls (43%); however, a significantly higher percentage of CS reported multimorbidity (p < 0.001). Prescription medication use was also found to be significantly higher among CS (2.3 ± 2.6) compared to non-cancer controls (1.8 ± 2.3; p < 0.0001). Exploratory comorbidity-polypharmacy score analyses indicated that CS had a significantly higher overall disease burden than the age/sex-matched non-cancer controls.

CONCLUSIONS

As CS appear to be at a higher risk of multimorbidity and polypharmacy and by extension, increased healthcare burden, ongoing education on the prevention of medication-related harm, and interventions to reduce the occurrence of both co-morbid disease and unnecessary medications are warranted.

Use of medicines by adults in primary care: Survey on health services in Minas Gerais, Brazil

INTRODUCTION

Inappropriate use and increase of health care spending reinforce the need to extend our knowledge about the quality of medication use.

OBJECTIVES

To describe and evaluate the profile of medication use in a representative sample of adult users of primary care services in the Unified Health System (SUS) of Minas Gerais.

METHOD

Cross-sectional study, with 1,159 interviewees in 104 municipalities and 253 health care services. Data on sociodemographic characteristics, health conditions and use of medicines were collected, and these variables were stratified by age group. Univariate and multivariate analyses, using logistic regression, were conducted to identify predictors of self-medication. We set a significance level of 5% for all tests.

RESULTS

The prevalence of medication use was 81.8%, with an average of 2.67 medicines per user, which increased with age. The most used drugs were losartan, hydrochlorothiazide and simvastatin, which differed between age groups. Significant self-medication was observed not only in young adults but also in the elderly. The predictors of self-medication were: being a young adult, having a higher level of education, not having chronic diseases, having worse self-perception of health and not adhering to prescription drugs. Young and elderly adults showed characteristics that made them more vulnerable in relation to the rational use of medicines.

CONCLUSION

This study can contribute to improving primary care, where it identified problems related to the extent of medication use, especially among young adults and the elderly in Minas Gerais.

Development of an electronic tool (e-AdPharm) to address unmet needs and barriers of community pharmacists to provide medication adherence support to patients

BACKGROUND

Community pharmacists are best placed to improve medication adherence because they frequently interact with patients and have been trained to manage medication-related problems. Therefore, it is essential to equip pharmacists adequately to detect non-adherent patients quickly and intervene to improve medication adherence.

OBJECTIVE

To design e-AdPharm, a tool that addresses unmet needs and barriers of community pharmacists to provide medication adherence support to patients with chronic diseases.

METHODS

A qualitative study using 4 focus group discussions with community pharmacists was conducted with a semi-structured interview guide and discussions lasting for 1-2 h. The discussions covered the barriers and needs of pharmacists related to medication adherence support provided to patients, their expectations of an electronic tool based on prescription refills to help them provide this support, and the design of the tool. Focus group data were coded and analyzed using an iterative process, with thematic and descriptive analyses.

RESULTS

Twenty-six community pharmacists participated. Lack of time and motivation from pharmacists and patients were common barriers to the provision of medication adherence support. Accordingly, community pharmacists wished to measure medication adherence quickly, provide easily interpretable data to patients on their medication use, and raise the patient's awareness of non-adherence. The pharmacists expressed their need to have an electronic tool to share medication adherence information with the treating physician. Regarding the design of e-AdPharm, the pharmacists wanted a table displaying medication adherence with a color code representing adherence level. They also stressed the importance of a structured section enabling them to continuously document the interventions made and the need for patient follow-ups.

CONCLUSIONS

e-AdPharm meet the needs and overcome the barriers of community pharmacists to provide medication adherence support to their patients. Future studies should examine the feasibility of implementing e-AdPharm in community pharmacies and test its efficacy for improving medication adherence.

Achieving sequential therapy in advanced gastric cancer: the importance of appropriate patient management for the elderly and/or those with ascites

Treatment options for patients with advanced gastric cancer (AGC) are limited. One approach to improving survival in patients with AGC is to optimize the available agents via sequential therapy. However, clinical trial reports of first-line chemotherapy indicate that elderly patients and patients with massive ascites are less likely to receive subsequent lines of therapy. In addition, clinical trials of second- and third-line chemotherapy generally exclude these two patient populations because they are likely to have poor performance status and additional issues that are difficult to manage. Good patient management is likely to be key to the successful use of sequential therapy in these two patient populations by minimizing adverse effects to allow patients to derive benefit from the additional treatment. This narrative review summarizes the available information on AGC treatment and patient management in elderly patients and patients with massive ascites. The available data suggest that elderly patients benefit from chemotherapy; however, monitoring toxicity is essential to avoid chemotherapy-related toxicities. Important aspects of patient management for elderly patients include symptom monitoring, nutritional support, and fall prevention. The available data for patients with massive ascites show limited success for a range of treatment approaches, including systemic chemotherapy. The management of ascites is also challenging, with no clear guidance on the preferred strategies. To address these gaps in knowledge, future clinical trials should incorporate more inclusive eligibility criteria to enroll populations of patients with AGC that are more reflective of the real-world population with respect to age, complications, and overall health status.

Diagnosis and Management of Dementia: Review

Importance

Worldwide, 47 million people live with dementia and, by 2050, the number is expected to increase to 131 million.

Observations

Dementia is an acquired loss of cognition in multiple cognitive domains sufficiently severe to affect social or occupational function. In the United States, Alzheimer disease, one cause of dementia, affects 5.8 million people. Dementia is commonly associated with more than 1 neuropathology, usually Alzheimer disease with cerebrovascular pathology. Diagnosing dementia requires a history evaluating for cognitive decline and impairment in daily activities, with corroboration from a close friend or family member, in addition to a thorough mental status examination by a clinician to delineate impairments in memory, language, attention, visuospatial cognition such as spatial orientation, executive function, and mood. Brief cognitive impairment screening questionnaires can assist in initiating and organizing the cognitive assessment. However, if the assessment is inconclusive (eg, symptoms present, but normal examination findings), neuropsychological testing can help determine whether dementia is present. Physical examination may help identify the etiology of dementia. For example, focal neurologic abnormalities suggest stroke. Brain neuroimaging may demonstrate structural changes including, but not limited to, focal atrophy, infarcts, and tumor, that may not be identified on physical examination. Additional evaluation with cerebrospinal fluid assays or genetic testing may be considered in atypical dementia cases, such as age of onset younger than 65 years, rapid symptom onset, and/or impairment in multiple cognitive domains but not episodic memory. For treatment, patients may benefit from nonpharmacologic approaches, including cognitively engaging activities such as reading, physical exercise such as walking, and socialization such as family gatherings. Pharmacologic approaches can provide modest symptomatic relief. For Alzheimer disease, this includes an acetylcholinesterase inhibitor such as donepezil for mild to severe dementia, and memantine (used alone or as an add-on therapy) for moderate to severe dementia. Rivastigmine can be used to treat symptomatic Parkinson disease dementia.

Conclusions and Relevance

Alzheimer disease currently affects 5.8 million persons in the United States and is a common cause of dementia, which is usually accompanied by other neuropathology, often cerebrovascular disease such as brain infarcts. Causes of dementia can be diagnosed by medical history, cognitive and physical examination, laboratory testing, and brain imaging. Management should include both nonpharmacologic and pharmacologic approaches, although efficacy of available treatments remains limited.

Older persons' experiences regarding evaluation of their medication treatment-An interview study in Sweden

BACKGROUND

Older persons with polypharmacy are at increased risk of harm from medications, and this issue is a global patient safety challenge. Harm may arise at all stages of medication use and may cause hospital admission, additional resource utilization and lower patient satisfaction. Older persons' participation in their own care may increase patient safety. Their views on the evaluation of their medication treatment, and their own involvement in it, are crucial yet poorly understood.

OBJECTIVES

To identify opportunities to make the medication use process safer, we explored and described older persons' experiences of evaluation of their medication treatment.

DESIGN

Semi-structured interviews were performed with 20 community-dwelling older persons (age 75-91 years) in Sweden. Data were analysed using inductive qualitative content analysis.

RESULTS

These older persons reported having a responsibility to engage in their medication evaluations, although some felt unable to do so or considered themselves unconcerned. Evaluation, in their experience, was facilitated by continuity of care and an invitation to participate. However, some older persons experienced not receiving a comprehensive medication evaluation.

DISCUSSION AND CONCLUSION

Older persons want to be actively involved in their medication evaluations, and this may represent an underutilized resource in the pursuit of patient safety. Their trust in physicians to undertake evaluations on a regular basis, although that does not necessarily occur, may cause harm. Patient safety could benefit from a co-production approach to medication evaluations, with health-care professionals explicitly sharing information with older persons and agreeing on responsibilities related to on-going medication treatment.

Development and Application of a Measurement Framework to Evaluate Safe, Effective and Efficient Medication Use Among Older Adults

Background

A majority of older adults in the United States (US) use prescription medications. Comprehensive population-level approaches to examine medication safety, effectiveness, and costs among older adults are needed.

Objectives

The objectives of this study were to develop a framework of quality measures spanning the domains of safety, effectiveness, and efficiency of prescription medication use among older adults, and to apply those measures using pharmacy claims data.

Methods

We performed a retrospective study among adults age 65 years and older of a US East Coast state who filled at least one prescription from a particular pharmacy chain during 2016 (N = 99,056). Firstly, we performed an environmental scan to identify quality measures and potentially relevant measures addressing prescription medication use. These measures were reviewed and rated by local geriatric pharmacotherapy experts. After evaluating feasibility, evidence, and relevance, a total of 19 measures representing the domains of safety (n = 7), effectiveness (n = 7), and efficiency (n = 5) were identified. These measures were then applied to an older adult population using prescription data for the year 2016 provided by a national pharmacy chain. All measures were configured such that a score of 100% corresponded to optimal performance.

Results

For the domain of safety, 12.8% of patients received a benzodiazepine chronically, 23.6% received central nervous system depressants, 16.7% received fluoroquinolones as first-line antibiotic therapy, and 21.9% of those who were prescribed opioids received them in excessive quantities. For the domain of effectiveness, one-fourth of the diabetes patients did not receive statins and angiotensin-acting medications, while 18.0% were not adherent to oral anticoagulant medications and 54% were not adherent to respiratory inhalers. For the domain of efficiency, 12.0% of the patients received prescriptions from five or more unique prescribers. Overall, 85.7%, 76.1%, and 87.9% of the older adults showed safe, effective, and efficient prescription medication use, respectively.

Conclusion

A novel approach to comprehensively examine the quality of medication use among older adults using prescription claims data is provided in our study. A considerable proportion of the older adults in our study received safe, effective, and efficient prescription medications. However, within each domain, several opportunities for improving the alignment of prescription medication use with current recommendations were identified.

Electronic supplementary material

The online version of this article (10.1007/s40801-019-00162-x) contains supplementary material, which is available to authorized users.

Self-reported barriers to medication use in older women: Findings from the Women's Health Initiative

OBJECTIVES

To describe the prevalence of, types of, and characteristics associated with self-reporting multiple (≥ 2) barriers to medication use in older women using long-term cardiovascular and oral hypoglycemic medications.

METHODS

This cross-sectional study set at the Women's Health Initiative during 2005-2010 included women who were using any chronic medication from 3 target classes (i.e., antilipemics, antihypertensives, oral hypoglycemics) for at least 1 month and who had answered questions about barriers to medication use at year 4 (2009) of the study period (N = 59,054). Measurements included common self-reported barriers to medication use, and sociodemographic, health characteristic, medication use, and access to care variables were evaluated. Multivariable logistic regression models were used to examine associations between participant characteristics and barriers to medication use.

RESULTS

Among the participants, 47,846 (81%) reported no barriers, 7105 (12%) reported 1 barrier, and 4103 (6.9%) reported 2 or more barriers to medication use. The most common barriers reported were having concerns about adverse effects, not liking to take medications, and medications costing too much. Several characteristics were found to be associated with reporting 2 or more barriers in multivariable modeling, including demographic (e.g., lower age, black race, Hispanic ethnicity) and health or medication (e.g., lower quality of life, lower physical function, higher number of concurrent medications) characteristics.

CONCLUSION

Among older women using chronic cardiovascular and oral hypoglycemic medications, approximately 20% reported at least 1 barrier to medication use, with 7% of women reporting multiple barriers. Pharmacists should prioritize identifying barriers to medication use in older women using chronic medications to improve patient care.

Development of a trigger tool for the detection of adverse drug events in Chinese geriatric inpatients using the Delphi method

Background The global trigger tool is a method of retrospective medical record review that identifies possible harm in hospitalized patients using "triggers". Elderly patients with multiple co-morbid illnesses are especially vulnerable to adverse drug events (ADEs) that have high prevalence rates. Objective The purpose of this study was to develop an appropriate trigger tool to detect ADEs in Chinese geriatric inpatients by combining a literature review with the Delphi method. Setting Chinese geriatric inpatients. Methods Two steps were used to develop the trigger tool. First, we conducted a comprehensive literature review for existing ADE triggers (adult or elderly) to form the initial triggers for the Delphi process. Second, a group of clinical experts, including physicians, clinical pharmacists and nurses, was established to score candidate triggers for utility according to the usefulness and feasibility of implementing triggers in clinical practice. Main outcome measures The frequency of the full mark, arithmetic mean and coefficient of variation of each trigger. Results An initial set of 51 triggers was selected by literature review for evaluation. The group of experts was composed of 18 clinical experts: 13 physicians, 4 clinical pharmacists, and 1 nurse. Based on the two-phase Delphi process, 42 triggers in five categories (laboratory index, plasma concentration, antidotes, clinical symptoms and intervention) were retained. Conclusion The 42-trigger tool was developed to identify ADEs in Chinese geriatric inpatients. A pilot study that tests the list of triggers to identify ADEs in Chinese geriatric inpatients is the next step for establishing a specific trigger tool for Chinese geriatric inpatients.

Adverse events identified by the global trigger tool at a university hospital: A retrospective medical record review

OBJECTIVES

The purpose of this study was to describe the level, preventability and categories of adverse events (AEs) in Chinese geriatric patients identified by medical record review using the Global Trigger Tool. The applicability of the GTT was also assessed to explore possible modifications for trigger tools.

METHODS

The study was conducted at a 4300-bed tertiary teaching hospital. Twenty randomly-selected medical records for patients over 60 were reviewed every 2 weeks from January 1 2015 to December 31st, 2015. We studied 480 medical records in total. Two trained specialists reviewed the presence of AEs using 43 triggers, and a physician reviewed and validated the findings. The outcome measures included the number of AEs per 1000 patient days, AEs per 100 admissions, the percentage of entries with at least 1 AE and AE categorisation. Also, we carried out a descriptive analysis of the suspected factors of AEs, such as age, gender, length of stay, surgery.

RESULTS

A total of 610 AEs were detected in the 480 medical records reviewed, corresponding to 127 injuries per 100 admissions. The number of AEs per 1000 patient days was 22.43. AEs occurred at least once in 329 (68.54%) patients. The rate of care harms ranked highest of all AEs, followed by the rate of medication harms and surgical harms. Patients with a more extended hospital stay or surgery was more likely to experience AEs. However, there was a negative correlation between age and the rate of AEs.

CONCLUSION

The Global Trigger Tool was a useful method for detecting the characteristics of AEs in geriatric patients in a Chinese tertiary teaching hospital. To improve patients' safety, this tool should be incorporated into routine screening systems.

Nurses' Perspectives on Family Caregiver Medication Management Support and Deprescribing

Nurses who care for patients with life-limiting illness operate at the interface of family caregivers (FCGs), patients, and prescribers and are uniquely positioned to guide late-life medication management, including challenging discussions about deprescribing. The study objective was to describe nurses' perspectives about their role in hospice FCG medication management. Content analysis was used to analyze qualitative interviews with nurses from a parent study exploring views on medication management and deprescribing for advanced cancer patients. Ten home and inpatient hospice nurses, drawn from 3 hospice agencies and their referring hospital systems in New England, were asked to describe current practices of medication management and deprescribing and to evaluate a pilot tool to standardize hospice medication review. Analysis of the 10 interviews revealed that hospice nurses are receptive to a standardized approach for comprehensive medication review upon hospice transition and responded favorably to opportunities to discuss medication discontinuation with FCGs and prescribers. Effective framing for discussions included focus on reducing harmful and nonessential medications and reducing caregiver burden. Results indicate that nurses who care for hospice-eligible and enrolled patients are willing to discuss deprescribing with FCGs and prescribers when conversations are framed around medication harms and their impact on quality of life.

Explicit criteria as clinical tools to minimize inappropriate medication use and its consequences

Polypharmacy and prescribing of potentially inappropriate medications (PIMs) are the key elements of inappropriate medication use (IMU) in older multimorbid people. IMU is associated with a range of negative healthcare consequences including adverse drug events and unplanned hospitalizations. Furthermore, prescribing guidelines are commonly derived from randomized controlled clinical trials which have specifically excluded older adults with multimorbidity. Consequently, indiscriminate application of single disease pharmacotherapy guidelines to older multimorbid patients can lead to increased risk of drug-drug interactions, drug-disease interactions and poor drug adherence. Both polypharmacy and PIMs are highly prevalent in older people and strategies to improve the quality and safety of prescribing, largely through avoidance of IMU, are needed. In the last 30 years, numerous explicit PIM criteria-based tools have been developed to assist physicians with medication management in clinically complex multimorbid older people. Very few of these PIM criteria sets have been tested as an intervention compared with standard pharmaceutical care in well-designed clinical trials. In this review, we describe the most widely used sets of explicit PIM criteria to address inappropriate polypharmacy with particular focus on STOPP/START criteria and FORTA criteria which have been associated with positive patient-related outcomes when used as interventions in recent randomized controlled trials.

Clusters of non-adherence to medication in neurological patients

BACKGROUND

Non-adherence to medication is a common and serious problem in health care. To develop more effective interventions to improve adherence, there is a need for a better understanding of the individual types of non-adherence.

OBJECTIVE

To determine clusters of non-adherence in neurological patients using a complex adherence questionnaire.

METHODS

In this observational, monocentric study 500 neurological patients (consecutive sampling) were recruited in the Department of Neurology at the Jena University Hospital, Germany (outpatient clinic, wards) over a period of 5 months. Patients with severe dementia or delirium who were unable to complete the questionnaire were excluded. Due to missing adherence data, in total, 429 patients with common neurological disorders were analyzed. Different types and clusters of non-adherence using the German Stendal Adherence to Medication Score (SAMS) were determined.

RESULTS

For the 429 patients, the mean age was 63 years (SD = 16), 189 were female. According to the SAMS total score 74 (17.2%) were fully adherent, 252 (58.7%) showed moderate non-adherence and 103 (24%) showed clinically significant non-adherence. Principal component analysis with Varimax rotation revealed three independent factors explaining 60.5% of the SAMS variance. The bulk of non-adherence was attributed to modifications of medication (41.7%) and forgetting to take the medication (33.2%) followed by lack of knowledge 25.1% about reasons, dosages and time of administration for the medication.

CONCLUSIONS

Intentional non-adherence was the primary self-reported behavior identified among non-adherent neurological participants. Many patients modified their prescribed medication due to various reasons, such as side effects or lacking effect. Different clusters require different interventions. While for the cluster ´forgetfulness' the reduction of poly-medication and a behavioral approach with reminders seems reasonable, patients in cluster ´missing knowledge' and cluster ´modifications' may need an educational approach.