Factors associated with medication regimen complexity in older people: a cross-sectional population-based study

Evaluation of potentially inappropriate medications use and medication complexity in elderly patients applying to community pharmacy in Turkey

BACKGROUND

Older adults often use multiple medicines to manage comorbidities well or to prevent associated complications. This study aims to determine polypharmacy, the use of potentially inappropriate medications (PIMs) using the 2019 Beers Criteria and to determine the Medication Regimen Complexity Index (MRCI) score. It also aims to identify factors associated with the presence of PIMs and the MRCI score.

METHODS

This cross-sectional study was carried out between 6 and 2023 and 5 May 2023 in a community pharmacy in Turkey. Elderly patients over 65 years of age, who used at least one drug, and who came to the pharmacy for any reason were included in the study. PIMs were determined according to the 2019 Beers Criteria. The Turkish validated version of the MRCI was used to determine the medication complexity score.

RESULTS

200 patients were included in this study. 59.5% of the patients were female and the median age was 70 (IQR, 66-74.75). Polypharmacy was detected in 33% of patients. The use of PIMs was determined in 63.5% of the patients. The median of the MRCI score was 11 (IQR, 7-15). The number of chronic diseases and drugs, presence of polypharmacy, MRCI score and mental disorders were found to be significantly higher in those with PIMs than in those without (p < 0.05). Having less than eight years of education, presence of polypharmacy, the presence of comorbidity (diabetes mellitus, cardiovascular disease, thyroid, chronic obstructive pulmonary disease (COPD), asthma and mental disorders) were associated with significantly higher MRCI scores (p < 0.05).

CONCLUSIONS

According to the results of our study, it was found that the elderly patients who came to the pharmacy had low MRCI scores, but had high PIMs use. Community pharmacists have an important role in identifying inappropriate drug use, so they should be trained to develop skills in identifying and reducing PIMs in older patients.

Perceived Usability of Tablet Crushers: Comparison of Devices by People with and without Limited Hand Functions

Tablet crushing is a common practice used by patients and their carers, mainly to facilitate swallowing. Various tablet-crushing devices with different designs are currently available on the market. This study aimed to compare the usability of different tablet-crushing devices in people with and without limited hand functions. The hand function of 100 adults recruited from the general community (40 of whom self-reported a limited hand function) was assessed using the hand and finger function subscale of the Arthritis Impact Measurement Scale version 2. The hand strength was measured using a dynamometer. Participants crushed tablets using 11 crushing devices and completed a Rapid Assessment of Product Usability and Universal Design questionnaire for each device. Hand-held twist-action crushers with an ergonomic grip received the highest usability scores among both groups, irrespective of the cost (p < 0.05). Crushers with bags were scored lower by those with limited hand functions, although the score improved if the device was automatic. Preferences regarding electronic crushers significantly changed once the cost was revealed. Economical twist-action crushers with ergonomic grips and without bags or cups were the most favoured crushers.

Medication regimen complexity index and rehabilitation outcomes in post-acute hip fracture patients study: a retrospective study

BACKGROUND

Polypharmacy is a common problem amongst the elderly population. The complexity of the drug regimen refers not only to a simple medication count, but also to the number of daily doses, frequency, and special instructions given for their use. Medication regimen complexity may affect health outcomes, including an increase in hospitalization rates, drug non-adherence, and mortality rates.

AIM

To assess whether the admission medication regimen complexity index score is associated with rehabilitation outcomes in hip fracture patients; secondary- to assess whether changes in the medication regimen complexity index scores during rehabilitation are associated with rehabilitation outcomes.

METHOD

A retrospective study of 336 hip fracture patients admitted to a post-acute rehabilitation hospital. Primary rehabilitation outcome was assessed via the discharge functional independence measure score. Secondary outcomes included functional independence measure score changes, length of stay and discharge destination.

RESULTS

Patients with low admission medication regimen complexity index scores attained significantly higher admission and discharge motor functional independence measure scores (40.1 vs. 37.1, p = 0.044; 57.1 vs. 52.9, p = 0.014, respectively), a higher motor functional independence measure score effectiveness (36.1 vs. 31.3, p = 0.030) and a higher rate of favorable motor functional independence measure effectiveness score (58.1% vs. 42.0%, p = 0.004). A multiple linear regression analysis revealed that the admission medication regimen complexity index score was not associated with the discharge functional independence measure score (standardized coefficient = - 0.058; p = 0.079).

CONCLUSION

A high medication regimen complexity which usually implies severe comorbidity should not be considered a barrier for the rehabilitation of older patients.

Prevalence and factors associated with potentially inappropriate medication and medication complexity for older adults in the emergency department of a secondary teaching hospital in Indonesia

Background

Older adults experience progressive decline in various organs and changes in pharmacokinetics and pharmacodynamics of the drugs in the body which lead to an increased risk of medication-related problems. Potentially inappropriate medications (PIMs) and medication complexity are key factors contributing to adverse drug events in the emergency department (ED).

Objective

To estimate the prevalence and investigate the risk factors of PIMs and medication complexity among older adults admitted to the ED.

Methods

A retrospective observational study was conducted among patients aged > 60 years admitted to the ED of Universitas Airlangga Teaching Hospital in January - June 2020. PIMs and medication complexity were measured using the 2019 American Geriatrics Society Beers Criteria® and Medication Regimen Complexity Index (MRCI), respectively.

Results

A total of 1005 patients were included and 55.0% (95% confidence interval [CI]: 52 - 58%) of them received at least one PIM. Whereas, the pharmacological therapy prescribed to older adults had a high complexity index (mean MRCI 17.23 + 11.15). Multivariate analysis showed that those with polypharmacy (OR= 6.954; 95% CI: 4.617 - 10.476), diseases of the circulatory system (OR= 2.126; 95% CI: 1.166 - 3.876), endocrine, nutritional, and metabolic diseases (OR= 1.924; 95% CI: 1.087 - 3.405), and diseases of the digestive system (OR= 1.858; 95% CI: 1.214 - 2.842) had an increased risk of receiving PIM prescriptions. Meanwhile, disease of the respiratory system (OR = 7.621; 95% CI: 2.833 - 15.150), endocrine, nutritional and metabolic diseases (OR = 6.601; 95% CI: 2.935 - 14.847), and polypharmacy (OR = 4.373; 95% CI: 3.540 - 5.401) were associated with higher medication complexity.

Conclusion

In our study, over one in every two older adults admitted to the ED had PIMs, and a high medication complexity was observed. Endocrine, nutritional and metabolic disease was the leading risk factors for receiving PIMs and high medication complexity.

Pharmacists' Role in Older Adults' Medication Regimen Complexity: A Systematic Review

Medication regimen complexity (MRC) may influence health outcomes, such as hospitalisation, hospital readmission and medication adherence. Pharmacists have been referred to as health professionals with the opportunity to act on MRC reduction. This study aimed to investigate pharmacists' role in studies about older adults' medication regimen complexity. A literature search was performed in PubMed, Web of Science and the Cochrane Library-CENTRAL-up to October 2019. Out of 653 potentially relevant studies, 17 articles met the inclusion criteria for this review. Most studies used the 65-item medication regimen complexity index (MRCI) to assess medication complexity. Pharmacists' role was mainly confined to data collection. It seems that pharmacists' active role in older adults' medication complexity has not been studied in depth so far. However, the few existing interventional ones suggest that, after previous training, regimen simplification is feasible.

Student Pharmacists' Ability to Organize Complex Medication Regimens According to the Universal Medication Schedule

Objective. To assess student pharmacists' ability to impact the administration of complex prescription regimens using the universal medication schedule in a standardized laboratory exercise. Methods. First and third professional year (P1 and P3) student pharmacists at three colleges of pharmacy completed a required activity to simplify and organize a complex medication regimen. Using a medication box, students planned how and when they would advise a patient to take seven fictitious medications over a 24-hour period. Picture documentation of each students' activity was used for data analysis. Descriptive statistics were used to compare P1 and P3 students' performance, and an independent t test was used to assess the frequency of daily dosing. A chi-square analysis was used to compare differences between P1 and P3 students, and analysis of variance was used to compare differences among individual institutions. Results. Of 842 students invited, 459 P1 and 372 P3 students (98.7%) consented to participate. Student pharmacists recommended 5.1 (SD=1.0; Range=3-11) dosing intervals per 24 hours, with 27% of students successfully reducing the regimen to four total intervals. The P3 students were more effective than the P1 students in planning the number of dosing intervals (4.9 vs 5.4 per 24 hours). Conclusion. Student pharmacists may become more effective at organizing complex medication regimens as they proceed through the pharmacy curriculum and gain experience. Student pharmacists can translate what they learned from this exercise to potentially improve patients' self-organized medication regimens.

Medication Regimen Complexity Index Prediction of Adverse Drug Reaction-Related Hospital Admissions

BACKGROUND

The relationship between the medication regimen complexity index (MRCI) and adverse drug reaction (ADR)-related hospital admissions has not yet specifically been investigated.

OBJECTIVE

To evaluate the MRCI and compare with medication count for prediction of ADR-related hospital admissions in older patients.

METHODS

This was a retrospective analysis of a prospectively collected convenience sample of 768 unplanned medical admissions of Australians aged 65 years old and older. The sample consisted of 115 (15.0%) ADR-related unplanned hospital admissions and 653 (85.0%) non-ADR-related unplanned medical admissions. The MRCI score was calculated from the medical records and analyzed to predict ADR-related hospital admissions.

RESULTS

The cohort had a median age of 81 years, 5 comorbidities, and 11 medications, with a slight majority of women. The MRCI score was not significantly different in patients who had ADR-related admissions compared with other medical admissions-38.5 versus 34.0, respectively; Wilcoxon Rank Sum test W = 33 522; P = 0.067. The medication count was significantly different between the ADR-related admissions compared with other medical admissions: 12 versus 10; W = 32 508; P = 0.021. However, the medication count was not a strong predictor of ADR-related admissions; unadjusted odds ratio = 1.044; 95% CI = 1.006-1.084.

CONCLUSION AND RELEVANCE

The MRCI score did not discriminate between ADR-related admissions and other medical admissions despite taking time to calculate with potential for inconsistent application. Medication count is more readily applicable with marginally greater relevance in this cohort; however, both measures do not appear to be useful when used alone for clinicians to identify patients at risk of ADRs.

Prevalence and treatment outcomes of skin infections among elderly population: a retrospective cross-sectional study

Background: Geriatric population is increasing day by day throughout the world and there is a critical need to provide them the best health services including dermatological care due to their weakened immune system. The main objective of this study is to determine the prevalence and factors affecting the treatment outcomes of skin infections among elderly population.Methods: A 5-year retrospective cross-sectional study was conducted at the Department of Dermatology, Hospital Pulau Pinang. Patients aged ≥65 years of age with confirmed diagnosis of skin infection were included in the study.Results: A total of 455 patients were included and the most prevalent skin infections were eczema (27.6%) followed by dermatitis (13.8%), xerosis (13.8%), and bullous pemphigoid (8.8%). Cloxacillin (18%), Tetracycline (7.9%), and Unasyn (Ampicillin and Sulbactam) (5.7%) are the common antibiotics prescribed to treat skin infections. Age, alcohol consumption, polypharmacy, and presence of other co-morbidities are the most important factors that affected the treatment outcomes of skin infections among geriatrics.Conclusion: Eczema is the most prevalent skin infection among the elderly population. Age, consumption of alcohol, usage of more than five medicines simultaneously, and presence of co-morbidities are the main factors that are involved in better treatment outcomes of skin infections among study population.

Are Clinical Outcomes Associated With Medication Regimen Complexity? A Systematic Review and Meta-analysis

Background: Current evidence of the influence of the medication regimen complexity (MRC) on the patients’ clinical outcomes are not conclusive. Objective: To systematically and analytically assess the association between MRC measured by the Medication Regimen Complexity Index (MRCI) and clinical outcomes. Methods: A search was carried out in the databases Cochrane Library, LILACS, PubMed, Scopus, EMBASE, Open Thesis, and Web of Science to identify studies evaluating the association between MRC and clinical outcomes that were published from January 1, 2004, to April 2, 2018. The search terms included outcome assessment, drug therapy, and medication regimen complexity index and their synonyms in different combinations for case-control and cohort studies that used the MRCI to measure MRC and related the MRCI with clinical outcomes. Odds ratios (ORs), hazard ratios (HRs), and mean differences (WMDs) were calculated, and heterogeneity was assessed using the I2 test. Results: A total of 12 studies met the eligibility criteria. The meta-analysis showed that MRC is associated with the following clinical outcomes: hospitalization (HR = 1.20; 95% CI = 1.14 to 1.27; I2 = 0%) in cohort studies, hospital readmissions (WMD = 7.72; 95% CI = 1.19 to 14.25; I2 = 84%) in case-control studies, and medication nonadherence (adjusted OR = 1.05; 95% CI = 1.02 to 1.07; I2 = 0%) in cohort studies. Conclusion and Relevance: This systematic review and meta-analysis gathered relevant scientific evidence and quantified the combined estimates to show the association of MRC with clinical outcomes: hospitalization, hospital readmission, and medication adherence.

Medication regimen complexity on hospital admission in patients with advanced chronic conditions in need of palliative care

Objectives

To evaluate characteristics of the medication complexity, risk factors associated with high medication complexity and their clinical consequences in patients with advanced chronic conditions.

Methods

A 10-month cross-sectional study was performed in an acute-hospital care Geriatric Unit. Patients with advanced chronic conditions were identified by the NECPAL test. Medication complexity was established using the Medication Regimen Complexity Index (MRCI) tool. Demographic, pharmacological and clinical patient data were collected with the objective of determining risk factors related to high medication complexity. Measured clinical outcomes were hospital length of stay, destination on hospital discharge, in-hospital mortality and 2-year survival.

Results

Two hundred and thirty-five patients (mean age 86.8, SD 5.37; 65.5% female) were recruited. MRCI's mean score was 38 points (SD 16.54, rank: 2.00-98.50), with 57.9% of patients with high medication complexity (MRCI >35 points).

Medication Regimen Complexity In 8 Australian Residential Aged Care Facilities: Impact Of Age, Length Of Stay, Comorbidity, Frailty, And Dependence In Activities Of Daily Living

Objective

To explore variation in medication regimen complexity in residential aged care facilities (RACFs) according to resident age, length of stay, comorbidity, dementia severity, frailty, and dependence in activities of daily living (ADLs), and compare number of daily administration times and Medication Regimen Complexity Index (MRCI) as measures of regimen complexity.

Methods

This study was a cross-sectional analysis of baseline data from the SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) cluster-randomized controlled trial. The SIMPLER study recruited 242 residents with at least one medication charted for regular administration from 8 RACFs in South Australia. Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Dementia severity was assessed using the Dementia Severity Rating Scale. Frailty was assessed using the FRAIL-NH scale. Dependence in ADLs was assessed using the Katz ADL scale.

Results

The median age of participants was 87 years (interquartile range 81–92). Over one-third of participants (n=86, 36%) had 5 or more daily medication administration times. The number of daily administration times and MRCI scores were positively correlated with resident length of stay (r_s=0.19; 0.27), FRAIL-NH score (r_s=0.23; 0.34) and dependence in ADLs (r_s=−0.21; −0.33) (all p<0.01). MRCI was weakly negatively correlated with CCI score (r_s=−0.16; p=0.013). Neither number of daily administration times nor MRCI score were correlated with age or dementia severity. In multivariate analysis, frailty was associated with number of daily administration times (OR: 1.13, 95% CI: 1.03–1.24) and MRCI score (OR: 1.26, 95% CI: 1.13–1.41). Dementia severity was inversely associated with both multiple medication administration times (OR: 0.97, 95% CI: 0.94–0.99) and high MRCI score (OR: 0.95, 95% CI: 0.92–0.98).

Conclusion

Residents with longer lengths of stay, more dependent in ADLs and most frail had the most complex medication regimens and, therefore, may benefit from targeted strategies to reduce medication regimen complexity.

Impact of pharmacists' interventions on the pharmacotherapy of patients with complex needs monitored in multidisciplinary primary care teams

OBJECTIVES

Recently, pharmacists have joined multidisciplinary healthcare teams within family medicine groups (FMG) in Quebec Province, Canada. This study assessed the impact of their interventions on the pharmacotherapy of patients with complex needs monitored in FMGs.

METHODS

We performed a pre/post real-life intervention study among patients with complex needs referred to the FMG pharmacist in four FMGs in Quebec City. Pharmacists collected data at baseline, during follow-up and up to 6 months after the first encounter. They recorded all drug-related problems (DRPs) identified, interventions made and recommendations that were accepted by physicians. The researchers used the data collected to compare the medication regimen complexity index (MRCI) and medication adherence (using the proportion of days covered (PDC)) before and after the pharmacist's interventions. Descriptive statistics and paired sample t-tests were computed.

KEY FINDINGS

Sixty-four patients (median age: 74.5 years) were included; four patients were lost to follow-up. Pharmacists detected 300 DRPs (mean: 7.2 per patient) during the study period for which they made an intervention. The most common DRP was 'drug use without indication' (27%). The physicians accepted 263 (87.7%) of those interventions. The mean number of prescribed drugs per patient decreased from 13.8 (95% confidence interval (CI): 12.24 to 15.29) to 12.4 (95% CI: 10.92 to 13.90). The mean MRCI decreased from 47.18 to 41.74 (-5.44; 95% CI: 1.71 to 9.17), while the mean PDC increased from 84.4% to 90.0% (+5.6%; 95% CI: 2.7% to 8.4%).

CONCLUSION

Family medicine groups pharmacists can detect and resolve DRPs and can reduce medication regimen complexity and non-adherence to treatment in patients with complex needs monitored in FMGs.

Development and validation of the Korean version of the medication regimen complexity index

The medication regimen complexity index (MRCI), originally developed in English, is a reliable and valid tool to assess the complexity of pharmacotherapy. This study aimed to validate the Korean version of MRCI (MRCI-K). A cross-cultural methodological study comprising 335 discharged patients of a tertiary hospital in Korea was conducted. The translation process included translation into Korean by two clinical pharmacists, back translation by two native speakers, and a pretest of the tool, culminating in the Korean version of MRCI-K. Reliability analysis was assessed using inter-rater and test–retest reliability with 25 randomly selected patients. Convergent and discriminant validity analyses were conducted by correlating MRCI scores with medication number, age, sex, adverse drug reaction (ADR) reports, and length of stay. The criterion validity was confirmed through evaluation by a nine-member expert panel that subjectively ranked these regimens. The reliability analysis demonstrated excellent internal consistency (Cronbach’s α = 0.977), and the intraclass correlation coefficient exceeded 0.90 for all cases. The correlation coefficient for the number of medications was 0.955 (P < 0.001). Weak significant correlations were observed with age and length of stay. The MRCI-K group with ADR reports scored higher (mean, 31.8) than the group without ADR reports (mean, 27.3). The expert panel’s ranking had a stronger correlation with the MRCI ranking than the medication number ranking. MRCI-K has similar reliability and validity as MRCI and is useful for analyzing therapeutic regimens with potential applications in both practice and research in Korea.

Medication regimen complexity and medication adherence in elderly patients with chronic kidney disease

INTRODUCTION

Elderly patients with chronic kidney disease (CKD) stage 5 with or without dialysis treatment usually have concomitant comorbidities, which often result in multiple pharmacological therapies. This study aimed to identify factors associated with medication complexity and medication adherence, as well as the association between medication complexity and medication adherence, in elderly patients with CKD.

METHODS

This prospective study involved elderly patients with CKD stage 5 (estimated glomerular filtration rate < 15 ml/min/1.73m² ) recruited from three Norwegian hospitals. Most of the patients were receiving either hemodialysis or peritoneal dialysis. We used the Medication Regimen Complexity Index (MRCI) to assess the complexity of medication regimens, and the eight-item Morisky Medication Adherence Scale (MMAS-8) to assess medication adherence. Factors associated with the MRCI and MMAS-8 score were determined using either multivariable linear or ordinal logistic regression analysis.

FINDINGS

In total, 157 patients aged 76 ± 7.2 years (mean ± SD) were included in the analysis. Their overall MRCI score was 22.8 ± 7.7. In multivariable linear regression analyses, female sex (P = 0.044), Charlson Comorbidity Index of 4 or 5 (P = 0.029) and using several categories of phosphate binders (P < 0.001 to 0.04) were associated with the MRCI. Moderate or high adherence (MMAS-8 score ≥ 6) was demonstrated by 83% of the patients. The multivariable logistic regression analyses found no association of medication complexity, age or other variables with medication adherence as assessed using the MMAS-8.

DISCUSSION

Female sex, comorbidity and use of phosphate binders were associated with more-complex medication regimens in this population. No association was found between medication regimen complexity, phosphate binders or age and medication adherence. These findings are based on a homogeneous elderly group, and so future studies should test if they can be generalized to patients of all ages with CKD.

Evaluation of Hospital Discharge Prescriptions in the Elderly and Younger Adults Using the Medication Regimen Complexity Index

BACKGROUND

Advances in the clinical management of diseases have been accompanied by increasing complexity of treatment regimens. The complexity of medication regimen is of concern for patients as well as doctors as it may adversely affect patient compliance and treatment outcomes. It may result in medication errors, increased utilization of health resources owing to a reduction in treatment effectiveness, and increased risk of therapeutic failure.

OBJECTIVE

This study aimed to assess the complexity of medication regimen prescribed to patients on hospital discharge using the medication regimen complexity index (MRCI).

METHODS

A cross-sectional, descriptive study was conducted. Hospital discharge prescriptions written for patients discharged from the General Medicine wards of a tertiary care teaching hospital in South India were scored for their complexity using MRCI. The correlation of age and gender with the MRCI scores was also assessed. Patients ≥60 years of age were considered elderly.

RESULTS

The median MRCI score for 563 prescriptions studied was 14 (Interquartile range, 9-21). Elderly patients received a significantly more complex medication regimen compared with younger patients (p < 0.001) at the time of hospital discharge. Gender variation was seen with higher MRCI scores in females, but this was not statistically significant in the elderly group.

CONCLUSION

MRCI scores are significantly high in elderly patients at the time of hospital discharge. Although a strong correlation is seen between the number of medications and the MRCI score, the latter helps to distinguish regimen complexity between prescriptions with the same number of medications.

The association between polypharmacy and medication regimen complexity and antibiotic use in bronchiectasis

Background Polypharmacy is associated with an increased risk of adverse drug events, inappropriate prescribing and medication errors. People with bronchiectasis have frequent pulmonary exacerbations that require antibiotic therapy. Objective This study aimed to measure polypharmacy and medication regimen complexity in bronchiectasis patients and to explore associations between these factors and oral and intravenous (IV) antibiotic use for suspected pulmonary exacerbations. Setting Patients were sampled from the Regional Bronchiectasis Clinic at the Belfast Health and Social Care Trust, Northern Ireland. Method Data on medicines were collected from patients’ records and used to measure polypharmacy using three thresholds (≥ 4, ≥ 10, and ≥ 15 medicines’). Medication regimen complexity was calculated using the medication regimen complexity index (MRCI). Data analysis investigated differences in outcomes across polypharmacy thresholds and correlations with MRCI. Main outcome measure Primary outcomes were prescriptions for oral antibiotics and IV antibiotics, in the past 6 months and 2 years, respectively. Results Over three-quarters of the sample (N = 95) were prescribed ≥ 4 medicines (n = 74; 77.9%), 31 patients were prescribed ≥ 10 medicines (33.0%), and 12 patients (12.8%) were prescribed ≥ 15 medicines. The median MRCI was 26. Patients prescribed ≥ 10 medicines were over three times more likely to have had an IV antibiotic in the past 2 years (adjusted odd ratio 3.44, 95% confidence intervals 1.15–10.31). Conclusion There were significant differences in all outcomes across the ‘≥ 10 medicines’ threshold. MRCI was positively correlated with oral and IV antibiotic usage. These findings also suggest a possible link between polypharmacy and medicines regimen complexity, and poorer outcomes.

Inappropriate Use of Medication by Elderly, Polymedicated, or Multipathological Patients with Chronic Diseases

The growth of the aging population leads to the increase of chronic diseases, of the burden of multimorbility, and of the complexity polypharmacy. The prevalence of medication errors rises in patients with polypharmacy in primary care, and this is a major concern to healthcare systems. This study reviews the published literature on the inappropriate use of medicines in order to articulate recommendations on how to reduce it in chronic patients, particularly in those who are elderly, polymedicated, or multipathological. A systematic review of articles published from January 2000 to October 2015 was performed using MEDLINE, EMBASE, PsychInfo, Scopus, The Cochrane Library, and Index Medicus databases. We selected 80 studies in order to analyse the content that addressed the question under consideration. Our literature review found that half of patients know what their prescribed treatment is; that most of elderly people take five or more medications a day; that in elderly, polymedicated people, the probability of a medication error occurring is higher; that new tools have been recently developed to reduce errors; that elderly patients can understand written information but the presentation and format is an important factor; and that a high percentage of patients have remaining doubts after their visit. Thus, strategies based on the evidence should be applied in order to reduce medication errors.

SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER): study protocol for a cluster randomised controlled trial

Background

Complex medication regimens are highly prevalent in residential aged care facilities (RACFs). Strategies to reduce unnecessary complexity may be valuable because complex medication regimens can be burdensome for residents and are costly in terms of nursing time. The aim of this study is to investigate application of a structured process to simplify medication administration in RACFs.

Methods

SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) is a non-blinded, matched-pair, cluster randomised controlled trial of a single multidisciplinary intervention to simplify medication regimens. Trained study nurses will recruit English-speaking, permanent residents from eight South Australian RACFs. Medications taken by residents in the intervention arm will be assessed once using a structured tool (the Medication Regimen Simplification Guide for Residential Aged CarE) to identify opportunities to reduce medication regimen complexity (e.g. by administering medications at the same time, or through the use of longer-acting or combination formulations). Residents in the comparison group will receive routine care. Participants will be followed for up to 36 months after study entry. The primary outcome measure will be the total number of charted medication administration times at 4 months after study entry. Secondary outcome measures will include time spent administering medications, medication incidents, resident satisfaction, quality of life, falls, hospitalisation and mortality. Individual-level analyses that account for clustering will be undertaken to determine the impact of the intervention on the study outcomes.

Discussion

Ethical approval has been obtained from the Monash University Human Research Ethics Committee and the aged care provider organisation. Research findings will be disseminated through conference presentations and peer-reviewed publications. SIMPLER will enable an improved understanding of the burden of medication use in RACFs and quantify the impact of regimen simplification on a range of outcomes important to residents and care providers.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12617001060336. Retrospectively registered on 20 July 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-017-2417-2) contains supplementary material, which is available to authorized users.

Association between medication regimen complexity and pharmacotherapy adherence: a systematic review

PURPOSE

The purpose of this study was to systematically review evidence regarding the association between regimen complexity and adherence.

METHODS

Articles were searched in MEDLINE, LILACS, Cochrane, CINAHL, PsycINFO and references of included studies. Search terms included medication regimen complexity, medication adherence and their synonyms. Randomized clinical trials, cross-sectional, cohort or case-control studies published until March 2016 in English, Portuguese or Spanish were eligible if quantitatively examined the association between complexity and adherence in patients of any age and sex, under any type of medication therapy. Complexity was defined according to the strategy used to assess it in the individual studies. All types of instruments used to assess complexity and adherence were considered. Data extraction was performed using an electronic spreadsheet. Quality assessment was conducted independently using standard scales. The data were qualitatively synthesized.

RESULTS

Fifty-four studies were included: 37 cross-sectional and 17 cohorts. Most were conducted in outpatient setting. Most frequently, studies were carried out with HIV-infected individuals or patients with chronic conditions. The most frequent methods used to assess complexity and adherence were complexity index (19) and self-report (27), respectively. Complexity was associated with adherence in 35 studies. Most of them (28) identified that participants with more complex regimens were less likely to adhere to pharmacotherapy; seven studies found a direct correlation. The others found inconclusive results or no association between complexity and adherence. The studies had low to moderate-methodological quality.

CONCLUSION

Although there was variability regarding the association between complexity and adherence, most studies showed that an increased regimen complexity reduces medication adherence.

Addressing medical needs of adolescents and adults with autism spectrum disorders in a primary care setting

Little has been reported about how to improve health care access and delivery for adolescents and adults with autism spectrum disorder. To understand the contributions to the health disparities in the autism spectrum disorder population, we conducted two independent research approaches to learn about current medical needs. A retrospective chart review was performed to evaluate medical comorbidities and medication use. A focus group was also created to address barriers faced in providing medical care. Of 126 charts reviewed, 49% (n = 62) had intellectual disability, 49% (n = 62) had attention-deficit hyperactivity disorder, 52% (n = 65) had anxiety, 41% (n = 52) had obesity, 31% (n = 39) with a history of aggressive behavior, 31% (n = 31) had depression, 22% (n = 28) had seizures, and 9% (n = 11) had hypertension. A Medical Regimen Complexity Index score was determined to examine medication use trends in the autism spectrum disorder population. Medical Regimen Complexity Index scores were significantly higher for patients with intellectual disability, patients with seizures, and patients with a history of aggressive behavior. Both the focus group and our pre-visit assessment identified the waiting room and waiting time as barriers to care. Understanding the comorbidities, polypharmacy, and medical barriers should provide a better understanding of the current health care access and delivery needs of adolescents and adults with autism spectrum disorder.

Evaluation of pharmacotherapy complexity in residents of long-term care facilities: a cross-sectional descriptive study

BACKGROUND

Polypharmacy is a reality in long-term care facilities. However, number of medications used by the patient should not be the only predictor of a complex pharmacotherapy. Although the level of complexity of pharmacotherapy is considered an important factor that may lead to side effects, there are few studies in this field. The aim of this study was to evaluate the complexity of pharmacotherapy in residents of three long-term care facilities.

METHODS

A cross-sectional study was performed to evaluate the complexity of pharmacotherapy using the protocols laid out in the Medication Regimen Complexity Index instrument in three long-term care facilities in northeastern Brazil. As a secondary result, potential drug interactions, potentially inappropriate medications, medication duplication, and polypharmacy were evaluated. After the assessment, the association among these variables and the Medication Regimen Complexity Index was performed.

RESULTS

In this study, there was a higher prevalence of women (64.4%) with a high mean age among the study population of 81.8 (±9.7) years. The complexity of pharmacotherapy obtained a mean of 15.1 points (±9.8), with a minimum of 2 and a maximum of 59. The highest levels of complexity were associated with dose frequency, with a mean of 5.5 (±3.6), followed by additional instructions of use averaging 4.9 (±3.7) and by the dosage forms averaging 4.6 (±3.0).

CONCLUSIONS

The present study evaluated some factors that complicate the pharmacotherapy of geriatric patients. Although polypharmacy was implicated as a factor directly related to complexity, other indicators such as drug interactions, potentially inappropriate medications, and therapeutic duplication can also make the use of pharmacotherapy in such patients more difficult.

Medication regimen complexity in ambulatory older adults with heart failure

PURPOSE

Heart failure prevalence is increasing in older adults, and polypharmacy is a major problem in this population. We compared medication regimen complexity using the validated patient-level Medication Regimen Complexity Index (pMRCI) tool in "young-old" (60-74 years) versus "old-old" (75-89 years) patients with heart failure. We also compared pMRCI between patients with ischemic cardiomyopathy (ISCM) versus nonischemic cardiomyopathy (NISCM).

PATIENTS AND METHODS

Medication lists were retrospectively abstracted from the electronic medical records of ambulatory patients aged 60-89 years with heart failure. Medications were categorized into three types - heart failure prescription medications, other prescription medications, and over-the-counter (OTC) medications - and scored using the pMRCI tool.

RESULTS

The study evaluated 145 patients (n=80 young-old, n=65 old-old, n=85 ISCM, n=60 NISCM, mean age 73±7 years, 64% men, 81% Caucasian). Mean total pMRCI scores (32.1±14.4, range 3-84) and total medication counts (13.3±4.8, range 2-30) were high for the entire cohort, of which 72% of patients were taking eleven or more total medications. Total and subtype pMRCI scores and medication counts did not differ significantly between the young-old and old-old groups, with the exception of OTC medication pMRCI score (6.2±4 young-old versus 7.8±5.8 old-old, P=0.04). With regard to heart failure etiology, total pMRCI scores and medication counts were significantly higher in patients with ISCM versus NISCM (pMRCI score 34.5±15.2 versus 28.8±12.7, P=0.009; medication count 14.1±4.9 versus 12.2±4.5, P=0.008), which was largely driven by other prescription medications.

CONCLUSION

Medication regimen complexity is high in older adults with heart failure, and differs based on heart failure etiology. Additional work is needed to address polypharmacy and to determine if medication regimen complexity influences adherence and clinical outcomes in this population.

Polypathology, polypharmacy, medication regimen complexity and drug therapy appropriateness

Polypathological patients are usually elderly and take numerous drugs. Polypharmacy affects 85% of these individuals and is not associated with greater survival. On the contrary, polypharmacy exposes these individuals to more adverse effects, such as weight loss, falls, functional and cognitive impairment and hospitalisations. The complexity of a drug regimen covers more aspects than the simple number of drugs consumed. The galenic form, the dosage and the method for preparing the drug can impede the understanding of and compliance with prescriptions. Both polypharmacy and therapeutic complexity are associated with poorer adherence by patients. To prevent polypharmacy, reduce complexity and improve adherence, the appropriate use of drugs is needed. Proper prescribing consists of selecting drugs that have clear evidence for their use in the indication, which are appropriate for the patient's circumstances, are well tolerated and cost-effective and whose benefits outweigh the risks. To improve the drug prescription, periodic reviews of the drugs need to be conducted, especially when the patient changes doctor and during healthcare transitions. The Beers and STOPP/START (Screening Tool of Older Person's potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment) criteria are effective tools for this improvement. Deprescription for polymedicated polypathological patients that considers their clinical circumstances, prognosis and preferences can contribute to a more appropriate use of drugs.

Clinical Outcomes Associated with Medication Regimen Complexity in Older People: A Systematic Review

OBJECTIVES

To systematically review clinical outcomes associated with medication regimen complexity in older people.

DESIGN

Systematic review of EMBASE, MEDLINE, International Pharmaceutical Abstracts, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane library.

SETTING

Hospitals, home, and long-term care.

PARTICIPANTS

English-language peer-reviewed original research published before June 2016 was eligible if regimen complexity was quantified using a metric that considered number of medications and at least one other parameter, regimen complexity was calculated for participants' overall regimen, at least 80% of participants were aged 60 and older, and the study investigated a clinical outcome associated with regimen complexity.

MEASUREMENTS

Quality assessment was conducted using an adapted version of the Joanna Briggs Institute critical appraisal tool.

RESULTS

Sixteen observational studies met the inclusion criteria. Regimen complexity was associated with medication nonadherence (2/6 studies) and higher rates of hospitalization (2/4 studies). One study found that participants with less-complex medication administration were more likely to stop medications when feeling worse. One study each identified an association between regimen complexity and higher ability to administer medications as directed, medication self-administration errors, caregiver medication administration hassles, hospital discharge to non-home settings, postdischarge potential adverse drug events, all-cause mortality, and lower patient knowledge of their medication. Regimen complexity had no association with postdischarge medication modification, change in medication- and health-related problems, emergency department visits, or quality of life as rated by nursing staff.

CONCLUSION

Research into whether medication regimen complexity is associated with nonadherence and hospitalization has produced inconsistent results. Moderate-quality evidence from four studies (two each for nonadherence and hospitalization) suggests that medication regimen complexity is associated with nonadherence and higher rates of hospitalization.

Validation of the Turkish version of medication regimen complexity index among elderly patients

OBJECTIVE

The aim of this study was to validate the Turkish version of the 'Medication Regimen Complexity Index' (MRCI).

METHODS

This validation study has been conducted in prescriptions of the first 100 elderly patients who had visited the pharmacy for their prescription refill to evaluate convergent and divergent validity of the Turkish version. The reliability of the Turkish version was assessed with inter-rater and test-retest analysis after its translation and cultural adaptation.

RESULTS

The mean age of the 100 patients (53 women) was 74.9 years (SD = 7.58, 65-95). The scale showed high inter-rater reliability and test-retest reliability for the total and subscale scores (p < 0.05). A strong and positive correlation between the number of medications in a prescription and the total Medication Regimen Complexity Index scores (r = 0.930, p < 0.001) was determined. There were no statistically significant differences between age, gender and MRCI scores (p > 0.05).

CONCLUSION

These results show that the Turkish version of MRCI is a reliable and valid tool in elderly patients.

Medication Regimen Complexity and Polypharmacy as Factors Associated With All-Cause Mortality in Older People: A Population-Based Cohort Study

Objectives: To investigate whether medication regimen complexity and/or polypharmacy are associated with all-cause mortality in older people. Methods: This was a population-based cohort study among community-dwelling and institutionalized people ≥60 years old (n = 3348). Medication regimen complexity was assessed using the 65-item Medication Regimen Complexity Index (MRCI) in 10-unit steps. Polypharmacy was assessed as a continuous variable (number of medications). Mortality data were obtained from the Swedish National Cause of Death Register. Cox proportional hazard models were used to compute unadjusted and adjusted hazard ratios (HRs) and 95% CIs for the association between regimen complexity and polypharmacy with all-cause mortality over a 3-year period. Subanalyses were performed stratifying by age (≤80 and>80 years), sex, and cognition (Mini-Mental State Examination [MMSE] <26 and ≥26). Results: During follow-up, 14% of the participants (n = 470) died. After adjusting for age, sex, comorbidity, educational level, activities of daily living, MMSE, and residential setting, a higher MRCI was associated with mortality (adjusted HR = 1.12; 95% CI = 1.01-1.25). Polypharmacy was not associated with mortality (adjusted HR = 1.03; 95% CI = 0.99-1.06). When stratifying by sex, both MRCI and polypharmacy were associated with mortality in men but not in women. MRCI was associated with mortality in participants ≤80 years old and in participants with MMSE ≥26 but not in participants >80 years old or with MMSE <26. Conclusion: Regimen complexity was a better overall predictor of mortality than polypharmacy. However, regimen complexity was not predictive of mortality in women, in participants >80 years old, or in those with MMSE<26. These different associations with mortality deserve further investigation.