1
|
Mok PLH, Carr MJ, Guthrie B, Morales DR, Sheikh A, Elliott RA, Camacho EM, van Staa T, Avery AJ, Ashcroft DM. Multiple adverse outcomes associated with antipsychotic use in people with dementia: population based matched cohort study. BMJ 2024; 385:e076268. [PMID: 38631737 PMCID: PMC11022137 DOI: 10.1136/bmj-2023-076268] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE To investigate risks of multiple adverse outcomes associated with use of antipsychotics in people with dementia. DESIGN Population based matched cohort study. SETTING Linked primary care, hospital and mortality data from Clinical Practice Research Datalink (CPRD), England. POPULATION Adults (≥50 years) with a diagnosis of dementia between 1 January 1998 and 31 May 2018 (n=173 910, 63.0% women). Each new antipsychotic user (n=35 339, 62.5% women) was matched with up to 15 non-users using incidence density sampling. MAIN OUTCOME MEASURES The main outcomes were stroke, venous thromboembolism, myocardial infarction, heart failure, ventricular arrhythmia, fracture, pneumonia, and acute kidney injury, stratified by periods of antipsychotic use, with absolute risks calculated using cumulative incidence in antipsychotic users versus matched comparators. An unrelated (negative control) outcome of appendicitis and cholecystitis combined was also investigated to detect potential unmeasured confounding. RESULTS Compared with non-use, any antipsychotic use was associated with increased risks of all outcomes, except ventricular arrhythmia. Current use (90 days after a prescription) was associated with elevated risks of pneumonia (hazard ratio 2.19, 95% confidence interval (CI) 2.10 to 2.28), acute kidney injury (1.72, 1.61 to 1.84), venous thromboembolism (1.62, 1.46 to 1.80), stroke (1.61, 1.52 to 1.71), fracture (1.43, 1.35 to 1.52), myocardial infarction (1.28, 1.15 to 1.42), and heart failure (1.27, 1.18 to 1.37). No increased risks were observed for the negative control outcome (appendicitis and cholecystitis). In the 90 days after drug initiation, the cumulative incidence of pneumonia among antipsychotic users was 4.48% (4.26% to 4.71%) versus 1.49% (1.45% to 1.53%) in the matched cohort of non-users (difference 2.99%, 95% CI 2.77% to 3.22%). CONCLUSIONS Antipsychotic use compared with non-use in adults with dementia was associated with increased risks of stroke, venous thromboembolism, myocardial infarction, heart failure, fracture, pneumonia, and acute kidney injury, but not ventricular arrhythmia. The range of adverse outcomes was wider than previously highlighted in regulatory alerts, with the highest risks soon after initiation of treatment.
Collapse
Affiliation(s)
- Pearl L H Mok
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, University of Manchester, Manchester, M13 9PT, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Matthew J Carr
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, University of Manchester, Manchester, M13 9PT, UK
- Manchester Academic Health Science Centre, Manchester, UK
- NIHR Greater Manchester Patient Safety Research Collaboration, University of Manchester, Manchester, UK
| | - Bruce Guthrie
- Advanced Care Research Centre, Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Daniel R Morales
- Population Health and Genomics, University of Dundee, Dundee, UK
| | - Aziz Sheikh
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rachel A Elliott
- NIHR Greater Manchester Patient Safety Research Collaboration, University of Manchester, Manchester, UK
- Manchester Centre for Health Economics, Division of Population Health, Manchester, UK
| | - Elizabeth M Camacho
- Manchester Centre for Health Economics, Division of Population Health, Manchester, UK
| | - Tjeerd van Staa
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Anthony J Avery
- NIHR Greater Manchester Patient Safety Research Collaboration, University of Manchester, Manchester, UK
- Centre for Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, University of Manchester, Manchester, M13 9PT, UK
- Manchester Academic Health Science Centre, Manchester, UK
- NIHR Greater Manchester Patient Safety Research Collaboration, University of Manchester, Manchester, UK
| |
Collapse
|
2
|
Rodríguez Espinosa N, Gonzalez-Colaço Harmand M, Moro Miguel MA. [Use of antipsychotics in patients with dementia in Spain: Comparison with prescription of acetylcholinesterase inhibitors and memantine and analysis of associations]. Rev Esp Geriatr Gerontol 2024; 59:101446. [PMID: 38029634 DOI: 10.1016/j.regg.2023.101446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 10/25/2023] [Accepted: 11/02/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE We have analyzed the prevalence of antipsychotics in patients with dementia in Spain, their age distribution and the influence of treatment with IACEs and memantine on their prescription. METHOD Descriptive, retrospective and cross-sectional study of the 2017 BIFAP database in over 65 years of age with dementia. Prescriptions of antipsychotics, IACEs and memantine were collected. For antipsychotics were also collected, the duration of treatment and time from dementia diagnosis to prescription. RESULTS A total of 1,327,792 subjects were retrieved, 89,464 (6.73%) with dementia. Antipsychotics were prescribed in 31.76%; by frequency: quetiapine (58.47%), risperidone (21%) and haloperidol (19.34%). Prescriptions of IACEs and memantine were clustered in those younger than 84 years and antipsychotics in those older than 85 (P<.001). Antipsychotics were maintained for a mean of 1174.5 days. In 26.4% of cases they were prescribed alone, OR 0.61 (95% CI: 0.59-0.62), in 35.85% associated with IACEs, OR 1.26 (95% CI: 1.22-1.30) and in 42.4% with memantine, OR 1.69 (95% CI: 1.62-1.78) (P<.000). From the diagnosis of dementia, 461 days (±1576.5) elapsed when isolated drugs were prescribed; 651 days (±1574.25) associated with IACEs and 1224 (±1779) with memantine. CONCLUSIONS One third of patients with dementia were prescribed antipsychotics, mostly atypical, more frequently in those older than 85 years and for prolonged periods. IACEs and memantine were associated with the risk of antipsychotic prescription, but paradoxically, with prolonged time to onset.
Collapse
Affiliation(s)
- Norberto Rodríguez Espinosa
- Unidad de Neurología de la Conducta y Memoria, Servicio de Neurología, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Tenerife, España; Departamento de Medicina, Psiquiatría y Dermatología, Sección de Medicina, Facultad de Ciencias de la Salud, Universidad de La Laguna, San Cristóbal de La Laguna/Santa Cruz de Tenerife, Tenerife, España.
| | - Magali Gonzalez-Colaço Harmand
- Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Tenerife, España; Universidad Europea de Canarias, La Orotava/Santa Cruz de Tenerife, Tenerife, España
| | - María Adoración Moro Miguel
- Unidad de Neurología de la Conducta y Memoria, Servicio de Neurología, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Tenerife, España
| |
Collapse
|
3
|
Basaeed AJ, Wafia G, Alhidri B, Sindi LA, Hakami A, Jastaniah N. The Prevalence of Atypical Antipsychotics, Antidepressants, and Benzodiazepines Use in Dementia Patients in King Abdulaziz Medical City. Cureus 2022; 14:e30460. [DOI: 10.7759/cureus.30460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2022] [Indexed: 11/05/2022] Open
|
4
|
Psychotropic drug use among older people with major neurocognitive disorder: a cross-sectional study based on Swedish national registries. Eur J Clin Pharmacol 2021; 78:477-487. [PMID: 34738182 PMCID: PMC8818624 DOI: 10.1007/s00228-021-03241-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/21/2021] [Indexed: 10/27/2022]
Abstract
AIM Psychotropic medications include many drugs that may be inappropriate for older individuals with cognitive impairment. In Sweden, many people become registered in the Swedish Dementia Registry when they are diagnosed with major neurocognitive disorder (NCD). In this study, we aim to describe psychotropic drug use and associated factors among older Swedish people with major NCD. METHODS This study included 38,251 people ≥ 65 years from the Swedish registry for cognitive/dementia disorders diagnosed during 2007-2017. Drug use was defined as one or more filled prescription(s) recorded in the Swedish Prescribed Drug Register during 1 July to 31 December 2017. Associations between psychotropics and age, sex, diagnosis date, Mini-Mental State Examination score and major NCD subtype were analysed through multiple logistic regression. RESULTS We found that 12.0% of the individuals filled at least one prescription for antipsychotics, 22.0% for anxiolytics, 23.0% for sedatives or hypnotics, 43.2% for antidepressants and 56.7% for antidementia drugs. In brief, psychotropic use was associated with female sex, higher age, longer time since diagnosis and specific subtypes of major NCD; the strongest association was found between antipsychotics and Lewy body dementia (odds ratio 2.40, 95% confidence interval 2.04-2.82). CONCLUSION Psychotropic drugs were frequently dispensed among older Swedish people with major NCD. The use of antipsychotics and medications with sedative properties warrants concern, especially among those with Lewy body dementia who are severely sensitive to antipsychotics. A more restrictive prescribing pattern regarding these medications might reduce the risk of drug-related problems in this vulnerable group of people.
Collapse
|
5
|
Vohra N, Hadi MA, Khanal S, Kurmi OP, Paudyal V. Impact of deprivation, dementia prevalence and regional demography on prescribing of antidementia drugs in England: A time trend analysis. Br J Clin Pharmacol 2021; 87:3747-3755. [PMID: 33599972 DOI: 10.1111/bcp.14782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 01/19/2021] [Accepted: 02/12/2021] [Indexed: 11/30/2022] Open
Abstract
AIM This study aimed to examine trends in prescribing of antidementia drugs in primary care in England between 2009 and 2019, and investigate the impact of deprivation, regional demography and disease prevalence on prescribing practices. METHODS Analysis of publicly available government data from various sources pertaining to primary care prescribing and demographics was conducted. All primary care prescription data pertaining to antidementia drugs in England between 2009 and 2019 were extracted and adjusted for inflation and population changes. Data across English clinical commissioning regions were compared to explore the association between prescribing trend, deprivation, regional demography and dementia prevalence. RESULTS The number of prescription items for antidementia drugs in England increased by approximately 3-fold (195.4%) from 24 items/1000 population in 2009 to 70.9 items/1000 population in 2019. In 2019, the least-deprived areas had approximately twice the rate of prescribing of antidementia drugs compared to the most-deprived areas (median [IQR] values of 46.7 [36.6-64.8] vs 91.23 [76.2-95.1] items/1000 population, respectively). In the multivariable analysis, the number of prescription items showed an inverse relationship with deprivation (coefficient -0.046, 95% CI -0.47 to -0.045) after adjustment for number of populations aged 65+ years and prevalence of dementia. CONCLUSIONS The 3-fold rise in the number of prescription items for antidementia drugs in the study period reflects the policy emphasis on early diagnosis and treatment of dementia. Higher rates of prescribing in the least-deprived areas may be reflective of better and early diagnoses and access to treatments. Such inequality in access to the treatments needs to be investigated further.
Collapse
Affiliation(s)
- Neha Vohra
- Institute of Clinical Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Muhammad Abdul Hadi
- Institute of Clinical Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Saval Khanal
- Behavioral Science Group, Warwick Business School, University of Warwick, Coventry, CV4 7AL, UK
| | - Om P Kurmi
- Faculty of Health and Life Sciences, Coventry University, CV1 5FB, UK
| | - Vibhu Paudyal
- Institute of Clinical Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| |
Collapse
|
6
|
Walsh KA, Byrne S, McSharry J, Browne J, Irving K, Hurley E, Rochford-Brennan H, Geoghegan C, Presseau J, Timmons S. Developing a complex intervention targeting antipsychotic prescribing to nursing home residents with dementia. HRB Open Res 2021; 4:23. [PMID: 34136749 PMCID: PMC8185579 DOI: 10.12688/hrbopenres.13228.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 01/23/2023] Open
Abstract
Background: Antipsychotics are commonly prescribed to people living with dementia in nursing home settings, despite strong guideline recommendations against their use except in limited circumstances. We aimed to transparently describe the development process for a complex intervention targeting appropriate requesting and prescribing of antipsychotics to nursing home residents with dementia in Ireland, by nurses and general practitioners (GPs) respectively. Methods: We report the development process for the 'Rationalising Antipsychotic Prescribing in Dementia' (RAPID) complex intervention, in accordance with the 'Guidance for reporting intervention development studies in health research' (GUIDED) checklist. The UK Medical Research Council framework for developing and evaluating complex interventions guided our overall approach, incorporating evidence and theory into the intervention development process. To unpack the intervention development process in greater detail, we followed the Behaviour Change Wheel approach. Guided by our stakeholders, we conducted three sequential studies (systematic review and qualitative evidence synthesis, primary qualitative study and expert consensus study), to inform the intervention development. Results: The RAPID complex intervention was developed in collaboration with a broad range of stakeholders, including people living with dementia and family carers, between 2015 and 2017. The finalised RAPID complex intervention was comprised of the following three components; 1) Education and training sessions with nursing home staff; 2) Academic detailing with GPs; 3) Introduction of an assessment tool to the nursing home. Conclusions: This paper describes the steps used by the researchers to develop a complex intervention targeting antipsychotic prescribing to nursing home residents with dementia in Ireland, according to the GUIDED checklist. We found that the GUIDED checklist provided a useful way of reporting all elements in a cohesive manner and complemented the other tools and frameworks used. Transparency in the intervention development processes can help in the translation of evidence into practice.
Collapse
Affiliation(s)
- Kieran A. Walsh
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, T12XH60, Ireland
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, T12YN60, Ireland
- School of Public Health, University College Cork, Cork, T12K8AF, Ireland
| | - Stephen Byrne
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, T12YN60, Ireland
| | - Jenny McSharry
- Health Behaviour Change Research Group, School of Psychology, National University of Ireland, Galway, Galway, H91TK33, Ireland
| | - John Browne
- School of Public Health, University College Cork, Cork, T12K8AF, Ireland
| | - Kate Irving
- School of Nursing, Psychotherapy and Community Health, Dublin City University, Dublin, Ireland
| | - Eimir Hurley
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - Helen Rochford-Brennan
- Expert by Experience, N/A, N/A, Ireland
- Irish Dementia Working Group, The Alzheimer Society of Ireland, Dublin, Ireland
| | | | - Justin Presseau
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, K1H 8L6, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, K1G 5Z3, Canada
| | - Suzanne Timmons
- Centre for Gerontology and Rehabilitation, School of Medicine, University College Cork, Cork, T12XH60, Ireland
| |
Collapse
|
7
|
Morales DR, Macfarlane T, MacDonald TM, Hallas J, Ernst MT, Herings RMC, Smits E, Overbeek JA, Mitchell L, Morant S, Mackenzie I, Doney ASF, Robertson C, Bennie M, Wei L, Nicholson L, Morris C, Flynn RWF. Impact of EMA regulatory label changes on hydroxyzine initiation, discontinuation and switching to other medicines in Denmark, Scotland, England and the Netherlands: An interrupted time series regression analysis. Pharmacoepidemiol Drug Saf 2021; 30:482-491. [PMID: 33386650 DOI: 10.1002/pds.5191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 12/11/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Hydroxyzine is indicated for the management of anxiety, skin and sleep disorders. In 2015, the European Medicines Agency (EMA) concluded that hydroxyzine was pro-arrhythmogenic and changes to the product information were implemented in Europe. This study aimed to evaluate their impact in Denmark, Scotland, England and the Netherlands. METHOD Quarterly time series analyses measuring hydroxyzine initiation, discontinuation, and switching to other antihistamines, benzodiazepines and antidepressants in Denmark, England, Scotland and the Netherlands from 2009 to 2018. Data were analysed using interrupted time series regression. RESULTS Hydroxyzine initiation in quarter one 2010 in Denmark, Scotland, England and the Netherlands per 100 000 was: 23.5, 91.5, 35.9 and 34.4 respectively. Regulatory action was associated with a significant: immediate fall in hydroxyzine initiation per 100 000 in England (-12.05, 95%CI -18.47 to -5.63) and Scotland (-19.01, 95%CI -26.99 to -11.02); change to a negative trend in hydroxyzine initiation per 100 000/quarter in England (-1.72, 95%CI -2.69 to -0.75) and Scotland (-2.38, 95%CI -3.32 to -1.44). Regulatory action was associated with a significant: immediate rise in hydroxyzine discontinuation per 100 000 in England (3850, 95%CI 440-7240). No consistent changes were observed in the Netherlands or Denmark. Regulatory action was associated with no switching to other antihistamines, benzodiazepines or antidepressants following hydroxyzine discontinuation in any country. CONCLUSION The 2015 EMA regulatory action was associated with heterogeneous impact with reductions in hydroxyzine initiation varying by country. There was limited impact on discontinuation with no strong evidence suggesting unintended consequences of major switching to other antihistamines, benzodiazepines or antidepressants.
Collapse
Affiliation(s)
- Daniel R Morales
- MEMO Research, University of Dundee, Dundee, UK.,Department of Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense, Denmark
| | | | | | - Jesper Hallas
- Department of Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense, Denmark
| | - Martin Thomsen Ernst
- Department of Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense, Denmark
| | - Ron M C Herings
- PHARMO Institute for Drug Outcomes Research, Utrecht, The Netherlands
| | - Elisabeth Smits
- PHARMO Institute for Drug Outcomes Research, Utrecht, The Netherlands
| | - Jetty A Overbeek
- PHARMO Institute for Drug Outcomes Research, Utrecht, The Netherlands
| | | | | | | | | | - Chris Robertson
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
| | - Marion Bennie
- Strathclyde Onstitute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Li Wei
- School of Pharmacy, University College London, London, UK
| | - Lizzie Nicholson
- Electronic Data Research and Innovation Service, NHS National Services Scotland, Edinburgh, UK
| | - Carole Morris
- Electronic Data Research and Innovation Service, NHS National Services Scotland, Edinburgh, UK
| | | |
Collapse
|
8
|
Magierski R, Sobow T, Schwertner E, Religa D. Pharmacotherapy of Behavioral and Psychological Symptoms of Dementia: State of the Art and Future Progress. Front Pharmacol 2020; 11:1168. [PMID: 32848775 PMCID: PMC7413102 DOI: 10.3389/fphar.2020.01168] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 07/17/2020] [Indexed: 12/12/2022] Open
Abstract
The core symptoms of different dementia subtypes are the behavioral and psychological symptoms of dementia (BPSD) and its neuropsychiatric symptoms (NPS). BPSD symptoms may occur at any stage in the case of dementia due to Alzheimer's disease (AD), whereas they tend to occur early on in the case of its behavioral variant frontotemporal dementia or dementia with Lewy bodies and are essential for diagnosis. BPSD treatment consists of non-pharmacological as well as pharmacological interventions, with non-pharmacological interactions being suggested as first-line treatment. Agitation, psychotic features, apathy, depression, and anxiety may not respond to acetylcholinesterase inhibitors or memantine in AD cases; therefore, antipsychotics, antidepressants, sedative drugs or anxiolytics, and antiepileptic drugs are typically prescribed. However, such management of BPSD can be complicated by hypersensitivity to antipsychotic drugs, as observed in DLB, and a lack of effective pro-cognitive treatment in the case of frontotemporal dementia. The present paper reviews current knowledge of the management of BPSD and its limitations and discusses on-going clinical trials and future therapeutic options.
Collapse
Affiliation(s)
- Radoslaw Magierski
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, Lodz, Poland
| | - Tomasz Sobow
- Dialog Therapy Centre, Warsaw & Institute of Psychology, University of Lodz, Lodz, Poland
| | - Emilia Schwertner
- Center for Alzheimer Research, Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Dorota Religa
- Center for Alzheimer Research, Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.,Tema Aging, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
9
|
Giguère A, Zomahoun HTV, Carmichael PH, Uwizeye CB, Légaré F, Grimshaw JM, Gagnon MP, Auguste DU, Massougbodji J. Printed educational materials: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2020; 8:CD004398. [PMID: 32748975 PMCID: PMC8475791 DOI: 10.1002/14651858.cd004398.pub4] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Printed educational materials are widely used dissemination strategies to improve the quality of healthcare professionals' practice and patient health outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines. This is the fourth update of the review. OBJECTIVES To assess the effect of printed educational materials (PEMs) on the practice of healthcare professionals and patient health outcomes. To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on healthcare professionals' practice and patient health outcomes. SEARCH METHODS We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and EPOC Register from their inception to 6 February 2019. We checked the reference lists of all included studies and relevant systematic reviews. SELECTION CRITERIA We included randomised trials (RTs), controlled before-after studies (CBAs) and interrupted time series studies (ITSs) that evaluated the impact of PEMs on healthcare professionals' practice or patient health outcomes. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. Any objective measure of professional practice (e.g. prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included. DATA COLLECTION AND ANALYSIS Two reviewers undertook data extraction independently. Disagreements were resolved by discussion. For analyses, we grouped the included studies according to study design, type of outcome and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where data were available, we re-analysed the ITS studies by converting all data to a monthly basis and estimating the effect size from the change in the slope of the regression line between before and after implementation of the PEM. We reported median changes in slope for each outcome, for each study, and then across studies. We standardised all changes in slopes by their standard error, allowing comparisons and combination of different outcomes. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format. We assessed the risks of bias of all the included studies. MAIN RESULTS We included 84 studies: 32 RTs, two CBAs and 50 ITS studies. Of the 32 RTs, 19 were cluster RTs that used various units of randomisation, such as practices, health centres, towns, or areas. The majority of the included studies (82/84) compared the effectiveness of PEMs to no intervention. Based on the RTs that provided moderate-certainty evidence, we found that PEMs distributed to healthcare professionals probably improve their practice, as measured with dichotomous variables, compared to no intervention (median absolute risk difference (ARD): 0.04; interquartile range (IQR): 0.01 to 0.09; 3,963 healthcare professionals randomised within 3073 units). We could not confirm this finding using the evidence gathered from continuous variables (standardised mean difference (SMD): 0.11; IQR: -0.16 to 0.52; 1631 healthcare professionals randomised within 1373 units ), from the ITS studies (standardised median change in slope = 0.69; 35 studies), or from the CBA study because the certainty of this evidence was very low. We also found, based on RTs that provided moderate-certainty evidence, that PEMs distributed to healthcare professionals probably make little or no difference to patient health as measured using dichotomous variables, compared to no intervention (ARD: 0.02; IQR: -0.005 to 0.09; 935,015 patients randomised within 959 units). The evidence gathered from continuous variables (SMD: 0.05; IQR: -0.12 to 0.09; 6,737 patients randomised within 594 units) or from ITS study results (standardised median change in slope = 1.12; 8 studies) do not strengthen these findings because the certainty of this evidence was very low. Two studies (a randomised trial and a CBA) compared a paper-based version to a computerised version of the same PEM. From the RT that provided evidence of low certainty, we found that PEM in computerised versions may make little or no difference to professionals' practice compared to PEM in printed versions (ARD: -0.02; IQR: -0.03 to 0.00; 139 healthcare professionals randomised individually). This finding was not strengthened by the CBA study that provided very low certainty evidence (SMD: 0.44; 32 healthcare professionals). The data gathered did not allow us to conclude which PEM characteristics influenced their effectiveness. The methodological quality of the included studies was variable. Half of the included RTs were at risk of selection bias. Most of the ITS studies were conducted retrospectively, without prespecifying the expected effect of the intervention, or acknowledging the presence of a secular trend. AUTHORS' CONCLUSIONS The results of this review suggest that, when used alone and compared to no intervention, PEMs may slightly improve healthcare professionals' practice outcomes and patient health outcomes. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.
Collapse
Affiliation(s)
- Anik Giguère
- Department of Family Medicine and Emergency Medicine, Laval University, Québec, Canada
- VITAM Research center on Sustainable Health, Quebec, Canada
| | - Hervé Tchala Vignon Zomahoun
- Health and Social Services Systems, Knowledge Translation and Implementation Component of the SPOR-SUPPORT Unit of Québec, Centre de recherche sur les soins et les services de première ligne - Université Laval, Quebec, Canada
| | | | - Claude Bernard Uwizeye
- Laval University Research Center on Primary Health Care and Services (CERSSPL-UL), Québec, Canada
| | - France Légaré
- Centre de recherche sur les soins et les services de première ligne de l'Université Laval (CERSSPL-UL), Université Laval, Quebec, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marie-Pierre Gagnon
- Population Health and Optimal Health Practices Research Unit, CHU de Québec - Université Laval Research Centre, Québec City, Canada
| | - David U Auguste
- Département de médecine familiale et de médecine d'urgence, Université Laval, Québec, Canada
| | - José Massougbodji
- Health and Social Services Systems, Knowledge Translation and Implementation Component of the SPOR-SUPPORT Unit of Québec, Quebec SPOR-SUPPORT Unit, Québec, Canada
| |
Collapse
|
10
|
Imai H, Hirai T, Kumazawa R, Nakagawa S, Yonezawa A, Matsubara K, Nakao H. Prevalence of and risk factors for adverse events in Alzheimer's patients receiving anti-dementia drugs in at-home care. PLoS One 2020; 15:e0231226. [PMID: 32251456 PMCID: PMC7135264 DOI: 10.1371/journal.pone.0231226] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 03/18/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The objective of this study was to clarify the types and prevalence of, and the risk factors for, the adverse events that occur in patients receiving anti-dementia drugs. METHODS A questionnaire survey was conducted. The respondents were pharmacists who were dispensing anti-dementia drugs. The pharmacists responded to questions about patients who were receiving anti-dementia drugs delivered to them at home by the pharmacists. The survey questions included questions about whether or not the patients experienced adverse reactions to the drugs, about the patients' background characteristics, about the numbers of drugs the patients were taking when the pharmacists first visited the patients at home, and about the pharmacists' assessments of the appropriateness of the use of the anti-dementia drugs. RESULTS Data were collected on 3712 patients from 1673 pharmacies in a nationwide survey. Anti-dementia drugs had been prescribed to 863 of these patients; and 801 (92.8%) of these 863 patients were 75 years of age or older, and. confirmed adverse events occurred in 170 (21%) of these 863 patients. The most common adverse event was excitation/anxiety, at 45.1%. A multivariate analysis found that polypharmacy (10 or more types of drugs per day) (P = 0.030), inappropriate use (P = 0.002), and irregular medication use (P = 0.034) were risk factors. INTERPRETATION In order to avoid adverse events when using anti-dementia drugs, doctors and pharmacists should carefully examine the prescribing of multiple medications, assess the applicability of the use of anti-dementia drugs, and investigate how to best manage patients' drug use.
Collapse
Affiliation(s)
- Hirohisa Imai
- Department of Medical and Pharmaceutical Community Healthcare, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- * E-mail:
| | - Takuya Hirai
- Department of Biostatistics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryosuke Kumazawa
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Shunsaku Nakagawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Atsushi Yonezawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Kazuo Matsubara
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Hiroyuki Nakao
- Humanics in Nursing III, Basic Professional Educational Course, Faculty of Nursing, Miyazaki Prefectural Nursing University, Miyazaki, Japan
| |
Collapse
|
11
|
Georgi U, Lämmel J, Datzmann T, Schmitt J, Deckert S. Do drug-related safety warnings have the expected impact on drug therapy? A systematic review. Pharmacoepidemiol Drug Saf 2020; 29:229-251. [PMID: 32045502 DOI: 10.1002/pds.4968] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/22/2019] [Accepted: 01/28/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE The need for drug-related safety warnings is undisputed, and their impact should also be evaluated. This systematic review investigates and assesses the impact of safety warnings on drug therapy. METHODS Studies published in English between January 1998 and December 2018 were searched in EMBASE and MEDLINE, complemented by manual search. Randomised controlled trials, cohort studies with a before/after component, and case-control studies were included, selected to predefined criteria, and assessed for their reporting and methodological quality. RESULTS Out of 7454 references identified, 72 studies were included. A total of 28/72 (39%) studies described the impact of safety warnings on drug therapy as being effective, whereas 12/72 (17%) studies did not. Further, 26/72 (36%) studies described a partial implementation of the warnings (one part of the warning had an impact on drug therapy and another did not). Unintended effects were investigated in 6/72 (8%) studies. While 34 (47%) studies examined safety warnings on psychotropic drugs using an interrupted time series (ITS) design (53%), a before/after (26%), and a time series design (21%), 38 (53%) studied other substances using an ITS design (34%), a before/after (40%), and a time series design (26%). The proportion of an effective impact on drug therapy was lower in the "psychotropic drugs" group (23%) than in the "others" group (53%). CONCLUSION Drug-related safety warnings induce intended and unintended effects. The included studies are of broadly varying methodological quality. To better compare their effectiveness, studies should be conducted using standardised procedures.
Collapse
Affiliation(s)
- Ulrike Georgi
- Pharmacy Service of Clinical Center, Chemnitz, Germany.,Center for Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Julia Lämmel
- Center for Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany.,Pharmacy Service, Medical Center of the Carl Gustav Carus Technical University, Dresden, Germany
| | - Thomas Datzmann
- Center for Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany.,National Center for Tumor Diseases, Dresden, Germany
| | - Jochen Schmitt
- Center for Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Stefanie Deckert
- Center for Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany
| |
Collapse
|
12
|
Roux B, Sirois C, Simard M, Gagnon ME, Laroche ML. One-year persistence of potentially inappropriate medication use in older adults: A population-based study. Br J Clin Pharmacol 2020; 86:1062-1080. [PMID: 31916266 DOI: 10.1111/bcp.14214] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/25/2019] [Accepted: 12/09/2019] [Indexed: 12/30/2022] Open
Abstract
AIMS To assess the 1-year persistence of potentially inappropriate medication (PIM) use and identify associated factors in community-dwelling older adults in Quebec, Canada. METHODS A population-based cohort study was conducted using the Quebec Integrated Chronic Disease Surveillance System. Individuals insured by the public drug plan and aged ≥66 years who initiated a PIM between 1 April 2014 and 31 March 2015 were followed-up for 1 year. PIMs were identified using the 2015 Beers criteria. One-year persistence of PIM use was defined as continuous treatment with any PIM, without interruption for more than 60 days between prescriptions refills. Poisson regression models were performed to identify factors associated with 1-year persistence of any PIM. RESULTS In total, 25.1% of PIM initiators were persistent at 1 year. In non-persistent individuals, the median time to PIM discontinuation was 31 days (interquartile range 21-92). Individuals were more persistent at 1 year with antipsychotics (43.9%), long-duration sulphonylureas (40.2%), antiarrhythmics/immediate-release nifedipine (36.5%) and proton pump inhibitors (36.0%). Factors significantly associated with persistence were an increased age, being a man and having a high number of medications and chronic diseases, especially dementia, diabetes and cardiovascular diseases. CONCLUSIONS One-quarter of community-dwelling older adults are continuously exposed to PIMs. To optimize medication prescribing in the older population, further interventions are needed to limit the use of PIMs most likely to be continued, especially in individuals most at risk of being persistent and also particularly vulnerable to adverse events.
Collapse
Affiliation(s)
- Barbara Roux
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Pharmacology-Toxicology and Centre of Pharmacovigilance, University Hospital of Limoges, Limoges, France.,INSERM UMR 1248, Faculty of Medicine, University of Limoges, Limoges, France.,Quebec National Institute of Public Health, Quebec, Canada
| | - Caroline Sirois
- Quebec National Institute of Public Health, Quebec, Canada.,Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec, Canada.,Centre of Excellence on Aging of Quebec, Integrated University Health and Social Services Centres of the Capitale-Nationale, Québec, Canada
| | - Marc Simard
- Quebec National Institute of Public Health, Quebec, Canada
| | - Marie-Eve Gagnon
- Quebec National Institute of Public Health, Quebec, Canada.,Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Quebec, Canada
| | - Marie-Laure Laroche
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Pharmacology-Toxicology and Centre of Pharmacovigilance, University Hospital of Limoges, Limoges, France.,INSERM UMR 1248, Faculty of Medicine, University of Limoges, Limoges, France
| |
Collapse
|
13
|
Mar J, Gorostiza A, Ibarrondo O, Cernuda C, Arrospide A, Iruin Á, Larrañaga I, Tainta M, Ezpeleta E, Alberdi A. Validation of Random Forest Machine Learning Models to Predict Dementia-Related Neuropsychiatric Symptoms in Real-World Data. J Alzheimers Dis 2020; 77:855-864. [PMID: 32741825 PMCID: PMC7592688 DOI: 10.3233/jad-200345] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Neuropsychiatric symptoms (NPS) are the leading cause of the social burden of dementia but their role is underestimated. OBJECTIVE The objective of the study was to validate predictive models to separately identify psychotic and depressive symptoms in patients diagnosed with dementia using clinical databases representing the whole population to inform decision-makers. METHODS First, we searched the electronic health records of 4,003 patients with dementia to identify NPS. Second, machine learning (random forest) algorithms were applied to build separate predictive models for psychotic and depressive symptom clusters in the training set (N = 3,003). Third, calibration and discrimination were assessed in the test set (N = 1,000) to assess the performance of the models. RESULTS Neuropsychiatric symptoms were noted in the electronic health record of 58% of patients. The area under the receiver operating curve reached 0.80 for the psychotic cluster model and 0.74 for the depressive cluster model. The Kappa index and accuracy also showed better discrimination in the psychotic model. Calibration plots indicated that both types of model had less predictive accuracy when the probability of neuropsychiatric symptoms was <25%. The most important variables in the psychotic cluster model were use of risperidone, level of sedation, use of quetiapine and haloperidol and the number of antipsychotics prescribed. In the depressive cluster model, the most important variables were number of antidepressants prescribed, escitalopram use, level of sedation, and age. CONCLUSION Given their relatively good performance, the predictive models can be used to estimate prevalence of NPS in population databases.
Collapse
Affiliation(s)
- Javier Mar
- Basque Health Service (Osakidetza), Debagoiena Integrated Healthcare Organisation, Research Unit, Arrasate-Mondragón, Guipúzcoa, Spain
- Kronikgune Institute for Health Service Research, Barakaldo, Spain
- Biodonostia Health Research Institute, Donostia-San Sebastán, Guipúzcoa, Spain
- Health Services Research on Chronic Patients Network (REDISSEC), Bilbao, Vizcaya, Spain
| | - Ania Gorostiza
- Basque Health Service (Osakidetza), Debagoiena Integrated Healthcare Organisation, Research Unit, Arrasate-Mondragón, Guipúzcoa, Spain
- Kronikgune Institute for Health Service Research, Barakaldo, Spain
| | - Oliver Ibarrondo
- Basque Health Service (Osakidetza), Debagoiena Integrated Healthcare Organisation, Research Unit, Arrasate-Mondragón, Guipúzcoa, Spain
- Kronikgune Institute for Health Service Research, Barakaldo, Spain
- Biodonostia Health Research Institute, Donostia-San Sebastán, Guipúzcoa, Spain
| | - Carlos Cernuda
- Mondragon Unibertsitatea, Faculty of Engineering, Electronics and Computing Department, Arrasate-Mondragon, Gipuzkoa, Spain
| | - Arantzazu Arrospide
- Basque Health Service (Osakidetza), Debagoiena Integrated Healthcare Organisation, Research Unit, Arrasate-Mondragón, Guipúzcoa, Spain
- Kronikgune Institute for Health Service Research, Barakaldo, Spain
- Biodonostia Health Research Institute, Donostia-San Sebastán, Guipúzcoa, Spain
- Health Services Research on Chronic Patients Network (REDISSEC), Bilbao, Vizcaya, Spain
| | - Álvaro Iruin
- Biodonostia Health Research Institute, Donostia-San Sebastán, Guipúzcoa, Spain
- Basque Health Service (Osakidetza), Gipuzkoa Mental Health Network, Donostia-San Sebastián, Guipúzcoa, Spain
| | - Igor Larrañaga
- Basque Health Service (Osakidetza), Debagoiena Integrated Healthcare Organisation, Research Unit, Arrasate-Mondragón, Guipúzcoa, Spain
- Kronikgune Institute for Health Service Research, Barakaldo, Spain
| | - Mikel Tainta
- Kronikgune Institute for Health Service Research, Barakaldo, Spain
- Department of Neurology, Basque Health Service (Osakidetza), Goierri-Urola Garaia Integrated Healthcare Organisation, Zumarraga, Guipúzcoa, Spain
- Fundación CITA-Alzheimer Fundazioa, Donostia-San Sebastián, Guipúzcoa, Spain
| | - Enaitz Ezpeleta
- Mondragon Unibertsitatea, Faculty of Engineering, Electronics and Computing Department, Arrasate-Mondragon, Gipuzkoa, Spain
| | - Ane Alberdi
- Mondragon Unibertsitatea, Faculty of Engineering, Electronics and Computing Department, Arrasate-Mondragon, Gipuzkoa, Spain
| |
Collapse
|
14
|
Weatherburn CJ, Guthrie B, Dreischulte T, Morales DR. Impact of medicines regulatory risk communications in the UK on prescribing and clinical outcomes: Systematic review, time series analysis and meta-analysis. Br J Clin Pharmacol 2019; 86:698-710. [PMID: 31465123 DOI: 10.1111/bcp.14104] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 08/13/2019] [Accepted: 08/20/2019] [Indexed: 12/18/2022] Open
Abstract
AIMS Regulatory risk communications are important to ensure medication safety, but their impact is poorly understood. The aim was to quantify the impact of UK risk communications on medication use and other outcomes. METHODS We conducted a systematic review of studies reporting prescribing/health outcome data relevant to UK regulatory risk communication. Data were reanalysed using interrupted time series regression 12 months after each regulatory intervention. Mean changes were pooled using random-effects generic inverse variance examining the following subgroups: drug withdrawals; restrictions/changes in indications; be aware messages without specific recommendations for action; communication via direct healthcare practitioner communications; communication via drug bulletins. RESULTS Of 11 466 articles screened, 40 studies examining 25 UK regulatory risk communications were included. Product withdrawals, restriction in indications and be aware communications were associated with relative mean changes of -78% (95% confidence interval [CI] -60 to -96%), -34% (95% confidence interval [CI] -12 to -55%) and -11% (95%CI -8 to -15%) in targeted drug prescribing respectively. Direct healthcare professional communications were associated with relative mean changes of -47% (95%CI -27 to -68%) compared to -13% (95%CI -6 to -20%) for drug bulletins. Of 7 studies examining unique health outcomes related to the safety concern, risk communications were associated with a mean -10% (95%CI -3 to -16%) decrease in intended and a 7% (95%CI 4 to 10%) increase in unintended health outcomes. DISCUSSION UK regulatory risk communications were associated with significant changes in targeted prescribing and potential changes in clinical outcomes. Further research is needed to systematically study the impact of regulatory interventions.
Collapse
Affiliation(s)
| | - Bruce Guthrie
- General Practice, Centre for Population Health Sciences, Usher Institute, University of Edinburgh, UK
| | - Tobias Dreischulte
- Clinical Health Services Research, Institute of General Practice and Family Medicine, University Hospital of Ludwig-Maximilians-University Munich, Germany
| | - Daniel R Morales
- Discovery Fellow and General Practitioner, Division of Population Health and Genomics, University of Dundee, UK
| |
Collapse
|
15
|
Gafoor R, Charlton J, Ravindrarajah R, Gulliford MC. Importance of Frailty for Association of Antipsychotic Drug Use With Risk of Fracture: Cohort Study Using Electronic Health Records. J Am Med Dir Assoc 2019; 20:1495-1501.e1. [DOI: 10.1016/j.jamda.2019.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 05/09/2019] [Accepted: 05/11/2019] [Indexed: 12/01/2022]
|
16
|
Bargagli AM, Cascini S, Agabiti N, Kirchmayer U, Marino C, Davoli M. Determinants Of Antipsychotic Drugs Prescription Among Community-Living Older Adults With Dementia: A Population-Based Study Using Health Information Systems In The Lazio Region, Italy. Clin Interv Aging 2019; 14:2071-2083. [PMID: 31819389 PMCID: PMC6877449 DOI: 10.2147/cia.s218641] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 09/11/2019] [Indexed: 12/28/2022] Open
Abstract
Introduction Despite recommendations from associations of geriatric and psychiatry societies and warnings from drug agencies, antipsychotic (AP) drugs are frequently used to control behavioral and psychological symptoms of dementia. APs are associated with a range of potential adverse events, including increased risk of cerebrovascular events and mortality. Evidence suggests limited efficacy of APs for aggression and psychosis. Our objectives were to investigate patterns and predictors for prescription of APs among older adults with dementia residing in a large region of central Italy, and to identify patient characteristics related to typical or atypical APs prescribing. Methods This is a retrospective population-based cohort study using data from regional health information systems (HIS). We included dementia patients aged ≥65 years residing in the Lazio region. The exposure was defined as new use vs non-use of APs. Dementia patients with incident use of APs during 2015 were followed-up from the date of first prescription to the earliest among discontinuation of use, death, or end of study (December 31, 2016). Results We enrolled 24,735 dementia patients, 1727 (6.7%) new users and 23,008 non-users of APs. Forty-four percent of AP users were treated for more than 3 months, and among these about 60% received APs continuously for at least 12 months. Individuals using antidepressant or anti-dementia drugs had higher odds of being prescribed with APs (OR: 1.67 and OR: 1.86, respectively). Patients exposed to polypharmacy were less likely to receive APs (OR: 0.82). Cardiovascular risk factors and comorbidities were not associated with APs use. Low socio-economic position was associated with lower odds of atypical AP prescribing (OR: 0.57). Conclusion The study showed that a not negligible proportion of patients had a period of AP use longer than recommended by guidelines. We identified socio-demographic and clinical factors associated with first use of APs, providing insight into prescribing practices in a community setting and useful information to address areas of potential inappropriateness.
Collapse
Affiliation(s)
- Anna Maria Bargagli
- Department of Epidemiology, Regional Health Service Lazio Region, Rome, Italy
| | - Silvia Cascini
- Department of Epidemiology, Regional Health Service Lazio Region, Rome, Italy
| | - Nera Agabiti
- Department of Epidemiology, Regional Health Service Lazio Region, Rome, Italy
| | - Ursula Kirchmayer
- Department of Epidemiology, Regional Health Service Lazio Region, Rome, Italy
| | - Claudia Marino
- Department of Epidemiology, Regional Health Service Lazio Region, Rome, Italy
| | - Marina Davoli
- Department of Epidemiology, Regional Health Service Lazio Region, Rome, Italy
| |
Collapse
|
17
|
Mar J, Arrospide A, Soto-Gordoa M, Iruin Á, Tainta M, Gabilondo A, Mar-Barrutia L, Calvo M, Mateos M, Ibarrondo O. Dementia-related neuropsychiatric symptoms: inequalities in pharmacological treatment and institutionalization. Neuropsychiatr Dis Treat 2019; 15:2027-2034. [PMID: 31413574 PMCID: PMC6657654 DOI: 10.2147/ndt.s209008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 06/24/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Dementia-related neuropsychiatric symptoms (NPS) are the main determinant of family stress and institutionalization of patients. This study aimed to identify inequalities by gender and socioeconomic status in the management of NPS in patients diagnosed with dementia. METHODS An observational study was carried out to study all the cases of dementia in the corporate database of the Basque Health Service (29,864 patients). The prescription of antipsychotics and antidepressants and admission to a nursing home were used to establish the presence of NPS. The socioeconomic status of individuals was classified by a deprivation index. Logistic regressions were used to identify drivers for drug prescriptions and institutionalization. RESULTS NPS are poorly recorded in the clinical databases (12%). Neuropsychiatric symptoms were severe enough in two thirds of patients with dementia to be treated with psychoactive medication. Institutionalization showed an increase from those who did not receive medication to those who had been prescribed antidepressants (OR: 1.546), antipsychotics (OR: 2.075) or both (OR: 2.741). The resulting inequalities were the increased prescription of antidepressant drugs in women and more nursing-home admissions for women who were the least socioeconomically deprived and men who were the most deprived. CONCLUSIONS In large clinical databases, psychoactive drugs prescriptions can be useful to underscore the considerable burden of dementia-related NPS. Specific tools are needed to monitor social and health care programs targeted to dementia-related NPS from a population perspective. Programs aimed at reducing the family burden of care of dementia patients at home become the key elements in reducing inequalities in these patients' care. Socioeconomic status is the most important driver of inequality, and gender inequality may simply be hidden within the social environment. Integrated programs boosting the continuity of care are an objective for which compliance could be measured according to the NPS coding in the electronic health record.
Collapse
Affiliation(s)
- Javier Mar
- Clinical Management Unit, OSI Alto Deba, Arrasate-Mondragón, España
- AP-OSIs Gipuzkoa Research Unit, OSI Alto Deba, Arrasate-Mondragón, España
- Economic Evaluation Department, Health Services Research on Chronic Patients Network (REDISSEC), Bilbao, Spain
- Economic Evaluation Department, Biodonostia Health Research Institute, Donostia-San Sebastián, Spain
| | - Arantzazu Arrospide
- AP-OSIs Gipuzkoa Research Unit, OSI Alto Deba, Arrasate-Mondragón, España
- Economic Evaluation Department, Health Services Research on Chronic Patients Network (REDISSEC), Bilbao, Spain
- Economic Evaluation Department, Biodonostia Health Research Institute, Donostia-San Sebastián, Spain
| | - Myriam Soto-Gordoa
- Departamento de Ingeniería de Organización, Mondragón Unibertsitatea, Arrasate-Mondragón, España
| | - Álvaro Iruin
- Economic Evaluation Department, Biodonostia Health Research Institute, Donostia-San Sebastián, Spain
- Psychiatry Service, Gipuzkoa Mental Health Network, Donostia-San Sebastián, España
| | - Mikel Tainta
- Psychiatry Service, CITA Alzheimer Foundation, Donostia-San Sebastián, España
- Neurology Service, OSI Goierri-Alto Urola, Zumárraga, España
| | - Andrea Gabilondo
- Economic Evaluation Department, Biodonostia Health Research Institute, Donostia-San Sebastián, Spain
- Psychiatry Service, Gipuzkoa Mental Health Network, Donostia-San Sebastián, España
| | - Lore Mar-Barrutia
- Psychiatry Service, Hospital Bellvitge, Hospitalet de Llobregat, España
| | | | - Maider Mateos
- Health Department, Basque Government, Vitoria-Gasteiz, España
| | - Oliver Ibarrondo
- AP-OSIs Gipuzkoa Research Unit, OSI Alto Deba, Arrasate-Mondragón, España
- Economic Evaluation Department, Biodonostia Health Research Institute, Donostia-San Sebastián, Spain
| |
Collapse
|
18
|
Bala SS, Jamieson HA, Nishtala PS. Determinants of prescribing potentially inappropriate medications in a nationwide cohort of community dwellers with dementia receiving a comprehensive geriatric assessment. Int J Geriatr Psychiatry 2019; 34:153-161. [PMID: 30251394 DOI: 10.1002/gps.5004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 09/08/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To identify the prevalence and predictors of prescribing potentially inappropriate medications (PIMs) in a nationwide cohort of community dwellers with dementia requiring complex care needs. METHODS A cross-matched data of the International Resident Assessment Instrument-Home Care (9.1) (interRAI-HC) and prescribing data obtained from the Pharmaceutical Claims Data Mart (Pharms) extract files for older adults (≥65 y) requiring complex care needs were utilized for this study. The 2015 Beers criteria were applied to identify the prevalence of PIMs in older adults with dementia. Sociodemographic and clinical predictors of PIMs were analysed using a logistic regression model. RESULTS The study population consisted of 16 568 individuals who had their first interRAI assessment from 1 January 2015 to 31 December 2015. The estimated prevalence of dementia was 13.2% (2190/16 568). 66.9% (1465/2190) of the older adults diagnosed with dementia were prescribed PIMs, of which anticholinergic medications constituted 59.6% (873/1465). Males and individuals who were prescribed a greater number of medications were more likely to be prescribed PIMs. Individuals over 85 years of age, Māori ethnic group of individuals, older adults who were being supervised with respect to their activities of daily living, and individuals who reported good or excellent self-reported health had a lesser likelihood of being prescribed PIMs. CONCLUSION We found that PIMs are prescribed frequently in older adults with dementia. Comprehensive geriatric assessments can serve as a potential tool to decrease the occurrence of PIMs in vulnerable groups with poor functional and cognitive status.
Collapse
Affiliation(s)
- Sharmin S Bala
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - Hamish A Jamieson
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Prasad S Nishtala
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| |
Collapse
|
19
|
Prescribing Variation in General Practices in England Following a Direct Healthcare Professional Communication on Mirabegron. J Clin Med 2018; 7:jcm7100320. [PMID: 30282903 PMCID: PMC6210595 DOI: 10.3390/jcm7100320] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 09/28/2018] [Accepted: 10/02/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction: Pharmacovigilance may detect safety issues after marketing of medications, and this can result in regulatory action such as direct healthcare professional communications (DHPC). DHPC can be effective in changing prescribing behaviour, however the extent to which prescribers vary in their response to DHPC is unknown. This study aims to explore changes in prescribing and prescribing variation among general practitioner (GP) practices following a DHPC on the safety of mirabegron, a medication to treat overactive bladder (OAB). Methods: This is an interrupted time series study of English GP practices from 2014–2017. National Health Service (NHS) Digital provided monthly statistics on aggregate practice-level prescribing and practice characteristics (practice staff and registered patient profiles, Quality and Outcomes Framework indicators, and deprivation of the practice area). The primary outcome was monthly mirabegron prescriptions as a percentage of all OAB drug prescriptions and we assessed the change following a DHPC issued by the European Medicines Agency in September 2015. The DHPC stated mirabegron use was contraindicated with severe uncontrolled hypertension and cautioned with hypertension. Variation between practices in mirabegron prescribing before and after the DHPC was assessed using the systematic component of variation (SCV). Multilevel segmented regression with random effects quantified the change in level and trend of prescribing after the DHPC. Practice characteristics were assessed for their association with a reduction in prescribing following the DHPC. Results: This study included 7408 practices. During September 2015, 88.9% of practices prescribed mirabegron and mirabegron comprised a mean of 8.2% (SD 6.8) of OAB prescriptions. Variation between practices was classified as very high and the median SCV did not change significantly (p = 0.11) in the six months after the September 2015 DHPC (12.4) compared to before (11.6). Before the DHPC, the share of mirabegron over all OAB drug prescriptions increased by 0.294 (95% confidence interval (CI), 0.287, 0.301) percentage points per month. There was no significant change in the month immediately after the DHPC (−0.023, 95% CI −0.105 to 0.058), however there was a significant reduction in trend (−0.036, 95% CI −0.049 to −0.023). Higher numbers of registered patients, patients aged ≥65 years, and practice area deprivation were associated with having a significant decrease in level and slope of mirabegron prescribing post-DHPC. Conclusion: Variation in mirabegron prescribing was high over the study period and did not change substantively following the DHPC. There was no immediate prescribing change post-DHPC, although the monthly growth did slow. Knowledge of the degree of variation in and determinants of response to safety communications may allow those that do not change prescribing habits to be provided with additional support.
Collapse
|
20
|
Fulone I, Lopes LC. Potentially inappropriate prescriptions for elderly people taking antidepressant: comparative tools. BMC Geriatr 2017; 17:278. [PMID: 29197326 PMCID: PMC5712132 DOI: 10.1186/s12877-017-0674-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 11/23/2017] [Indexed: 12/28/2022] Open
Abstract
Background The use of psychotropic drugs by elderly people is widely spread around the world, given that prevalence of inappropriate medication is frequent. Strictly speaking, in Brazil, the vulnerable population of elderly people is more likely to use Potentially Inappropriate Psychotropic (PIP) due to the impact of social-economic characteristics, to the Brazilian Public Health System, and to the lack of patient monitoring. However, neither the use pattern nor the prevalence rate of PIP have been studied in Brazil so far. The objectives of this study were to determine the prevalence of PIP in elderly outpatients taking antidepressants, and to compare the performance of two different tools (Beers, STOPP). Methods This cross-sectional study involved all the aged outpatients (≥ 60 years of age) taking antidepressants attended by the public health system in a city of the State of São Paulo, Brazil. Data were obtained from a pharmacy database and medical records. All psychotropic drugs evaluated included: antidepressants, antipsychotics, anti-epileptics and benzodiazepines. STOPP and Beers criteria were applied to detect PIP. Results One thousand one hundred forty prescriptions from 174 outpatients were subjected to two different screening tools. The average patient age was 67 (interquartile range 63–74) and the median number of drugs used was 3.0 (interquartile 2–4) per patient. The overall prevalence of PIP was 121 (69.5%). The levels of PIP observed according to tools were 39.6% (STOPP) and 29.9% (Beers).The long-term use of benzodiazepines was the most common PIP recognized, and the one which contributed more significantly to higher levels of PIP than other medications. Conclusions The prevalence of PIP was high among the elderly. STOPP criteria identified more PIP than Beers criteria. Knowledge of PIP prevalence should gear efforts to reduce the level of inappropriate prescriptions and may provide the need for developing national criteria.
Collapse
Affiliation(s)
- Izabela Fulone
- Pharmaceutical Sciences Post graduate Course, University of Sorocaba, UNISO, Rodovia Raposo Tavares, KM 92,5, Sorocaba, São Paulo, ZIP Code 18023-000, Brazil
| | - Luciane Cruz Lopes
- Pharmaceutical Sciences Post graduate Course, University of Sorocaba, UNISO, Rodovia Raposo Tavares, KM 92,5, Sorocaba, São Paulo, ZIP Code 18023-000, Brazil.
| |
Collapse
|
21
|
Over-prescribing of antipsychotics in dementia: have warnings worked? Drug Ther Bull 2017; 55:123-124. [PMID: 29089303 DOI: 10.1136/dtb.2017.10.0546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
|
22
|
|