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Moon A, Jang S, Kim JH, Jang S. Risk of falls or fall-related injuries associated with potentially inappropriate medication use among older adults with dementia. BMC Geriatr 2024; 24:699. [PMID: 39179955 PMCID: PMC11342481 DOI: 10.1186/s12877-024-05300-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 08/13/2024] [Indexed: 08/26/2024] Open
Abstract
BACKGROUND Potentially inappropriate medications (PIMs) are prevalent in older adults with dementia and subsequent falls or fall-related injuries. The present study determined the risk of falls or fall-related injuries associated with PIM use in older adults with dementia. METHODS The National Health Insurance Service-Elderly Cohort Database 2.0 (NHIS-ECDB 2.0) was used for this self-controlled case series (SCCS) study. This study included 1430 participants who went through exposure and non-exposure periods of PIM application among patients with dementia and experienced outcome events of falls or fall-related injuries between January 2016 and December 2019. The incidence of falls or fall-related injuries during the exposure and post-exposure periods was compared with that during the non-exposure period. Beers Criteria were used to define PIMs in patients with dementia. Negative binomial regression was conducted. The incidence rate ratio (IRR) was used to determine the risk of falls or fall-related injuries. RESULTS During the exposure periods in which falls or fall-related injuries occurred, the mean number of PIMs among patients with dementia was 3.76 (SD = 2.99), and the most commonly used PIMs among patients with dementia were first-generation antihistamines (n = 283; 59.1%). Compared to the non-exposure period, the adjusted IRR during the exposure period was 1.57 (95% CI = 1.39-1.76). The risk of falls or fall-related injuries was increased when PIM use in patients with dementia was initiated (1-14 days: IRR = 2.76, 95% CI = 2.31-3.28; 15-28 days: IRR = 1.95, 95% CI = 1.48-2.56; ≥ 29 days: IRR = 1.17, 95% CI = 1.01-1.35). Especially, an increased risk of falls or fall-related injuries was associated with greater PIM use among patients with dementia. CONCLUSION Among older adults with dementia, PIMs significantly increase the risk of falls and fall-related injuries. Therefore, strategies should be developed to manage PIM prescriptions in patients with dementia to prevent falls.
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Affiliation(s)
- Arum Moon
- College of Pharmacy, Gachon University, 191 Hambakmoe‑Ro, Yeonsu‑Gu, Incheon, 21936, Republic of Korea
- Gachon Institute of Pharmaceutical Sciences, Incheon, Republic of Korea
| | - Suhyun Jang
- College of Pharmacy, Gachon University, 191 Hambakmoe‑Ro, Yeonsu‑Gu, Incheon, 21936, Republic of Korea
- Gachon Institute of Pharmaceutical Sciences, Incheon, Republic of Korea
| | - Jung-Ha Kim
- Department of Family Medicine, Chung-Ang University Medical Center, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Sunmee Jang
- College of Pharmacy, Gachon University, 191 Hambakmoe‑Ro, Yeonsu‑Gu, Incheon, 21936, Republic of Korea.
- Gachon Institute of Pharmaceutical Sciences, Incheon, Republic of Korea.
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Schulze Westhoff M, Schröder S, Heck J, Brod T, Winkelmann M, Bleich S, Frieling H, Jahn K, Wedegärtner F, Groh A. Drug Safety Profiles of Geriatric Patients Referred to Consultation Psychiatry in the Emergency Department-A Retrospective Cohort Study. J Geriatr Psychiatry Neurol 2023; 36:407-416. [PMID: 36592403 PMCID: PMC10394965 DOI: 10.1177/08919887221149158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Geriatric patients account for a significant proportion of the collective treated by psychiatric consultation service in hospitals. In the Emergency Department (ED), psychotropic drugs are frequently recommended, notwithstanding their extensive side-effect profiles. This study sought to investigate medication safety of geriatric patients referred to psychiatric consultation service in the ED. METHODS Medication lists of 60 patients from the general internal medicine and trauma surgery EDs referred to psychiatric consultation service were analyzed. Utilizing PRISCUS list and Fit fOR The Aged (FORTA) classification, prescriptions of potentially inappropriate medications (PIMs) were assessed. RESULTS 84 drugs were newly prescribed following psychiatric consultations. The total number of drugs per patient was 5.4 ± 4.2 before psychiatric consultation and 6.5 ± 4.2 thereafter (p < .001). 22.6 % of the newly recommended drugs were PIMs according to the PRISCUS list, while 54.8 % were designated as therapeutic alternatives to PIMs. 54.8 % and 20.2 % of the newly recommended drugs were FORTA category C and D drugs, respectively. An average of 1.2 ± 1.7 drug-drug interactions (DDIs) existed before psychiatric consultation and 1.3 ± 1.9 DDIs thereafter (p = .08). CONCLUSION The majority of newly recommended drugs by psychiatric consultation service in the ED were designated as suitable therapeutic alternatives to PIMs according to the PRISCUS list, but had comparatively unfavorable ratings according to the FORTA classification, demonstrating discrepancies between these two PIM classification systems. Physicians delivering psychiatric consultation services in the ED should not solely rely on one PIM classification system.
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Affiliation(s)
- Martin Schulze Westhoff
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Sebastian Schröder
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Johannes Heck
- Institute for Clinical Pharmacology, Hannover Medical School, Hannover, Germany
| | - Torben Brod
- Emergency Department, Hannover Medical School, Hannover, Germany
| | | | - Stefan Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Helge Frieling
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Kirsten Jahn
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Felix Wedegärtner
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Adrian Groh
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
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Al-Azayzih A, Jarab AS, Bani-Ahmad E, Smadi S, Kharaba Z, Al-Kubaisi KA. Anticholinergic burden risk and prevalence of medications carrying anticholinergic properties in elderly cancer patients in Jordan. Saudi Pharm J 2023; 31:101710. [PMID: 37559866 PMCID: PMC10406854 DOI: 10.1016/j.jsps.2023.101710] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/20/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Geriatric cancer patients are susceptible to adverse drug events due to the complexity of their chemotherapy regimens and collateral treatments for their comorbid conditions. Prescribing medications with anticholinergic burden characteristics can complicate their condition, leading to negative impacts on their health outcomes and quality of life, including an increase in adverse drug event frequency, physical and cognitive impairments. OBJECTIVE This study aims to examine the prevalence of anticholinergic prescribing and identify the cumulative anticholinergic load risk associated with drugs prescribed to elderly cancer patients. Also, to identify the predictors that might lead to raised anticholinergic burden in these patients. METHODOLOGY This retrospective cross-sectional study included elderly patients (age ≥ 65) diagnosed with cancer and admitted to the adult oncology unit at King Abdullah University Hospital (KAUH) in Jordan during the period between (January 1st, 2019, and January 1st, 2022). The medication charts of 420 patients were evaluated for study outcomes. RESULTS Of the total subjects, females represented 49.3%, and the average age was 72.95 (SD = 7.33). A total of 354 (84.3%) patients were prescribed at least one drug carrying anticholinergic burden properties. Median for anticholinergic medications was 3 (IQR = 4). Our study found that 194 (46.2%) patients were at a high risk of adverse events associated with anticholinergic load (cumulative score ≥ 3). Metoclopramide, furosemide, and tramadol were the most frequently prescribed drugs with anticholinergic properties. Alimentary tract drugs with anticholinergic action were the most commonly encountered items in our study population. CONCLUSION Our study revealed a significantly high prevalence of anticholinergic prescribing among elderly cancer patients. Nearly half of the patients were at high risk of developing serious effects related to anticholinergic activity from the drugs administered. Polypharmacy was strongly associated with increased anticholinergic burden score. Evidence-based recommendations utilizing prescribing strategies for safer alternatives and deprescribing of inappropriate medications could reduce such inappropriate prescribing.
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Affiliation(s)
- Ahmad Al-Azayzih
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology. P.O. Box 3030, Irbid 22110, Jordan
| | - Anan S. Jarab
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology. P.O. Box 3030, Irbid 22110, Jordan
- College of Pharmacy, AL Ain University, Abu Dhabi, United Arab Emirates
| | - Enas Bani-Ahmad
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology. P.O. Box 3030, Irbid 22110, Jordan
| | - Saja Smadi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology. P.O. Box 3030, Irbid 22110, Jordan
| | - Zelal Kharaba
- College of Pharmacy, AL Ain University, Abu Dhabi, United Arab Emirates
- Honorary Associate Lecturer, Faculty of Medical Sciences, Newcastle University, Newcastle upon tyne, UK
| | - Khalid A. Al-Kubaisi
- Department of Pharmacy Practice and Pharmacotherapeutics, College of Pharmacy, University of Sharjah, Sharjah, United Arab Emirates
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Zhao M, Chen Z, Xu T, Fan P, Tian F. Global prevalence of polypharmacy and potentially inappropriate medication in older patients with dementia: a systematic review and meta-analysis. Front Pharmacol 2023; 14:1221069. [PMID: 37693899 PMCID: PMC10483131 DOI: 10.3389/fphar.2023.1221069] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/03/2023] [Indexed: 09/12/2023] Open
Abstract
Background: Older patients with dementia always need multiple drugs due to comorbidities and cognitive impairment, further complicating drug treatment and increasing the risk of potentially inappropriate medication. The objective of our study is to estimate the global prevalence of polypharmacy and potentially inappropriate medication (PIM) and explore the factors of PIM for older patients with dementia. Methods: We searched PubMed, Embase (Ovid), and Web of Science databases to identify eligible studies from inception to 16 June 2023. We conducted a meta-analysis for observational studies reporting the prevalence of potentially inappropriate medication and polypharmacy in older patients with dementia using a random-effect model. The factors associated with PIM were meta-analyzed. Results: Overall, 62 eligible studies were included, of which 53 studies reported the prevalence of PIM and 28 studies reported the prevalence of polypharmacy. The pooled estimate of PIM and polypharmacy was 43% (95% CI 38-48) and 62% (95% CI 52-71), respectively. Sixteen studies referred to factors associated with PIM use, and 15 factors were further pooled. Polypharmacy (2.83, 95% CI 1.80-4.44), diabetes (1.31, 95% CI 1.04-1.65), heart failure (1.17, 95% CI 1.00-1.37), depression (1.45, 95% CI 1.14-1.88), history of cancer (1.20, 95% CI 1.09-1.32), hypertension (1.46, 95% CI 1.05-2.03), ischemic heart disease (1.55, 95% CI 0.77-3.12), any cardiovascular disease (1.11, 95% CI 1.06-1.17), vascular dementia (1.09, 95% CI 1.03-1.16), chronic obstructive pulmonary disease (1.39, 95% CI 1.13-1.72), and psychosis (1.91, 95% CI 1.04-3.53) are positively associated with PIM use. Conclusion: PIM and polypharmacy were highly prevalent in older patients with dementia. Among different regions, the pooled estimate of PIM use and polypharmacy varied widely. Increasing PIM in older patients with dementia was closely associated with polypharmacy. For other comorbidities such as heart failure and diabetes, prescribing should be cautioned.
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Affiliation(s)
| | | | | | - Ping Fan
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fangyuan Tian
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Lim J, Jeong S, Jang S, Jang S. Hospitalization and emergency department visits associated with potentially inappropriate medication in older adults: self-controlled case series analysis. Front Public Health 2023; 11:1080703. [PMID: 37469702 PMCID: PMC10352109 DOI: 10.3389/fpubh.2023.1080703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 05/30/2023] [Indexed: 07/21/2023] Open
Abstract
Introduction Potentially inappropriate medications (PIM) and resulting adverse health outcomes in older adults are a common occurrence. However, PIM prescriptions are still frequent for vulnerable older adults. Here, we sought to estimate the risk of hospitalization and emergency department (ED) visits associated with PIM prescriptions over different exposure periods and PIM drug categories. Methods We used the National Health Insurance Service-Elderly Cohort Database (NHIS-ECDB) to construct the cohort and implemented a Self-Controlled Case Series (SCCS) method. Hospitalization or ED visits during the exposure and post-exposure periods were compared to those during the non-exposure period, and six PIM drug categories were evaluated. A conditional Poisson regression model was applied, and the risk of outcomes was presented as the incidence rate ratio (IRR). All potential time-varying covariates were adjusted by year. A total of 43,942 older adults aged ≥65 y who had at least one PIM prescription and the events of either hospitalization or ED visits between Jan 2016 and Dec 2019 were selected.. Results Mean days of each exposure period was 46 d (±123); risk was highest in exposure1 (1-7 d, 37.8%), whereas it was similar during exposure2 (15-28 d), and exposure3 (29-56 d) (16.6%). The mean number of total PIM drugs administered during the study period was 7.34 (±4.60). Both hospitalization and ED visits were significantly higher in both exposure (adjusted IRR 2.14, 95% Confidence Interval (CI):2.11-2.17) and post-exposure periods (adjusted IRR 1.41, 95% CI:1.38-1.44) in comparison to non-exposure period. The risk of adverse health outcomes was highest during the first exposure period (1-14 d), but decreased gradually over time. Among the PIM categories, pain medication was used the most, followed by anticholinergics. All PIM categories significantly increased the risk of hospitalization and ED visits, ranging from 1.18 (other PIM) to 2.85 (pain medication). Sensitivity analyses using the first incidence of PIM exposure demonstrated similar results. All PIM categories significantly increased the risk of hospitalization and ED visits, with the initial period of PIM prescriptions showing the highest risk. In subgroup analysis stratified by the number of medications, PIM effects on the risk of hospitalization and ED visits remained significant but gradually attenuated by the increased number of medications. Discussion Therefore, the development of deprescribing strategies to control PIM and polypharmacy collectively is urgent and essential.
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Affiliation(s)
- Jaeok Lim
- College of Pharmacy and Gachon Institute of Pharmaceutical Sciences, Gachon University, Incheon, Republic of Korea
| | - Sohyun Jeong
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Suhyun Jang
- College of Pharmacy and Gachon Institute of Pharmaceutical Sciences, Gachon University, Incheon, Republic of Korea
| | - Sunmee Jang
- College of Pharmacy and Gachon Institute of Pharmaceutical Sciences, Gachon University, Incheon, Republic of Korea
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6
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Gosselin M, Talbot D, Simard M, Chiu YM, Mésidor M, Boiteau V, Carmichael PH, Sirois C. Classifying Polypharmacy According to Pharmacotherapeutic and Clinical Risks in Older Adults: A Latent Class Analysis in Quebec, Canada. Drugs Aging 2023; 40:573-583. [PMID: 37149556 DOI: 10.1007/s40266-023-01028-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2023] [Indexed: 05/08/2023]
Abstract
INTRODUCTION The simplistic definition of polypharmacy, often designated as the concomitant use of five medications or more, does not distinguish appropriate from inappropriate polypharmacy. Classifying polypharmacy according to varying levels of health risk would help optimise medication use. OBJECTIVE We aimed to characterise different types of polypharmacy among older adults and evaluate their association with mortality and institutionalisation. METHODS Using healthcare databases from the Quebec Integrated Chronic Disease Surveillance System, we selected a community-based random sample of the population ≥ 66 years old covered by the public drug plan. Categorical indicators used to describe polypharmacy included number of medications, potentially inappropriate medications (PIMs), drug-drug interactions, enhanced surveillance medications, complex route of administration medications, anticholinergic cognitive burden (ACB) score and use of blister cards. We used a latent class analysis to subdivide participants into distinct groups of polypharmacy. Their association with 3-year mortality and institutionalisation was assessed with adjusted Cox models. RESULTS In total, 93,516 individuals were included. A four-class model was selected with groups described as (1) no polypharmacy (46% of our sample), (2) high-medium number of medications, low risk (33%), (3) medium number of medications, PIM use with or without high ACB score (8%) and (4) hyperpolypharmacy, complex use, high risk (13%). Using the class without polypharmacy as the reference, all polypharmacy classes were associated with 3-year mortality and institutionalisation, with the most complex/inappropriate classes denoting the highest risk (hazard ratio [HR] [95% confidence interval]: class 3, 70-year-old point estimate for mortality 1.52 [1.30-1.78] and institutionalisation 1.86 [1.52-2.29]; class 4, 70-year-old point estimate for mortality 2.74 [2.44-3.08] and institutionalisation 3.11 [2.60-3.70]). CONCLUSIONS We distinguished three types of polypharmacy with varying pharmacotherapeutic and clinical appropriateness. Our results highlight the value of looking beyond the number of medications to assess polypharmacy.
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Affiliation(s)
- M Gosselin
- Department of Social and Preventive Medicine, Faculty of medicine, Université Laval, Québec, Canada
- Centre d'excellence sur le vieillissement de Québec, Québec, Canada
- VITAM, Centre de recherche en santé durable, Québec, Canada
- CHU de Québec- Université Laval Research Centre, Québec, Canada
| | - D Talbot
- Department of Social and Preventive Medicine, Faculty of medicine, Université Laval, Québec, Canada
- CHU de Québec- Université Laval Research Centre, Québec, Canada
| | - M Simard
- Department of Social and Preventive Medicine, Faculty of medicine, Université Laval, Québec, Canada
- Centre d'excellence sur le vieillissement de Québec, Québec, Canada
- VITAM, Centre de recherche en santé durable, Québec, Canada
- CHU de Québec- Université Laval Research Centre, Québec, Canada
- Institut national de santé publique du Québec, Québec, Canada
| | - Y M Chiu
- VITAM, Centre de recherche en santé durable, Québec, Canada
- Institut national de santé publique du Québec, Québec, Canada
- Faculty of pharmacy, Université Laval, Québec, Canada
| | - M Mésidor
- Department of Social and Preventive Medicine, Faculty of medicine, Université Laval, Québec, Canada
- CHU de Québec- Université Laval Research Centre, Québec, Canada
- Institut national de santé publique du Québec, Québec, Canada
| | - V Boiteau
- Institut national de santé publique du Québec, Québec, Canada
| | - P-H Carmichael
- Centre d'excellence sur le vieillissement de Québec, Québec, Canada
| | - C Sirois
- Centre d'excellence sur le vieillissement de Québec, Québec, Canada.
- VITAM, Centre de recherche en santé durable, Québec, Canada.
- CHU de Québec- Université Laval Research Centre, Québec, Canada.
- Institut national de santé publique du Québec, Québec, Canada.
- Faculty of pharmacy, Université Laval, Québec, Canada.
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Si Y, Bateman H, Chen S, Hanewald K, Li B, Su M, Zhou Z. Quantifying the financial impact of overuse in primary care in China: A standardised patient study. Soc Sci Med 2023; 320:115670. [PMID: 36669284 DOI: 10.1016/j.socscimed.2023.115670] [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: 06/09/2022] [Revised: 12/23/2022] [Accepted: 01/09/2023] [Indexed: 01/13/2023]
Abstract
Overuse of health care is a potential factor in explaining the rapid increase in health care expenditure in many countries; however, it is difficult to measure overuse. This study employed the novel method of using unannounced standardised patients (SPs) to identify overuse, document its patterns and quantify its financial impact on patients in primary care in China. We trained 18 SPs to present consistent cases of two common chronic diseases and recorded 492 physician-patient interactions in 63 public and private primary hospitals in a capital city in western China in 2017 and 2018. Overuse, defined as the provision of unnecessary medical tests and drugs, was identified by a panel of medical experts based on national clinical guidelines. We estimated linear regression models to investigate how hospital, physician and patient characteristics were associated with overuse and to quantify the financial impact of overuse after controlling for a series of fixed effects. We found overuse in 72.15% of the SP visits. The high prevalence of overuse was similar among public and private hospitals, low-competence and high-competence physicians, male and female physicians, junior and senior physicians and male and female patients, but it varied between patients presenting different diseases. Compared to the non-overuse group, overuse significantly increased the total cost by 117.8%, the test cost by 58.8% and the drug cost by 100.3%. The financial impact of overuse was consistent across the aforementioned hospital, physician and patient characteristics. We suggest that the overuse observed in this study is unlikely to be attributable to physician incompetence but rather to the financing framework for primary care in China. These findings illuminate the cost escalation of primary care in China, which is a form of medical inefficiency that should be urgently addressed.
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Affiliation(s)
- Yafei Si
- ARC Centre of Excellence in Population Ageing Research (CEPAR), University of New South Wales, Sydney, Australia; School of Risk & Actuarial Studies, University of New South Wales, Sydney, Australia.
| | - Hazel Bateman
- ARC Centre of Excellence in Population Ageing Research (CEPAR), University of New South Wales, Sydney, Australia; School of Risk & Actuarial Studies, University of New South Wales, Sydney, Australia
| | - Shu Chen
- ARC Centre of Excellence in Population Ageing Research (CEPAR), University of New South Wales, Sydney, Australia; School of Risk & Actuarial Studies, University of New South Wales, Sydney, Australia
| | - Katja Hanewald
- ARC Centre of Excellence in Population Ageing Research (CEPAR), University of New South Wales, Sydney, Australia; School of Risk & Actuarial Studies, University of New South Wales, Sydney, Australia
| | - Bingqin Li
- Social Policy Research Centre, University of New South Wales, Sydney, Australia
| | - Min Su
- School of Public Administration, Inner Mongolia University, Hohhot, China
| | - Zhongliang Zhou
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China.
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Schulze Westhoff M, Groh A, Schröder S, Proskynitopoulos PJ, Jahn K, Klietz M, Krichevsky B, Stichtenoth DO, Wedegärtner F, Bleich S, Frieling H, Heck J. Potentially inappropriate medications according to PRISCUS list and FORTA (Fit fOR The Aged) classification in geriatric psychiatry: a cross-sectional study. J Neural Transm (Vienna) 2022; 129:1367-1375. [PMID: 36050603 PMCID: PMC9550757 DOI: 10.1007/s00702-022-02541-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/23/2022] [Indexed: 11/24/2022]
Abstract
Adverse drug reactions (ADRs) constitute a frequent cause of hospitalization in older people. The risk of ADRs is increased by the prescription of potentially inappropriate medications for older people (PIMs). The PRISCUS list and the FORTA classification represent established tools to detect PIMs. The aim of the present study was to examine the prevalence and characteristics of PIM prescriptions on the gerontopsychiatric ward of a university hospital in Germany. To this aim, medication charts of 92 patients (mean age 75.9 ± 7.7 years; 66.3% female) were analyzed on a weekly basis until patient discharge by utilization of the PRISCUS list and the FORTA classification. Overall, 335 medication reviews comprising 2363 drug prescriptions were analyzed. 3.0% of the prescribed drugs were PIMs according to the PRISCUS list, with benzodiazepines and Z-drugs accounting for nearly half (49.3%) of all PIM prescriptions. 30.4% of the patients were prescribed at least one PRISCUS-PIM, while 43.5% of the study population took at least one FORTA class D drug. A considerable proportion of gerontopsychiatric patients were affected by PIMs; however, the overall number of PIM prescriptions in the study population was low. Further improvements in the quality of prescribing should target the use of sedating agents such as benzodiazepines and Z-drugs. Physicians should be aware of discrepancies between the PRISCUS list and the FORTA classification.
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Affiliation(s)
- Martin Schulze Westhoff
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Adrian Groh
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Sebastian Schröder
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Phileas Johannes Proskynitopoulos
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Kirsten Jahn
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Martin Klietz
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Benjamin Krichevsky
- Medical Service of the German Armed Forces, Kiel, Germany.,Institute for General Practice and Palliative Care, Hannover Medical School, Hannover, Germany
| | - Dirk O Stichtenoth
- Institute for Clinical Pharmacology, Hannover Medical School, Hannover, Germany.,Drug Commissioner of Hannover Medical School, Hannover, Germany
| | - Felix Wedegärtner
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Stefan Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Helge Frieling
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Johannes Heck
- Institute for Clinical Pharmacology, Hannover Medical School, Hannover, Germany
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Taylor-Rowan M, Kraia O, Kolliopoulou C, Noel-Storr AH, Alharthi AA, Cross AJ, Stewart C, Myint PK, McCleery J, Quinn TJ. Anticholinergic burden for prediction of cognitive decline or neuropsychiatric symptoms in older adults with mild cognitive impairment or dementia. Cochrane Database Syst Rev 2022; 8:CD015196. [PMID: 35994403 PMCID: PMC9394684 DOI: 10.1002/14651858.cd015196.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Medications with anticholinergic properties are commonly prescribed to older adults with a pre-existing diagnosis of dementia or cognitive impairment. The cumulative anticholinergic effect of all the medications a person takes is referred to as the anticholinergic burden because of its potential to cause adverse effects. It is possible that a high anticholinergic burden may be a risk factor for further cognitive decline or neuropsychiatric disturbances in people with dementia. Neuropsychiatric disturbances are the most frequent complication of dementia that require hospitalisation, accounting for almost half of admissions; hence, identification of modifiable prognostic factors for these outcomes is crucial. There are various scales available to measure anticholinergic burden but agreement between them is often poor. OBJECTIVES Our primary objective was to assess whether anticholinergic burden, as defined at the level of each individual scale, was a prognostic factor for further cognitive decline or neuropsychiatric disturbances in older adults with pre-existing diagnoses of dementia or cognitive impairment. Our secondary objective was to investigate whether anticholinergic burden was a prognostic factor for other adverse clinical outcomes, including mortality, impaired physical function, and institutionalisation. SEARCH METHODS We searched these databases from inception to 29 November 2021: MEDLINE OvidSP, Embase OvidSP, PsycINFO OvidSP, CINAHL EBSCOhost, and ISI Web of Science Core Collection on ISI Web of Science. SELECTION CRITERIA We included prospective and retrospective longitudinal cohort and case-control observational studies, with a minimum of one-month follow-up, which examined the association between an anticholinergic burden measurement scale and the above stated adverse clinical outcomes, in older adults with pre-existing diagnoses of dementia or cognitive impairment. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion, and undertook data extraction, risk of bias assessment, and GRADE assessment. We summarised risk associations between anticholinergic burden and all clinical outcomes in a narrative fashion. We also evaluated the risk association between anticholinergic burden and mortality using a random-effects meta-analysis. We established adjusted pooled rates for the anticholinergic cognitive burden (ACB) scale; then, as an exploratory analysis, established pooled rates on the prespecified association across scales. MAIN RESULTS: We identified 18 studies that met our inclusion criteria (102,684 older adults). Anticholinergic burden was measured using five distinct measurement scales: 12 studies used the ACB scale; 3 studies used the Anticholinergic Risk Scale (ARS); 1 study used the Anticholinergic Drug Scale (ADS); 1 study used the Anticholinergic Effect on Cognition (AEC) Scale; and 2 studies used a list developed by Tune and Egeli. Risk associations between anticholinergic burden and adverse clinical outcomes were highly heterogenous. Four out of 10 (40%) studies reported a significantly increased risk of greater long-term cognitive decline for participants with an anticholinergic burden compared to participants with no or minimal anticholinergic burden. No studies investigated neuropsychiatric disturbance outcomes. One out of four studies (25%) reported a significant association with reduced physical function for participants with an anticholinergic burden versus participants with no or minimal anticholinergic burden. No study (out of one investigating study) reported a significant association between anticholinergic burden and risk of institutionalisation. Six out of 10 studies (60%) found a significantly increased risk of mortality for those with an anticholinergic burden compared to those with no or minimal anticholinergic burden. Pooled analysis of adjusted mortality hazard ratios (HR) measured anticholinergic burden with the ACB scale, and suggested a significantly increased risk of death for those with a high ACB score relative to those with no or minimal ACB scores (HR 1.153, 95% confidence interval (CI) 1.030 to 1.292; 4 studies, 48,663 participants). An exploratory pooled analysis of adjusted mortality HRs across anticholinergic burden scales also suggested a significantly increased risk of death for those with a high anticholinergic burden (HR 1.102, 95% CI 1.044 to 1.163; 6 studies, 68,381 participants). Overall GRADE evaluation of results found low- or very low-certainty evidence for all outcomes. AUTHORS' CONCLUSIONS: There is low-certainty evidence that older adults with dementia or cognitive impairment who have a significant anticholinergic burden may be at increased risk of death. No firm conclusions can be drawn for risk of accelerated cognitive decline, neuropsychiatric disturbances, decline in physical function, or institutionalisation.
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Affiliation(s)
- Martin Taylor-Rowan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Olga Kraia
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | | | - Ahmed A Alharthi
- Department of Clinical Pharmacy, Umm Al Qura University, Makkah, Saudi Arabia
| | - Amanda J Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | | | - Phyo K Myint
- Division of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | | | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Zhao M, Chen Z, Tian F, Xu T. Potentially Inappropriate Medication Among People With Dementia in China: A Nationwide Cross-Sectional Study. Front Pharmacol 2022; 13:929584. [PMID: 35770092 PMCID: PMC9234126 DOI: 10.3389/fphar.2022.929584] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/24/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives: The purpose of this study was to explore the prevalence of potentially inappropriate medication (PIM) among older outpatients (age ≥ 65 years old) with dementia in eight cities in China using the AGS Beers criteria of 2019 and to identify the potential factor increasing the number of PIMs.Methods: A cross-sectional study about PIM in older outpatients with dementia from January 2020 to December 2020 was carried out in eight cities in China, Chengdu, Beijing, Guangzhou, Shanghai, Shenyang, Tianjin, Zhengzhou, and Hangzhou, distributing five major geographical regions in China (east, west, north, south, central). The diagnosis of dementia was based on the International Classification of Diseases (ICD-10) to identify. Based on the 2019 AGS Beers criteria, the PIM prescriptions were evaluated. The identification of potential factors was completed using a binary logistic regression model.Results: Of 18,624 older outpatients with dementia, 3.52% were detected with 1 PIM, and 35.91% received at least two PIMs. The antipsychotic drugs quetiapine and olanzapine were most frequently prescribed in patients with PIM, accounting for 8.01 and 7.36%, respectively. Logistic regression analyses showed that female patients with dementia aged >80 years who took more medications were exposed easily to PIM use.Conclusion: PIM use among older outpatients with dementia in China is highly prevalent, and the associated risk factors were increasing age, female sex, and number of medications. The most frequently prescribed drugs by clinicians were anpsychotropic drugs, which were much more frequent than other drugs.
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Affiliation(s)
- Mengnan Zhao
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Zhaoyan Chen
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
| | - Fangyuan Tian
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
| | - Ting Xu
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
- *Correspondence: Ting Xu,
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Shawaqfeh B, Hughes CM, McGuinness B, Barry HE. A systematic review of interventions to reduce anticholinergic burden in older people with dementia in primary care. Int J Geriatr Psychiatry 2022; 37:10.1002/gps.5722. [PMID: 35524704 PMCID: PMC9320938 DOI: 10.1002/gps.5722] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/20/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE This systematic review aimed to assess the types and effectiveness of interventions that sought to reduce anticholinergic burden (ACB) in people with dementia (PwD) in primary care. METHODS One trial registry and eight electronic databases were systematically searched to identify eligible English language studies from inception until December 2021. To be eligible for inclusion, studies had to be randomised controlled trials (RCTs) or non-randomised studies (NRS), including controlled before-and-after studies and interrupted time-series studies, of interventions to reduce ACB in PwD aged ≥65 years (either community-dwelling or care home residents). All outcomes were to be considered. Quality was to be assessed using the Cochrane Risk of Bias tool for RCTs and ROBINS-I tool for NRS. If data could not be pooled for meta-analysis, a narrative synthesis was to be conducted. RESULTS In total, 1880 records were found, with 1594 records remaining after removal of duplicates. Following title/abstract screening, 13 full-text articles were assessed for eligibility. None of these studies met the inclusion criteria for this review. Reasons for exclusion were incorrect study design, ineligible study population, lack of focus on reducing ACB, and studies conducted outside the primary care setting. CONCLUSIONS This 'empty' systematic review highlights the lack of interventions to reduce ACB in PwD within primary care, despite this being highlighted as a priority area for research in recent clinical guidance. Future research should focus on development and testing of interventions to reduce ACB in this patient population through high-quality clinical trials.
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Use of tricyclic antidepressants and other anticholinergic medicines by older Aboriginal Australians: association with negative health outcomes. Int Psychogeriatr 2022; 34:71-78. [PMID: 32985391 DOI: 10.1017/s104161022000174x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Aboriginal and Torres Strait Islander Australians have a relatively high prevalence of multimorbidity requiring treatment with medications. This study examines medication use and anticholinergic burden (ACB) among a cohort of older Aboriginal and Torres Strait Island people. METHOD This cross-sectional study involving five Aboriginal communities (two in metropolitan Sydney and three on the mid-north coast of New South Wales) used a structured interview process to assess cognition, depression, and activities of daily living for a cohort of older adults (aged 60 years and over). Participants also reported on their health status, medical history, and prescription medications during the interview. ACB was calculated, and its association with adverse health outcomes including cognitive impairment, falls, hospitalization, and depressive symptoms were examined. RESULTS Most participants (95%) were taking at least one regular medication with polypharmacy (≥5 medications) observed in 43% of participants; 12.2% had a significant ACB (≥3) with antidepressants being a major contributor. Anticholinergic medication use was associated with cognitive impairment, recent hospitalization (past 12 months), and depressive symptoms. After controlling for age, sex, and comorbidity, only the presence of depressive symptoms remained significantly associated with the use of anticholinergic medication (odds ratio 2.86; 95% confidence interval 1.48-5.51). CONCLUSIONS Clinically significant ACB was common in older Aboriginal Australians and was largely attributable to inappropriate use of tricyclic antidepressants. Greater awareness of medication-related risk factors among both health care professionals and Aboriginal communities can play an important role in improving health and quality of life outcomes.
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Anticholinergic burden for prediction of cognitive decline or neuropsychiatric symptoms in older adults with mild cognitive impairment or dementia. Cochrane Database Syst Rev 2021; 2021:CD015196. [PMCID: PMC8601112 DOI: 10.1002/14651858.cd015196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
This is a protocol for a Cochrane Review (prognosis). The objectives are as follows: Primary objective To assess whether anticholinergic burden, as defined at the level of each individual scale, is a prognostic factor for further cognitive decline or neuropsychiatric disturbances in people with mild cognitive impairment (MCI) or dementia.
Secondary objective To compare the prognostic validity of different anticholinergic burden scales. To examine the effect of type of dementia and severity of dementia on the association between anticholinergic burden and rate of cognitive decline or neuropsychiatric disturbances. To examine the effect of setting (care home versus non‐care home) on the association between anticholinergic burden and rate of cognitive decline or neuropsychiatric disturbances. To examine whether anticholinergic burden is a prognostic factor for other clinical outcomes in people with MCI or dementia
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Quantifying Anticholinergic Burden and Sedative Load in Older Adults with Polypharmacy: A Systematic Review of Risk Scales and Models. Drugs Aging 2021; 38:977-994. [PMID: 34751922 PMCID: PMC8592980 DOI: 10.1007/s40266-021-00895-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND Patients taking medication with high anticholinergic and sedative properties are at increased risk of experiencing poor cognitive and physical outcomes. Therefore, precise quantification of the cumulative burden of their drug regimen is advisable. There is no agreement regarding which scale to use to simultaneously quantify the burden associated with medications. OBJECTIVES The objective of this review was to assess the strengths and limitations of available tools to quantify medication-related anticholinergic burden and sedative load in older adults. We discuss specific limitations and agreements between currently available scales and models and propose a comprehensive table combining drugs categorized as high, moderate, low, or no anticholinergic or sedative activity as excerpted from the selected studies. METHODS A targeted search was carried out using the National Library of Medicine through PubMed using medical subject heading terms and text words around the following search terms: (anticholinergic OR sedative) AND (load OR burden OR scale) for studies published between 1 January 1945 and 5 June 2021. In addition, the following databases were searched using the same terms: MEDLINE-EBSCO, APA PsycInfo, CINAHL Plus, Cochrane Library, Scopus, OAIster, OVID-MEDLINE, Web of Science, and Google Scholar. Screening by titles was followed by an abstract and full-text review. After blind evaluation, agreement between reviewers was reached to establish drug characteristics and categories. RESULTS After 3163 articles were identified, 13 were included: 11 assigned risk scores to anticholinergic drugs and two to sedative drugs. Considerable variability between anticholinergic scales was observed; scales included between 27 and 548 drugs. We generated a comprehensive table combining the anticholinergic and sedative activities of drugs evaluated and proposed a categorization of these drugs based on available scientific and clinical evidence. Our table combines information about 642 drugs and categorizes 44, 25, 99, and 474 drugs as high, moderate, low, or no anticholinergic and sedative activity, respectively. CONCLUSIONS Variability and inconsistency exists among scales used to categorize drugs with anticholinergic or sedative burden. In this review, we provide a comprehensive table that proposes a new categorization of these drugs. A longitudinal study will be required to validate the new proposed anticholinergic and sedative burden catalog in an evidence-based manner.
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Liau SJ, Bell JS. Frailty Status and Cognitive Function Should Guide Prescribing in Long-term Care Facilities. Sr Care Pharm 2021; 36:469-473. [PMID: 34593087 DOI: 10.4140/tcp.n.2021.469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Frailty, dementia and complex multimorbidity are highly prevalent among residents of long-term care facilities (LTCFs). Prescribing for residents of LTCFs is often informed by disease-specific clinical practice guidelines based on research conducted among younger and more robust adults. However, frailty and cognitive impairment may modify medication benefits and risks. Residents with frailty and advanced dementia may be at increased susceptibility to adverse drug events (ADEs) and often have a lower likelihood of achieving long-term therapeutic benefit from chronic preventative medications. For this reason, there is a strong rationale for deprescribing, particularlyamong residents with high medication burdens, swallowing difficulties or limited dexterity. Conversely, frailty and dementia have also been associated with under-prescribing of clinically indicated medications. Unnecessarily withholding treatment based on assumed risk may deprive vulnerable population groups from receiving evidence-based care. There is a need for specific evidence regarding medication benefits and risks in LTCF residents with frailty and dementia. Observational studies conducted using routinely collected health data may complement evidence from randomized controlled trials that often exclude people living with dementia, frailty and in LTCFs. Balancing over- and under-prescribing requires consideration of each resident's frailty and cognitive status, therapeutic goals, time-to-benefit, potential ADEs, and individual values or preferences. Incorporating frailty screening into medication review may also provide better alignment of medication regimens to changing goals of care. Timely identification of frail residents as part of treatment decision-making may assist with targeting interventions to minimize and monitor for ADEs. Shifting away from rigid application of conventional disease-specific clinical practice guidelines may provide an individualized and more holistic assessment of medication benefits and risks in the LTCF setting.
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Affiliation(s)
- Shin J Liau
- Research Pharmacist, Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia, National Health and Medical Research Council (NHMRC), Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, South Australia, Australia
| | - J Simon Bell
- Professor and Director, Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia, National Health and Medical Research Council (NHMRC), Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, South Australia, Australia
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Nguyen TA, Gilmartin-Thomas J, Tan ECK, Kalisch-Ellett L, Eshetie T, Gillam M, Reeve E. The Impact of Pharmacist Interventions on Quality Use of Medicines, Quality of Life, and Health Outcomes in People with Dementia and/or Cognitive Impairment: A Systematic Review. J Alzheimers Dis 2020; 71:83-96. [PMID: 31356204 DOI: 10.3233/jad-190162] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Medication use in people with dementia and/or cognitive impairment (PWD/CI) is challenging. As medication experts, pharmacists have an important role in improving care of this vulnerable population. OBJECTIVE Systematically review evidence for the effectiveness of pharmacist-led interventions on quality use of medicines, quality of life, and health outcomes of PWD/CI. METHODS A systematic review was conducted using MEDLINE, EMBASE, PsycINFO, Allied and Complementary Medicine (AMED) and Cumulative index to Nursing and Allied Health Literature (CINAHL) databases from conception to 20 March 2017. Full articles published in English were included. Data were synthesized using a narrative approach. RESULTS Nine studies were eligible for inclusion. All studies were from high-income countries and assessed pharmacist-led medication management services. There was great variability in the content and focus of services described and outcomes reported. Pharmacists were found to provide a number of cognitive services including medication reconciliation, medication review, and medication adherence services. These services were generally effective with regards to improving quality use of medicines and health outcomes for PWD/CI and their caregivers, and for saving costs to the healthcare system. Pharmacist-led medication and dementia consultation services may also improve caregiver understanding of dementia and the different aspects of pharmacotherapy, thus improving medication adherence. CONCLUSION Emerging evidence suggests that pharmacist-led medication management services for PWD/CI may improve outcomes. Future research should confirm these findings using more robust study designs and explore additional roles that pharmacists could undertake in the pursuit of supporting PWD/CI.
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Affiliation(s)
- Tuan Anh Nguyen
- Quality Use of Medicines & Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia.,Health Strategy and Policy Institute, Ministry of Health of Vietnam
| | - Julia Gilmartin-Thomas
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Parkville, Australia
| | - Edwin Chin Kang Tan
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, NSW, Australia.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia.,Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Lisa Kalisch-Ellett
- Quality Use of Medicines & Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Tesfahun Eshetie
- Quality Use of Medicines & Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Marianne Gillam
- Quality Use of Medicines & Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Emily Reeve
- NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Geriatric Medicine Research and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority, NS, Canada.,College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
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Cross AJ, George J, Woodward MC, Le VJ, Elliott RA. Deprescribing potentially inappropriate medications in memory clinic patients (DePIMM): A feasibility study. Res Social Adm Pharm 2020; 16:1392-1397. [DOI: 10.1016/j.sapharm.2020.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 01/16/2020] [Accepted: 01/18/2020] [Indexed: 12/22/2022]
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Ruangritchankul S, Peel NM, Hanjani LS, Gray LC. Drug related problems in older adults living with dementia. PLoS One 2020; 15:e0236830. [PMID: 32735592 PMCID: PMC7394402 DOI: 10.1371/journal.pone.0236830] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/14/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Compared with those without dementia, older patients with dementia admitted to acute care settings are at higher risk for triad combination of polypharmacy (PP), potentially inappropriate medication (PIM), and drug-drug interaction (DDI), which may consequently result in detrimental health. The aims of this research were to assess risk factors associated with triad combination of PP, PIM and DDI among hospitalized older patients with dementia, and to assess prevalence and characteristics of PP, PIM and DDI in this population. METHODS In this retrospective cross-sectional study, 416 older inpatients diagnosed with dementia and referred for specialist geriatric consultation at a tertiary hospital in Brisbane, Australia during 2006-2016 were enrolled. Patients were categorized into two groups according to their exposure to the combination of PP, PIM and DDI: 'triad combination' and 'non-triad combination'. Data were collected using the interRAI Acute Care (AC) assessment instrument. Independent risk factors of exposure to the triad combination were evaluated using bivariate and multivariate logistic regression analyses. RESULTS Overall, 181 (43.5%) were classified as triad combination group. The majority of the population took at least 1 PIM (56%) or experienced at least one potential DDI (76%). Over 75% of the participants were exposed to polypharmacy. The most common prescribed PIMs were antipsychotics, followed by benzodiazepines. The independent risk factors of the triad combination were the presence of atrial fibrillation diagnosis and higher medications use in cardiac therapy, psycholeptics and psychoanaleptics. CONCLUSIONS The exposure to triad combination of PP, PIM and DDI are common among people with dementia as a result of their vulnerable conditions and the greater risks of adverse events from medications use. This study identified the use of cardiac therapy, psycholeptics and psychoanaleptics as predictors of exposure to PP, PIM and DDI. Therefore, use of these medications should be carefully considered and closely monitored. Furthermore, comprehensive medication reviews to optimize medication prescribing should be initiated and continually implemented for this vulnerable population.
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Affiliation(s)
- Sirasa Ruangritchankul
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nancye M. Peel
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Leila Shafiee Hanjani
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Leonard C. Gray
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Mate KE, Barnett M, Kerr KP, Pond CD, Magin PJ. Stability of anticholinergic load in Australian community-dwelling older people: a longitudinal analysis. Fam Pract 2020; 37:314-320. [PMID: 31784733 DOI: 10.1093/fampra/cmz076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND It is recommended that anticholinergic medication is avoided in older people, especially those with cognitive impairment. OBJECTIVE To investigate anticholinergic load (ACL) over time in older primary care patients with and without cognitive impairment. METHODS Community-dwelling general practice patients at baseline (n = 1768), at year one (n = 1373) and a restricted cohort (with possible or definite cognitive impairment) at year two (n = 370) had medication regimens documented by a research nurse during a home visit. Anticholinergic medicines were categorized as levels 1-3 (low-high potency) and summed for each participant as a measure of their ACL. RESULTS Most participants had no change in ACL over time, but there was some turnover in the anticholinergic medications used. The mean change in ACL was 0.012 ± 0.99 from baseline to 12 months and -0.04 ± 1.3 from baseline to 24 months. Cardiovascular drugs were the most commonly used level 1 anticholinergics, followed by antidepressants and opioids. Antidepressants and urologicals were the most commonly used level 3 anticholinergics. The rate of anticholinergic deprescribing was equivalent to the rate of anticholinergic initiation, and commonly involved the level 1 drugs warfarin, furosemide and temazepam, and the level 3 drugs amitriptyline and oxybutynin. People with dementia had a higher ACL at baseline and year one compared with other participants. CONCLUSION ACL of community-dwelling older people was very stable over time. This may represent lost opportunities for deprescribing as well as potentially inappropriate prescribing, particularly in those with cognitive impairment.
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Affiliation(s)
- Karen E Mate
- School of Biomedical Sciences and Pharmacy and, Callaghan, Australia
| | - Michelle Barnett
- School of Biomedical Sciences and Pharmacy and, Callaghan, Australia
| | - Karen P Kerr
- School of Biomedical Sciences and Pharmacy and, Callaghan, Australia
| | - C Dimity Pond
- Discipline of General Practice, School of Medicine & Public Health, University of Newcastle, Callaghan, Australia
| | - Parker J Magin
- Discipline of General Practice, School of Medicine & Public Health, University of Newcastle, Callaghan, Australia
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Potentially inappropriate medication and associated factors such as depression and dementia: An analysis of middle-aged and elderly people. SCIENTIA MEDICA 2020. [DOI: 10.15448/1980-6108.2020.1.34478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
AIMS: To establish the frequency potentially inappropriate medications use and the associated factors, such as signs and symptoms of depression and cognitive deficit among middle-aged and elderly people.METHODS: A cross-sectional population study was performed with 2,350 people, aged between 55-103 years, registered in the primary health care. Potentially inappropriate medications were defined by updated 2019 Beers criteria. Studied variables were sociodemographic, lifestyle and health, and signs and symptoms of depression and cognitive deficit. Multinomial regression analysis was executed.RESULTS: The frequency of potentially inappropriate medications use was 65.4%. Former and current smokers, regular self-perception of health, polypharmacy, and individuals with signs and symptoms of depression and cognitive deficit were significantly associated with potentially inappropriate medications use. Antiarrhythmics, antihistamines and antiadrenergic agents were the highest potentially inappropriate medications classes used for individuals with signs and symptoms of depression and cognitive deficit.CONCLUSIONS: The frequency of use of potentially inappropriate medications is high among middle-aged people, a population that was previously under-researched, as well as among elderly people. Cognitive impairment alone or together with depression symptoms were associated factor for a potentially inappropriate medications use. Knowledge of the pharmacoepidemiology of potentially inappropriate medications is an important for the promotion of the rational use of drugs in public health.
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Delgado J, Bowman K, Clare L. Potentially inappropriate prescribing in dementia: a state-of-the-art review since 2007. BMJ Open 2020; 10:e029172. [PMID: 31900263 PMCID: PMC6955517 DOI: 10.1136/bmjopen-2019-029172] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 11/12/2019] [Accepted: 11/13/2019] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES Dementia frequently occurs alongside comorbidities. Coexisting conditions are often managed with multiple medications, leading to increased risk of potentially inappropriate medication and adverse drug reactions. We aimed to estimate prevalence of, and identify factors reported to be associated with, potentially inappropriate prescribing (PIP) for older individuals diagnosed with dementia. DESIGN We used a state-of-the-art review approach, selecting papers written in English and published from 2007 to January 2018. Publications were retrieved from Scopus and Web of Science databases. Inclusion criteria included a formal diagnosis of dementia, a formal classification of PIP and reported prevalence of PIP as an outcome. Random effects models were used to provide a pooled estimate of prevalence of PIP. The Appraisal tool for Cross-Sectional Studies (AXIS tool) was used to assess bias in the included studies. RESULTS The bibliographic search yielded 221 citations, with 12 studies meeting the inclusion criteria. The estimates of PIP prevalence for people living with dementia ranged from 14% to 64%. Prevalence was 31% (95% CI 9 to 52) in the community, and 42% (95% CI 30 to 55) in nursing/care homes. PIP included prescribing likely related to dementia (eg, hypnotics and sedative and cholinesterase inhibitors) and prescribing related to treatment of comorbidities (eg, cardiovascular drugs and non-steroidal anti-inflammatory medication). Higher levels of comorbidity were associated with increased risk of PIP; however, only one study investigated associations with specific comorbidities of dementia. CONCLUSION PIP remains a significant issue in healthcare management for people living with dementia. Higher levels of comorbidity are associated with increased prevalence of PIP, but the specific conditions driving this increase remain unknown. Further work is necessary to investigate PIP related to the presence of common comorbidities in patients living with dementia.
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Affiliation(s)
- Joao Delgado
- College of Medicine and Health, University of Exeter, Exeter, Devon, UK
| | - Kirsty Bowman
- College of Medicine and Health, University of Exeter, Exeter, Devon, UK
| | - Linda Clare
- College of Medicine and Health, University of Exeter, Exeter, Devon, UK
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22
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López-Álvarez J, Sevilla-Llewellyn-Jones J, Agüera-Ortiz L. Anticholinergic Drugs in Geriatric Psychopharmacology. Front Neurosci 2019; 13:1309. [PMID: 31866817 PMCID: PMC6908498 DOI: 10.3389/fnins.2019.01309] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/22/2019] [Indexed: 12/31/2022] Open
Abstract
Drugs with anticholinergic action are widely prescribed in the elderly population due to their potential clinical benefits. However, these benefits are limited by adverse effects which may be serious in particular circumstances. This review presents different aspects of the use of anticholinergics in old age with a focus in psychogeriatric patients. We critically review published data on benefits and disadvantages of anticholinergics, which are often controversial. Prevalence, pathophysiology and measurement methods of the anticholinergic action of drugs are discussed. We also present the most important drawbacks resulting from its use, including effects on cognition in healthy and cognitively impaired people, in aged schizophrenia patients, emergence of delirium and psychiatric symptoms, influence in functionality, hospitalization, institutionalization and mortality, and the potential benefits and limitations of their discontinuation. Finally, we suggest practical recommendations for the safe use of anticholinergics in clinical conditions affecting elderly patients, such as dementia, schizophrenia and acute hallucinatory episodes, depression, anxiety, Parkinson's disease, cardiovascular conditions and urinary incontinence.
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Affiliation(s)
- Jorge López-Álvarez
- Servicio de Psiquiatría, Hospital 12 de Octubre (imas12), Madrid, Spain.,Instituto de Investigación, Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Julia Sevilla-Llewellyn-Jones
- Instituto de Psiquiatría y Salud Mental, Hospital Clínico San Carlos, Madrid, Spain.,Instituto de Investigación (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
| | - Luis Agüera-Ortiz
- Servicio de Psiquiatría, Hospital 12 de Octubre (imas12), Madrid, Spain.,Instituto de Investigación, Hospital 12 de Octubre (imas12), Madrid, Spain.,Centro de Investigación Biomédica en Red de Salud Mental, Ministry of Science and Innovation, Madrid, Spain.,Departamento de Medicina Legal, Psiquiatría y Patología, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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23
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Dyer AH, Murphy C, Segurado R, Lawlor B, Kennelly SP. Is Ongoing Anticholinergic Burden Associated With Greater Cognitive Decline and Dementia Severity in Mild to Moderate Alzheimer’s Disease? J Gerontol A Biol Sci Med Sci 2019; 75:987-994. [DOI: 10.1093/gerona/glz244] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Use of anticholinergic medication is associated with an increased risk of cognitive impairment and/or dementia. Despite this, the impact of continuing medication with anticholinergic properties in those diagnosed with Alzheimer’s Disease (AD) is not clear.
Methods
Analysis of data from NILVAD, an 18-month randomized controlled trial of Nilvadipine in AD. Effects of ongoing Anticholinergic Cognitive Burden (ACB) on cognition (ADAS-Cog: Alzheimer’s Disease Cog Subsection) and dementia severity (CDR-sb: Clinical Dementia Rating – Sum of Boxes/DAD: Disability Assessment for Dementia) over 18 months was evaluated adjusting for important clinical covariates.
Results
Just over one-quarter (27.90%, n = 142/510) of patients with mild to moderate AD were prescribed a potential/definite anticholinergic. While ACB score was not associated with greater progression on the ADAS-Cog/CDR-sb over time, a higher total ACB predicted greater dementia severity on the DAD, which persisted after robust covariate adjustment (β Coef: −1.53, 95% CI: −2.83 to −0.23, p = .021). There was a significant interaction between APOE ε4 status and ACB score, with carriers experiencing greater progression on both the CDR-Sb (β Coef: 0.36, 95% CI: 0.05–0.67, p = .021) and DAD (β Coef: −3.84, 95% CI: −7.65 to 0.03, p = .049).
Conclusions
Ongoing use of anticholinergic medication was associated with greater dementia progression on the DAD, but not the CDR-sb. APOE ε 4 carriers may be particularly vulnerable to the effect of ongoing anticholinergic medication on dementia severity, with significant APOE ε 4 x ACB score interactions demonstrated on both the DAD and CDR-sb.
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Affiliation(s)
- Adam H Dyer
- Department of Age-Related Healthcare, Tallaght University Hospital, Dublin
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Claire Murphy
- Department of Age-Related Healthcare, Tallaght University Hospital, Dublin
| | - Ricardo Segurado
- Centre for Support and Training in Analysis and Research (CSTAR), University College Dublin, Dublin, Ireland
| | - Brian Lawlor
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
- Mercer’s Institute for Research on Ageing, St James’s Hospital, Dublin, Ireland
| | - Sean P Kennelly
- Department of Age-Related Healthcare, Tallaght University Hospital, Dublin
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
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24
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Eshetie TC, Nguyen TA, Gillam MH, Kalisch Ellett LM. Potentially inappropriate prescribing in people with dementia: An Australian population-based study. Int J Geriatr Psychiatry 2019; 34:1498-1505. [PMID: 31173395 DOI: 10.1002/gps.5160] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 06/01/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To investigate the prevalence of potentially inappropriate prescribing (PIP) using the Screening Tool of Older Person's Prescriptions (STOPP) criteria in people with dementia compared with people without dementia. METHODS A retrospective cohort study was conducted using the Pharmaceutical Benefits Scheme 10% sample of pharmacy claims. People with dementia were defined as those dispensed a medicine for dementia (cholinesterase inhibitors, memantine, or risperidone for behavioural and psychological symptoms of dementia) between 1 January 2005 and 31 December 2015, aged 65 years or older at 1 January 2016 and alive at the end of 2016. An age- and gender-matched comparison cohort of people not dispensed medicines for dementia was identified. PIP prevalence was determined between 1 January 2016 and 31 December 2016. RESULTS In total, 8280 people dispensed medicines for dementia and 41 400 comparisons not dispensed medicines for dementia were included: 63% were female and the median age was 82 years. PIP prevalence was 79% among people with dementia compared with 70% among the comparison group (P < .0001). Use of anticholinergics, long-term use of high-dose proton pump inhibitors, and use of benzodiazepines were the most common instances of PIP in people with dementia. After adjustments for age, gender, comorbidity, and number of prescribers, people with dementia were more likely to be exposed to PIP than comparisons (adjusted OR 1.44, 95% CI, 1.35-1.53, P < .0001). CONCLUSIONS PIP was more common in people dispensed medicines for dementia than comparisons. These results highlight the need for effective interventions to optimize prescribing in people with dementia.
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Affiliation(s)
- Tesfahun C Eshetie
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Tuan A Nguyen
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Marianne H Gillam
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Lisa M Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
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25
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Cross AJ, Le VJ, George J, Woodward MC, Elliott RA. Stakeholder perspectives on pharmacist involvement in a memory clinic to review patients' medication management and assist with deprescribing. Res Social Adm Pharm 2019; 16:681-688. [PMID: 31405811 DOI: 10.1016/j.sapharm.2019.08.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 07/19/2019] [Accepted: 08/06/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Memory clinics usually involve a team of health professionals who assess and review people with memory impairment. Memory clinic patients are typically older, have multiple comorbidities and potentially inappropriate polypharmacy. Pharmacists are not typically part of memory clinic teams. OBJECTIVE To explore stakeholder perspectives on pharmacist involvement in a memory clinic to conduct medication reviews and assist with deprescribing potentially inappropriate/unnecessary medications. METHODS Quantitative and qualitative evaluation of stakeholder perspectives within a deprescribing feasibility study. Patient/carer questionnaires were administered at 6-month follow-up. Fax-back surveys were sent to general practitioners (GPs) shortly after the pharmacist review. A focus group was conducted with memory clinic staff and semi-structured interviews with pharmacists at conclusion of the study. Focus group/interviews were transcribed and thematically analysed. RESULTS Most patients/carers found the pharmacist medication review helpful (84%, 31/37) and believed it was important to have pharmacists in the memory clinic (92%, 36/39). Twenty-one (48%) GPs responded to the survey; most found the pharmacist reports useful for identifying inappropriate medication and providing deprescribing recommendations (86% and 81%, respectively), and 90% thought a pharmacist review should be part of the memory clinic service. Feedback from memory clinic staff and pharmacists was largely positive. Questions were raised by some staff about whether deprescribing fell within the clinic's scope of practice. Challenges associated with memory clinic-GP communication were highlighted. CONCLUSION Patients, GPs and memory clinic staff were receptive to increased pharmacist involvement in the memory clinic. Stakeholder feedback will inform the development and delivery of pharmacist medication reviews and deprescribing in memory clinics.
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Affiliation(s)
- Amanda J Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; Pharmacy Department, Austin Health, Heidelberg, Victoria, Australia
| | - Vivien J Le
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Johnson George
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Michael C Woodward
- Medical and Cognitive Research Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Rohan A Elliott
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; Pharmacy Department, Austin Health, Heidelberg, Victoria, Australia.
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26
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Lind KE, Jorgensen ML. Clearing the air: why a link between Alzheimer's disease and air quality cannot be validly determined using prescription data in Australia. Health Place 2019; 62:102169. [PMID: 31351750 DOI: 10.1016/j.healthplace.2019.102169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 07/17/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Kimberly E Lind
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Australia.
| | - Mikaela L Jorgensen
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Australia
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27
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Valladales‐Restrepo LF, Duran‐Lengua M, Machado‐Alba JE. Potentially inappropriate prescriptions of anticholinergics drugs in Alzheimer's disease patients. Geriatr Gerontol Int 2019; 19:913-917. [DOI: 10.1111/ggi.13748] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 06/04/2019] [Accepted: 07/02/2019] [Indexed: 01/20/2023]
Affiliation(s)
- Luis Fernando Valladales‐Restrepo
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnologica de Pereira‐Audifarma S.A Pereira Colombia
- Grupo de Biomedicina, Fundación Universitaria Autónoma de las Américas Pereira Colombia
| | | | - Jorge Enrique Machado‐Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnologica de Pereira‐Audifarma S.A Pereira Colombia
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28
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Scott IA. Audit‐based measures of overuse of medical care in Australian hospital practice. Intern Med J 2019; 49:893-904. [DOI: 10.1111/imj.14346] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 12/07/2018] [Accepted: 12/07/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Ian A. Scott
- Department of Internal Medicine and Clinical EpidemiologyPrincess Alexandra Hospital Brisbane Queensland Australia
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29
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Lind KE, Gray LC, Raban MZ, Georgiou A, Westbrook JI. Antidementia medication use by aged care facility residents with dementia. Int J Geriatr Psychiatry 2019; 34:1029-1040. [PMID: 30907450 DOI: 10.1002/gps.5105] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 03/17/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Little is known about the use of antidementia medications in Australia. Other countries have reported sociodemographic disparities in use. Our objective was to estimate prevalence, duration, and time to initiation of antidementia medication (cholinesterase inhibitors or memantine) among Australians with dementia in residential aged care facilities and to evaluate resident and facility factors associated with use. METHODS Dynamic retrospective cohort study of people with dementia in 68 residential aged care facilities during 2014 to 2017 using electronic health record and medication administration data. Regression evaluated relationships between medication use (prevalence, duration, and time to initiation) and resident and facility characteristics. RESULTS Five thousand three hundred fifty-four residents with dementia were included in the analyses. Annual prevalence of antidementia medication use was less than 10% each year and decreased during the study period by 2-percentage points by 2017 (relative to 2014). Antidementia medication use varied by sociodemographic characteristics (3-points lower for single, 4-points lower for divorced relative to married residents, and 3-points higher for Australian-born). Each point in ADL score was associated with 0.1-point lower medication use. Antidementia medication use was lower in outer regional facilities. Most comorbidities were associated with lower antidementia medication use (myocardial infarction, cerebrovascular disease and heart failure 3-points lower, respiratory disease, and diabetes 2-points lower). Age had a complex relationship with antidementia medication use that varied by sex and if medication was started before or after admission. After admission, males initiated antidementia medication earlier than females. CONCLUSIONS Antidementia medication use in Australian facilities was lower than in other countries and varied by clinical and sociodemographic factors.
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Affiliation(s)
- Kimberly E Lind
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Leonard C Gray
- Centre for Health Services Research, Faculty of Medicine, University of Queensland, Woolloongabba, Queensland, Australia
| | - Magdalena Z Raban
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Andrew Georgiou
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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30
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Abstract
OBJECTIVES Older adults with dementia are particularly vulnerable to adverse outcomes resulting from anticholinergic use. We aimed to: (i) Examine the anticholinergic burden of patients with dementia attending a Psychiatry of Later Life (PLL) service (ii) Examine concomitant prescription of acetylcholinesterase inhibitors (AChEIs) and anticholinergics and (iii) Compare the Anticholinergic Cognitive Burden (ACB) scale with a recently published composite list of anticholinergics. METHODS Retrospective chart review of new referrals with a diagnosis of dementia (n = 66) seen by the PLL service, Tallaght University Hospital, Dublin, Ireland, over a consecutive period of 4 months. RESULTS The mean ACB score was 2.2 (range = 0-9, SD = 2.1). 37.9% (n = 25) had a clinically significant ACB score (>3) and 42.1% (n = 8) of those taking AChEIs had a clinically significant ACB score. A significantly greater number of medications with anticholinergic activity were identified using the composite list versus the traditional ACB scale (2.3 v.1.5, p = 0.001). CONCLUSIONS We demonstrated a significant anticholinergic burden amongst patients with dementia attending a specialist PLL service. There was no difference in anticholinergic burden between groups prescribed and not prescribed AChEIs, indicating that these medications are being prescribed without discontinuation of potentially inappropriate medications with anticholinergic activity. The true anticholinergic burden experienced by patients may be underestimated by the use of the ACB score alone, although the clinical significance of this finding is unclear. Calculation of true clinical anticholinergic burden load and its translation to a specific rating scale remains a challenge.
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31
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Eshetie TC, Nguyen TA, Gillam MH, Kalisch Ellett LM. Potentially inappropriate prescribing before and after initiation of medicines for dementia: An Australian population-based study. Geriatr Gerontol Int 2019; 19:654-659. [PMID: 31074090 DOI: 10.1111/ggi.13686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 03/20/2019] [Accepted: 04/16/2019] [Indexed: 11/30/2022]
Abstract
AIM To evaluate the prevalence of potentially inappropriate prescribing (PIP), as defined by the internationally validated Screening Tool of Older Person's Prescriptions (STOPP) criteria, in 12 months before and after initiation of medicines for dementia. METHODS A retrospective cohort study was carried out involving people with their first claim for dispensing of medicines for dementia (cholinesterase inhibitor or memantine) between 1 January 2015 and 31 December 2015, aged ≥65 years at 1 January 2016 and alive at the end of 2016. The index date was defined as the date of first supply of medicines for dementia. PIP was identified using the Screening Tool of Older Person's Prescriptions criteria, and PIP prevalence was compared in the 12 months pre- and post-index date. The McNemar's test was used to test differences in the prevalence of PIP between the two time periods. RESULTS The cohort included 1176 patients: 60% were women and the median age was 80 years. The overall PIP prevalence was 85% in the 12 months pre-initiation of medicines for dementia compared with 89% in the 12 months post-initiation (P < 0.0001). The median number of Screening Tool of Older Person's Prescriptions criteria was two (interquartile range 1-4) in the 12 months pre-initiation of medicines for dementia, increasing to three (range 2-4) in the 12 months post-initiation. CONCLUSIONS PIP was common in people dispensed medicines for dementia, with a significant increase in prevalence post-initiation of medicines for dementia compared with pre-initiation. These results highlight the need for targeted interventions to minimize inappropriate use of medicines in people with dementia. Geriatr Gerontol Int 2019; 19: 654-659.
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Affiliation(s)
- Tesfahun C Eshetie
- Quality Use of Medicines and Pharmacy Research Center, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Tuan A Nguyen
- Quality Use of Medicines and Pharmacy Research Center, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Marianne H Gillam
- Quality Use of Medicines and Pharmacy Research Center, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Lisa M Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Center, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
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Identifying potentially inappropriate prescribing in older people with dementia: a systematic review. Eur J Clin Pharmacol 2019; 75:467-481. [PMID: 30610274 DOI: 10.1007/s00228-018-02612-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 12/13/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE Older people with dementia are at risk of adverse events associated with potentially inappropriate prescribing. AIM to describe (1) how international tools designed to identify potentially inappropriate prescribing have been used in studies of older people with dementia, (2) the prevalence of potentially inappropriate prescribing in this cohort and (3) advantages/disadvantages of tools METHODS: Systematic literature review, designed and reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). MEDLINE, EMBASE, PsychInfo, CINAHL, the Cochrane Library, the Social Science Citation Index, OpenGrey, Base, GreyLit, Mednar and the National Database of Ageing Research were searched in April 2016 for studies describing the use of a tool or criteria to identify potentially inappropriate prescribing in older people with dementia. RESULTS Three thousand three hundred twenty-six unique papers were identified; 26 were included in the review. Eight studies used more than one tool to identify potentially inappropriate prescribing. There were variations in how the tools were applied. The Beers criteria were the most commonly used tool. Thirteen of the 15 studies using the Beers criteria did not use the full tool. The prevalence of potentially inappropriate prescribing ranged from 14 to 74% in older people with dementia. Benzodiazepines, hypnotics and anticholinergics were the most common potentially inappropriately prescribed medications. CONCLUSIONS Variations in tool application may at least in part explain variations in potentially inappropriate prescribing across studies. Recommendations include a more standardised tool usage and ensuring the tools are comprehensive enough to identify all potentially inappropriate medications and are kept up to date.
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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.
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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
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Nguyen TA, Pham T, Vu HTT, Nguyen TX, Vu TT, Nguyen BTT, Nguyen NQ, Nguyen BT, Nguyen BT, Nguyen TN, Phan SV, Nguyen AT, Pham TL, Dang HT, Kalisch-Ellett L, Gillam M, Pratt N, Qiang S, Wang H, Kanjanarach T, Hassali MAA, Babar ZUD, Razak AA, Chinwong D, Roughead EE. Use of Potentially Inappropriate Medications in People With Dementia in Vietnam and Its Associated Factors. Am J Alzheimers Dis Other Demen 2018; 33:423-432. [PMID: 29642720 PMCID: PMC10852524 DOI: 10.1177/1533317518768999] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2024]
Abstract
This study examined the use of potentially inappropriate medicines that may affect cognition (PIMcog) in people with dementia and its associated factors. Medical records of all outpatients with dementia attending a tertiary hospital in Vietnam between January 1, 2015, and December 31, 2016, were examined. Medicine use was assessed against a list of PIMcog. Variables associated with having a PIMcog were assessed using a multiple logistic regression. Of the 128 patients, 41% used a PIMcog, 39.1% used cholinesterase inhibitors (CEIs) concomitantly with anticholinergics, and 18% used antipsychotics. The number of hospital visits (adjusted odds ratio [OR]: 1.08; 95% confidence interval [CI]: 1.02-1.16) and number of treating specialists (adjusted OR: 0.61; 95% CI: 0.45-0.83) were associated with PIMcog use. This study highlights a high-level use of medicines that can further impair cognition or reduce the effectiveness of CEIs in people with dementia. Efforts to improve quality use of medicines for this population are warranted.
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Affiliation(s)
- Tuan Anh Nguyen
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Thang Pham
- National Geriatric Hospital of Vietnam, Hanoi, Vietnam
| | | | | | - Trinh Thi Vu
- National Geriatric Hospital of Vietnam, Hanoi, Vietnam
| | | | | | | | | | | | | | | | - Tuan Le Pham
- Hanoi Medical University and Ministry of Health of Vietnam, Hanoi, Vietnam
| | - Ha Thu Dang
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Lisa Kalisch-Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Marianne Gillam
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Nicole Pratt
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Sun Qiang
- Center for Health Management and Policy, School of Health Care Management, Shandong University, Jinan, China
| | - Haipeng Wang
- Center for Health Management and Policy, School of Health Care Management, Shandong University, Jinan, China
| | | | | | | | - Asrenee Ab Razak
- Department of Psychiatry, School of Medical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Dujrudee Chinwong
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Elizabeth E. Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
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Williams A, Sera L, McPherson ML. Anticholinergic Burden in Hospice Patients With Dementia. Am J Hosp Palliat Care 2018; 36:222-227. [PMID: 30213190 DOI: 10.1177/1049909118800281] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND End-of-life (EOL) patients with dementia have an increased risk for anticholinergic toxicities due to age-related pharmacokinetic and physiologic changes in conjunction with an increased susceptibility to drug-induced cognitive impairments. Despite this well-documented risk, the use of drugs with anticholinergic properties (DAPs) remains prevalent in EOL patients with dementia. OBJECTIVE The aims of this study were to describe prescribing patterns and characterize anticholinergic burden among hospice patients with dementia, as measured by the Anticholinergic Cognitive Burden (ACB) scale. METHODS This was a retrospective review of a national hospice patient information database. Patients included were admitted on January 1, 2016, discharged by death by December 31, 2016, and had a primary diagnosis of dementia. Patients' anticholinergic burden was calculated using ACB scores. RESULTS A total of 1283 patients met the inclusion criteria. Of those, 37.1% (n = 476) were prescribed at least 1 DAP. Specifically, 28.9% (n = 371) were prescribed 1 DAP, 6.6% (n = 84) were prescribed 2 DAPs, 1.6% (n = 20) were prescribed 3 DAPs, and 0.08% (n = 1) were prescribed 4 DAPs. The majority of patients prescribed a DAP had an ACB score of 3 (n = 359, 75.4%) and an average ACB score of 3.8. The most common DAPs prescribed in patients with an ACB score of 2 or higher were quetiapine (n = 202, 42.4%), atropine (n = 155, 32.6%), hyoscyamine (n = 61, 12.8%), olanzapine (n = 46, 9.6%), and scopolamine (n = 35, 7.4%). CONCLUSION Due to the limited benefit and increased harms with the use of DAPs, providers should aim to maximize nonpharmacologic options. By reducing the use of the top 5 DAPs identified in this study, the quality of life and care for EOL patients with dementia can potentially be improved.
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Affiliation(s)
- Anne Williams
- School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | - Leah Sera
- School of Pharmacy, University of Maryland, Baltimore, MD, USA
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Eshetie TC, Nguyen TA, Gillam MH, Kalisch Ellett LM. A narrative review of problems with medicines use in people with dementia. Expert Opin Drug Saf 2018; 17:825-836. [DOI: 10.1080/14740338.2018.1497156] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Tesfahun C. Eshetie
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Tuan A. Nguyen
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Marianne H. Gillam
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Lisa M. Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
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Sevilla-Sánchez D, Molist-Brunet N, González-Bueno J, Solà-Bonada N, Espaulella-Panicot J, Codina-Jané C. Prevalence, risk factors and adverse outcomes of anticholinergic burden in patients with advanced chronic conditions at hospital admission. Geriatr Gerontol Int 2018; 18:1159-1165. [DOI: 10.1111/ggi.13330] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 02/14/2018] [Accepted: 03/07/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Daniel Sevilla-Sánchez
- Pharmacy Department, Vic University Hospital - Vic Hospital Consortium; Hospital of Santa Creu of Vic (Barcelona); Spain
| | - Núria Molist-Brunet
- Acute Geriatric Unit, Vic University Hospital, Hospital of Santa Creu of Vic (Barcelona); Spain
| | - Javier González-Bueno
- Pharmacy Department, Vic University Hospital - Vic Hospital Consortium; Hospital of Santa Creu of Vic (Barcelona); Spain
| | - Núria Solà-Bonada
- Pharmacy Department, Vic University Hospital - Vic Hospital Consortium; Hospital of Santa Creu of Vic (Barcelona); Spain
| | - Joan Espaulella-Panicot
- Acute Geriatric Unit, Vic University Hospital, Hospital of Santa Creu of Vic (Barcelona); Spain
- Geriatric and Palliative Care Territorial Unit, Hospital of Santa Creu of Vic, Vic Hospital Consortium (Barcelona); Spain
| | - Carles Codina-Jané
- Pharmacy Department, Vic University Hospital - Vic Hospital Consortium; Hospital of Santa Creu of Vic (Barcelona); Spain
- Pharmacy Department. Hospital Clinic of Barcelona, Barcelona; Spain
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Cross AJ, George J, Woodward MC, Ames D, Brodaty H, Wolfe R, Connors MH, Elliott RA. Potentially Inappropriate Medication, Anticholinergic Burden, and Mortality in People Attending Memory Clinics. J Alzheimers Dis 2017; 60:349-358. [DOI: 10.3233/jad-170265] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Amanda J. Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Johnson George
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Michael C. Woodward
- Medical and Cognitive Research Unit, Austin Health, Heidelberg, VIC, Australia
| | - David Ames
- National Ageing Research Institute, Parkville, VIC, Australia
- University of Melbourne Academic Unit for Psychiatry of Old Age, St George’s Hospital, Kew, VIC, Australia
| | - Henry Brodaty
- Dementia Collaborative Research Centre, School of Psychiatry, UNSW Australia, Sydney, NSW, Australia
- Center for Healthy Brain Ageing, School of Psychiatry, UNSW Australia, Sydney, NSW, Australia
| | - Rory Wolfe
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Michael H. Connors
- Dementia Collaborative Research Centre, School of Psychiatry, UNSW Australia, Sydney, NSW, Australia
- Center for Healthy Brain Ageing, School of Psychiatry, UNSW Australia, Sydney, NSW, Australia
| | - Rohan A. Elliott
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
- Pharmacy Department, Austin Health, Heidelberg, VIC, Australia
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Parsons C. Polypharmacy and inappropriate medication use in patients with dementia: an underresearched problem. Ther Adv Drug Saf 2017; 8:31-46. [PMID: 28203365 PMCID: PMC5298466 DOI: 10.1177/2042098616670798] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Multimorbidity and polypharmacy are increasingly prevalent across healthcare systems and settings as global demographic trends shift towards increased proportions of older people in populations. Numerous studies have demonstrated an association between polypharmacy and potentially inappropriate prescribing (PIP), and have reported high prevalence of PIP across settings of care in Europe and North America and, as a consequence, increased risk of adverse drug reactions, healthcare utilization, morbidity and mortality. These studies have not focused specifically on people with dementia, despite the high risk of adverse drug reactions and PIP in this patient cohort. This narrative review considers the evidence currently available in the area, including studies examining prevalence of PIP in older people with dementia, how appropriateness of prescribing is assessed, the medications most commonly implicated, the clinical consequences, and research priorities to optimize prescribing for this vulnerable patient group. Although there has been a considerable research effort to develop criteria to assess medication appropriateness in older people in recent years, the majority of tools do not focus on people with dementia. Of the limited number of tools available, most focus on the advanced stages of dementia in which life expectancy is limited. The development of tools to assess medication appropriateness in people with mild to moderate dementia or across the full spectrum of disease severity represents an important gap in the research literature and is beginning to attract research interest, with recent studies considering the medication regimen as a whole, or misprescribing, overprescribing or underprescribing of certain medications/medication classes, including anticholinergics, psychotropics, antibiotics and analgesics. Further work is required in development and validation of criteria to assess prescribing appropriateness in this vulnerable patient population, to determine prevalence of PIP in large cohorts of people with the full spectrum of dementia variants and severities, and to examine the impact of PIP on health outcomes.
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Affiliation(s)
- Carole Parsons
- Queen’s University Belfast, 97 Lisburn Road, Belfast, Northern Ireland BT9 7BL, UK
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Wucherer D, Eichler T, Hertel J, Kilimann I, Richter S, Michalowsky B, Thyrian JR, Teipel S, Hoffmann W. Potentially Inappropriate Medication in Community-Dwelling Primary Care Patients who were Screened Positive for Dementia. J Alzheimers Dis 2017; 55:691-701. [PMID: 27716668 PMCID: PMC5147617 DOI: 10.3233/jad-160581] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND Potentially inappropriate medication (PIM) in older people is a risk factor for adverse drug effects. This risk is even higher in older people with dementia (PWD). OBJECTIVE Our study aimed to determine (1) the prevalence of PIM among primary care patients who were screened positive for dementia and (2) the sociodemographic and clinical variables associated with the use of PIM. METHODS DelpHi-MV (Dementia: life- and person-centered help in Mecklenburg-Western Pomerania) is a general practitioner-based, cluster-randomized, controlled intervention study to implement and evaluate an innovative concept of collaborative dementia care management in Germany. The comprehensive baseline assessment includes a home medication review. The present analyses are based on the data from 448 study participants (age 70+, DemTect <9). PIMs were identified using the list of Potentially Inappropriate Medications in the Elderly (Priscus). RESULTS (1) A total of 99 study participants (22%) received at least one PIM. The highest prevalence was found for antidepressants, benzodiazepines, and analgetics. The most frequently prescribed PIMs were amitriptyline, etoricoxib, and doxazosin. (2) Use of a PIM was significantly associated with a diagnosis of a mental or behavioral disorder. CONCLUSIONS The prescription rate of PIMs for community-dwelling PWD was comparable with the rates found for the general population of older people in Germany (20-29%). Antidepressants with anticholinergic properties and long-acting benzodiazepines were the most prescribed PIMs, despite having an unfavorable benefit-risk ratio. This high prevalence of PIM prescriptions in a vulnerable population of PWD indicates that standard care for dementia should include careful medication review and management.
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Affiliation(s)
- Diana Wucherer
- German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Greifswald, Germany
| | - Tilly Eichler
- German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Greifswald, Germany
| | - Johannes Hertel
- German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Greifswald, Germany
- Department of Psychiatry and Psychotherapy, University Medicine Greifswald, Greifswald, Germany
| | - Ingo Kilimann
- German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Rostock, Germany
- Department of Psychosomatic Medicine, University of Rostock, Rostock, Germany
| | - Steffen Richter
- German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Greifswald, Germany
| | - Bernhard Michalowsky
- German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Greifswald, Germany
| | - Jochen René Thyrian
- German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Greifswald, Germany
| | - Stefan Teipel
- German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Rostock, Germany
- Department of Psychosomatic Medicine, University of Rostock, Rostock, Germany
| | - Wolfgang Hoffmann
- German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Greifswald, Germany
- Department of Epidemiology of Health Care and Community Health, Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
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Bernstein DI, Schwartz G, Bernstein JA. Allergic Rhinitis: Mechanisms and Treatment. Immunol Allergy Clin North Am 2016; 36:261-78. [PMID: 27083101 DOI: 10.1016/j.iac.2015.12.004] [Citation(s) in RCA: 136] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The prevalence of allergic rhinitis (AR) has been estimated at 10% to 40%, and its economic burden is substantial. AR patients develop specific immunoglobulin E (IgE) antibody responses to indoor and outdoor environmental allergens with exposure over time. These specific IgE antibodies bind to high-affinity IgE receptors on mast cells and basophils. Key outcome measures of therapeutic interventions include rhinitis symptom control, rescue medication requirements, and quality-of-life measures. A comprehensive multiple modality treatment plan customized to the individual patient can optimize outcomes.
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Affiliation(s)
- David I Bernstein
- Division of Immunology and Allergy, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Gene Schwartz
- Division of Immunology and Allergy, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jonathan A Bernstein
- Division of Immunology and Allergy, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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