Impact of a geriatric nursing home palliative care service on unnecessary medication prescribing

Prescribing and deprescribing in older people with life-limiting illnesses receiving hospice care at the end of life: A longitudinal, retrospective cohort study

BACKGROUND

Although prescribing and deprescribing practices in older people have been the subject of much research generally, there are limited data in older people at the end of life. This highlights the need for research to determine prescribing and deprescribing patterns, as a first step to facilitate guideline development for medicines optimisation in this vulnerable population.

AIMS

To examine prescribing and deprescribing patterns in older people at the end of life and to determine the prevalence of potentially inappropriate medication use.

DESIGN

A longitudinal, retrospective cohort study where medical records of eligible participants were reviewed, and data extracted. Medication appropriateness was assessed using two sets of consensus-based criteria; the STOPPFrail criteria and criteria developed by Morin et al.

SETTING/PARTICIPANTS

Decedents aged 65 years and older admitted continuously for at least 14 days before death to three inpatient hospice units across Northern Ireland, who died between 1st January and 31st December 2018, and who had a known diagnosis, known cause of death and prescription data. Unexpected/sudden deaths were excluded.

RESULTS

Polypharmacy was reported to be continued until death in 96.2% of 106 decedents (mean age of 75.6 years). Most patients received at least one potentially inappropriate medication at the end of life according to the STOPPFrail and the criteria developed by Morin et al. (57.5 and 69.8% respectively). Limited prevalence of proactive deprescribing interventions was observed.

CONCLUSIONS

In the absence of systematic rationalisation of drug treatments, a substantial proportion of older patients continued to receive potentially inappropriate medication until death.

Survival and factors affecting the survival of older adult patients in palliative care

PURPOSE

Investigate the survival and risk factors that affect the survival of aged patients in a palliative care center (PCC).

METHODS

A total of 180 inpatients (aged ≥ 65 years) who were admitted to a PCC from January 2018 to March 2020 were included. Information regarding patients' demographic characteristics, chronic diseases, length of hospital stay, nutrition provided at the first hospital stay, pressure wound, pain, and laboratory results were evaluated.

RESULTS

The patients 50% were women (n = 90). The mean age, mean comorbidity, and mean follow-up duration was 77.6 years, 3.4, and 115 days (median: 29 days), respectively. The mean NRS2002 score of patients was 4.0 ± 1.0 and the risk of malnutrition was 93%. The mortality rate of the patients was 91.7%. The life expectancy of patients without malignancy was higher than those with malignancy (p < 0.001). Enteral nutrition (EN) via percutaneous endoscopic gastrostomy (PEG) was associated with up to two-fold increase in the survival rates of patients with PCC (p = 0.049, HR: 2.029). High neutrophil/lymphocyte ratio (p = 0.002, HR: 1.017) and high ferritin (p = 0.001, HR: 1.000) and C-reactive protein (CRP) levels (p < 0.001, HR: 1.006) were adverse risk factors affecting life expectancy. Malignity reduced the survival rate of aged patients with PCC by 40% (p = 0.008).

CONCLUSION

EN via PEG was found to be a positive factor affecting survival rates of older adult patients in palliative care, whereas malignity, high neutrophil/lymphocyte ratio, high CRP and ferritin levels, and prolonged hospital stays were negative risk factors.

Perspectives on deprescribing in palliative care

INTRODUCTION

Pharmacotherapy plays a critical role in the delivery of high-quality palliative care, but the intersection of palliative care and deprescribing has received little attention.

AREAS COVERED

We conducted a scoping review of English language articles using PubMed to identify relevant publications between 1 January 2000 to 31 July 2022 using search terms of deprescribing, palliative care, end of life, and hospice. We summarize current definitions and developments in palliative care and deprescribing from both clinical and research perspectives. We highlight key challenges and outline proposed solutions and needed research.

EXPERT OPINION

The future of deprescribing in palliative care requires the development and adoption of individualized approaches to medication management, including a reconsidered approach to communication about deprescribing. Evidence from high-quality clinical outcomes studies is lacking, and the field needs new approaches to coordination of care delivery. This review article will be of interest to both clinical and research-based pharmacists, physicians, and nurses interested in improving care for patients with serious illness.

The Role of an Inpatient Hospice and Palliative Clinical Pharmacist in the Interdisciplinary Team

Palliative care is a specialized health care service for individuals with serious illness at any stage and can be provided in any setting. Current national consensus developed by palliative care experts recommends the inclusion of pharmacists in an interdisciplinary team (IDT) to provide quality palliative care. However, national registry data report that less than 10% of inpatient palliative teams in the U.S. have a clinical pharmacist. Clinical pharmacists have an impactful role in palliative patients' quality of life by optimizing symptom management, deprescribing, and providing education to the palliative care team as well as patients and their families. In this report, we review the current literature on the role of a palliative pharmacist in an inpatient palliative care setting and compare and contrast this with our own clinical practice, providing case examples about the role of a palliative clinical pharmacist in an interdisciplinary inpatient palliative care setting. Future strategies are needed to increase post-graduate specialized pharmacy residency training in palliative care as well as education on palliative and hospice care in pharmacy schools to support the role of clinical pharmacists in palliative care.

High-Quality Nursing Home and Palliative Care-One and the Same

Many individuals receiving post-acute and long-term care services in nursing homes have unmet palliative and end-of-life care needs. Hospice has been the predominant approach to meeting these needs, although hospice services generally are available only to long-term care residents with a limited prognosis who choose to forego disease-modifying or curative therapies. Two additional approaches to meeting these needs are the provision of palliative care consultation through community- or hospital-based programs and facility-based palliative care services. However, access to this specialized care is limited, services are not clearly defined, and the empirical evidence of these approaches' effectiveness is inadequate. In this article, we review the existing evidence and challenges with each of these 3 approaches. We then describe a model for effective delivery of palliative and end-of-life care in nursing homes, one in which palliative and end-of-life care are seen as integral to high-quality nursing home care. To achieve this vision, we make 4 recommendations: (1) promote internal palliative and end-of-life care capacity through comprehensive training and support; (2) ensure that state and federal payment policies and regulations do not create barriers to delivering high-quality, person-centered palliative and end-of-life care; (3) align nursing home quality measures to include palliative and end-of-life care-sensitive indicators; and (4) support access to and integration of external palliative care services. These recommendations will require changes in the organization, delivery, and reimbursement of care. All nursing homes should provide high-quality palliative and end-of-life care, and this article describes some key strategies to make this goal a reality.

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

Purpose of Review

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

Recent Findings

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

Summary

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

Prescribing practices, patterns, and potential harms in patients receiving palliative care: A systematic scoping review

Background

Patients receiving palliative care often have existing comorbidities necessitating the prescribing of multiple medications. To maximize quality of life in this patient cohort, it is important to tailor prescribing of medication for preventing and treating existing illnesses and those for controlling symptoms, such as pain, according to individual specific needs.

Objective(s)

To provide an overview of peer-reviewed observational research on prescribing practices, patterns, and potential harms in patients receiving palliative care.

Methods

A systematic scoping review was conducted using four electronic databases (PubMed, EMBASE, CINAHL, Web of Science). Each database was searched from inception to May 2020. Search terms included ‘palliative care,’ ‘end of life,’ and ‘prescribing.’ Eligible studies had to examine prescribing for adults (≥18 years) receiving palliative care in any setting as a study aim or outcome. Studies focusing on single medication types (e.g., opioids), medication classes (e.g., chemotherapy), or clinical indications (e.g., pain) were excluded. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews, and the findings were described using narrative synthesis.

Results

Following deduplication, 16,565 unique citations were reviewed, and 56 studies met inclusion criteria. The average number of prescribed medications per patient ranged from 3 to 23. Typically, prescribing changes involved decreases in preventative medications and increases in symptom-specific medications closer to the time of death. Twenty-one studies assessed the appropriateness of prescribing using various tools. The prevalence of patients with ≥1 potentially inappropriate prescription ranged from 15 to 92%. Three studies reported on adverse drug events.

Conclusions

This scoping review provides a broad overview of existing research and shows that many patients receiving palliative care receive multiple medications closer to the time of death. Future research should focus in greater detail on prescribing appropriateness using tools specifically developed to guide prescribing in palliative care and the potential for harm.

Would people living with epilepsy benefit from palliative care?

Palliative care (PC) is an approach to the care of persons living with serious illness and their families that focuses on improving quality of life and reducing suffering by addressing complex medical symptoms, psychosocial needs, spiritual well-being, and advance care planning. While PC has traditionally been associated with hospice care for persons with cancer, there is now recognition that PC is relevant to many noncancer diagnoses, including neurologic illness, and at multiple points along the illness journey, not just end of life. Despite the recent growth of the field of neuropalliative care there has been scant attention paid to the relevance of PC principles in epilepsy or the potential for PC approaches to improve outcomes for persons living with epilepsy and their families. We believe this has been a significant oversight and that PC may provide a useful framework for addressing the many sources of suffering facing persons living with epilepsy, for engaging patients and families in challenging conversations, and to focus efforts to improve models of care for this population. In this manuscript we review areas of significant unmet needs where a PC approach may improve patient and family-centered outcomes, including complex symptom management, goals of care, advance care planning, psychosocial support for patient and family and spiritual well-being. When relevant we highlight areas where epilepsy patients may have unique PC needs compared to other patient populations and conclude with suggestions for future research, clinical, and educational efforts.

Polypharmacy in Palliative Care: Two Deprescribing Tools Compared with a Clinical Review

Background: Lack of guidance is highlighted as a barrier to deprescribing in palliative care. Two deprescribing tools exist, but with inclusion and exclusion criteria that limit utility. The tools have not previously been compared directly or used in an unselected palliative population. Objective: To compare the OncPal and STOPPFrail deprescribing tools to an expert review in an unselected palliative population. Secondary aims included a description of medicines incorrectly classified by both tools. Design: Fifty palliative inpatients were retrospectively reviewed by an expert panel, and both tools were independently applied to the patients. Positive and negative predictive values (PPV and NPV) were calculated per patient using the expert review as the gold standard. Results: The median number of medicines per patient was 11, with 19% of medicines deemed inappropriate. The PPV and NPV were 75% (interquartile range 50-100) and 91% (interquartile range 84-100), respectively, for OncPal, and 100% (interquartile range 50-100) and 90% (interquartile range 78-100), respectively, for STOPPFrail. There was no statistically significant difference between the tools (PPV p = 0.42 and NPV p = 0.07). The main medicines incorrectly ceased by OncPal were antianginals for stable coronary artery disease, and haloperidol for nausea by STOPPFrail. Conclusion: There was no significant difference between the tools. Both tools performed well in an unselected population. Some minor amendments could improve the PPV of both tools.

Medication use in aged care residents in the last year of life: A scoping review

BACKGROUND

A substantial number of older adults die in residential aged care facilities, yet little is known about the characteristics of and how best to optimise medication use in the last year of life.

AIM

The aim of this review was to map characteristics of medication use in aged care residents during the last year of life in order to examine key concepts related to medication safety and draw implications for further research and service provision.

DESIGN

A scoping review following Arskey and O'Malley's framework was conducted using a targeted keyword search, followed by assessments of eligibility based on title and content of abstracts and full papers. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the scoping review protocol was prospectively registered to the Open Science Framework on 27 November 2018.

DATA SOURCES

We searched MEDLINE, EMBASE, AMED, CINAHL and Cochrane databases to identify peer-reviewed studies published between 1937 and 2018, written in English and looking at medication use in individuals living in aged care facilities within their last year of life.

RESULTS

A total of 30 papers were reviewed. Five key overarching themes were derived from the analysis process: (1) access to medicines at the end of life, (2) categorisation and classes: medicines and populations, (3) polypharmacy and total medication numbers, (4) use of symptomatic versus preventive medications and (5) 'inappropriate' medications.

CONCLUSION

Number of prescriptions or blunt categorisations of medications to assess their appropriateness are unlikely to be sufficient to promote well-being and medication safety for older people in residential aged care in the final stages of life.

Outcomes of deprescribing interventions in older patients with life-limiting illness and limited life expectancy: A systematic review

AIMS

Older patients with life-limiting illness (LLI) and limited life expectancy (LLE) continue to receive potentially inappropriate medicines, consequently deprescribing is often necessary. However, deprescribing in this population can be complex and challenging. Therefore, we aimed to investigate the evidence for outcomes of deprescribing interventions in older patients with LLI and LLE.

METHODS

Studies on deprescribing intervention and their outcomes in age ≥65 years with LLI and LLE were searched using PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Google Scholar. Medication appropriateness was primary outcome, while clinical and cost-related outcomes were secondary. Eligibility, data extraction and quality assessment were followed by a narrative synthesis of data.

RESULTS

Of 9 studies (1375 participants), 3 reported on primary outcome. One study showed a significant reduction in medication inappropriateness by 34.9% (P < .001) from admission to close-out, the second achieved 29.4% (P < .001) and 15.1% (P = .003) reduction at 12 and 24 months, respectively. The third reported that their intervention stopped (17.2%) and altered the dose (2.6%) of high-risk medications. Commonly reported clinical outcomes were mortality (n = 3), quality of life (n = 2) and falls (n = 2). Outcomes in terms of cost were reported as overall cost (n = 2), medication cost (n = 1) and health care expenditure (n = 1).

CONCLUSION

Our findings suggest that deprescribing in older patients with LLI and LLE can improve medication appropriateness, and has potential for enhancement of several clinical outcomes and cost savings, but the evidence needs to be better established.

Prescription and deprescription of medications for older adults receiving palliative care during the last 3 months of life: a single-center retrospective cohort study

PURPOSE

Near the end of life, drugs to ensure comfort and improve quality of life should be prioritized, and unnecessary drugs should be avoided. The aim was to assess the evolution and quality of drug therapy throughout the last 3 months of life of older adults in need of palliative care.

METHODS

A single-center retrospective cohort study included older adults (≥ 65 years) who died in a teaching hospital between 1 January 2014 and 30 June 2014 and had been identified as patients in need of palliative care in their last 3 months of life. Drugs were collected from electronic medical records and defined as 'unnecessary' or 'essential' based on a review of the literature.

RESULTS

A total of 149 patients were included [age: 82.1 (SD 8.6) years, women: 46.3%]. The mean number of medications varied from 6.7 (SD 3.3) drugs 90 days before death, to 7.5 (SD 4.1) 7 days before death, to 5.6 (SD 3.6) on the day of death. During the final week of life, one additional prescription of essential drugs was observed for 75.2% of patients and 79.3% of patients had at least one unnecessary drug deprescribed. The most prescribed and deprescribed drug classes were, respectively, analgesics (56.4%) and antithrombotic agents (38.2%) during the last week of life.

CONCLUSIONS

Near the end of life, medication therapy is adapted to the goals of palliative care. However, this only occurs during the last week of life. Earlier transition to palliative care is necessary to avoid exposure to unnecessary drugs.

Drug Prescriptions in Nursing Home Residents during their Last 6 Months of Life: Data from the IQUARE Study

OBJECTIVE

To assess the drug prescriptions of nursing home (NH) residents during the 6 months prior to their death, and the impact of the recognition of « life expectancy lower than 6 months » by the NH staff on the prescriptions.

DESIGN

Prospective study.

SETTING

175 nursing homes in France.

PARTICIPANTS

6275 residents were included from May to June 2011.

MEASUREMENTS

The initial drug prescriptions of the residents who deceased within 6 months were compared with those who did not decease. Among the residents deceased within 6 months, the drug prescriptions were compared between the residents who were «considered at the end of their life» and those who were not. Potentially inappropriate prescriptions (PIP) were analyzed using Laroche criteria and a list of therapies considered as inappropriate at the end of life.

RESULTS

498 residents (7.9%) died within 6 months after their inclusion: they had significantly more therapies (8.3 ± 3.8 vs. 7.9 ± 3.5, p=0.048) than non-deceased people. Sixty-one of the residents deceased within 6 months were considered by the NH staff as «end of life residents » (12.2%). They received significantly less drugs (6.4 ± 4.2 vs 8.5 ± 3.6, p<0.001) than NH's residents not identified at the end of their life. They had a more frequent prescription of opioids (p<0.001), and less antipsychotics (p<0.001), lipid-lowering drugs (p=0.006), or antihypertensive therapies (p<0.01). They also received significantly less PIP (59.0% received at least one inappropriate prescription, vs. 87.2%, p<0.001).

CONCLUSION

An important proportion of nursing home residents received PIP. The quality of prescriptions in patients identified at the end of their life seems to improve, but more than half still receive inappropriate drugs. Special attention in prescribing should be given to these patients presenting a high risk of adverse events.

Palliative Care Consults in U.S. Nursing Homes: Not Just for the Dying

BACKGROUND

Little is known about nursing home (NH) residents who receive palliative care (PC) consults in the United States.

OBJECTIVE

Separately by short versus long (≥90 days) stays, to describe NH residents with PC consults compared to a prevalent NH sample.

DESIGN

Descriptive longitudinal study.

SETTING/SUBJECTS

NH residents in 2008-2010 in 54 NHs.

MEASUREMENTS

Resident characteristics came from merged Medicare and NH data from the Centers for Medicare and Medicaid Services and consult information from two PC organizations that were the sole PC consult providers in the study NHs.

RESULTS

Four percent of all NH residents received a PC consult during the study period. Two-thirds had short NH stays, and 81% of short- and 27% of long-stay consult recipients were on the Medicare skilled nursing facility (SNF) benefit at the time of initial consult. Short- and long-stay NH residents with PC consults differed not only, in many respects, from NH residents generally but also from each other. Despite these differences, half of short-stay and 57% of long-stay residents were alive six months after initial consults. Residents dead at six months died at 33.5 and 34.5 median days (respectively) after initial consults. At six months, 65% of surviving short-stay consult recipients were in the community without hospice, while 59% of long-stay residents were in the NH without hospice or Medicare SNF care.

CONCLUSION

The high rates of SNF care and six-month survival among NH recipients of PC consults demonstrate the utility of these consults before Medicare hospice eligibility or use.

Potentially inappropriate medication at hospital admission in patients with palliative care needs

Background Potentially inappropriate medications (PIMs) are common in older patients with polypharmacy, and are related to negative clinical results. Little information is available on the characteristics and consequences of PIMs in patients with advanced chronic conditions and palliative care needs. Objective To evaluate, for this population: (i) the prevalence of PIMs; (ii) the possible risk factors associated with its onset; and (iii) the related clinical consequences. Setting Acute-hospital care Geriatric Unit (AGU) in County of Osona, Spain. Method Ten-month prospective cross-sectional study. Patients with palliative care needs were identified according to the NECPAL CCOMS-ICO^® test. Upon hospital admission, a multidisciplinary team consisting of a pharmacist and two AGU physicians determined the PIMs of the routine chronic medication of the patients. Sociodemographic and pharmacological data were collected with the objective of determining possible risk factors related to the existence of PIMs. Main outcome measure Prevalence and type of PIMs according to STOPP version 2 and MAI criteria at the time of hospital admission. Furthermore, days of hospital admission, destination at hospital discharge and survival analysis at 12 months related to PIMs were evaluated. Results Two hundred thirty-five patients (mean age 86.80, SD 5.37; 65.50% women) were recruited. According to the STOPP criteria, 88.50% of patients had ≥1 criterion (mainly 'indication of medication', followed by those that affect the nervous system and psychotropic drugs and risk drugs in people suffering from falls), and according to the MAI tool, 97.40% of the patients had some criterion related to inappropriate medication (mainly, duration of therapy). The following conditions were identified as risk factors for the existence of PIMs: insomnia, anxiety-depressive disorder, falls, pain, excessive polypharmacy and therapeutic complexity. There were no differences among patients in days of hospital stay, discharge's destination or survival at 12 months, regardless of the tool used. Conclusion The presence of PIMs is high in patients requiring palliative care. Some potentially modifiable risk factors such as the pharmacological ones are associated with a greater presence of inappropriate medication. The presence of PIMs does not affect this population in terms of mortality.

Retrospective analysis of pharmacist interventions in an ambulatory palliative care practice

BACKGROUND

We have previously reported the development of an outpatient palliative care practice under pharmacist-physician collaboration. The Doris A. Howell Service at the University of California, San Diego Moores Cancer Center includes two pharmacists who participate in a transdisciplinary clinic and provide follow-up care to patients.

OBJECTIVE

This study evaluated pharmacist interventions and patient outcomes of a pharmacist-led outpatient palliative care practice.

METHODS

This was a retrospective data analysis conducted at a single, academic, comprehensive cancer center. New (first visit) patient consultations were referred by an oncologist or hematologist to an outpatient palliative care practice. A pharmacist evaluated the patient at the first visit and at follow-up (second, third, and fourth visits). Medication problems identified, medication changes made, and changes in pain scores were assessed.

RESULTS

Eighty-four new and 135 follow-up patient visits with the pharmacist occurred from March 2011 to March 2012. All new patients (n = 80) were mostly women (n = 44), had localized disease (n = 42), a gastrointestinal cancer type (n = 21), and were on a long-acting (n = 61) and short-acting (n = 70) opioid. A lack of medication efficacy was the most common problem for symptoms of pain, constipation, and nausea/vomiting that was identified by the pharmacist at all visits. A change in pain medication dose and initiation of a new medication for constipation and nausea/vomiting were the most common interventions by the pharmacist. A statistically significant change in pain score was observed for the third visit, but not for the second and fourth visits.

CONCLUSIONS

A pharmacist-led outpatient palliative care practice identified medication problems for management of pain, constipation, and nausea/vomiting. Medication changes involved a change in dose and/or initiating a new medication. Trends were observed in improvement and stabilization of pain over subsequent clinic visits.

Optimizing pharmacotherapy in elderly patients: the role of pharmacists

As the world's population ages, global health care systems will face the burden of chronic diseases and polypharmacy use among older adults. The traditional tasks of medication dispensing and provision of basic education by pharmacists have evolved to active engagement in direct patient care and collaborative team-based care. The care of older patients is an especially fitting mission for pharmacists, since the key to geriatric care often lies with management of chronic diseases and polypharmacy use, and preventing harmful consequences of both. Because most chronic conditions are treated with medications, pharmacists, with their extensive training in pharmacotherapy and pharmacokinetics, are in a unique and critical position in the management of them. Pharmacists have the expertise to detect, resolve, and prevent medication errors and drug-related problems, such as overtreatment, undertreatment, adverse drug events, and nonadherence. Pharmacists are also competent in critically reviewing and applying clinical guidelines to the care of individual patients, and in some instances confront the lack of data (common in older adults) to provide the best possible patient-centered care. The current review aimed to depict the evidence of geriatric pharmacy care, demonstrate current impact of pharmacists' interventions on older patients, survey the tools used by pharmacists to provide effective care, and explore their role in pharmacotherapy optimization in elders. The findings of the current review strongly support previous studies that showed positive impact of pharmacists' interventions on older patients' health-related outcomes. There is a clear role for pharmacists working directly or collaboratively to improve medication use and management in older populations. Therefore, in global health care systems, teams caring for elders should involve pharmacists to optimize pharmacotherapy.

Therapeutic futility in cancer patients at the time of palliative care transition: An analysis with a modified version of the Medication Appropriateness Index

BACKGROUND

Palliative Care professionals are often confronted with therapeutic futility, consisting in inappropriate strategies that do not add any advantage to the patient and may actually increase adverse events. Scientific literature concerning this issue is lacking. This article is one of the first to study therapeutic futility specifically at the time of transition to the palliative care setting.

AIM

To study the phenomenon of pharmacologic therapeutic futility at the time of transition of a cancer patient to palliative care.

DESIGN

The pharmacological prescriptions at the time of the first appointment at an oncological palliative care unit during a time period of 2 months were prospectively collected and characterized using the Medication Appropriateness Index.

PARTICIPANTS

The sample comprised 71 patients with a mean age of 68.2 years.

RESULTS

The most common pharmacological groups were analgesics (n = 121; 19.2%), psychoactive drugs (n = 89; 14.1%), and antihypertensives (n = 51; 8.1%). A total of 61 patients (85.9%) consumed 5 drugs or more at the time of the first appointment. The mean number of daily medications decreased significantly after the palliative care team intervention, from 7.15 to 5.73 (p < 0.05). The principal causes of inappropriateness were absence of indication for the drug (23.0% "inappropriate"), the drugs' adverse interactions (11.1%), and inadequate dosage (9.9%). After the first consultation in the palliative care setting, 28.2% of the drugs were suspended.

CONCLUSION

This article tried to evaluate the main causes of therapeutic futility at the palliative care transition. The principal causes of inappropriateness were absence of clinical indication, clinically significant drug-disease/comorbidity interactions, and incorrect dosage/posology.

Effects of a multifactorial fall prevention program on balance, gait, and fear of falling in post-stroke inpatients

[Purpose] This study investigated the effects of a multifactorial fall prevention program on balance, gait, and fear of falling in stroke patients. [Subjects] Twenty-five stroke patients were divided randomly into multifactorial fall prevention program group (n=15) and control treadmill group (n=10). [Methods] All interventions were applied for 30 min, five times per week, for five weeks. The fall prevention program included interventions based on the “Step Up to Stop Falls” initiative and educational interventions based on the Department of Health guidelines. For those in the treadmill group, the speed was increased gradually. The Korean falls efficacy scale and Korean activities-specific balance confidence scale were used to assess fear of falling. To assess balance and walking ability, the Korean performance-oriented mobility assessment scale and the 10-m and 6-minute walk tests were used. [Results] The fall prevention program interventions were found to be very effective at improving gait, balance, and fear of falling compared with the treadmill intervention and therefore seem appropriate for stroke patients. [Conclusion] A multifactorial fall prevention program is effective at improving balance, gait ability, and fear of falling. It is a more specific and broad intervention for reducing falls among inpatients in facilities and hospitals.

The medication appropriateness index at 20: where it started, where it has been, and where it may be going

Potentially inappropriate prescribing for older adults is a major public health concern. While there are multiple measures of potentially inappropriate prescribing, the medication appropriateness index (MAI) is one of the most common implicit approaches published in the scientific literature. The objective of this narrative review is to describe findings regarding the MAI's reliability, comparison of the MAI with other quality measures of potentially inappropriate prescribing, its predictive validity with important health outcomes, and its responsiveness to change within the framework of randomized controlled trials. A search restricted to English-language literature involving humans aged 65+ years from January 1992 to June 2013 was conducted using MEDLINE and EMBASE databases using the search term 'medication appropriateness index'. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. A total of 26 articles were identified for inclusion in this narrative review. The main findings were that the MAI has acceptable inter- and intra-rater reliability, it more frequently detects potentially inappropriate prescribing than a commonly used set of explicit criteria, it predicts adverse health outcomes, and it is able to demonstrate the positive impact of interventions to improve this public health problem. We conclude that the MAI may serve as a valuable tool for measuring potentially inappropriate prescribing in older adults.

Studies to reduce unnecessary medication use in frail older adults: a systematic review

BACKGROUND

Overuse of unnecessary medications in frail older adults with limited life expectancy remains an understudied challenge.

OBJECTIVE

To identify intervention studies that reduced use of unnecessary medications in frail older adults. A secondary goal was to identify and review studies focusing on patients approaching end of life. We examined criteria for identifying unnecessary medications, intervention processes for medication reduction, and intervention effectiveness.

METHODS

A systematic review of English articles using MEDLINE, EMBASE, and International Pharmaceutical Abstracts from January 1966 to September 2012. Additional studies were identified by searching bibliographies. Search terms included prescription drugs, drug utilization, hospice or palliative care, and appropriate or inappropriate. A manual review of 971 identified abstracts for the inclusion criteria (study included an intervention to reduce chronic medication use; at least 5 participants; population included patients aged at least 65 years, hospice enrollment, or indication of frailty or risk of functional decline-including assisted living or nursing home residence, inpatient hospitalization) yielded 60 articles for full review by 3 investigators. After exclusion of review articles, interventions targeting acute medications, or studies exclusively in the intensive care unit, 36 articles were retained (including 13 identified by bibliography review). Articles were extracted for study design, study setting, intervention description, criteria for identifying unnecessary medication use, and intervention outcomes.

RESULTS

The studies included 15 randomized controlled trials, 4 non-randomized trials, 6 pre-post studies, and 11 case series. Control groups were used in over half of the studies (n = 20). Study populations varied and included residents of nursing homes and assisted living facilities (n = 16), hospitalized patients (n = 14), hospice/palliative care patients (n = 3), home care patients (n = 2), and frail or disabled community-dwelling patients (n = 1). The majority of studies (n = 21) used implicit criteria to identify unnecessary medications (including drugs without indication, unnecessary duplication, and lack of effectiveness); only one study incorporated patient preference into prescribing criteria. Most (25) interventions were led by or involved pharmacists, 4 used academic detailing, 2 used audit and feedback reports targeting prescribers, and 5 involved physician-led medication reviews. Overall intervention effect sizes could not be determined due to heterogeneity of study designs, samples, and measures.

CONCLUSIONS

Very little rigorous research has been conducted on reducing unnecessary medications in frail older adults or patients approaching end of life.

Preventive medication use among persons with limited life expectancy

Persons with limited life expectancy (LLE) – less than 1 year – are significant consumers of health care, are at increased risk of polypharmacy and adverse drug events, and have dynamic health statuses. Therefore, medication use among this population must be appropriate and regularly evaluated. The objective of this review is to assess the current state of knowledge and clinical practice presented in the literature regarding preventive medication use among persons with LLE. We searched Medline, Embase, and CINAHL using Medical Subject Headings. Broad searches were first conducted using the terms ‘terminal care or therapy’ or ‘advanced disease’ and ‘polypharmacy’ or ‘inappropriate medication’ or ‘preventive medicine’, followed by more specific searches using the terms ‘statins’ or ‘anti-hypertensives’ or ‘bisphosphonates’ or ‘laxatives’ and ‘terminal care’. Frameworks to assess appropriate versus inappropriate medications for persons with LLE, and the prevalence of potentially inappropriate medication use among this population, are presented. A considerable proportion of individuals with a known terminal condition continue to take chronic disease preventive medications until death despite questionable benefit. The addition of palliative preventive medications is advised. There is an indication that as death approaches the shift from a curative to palliative goal of care translates into a shift in medication use. This literature review is a first step towards improving medication use and decreasing polypharmacy in persons at the end of life. There is a need to develop consensus criteria to assess appropriate versus inappropriate medication use, specifically for individuals at the end of life.

Geriatric patient care by U.S. pharmacists in healthcare teams: systematic review and meta-analyses

OBJECTIVES

To conduct a systematic review and meta-analyses to examine the effects of pharmacists' care on geriatric patient-oriented health outcomes in the United States (U.S.).

DESIGN

Studies examining U.S. pharmacists' patient care services from inception of the databases through July 2012 were searched. The databases searched include PubMed/MEDLINE, Ovid/MEDLINE, ABI/INFORM, Health Business Fulltext Elite, Academic Search Complete, International Pharmaceutical Abstracts, PsycINFO, Cochrane Database, and Clinical Trials.gov. Studies reporting pharmacists' intervention for geriatric patients, comparison groups, and patient-oriented outcomes were assessed. Dual review for inclusion and data extraction were performed.

SETTING

University of Arizona College of Pharmacy.

MEASUREMENTS

Study and participant characteristics, pharmacist intervention, and outcomes with data for meta-analyses were collected. A forest plot was constructed to obtain a pooled standardized mean difference using a random effects model.

RESULTS

One hundred fifty-two articles were reviewed, with 20 resulting studies included in the final meta-analyses. Study sample size ranged from 36 to 4,218, with mean age of subjects being 65 and older. The studies were most frequently conducted in ambulatory care clinics, followed by inpatient settings; the majority focused on multiple diseases and conditions. Pharmacist activities varied widely, with technical interventions used most often. Favorable results were found in all outcome categories, and meta-analyses conducted for therapeutic, safety, hospitalization, and adherence were significant (P < .001), favoring pharmacist care over comparison. Some identifiable variability existed between included studies.

CONCLUSION

Pharmacist intervention has favorable effects on therapeutic, safety, hospitalization, and adherence outcomes in older adults. Pharmacists should be involved in team-based care of older adults.

Department of Veterans Affairs Geriatric Research, Education and Clinical Centers: translating aging research into clinical geriatrics

Department of Veterans Affairs (VA) Geriatric Research, Education and Clinical Centers (GRECCs) originated in 1975 in response to the rapidly aging veteran population. Since its inception, the GRECC program has made major contributions to the advancement of aging research, geriatric training, and clinical care within and outside the VA. GRECCs were created to conduct translational research to enhance the clinical care of future aging generations. GRECC training programs also provide leadership in educating healthcare providers about the special needs of older persons. GRECC programs are also instrumental in establishing robust clinical geriatric and aging research programs at their affiliated university schools of medicine. This report identifies how the GRECC program has successfully adapted to changes that have occurred in VA since 1994, when the program's influence on U.S. geriatrics was last reported, focusing on its effect on advancing clinical geriatrics in the last 10 years. This evidence supports the conclusion that, after more than 30 years, the GRECC program remains a vibrant "jewel in the crown of the VA" and is poised to make contributions to aging research and clinical geriatrics well into the future.

Jurisdiction over nursing care systems in nursing homes: latent class analysis

BACKGROUND

In the context of declining registered nurse (RN) staffing levels in nursing homes, professional nursing jurisdiction over nursing care systems may erode.

OBJECTIVE

The aim of this study was to develop a typology of professional nursing jurisdiction in nursing homes in relation to characteristics of RN staffing, drawing upon Abbott's tasks and jurisdictions framework.

METHODS

The study was a cross-sectional, observational study using the 2004 National Nursing Home Survey (n = 1,120 nursing homes). Latent class analysis was used to test whether RN staffing indicators differentiated facilities in a typology of RN jurisdiction and compared classes on key organizational environment characteristics. Multiple logistic regression analysis related the emergent classes to presence or absence of specialty care programs in eight clinical areas.

RESULTS

Three classes of capacity for jurisdiction were identified, including low capacity (41% of homes) with low probabilities of having any indicators of RN jurisdiction, mixed capacity (26% of homes) with moderate to high probabilities of having higher RN education and staffing levels, and high capacity (32% of homes) with moderate to high probabilities of having almost all indicators of RN jurisdiction. High-capacity homes were more likely to have specialty care programs relative to low-capacity homes; such homes were less likely to be chain-owned and more likely to be larger, provide higher technical levels of patient care, have unionized nursing assistants, have a lower ratio of licensed practical nurses to RNs, and have an administrator with higher education level.

DISCUSSION

Findings provide preliminary support for the theoretical framework as a starting point to move beyond extensive reliance on staffing levels and mix as indicators of quality. Furthermore, findings indicate the importance of RN specialty certification.

Polypharmacy and food-drug interactions among older persons: a review

Polypharmacy is generally defined as the use of 5 or more prescription medications on a regular basis. The average number of prescribed and over-the-counter medications used by community-dwelling older adults per day in the United States is 6 medications, and the number used by institutionalized older persons is 9 medications. Almost all medications affect nutriture, either directly or indirectly, and nutriture affects drug disposition and effect. This review will highlight the issues surrounding polypharmacy, food-drug interactions, and the consequences of these interactions for the older adult.

Interventions for improving palliative care for older people living in nursing care homes

BACKGROUND

Residents of nursing care homes for older people are highly likely to die there, making these places where palliative care is needed.

OBJECTIVES

The primary objective was to determine effectiveness of multi-component palliative care service delivery interventions for residents of care homes for older people. The secondary objective was to describe the range and quality of outcome measures.

SEARCH STRATEGY

The grey literature and the following electronic databases were searched: Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness (all issue 1, 2010); MEDLINE, EMBASE, CINAHL, British Nursing Index, (1806 to February 2010), Science Citation Index Expanded & AMED (all to February 2010). Key journals were hand searched and a PubMed related articles link search was conducted on the final list of articles.

SELECTION CRITERIA

We planned to include Randomised Clinical Trials (RCTs), Controlled Clinical Trials (CCTs), controlled before-and-after studies and interrupted time series studies of multi-component palliative care service delivery interventions for residents of care homes for older people. These usually include the assessment and management of physical, psychological and spiritual symptoms and advance care planning. We did not include individual components of palliative care, such as advance care planning.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data, and assessed quality and risk of bias. Meta analysis was not conducted due to heterogeneity of studies. The analysis comprised a structured narrative synthesis. Outcomes for residents and process of care measures were reported separately.

MAIN RESULTS

Two RCTs and one controlled before-and-after study were included (735 participants). All were conducted in the USA and had several potential sources of bias. Few outcomes for residents were assessed. One study reported higher satisfaction with care and the other found lower observed discomfort in residents with end-stage dementia. Two studies reported group differences on some process measures. Both reported higher referral to hospice services in their intervention group, one found fewer hospital admissions and days in hospital in the intervention group, the other found an increase in do-not-resuscitate orders and documented advance care plan discussions.

AUTHORS' CONCLUSIONS

We found few studies, and all were in the USA. Although the results are potentially promising, high quality trials of palliative care service delivery interventions which assess outcomes for residents are needed, particularly outside the USA. These should focus on measuring standard outcomes, assessing cost-effectiveness, and reducing bias.

Challenges and opportunities in advancing models of care for older adults: an assessment of the National Institute on Aging research portfolio

OBJECTIVES

To identify existing projects supported by the National Institute on Aging (NIA) that may relate to the recommendations for models of care (MOCs) presented in the 2008 Institute of Medicine Report, Retooling for an Aging America: Building the Healthcare Workforce.

DESIGN

Cross-sectional analysis of NIA's grant portfolio.

SETTING

NIA.

PARTICIPANTS

NIA grantees.

MEASUREMENTS

NIA's grant portfolio was queried for the period 1999 to 2008 using a variety of search terms related to MOCs. Inclusion criteria were adherence to guiding principles for MOCs (comprehensive care, efficient care, older person as an active partner) or focus on innovative feature(s) of MOCs (interdisciplinary care, care management, chronic disease self-management, pharmaceutical management, preventive home visits, proactive rehabilitation, transitional care). Exclusion criteria were lack of focus on an intervention and focus on informal caregivers. Expert NIA staff reviewed and validated projects.

RESULTS

One hundred thirty-five grants were identified. These grants represent fewer than 1% of the approximate number of grants NIA has funded over this same period of time (∼24,000 grants). Forty-four percent focused on components of comprehensive care and 34% on active involvement of older adults. Approximately half specifically focused on innovative features of MOCs, ranging from chronic disease self-management (32%) and proactive rehabilitation (26%) to preventive home visits (1%) and transitional care (1%). The majority of projects were investigator-initiated grants (46%).

CONCLUSION

NIA has supported the development of many interventions that include components of MOCs related to recommendations from the IOM report. The challenge for the future will be determining which of the many components of comprehensive care systems are most effective for which subsets of the elderly population and assessing opportunities for enhanced collaboration between public and private aging research stakeholders.

Polypharmacy in older adults with cancer

The definition of "polypharmacy" ranges from the use of a large number of medications; the use of potentially inappropriate medications, which can increase the risk for adverse drug events; medication underuse despite instructions to the contrary; and medication duplication. Older adults are particularly at risk because they often present with several medical conditions requiring pharmacotherapy. Cancer-related therapy adds to this risk in older adults, but few studies have been conducted in this patient population. In this review, we outline the adverse outcomes associated with polypharmacy and present polypharmacy definitions offered by the geriatrics literature. We also examine the strengths and weaknesses of these definitions and explore the relationships among these definitions and what is known about the prevalence and impact of polypharmacy.

The basis for improving and reforming long-term care. Part 4: identifying meaningful improvement approaches (segment 1)

While many aspects of nursing home care have improved over time, numerous issues persist. Presently, a potpourri of approaches and a push to "fix" the problem have overshadowed efforts to correctly define the issues and identify their diverse causes. Together, the two segments of this fourth and final article (divided between this month's issue and the next one) in the series identify strategies that should tie reform efforts together. This Segment 1 of Article 4 discusses the need to judge initiatives and proposals by how well they support and/or promote critical elements such as the care delivery process and clinical problem solving and decision making activities. It also covers the need to critically scrutinize and modify the conventional wisdom and to suppress "political correctness" thatcontinues to inhibit vital critical inquiry and dialogue that are needed to define issues correctly and make further progress. Ultimately, relatively uncomplicated and inexpensive strategies have the potential to bring dramatic progress. But there needs to be more willingness to rethink the issues and reconsider current approaches.