Outcomes of polypharmacy in nursing home residents

Polypharmacy Pattern in Iran: A Comprehensive Analysis of a Large Prescription Database

Background

Polypharmacy is a significant patient safety concern.

Objectives

This study aims to estimate the prevalence of polypharmacy, its continuity and associated factors, and common medication classes among a large outpatient population in East Azerbaijan province, Iran.

Methods

A retrospective prescription data analysis was performed. The cohort included all ≥ 20 years old subjects with at least one prescription filled during the main three-month study period (2020 March 1 - 2020 May 31). Polypharmacy was defined as being exposed to more than four different medications during the main study period, and continuous polypharmacy was defined as being exposed to more than four medications during both the main study period and follow-up period (2020 October 1 - 2020 December 31). The frequency and prevalence of polypharmacy, along with predictive factors, were estimated. We performed multivariate logistic regression and estimated odds ratios (ORs) to investigate the risk factors for polypharmacy.

Results

307,820 patients included (mean age 49.8 years, 62.9% female, mean drug use 3.7 (SD = 2.6). Polypharmacy was observed in 28.3% (CI: 28.1 - 28.4), of which 36.6% experienced continuous polypharmacy. The odds of being exposed to polypharmacy increased with being female, increasing age, and exposure to chronic conditions. The groups of medications most utilized by polypharmacy patients were those indicated for gastro-esophageal reflux diseases, beta-blocking agents, antidepressants, blood glucose-lowering drugs, and antithrombotic agents.

Conclusions

Strategies should be formulated to inform healthcare policymakers and providers about the magnitude of the polypharmacy phenomenon, associated factors, and the common medication classes involved.

Medicine-related problems: A recurrent issue among residents living in nursing homes

Aim: To examine the incidence and nature of medicine-related problems over time experienced by nursing home residents.

Method: We analyzed records collected in the Reducing Medicine-Induced Deterioration and Adverse Events (ReMInDAR) trial. The trial pharmacists provided services to reduce medicine-induced deterioration and adverse reactions for residents every 8-weeks over a year. The problems identified by the pharmacists were documented in reports and subsequently classified independently by research pharmacists using the D.O.C.U.M.E.N.T system. The number and type of problems at each service and time to develop a new problem post first session were assessed. All analyses were performed using R software (Version 4.1.1).

Results: The cohort was 115 nursing home residents who received 575 services. In the 12-months, a total of 673 medicine-related problems or symptom reports were identified in 112 residents. Most residents (75%) experienced a new medicine-related problem by the fourth month post the first assessment. After the first session, the proportion of residents with a new medicine-related problem or symptom report declined at each repeated pharmacy session (59% at visit 2 vs. 28% at visit 6, p < 0.01).

Conclusion: Residents living in nursing homes frequently experience medicine-related problems. Our results suggest clinical pharmacist services performed every 4-months may have the potential to reduce the medicine-related problems in nursing homes.

Experience and Appreciation of Health Care Teams Regarding a New Model of Pharmaceutical Care in Long-Term Care Settings

In long-term care (LTC) homes, the management of frail older residents’ pharmacotherapy may be challenging for health care teams. A new pharmaceutical care model highlighting the recently expanded scope of pharmacists’ practice in Quebec, Canada, was implemented in two LTC homes. This study aimed to evaluate health care providers’ experience and satisfaction with this new practice model. Twenty-three semi-structured interviews were performed and analyzed thematically. Positive results of the model have been identified, such as increased timeliness of interventions. Barriers were encountered, such as lack of clarity regarding roles, and suboptimal communication. The increased involvement of pharmacists was perceived as useful in the context of scarce medical resources. Although requiring time and adjustments from health care teams, the new model seems to contribute to the health care providers’ work satisfaction and to positively influence the timeliness and quality of care offered to LTC residents.

Medication Management and Deprescribing in Assisted Living Facilities

Medication management for seniors is a foundation for keeping them healthy and independent. A vital aspect of medication management is the selective discontinuation of medications, or deprescribing. While this is a common practice within nursing homes it seems to be less common among those who live in assisted living facilities. Shockingly little exiting literature was found when conducting a literature review concerning deprescribing in assisted living facilities. Therefore, it was determined to set forth this call to action to focus on deprescribing in assisted living facilities hoping that it would be given more attention to keep our seniors healthy and safe.

A whole of population retrospective observational study on the rates of polypharmacy in New Zealand 2014 to 2018 Polypharmacy in New Zealand: What is the current status?

BACKGROUND AND AIMS

Polypharmacy (≥5 medicines) and hyperpolypharmacy (≥10 medicines) can significantly impact people's health. The literature surrounding polypharmacy focuses on the elderly, particularly rest home populations, with few studies looking into younger age bands. Moreover, there have been no recent studies looking into the rates of polypharmacy in New Zealand. This study aimed to determine whether polypharmacy rates have increased over time in the New Zealand population. Specifically investigating polypharmacy rates across age and ethnicity, and identifying which medicines are most commonly prescribed in people with polypharmacy.

METHODS

A nationwide retrospective observational study was carried out between 2014 and 2018 on 4 697 274 New Zealanders (96% of the population) by linking dispensing data from the Pharmaceutical Collection to patient enrolment data using a National Health Identifier (NHI) to identify the rate of long-term medicine prescribing in New Zealand.

RESULTS

Our study found the rate of polypharmacy to be 9.93% and hyperpolypharmacy to be 1.92% nationwide in 2018, a percentage increase of 4.1% and 7.11% from 2014, respectively. During the same period, we observed the greatest percentage increase (30.37%) in the rate of polypharmacy in the 20 to 29 age band while the rates decreased in older populations. Variation was also noted between ethnicities. Medicines contributing to polypharmacy differed by age group.

CONCLUSION

Current methods for minimizing polypharmacy and optimizing medicines use are narrowly focused on the elderly. Despite an increase in education and awareness raising campaigns, rates continue to rise in New Zealand's population.

Association between anticholinergic burden and anticholinergic adverse outcomes in the elderly: Pharmacological basis of their predictive value for adverse outcomes

The use of anticholinergic drugs and other drugs with anticholinergic activity is highly prevalent in older people. Cumulative anticholinergic effects, known as anticholinergic burden, are associated with important peripheral and central adverse effects and outcomes. Several methods have been developed to quantify anticholinergic burden and to estimate the risk of adverse anticholinergic effects. Serum anticholinergic activity (SAA) and anticholinergic burden scoring systems are the most commonly used methods to predict the occurrence of important negative outcomes. These tools could guide clinicians in making more rational prescriptions to enhance patient safety, especially in older people. However, the literature has reported conflicting results about the predictive ability of these tools. The majority of these instruments ignore relevant pharmacologic aspects such as the doses used, differential muscarinic receptor subtype affinities, and blood-brain barrier permeability. To increase the clinical relevance of these tools, mechanistic and clinical pharmacology should collaborate. This narrative review describes the rational and pharmacological basis of anticholinergic burden tools and provides insight about their predictive value for adverse outcomes.

Analysis of Fall Risk Factors in an Aging Population Living in Long-Term Care Institutions in SPAIN: A Retrospective Cohort Study

Falls in the elderly are associated with morbidity and mortality. Research about fall risk factors in Spanish care facilities is scarce. This study aimed to assess the prevalence of falls among residents living in long-term care Spanish institutions and to identify fall risk factors in this population. A nationwide retrospective cohort study was conducted in 113 centers. Persons over 70 years old who were living in a residential setting for at least 1 year were included. Simple and multiple regression analyses were conducted to estimate the associations between the main clinical variables registered in the databases and the presence of falls. A total of 2849 subjects were analyzed (mean age 85.21 years). The period prevalence of fallers in the last 12 months was 45.3%, with a proportion of recurrent fallers of 51.7%. The presence of falls was associated with lower Tinetti Scale scores (OR = 1.597, 95% CI: 1.280, 1.991; OR = 1.362, 95% CI: 1.134, 1.635), severe or moderate cognitive impairment (OR= 1.992, 95% CI: 1.472, 2.695; OR = 1.507, 95% CI: 1.231, 1.845, respectively), and polypharmacy (OR = 1.291, 95% CI: 1.039, 1.604). Fall prevention interventions should focus on the prevention of balance and cognitive deterioration and the improvement of these functions when possible. It should also focus on a periodical medication history revision aiming to avoid inappropriate prescriptions.

The Roles and Responsibilities of Community Pharmacists Supporting Older People with Palliative Care Needs: A Rapid Review of the Literature

Globally, the number of older people requiring appropriate and safe management of medicines is growing. This review aimed to identify the roles and responsibilities of pharmacists supporting older people living in a community setting with their palliative care needs and to synthesise key themes emerging from the data, as well as any gaps in knowledge. The literature search included Medline (Ovid), Scopus, and Cinahl (Ebsco) databases. An English language limit was applied. The search included all international articles and any date of publication. Data were synthesised utilizing a systematic text condensation technique and presented according to Theme, Domain, and Meaning Units. Fourteen studies met the inclusion criteria. Selected papers predominantly focused on care provided by the pharmacists supporting people receiving residential aged care services. Clinical review, supply of medicines, and clinical governance were identified as key pharmacist roles. Pharmacists’ communication skills, personal behavioural approach, and positive attitude emerged as supportive characteristics for effective person-centered care. Minimal, or no information, were available related to pharmacists located in general medical practices and in Aboriginal health services sector, respectively. The multifaceted role of pharmacists presents an opportunity to provide comprehensive health care for older populations at the end of their life.

Increasing Complexity of New Nursing Home Residents in Ontario, Canada: A Serial Cross-Sectional Study

OBJECTIVES

The main objective of the study was to investigate annual changes in the sociodemographic characteristics, morbidity, and functional status of new nursing home residents in Ontario, Canada, between 2000 and 2015. A secondary objective was to develop and assess the quality of an algorithm for ascertaining admissions into publicly funded nursing homes in Ontario using a combination of health administrative data sources that indirectly identifies the residential status of new nursing home residents.

DESIGN

Population-based serial cross-sectional study with an accompanying quality assessment study of algorithms.

SETTING

Publicly funded nursing care homes in Ontario, Canada.

PARTICIPANTS

The reference standard for the assessment of algorithm performance was 21 544 newly admitted nursing home residents identified from the Resident Assessment Instrument-Minimum Data Set in 2012. The selected algorithm was then used to identify serial cross-sectional cohorts of newly admitted residents between 2000 and 2015 that ranged in size between 14 651 and 23 630 residents.

MEASUREMENTS

Sociodemographic characteristics, morbidity, and functional status of new residents were determined upon admission to examine patterns in the cohorts' profiles.

RESULTS

The proportion of residents aged 85 years and older increased from 45.1% to 53.8% over 16 years. The proportions of individuals with seven or more chronic conditions (from 14.1% to 22.1%) and with nine or more prescription medications (from 44.9% to 64.2%) have also increased in parallel over time. Hypertension, osteoarthritis, and dementia were the most prevalent conditions captured, with the proportion of incoming residents with dementia increasing from 42.3% to 54.1% between 2000 and 2015. Newly admitted residents were more likely to have extensive physical and cognitive impairments upon admission.

CONCLUSION

Admission trends show that new residents were older and had greater multimorbidity and limitations in physical functioning over time. J Am Geriatr Soc 68:1293-1300, 2020.

Restoring trust: COVID-19 and the future of long-term care in Canada

The Royal Society of Canada Task Force on COVID-19 was formed in April 2020 to provide evidence-informed perspectives on major societal challenges in response to and recovery from COVID-19. The Task Force established a series of working groups to rapidly develop policy briefings, with the objective of supporting policy makers with evidence to inform their decisions. This paper reports the findings of the COVID-19 Long-Term Care (LTC) working group addressing a preferred future for LTC in Canada, with a specific focus on COVID-19 and the LTC workforce. First, the report addresses the research context and policy environment in Canada’s LTC sector before COVID-19 and then summarizes the existing knowledge base for integrated solutions to challenges that exist in the LTC sector. Second, the report outlines vulnerabilities exposed because of COVID-19, including deficiencies in the LTC sector that contributed to the magnitude of the COVID-19 crisis. This section focuses especially on the characteristics of older adults living in nursing homes, their caregivers, and the physical environment of nursing homes as important contributors to the COVID-19 crisis. Finally, the report articulates principles for action and nine recommendations for action to help solve the workforce crisis in nursing homes.

[Selected safety-relevant medication processes in Swiss nursing homes: Current state of affairs and optimization potentials]

BACKGROUND

Reducing adverse drug events in nursing homes is a central patient safety concern. The aim of this study was to assess how often selected medication processes to increase medication safety are already implemented in Swiss nursing homes and to examine how nursing homes that have not yet implemented these processes can be characterized based on their organizational features.

METHODS

Cross-sectional survey study among directors of nursing in Swiss nursing homes.

RESULTS

420 of 1,525 invited individuals participated in the survey (response rate: 27.5 %). Of these, 65.0 % stated that regular systematic medication reviews have been provided in their institution. 9.5 % of the nursing homes use a list to identify potentially inappropriate medication, and 6.7 % of the nursing homes have a standardized process to monitor side effects of medications. 66.0 % of the participating nursing homes have implemented at least one of these three processes, 34.0 % of the participating nursing homes have not implemented any of the three processes. Statistically significant differences in process implementation were found according to the geographical location of the nursing home, the type of documentation used for medications, the physician model, the number of external general practitioners, as well as the medication supply channel and the legal obligation to cooperate with pharmacists. No differences were found with regard to the nursing home size.

CONCLUSION

In Swiss nursing homes, central safety-relevant medication processes have not yet been implemented nationwide. In particular, implementation is not widespread in nursing homes where medical care for their residents is provided by many different external general practitioners. The organizational features need to be taken into account to successfully implement quality improvement measures.

Impact of frailty status on the cost of drugs and dietary supplements prescribed to nursing home residents: the SENIOR cohort

BACKGROUND

The financial impact associated with drug consumption has been poorly investigated among frail subjects and, specifically, in nursing home settings.

AIMS

To determine the association of the average monthly cost of the drugs and dietary supplements consumed by nursing home residents with their frailty status.

METHODS

This is an analysis of the first follow-up year of the SENIOR cohort. All participants were classified into "frail" or "non-frail" categories according to Fried's criteria at baseline. Monthly bills from the pharmacy were analysed to determine the association between the average monthly cost of the drugs and dietary supplements consumed and frailty status.

RESULTS

A sample of 87 residents (83.8 ± 9.33 years and 75.9% women) from the SENIOR cohort was included. The prevalence of frailty was 28%. The median number of medications consumed each day was 9 (6-12) (no difference between frail and non-frail subjects; p = 0.15). The overall median monthly cost was € 109.6, of which 49% was covered by Belgian social security and the remaining balance was paid by the patient. When comparing the drug expenses of the frail subjects and the non-frail subjects, the overall average monthly cost did not differ between the 2 groups (p = 0.057). Nevertheless, the expenditure remaining to be paid by the residents, after the Belgian social security intervention, was significantly higher among the frail residents (€ 65.7) than among the non-frail residents (€ 47.6; p = 0.017).

CONCLUSIONS

Frailty status has an impact on the expenditures related to the consumption of drugs.

Deprescribing in Nursing Home Residents on Polypharmacy: Incidence and Associated Factors

OBJECTIVES

To assess 1-year incidence and factors related to deprescribing in nursing home (NH) residents in Europe.

DESIGN

Longitudinal multicenter cohort study based on data from the Services and Health for Elderly in Long TERm care (SHELTER) study.

SETTING

NHs in Europe and Israel.

PARTICIPANTS

1843 NH residents on polypharmacy.

METHODS

Polypharmacy was defined as the concurrent use of 5 or more medications. Deprescribing was defined as a reduction in the number of medications used over the study period. Residents were followed for 12 months.

RESULTS

Residents in the study sample were using a mean number of 8.6 (standard deviation 2.9) medications at the baseline assessment. Deprescribing was observed in 658 residents (35.7%). Cognitive impairment (mild/moderate impairment vs intact, odds ratio [OR] 1.41, 95% confidence interval [CI] 1.11-1.79; severe impairment vs intact, OR 1.60, 95% CI 1.23-2.09), presence of the geriatrician within the facility staff (OR 1.41, 95% CI 1.15-1.72), and number of medications used at baseline (OR 1.10, 95% CI 1.06-1.14) were associated with higher probabilities of deprescribing. In contrast, female gender (OR 0.76, 95% CI 0.61-0.96), heart failure (OR 0.69, 95% CI 0.53-0.89), and cancer (OR 0.64, 95% CI 0.45-0.90) were associated with a lower probability of deprescribing.

CONCLUSIONS AND IMPLICATIONS

Deprescribing is common in NH residents on polypharmacy, and it is associated with individual and organizational factors. More evidence is needed on deprescribing, and clear strategies on how to withdraw medications should be defined in the future.

Is the Drug Burden Index Related to Declining Functional Status at Follow-up in Community-Dwelling Seniors Consulting for Minor Injuries? Results from the Canadian Emergency Team Initiative Cohort Study

BACKGROUND

The Canadian Emergency Team Initiative (CETI) cohort showed that minor injuries like sprained ankles or small fractures trigger a downward spiral of functional decline in 16% of independent seniors up to 6 months post-injury. Such seniors frequently receive medications with sedative or anticholinergic properties. The Drug Burden Index (DBI), which summarises the drug burden of these specific medications, has been associated with decreased physical and cognitive functioning in previous research.

OBJECTIVES

We aimed to assess the contribution of the DBI to functional decline in the CETI cohort.

METHODS

CETI participants were assessed physically and cognitively at baseline during their consultations at emergency departments (EDs) for their injuries and up to 6 months thereafter. The medication data were used to calculate baseline DBI and functional status was measured with the Older Americans Resources and Services (OARS) scale. Multivariate linear regression models assessed the association between baseline DBI and functional status at 6 months, adjusting for age, sex, baseline OARS, frailty level, comorbidity count, and mild cognitive impairment.

RESULTS

The mean age of the 846 participants was 77 years and their mean DBI at baseline was 0.24. Complete follow-up data at 3 or 6 months was available for 718 participants among whom a higher DBI at the time of injury contributed to a lower functional status at 6 months. Each additional point in the DBI lead to a loss of 0.5 points on the OARS functional scale, p < 0.001. Among those with a DBI ≥ 1, 27.4% were considered 'patients who decline' at 3 or 6 months' follow-up, compared with 16.0% of those with a DBI of 0 (p = 0.06).

CONCLUSIONS

ED visits are considered missed opportunities for optimal care interventions in seniors; Identifying their DBI and adjusting treatment accordingly may help limit functional decline in those at risk after minor injury.

Health Outcomes of Deprescribing Interventions Among Older Residents in Nursing Homes: A Systematic Review and Meta-analysis

OBJECTIVES

Deprescribing is effective in addressing concerns relating to polypharmacy in residents of nursing homes. However, the clinical outcomes of deprescribing interventions among residents in nursing homes are not well understood. We evaluated the impact of deprescribing interventions by health care professionals on clinical outcomes among the older residents in nursing homes.

DESIGN

Systematic review and meta-analysis of randomized controlled trials. CINAHL, International Pharmaceutical Abstracts, MEDLINE, EMBASE, and Cochrane Library were searched from inception until September 2017; manual searches of reference lists of systematic reviews identified in the electronic search; and online trial registries for unpublished, ongoing, or planned trials. (PROSPERO CRD42016050028).

SETTING AND PARTICIPANTS

Randomized controlled trials in a nursing home setting that included participants of at least 60 years of age.

MEASURES

Falls, all-cause mortality, hospitalization, and potentially inappropriate medication were assessed in the meta-analysis.

RESULTS

A total of 41 randomized clinical studies (18,408 residents) that examined deprescribing (defined as either medication discontinuation, substitution, or reduction) in nursing were identified. Deprescribing interventions significantly reduced the number of residents with potentially inappropriate medications by 59% (odds ratio [OR] 0.41, 95% confidence interval [CI] 0.19-0.89). In subgroup analysis, medication review-directed deprescribing interventions reduced all-cause mortality by 26% (OR 0.74, 95% CI 0.65-0.84), as well as the number of fallers by 24% (OR 0.76, 95% CI 0.62-0.93).

CONCLUSIONS

Compared to other deprescribing interventions, medication review-directed deprescribing had significant benefits on older residents in nursing homes. Further research is required to elicit other clinical benefits of medication review-directed deprescribing practice.

Anticholinergic burden in adult and elderly people with intellectual disabilities: Results from an Italian multicenter cross-sectional study

BACKGROUND

Adults and older people with intellectual disabilities (ID) frequently receive anti-cholinergic drugs in chronic use, but no studies in Italy to date have investigated cumulative anticholinergic exposure and factors associated with high anticholinergic burden in this frail population.

AIM

To probe the cumulative exposure to anticholinergics and the demographic, social and clinical factors associated with high exposure.

METHODS

The 2012 updated version of the Anticholinergic Burden Score (ACB) was calculated for a multicentre sample of 276 adult and older people over 40 years with ID and associations with factors assessed.

RESULTS

Overall, antipsychotics, antiepileptics, anxiolytics, and antidepressants were the most frequent classes contributing to the total ACB score. People living in residential care were more likely exposed to high anticholinergic burden (an ACB score of 3+): both community housing (odds ratio [OR] 4.63, 95%CI 1.08-19.95) and nursing home facility ([OR] 9.99, 95%CI 2.32-43.04). There was also a significant association between an ACB score of 3+ and reporting mental health conditions ([OR] 25.56, 95% CI 8.08-80.89) or a neurological disease ([OR] 4.14, 95%CI 1.32-12.94). Neither demographic characteristics (age and gender) nor other clinical conditions (somatic comorbidity, levels and typology of ID) were associated with higher anticholinergic load. A high burden of anticholinergic was significantly more frequent in laxative users (22.6% ACB3+ vs. 5.1% ACB 0) (p = 0.003).

CONCLUSIONS

Psychotropics drugs were the highest contributors to the anticholinergic burden in adult and old age ID, especially in those people living in institutional settings with mental health and/or neurological conditions. High anticholinergic load has shown to be associated with the use of laxatives.

Quality use of medicines in aged care facilities: A need for new models of care

WHAT IS KNOWN AND OBJECTIVE

Despite all the advancement in aged care, medication adverse events are still reported to occur frequently in aged care residents and to be a major contributor to hospitalization and reduced quality of life in older adults. Thus, there is an urgent need for interventions and developing new models of care to address medication safety.

COMMENT

Interdisciplinary collaboration, as well as accessibility to health professionals, is amongst the factors affecting medication safety in aged care. Increasing access to pharmacists and forming an interdisciplinary team with doctors and nursing staff may improve medication safety in aged care facilities.

WHAT IS NEW AND CONCLUSION

To address the medication safety, we suggest a novel model of care in residential aged care facilities, in which an on-site pharmacist integrates with nursing staff to form an interdisciplinary team to prevent medication-related harm and improves the quality use of medicines.

Development and evaluation of an algorithm-based tool for Medication Management in nursing homes: the AMBER study protocol

BACKGROUND

Residents of nursing homes are susceptible to risks from medication. Medication Reviews (MR) can increase clinical outcomes and the quality of medication therapy. Limited resources and barriers between healthcare practitioners are potential obstructions to performing MR in nursing homes. Focusing on frequent and relevant problems can support pharmacists in the provision of pharmaceutical care services. This study aims to develop and evaluate an algorithm-based tool that facilitates the provision of Medication Management in clinical practice.

METHODS AND ANALYSIS

This study is subdivided into three phases. In phase I, semistructured interviews with healthcare practitioners and patients will be performed, and a mixed methods approach will be chosen. Qualitative content analysis and the rating of the aspects concerning the frequency and relevance of problems in the medication process in nursing homes will be performed. In phase II, a systematic review of the current literature on problems and interventions will be conducted. The findings will be narratively presented. The results of both phases will be combined to develop an algorithm for MRs. For further refinement of the aspects detected, a Delphi survey will be conducted. In conclusion, a tool for clinical practice will be created. In phase III, the tool will be tested on MRs in nursing homes. In addition, effectiveness, acceptance, feasibility and reproducibility will be assessed. The primary outcome of phase III will be the reduction of drug-related problems (DRPs), which will be detected using the tool. The secondary outcomes will be the proportion of DRPs, the acceptance of pharmaceutical recommendations and the expenditure of time using the tool and inter-rater reliability.

ETHICS AND DISSEMINATION

This study intervention is approved by the local Ethics Committee. The findings of the study will be presented at national and international scientific conferences and will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

DRKS00010995.

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.

Evaluation of Drug-Disease Interactions and Their Association with Unplanned Hospital Readmission Utilizing STOPP Version 2 Criteria

Early hospital readmission is a common problem among geriatric patients, as they are more susceptible to adverse drug events, which are associated with increased hospital admission. The objective is to examine the association between exposure to potentially inappropriate medications under selected STOPP version 2 criteria related to drug-disease interactions and unplanned early hospitalization within 28 days of index admission in elderly patients prescribed a potentially inappropriate medication. This retrospective single-center study reviewed patients 75 years of age or older that were discharged with 5 or more medications, including at least one selected medication listed in the STOPP version 2 criteria relating to drug-disease interactions. 182 patients, with a mean age of 83.5 years, were included in the study, with anticholinergics being the most common potentially inappropriate medications (22.4%). Potentially inappropriate medications (57.1% vs. 17.1%, p < 0.001), gout (31% vs. 11.5%, p = 0.003), and gastrointestinal disease (11.9% vs. 2.5%, p = 0.026) were shown to increase risk of 28-day readmission, whereas no other factors assessed correlated with readmission. A rapid evaluation of elderly patient discharge medications and concomitant disease states with the aid of the STOPP version 2 criteria could potentially reduce hospital readmissions or emergency department visits.

Frequency of and factors related to pro re nata (PRN) medication use in aged care services

BACKGROUND

Little is known about the contribution of 'pro re nata' (PRN) medications to overall medication burden in residential aged care services (RACS).

OBJECTIVES

To determine the frequency of, and factors associated with PRN medication administration in RACS.

MEASUREMENTS

Details of all medications charted for regular or PRN use were extracted from medication charts for 383 residents of 6 Australian RACS. Records of medications administered over a 7 day period were also extracted. Factors associated with PRN medication administration among residents charted ≥1 PRN were determined using multivariate logistic regression.

RESULTS

Of the 360 (94%) residents charted ≥1 PRN medication, 99 (28%) were administered PRN medication at least once. The most prevalent PRN medications were analgesics and laxatives. Residents with greater dependence with activities of daily living (ADL) (adjusted odds ratio (aOR) per additional point on Katz ADL scale: 0.80; 95% confidence interval (CI) 0.72-0.89; p < 0.001) and a greater number of regular medications (aOR per additional medication: 1.06; 95% CI 1.00-1.13; p = 0.042) were more likely to be administered PRN medication.

CONCLUSIONS

Although most residents are charted PRN medications, rates of administration are relatively low, suggesting the contribution of PRNs to medication burden in RACS may be lower than previously thought.

Prevalence and Variability in Medications Contributing to Polypharmacy in Long-Term Care Facilities

Background

Research into which medications contribute to polypharmacy and the variability in these medications across long-term care facilities (LTCFs) has been minimal.

Objective

Our objective was to investigate which medications were more prevalent among residents with polypharmacy and to determine the variability in prescribing of these medications across LTCFs.

Methods

This was a cross-sectional study of 27 LTCFs in regional and rural Victoria, Australia. An audit of the medication charts and medical records of 754 residents was performed in May 2015. Polypharmacy was defined as nine or more regular medications. Logistic regression was performed to determine the association between medications and resident characteristics with polypharmacy. Analyses were adjusted for age, sex and Charlson’s comorbidity index. Variability in the use of the ten most prevalent medication classes was explored using funnel plots. Characteristics of LTCFs with low (< 30%), moderate (30–49%) and high (≥ 50%) polypharmacy prevalence were compared.

Results

Polypharmacy was observed in 272 (36%) residents. In adjusted analyses, each of the top ten most prevalent medication classes, with the exception of antipsychotics, were associated with polypharmacy. Between 7 and 23% of LTCFs fell outside the 95% control limits for each of the ten most prevalent medications. LTCFs with ≥ 50% polypharmacy prevalence were predominately smaller.

Conclusion

Polypharmacy was associated with nine of the ten most prevalent medication classes. There was greater than fourfold variability in nine of the ten most prevalent medications across LTCFs. Further studies are needed to investigate the clinical appropriateness of the variability in polypharmacy.

A multi-center, randomized, controlled trial to assess the efficacy of optimization of drug prescribing in an elderly population, at 18 months of follow-up, in the evolution of functional autonomy: the OPTIM study protocol

BACKGROUND

Pharmacotherapy is necessary for the management of many diseases which number increased with aging. However, potentially inappropriate prescriptions and polymedication increases iatrogenic risks and can lead to adverse events. To limit the consequences of potentially harmful prescriptions, optimization of drug prescribing is a major stake of improving quality and safety of care in the elderly. The purpose of the OPTIM study is to study the impact of the optimization of drug prescribing on the evolution of functional autonomy at 18 months of follow-up.

METHODS

A multicenter, open-label, Randomized Controlled Trial was designed to assess the impact of an optimization program of drug prescribing consisting in a clinical medication review by a pharmacist, in collaboration with specialist physician of the geriatric/memory center and the referent physician, on the evolution of functional autonomy level, measured during 18 months of follow-up. The study will include 302 elderly outpatients visiting geriatric and memory centers, randomly distributed in one of the two parallel groups. One group will benefit of the intervention, while the other will be considered as control group. The effect of the intervention on evolution of the level of autonomy function, defined with repeated measures, will be estimated in a generalized linear mixed model. The intervention will be considered significant if the interaction between time and the study group is significant. Secondary analysis will be conducted to assess the impact of the intervention on secondary clinical outcomes.

DISCUSSION

The "OPTIM" program should enable optimization of drug prescribing in elderly patients and therefore slow or prevent progression to loss of functional autonomy. It should also help to strengthen collaboration between the hospital team of geriatric/neurologist, the pharmacist and the private practice who are all involved in caring for the patient's health. The benefits for the patient are thus optimizing its medical management by linking health professionals met during his care pathway. In addition, pharmaceutical recommendations sent to referent physicians should help raise awareness of the prescription of drugs in these patients.

TRIAL REGISTRATION NUMBER CLINICALTRIALS

NCT02740764.

Systematic Review of the Prevalence of Medication Errors Resulting in Hospitalization and Death of Nursing Home Residents

Medication errors (MEs) result in preventable harm to nursing home (NH) residents and pose a significant financial burden. Institutionalized older people are particularly vulnerable because of various organizational and individual factors. This systematic review reports the prevalence of MEs leading to hospitalization and death in NH residents and the factors associated with risk of death and hospitalization. A systematic search was conducted of the relevant peer-reviewed research published between January 1, 2000, and October 1, 2015, in English, French, German, or Spanish examining serious outcomes of MEs in NHs residents. Eleven studies met the inclusion criteria and examined three types of MEs: all MEs (n = 5), transfer-related MEs (n = 5), and potentially inappropriate medications (PIMs) (n = 1). MEs were common, involving 16-27% of residents in studies examining all types of MEs and 13-31% of residents in studies examining transfer-related MEs, and 75% of residents were prescribed at least one PIM. That said, serious effects of MEs were surprisingly low and were reported in only a small proportion of errors (0-1% of MEs), with death being rare. Whether MEs resulting in serious outcomes are truly infrequent, or are underreported because of the difficulty in ascertaining them, remains to be elucidated to assist in designing safer systems.

Why is polypharmacy increasing in aged care facilities? The views of Australian health care professionals

RATIONALE, AIMS AND OBJECTIVES

The prevalence of polypharmacy in residential aged care facilities (RACFs) is high and increasing. Although not necessarily inappropriate, polypharmacy has been associated with drug interactions, adverse drug events, geriatric syndromes and hospital admissions. The aim of this study was to identify and prioritize factors contributing to the increasing prevalence of polypharmacy in RACFs.

METHODS

Seventeen health care professionals from metropolitan and regional Victoria and South Australia identified and prioritized factors using a modified nominal group technique.

RESULTS

The top five factors ranked from most important to fifth most important were 'changes in resident mix', 'increasing numbers of prescribers and the reluctance of one prescriber to discontinue a medicine commenced by another prescriber', 'better adherence to clinical practice guidelines', 'increasing reliance on locums' and 'greater recognition and pharmacological management of pain'.

CONCLUSIONS

Reasons for the increase in polypharmacy are multifactorial. Understanding the factors contributing to polypharmacy may help to guide future research and develop interventions to manage polypharmacy in RACFs.

Prioritizing interventions to manage polypharmacy in Australian aged care facilities

BACKGROUND

Polypharmacy is highly prevalent in residential aged care facilities (RACFs). Although polypharmacy is sometimes unavoidable, polypharmacy has been associated with increased morbidity and mortality.

OBJECTIVE

To identify and prioritize a range of potential interventions to manage polypharmacy in RACFs from the perspectives of health care professionals, health policy and consumer representatives.

METHODS

Two nominal group technique (NGT) sessions were convened in August 2015. A purposive sample (n = 19) of clinicians, researchers, managers and representatives of consumer, professional and health policy organizations were asked to nominate interventions to address the prevalence and appropriateness of medication use. Participants were then asked to prioritize five interventions suitable for possible implementation at the system level.

RESULTS

Six of 16 potential interventions were prioritized highest for possible implementation in clinical practice, with two interventions prioritized as second highest. The top interventions in rank order were 'implementation of a pharmacist-led medication reconciliation service for new residents,' 'conduct facility-level audits and feedback to staff and health care professionals,' 'develop deprescribing scripts to assist clinician-resident discussion,' 'develop or revise prescribing guidelines specific to older people with multimorbidity in RACFs,' 'implement electronic medication charts and records' and 'better support Medication Advisory Committees (MACs) to address medication appropriateness.'

CONCLUSION

This study prioritized a range of potential interventions that may be used to assist clinicians and policy makers develop a comprehensive strategy to manage polypharmacy in RACFs.

Impact of strategies to reduce polypharmacy on clinically relevant endpoints: a systematic review and meta-analysis

AIM

The aim of the present study was to explore the impact of strategies to reduce polypharmacy on mortality, hospitalization and change in number of drugs.

METHODS

Systematic review and meta-analysis: a systematic literature search targeting patients ≥65 years with polypharmacy (≥4 drugs), focusing on patient-relevant outcome measures, was conducted. We included controlled studies aiming to reduce polypharmacy. Two reviewers independently assessed studies for eligibility, extracted data and evaluated study quality.

RESULTS

Twenty-five studies, including 10 980 participants, were included, comprising 21 randomized controlled trials and four nonrandomized controlled trials. The majority of the included studies aimed at improving quality or the appropriateness of prescribing by eliminating inappropriate and non-evidence-based drugs. These strategies to reduce polypharmacy had no effect on all-cause mortality (odds ratio 1.02; 95% confidence interval 0.84, 1.23). Only single studies found improvements, in terms of reducing the number of hospital admissions, in favour of the intervention group. At baseline, patients were taking, on average, 7.4 drugs in both the intervention and the control groups. At follow-up, the weighted mean number of drugs was reduced (-0.2) in the intervention group but increased (+0.2) in controls.

CONCLUSIONS

There is no convincing evidence that the strategies assessed in the present review are effective in reducing polypharmacy or have an impact on clinically relevant endpoints. Interventions are complex; it is still unclear how best to organize and implement them to achieve a reduction in inappropriate polypharmacy. There is therefore a need to develop more effective strategies to reduce inappropriate polypharmacy and to test them in large, pragmatic randomized controlled trials on effectiveness and feasibility.

Pharmacist review and its impact on Singapore nursing homes

INTRODUCTION

There is a high prevalence of polypharmacy and inappropriate medication use in Singapore nursing homes. This study primarily explored the benefits of pharmacist reviews in local nursing homes. The secondary aims were to review the potential cost savings gained from following the pharmacists' recommendations and to identify the possible risks associated with polypharmacy and inappropriate medication use.

METHODS

A retrospective period prevalence study was performed. We analysed the pharmacotherapy problems highlighted by pharmacists in three nursing homes and the rate of acceptance of pharmacists' recommendations. Data was collected in two phases: (a) a one-month pre-setup period, during which 480 patients were reviewed (i.e. one-time review before weekly pharmacist visits); and (b) a six-month post-setup period, during which the 480 patients were reviewed again. Pharmacotherapy problems were classified according to a clinical pharmacist recommendation taxonomy and potential risks were identified. Monthly cost savings were calculated and compared with the monthly costs of pharmacist reviews.

RESULTS

A total of 392 pharmacotherapy problems were identified, with pharmacist recommendations noted for each problem. Among the 392 recommendations, 236 (60.2%) were accepted. The pharmacotherapy problems were analysed for potential risks, including falls (16.0%) and constipation (13.1%). The acceptance rates were higher during the post-setup period compared to the pre-setup period (p < 0.0001). Total direct acquisition cost savings during the pre- and post-setup periods were SGD 388.30 and SGD 876.69, respectively.

CONCLUSION

The provision of pharmaceutical care to nursing home residents resulted in improved medication safety and quality of care.

What factors are important for deprescribing in Australian long-term care facilities? Perspectives of residents and health professionals

OBJECTIVES

Polypharmacy and multimorbidity are common in long-term care facilities (LTCFs). Reducing polypharmacy may reduce adverse events and maintain quality of life. Deprescribing refers to reducing medications after consideration of therapeutic goals, benefits and risks, and medical ethics. The objective was to use nominal group technique (NGT) to generate then rank factors that general medical practitioners (GPs), nurses, pharmacists and residents or their representatives perceive are most important when deciding whether or not to deprescribe medications.

DESIGN

Qualitative research using NGT.

SETTING

Participants were invited if they worked with, or resided in LTCFs across metropolitan and regional South Australia.

PARTICIPANTS

11 residents/representatives, 19 GPs, 12 nurses and 14 pharmacists participated across six separate groups.

METHODS

Individual groups of GPs, nurses, pharmacists and residents/representatives were convened. Using NGT each group ranked factors perceived to be most important when deciding whether or not to deprescribe. Then, using NGT, the prioritised factors from individual groups were discussed and prioritised by a multidisciplinary metropolitan and regional group comprised of resident representatives, GPs, nurses and pharmacists.

RESULTS

No two groups had the same priorities. GPs ranked 'evidence for deprescribing' and 'communication with family/resident' as most important factors. Nurses ranked 'GP receptivity to deprescribing' and 'nurses ability to advocate for residents' as most important. Pharmacists ranked 'clinical appropriateness of therapy' and 'identifying residents' goals of care' as most important. Residents ranked 'wellbeing of the resident' and 'continuity of nursing staff' as most important. The multidisciplinary groups ranked 'adequacy of medical and medication history' and 'identifying residents' goals of care' as most important.

CONCLUSIONS

While each group prioritised different factors, common and contrasting factors emerged. Future deprescribing interventions need to consider the similarities and differences within the range of factors prioritised by residents and health professionals.

Anticholinergic drugs and negative outcomes in the older population: from biological plausibility to clinical evidence

The use of medication with anticholinergic properties is widespread among older subjects. Many drugs of common use such as antispasmodics, bronchodilators, antiarrhythmics, antihistamines, anti-hypertensive drugs, antiparkinson agents, skeletal muscle relaxants, and psychotropic drugs have been demonstrated to have an anticholinergic activity. The most frequent adverse effects are dry mouth, nausea, vomiting, constipation, abdominal pain, urinary retention, blurred vision, tachycardia and neurologic impairment such as confusion, agitation and coma. A growing evidence from experimental studies and clinical observations suggests that drugs with anticholinergic properties can cause physical and mental impairment in the elderly population. However, the morbidity and management issues associated with unwanted anticholinergic activity are underestimated and frequently overlooked. Moreover, their possible relation with specific negative outcome in the elderly population is still not firmly established. The aim of the present review was to evaluate the relationship between the use of drugs with anticholinergic activity and negative outcomes in older persons. We searched PubMed and Cochrane combining the search terms "anticholinergic", "delirium", "cognitive impairment", "falls", "mortality" and "discontinuation". Medicines with anticholinergic properties may increase the risks of functional and cognitive decline, morbidity, institutionalization and mortality in older people. However, such evidences are still not conclusive probably due to possible confounding factors. In particular, more studies are needed to investigate the effects of discontinuation of drug with anticholinergic properties. Overall, minimizing anticholinergic burden should always be encouraged in clinical practice to improve short-term memory, confusion and delirium, quality of life and daily functioning.

Exploring the past, present and future of care home medicine management systems: pharmacists' perceptions of multicompartment compliance aids

Objectives

Medicines maintain and improve care home (CH) residents' health and therefore, it is imperative that CH medicine management systems are regularly evaluated to ensure they continually provide a high standard of care. Multicompartment compliance aid (MCA) medicine management systems are often used to assist United Kingdom CH staff with managing the large volume of medicines used by residents. This study aimed to identify the factors that led to the widespread adoption of MCAs into United Kingdom CHs, limitations associated with their current use and their relevance in the future.

Method

In June and July 2014 semi-structured interviews were conducted with eight pharmacists who were purposively selected for their expertise in CH medicine management systems in the United Kingdom. A qualitative thematic approach was employed in the analysis of data.

Key findings

Findings indicated that MCAs were introduced into CHs to address unsafe medicine administration practices and because of pharmacy commercial interest. Identified limitations included reduced staff alertness during medicine administration, restricted ability to identify medicines, and medicine wastage. Participants predicted continued use of MCAs in the future due to their perceived benefits of improved safety and efficiency, although some pharmacists recommended that they be removed and CH staff trained to administer medicines from original packaging.

Conclusion

These findings can contribute towards information used by health care providers when deciding on the relevance of MCAs in their current medicine management systems. Additionally, they can contribute towards information used by policy makers when revising United Kingdom CH medicine management guidelines.

Prevalence and factors associated with polypharmacy in long-term care facilities: a systematic review

OBJECTIVE

The objective of the study was to investigate the prevalence of, and factors associated with, polypharmacy in long-term care facilities (LTCFs).

METHODS

MEDLINE, EMBASE, International Pharmaceutical Abstracts, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library were searched from January 2000 to September 2014. Primary research studies in English were eligible for inclusion if they fulfilled the following criteria: (1) polypharmacy was quantitatively defined, (2) the prevalence of polypharmacy was reported or could be extracted from tables or figures, and (3) the study was conducted in a LTCF. Methodological quality was assessed using an adapted version of the Joanna Briggs Institute Critical Appraisal Checklist.

RESULTS

Forty-four studies met the inclusion criteria and were included. Polypharmacy was most often defined as 5 or more (n = 11 studies), 9 (n = 13), or 10 (n = 11) medications. Prevalence varied widely between studies, with up to 91%, 74%, and 65% of residents taking more than 5, 9, and 10 medications, respectively. Seven studies performed multivariate analyses for factors associated with polypharmacy. Positive associations were found for recent hospital discharge (n = 2 studies), number of prescribers (n = 2), and comorbidity including circulatory diseases (n = 3), endocrine and metabolic disorders (n = 3), and neurological motor dysfunctioning (n = 3). Older age (n = 5), cognitive impairment (n = 3), disability in activities of daily living (n = 3), and length of stay in the LTCF (n = 3) were inversely associated with polypharmacy.

CONCLUSIONS

The prevalence of polypharmacy in LTCFs is high, varying widely between facilities, geographical locations and the definitions used. Greater use of multivariate analysis to investigate factors associated with polypharmacy across a range of settings is required. Longitudinal research is needed to explore how polypharmacy has evolved over time.

Polypharmacy and frailty: prevalence, relationship, and impact on mortality in a French sample of 2350 old people

PURPOSE

To assess the prevalence of polypharmacy and frailty, to examine their association, and to establish their independent and combined effects on mortality in a sample of French old people.

METHODS

This is a cross-sectional population study of people aged 70 years and over. A total of 2350 respondents were interviewed at home in 2008-2010. Frailty was defined as impairment in three domains or more among nutrition, energy, physical activity, strength, and mobility, in the absence of difficulties in basic activities of daily living. Mortality data were documented after a mean follow-up period of 2.6 years.

RESULTS

Mean age of the population was 83.3 +/- 7.5 years, with 59.4% of women. Prevalence of frailty was 17.0%. Polypharmacy (5-9 drugs) was reported in 53.6% of the population, and excessive polypharmacy (10 drugs or more) in 13.8%. After adjustment for socio-demographic and health variables, polypharmacy and excessive polypharmacy were associated with frailty with odds ratio 1.77 [1.20-2.61] and 4.47 [2.37-8.42], respectively. Frailty (hazard ratio [HR] 2.56 [1.63-4.04]) and excessive polypharmacy (HR 1.83 [1.28-2.62]) were independent predictors of mortality. Compared with non-frail people without polypharmacy, frail people with excessive polypharmacy were six times more likely to die during the follow-up period (HR 6.30 [3.09-12.84]).

CONCLUSION

By showing the independent and combined effects of polypharmacy and frailty on mortality risk, this study should reinforce the awareness of clinicians with regard to these factors, rather prevalent in old people.

Exposure to anticholinergic and sedative drugs, risk of falls, and mortality: an elderly inpatient, multicenter cohort

This study aimed to assess whether exposure to anticholinergic and sedative medications and its evolution was associated with increased risk of in-hospital falls and all-cause mortality. Furthermore, results were compared with 2 definitions of drug burden index (DBI) against the outcomes.This observational, multicentric, and longitudinal study was conducted among patients aged 65 years or older, in 3 geriatric hospitals, in Francheville, Lyon, and Villeurbanne, France (duration of follow-up, 11.6 months). The exposure to anticholinergic and sedative medications was quantified using a DBI, at admission and at the end of observation for 337 patients. The evolution of exposure was the absolute difference between the index at admission and at the end of observation. The outcomes were in-hospital falls and all-cause mortality.Overall, 5.9% of patients experienced a fall. The risk of fall was nearly 3-fold in patients whose DBI increased during hospital stay compared to those with stable or decreased DBI (hazard ratio, 2.9 [1.14-7.12]; P = 0.03), after adjustment for comorbidities.The overall proportion of mortality was 6.5%. The evolution of DBI during hospital stay was not related to the risk of mortality (hazard ratio, 1.9 [0.8-4.4]; P = 0.14). Results were similar with the 2 definitions of DBI.Increased exposure to anticholinergic and sedative medications during hospital stay is associated with a higher risk of in-hospital falls but not with mortality. The DBI could be implemented in hospital, to guide prescription and reduce anticholinergic and sedative drug exposure.

Association between inherited CYP2D6/2C19 phenotypes and anticholinergic measures in elderly patients using anticholinergic drugs

BACKGROUND

To compare measures of anticholinergic activity between metabolic phenotypes of the polymorphic enzymes cytochrome P450 2D6 (CYP2D6) and CYP2C19 in the elderly patients exposed to anticholinergic agents.

METHODS

Long-term nursing home patients (n = 80) with an anticholinergic drug scale (ADS) score ≥3 were recruited from 22 nursing homes in Norway. Based on pharmacogenetic analyses of mutations encoding absent CYP2D6 or CYP2C19 metabolism, patients were divided into subgroups of poor metabolizers (PMs) (n = 8) and extensive metabolizers (n = 72). Serum anticholinergic activity (SAA) was determined by a validated, 96-well format radio receptor assay and adjusted for ADS score. Unadjusted and adjusted SAAs, mouth dryness, and cognitive function (Mini-Mental State Examination and verbal recall tests from Consortium to Establish a Registry for Alzheimer Disease) were compared between the subgroups with Mann-Whitney tests.

RESULTS

The study population was represented by 78% women, 68% had mild to moderate dementia, and mean age was 86 years. More than 80% used more than 1 anticholinergic agent, and their median ADS score was 4. The subpopulation of PMs had significantly higher median SAA than the extensive metabolizers (10.3 versus 4.2 pmol atropine equivalents per milliliter, P = 0.012). This difference remained significant after adjusting for ADS score (P = 0.013). No significant differences in mouth dryness and cognitive function were observed between the subgroups (P > 0.3).

CONCLUSIONS

These preliminary findings suggest that elderly CYP2D6/CYP2C19 PMs with a high anticholinergic drug burden are at increased risk of elevated SAA. Whether PMs are also more prone to experience anticholinergic side effects needs to be further studied in larger patient populations.

Potentially inappropriate medication use in older patients in Swiss managed care plans: prevalence, determinants and association with hospitalization

Objectives

To describe the prevalence and determinants of potentially inappropriate medication (PIM) use and association with hospitalizations in an elderly managed care population in Switzerland.

Methods

Using health care claims data of four health insurers for a sample of managed care patients 65 years of age and older to compare persons on PIM with persons not on PIM. Beers' 2012 and PRISCUS criteria were used to determine the potential inappropriateness of prescribed medications. The sample included 16′490 elderly patients on PIM and 33′178 patients not on PIM in the time period of January 1, 2008 through December 31, 2012. Prevalence estimates are standardized to the population of Switzerland. Associations between PIM and hospitalizations were examined by multivariate Cox regression analyses controlling for possible confounding variables.

Results

The estimated prevalence of PIM use in our managed care sample was 22.5%. Logistic regression analysis showed that number of different medications used in the previous year, total costs in the previous year and hospitalization in the previous year all significantly increased the likelihood of receiving PIM. Multiple Cox regression analysis revealed that those on cumulative levels of PIM use acted significantly as a factor related to greater hospitalization rates: the adjusted HR was 1.13 (95% CI 1.07–1.19) for 1 PIM, 1.27 (95% CI 1.19–1.35) for 2 PIM, 1.35 (95% CI 1.22–1.50) for 3 PIM, and 1.63 (95% CI 1.40–1.90) for more than 3 PIM compared to no PIM use.

Conclusions

The prevalence of PIM in managed care health plans are widely found but seem to be much lower than rates of non-managed care plans. Furthermore, our study revealed a significant association with adverse outcomes in terms of hospitalizations. These findings stress the need for further development of interventions to decrease drug-related problems and manage patients with multiple chronic conditions.