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Shahrzad S, Overbeck G, Holm A, Høj K, Hølmkjaer P. Factors promoting and impeding efforts to deprescribe antidepressants among nursing home residents with dementia- a process evaluation guided by normalization process theory. BMC Nurs 2024; 23:287. [PMID: 38679697 PMCID: PMC11057106 DOI: 10.1186/s12912-024-01932-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 04/11/2024] [Indexed: 05/01/2024] Open
Abstract
BACKGROUND Despite recommendations against psychotropic medication in older nursing homes residents with behavioral and psychological symptoms of dementia (BPSD), antidepressants and other psychotropic drugs are still prescribed. We performed a cluster-randomized controlled trial to evaluate the effect of a complex intervention aiming to promote the deprescribing of antidepressants in institutionalized older persons with dementia. To understand the underlying mechanisms of trial outcomes, we conducted a process evaluation exploring the interventions implementation, areas of impact, and contextual factors. The aim of this study was to explore the implementation process and the key factors that promoted and inhibited intervention implementation in the care home setting (Clinicaltrials.gov: NCT04985305. Registered 30 July 2021). METHODS Qualitative interviews were conducted between August 2022 and February 2023 with four general practitioners and eight nursing home staff from four associated nursing homes in the Capital Region of Denmark. We coded the interview data according to the four constructs of the Normalization Process Theory (coherence, cognitive participation, collective action, and reflexive monitoring). RESULTS There was a common understanding of the intervention aim. We observed a raised awareness concerning the deprescription of antidepressants among healthcare professionals with good collaboration (coherence). An overall buy-in to a deprescribing mentality was seen (cognitive participation). There were barriers to the GPs and nursing home staff's use of the intervention elements and how they implemented it, but to some, a common language was created (collective action). Professionals overall valued the idea of deprescribing, but lack of time, high staff turnover, and low education level among nursing home staff hampered the integration (reflexive monitoring). CONCLUSION Successful implementation seemed to be dependent on the quality of the relationship between the single GP and the single nursing home professional. A common deprescribing mentality promoted the uptake of the intervention. However, several barriers related to lack of resources hindered implementation. It is imperative to adapt complex interventions to the available resources and context.
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Affiliation(s)
- Sinead Shahrzad
- Department of Public Health, University of Copenhagen, Section of General Practice and Research Unit for General Practice, Copenhagen, Denmark
| | - Gritt Overbeck
- Department of Public Health, University of Copenhagen, Section of General Practice and Research Unit for General Practice, Copenhagen, Denmark
| | - Anne Holm
- Department of Public Health, University of Copenhagen, Section of General Practice and Research Unit for General Practice, Copenhagen, Denmark
| | - Kirsten Høj
- Research Unit for General Practice, Aarhus, Denmark
| | - Pernille Hølmkjaer
- Department of Public Health, University of Copenhagen, Section of General Practice and Research Unit for General Practice, Copenhagen, Denmark.
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Wang J, Shen JY, Conwell Y, Podsiadly EJ, Caprio TV, Nathan K, Yu F, Ramsdale EE, Fick DM, Mixon AS, Simmons SF. Implementation considerations of deprescribing interventions: A scoping review. J Intern Med 2024; 295:436-507. [PMID: 36524602 DOI: 10.1111/joim.13599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Over half of older adults experience polypharmacy, including medications that may be inappropriate or unnecessary. Deprescribing, which is the process of discontinuing or reducing inappropriate and/or unnecessary medications, is an effective way to reduce polypharmacy. This review summarizes (1) the process of deprescribing and conceptual models and tools that have been developed to facilitate deprescribing, (2) barriers, enablers, and factors associated with deprescribing, and (3) characteristics of deprescribing interventions in completed trials, as well as (4) implementation considerations for deprescribing in routine practice. In conceptual models of deprescribing, multilevel factors of the patient, clinician, and health-care system are all related to the efficacy of deprescribing. Numerous tools have been developed for clinicians to facilitate deprescribing, yet most require substantial time and, thus, may be difficult to implement during routine health-care encounters. Multiple deprescribing interventions have been evaluated, which mostly include one or more of the following components: patient education, medication review, identification of deprescribing targets, and patient and/or provider communication about high-risk medications. Yet, there has been limited consideration of implementation factors in prior deprescribing interventions, especially with regard to the personnel and resources in existing health-care systems and the feasibility of incorporating components of deprescribing interventions into the routine care processes of clinicians. Future trials require a more balanced consideration of both effectiveness and implementation when designing deprescribing interventions.
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Affiliation(s)
- Jinjiao Wang
- Elaine, Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Eric J Podsiadly
- Harriet J. Kitzman Center for Research Support, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Thomas V Caprio
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- UR Medicine Home Care, University of Rochester Medical Center, Rochester, New York, USA
- University of Rochester Medical Center, Finger Lakes Geriatric Education Center, Rochester, New York, USA
| | - Kobi Nathan
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York, USA
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA
| | - Erika E Ramsdale
- Department of Medicine, Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Donna M Fick
- Ross and Carol Nese College of Nursing, Penn State University, University Park, Pennsylvania, USA
| | - Amanda S Mixon
- Department of Medicine, Division of General Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Sandra F Simmons
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Wang B, Cui C, Chen Y, Liang Z. The mediating effect of 18F-FDG metabolism in right caudate between depressive symptoms and cognitive function in Alzheimer's disease. Front Aging Neurosci 2024; 16:1328143. [PMID: 38511197 PMCID: PMC10950943 DOI: 10.3389/fnagi.2024.1328143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/14/2024] [Indexed: 03/22/2024] Open
Abstract
Purpose The objective of this study was to investigate the accumulation of 18F-fluorodeoxyglucose (18F-FDG) in the whole brain between Alzheimer's disease (AD) with depressive (ADD) symptoms compared with AD without depressive (ADND) symptoms using positron emission tomography/magnetic resonance imaging (PET/MRI). Additionally, this study aimed to explore the associations among the accumulation of 18F-FDG in the brain, depressive symptoms, and cognitive function in ADD patients. Methods In this study, 25 AD patients and 22 healthy controls were enrolled. The AD patients were stratified into two groups, namely ADD and ADND, based on their scores of the Hamilton Depression Scale (HAMD). Both AD patients and healthy controls underwent an 18F-FDG PET/MRI scan. A standardized uptake value ratio (SUVR) was calculated to examine the accumulation of 18F-FDG in the brain. A simple mediation model was employed to examine the mediation effect between SUVR, depressive symptoms and cognitive function in ADD patients. Results The ADD group exhibited significant cognitive impairment compared to the ADND group (p < 0.001) and healthy controls (p < 0.001). The ADD patients exhibited the reduced SUVR (0.228 ± 0.126) in the right caudate (the voxel level p < 0.005, cluster level p < 0.05, after false discovery rate (FDR) correction) compared to ADND patients (0.459 ± 0.064) and healthy controls (0.706 ± 0.122). The SUVR of the right caudate was correlated with the HAMD scores (r = -0.792, p < 0.001) and mini-mental state examination (MMSE) (r = 0.738, p < 0.01). The relationship between depressive symptoms and the cognitive function in ADD patients is mediated by the right caudate SUVR (total effects = -0.385, direct effects = -0.02, total indirect effects = -0.405). Conclusion The ADD group exhibited the reduced SUVR in the right caudate compared to the ADND group and healthy controls. The relationship between depressive symptoms and the cognitive ability of AD patients was mediated by the right caudate SUVR. The results contribute to a deeper understanding of the neurobiological mechanisms related to AD with depressive symptoms.
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Affiliation(s)
- Bojun Wang
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chunlei Cui
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yifan Chen
- Department of Radiology, Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing, China
| | - Zhigang Liang
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
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Romagnoli A, Zovi A, Santoleri F, Lasala R. Antidepressant deprescribing: State of the art and recommendations-A literature overview. Eur J Clin Pharmacol 2024; 80:417-433. [PMID: 38189859 DOI: 10.1007/s00228-023-03617-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/29/2023] [Indexed: 01/09/2024]
Abstract
INTRODUCTION In recent years, the consumption of antidepressants has arisen. However, deprescribing antidepressant therapy is very complicated. The aim of this study was to implement practical recommendations for the development of guidelines to be used for antidepressant deprescription in clinical practice. MATERIALS AND METHODS The literature search has been conducted on March 13, 2023, using Scopus and PubMed databases. The following search string has been used: "antidepressants AND (deprescribing OR deprescription)". All studies reporting a deprescribing intervention for antidepressant medication, regardless of the study design, have been included. Studies that did not report antidepressant drug deprescription interventions and non-English-language papers have been excluded. RESULTS From the literature search, a total of 230 articles have been extracted. Applying the exclusion criteria, 26 articles have been considered eligible. Most of the analyzed studies (16, 61%) have been carried out in the real world, 3 (11%) were RCTs, 5 (19%) were qualitative studies, in particular expert opinions, 1 (4%) was a literature review, and 1 (4%) was a post-trial observational follow-up of an RCT. In 8 out of 26 studies (31%), the analyzed antidepressants have been specified: 2 (8%) focused on anticholinergics, 2 (8%) on SSRIs, 3 (11%) on tricyclic antidepressants, and 1 (4%) on esketamine. Nineteen out of 26 studies (73%) did not stratify antidepressants by therapeutic class. The sample sizes analyzed in the studies ranged from a minimum of 4 patients to a maximum of 113,909, and 12 studies included geriatric age as an inclusion criterion. A patient's therapy review has been the main deprescribing intervention, and it has been identified in 14 (54%) articles. Interventions have been carried out by clinicians in 4 (15%) studies, general practitioners in 5 (19%) studies, nurses in 2 (8%) studies, pharmacists in 4 (15%) studies, multidisciplinary teams in 10 (38%) studies, and patients in 1 (4%) study. CONCLUSIONS From the literature review, it emerged that there is no clear evidence useful to support clinicians in antidepressant deprescribing interventions.
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Affiliation(s)
- Alessia Romagnoli
- Territorial Pharmaceutical Service, Local Health Unit Lanciano Vasto Chieti, Chieti, Italy.
| | - Andrea Zovi
- Ministry of Health, Viale Giorgio Ribotta 5, 00144, Rome, Italy
| | | | - Ruggero Lasala
- Hospital Pharmacy of Corato, Local Health Unit of Bari, Corato, Italy
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Kopf D. [Safe discontinuation of psychotropic drugs in older people? : New evidence and practical approach]. DER NERVENARZT 2024; 95:35-40. [PMID: 38189939 DOI: 10.1007/s00115-023-01600-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/31/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Many older patients are permanently prescribed one or more psychotropic drugs for treatment of symptoms, such as behavioral and psychological symptoms in dementia, depressive symptoms, anxiety, and insomnia. They therefore contribute to the risk of polypharmacy. Recently, deprescribing studies have been published in order to clarify if inadequate medications can be safely discontinued. This mini-review summarizes the study results and derives practical recommendations for routine use. METHOD A literature search was carried out in PubMed for clinical studies on deprescribing in association with psychotropic substances. RESULTS After removal of duplications, 12 heterogeneous clinical studies were identified and reduction of psychotropic substances could be successfully achieved in 8 studies. In four of these studies psychological, behavioral and functional endpoints were reported. Criteria for successful deprescribing of sedatives were in particular motivation, information and sufficient cooperation of the patients and for antipsychotic drugs in people with dementia, the sustainable establishment of nonpharmaceutical treatment strategies. Deprescribing was not attempted in cases of a history of severe chronic mental illness and in cases of severe behavioral symptoms in dementia. Evidence for antidepressants was not sufficient to extract practical recommendations. CONCLUSION Safe deprescribing of antipsychotic drugs in patients with dementia is justified if non-pharmacological treatment options are sustainably implemented, and for sedative drugs in well-informed, highly motivated and cooperative patients.
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Affiliation(s)
- Daniel Kopf
- Geriatrischer Schwerpunkt und Klinik für Geriatrie, Endokrinologie und Diabetologie, RKH-Kliniken Ludwigsburg/Bietigheim, Riedstr. 12, 74321, Bietigheim-Bissingen, Deutschland.
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Hellinger BJ, Remane Y, Bertsche T, Gries A. [Adverse drug reactions as cause of nonspecific symptoms in patients in the emergency department]. DIE ANAESTHESIOLOGIE 2023; 72:887-893. [PMID: 37978070 DOI: 10.1007/s00101-023-01355-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/19/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND In a large proportion of patients admitted to the emergency department (ED), the initial main symptom is nonspecific. One possible reason for this, especially in older patients, may be adverse drug reactions (ADR) due to their frequent polypharmacy. AIM To illustrate the incidence of ADRs, the affected patient population including risk factors, and drug classes with ADRs leading to nonspecific symptoms. To provide practice recommendations for the management of ADRs in the ED. MATERIAL AND METHODS Presentation of the pharmacological principles on ADRs, statistics of pharmacovigilance centers as well as original literature including experiences from clinical practice and own projects. RESULTS In 10% of patients with nonspecific symptoms an ADR is responsible for presentation in the ED. In 60% of cases these ADRs are not correctly identified in the ED setting. A small number of drug classes are responsible for most of these referrals. Databases, risk stratification, clinical pharmacists, or clinical decision support systems are available to improve ADR identification and management. As these options are partly associated with considerable costs or the validation for German EDs is missing, a widespread application does not take place. CONCLUSION Correct identification of ADRs in patients with nonspecific symptoms in the ED is necessary to initiate adequate treatment. These ADRs are often overlooked because processes and tools for identification and management are not applied in the ED, leading to a lack of awareness. For high-risk patients in the ED, the focus should be on drug history, ideally considering patient-specific risk factors and specific drug classes.
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Affiliation(s)
- Benjamin J Hellinger
- Klinikapotheke, Universitätsklinikum Leipzig AöR, Leipzig, Deutschland.
- Abteilung für Klinische Pharmazie, Medizinische Fakultät, Universität Leipzig, Leipzig, Deutschland.
- Zentrale Notaufnahme/Beobachtungsstation, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103, Leipzig, Deutschland.
| | - Yvonne Remane
- Klinikapotheke, Universitätsklinikum Leipzig AöR, Leipzig, Deutschland
| | - Thilo Bertsche
- Abteilung für Klinische Pharmazie, Medizinische Fakultät, Universität Leipzig, Leipzig, Deutschland
| | - André Gries
- Zentrale Notaufnahme/Beobachtungsstation, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103, Leipzig, Deutschland
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Lan CH, Yeh HC, Tsai WH, Lee SC, Chou SS. Smart humancentric lighting system improves sleep efficiency of nursing home residents. Arch Gerontol Geriatr 2023; 115:105112. [PMID: 37399683 DOI: 10.1016/j.archger.2023.105112] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 07/05/2023]
Abstract
The global phenomenon of population aging presents a significant challenge, affecting both the increasing number of older individuals and their duration of living with disability. Tailored care services are crucial for improving the quality of life of older adults, particularly those with disabilities residing in nursing homes. However, ensuring personalized care and mitigating the risks associated with institutionalization are essential in optimizing care quality. One particular challenge in nursing homes is maintaining residents' personal routines and addressing sleep disturbances linked to neurodegenerative disorders. Non-pharmacological interventions are increasingly recognized as preventive and management strategies for behavioral and psychiatric symptoms in nursing home residents. Sleep disruptions, such as reduced duration and increased nocturnal awakenings, are prevalent among nursing home residents. Excessive nocturnal lighting and frequent caregiver interventions contribute to these disturbances. This study aimed to investigate the impact of implementing smart humancentric lighting on the sleep efficiency of nursing home residents. Data from pressure sensors embedded in mattresses were collected to assess sleep efficiency. The findings suggest that smart humancentric lighting can significantly reduce sleep disturbances and improve sleep quality in nursing home residents. Future research should delve into specific symptoms, care burden, and psychotropic agent utilization to validate the effectiveness of this intervention.
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Affiliation(s)
- Cheng-Hsien Lan
- Division of Engineering, Taipei Municipal Gan-Dau Hospital (Managed by Taipei Veterans General Hospital), Taipei, Taiwan
| | - Hsiao-Chien Yeh
- Taipei Municipal Gan-Dau Hospital (Managed by Taipei Veterans General Hospital) affiliated Nursing Home, Taipei, Taiwan
| | - Wen-Huey Tsai
- Center for Hospital Administration and Management, Taipei Municipal Gan-Dau Hospital (Managed by Taipei Veterans General Hospital), Taipei, Taiwan
| | - Shu-Chiung Lee
- Department of Nursing, Taipei Municipal Gan-Dau Hospital (Managed by Taipei Veterans General Hospital), Taipei, Taiwan
| | - Shin-Shang Chou
- Vice Superintendent Office, Taipei Municipal Gan-Dau Hospital (Managed by Taipei Veterans General Hospital), Taipei, Taiwan; National Yang Ming Chiao Tung University School of Nursing, Taipei, Taiwan.
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Benthien KS, Lech LVJ, Birke H, Jørgensen SM, Andersen T, Hansen SV, Andersen JT, Karstoft K, Schiøtz M, Vermehren C. Protocol for DEprescribing and Care to reduce Antipsychotics in Dementia (DECADE)-A hybrid effectiveness-implementation pilot study. PLoS One 2023; 18:e0294024. [PMID: 37943780 PMCID: PMC10635464 DOI: 10.1371/journal.pone.0294024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 08/08/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION Behavioural and psychological symptoms of dementia (BPSD) should only rarely and briefly be treated with antipsychotics. Despite recommendations to the contrary, the use of antipsychotics in nursing home residents with dementia is widespread and followed by serious adverse effects. Intervention studies on methods to reduce the use of antipsychotics in persons with dementia are few and needed. The aim of this protocol is to describe the rationale and content of the intervention DEprescribing and Care to reduce Antipsychotics in DEmentia (DECADE)-a hybrid effectiveness-implementation pilot study. MATERIALS AND METHODS This is a protocol of a prospective hybrid effectiveness-implementation pilot study. The primary aim of DECADE is to reduce the use of antipsychotic drugs by 50% in 50% of nursing home residents with dementia while maintaining or improving BPSD. The intervention is implemented in six nursing homes including approximately 190 residents with dementia and consists of Academic Detailing, medication review, education of nursing home staff, and care plans. The evaluation of feasibility and potential effectiveness is an overall assessment of all clinical and process outcomes. Logistic regression analyses will be used to investigate factors characterizing situations with prescription of antipsychotics. BPSD is analysed with a before- and after design using self-controlled case series methods and the use of antipsychotics is analysed as interrupted time series. DISCUSSION This protocol describes a study that will provide an indication of DECADE effectiveness and a model for upscaling and further evaluation in a controlled design.
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Affiliation(s)
- Kirstine Skov Benthien
- Palliative Care Unit, Copenhagen University Hospital–Hvidovre, Hvidovre, Denmark
- Center for Clinical Research and Prevention, Copenhagen University Hospital–Frederiksberg, Frederiksberg, Denmark
| | | | - Hanne Birke
- Center for Clinical Research and Prevention, Copenhagen University Hospital–Frederiksberg, Frederiksberg, Denmark
| | - Sidsel Maria Jørgensen
- Center for Clinical Research and Prevention, Copenhagen University Hospital–Frederiksberg, Frederiksberg, Denmark
| | | | | | - Jon Trærup Andersen
- Department of Clinical Pharmacology, Copenhagen University Hospital–Bispebjerg, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kristian Karstoft
- Department of Clinical Pharmacology, Copenhagen University Hospital–Bispebjerg, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Michaela Schiøtz
- Center for Clinical Research and Prevention, Copenhagen University Hospital–Frederiksberg, Frederiksberg, Denmark
| | - Charlotte Vermehren
- Department of Clinical Pharmacology, Copenhagen University Hospital–Bispebjerg, Copenhagen, Denmark
- Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Hospital Pharmacy, Capital Region, Herlev, Denmark
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Santiago Martinez P, Lord SR, Close JCT, Taylor ME. Associations between psychotropic and anti-dementia medication use and falls in community-dwelling older adults with cognitive impairment. Arch Gerontol Geriatr 2023; 114:105105. [PMID: 37364485 DOI: 10.1016/j.archger.2023.105105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/05/2023] [Accepted: 06/16/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVES Evidence for effective fall prevention strategies is limited for people with cognitive impairment. Understanding what factors contribute to fall risk identifies potential intervention strategies. We aimed to determine if psychotropic and anti-dementia medication use are associated with falls in community-dwelling older people with mild-moderate cognitive impairment and dementia. DESIGN Secondary analysis of an RCT (i-FOCIS). PARTICIPANTS AND SETTING 309 community-dwelling people with mild to moderate cognitive impairment or dementia from Sydney, Australia. METHODS Demographic information, medical history, and medication use were collected at baseline and participants were followed up for 1-year for falls using monthly calendars and ancillary telephone falls. RESULTS Psychotropic medication use was associated with an increased rate of falls (IRR 1.41, 95%CI 1.03, 1.93) and slower gait speed, poor balance and reduced lower limb function when adjusting for age, sex, education and cognition, as well as RCT group allocation when examining prospective falls. Antidepressants use increased the rate of falls in a similarly adjusted model (IRR 1.54, 95%CI 1.10, 2.15), but when additionally adjusting for depressive symptoms, antidepressant use was no longer significantly associated with falls while depressive symptoms was. Anti-dementia medication use was not associated with rate of falls. CONCLUSIONS Psychotropic medication use increases fall risk, and anti-dementia medication does not reduce fall risk in older adults with cognitive impairment. Effective management of depressive symptoms, potentially with non-pharmacological approaches, is needed to prevent falls in this population. Research is also required to ascertain the risks/benefits of withdrawing psychotropic medications, particularly in relation to depressive symptoms.
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Affiliation(s)
| | - Stephen R Lord
- Population Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia; Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Sydney, New South Wales, Australia
| | - Jacqueline C T Close
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Sydney, New South Wales, Australia; School of Clinical Medicine, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Morag E Taylor
- Population Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia; Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Sydney, New South Wales, Australia.
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Lühnen J, Richter T, Calo S, Meyer G, Köpke S, Möhler R. Psychosocial interventions for reducing antipsychotic medication in care home residents. Cochrane Database Syst Rev 2023; 8:CD008634. [PMID: 37650479 PMCID: PMC10471006 DOI: 10.1002/14651858.cd008634.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND Antipsychotic medications are regularly prescribed in care home residents for the management of behavioural and psychological symptoms of dementia (BPSD) despite questionable efficacy, important adverse effects, and available non-pharmacological interventions. Prescription rates are related to organisational factors, staff training and job satisfaction, patient characteristics, and specific interventions. Psychosocial intervention programmes aimed at reducing the prescription of antipsychotic drugs are available. These programmes may target care home residents (e.g. improving communication and interpersonal relationships) or target staff (e.g. by providing skills for caring for people with BPSD). Therefore, this review aimed to assess the effectiveness of these interventions, updating our earlier review published in 2012. OBJECTIVES To evaluate the benefits and harms of psychosocial interventions to reduce antipsychotic medication use in care home residents compared to regular care, optimised regular care, or a different psychosocial intervention. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 14 July 2022. SELECTION CRITERIA We included individual or cluster-randomised controlled trials comparing a psychosocial intervention aimed primarily at reducing the use of antipsychotic medication with regular care, optimised regular care, or a different psychosocial intervention. Psychosocial interventions were defined as non-pharmacological intervention with psychosocial components. We excluded medication withdrawal or substitution interventions, interventions without direct interpersonal contact and communication, and interventions solely addressing policy changes or structural interventions. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Critical appraisal of studies addressed risks of selection, performance, attrition and detection bias, as well as criteria related to cluster randomisation. We retrieved data on the complex interventions on the basis of the TIDieR (Template for Intervention Description and Replication) checklist. Our primary outcomes were 1. use of regularly prescribed antipsychotic medication and 2. ADVERSE EVENTS Our secondary outcomes were 3. mortality; 4. BPSD; 5. quality of life; 6. prescribing of regularly psychotropic medication; 7. regimen of regularly prescribed antipsychotic medication; 8. antipsychotic medication administered 'as needed'; 9. physical restraints; 10. cognitive status; 11. depression; 12. activities of daily living; and 13. COSTS We used GRADE to assess certainty of evidence. MAIN RESULTS We included five cluster-randomised controlled studies (120 clusters, 8342 participants). We found pronounced clinical heterogeneity and therefore decided to present study results narratively. All studies investigated complex interventions comprising, among other components, educational approaches. Because of the heterogeneity of the results, including the direction of effects, we are uncertain about the effects of psychosocial interventions on the prescription of antipsychotic medication. One study investigating an educational intervention for care home staff assessed the use of antipsychotic medication in days of use per 100 resident-days, and found this to be lower in the intervention group (mean difference 6.30 days, 95% confidence interval (CI) 6.05 to 6.66; 1152 participants). The other four studies reported the proportion of participants with a regular antipsychotic prescription. Of two studies implementing an intervention to promote person-centred care, one found a difference in favour of the intervention group (between-group difference 19.1%, 95% CI 0.5% to 37.7%; 338 participants), while the other found a difference in favour of the control group (between-group difference 11.4%, 95% CI 0.9% to 21.9%; 862 participants). One study investigating an educational programme described as "academic detailing" found no difference between groups (odds ratio 1.06, 95% CI 0.93 to 1.20; 5363 participants). The fifth study used a factorial design to compare different combinations of interventions to supplement person-centred care. Results showed a positive effect of medication review, and no clear effect of social interaction or exercise. We considered that, overall, the evidence about this outcome was of low certainty. We found high-certainty evidence that psychosocial interventions intended primarily to reduce antipsychotic use resulted in little to no difference in the number of falls, non-elective hospitalisations, or unplanned emergency department visits. Psychosocial interventions intended primarily to reduce antipsychotic use also resulted in little to no difference in quality of life (moderate-certainty evidence), and BPSD, regular prescribing of psychotropic medication, use of physical restraints, depression, or activities of daily living (all low-certainty evidence). We also found low-certainty evidence that, in the context of these interventions, social interaction and medication review may reduce mortality, but exercise does not. AUTHORS' CONCLUSIONS All included interventions were complex and the components of the interventions differed considerably between studies. Interventions and intervention components were mostly not described in sufficient detail. Two studies found evidence that the complex psychosocial interventions may reduce antipsychotic medication use. In addition, one study showed that medication review might have some impact on antipsychotic prescribing rates. There were no important adverse events. Overall, the available evidence does not allow for clear generalisable recommendations.
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Affiliation(s)
- Julia Lühnen
- Institute of Health and Nursing Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Institute of Clinical Nursing Science, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Tanja Richter
- Unit of Health Sciences and Education, University of Hamburg, Hamburg, Germany
| | - Stella Calo
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Gabriele Meyer
- Institute of Health and Nursing Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Sascha Köpke
- Unit of Health Sciences and Education, University of Hamburg, Hamburg, Germany
- Institute of Nursing Science, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ralph Möhler
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
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11
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Cognat E, Sabia S, Fayel A, Lilamand M, Handels R, Fascendini S, Bergh S, Frisoni GB, Fabbo A, Tsolaki M, Frölich L, Peters O, Merlo P, Ciccone A, Mecocci P, Dumurgier J, Defanti CA, Hugon J, Paquet C. BPSD Patterns in Patients With Severe Neuropsychiatric Disturbances: Insight From the RECAGE Study. Am J Geriatr Psychiatry 2023; 31:633-639. [PMID: 37183097 DOI: 10.1016/j.jagp.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/23/2023] [Accepted: 03/23/2023] [Indexed: 05/16/2023]
Abstract
OBJECTIVE Behavioral and psychological symptoms of dementia (BPSD) profiles vary depending on etiology in patients with mild-to-moderate BPSD. It is not known if similar differences exist in patients with severe BPSD. METHODS We analyzed data collected at baseline in 398 patients with severe BPSD (NPI ≥ 32) and defined diagnosis of dementia (Alzheimer's disease [AD] 297; frontotemporal dementia [FTD] 39; Lewy body disease/Parkinsonian dementia [LBD/PD] 31; and vascular dementia [VD] 31) included in the European multicenter cohort RECAGE. RESULTS Mean total NPI was 52.11 (18.55). LBD/PD patients demonstrated more hallucinations, more anxiety and more delusions than patients with other dementia. FTD patients had less delusions and more disinhibition than patients with other neurodegenerative disorders. These profiles overlapped partially with those reported in the literature in patients with less severe symptoms. CONCLUSION Patients with severe BPSD display different and specific profiles of neuropsychiatric symptoms depending on dementia etiology.
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Affiliation(s)
- Emmanuel Cognat
- Université Paris Cité (EC, ML, CP, SS, JD, JH), UMR-S 1144, INSERM, Paris, France; Cognitive Neurology Center (EC, AF, ML, JD, JH, CP), AP-HP.Nord, Site Lariboisière Fernand-Widal, Paris, France.
| | - Séverine Sabia
- Université Paris Cité (EC, ML, CP, SS, JD, JH), UMR-S 1144, INSERM, Paris, France; Université Paris Cité (SS, JD), Inserm U1153, Epidemiology of Ageing and Neurodegenerative diseases, Paris, France
| | - Alexandra Fayel
- Université Paris Cité (SS, JD), Inserm U1153, Epidemiology of Ageing and Neurodegenerative diseases, Paris, France
| | - Matthieu Lilamand
- Université Paris Cité (EC, ML, CP, SS, JD, JH), UMR-S 1144, INSERM, Paris, France; Cognitive Neurology Center (EC, AF, ML, JD, JH, CP), AP-HP.Nord, Site Lariboisière Fernand-Widal, Paris, France; Department of Geriatry (ML), AP-HP.Nord, Site Lariboisière Fernand-Widal, Paris, France
| | - Ron Handels
- Alzheimer Centre Limburg (RH), School for Mental Health and Neuroscience, Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Sara Fascendini
- Fondazione Europea di Ricerca Biomedica (FERB Onlus) (SF), Gazzaniga, Italy
| | - Sverre Bergh
- The Research Centre for Age-related Functional Decline and Disease (SB), Innlandet Hospital Trust, Ottestad, Norway; The Norwegian National Centre for Aging and Health (SB), Vestfold Hospital Trust, Tønsberg, Norway
| | - Giovanni B Frisoni
- Memory Clinic (GBF), Geneva University Hospitals, Geneva, Switzerland; Laboratory of Neuroimaging of Aging (LANVIE) (GBF), University of Geneva, Geneva, Switzerland
| | - Andrea Fabbo
- Geriatric Service-Cognitive Disorders and Dementia (AF), Department of Primary Care, Health Authority and Services of Modena, Modena, Italy
| | - Magdalina Tsolaki
- Greek Association of Alzheimer's Disease and Related Disorders (GAADRD) (MT), Thessaloniki, Hellas, Macedonia Greece; First Department of Neurology, School of Medicine (MT), Aristotle University of Thessaloniki (AUTh), Hellas, Macedonia Greece
| | - Lutz Frölich
- Department of Geriatric Psychiatry (LF), Central Institute of Mental Health; Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Oliver Peters
- Department of Psychiatry (OP), Charité Universitätsmedizin Berlin, Berlin, Germany; German Center for Neurodegenerative Diseases (DZNE) (OP), Berlin, Germany
| | - Paola Merlo
- Neurological Unit (PM), U.V.A. Centre, Humanitas Gavazzeni, Bergamo, Italy
| | - Alfonso Ciccone
- Department of Neurology with neurosurgical activity and stroke unit (AC), ASST di Mantova, Mantova, Italy
| | - Patrizia Mecocci
- Section of Gerontology and Geriatrics (PM), Department of Medicine and Surgery, University of Perugia, Perugia, Italy; Clinical Geriatrics (PM), NVS Department, Karolinska Institutet, Stockholm, Sweden
| | - Julien Dumurgier
- Université Paris Cité (EC, ML, CP, SS, JD, JH), UMR-S 1144, INSERM, Paris, France; Cognitive Neurology Center (EC, AF, ML, JD, JH, CP), AP-HP.Nord, Site Lariboisière Fernand-Widal, Paris, France; Université Paris Cité (SS, JD), Inserm U1153, Epidemiology of Ageing and Neurodegenerative diseases, Paris, France
| | - Carlo A Defanti
- Fondazione Europea di Ricerca Biomedica (FERB Onlus) (SF), Gazzaniga, Italy
| | - Jacques Hugon
- Université Paris Cité (EC, ML, CP, SS, JD, JH), UMR-S 1144, INSERM, Paris, France; Cognitive Neurology Center (EC, AF, ML, JD, JH, CP), AP-HP.Nord, Site Lariboisière Fernand-Widal, Paris, France
| | - Claire Paquet
- Université Paris Cité (EC, ML, CP, SS, JD, JH), UMR-S 1144, INSERM, Paris, France; Cognitive Neurology Center (EC, AF, ML, JD, JH, CP), AP-HP.Nord, Site Lariboisière Fernand-Widal, Paris, France
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12
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Nizet P, Evin A, Brociero E, Vigneau CV, Huon JF. Outcomes in deprescribing implementation trials and compliance with expert recommendations: a systematic review. BMC Geriatr 2023; 23:428. [PMID: 37438697 DOI: 10.1186/s12877-023-04155-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 07/05/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Deprescribing, defined as discontinuing or reducing the dose of medications that are no longer needed or for which the risks outweigh the benefits is a way to reduce polypharmacy. In 2022, the US Deprescribing Research Network (USDeN) published recommendations concerning the measurement of outcomes for deprescribing intervention studies. The objectives of this systematic review were to identify the outcome categories used in deprescribing intervention trials and to relate them to the previously published recommendations. METHODS We searched MEDLINE, Embase, PsychInfo, and the Cochrane library from January 2012 through January 2022. Studies were included if they were randomized controlled trials evaluating a deprescribing intervention. After data extraction, outcomes were categorized by type: medication outcomes, clinical outcomes, system outcomes, implementation outcomes, and other outcomes based on the previously published recommendations. RESULTS Thirty-six studies were included. The majority of studies focused on older adults in nursing homes and targeted inappropriate medications or polypharmacy. In 20 studies, the intervention was a medication review; in seven studies, the intervention was educational or informative; and three studies based their intervention on motivational interviewing or patient empowerment. Thirty-one studies presented a medication outcome (primary outcome in 26 studies), 25 a clinical outcome, 18 a system outcome, and seven an implementation outcome. Only three studies presented all four types of outcomes, and 10 studies presented three types of outcomes. CONCLUSIONS This review provides an update on the implementation of gold standard deprescribing studies in clinical practice. Implementation outcomes need to be developed and specified to facilitate the implementation of these practices on a larger scale and clinical outcome need to be prioritized. Finally, this review provides new elements for future real-life deprescribing studies.
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Affiliation(s)
- Pierre Nizet
- Nantes Université, CHU Nantes, 44000, Pharmacie, France.
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France.
| | - Adrien Evin
- Nantes Université, CHU Nantes, Service de Soins Palliatifs Et de Support, 44000, Nantes, France
| | - Emma Brociero
- Nantes Université, CHU Nantes, 44000, Pharmacie, France
| | - Caroline Victorri Vigneau
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France
- Nantes Université, CHU Nantes, Service de Pharmacologie Clinique, 44000, Nantes, France
| | - Jean-François Huon
- Nantes Université, CHU Nantes, 44000, Pharmacie, France
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France
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13
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[Safe discontinuation of psychotropic drugs in older people? : New evidence and practical approach]. Z Gerontol Geriatr 2023; 56:93-99. [PMID: 36862243 DOI: 10.1007/s00391-023-02168-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 01/31/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND Many older patients are permanently prescribed one or more psychotropic drugs for treatment of symptoms, such as behavioral and psychological symptoms in dementia, depressive symptoms, anxiety, and insomnia. They therefore contribute to the risk of polypharmacy. Recently, deprescribing studies have been published in order to clarify if inadequate medications can be safely discontinued. This mini-review summarizes the study results and derives practical recommendations for routine use. METHOD A literature search was carried out in PubMed for clinical studies on deprescribing in association with psychotropic substances. RESULTS After removal of duplications, 12 heterogeneous clinical studies were identified and reduction of psychotropic substances could be successfully achieved in 8 studies. In four of these studies psychological, behavioral and functional endpoints were reported. Criteria for successful deprescribing of sedatives were in particular motivation, information and sufficient cooperation of the patients and for antipsychotic drugs in people with dementia, the sustainable establishment of nonpharmaceutical treatment strategies. Deprescribing was not attempted in cases of a history of severe chronic mental illness and in cases of severe behavioral symptoms in dementia. Evidence for antidepressants was not sufficient to extract practical recommendations. CONCLUSION Safe deprescribing of antipsychotic drugs in patients with dementia is justified if non-pharmacological treatment options are sustainably implemented, and for sedative drugs in well-informed, highly motivated and cooperative patients.
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14
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Wang J, Shen JY, Conwell Y, Podsiadly EJ, Caprio TV, Nathan K, Yu F, Ramsdale EE, Fick DM, Mixon AS, Simmons SF. How "age-friendly" are deprescribing interventions? A scoping review of deprescribing trials. Health Serv Res 2023; 58 Suppl 1:123-138. [PMID: 36221154 DOI: 10.1111/1475-6773.14083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To assess how age-friendly deprescribing trials are regarding intervention design and outcome assessment. Reduced use of potentially inappropriate medications (PIMs) can be addressed by deprescribing-a systematic process of discontinuing and/or reducing the use of PIMs. The 4Ms-"Medication", "Mentation", "Mobility", and "What Matters Most" to the person-can be used to guide assessment of age-friendliness of deprescribing trials. DATA SOURCE Published literature. STUDY DESIGN Scoping review. DATA EXTRACTION METHODS The literature was identified using keywords related to deprescribing and polypharmacy in PubMed, EMBASE, Web of Science, ProQuest, CINAHL, and Cochrane and snowballing. Study characteristics were extracted and evaluated for consideration of 4Ms. PRINCIPAL FINDINGS Thirty-seven of the 564 trials identified met the review eligibility criteria. Intervention design: "Medication" was considered in the intervention design of all trials; "Mentation" was considered in eight trials; "Mobility" (n = 2) and "What Matters Most" (n = 6) were less often considered in the design of intervention. Most trials targeted providers without specifying how matters important to older adults and their families were aligned with deprescribing decisions. OUTCOME ASSESSMENT "Medication" was the most commonly assessed outcome (n = 33), followed by "Mobility" (n = 13) and "Mentation" (n = 10) outcomes, with no study examining "What Matters Most" outcomes. CONCLUSIONS "Mentation" and "Mobility", and "What Matters Most" have been considered to varying degrees in deprescribing trials, limiting the potential of deprescribing evidence to contribute to improved clinical practice in building an age-friendly health care system.
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Affiliation(s)
- Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Eric J Podsiadly
- Elaine Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Thomas V Caprio
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Kobi Nathan
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York, USA
| | - Fang Yu
- Arizona State University, Edson College of Nursing and Health Innovation, Phoenix, Arizona, USA
| | - Erika E Ramsdale
- University of Rochester Medical Center, Department of Medicine, Division of Hematology/Oncology, Rochester, New York, USA
| | - Donna M Fick
- Penn State University, Ross and Carol Nese College of Nursing, University Park, Pennsylvania, USA
| | - Amanda S Mixon
- Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sandra F Simmons
- Division of Geriatrics & Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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15
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Factors associated with formal and informal resource utilization in nursing home patients with and without dementia: cross-sectional analyses from the COSMOS trial. BMC Health Serv Res 2022; 22:1306. [PMID: 36324159 PMCID: PMC9628082 DOI: 10.1186/s12913-022-08675-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 10/13/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To investigate the association between clinical, demographic, and organizational factors and formal (health professionals) and informal (relatives) resource utilization in nursing home patients with and without dementia. METHODS Baseline data from the multicomponent cluster randomized control COSMOS trial including 33 Norwegian nursing homes and 723 residents with and without dementia. Nursing home staff (n = 117) participated as proxy raters to approximate formal and informal resource use in daily care. MEASUREMENTS The primary outcome was the Resource Utilization in Dementia - Formal Care scale to assess formal and informal care time in hours/month regarding basic activities of daily living (ADL), instrumental ADL, and supervision. Secondary outcomes were hours/week spent on formal and informal leisure activities. Behavioral and psychological symptoms in dementia (BPSD) were assessed by the Neuropsychiatric Inventory-Nursing Home version, physical function by the Physical Self-Maintenance Scale, and psychotropic drug use by the Anatomical Therapeutic Chemical classification system. Organizational factors were ward size and staff ratio. RESULTS Generalized linear mixed-effect models and two-part modelling revealed an association between increased formal care time and poorer physical function, higher agitation and psychotropic drug use and lower cognitive function (all p < .05). Enhanced formal leisure time was related to better ADL function (p < .05) and smaller wards (p < .05). The family related leisure time was associated with agitation, decline in ADL function, smaller wards, and better staffing ratio (all p < .05). Married patients received more informal direct care (p < .05) and leisure time (p < .05) compared to unmarried/widowed. CONCLUSION For nursing home staff, higher agitation and psychotropic drug use, and lower cognitive function, is associated with more direct care time, whereas leisure time activities are less prioritized in people with lower physical function. Informal caregivers' engagement is encouraged by smaller nursing homes and better staff ratio. Therefore, we recommend stakeholders and healthcare professionals to consider these clinical and organizational factors to optimize treatment and leisure time activities in nursing home patients with various needs. TRIAL REGISTRATION ClinicalTrials.gov ; NCT02238652.
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16
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Lederle LI, Steinman MA, Jing B, Nguyen B, Lee SJ. Glycemic treatment deintensification practices in nursing home residents with type 2 diabetes. J Am Geriatr Soc 2022; 70:2019-2028. [PMID: 35318647 PMCID: PMC9283249 DOI: 10.1111/jgs.17735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/02/2022] [Accepted: 02/12/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Older nursing home (NH) residents with glycemic overtreatment are at significant risk of hypoglycemia and other harms and may benefit from deintensification. However, little is known about deintensification practices in this setting. METHODS We conducted a cohort study from January 1, 2013 to December 31, 2019 among Veterans Affairs (VA) NH residents. Participants were VA NH residents age ≥65 with type 2 diabetes with a NH length of stay (LOS) ≥ 30 days and an HbA1c result during their NH stay. We defined overtreatment as HbA1c <6.5 with any insulin use, and potential overtreatment as HbA1c <7.5 with any insulin use or HbA1c <6.5 on any glucose-lowering medication (GLM) other than metformin alone. Our primary outcome was continued glycemic overtreatment without deintensification 14 days after HbA1c. RESULTS Of the 7422 included residents, 17% of residents met criteria for overtreatment and an additional 23% met criteria for potential overtreatment. Among residents overtreated and potentially overtreated at baseline, 27% and 19%, respectively had medication regimens deintensified (73% and 81%, respectively, continued to be overtreated). Long-acting insulin use and hyperglycemia ≥300 mg/dL before index HbA1c were associated with increased odds of continued overtreatment (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.14-1.65 and OR 1.35, 95% CI 1.10-1.66, respectively). Severe functional impairment (MDS-ADL score ≥ 19) was associated with decreased odds of continued overtreatment (OR 0.72, 95% CI 0.56-0.95). Hypoglycemia was not associated with decreased odds of overtreatment. CONCLUSIONS Overtreatment of diabetes in NH residents is common and a minority of residents have their medication regimens appropriately deintensified. Deprescribing initiatives targeting residents at high risk of harms and with low likelihood of benefit such as those with history of hypoglycemia, or high levels of cognitive or functional impairment are most likely to identify NH residents most likely to benefit from deintensification.
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Affiliation(s)
- Lauren I. Lederle
- Geriatrics and Extended Care ServiceSan Francisco Virginia Medical CenterSan FranciscoCaliforniaUSA
- Veterans Affairs Quality Scholars FellowshipSan Francisco Virginia Medical CenterSan FranciscoCaliforniaUSA
- Division of GeriatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Michael A. Steinman
- Geriatrics and Extended Care ServiceSan Francisco Virginia Medical CenterSan FranciscoCaliforniaUSA
- Division of GeriatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Bocheng Jing
- Division of GeriatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Brian Nguyen
- Division of GeriatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Sei J. Lee
- Geriatrics and Extended Care ServiceSan Francisco Virginia Medical CenterSan FranciscoCaliforniaUSA
- Veterans Affairs Quality Scholars FellowshipSan Francisco Virginia Medical CenterSan FranciscoCaliforniaUSA
- Division of GeriatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
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17
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Gedde MH, Husebo BS, Mannseth J, Naik M, Selbaek G, Vislapuu M, Berge LI. The impact of medication reviews by general practitioners on psychotropic drug use and behavioral and psychological symptoms in home-dwelling people with dementia: results from the multicomponent cluster randomized controlled LIVE@Home.Path trial. BMC Med 2022; 20:186. [PMID: 35614509 PMCID: PMC9132600 DOI: 10.1186/s12916-022-02382-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 04/25/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND There is limited knowledge regarding the process of deprescribing psychotropic drugs to people with dementia (PwD) conducted by general practitioners (GP). We investigated the impact of a multicomponent intervention, emphasizing medication reviews, on psychotropic drugs and behavioral and psychological symptoms (BPSD) in home-dwelling PwD and quantified change in patient-GP communication evaluated by their informal caregivers. METHODS LIVE@Home.Path is a stepped-wedge closed-cohort cluster randomized controlled trial for people with mild to moderate dementia aged ≥65 and their informal caregivers (dyads) in Norway. Complementary to health care as usual (control condition), municipal coordinators implemented the multicomponent LIVE intervention: Learning, Innovation, Volunteer support, and Empowerment (including medication review by the PwD's regular GPs). Block-randomization was used to allocate dyads in three groups receiving the intervention sequentially in periods of 6 months duration. Prepandemic data from the first period is reported, resulting in a 1:2 intervention-to-control ratio. Primary outcome was change in psychotropic drug use. Secondary outcomes were changes in BPSD by Neuropsychiatric Inventory and Cornell Scale of Depression in Dementia and patient-GP communication by an adaption of the Clinical Global Impression of Change. RESULTS Four hundred thirty-eight dyads were screened, 280 included, and 237 participated at 6 months (intervention group n=67; control condition n=170). At baseline, 63% used psychotropic medication regularly: antidementia drugs (47%), antidepressants (13%), hypnotics/sedatives (13%), antipsychotics (5%), and anxiolytics (2%). At 6 months, medication reviews were more frequently conducted in the intervention group compared to control (66% vs 42%, P=0.001). We found no differences regarding a change in drug use and BPSD. Patient-GP communication enhanced in the intervention group (mean score 0.95 [standard deviation 1.68] vs 0.41 [1.34], P=0.022). In the intervention group, control group, and overall sample, the informal caregivers of those who had their medications reviewed reported improved patient-GP communication compared to those who did not. CONCLUSIONS Change in psychotropic drug use and BPSD did not differ, even though patient-GP communication improved with medication reviews. Restricted psychotropic drug use among PwD likely reflects more judicious prescribing practices in recent years. Nevertheless, medication reviews could be cultivated to optimize pharmacologic treatment for this complex population. TRIAL REGISTRATION ClinicalTrials.gov : NCT04043364 ; registered 15/03/2019.
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Affiliation(s)
- Marie H Gedde
- Centre for Elderly and Nursing Home Medicine, Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway. .,Haraldsplass Deaconess Hospital, Bergen, Norway.
| | - Bettina S Husebo
- Centre for Elderly and Nursing Home Medicine, Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway.,Municipality of Bergen, Bergen, Norway
| | - Janne Mannseth
- Section for Epidemiology and Medical Statistic, Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Mala Naik
- Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Geir Selbaek
- Norwegian National Centre for Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Geriatric Department, Oslo University Hospital, Oslo, Norway
| | - Maarja Vislapuu
- Centre for Elderly and Nursing Home Medicine, Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Line Iden Berge
- Centre for Elderly and Nursing Home Medicine, Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway.,NKS Olaviken Gerontopsychiatric Hospital, Askøy, Norway
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18
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Mendez MF. Managing the Behavioral and Psychological Symptoms of Dementia. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00715-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Bawazeer G, Alsaad S, Almalag H, Alqahtani A, Altulaihi N, Alodhayani A, AlHossan A, Sales I. Impact of Specialized Clinics on Medications Deprescribing in Older Adults: A Pilot Study in Ambulatory Care Clinics in a Teaching Hospital. Saudi Pharm J 2022; 30:1027-1035. [PMID: 35903532 PMCID: PMC9315319 DOI: 10.1016/j.jsps.2022.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/26/2022] [Indexed: 12/03/2022] Open
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Gedde MH, Husebo BS, Vahia IV, Mannseth J, Vislapuu M, Naik M, Berge LI. Impact of COVID-19 restrictions on behavioural and psychological symptoms in home-dwelling people with dementia: a prospective cohort study (PAN.DEM). BMJ Open 2022; 12:e050628. [PMID: 35074810 PMCID: PMC8787843 DOI: 10.1136/bmjopen-2021-050628] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES To investigate the impact of the COVID-19 restrictions on behavioural and psychological symptoms of dementia (BPSD). DESIGN Prospective cohort study (PAN.DEM) nested within the halted parent trial (LIVE@Home.Path). SETTING Households in Norway immediate before and 6-9 weeks into the COVID-19 restrictions. PARTICIPANTS 104 dyads (persons with mild to moderate dementia aged ≥65 and their informal carers) completed both prepandemic and pandemic assessments, among 237 in the parent trial. Mini-Mental Status Examination score 15-26 or Functional Assessment Staging score 3-7 covered dementia severity. MAIN OUTCOME MEASURES Neuropsychiatric Inventory (NPI-12) total (range 0-144), psychosis (range 0-24), hyperactive behaviour (range 0-60) and mood subsyndrome (range 0-48) scores; Cornell Scale for Depression in Dementia (CSDD) total score (range 0-38). RESULTS We found an overall increase in BPSD by NPI-12 total score comparing prepandemic to pandemic levels (median 16 IQR (4.5-29) to 20 (7-32.5), p=0.03) over a mean of 86 days (SD 19). NPI-12 total score worsened in 57 (55%) of people with dementia and was associated with postponed or averted contacts with healthcare professionals (logistic regression, OR 3.96, 95% CI 1.05 to 14.95). Psychosis subsyndrome levels increased (0 (0-3) to 0.5 (0-6), p=0.01) in 37 (36%) persons; this worsening was associated with partial insight (9.57, 1.14 to 80.71) and reduced informal carer contact (4.45, 1.01 to 19.71). Moreover, depressive symptoms increased as assessed by CSDD total score (5 (3-9) to 7 (4-12), p=0.01) and worsened for 56 (54%), which was inversely associated with psychotropic drugs on-demand (0.16, 0.03 to 0.75). CONCLUSIONS BPSD worsened during the first months of the COVID-19 restrictions, most pronounced for psychosis and depression. These BPSD exacerbations have implications for pandemic policies, emphasising that restrictions must balance COVID-19 morbidity and mortality against dementia deterioration. TRIAL REGISTRATION NUMBER NCT04043364; Results.
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Affiliation(s)
- Marie H Gedde
- Haraldsplass Deaconess Hospital, Bergen, Norway
- Centre for Elderly and Nursing Home Medicine, Department of Global Public Health Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Bettina S Husebo
- Centre for Elderly and Nursing Home Medicine, Department of Global Public Health Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
- Bergen Municipality, Bergen, Norway
| | - Ipsit V Vahia
- McLean Hospital, Belmont, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Janne Mannseth
- Section for Epidemiology and Medical Statistic, Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Maarja Vislapuu
- Centre for Elderly and Nursing Home Medicine, Department of Global Public Health Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Mala Naik
- Haraldsplass Deaconess Hospital, Bergen, Norway
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Line I Berge
- Centre for Elderly and Nursing Home Medicine, Department of Global Public Health Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
- NKS Olaviken Gerontopsychiatric Hospital, Askøy, Norway
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21
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OUP accepted manuscript. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2022; 30:394-397. [DOI: 10.1093/ijpp/riac045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 05/06/2022] [Indexed: 11/14/2022]
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22
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Santagata F, Massaia M, D'Amelio P. The doll therapy as a first line treatment for behavioral and psychologic symptoms of dementia in nursing homes residents: a randomized, controlled study. BMC Geriatr 2021; 21:545. [PMID: 34641791 PMCID: PMC8507228 DOI: 10.1186/s12877-021-02496-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 09/16/2021] [Indexed: 11/30/2022] Open
Abstract
Background Patients living with dementia are severely affected by the development of behavioral and psychologic symptoms (BPSD) which represent a burden for patients and caregivers. The use of psychotropic drugs in the control of BPSD is widely diffused, however the use of a first line non-pharmacologic approach is highly recommended. Here we evaluate the effect of doll therapy (DT) in the management of BPSD, on the reduction of caregiver burden and delirium incidence in nursing home residents by a randomized controlled trial. Methods We enrolled fifty-two nursing homes residents living with dementia and BPSD. Subjects were randomized to DT (26) or standard treatment (ST, 26), we measured BPSD, caregiver burden and delirium with standard clinical scales at baseline, after 45 and 90 days. In order to evaluate the presence of BPSD we used Neuropsychiatric Inventory (NPI) scale and the A.Di.CO scale, the caregiver burden was measured by the Greutzner scale and delirium by the Confusion Assessment Method (CAM) scale. Results DT was more effective in reducing agitation and aggressiveness as respect to ST. Moreover DT globally reduced the presence of BPSD as dysphoria, wandering and apathy. We observed a significant reduction of the professional caregiver burden and the incidence of delirium was significantly reduced in subjects treated with DT. Conclusions We show that DT is more effective that ST in the control of BSPD in patients affected by moderate to severe dementia. Moreover we suggest that DT may effective in reducing the incidence of delirium. Trial registration Retrospectively registered in ClinicalTrials.gov the 10th June 2, 2021 trial registration number NCT04920591.
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Affiliation(s)
- Francesca Santagata
- Department of Medical Science, Geriatric and Bone Diseases Unit, University of Turin, corso Dogliotti 14, 10126, Torino, Italy
| | - Massimiliano Massaia
- Department of Medical Science, Geriatric and Bone Diseases Unit, University of Turin, corso Dogliotti 14, 10126, Torino, Italy
| | - Patrizia D'Amelio
- Department of Medical Science, Geriatric and Bone Diseases Unit, University of Turin, corso Dogliotti 14, 10126, Torino, Italy. .,Department of Medicine, Service of Geriatric Medicine & Geriatric Rehabilitation, University of Lausanne Hospital (CHUV), Lausanne, Switzerland.
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23
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Wright DJ, Blyth A, Maskrey V, Norris N, Bond CM, Hughes CM, Alldred DP, Holland RC. Development and feasibility testing of an evidence-based training programme for pharmacist independent prescribers responsible for the medicines-related activities within care homes. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2021; 29:376-384. [PMID: 34018561 DOI: 10.1093/ijpp/riab025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 04/20/2021] [Indexed: 11/14/2022]
Abstract
INTRODUCTION The UK pharmacists with independent prescribing rights (pharmacist independent prescribers [PIPs]) are authorised to prescribe within their areas of competence. To enable PIPs to provide pharmaceutical care to residents in care homes and assume responsibility for medicines management, a process for development and assessment of competence is required. The aim of this research was to develop a training and accreditation process (training programme) to enable PIPs to operate safely and effectively within care homes. METHODS Located in England, Scotland and Northern Ireland across four sites and based on a systematic review, it consisted of four phases: (1) initial stakeholder engagement, (2) uni-professional focus groups and interviews, (3) expert panel consensus and (4) feasibility testing. Four PIPs were trained each to provide pharmaceutical care to 10 care home residents. An expert panel synthesised the evidence at each stage to develop each iteration of the training programme. Content analysis was used throughout. RESULTS Differences in baseline knowledge of PIPs required inclusion of a Personal Development Framework and the provision of a mentor. Face-to-face training focussed on managing medicines for a complex older person, minimising prescribing costs and supporting people without capacity. Provision of time to understand local context and develop relationships with care homes and general practitioners was identified as a central requirement. PIPs were assessed for competency via viva. Feasibility testing demonstrated that the derived training programme was acceptable, practical and effective. DISCUSSION The model seemed to work, but due to small numbers, larger-scale testing of the training programme is now required.
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Affiliation(s)
- David J Wright
- School of Pharmacy, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Annie Blyth
- School of Pharmacy, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Vivienne Maskrey
- School of Medicine, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Nigel Norris
- School of Education, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Christine M Bond
- General Practice & Primary Care, University of Aberdeen, Aberdeen, UK
| | | | - David P Alldred
- School of Healthcare, University of Leeds, Leeds, UK
- Yorkshire and Humber NIHR Patient Safety Translational Research Centre/University of Leeds, Leeds, UK
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24
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Thiem U, Heppner HJ, Sieber C. [Less can be more-Examples on medication in older and geriatric patients from current studies]. Internist (Berl) 2021; 62:363-372. [PMID: 33630097 DOI: 10.1007/s00108-021-00981-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 11/25/2022]
Abstract
Polypharmacy, i.e. the prescription of five or more different drugs for medicinal treatment, is a typical problem in older and geriatric patients. Polypharmacy predisposes to different negative health sequelae, such as undesired side effects, drug interactions, potentially inappropriate medication, reduced functional abilities, increased hospitalization and increased mortality. Various consensus groups and specialist societies have developed recommendations on how to handle polypharmacy in geriatric patients. Although concepts to reduce the number of drugs are considered necessary, in many areas there is a lack of evidence on how to limit polypharmacy in geriatric patients and to reduce and discontinue medication. This article presents examples of recent studies dealing with potentially inappropriate medication, vitamin D substitution and antipsychotic drugs, which show how to critically appraise a prescribed medication, to critically check the indications for drugs and to discontinue drug use.
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Affiliation(s)
- U Thiem
- Lehrstuhl für Geriatrie und Gerontologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland.
- Zentrum für Altersmedizin, Medizinisch-Geriatrische Klinik, Albertinen-Haus, Sellhopsweg 18-22, 22459, Hamburg, Deutschland.
| | - H J Heppner
- Lehrstuhl für Geriatrie, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten, Deutschland
- Klinik für Geriatrie mit Tagesklinik, Helios Klinikum, Schwelm, Deutschland
- Lehrstuhl für Innere Medizin und Geriatrie, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nürnberg, Deutschland
| | - C Sieber
- Lehrstuhl für Innere Medizin und Geriatrie, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nürnberg, Deutschland
- Department für Innere Medizin, Kantonsspital Winterthur, Winterthur, Schweiz
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Husebo BS, Kerns RD, Han L, Skanderson M, Gnjidic D, Allore HG. Pain, Complex Chronic Conditions and Potential Inappropriate Medication in People with Dementia. Lessons Learnt for Pain Treatment Plans Utilizing Data from the Veteran Health Administration. Brain Sci 2021; 11:86. [PMID: 33440668 PMCID: PMC7827274 DOI: 10.3390/brainsci11010086] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/05/2021] [Accepted: 01/07/2021] [Indexed: 12/21/2022] Open
Abstract
Alzheimer's disease and related dementias (ADRD), pain and chronic complex conditions (CCC) often co-occur leading to polypharmacy and with potential inappropriate medications (PIMs) use, are important risk factors for adverse drug reactions and hospitalizations in older adults. Many US veterans are at high risk for persistent pain due to age, injury or medical illness. Concerns about inadequate treatment of pain-accompanied by evidence about the analgesic efficacy of opioids-has led to an increase in the use of opioid medications to treat chronic pain in the Veterans Health Administration (VHA) and other healthcare systems. This study aims to investigate the relationship between receipt of pain medications and centrally (CNS) acting PIMs among veterans diagnosed with dementia, pain intensity, and CCC 90-days prior to hospitalization. The final analytic sample included 96,224 (81.7%) eligible older veterans from outpatient visits between October 2012-30 September 2013. We hypothesized that veterans with ADRD, and severe pain intensity may receive inappropriate pain management and CNS-acting PIMs. Seventy percent of the veterans, and especially people with ADRD, reported severe pain intensity. One in three veterans with ADRD and severe pain intensity have an increased likelihood for CNS-acting PIMs, and/or opioids. Regular assessment and re-assessment of pain among older persons with CCC, patient-centered tapering or discontinuation of opioids, alternatives to CNS-acting PIMs, and use of non-pharmacological approaches should be considered.
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Affiliation(s)
- Bettina S. Husebo
- Centre for Elderly and Nursing Home Medicine, Department of Global Public Health and Primary Care, University of Bergen, 5020 Bergen, Norway
- Municipality of Bergen, 5020 Bergen, Norway
| | - Robert D. Kerns
- Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, CT 06511, USA;
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT 06516, USA;
| | - Ling Han
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT 06511, USA; (L.H.); (H.G.A.)
| | - Melissa Skanderson
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT 06516, USA;
| | - Danijela Gnjidic
- Charles Perkins Centre, Faculty of Medicine and Health, School of Pharmacy, University of Sydney, Sydney 2006 NSW, Australia;
| | - Heather G. Allore
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT 06511, USA; (L.H.); (H.G.A.)
- Department of Biostatistics, School of Public Health, Yale University, New Haven, CT 06511, USA
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Tinoco MS, Baldoni MO, Silva ÉO, Paiva AMD, Chaves PRD, Pereira ML, Chequer FMD, Baldoni AO. Deprescribing benzodiazepines: Do Brazilian package inserts address this issue? GERIATRICS, GERONTOLOGY AND AGING 2021. [DOI: 10.53886/gga.e0210046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE: To analyze the presence and quality of content on drug deprescribing in Brazilian package inserts for benzodiazepine drugs. METHODS: Documentary study where we analyzed data on deprescribing extracted from electronic package inserts of drugs containing benzodiazepines; these documents were available at the Brazilian Health Surveillance Agency website. Our search was performed independently by 2 researchers who used the following keywords: “deprescription,” “withdrawal,” and “tapering.” The deprescribing plan, when presented by the package insert, was compared to deprescribing protocols for benzodiazepines found in the literature. Moreover, we assessed the presence of guidance on the maximum length of treatment and risks of long-term use. RESULTS: We found 12 package inserts for benzodiazepines and 100% of them suggested gradual withdrawal; only 1 (8.33%) suggested a systematized deprescribing plan. One document (8.33%) did not offer guidance on maximum treatment duration. Eleven (91.67%) had the information on long-term use possibly causing dependence or tolerance, and 1 (8.33%) did not describe the risks of continuous use. CONCLUSIONS: It is known that benzodiazepines should be withdrawn in a gradual and schematized manner, but package inserts do not currently bring this information in detail. It is of utmost importance that health professionals be educated on their conduct, hence the necessity for updating medication package inserts.
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