Polypharmacy in nursing home residents with severe cognitive impairment: Results from the SHELTER Study

Comparison of polypharmacy and potentially inappropriate medication use in older adults with and without dementia receiving residential medication management reviews

OBJECTIVES

Among residents who had a residential medication management review (RMMR), there is a lack of studies assessing exposure to polypharmacy and potentially inappropriate medications (PIMs) in people with dementia. This study compared the exposure to polypharmacy and PIMs in residents with dementia and without dementia receiving RMMR.

METHODS

A retrospective analysis was performed using data of 16,261 residents living in 343 Australian residential aged care facilities who had an RMMR in 2019. Medication use was assessed as polypharmacy (defined as ≥9 medications) and use of ≥1 PIMs using the 2019 updated Beers criteria. Dementia diagnosis was determined with ICD-10 coding from medical records. Descriptive analyses reported resident demographics and patterns of medication use. Pearson's χ2 tests and logistic regression analysis were conducted to compare medication exposure between residents with and without dementia.

RESULTS

Among 16,261 residents, 6781 (42%) had dementia. Residents with dementia were significantly more likely to be exposed to polypharmacy and PIMs, compared to those without dementia (74% vs. 70% and 83% vs. 73%, p < .001 respectively). Residents with dementia had 1.31 times the odds of exposure to polypharmacy (adjusted OR: 1.31, 95% CI: 1.22-1.41, p < .001) and 1.88 times the odds of being prescribed ≥1 PIMs than people without dementia (adjusted OR: 1.88, 95% CI: 1.73-2.04, p < .001).

CONCLUSIONS

In a study of residents receiving RMMR, polypharmacy and PIMs were highly common, and those with dementia were more likely to be exposed to inappropriate polypharmacy. There is a need for targeted deprescribing strategies to immediately address inappropriate prescribing in residents, particularly those living with dementia.

Therapeutic dilemma's: antipsychotics use for neuropsychiatric symptoms of dementia, delirium and insomnia and risk of falling in older adults, a clinical review

PURPOSE

Because of the common and increasing use of antipsychotics in older adults, we aim to summarize the current knowledge on the causes of antipsychotic-related risk of falls in older adults. We also aim to provide information on the use of antipsychotics in dementia, delirium and insomnia, their adverse effects and an overview of the pharmacokinetic and pharmacodynamic mechanisms associated with antipsychotic use and falls. Finally, we aim to provide information to clinicians for weighing the benefits and harms of (de)prescribing.

METHODS

A literature search was executed in CINAHL, PubMed and Scopus in March 2022 to identify studies focusing on fall-related adverse effects of the antipsychotic use in older adults. We focused on the antipsychotic use for neuropsychiatric symptoms of dementia, insomnia, and delirium.

RESULTS

Antipsychotics increase the risk of falls through anticholinergic, orthostatic and extrapyramidal effects, sedation, and adverse effects on cardio- and cerebrovascular system. Practical resources and algorithms are available that guide and assist clinicians in deprescribing antipsychotics without current indication.

CONCLUSIONS

Deprescribing of antipsychotics should be considered and encouraged in older people at risk of falling, especially when prescribed for neuropsychiatric symptoms of dementia, delirium or insomnia. If antipsychotics are still needed, we recommend that the benefits and harms of antipsychotic use should be reassessed within two to four weeks of prescription. If the use of antipsychotic causes more harm than benefit, the deprescribing process should be started.

[Neuroimaging Characteristics of Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) in Korean Based on Jeju Cohort: A Pictorial Essay]

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a hereditary small artery vasculopathy caused by mutations in the NOTCH3 gene on chromosome 19. Jeju Island has the highest reported prevalence of CADASIL patients in the world. Even though most studies on the neuroimaging characteristics of CADASIL have focused on Western populations, there are notable differences in Korean CADASIL patients compared to those in Western countries, which may impact their clinical manifestations and prognosis. Herein, this pictorial essay presents the neuroimaging patterns of CADASIL in patients in Korea, with an emphasis on the differences observed from previous reports based on a Western patient population.

Comorbidity among inpatients with dementia: a preliminary cross-sectional study in West China

OBJECTIVE

To investigate comorbidities among hospitalized patients with dementia.

METHOD

Data were extracted from the discharge records in our hospital. Comorbidities based on ICD-10 were selected from the Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI). The distributions of these comorbidities were described in dementia inpatients and age- and sex-matched nondementia controls, as well as in inpatients with Alzheimer's disease and vascular dementia. A logistic regression model was applied to identify dementia-specific morbid conditions.

RESULTS

A total of 3355 patients with dementia were included, with a majority of 1503 (44.8%) having Alzheimer's disease, 395 (11.8%) with vascular dementia, and 441 (13.1%) with mixed dementia. The mean number of comorbidities was 3.8 in dementia patients (vs. 2.9 in controls). The most prevalent comorbidities in inpatients with dementia compared with those without dementia were cerebral vascular disease (73.0% vs. 35.9%), hypertension (62.8% vs. 56.2%), and peripheral vascular disease (53.7% vs. 31.2%). Comorbidities associated with dementia included epilepsy (OR 4.8, 95% CI 3.5-6.8), cerebral vascular disease (OR 4.1, 95% CI 3.7-4.5), depression (OR 4.0, 95% CI 3.2-5.0), uncomplicated diabetes (OR 1.5, 95% CI 1.4-1.7), peripheral vascular disease (OR 1.8, 95% CI 1.6-2.0), rheumatoid arthritis collagen vascular disease (OR 1.7, 95% CI 1.3-2.3), and anemia (OR 1.2, 95% CI 1.04-1.3). Some comorbidities suggested a protective effect against dementia. They were hypertension (OR 0.8, 95% CI 0.7-0.9), COPD (OR 0.6, 95% CI 0.5-0.6), and solid tumor without metastasis (OR 0.4, 95% CI 0.3-0.4). Vascular dementia has more cardiovascular and cerebrovascular comorbidities than Alzheimer's disease.

CONCLUSION

Patients with dementia coexisted with more comorbidities than those without dementia. Comorbidities (esp. cardio-cerebral vascular risks) in patients with vascular dementia were more than those in patients with AD. Specifically, vascular and circulatory diseases, epilepsy, diabetes and depression increased the risk of dementia.

Do not PIMP my nursing home ride! The impact of Potentially Inappropriate Medications Prescribing on residents' emergency care use

Nursing home residents often are poly-medicated, which increases their risks of receiving potentially inappropriate medications. This problem has become a major public health issue in many countries, and in particular in France. Indeed, high uses of potentially inappropriate medication prescriptions can lead to adverse effects that are likely to increase emergency room (ER) visits. However, there is a lack of empirical evidence on the causal relationship between the amount of use of potentially inappropriate medications and ER visit risks among nursing homes residents. Indeed, this question is subject to endogeneity issues due to omitted variables that simultaneously affect inappropriate medications prescriptions and ER use. We take advantage of the IDEM Randomized Clinical Trial (Systematic Dementia Screening by Multidisciplinary Team Meetings in Nursing Homes for Reducing Emergency Department Transfers) to overcome that issue. Indeed, randomization in the IDEM intervention group created exogenous variations in potentially inappropriate prescriptions, and was thus used as an instrument. Using an instrumental variable model, we show that over a 12-month period, a 1% increase in the share of potentially inappropriate medications spending in total medication spending leads to a 5.7 percentage point increase in residents' ER use risks (p < 0.001). This effect is robust to various model specifications. Moreover, the intensity of this correlation persists over an 18-month period. While tackling wasteful spending has become a priority in most countries, our results have important policy implications. Indeed, reducing potentially inappropriate medication spending in nursing homes should be a key component of value-based aging policies, which objectives are to reduce inefficient care, and provide health care services centered in people's interest.

Perspectives of residents on shared decision making in medication management: A qualitative study

OBJECTIVES

Shared decision making is the process in which the person, their representative, and health care professional share information with each other, participate in the decision-making process, and agree on a course of action. At present, very little is known about shared decision making (SDM) in medication management from the perspective of long-term care facility residents. The objective of this study was to identify residents' beliefs, motivation, and aspects of the environment that facilitate or impede SDM.

DESIGN

A qualitative study was conducted using face-to-face semi-structured interviews, and data analysis was carried out using a thematic approach.

SETTING

Six long-term care facilities in Sydney, Australia.

PARTICIPANTS

Thirty-one residents.

RESULTS

Enablers to resident involvement in SDM were resident beliefs in exercising their right to take part in medication-related decisions, preference to maintain control over decisions, and motivation to raise concern about medication. Residents were not motivated to be involved in SDM if they believed they had no control over life circumstance, perceived that medications were necessary, or experienced no problems with their medications. Participation in SDM was hindered by limitations in opportunities for resident involvement, engagement with staff and primary care physician to discuss issues related to medications, and continuity of care with their regular physician.

CONCLUSION

This study highlights that the residents' beliefs in control over decisions and concerns about medication are a significant function of the SDM process. It is important that residents are given the choice to take part in SDM, their beliefs and values regarding SDM are understood, and the culture of the care facility respects residents' right to participate in SDM.

Community-Based Support and Social Services and Their Association with Frailty Factors in Older People with Intellectual Disability and Affective and Anxiety Disorders: A Swedish National Population-Based Register Study

Affective and anxiety diagnoses are common in older people with intellectual disability (ID). The aim was to describe support and social services for older people with ID and affective and/or anxiety diagnoses, also to investigate in this study group the association between support and social services and frailty factors in terms of specialist healthcare utilisation, multimorbidity, polypharmacy, level of ID and behavioural impairment. Data was selected from four population-based Swedish national registries, on 871 identified persons with affective and/or anxiety diagnoses and ID. Multivariate regression analysis was used to investigate associations between frailty factors during 2002-2012 and social services in 2012. People with multimorbidity who frequently utilised specialist healthcare were less likely to utilise residential arrangements. Those with polypharmacy were more likely utilise residential arrangements, and receive personal contact. People with moderate, severe/profound levels of ID were more likely to utilise residential arrangements and to pursue daily activities.

Update on the management of diabetes in long-term care facilities

The number of patients with diabetes is increasing among older adults in the USA, and it is expected to reach 26.7 million by 2050. In parallel, the percentage of older patients with diabetes in long-term care facilities (LTCFs) will also rise. Currently, the majority of LTCF residents are older adults and one-third of them have diabetes. Management of diabetes in LTCF is challenging due to multiple comorbidities and altered nutrition. Few randomized clinical trials have been conducted to determine optimal treatment for diabetes management in older adults in LTCF. The geriatric populations are at risk of hypoglycemia since the majority are treated with insulin and have different levels of functionality and nutritional needs. Effective approaches to avoid hypoglycemia should be implemented in these settings to improve outcome and reduce the economic burden. Newer medication classes might carry less risk of developing hypoglycemia along with the appropriate use of technology, such as the use of continuous glucose monitoring. Practical clinical guidelines for diabetes management including recommendations for prevention and treatment of hypoglycemia are needed to appropriately implement resources in the transition of care plans in this vulnerable population.

Geriatric Depression and Inappropriate Medication: Benefits of Interprofessional Team Cooperation in Nursing Homes

An investigation of inappropriate medication use in treatment of depressivity in institutionalized older adults, based on a nurse-led evaluation of functional status and depressive symptoms in nursing home residents. Methods: A cross-sectional multicenter study was performed using records from 1087 residents cared for in fifteen nursing homes (NHs) in the Czech Republic. Inclusion criteria were being a permanent resident of one of the facilities, being 60 years of age or older, having a Geriatric Depression Scale score of 6 or more, and having a Mini Mental State examination score 10 or more. The final sample for analysis included 317 depressed NH residents. Results: 52 percent of NH residents with depressivity had no antidepressant treatment. Benzodiazepines were the only medication in 16 percent of depressed residents, and were added to antidepressant treatment in 18 percent of residents. Benzodiazepine users had significantly higher GDS scores compared to non-users (p = 0.007). Conclusion: More than half of depressed NH residents remained without antidepressant treatment. Residents inappropriately treated with benzodiazepines were more depressed than residents treated with antidepressants only, or even not treated at all. Cooperation of the interprofessional team in the screening of depressive symptoms has the potential to improve the quality of care.

Prevalence of psychotropic polypharmacy in nursing home residents with dementia: a meta-analysis

OBJECTIVES

Nursing home (NH) residents with dementia is exposed to high rates of psychotropic prescriptions. Our objectives were to: (1) pool the prevalence estimates of psychotropic polypharmacy from the existing literature and (2) examine potentially influential factors that are related to a higher or lower prevalence.

DESIGN

Meta-analysis of data collected from randomized trials, quasi-experimental, prospective or retrospective cohort, and cross-sectional studies. English-language searches of PubMed and PsycINFO were completed by November 2020. Included studies reported prevalence estimates of psychotropic polypharmacy (i.e. defined as either two-or-more or three-or-more medications concurrently) in NH residents with dementia.

SETTING AND PARTICIPANTS

NH residents with dementia.

MEASUREMENTS

Random-effects models were used to pool the prevalence of psychotropic polypharmacy in NH residents with dementia across studies. Estimates were provided for both two-or-more and three-or-more concurrent medications. Heterogeneity and publication bias were measured. Meta-regression examined the influence of the percentage of the sample who were male, mean age of the sample, geographic region (continent), sample size, and study year on the prevalence of psychotropic polypharmacy.

RESULTS

Twenty-five unique articles were included comprising medications data from 92,370 NH residents with dementia in 12 countries. One-in-three (33%, [95% CI: 28%, 39%]) NH residents with dementia received two-or-more psychotropic medications concurrently. One-in-eight (13%, [95% CI: 10%, 17%]) received three-or-more psychotropic medications concurrently. Estimates were highly variable across both definitions of psychotropic polypharmacy (p < 0.001). Among study-level demographics, geographic region, sample size, or study year, only male sex was associated with greater use of two-or-more psychotropic medications (Unadjusted OR = 1.02, p = 0.006; Adjusted OR = 1.04, p = 0.07).

CONCLUSIONS

Psychotropic polypharmacy is common among NH residents with dementia. Identifying the causes of utilization and the effects on resident health and well-being should be prioritized by federal entities seeking to improve NH quality.

Adverse Drug Reactions of Acetylcholinesterase Inhibitors in Older People Living with Dementia: A Comprehensive Literature Review

The rising of global geriatric population has contributed to increased prevalence of dementia. Dementia is a neurodegenerative disease, which is characterized by progressive deterioration of cognitive functions, such as judgment, language, memory, attention and visuospatial ability. Dementia not only has profoundly devastating physical and psychological health outcomes, but it also poses a considerable healthcare expenditure and burdens. Acetylcholinesterase inhibitors (AChEIs), or so-called anti-dementia medications, have been developed to delay the progression of neurocognitive disorders and to decrease healthcare needs. AChEIs have been widely prescribed in clinical practice for the treatment of Alzheimer's disease, which account for 70% of dementia. The rising use of AChEIs results in increased adverse drug reactions (ADRs) such as cardiovascular and gastrointestinal adverse effects, resulting from overstimulation of peripheral cholinergic activity and muscarinic receptor activation. Changes in pharmacokinetics (PK), pharmacodynamics (PD) and pharmacogenetics (PGx), and occurrence of drug interactions are said to be major risk factors of ADRs of AChEIs in this population. To date, comprehensive reviews in ADRs of AChEIs have so far been scarcely studied. Therefore, we aimed to recapitulate and update the diverse aspects of AChEIs, including the mechanisms of action, characteristics and risk factors of ADRs, and preventive strategies of their ADRs. The collation of this knowledge is essential to facilitate efforts to reduce ADRs of AChEIs.

The value of deprescribing in older adults with dementia: a narrative review

Introduction:Mitigating the burden of unnecessary polypharmacy or multiple medication use in people living with dementia has been recognized as a key priority internationally. One approach to reducing inappropriate polypharmacy is through medication withdrawal or deprescribing.Area covered:Non-systematic searches of key databases including PubMed, Embase, and Google Scholar were conducted from inception to 28 February 2021 for articles that assessed the safety and/or efficacy of deprescribing in older adults living with dementia. Personal reference libraries were also utilized. Information on current clinical trials was found in clinicaltrial.gov.Expert Opinion: There is limited direct evidence to inform deprescribing in older adults with dementia specifically. This review identified nineteen studies that have assessed the impact of deprescribing interventions to reduce inappropriate polypharmacy or direct deprescribing of specific medications. However, the current evidence is limited in scope as most studies focused on medication-related outcomes (e.g. discontinuation of high-risk medications) rather than patient-centered outcomes in individuals living with dementia. Furthermore, most studies focused on addressing inappropriate polypharmacy in older adults with dementia living in long-term care facilities, and interventions did not involve the person and their carer. Further evidence on the impact of deprescribing in this population across clinical settings is needed.

Polypharmacy in chronic neurological diseases: Multiple sclerosis, dementia and Parkinson's disease

Polypharmacy is an important aspect of medication management and particularly affects elderly and chronically ill people. Patients with dementia, Parkinson's disease (PD) or multiple sclerosis (MS) are at high risk for multimedication due to their complex symptomatology. Our aim was to provide an overview of different definitions of polypharmacy and to present the current state of research on polypharmacy in patients with dementia, PD or MS. The most common definition of polypharmacy in the literature is the concomitant use of ≥5 medications (quantitative definition approach). Polypharmacy rates of up to >50% have been reported for patients with dementia, PD or MS, although MS patients are on average significantly younger than those with dementia or PD. The main predictor of polypharmacy is the complex symptom profile of these neurological disorders. Potentially inappropriate medication (PIM), drug-drug interactions, poor treatment adherence, severe disease course, cognitive impairment, hospitalisation, poor quality of life, frailty and mortality have been associated with polypharmacy in patients with dementia, PD or MS. For patients with polypharmacy, either the avoidance of PIM (selective deprescribing) or the substitution of PIM with more suitable drugs (appropriate polypharmacy) is recommended to achieve a more effective therapeutic management.

Polypharmacy and Cognition Function Among Rural Adults

BACKGROUND

Polypharmacy (using≥5 medications) is associated with poor health outcomes. Mixed results from past studies surrounding chronic medication use, control of chronic conditions, and their effects on cognitive performance warrant further attention.

OBJECTIVE

Investigate a link between polypharmacy and cognition function in rural-dwelling adults in Texas, USA.

METHODS

Project FRONTIER (Facing Rural Obstacles to Healthcare Now Through Intervention, Education & Research) is a cross-sectional epidemiological study using community-based participatory research in three counties of Texas. Residents age > 40 were eligible for inclusion. The primary outcome is cognitive impairment, and exposures of interest are polypharmacy; comorbidities; and diabetes, hypertension, and depression medication. Logistic regression was used to assess association.

RESULTS

Six hundred eighty-nine individuals participated; the mean age was 61, and the majority were female (68.7%).The median number of medications taken by participants was 3.3 (IQR: 0-5); the rate of polypharmacy was 29.6%. Anti-hypertensive agents were the most common medications (15%) used. Polypharmacy users were 2.84 times more likely to have cognitive impairment [OR: 2.84, 95%CI (1.32-6.09)] than those using < 5 medications. Participants on hypertensive medications had 1.85 times higher odds [OR: 1.85, 95%CI (1.14-3.01)] of having cognitive impairment than those who did not have cognitive impairment.

CONCLUSION

Polypharmacy increases the odds of cognitive impairment. The odds of presenting with cognitive impairment increased as the number of medications increased. Additionally, we identified a large, concerning number of participants with pharmacotherapy and poor chronic disease management. A larger study should examine medication adherence among rural elders to manage chronic disease and any healthcare barriers to adherence.

Relationship between administrative characteristics of long-term care institutions and use of antipsychotics and anxiolytics in residents with cognitive impairment

OBJECTIVES

To identify the facility characteristics that are associated with prescribing practices of typical and atypical antipsychotics, and anxiolytics in residents with cognitive impairment in long-term care (LTC) institutions.

METHODS

A cross-sectional analysis of a country-representative sample of 23 LTC institutions in Poland was conducted in 2015-2016. Trained staff from each facility used the InterRAI-LTCF tool and drug dispensary cards on the day of resident's assessment to collect data on medication use from 455 residents with cognitive impairment. We used the anatomical therapeutic chemical classification and a multiple correspondence analysis.

RESULTS

We identified facility characteristics associated with higher rate of prescribing of: typical antipsychotics (nursing home, private ownership status, higher staff/bed ratio of physicians and nurses, and lower as refers to care assistants); atypical antipsychotics (residential home, public ownership status, higher staff/bed ratio of care assistants, and lower as refers to physicians); and anxiolytics (residential home, facilities of small size, public ownership status, higher staff/bed ratio of care assistants, lower of nurses and physicians). In the facilities where less residents received typical antipsychotics, anxiolytics were prescribed more often, and vice versa (rho = -0.442; p = 0.035).

CONCLUSION

This study showed a considerable variation in the use of typical and atypical antipsychotics, and anxiolytics between nursing and residential homes, which was associated with their organization (type, size, ownership status, and employment rate). We found a negative correlation between prescribing typical antipsychotics and anxiolytics, which made us aware that these medications may be used interchangeably in LTC facilities, despite the fact that both should be avoided.

Factors associated with drug prescribing practices in long-term care patients with cognitive impairment

PURPOSE

To examine factors associated with prescribing anti-dementia medicines (ADM), atypical antipsychotics (A-APM), typical antipsychotics (T-APM), anxiolytics and other psychostimulants (OP) in the residents of long-term care institutions (LTCIs).

METHODS

A cross-sectional survey of a country-representative sample of randomly selected LTCIs in Poland, conducted in 2015-2016. First, we identified 1035 residents with cognitive impairment (CI) among all 1587 residents. Next, we randomly selected 20 residents from each institution. Study sample consists of 455 residents with CI: 214 recruited from 11 nursing homes and 241 from 12 residential homes. We used InterRAI-LTCF questionnaire and drug dispensary cards administered on the day of data collection to assess use of drugs. Multiple correspondence analysis (MCA), descriptive and logistic regression analyses were performed.

RESULTS

The residents were treated with ADM (13.4%), OP (14.3%), antipsychotics (46.4%) including A-APM (24.2%) and T-APM (27.9%), and anxiolytics (28.4%). Hydroxyzine was used most often among anxiolytics (71.3%). Prescribing of ADM was more likely in Alzheimer's disease (OR = 4.378; 95%CI 2.173-8.823), while OP in other dementia (OR = 1.873; 95%CI 1.007-3.485). Administration of A-APM was more likely in older residents (OR = 1.032, 95%CI 1.009-1.055), and when delusions appeared (OR = 2.082; 95%CI 1.199-3.613), while there were no neuropsychiatric factors increasing the odds of T-APM use. Prescribing of anxiolytics was less likely in moderate CI (by 47.2%) than in residents with mild CI.

CONCLUSION

Current practices of prescribing psychotropics are inadequate in Polish LTCIs, especially in terms of use of T-APM and hydroxyzine. More attention should be given to motivate physicians to change their prescribing practices.

Outcomes of Medication Misadventure Among People With Cognitive Impairment or Dementia: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate mortality and hospitalization outcomes associated with medication misadventure (including medication errors [MEs], such as the use of potentially inappropriate medications [PIMs], and adverse drug events [ADEs]) among people with cognitive impairment or dementia.

DATA SOURCES

Ovid MEDLINE, Ovid EMBASE, Ovid International Pharmaceutical Abstracts, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials were searched from inception to December 2019.

STUDY SELECTION AND DATA EXTRACTION

Relevant studies using any study design were included. Reviewers independently performed critical appraisal and extracted relevant data.

DATA SYNTHESIS

The systematic review included 10 studies that reported the outcomes of mortality or hospitalization associated with medication misadventure, including PIMs (n=5), ADEs (n=2), a combination of MEs and ADEs (n=2), and drug interactions (n=1). Five studies examining the association between PIMs and mortality/hospitalization were included in the meta-analyses. Exposure to PIMs was not associated with either mortality (odds ratio [OR]=1.36; 95%CI=0.79-2.35) or hospitalization (OR=1.02; 95%CI=0.83-1.26). In contrast, single studies indicated that ADEs with cholinesterase inhibitors were associated with mortality and hospitalization.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Individuals with cognitive impairment or dementia are at increased risk of medication misadventure; based on relatively limited published data, this does not necessarily translate to increased mortality and hospitalization.

CONCLUSIONS

Overall, medication misadventure was not associated with mortality or hospitalization in people with cognitive impairment or dementia, noting the limited number of studies, difficulty in controlling potential confounding variables, and that most studies focus on PIMs.

Pharmacist-led medication reviews in aged care residents with dementia: A systematic review

OBJECTIVES

To evaluate outcomes associated with pharmacist-led medication reviews in residential aged care facility (RACF) residents with dementia.

METHODS

Six scientific databases were searched. All study designs investigating pharmacist-led medication reviews in RACF residents with dementia were considered. The protocol was registered with PROSPERO (CRD42019121681).

RESULTS

One randomised controlled trial (RCT) and five observational studies were identified. Two studies reported reductions in medication usage per resident, and one study reported improved appropriateness of psychotropic use following reviews as part of multi-faceted, collaborative interventions. In three studies, reviews undertaken as an isolated intervention or by a visiting pharmacist with minimal collaboration with physicians were associated with low implementation rates of recommendations to alter therapy.

CONCLUSION

Pharmacist-led medication reviews, when conducted collaboratively, may improve the use of medicines in RACF residents with dementia. However, robust conclusions cannot be drawn, largely due to the low quality of evidence available, including only one RCT.

Psychotropic Medication Prescribing Practice Among Residents With Dementia in Nursing Homes: A Person-Centered Care Approach

Despite multiple national initiatives to improve quality of life in nursing home (NH) residents with dementia, inefficiencies still exist regarding inappropriate psychotropic medication use to manage communication of distress. The goals of the current article are to: (a) create a person-centered care plan/process for NH community staff to manage challenging dementia behaviors; (b) provide guidelines for geriatric practitioners (GPs) to decrease psychotropic medication use in residents with dementia; (c) discuss organizational culture and its relationship to the management of non-cognitive neuropsychiatric symptoms (NPS) of dementia; and (d) emphasize nonpharmacological approaches as first-line treatment of NPS in NH residents with dementia. [Journal of Gerontological Nursing, 46(2), 9-17.].

Laxative use among older adults with intellectual disability: a cross-sectional observational study

BACKGROUND

Chronic constipation is a prevalent issue in older people with intellectual disabilities and may have a significant negative impact on quality of life. The use of laxatives have not been adequately studied in this population.

OBJECTIVE

To examine laxatives in relation to prevalence, pattern, dosage, reported indication and correlates.

SETTING

Older people with intellectual disabilities who live independently, in community group homes or residential care in Ireland.

METHOD

Data was extracted from wave 2 (2013/2014) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA). Descriptive statistics, bivariate analyses and multiple logistic regression were carried out. Laxative use was analysed using two indicators for chronic constipation, reported doctor's diagnosis of constipation and Rome III criteria.

MAIN OUTCOME MEASURE

Laxative use.

RESULTS

Among the cohort n = 677, chronic constipation was reported by 38.5% (n = 257). In total 41.5% (n = 281) reported 431 laxatives (mean ± 1.53 ± 0.74), with 74.3% (n = 209) of those with laxative use reporting chronic constipation. There were 40% (n = 113) who took 2 + laxatives, within which, 60% (n = 67) were using a combination from same laxative class. Reporting chronic constipation, living in residential care, exposure to anticholinergics and receiving soft/liquidized food were significantly associated with laxative use.

CONCLUSION

Chronic constipation and laxative use were highly prevalent in this study of older adults with intellectual disabilities. The treatment of constipation appeared to be unsystematic. Intra-class laxative use was frequent. There is a need for evidence-based treatment guidelines developed especially for people with intellectual disabilities to provide effective, quality care.

Polypharmacy Increases Risk of Dyspnea Among Adults With Serious, Life-Limiting Diseases

BACKGROUND

Polypharmacy is associated with dyspnea in cross-sectional studies, but associations have not been determined in longitudinal analyses. Statins are commonly prescribed but their contribution to dyspnea is unknown. We determined whether polypharmacy was associated with dyspnea trajectory over time in adults with advanced illness enrolled in a statin discontinuation trial, overall, and in models stratified by statin discontinuation.

METHODS

Using data from a parallel-group unblinded pragmatic clinical trial (patients on statins ≥3 months with life expectancy of 1 month to 1 year, enrolled in the parent study between June 3, 2011, and May 2, 2013, n = 308/381 [81%]), we restricted analyses to patients with available baseline medication count and ≥1 dyspnea score. Polypharmacy was assessed by self-reported chronic medication count. Dyspnea trajectory group, our primary outcome, was determined over 24 weeks using the Edmonton Symptom Assessment System.

RESULTS

The mean age of the patients was 73.8 years (standard deviation [SD]: ±11.0) and the mean medication count was 11.6 (SD: ±5.0). We identified 3 dyspnea trajectory groups: none (n = 108), mild (n = 130), and moderate-severe (n = 70). Statins were discontinued in 51.8%, 48.5%, and 42.9% of patients, respectively. In multivariable models adjusting for age, sex, diagnosis, and statin discontinuation, each additional medication was associated with 8% (odds ratio [OR] = 1.08 [1.01-1.14]) and 16% (OR = 1.16 [1.08-1.25]) increased risk for mild and moderate-severe dyspnea, respectively. In stratified models, polypharmacy was associated with dyspnea in the statin continuation group only (mild OR = 1.12 [1.01-1.24], moderate-severe OR = 1.24 [1.11-1.39]) versus statin discontinuation (mild OR = 1.03 [0.95-1.12], and moderate-severe OR = 1.09 [0.98-1.22]).

CONCLUSION

Polypharmacy was strongly associated with dyspnea. Prospective interventions to decrease polypharmacy may impact dyspnea symptoms, especially for statins.

Polypharmacy and Potentially Inappropriate Medication in People with Dementia: A Nationwide Study

BACKGROUND

Polypharmacy (use of ≥5 different medications) and potentially inappropriate medication (PIM) are well-known risk factors for numerous negative health outcomes. However, the use of polypharmacy and PIM in people with dementia is not well-described.

OBJECTIVE

To examine the prevalence of polypharmacy and PIM in older people with and without dementia in a nationwide population.

METHODS

Cross-sectional study of the Danish population aged ≥65 in 2014 (n = 1,032,120) based on register data, including information on diagnoses and dispensed prescriptions. Polypharmacy and PIM use among people with (n = 35,476) and without dementia (n = 994,231) were compared, stratified by living situation and adjusted for age, sex, and comorbidity. The red-yellow-green list from the Danish Institute for Rational Pharmacotherapy and the German PRISCUS list were used to define PIM.

RESULTS

People with dementia were more frequently exposed to polypharmacy (dementia: 62.6% versus no-dementia: 35.1%, p < 0.001) and likewise PIM (red-yellow-green: 45.0% versus 29.7%, p < 0.001; PRISCUS: 24.4% versus 13.2%, p < 0.001). After adjustments for age, sex, and comorbidity, the likelihood of polypharmacy and PIM was higher for community-dwelling people with dementia than without dementia (odds ratio (OR); [95% confidence interval (CI)] polypharmacy: 1.50 [1.45-1.55]; red-yellow-green: 1.27 [1.23-1.31]; PRISCUS: 1.25 [1.20-1.30]). In contrast, dementia slightly decreased the odds of polypharmacy and PIM in nursing home residents.

CONCLUSION

Use of polypharmacy and PIM were widespread in the older population and more so in people with dementia. This could have negative implications for patient-safety and demonstrates the need for interventions to improve drug therapy in people with dementia.

Association between polypharmacy and dementia - A systematic review and metaanalysis

Objective: The association between polypharmacy and dementia is controversial. This systematic review and meta-analysis aims to summarize existing literature concerning the association between polypharmacy and dementia. Methods: A systematic literature review was performed by searching the EMBASE, PubMed, Scopus and International Pharmaceutical Abstract databases using terms related to polypharmacy and dementia. A meta-analysis was performed using random effect models. Results: Seven studies were included in this meta-analysis. The included studies were of medium to high quality with a potential for publication bias. A strong association between polypharmacy and dementia was found (pooled adjusted risk ratio (aRR) = 1.30 (95% CI: 1.16-1.46), I² = 68%). Excessive polypharmacy was also strongly associated with dementia (pooled aRR = 1.52 (95% CI: 1.39-1.67), I² = 24%). Conclusion: Pooled risk estimates from this meta-analysis showed that polypharmacy was associated with dementia. Although the causality of the relationship cannot be concluded from this analysis, the finding encourages the use of multidimensional assessment tools for dementia that includes the number of medications as a component.

Anticholinergic burden and risk of cognitive impairment in elderly nursing home residents with depression

BACKGROUND

Although the adverse cognitive effects of anticholinergic medications in the elderly are well-documented, little is known regarding the cognitive impact of anticholinergics among nursing home residents with depression.

OBJECTIVE

This study examined the risk of mild-to-moderate cognitive impairment due to anticholinergic burden among elderly nursing home residents with depression.

METHODS

A population-based nested case-control study was conducted using Minimum Data Set (MDS)-linked Medicare data where the base cohort included patients ≥ 65 years with depression who had intact cognition (MDS Cognition score of 0 or 1) and no dementia. Cases were identified as those who had mild-to-moderate cognition (MDS Cognition score of 2-4). Each case was matched on age and sex to one control using incidence density sampling. The study evaluated cumulative anticholinergic burden (defined as score of 3 or more) within 30, 60 and 90 days preceding the event date based on the Anticholinergic Drug Scale (ADS). Conditional logistic regression model stratified on matched case-control sets was performed to evalaute cognitive impairment due to cumulative anticholinergic burden after controlling for other risk factors.

RESULTS

The study sample included 3707 cases with mild-to-moderate cognition and 3707 matched controls with intact cognition. Bivariate analysis showed significant association between cumulative anticholinergic exposure and cognitive impairment (Odds Ratio [OR], 1.15; 95% Confidence Interval [CI],1.04-1.30); after controlling for potential risk factors, cumulative anticholinergic exposure 30 days preceding the event was no longer associated with cognitive impairment, (aOR, 1.07; 95% CI, 0.95-1.21). However, the odds of cognitive impairment increased with cumulative anticholinergic exposure 60 days (aOR 1.16; 1.04-1.30) and 90 days (aOR 1.28; 1.14-1.44) before the event date.

CONCLUSION

Cumulative anticholinergic use for prolonged exposure periods was associated with modestly increased risk of cognitive impairment in elderly residents with depression who had intact cognition. The findings suggest the need to be cautious when prescribing multiple anticholinergic drugs in residents, including those with intact cognition.

Identifying potentially inappropriate prescribing in older people with dementia: a systematic review

PURPOSE

Older people with dementia are at risk of adverse events associated with potentially inappropriate prescribing.

AIM

to describe (1) how international tools designed to identify potentially inappropriate prescribing have been used in studies of older people with dementia, (2) the prevalence of potentially inappropriate prescribing in this cohort and (3) advantages/disadvantages of tools METHODS: Systematic literature review, designed and reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). MEDLINE, EMBASE, PsychInfo, CINAHL, the Cochrane Library, the Social Science Citation Index, OpenGrey, Base, GreyLit, Mednar and the National Database of Ageing Research were searched in April 2016 for studies describing the use of a tool or criteria to identify potentially inappropriate prescribing in older people with dementia.

RESULTS

Three thousand three hundred twenty-six unique papers were identified; 26 were included in the review. Eight studies used more than one tool to identify potentially inappropriate prescribing. There were variations in how the tools were applied. The Beers criteria were the most commonly used tool. Thirteen of the 15 studies using the Beers criteria did not use the full tool. The prevalence of potentially inappropriate prescribing ranged from 14 to 74% in older people with dementia. Benzodiazepines, hypnotics and anticholinergics were the most common potentially inappropriately prescribed medications.

CONCLUSIONS

Variations in tool application may at least in part explain variations in potentially inappropriate prescribing across studies. Recommendations include a more standardised tool usage and ensuring the tools are comprehensive enough to identify all potentially inappropriate medications and are kept up to date.

Intensive Interaction and discourses of personhood: A focus group study with dementia caregivers

INTRODUCTION

Societal discourses of dementia are medicalised and dehumanising. This leads to a social problem: the loss of personhood in dementia care. The communication technique Intensive Interaction, however, honours personhood. The current study aimed to explore how paid caregivers of people with dementia enact societal discourses of dementia, with and without the context of Intensive Interaction. This was to explore ways to address the loss of personhood in dementia care.

METHOD

Paid caregivers from two residential care homes attended an Intensive Interaction training day. Caregivers participated in focus groups before and after training. Transcripts of the focus groups were analysed with Critical Discourse Analysis, an approach which relates discourse to social power.

RESULTS

Before Intensive Interaction training, carers accessed medical discourses of loss, non-communication and lack of personhood. 'Being with' people with dementia was framed as separate to paid work. After training, caregivers accessed discourses of communication and personhood. Intensive Interaction reframed 'being with' people with dementia as part of 'doing work'. Family caregivers were largely absent from discourses. Care home hierarchies and the industrialisation of care were barriers towards honouring personhood.

CONCLUSIONS

Medical discourses of dementia reinforce a status quo whereby interpersonal interactions are devalued in dementia care, and professional 'knowledge' (thereby professional power) is privileged over relationships. Intensive Interaction may enable paid caregivers to access person-centred discourses and related practices. However, this requires support from management, organisational structures, and wider society. More research is needed to identify ways to involve families in residential care and to explore the effects of using Intensive Interaction in practice.

Building interpretable models for polypharmacy prediction in older chronic patients based on drug prescription records

Background

Multimorbidity presents an increasingly common problem in older population, and is tightly related to polypharmacy, i.e., concurrent use of multiple medications by one individual. Detecting polypharmacy from drug prescription records is not only related to multimorbidity, but can also point at incorrect use of medicines. In this work, we build models for predicting polypharmacy from drug prescription records for newly diagnosed chronic patients. We evaluate the models’ performance with a strong focus on interpretability of the results.

Methods

A centrally collected nationwide dataset of prescription records was used to perform electronic phenotyping of patients for the following two chronic conditions: type 2 diabetes mellitus (T2D) and cardiovascular disease (CVD). In addition, a hospital discharge dataset was linked to the prescription records. A regularized regression model was built for 11 different experimental scenarios on two datasets, and complexity of the model was controlled with a maximum number of dimensions (MND) parameter. Performance and interpretability of the model were evaluated with AUC, AUPRC, calibration plots, and interpretation by a medical doctor.

Results

For the CVD model, AUC and AUPRC values of 0.900 (95% [0.898–0.901]) and 0.640 (0.635–0.645) were reached, respectively, while for the T2D model the values were 0.808 (0.803–0.812) and 0.732 (0.725–0.739). Reducing complexity of the model by 65% and 48% for CVD and T2D, resulted in 3% and 4% lower AUC, and 4% and 5% lower AUPRC values, respectively. Calibration plots for our models showed that we can achieve moderate calibration with reducing the models’ complexity without significant loss of predictive performance.

Discussion

In this study, we found that it is possible to use drug prescription data to build a model for polypharmacy prediction in older population. In addition, the study showed that it is possible to find a balance between good performance and interpretability of the model, and achieve acceptable calibration at the same time.

Hospital admissions and place of death of residents of care homes receiving specialist healthcare services: Protocol for a systematic review

AIM

To synthesize the evidence relating to the ability of specialist care home support services to prevent the hospital admission of older care home residents, including hospital admission at the end-of-life.

DESIGN

Systematic review and narrative synthesis.

METHODS

Ten electronic databases will be searched from 2010 - 31 December 2018 using predetermined search terms. All studies of specialist healthcare services to meet care home residents' physical healthcare needs which provide outcome data on hospital admission or place of death compared with usual care will be included. Two reviewers will independently assess studies' eligibility and methodological quality using the Effective Public Health Practice Project Quality Assessment Tool. Data will be extracted by one reviewer and checked by a second according to predetermined categories. Data will be synthesized in evidence tables and narrative. Funder: National Institute for Health Research School for Social Care Research, November 2016.

DISCUSSION

Care of older people in care home settings is a key aspect of nursing nationally and internationally. This review will increase understanding of the extent to which different models of specialist healthcare support for care homes are associated with key resident outcomes.

IMPACT

Standard healthcare support for care home residents is often inadequate, resulting in avoidable hospital admissions and lack of resident choice as to place of death. Although a range of specialist healthcare services are emerging, little is known about their relative effectiveness. This paper marshalls evidence of relevance to commissioners investing in healthcare provision to care homes to meet NHS targets.

The epidemiology of polypharmacy in older adults: register-based prospective cohort study

Objective

Polypharmacy is the concomitant use of several drugs by a single person, and it increases the risk of adverse drug-related events in older adults. Little is known about the epidemiology of polypharmacy at the population level. We aimed to measure the prevalence and incidence of polypharmacy and to investigate the associated factors.

Methods

A prospective cohort study was conducted using register data with national coverage in Sweden. A total of 1,742,336 individuals aged ≥65 years at baseline (November 1, 2010) were included and followed until death or the end of the study (December 20, 2013).

Results

On average, individuals were exposed to 4.6 (SD =4.0) drugs at baseline. The prevalence of polypharmacy (5+ drugs) was 44.0%, and the prevalence of excessive polypharmacy (10+ drugs) was 11.7%. The incidence rate of polypharmacy among individuals without polypharmacy at baseline was 19.9 per 100 person-years, ranging from 16.8% in individuals aged 65-74 years to 33.2% in those aged ≥95 years (adjusted hazard ratio [HR] =1.49, 95% confidence interval [CI] 1.42-1.56). The incidence rate of excessive polypharmacy was 8.0 per 100 person-years. Older adults using multi-dose dispensing were at significantly higher risk of developing incident polypharmacy compared with those receiving ordinary prescriptions (HR =1.51, 95% CI 1.47-1.55). When adjusting for confounders, living in nursing home was found to be associated with lower risks of incident polypharmacy and incident excessive polypharmacy (HR =0.79 and HR =0.86, p<0.001, respectively).

Conclusion

The prevalence and incidence of polypharmacy are high among older adults in Sweden. Interventions aimed at reducing the prevalence of polypharmacy should also target potential incident polypharmacy users as they are the ones who fuel future polypharmacy.

A Systematic Review of Practice Guidelines and Recommendations for Discontinuation of Cholinesterase Inhibitors in Dementia

Cholinesterase inhibitors (ChEIs) are the primary pharmacological treatment for symptom management of Alzheimer disease (AD), but they carry known risks during long-term use, and do not guarantee clinical effects over time. The balance of risks and benefits may warrant discontinuation at different points during the disease course. Indeed, although there is limited scientific study of deprescribing ChEIs, clinicians routinely face practical decisions about whether to continue or stop medications. This review examined published practice recommendations for discontinuation of ChEIs in AD. To characterize the scientific basis for recommendations, we first summarized randomized controlled trials of ChEI discontinuation. We then identified practice guidelines by professional societies and in textbooks and classified them according to 1) whether they made a recommendation about discontinuation, 2) what the recommendation was, and 3) the proposed grounds for discontinuation. There was no consensus in guidelines and textbooks about discontinuation. Most recommended individualized discontinuation decisions, but there was essentially no agreement about what findings or situations would warrant discontinuation, or even about what domains to consider in this process. The only relevant domain identified by most guidelines and textbooks was a lack of response or a loss of effectiveness, both of which can be difficult to ascertain in the course of a progressive condition. Well-designed, long-term studies of discontinuation have not been conducted; such evidence is needed to provide a scientific basis for practice guidelines. It seems reasonable to apply an individualized approach to discontinuation while engaging patients and families in treatment decisions. .

Research Priorities for Optimizing Geriatric Pharmacotherapy: An International Consensus

Medication management is becoming increasingly challenging for older people, and there is limited evidence to guide medication prescribing and administration for people with multimorbidity, frailty, or at the end of life. Currently, there is a lack of clear research priorities in the field of geriatric pharmacotherapy. To address this issue, international experts from 5 research groups in geriatric pharmacotherapy and pharmacoepidemiology research were invited to attend the inaugural Optimizing Geriatric Pharmacotherapy through Pharmacoepidemiology Network workshop. A modified nominal group technique was used to explore and consolidate the priorities for conducting research in this field. Eight research priorities were elucidated: quality of medication use; vulnerable patient groups; polypharmacy and multimorbidity; person-centered practice and research; deprescribing; methodological development; variability in medication use; and national and international comparative research. The research priorities are discussed in detail in this article with examples of current gaps and future actions presented. These priorities highlight areas for future research in geriatric pharmacotherapy to improve medication outcomes in older people.

Health determinants and survival in nursing home residents in Europe: Results from the SHELTER study

OBJECTIVE

The care processes directed towards institutionalized older people needs to be tailored on goals and priorities that are relevant for this specific population. The aim of the present study was (a) to describe the distribution of selected health determinants in a sample of institutionalized older adults, and (b) to investigate the impact on survival of such measures.

DESIGN

Multicentre longitudinal cohort-study.

SETTING

57 nursing homes (NH) in 7EU countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands) and 1 non-EU country (Israel).

PARTICIPANTS

3036 NH residents participating in the Services and Health for Elderly in Long TERm care (SHELTER) study.

MEASUREMENTS

We described the distribution of 8 health determinants (smoking habit, alcohol use, body mass index [BMI], physical activity, social participation, family visits, vaccination, and preventive visits) and their impact on 1-year mortality.

RESULTS

During the one-year follow up, 611 (20%) participants died. Overweight (HR 0.79; 95% C.I. 0.64-0.97) and obesity (HR 0.64; 95% C.I. 0.48-0.87) resulted associated with lower mortality then normal weight. Similarly, physical activity (HR 0.67; 95% C.I. 0.54-0.83), social activities (HR 0.63; 95% C.I. 0.51-0.78), influenza vaccination (HR 0.66; 95% C.I. 0.55-0.80) and pneumococcal vaccination (HR 0.76 95% C.I. 0.63-0.93) were associated with lower mortality. Conversely, underweight (HR 1.28; 95% C.I. 1.03-1.60) and frequent family visits (HR 1.75; 95% C.I. 1.27-2.42) were associated with higher mortality.

CONCLUSIONS

Health determinants in older NH residents depart from those usually accounted for in younger and fitter populations. Ad hoc studies are warranted in order to describe other relevant aspects of health in frail older adults, with special attention on those institutionalized, with the ultimate goal of improving the quality of care and life.

Poor adherence to chronic obstructive pulmonary disease medications in primary care: Role of age, disease burden and polypharmacy

AIM

The aim of the present study was to assess the occurrence and determinants of poor adherence to pharmacological treatment in a cohort of primary care patients with chronic obstructive pulmonary disease (COPD), paying special attention to the role of age, comorbidity and polypharmacy.

METHODS

We identified a cohort of COPD patients using the primary care Italian Health Search - IMS Longitudinal Patient Database. We assessed 1-year adherence to COPD maintenance pharmacotherapy (encompassing inhaled corticosteroids, long-acting beta agonists and long-acting anticholinergics). Poor adherence was defined as <80% of proportion of days covered by pharmacological treatment over a 1-year period.

RESULTS

Of 22 505 patients (mean age 67.3 ± 13.2; 41.3% women) entering the study, 17 486 (77.7%) were poorly adherent. According to multivariate analysis, poor adherence is less likely in older adults (OR 0.51, 95% CI 0.40-0.66), in non-smokers (OR 0.77, 95% CI 0.69-0.86) and in those with a history of alcohol abuse (OR 0.74, 95% CI 0.58-0.94). Higher comorbidity (OR 1.43, 95% CI 1.13-1.80) was positively associated with poor adherence. Polypharmacy was associated with poor adherence only in patients aged ≥65 years (OR 1.34, 95% CI 1.13-1.59). Finally, COPD severity was associated with a reduced likelihood of poor adherence (OR 0.20, 95% CI 0.07-0.61 for stage IV).

CONCLUSIONS

The present findings show that poor medication adherence is common in patients with COPD receiving long-term treatment. The interaction between age and polypharmacy, and the role of comorbidity suggest a pivotal role of biological age as a steering determinant of poor adherence. Geriatr Gerontol Int 2017; 17: 2500-2506.

Prevalence of Potentially Inappropriate Medication Use in Older Adults Living in Nursing Homes: A Systematic Review

IMPORTANCE

As older adults living in nursing homes are at a high risk of adverse drug-related events, medications with a poor benefit/risk ratio or with a safer alternative should be avoided.

OBJECTIVES

To systematically evaluate the prevalence of potentially inappropriate medication use in nursing home residents.

EVIDENCE REVIEW

We searched in PubMed and EMBASE databases (1990-2015) for studies reporting the prevalence of potentially inappropriate medication use in people ≥60 years of age living in nursing homes. The risk of bias was assessed with an adapted version of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist.

FINDINGS

A total of 91 articles were assessed for eligibility, and 48 met our inclusion criteria. These articles reported the findings from 43 distinct studies, of which 26 presented point prevalence estimates of potentially inappropriate medication use (227,534 nursing home residents). The overall weighted point prevalence of potentially inappropriate medication use in nursing homes was 43.2% [95% confidence interval (CI) 37.3%-49.1%], increasing from 30.3% in studies conducted during 1990-1999 to 49.8% in studies conducted after 2005 (P < .001). Point prevalence estimates reported in European countries were found to be higher (49.0%, 95% CI 42.5-55.5) than those reported in North America (26.8%, 95% CI 16.5-37.1) or in other countries (29.8%, 95% CI 19.3-40.3). In addition, 18 studies accounting for 326,562 nursing home residents presented 20 distinct period prevalence estimates ranging from 2.3% to 50.3%. The total number of prescribed medications was consistently reported as the main driving factor for potentially inappropriate medications use.

CONCLUSIONS AND RELEVANCE

This systematic review shows that almost one-half of nursing home residents are exposed to potentially inappropriate medications and suggests an increase prevalence over time. Effective interventions to optimize drug prescribing in nursing home facilities are, therefore, needed.

Factors associated with polypharmacy and excessive polypharmacy in older people with intellectual disability differ from the general population: a cross-sectional observational nationwide study

OBJECTIVES

(1) To evaluate the prevalence of polypharmacy (5-9 medicines) and excessive polypharmacy (10+ medicines) and (2) to determine associated demographic and clinical characteristics in an ageing population with intellectual disabilities (IDs).

DESIGN

Observational cross-sectional study.

SETTING

Wave One (2009/2010) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA).

PARTICIPANTS

A nationally representative sample of 753 persons with ID, aged between 41 and 90 years. Participants/proxy reported medicines (prescription and over the counter) taken on a regular basis; medication data was available for 736 participants (98%).

MAIN OUTCOME MEASURES/INTERVENTIONS

Participants were divided into those with no polypharmacy (0-4 medicines), polypharmacy (5-9 medicines) and excessive polypharmacy (10+ medicines). Medication use patterns were analysed according to demographic variables and reported chronic conditions. A multinomial logistic regression model identified factors associated with polypharmacy (5-9 medicines) and excessive polypharmacy (≥10 medicines).

RESULTS

Overall, 90% of participants reported use of medicines. Polypharmacy was observed in 31.5% of participants and excessive polypharmacy in 20.1%. Living in a residential institution, and reporting a mental health or neurological condition were strongly associated with polypharmacy and excessive polypharmacy after adjusting for confounders, but age or gender had no significant effect.

CONCLUSIONS

Polypharmacy was commonplace for older adults with ID and may be partly explained by the high prevalence of multimorbidity reported. Review of appropriateness of medication use is essential, as polypharmacy places ageing people with ID at risk of adverse effects.

Polypharmacy, potentially inappropriate medication and cognitive status in Austrian nursing home residents: results from the OSiA study

There is little research investigating polypharmacy and potentially inappropriate medications (PIM) in connection with cognitive status in residents of Austrian nursing homes. Our findings result from a cross-sectional survey of 425 residents (315 women, 110 men, mean 83.6 years) from 12 Austrian nursing homes. The number of systemically administered permanent prescription drugs was 8.99 ± 3.9 and decreased significantly with increasing cognitive impairment. Irrespective of cognitive status, polypharmacy (> 5 individual substances) was present in approximately 75% of the residents. Hyper-polypharmacy (> 10 individual substances) was present among almost 50% of the cognitively intact residents, and hence, significantly more frequent as compared with the group with the lowest cognitive performance (23.4%). At least one PIM was found in 72.4% of residents regardless of cognitive status. Predominantly, PIMs consisted of tranquilizers, antipsychotics, osmotic laxatives, non-steroidal anti-inflammatory drugs (NSAIDs) and anticholinergics, where only the number of NSAIDs decreased significantly with increasing cognitive impairment. In summary, our study shows a continued high prevalence of polypharmacy and PIM in long-term care institutions in Austria.

Chronic diseases and geriatric syndromes: The different weight of comorbidity

BACKGROUND

Comorbidity is a relevant health determinant in older adults. Co-occurrence of several diseases and other age-associated conditions generates new clinical phenotypes (geriatric syndromes [GS] as falls, delirium etc.). We investigated the association of chronic diseases, alone or in combination, and GS in older adults receiving home care services in 11 European countries and one Canadian province.

METHODS

Participants were cross-sectionally evaluated with the multidimensional assessment instrument RAI HC. We assessed 14 different diagnoses and 8 GS (pain, urinary incontinence, falls, disability, dizziness, weight loss, pressure ulcers and delirium). Adjusted mean number of GS per participant was calculated for groups of participants with each disease when occurring alone or with comorbidity.

RESULTS

The mean age of the 6903 participants was 82.2±7.4 years and 4750 (69%) were women. Participants presented with an average of 2.6 diseases and 2.0 GS: pain (48%), urinary incontinence (47%) and falls (33%) were the most prevalent. Parkinson's disease, cerebrovascular disease and peripheral artery disease were associated with the highest number of GS (2.5, 2.3 and 2.2, respectively). Conversely, hypertension, diabetes, dementia, cancer and thyroid dysfunction were associated with the lowest number of GS (2.0 on average). For 9/14 examined diseases (hypertension, diabetes, dementia, COPD, heart failure, ischemic heart disease, atrial fibrillation, cancer and thyroid dysfunction) the number of GS increased with the degree of comorbidity.

CONCLUSIONS

Comorbidity and GS are prevalent in older adults receiving home care. Different diseases have a variable impact on occurrence of GS. Comorbidity is not always associated with an increased number of GS.

Methodological challenges in assessing the impact of comorbidities on costs in Alzheimer's disease clinical trials

BACKGROUND

Alzheimer's disease (AD) is associated with considerable costs and has a significant impact on health and social care systems.

OBJECTIVE

This study assessed whether baseline comorbidities present in 2,594 patients with AD participating in two semagacestat randomized placebo-controlled trials (RCTs) would significantly impact overall costs.

METHODS

Resource utilization was captured using the Resource Utilization in Dementia Scale-Lite. Comorbidities and concomitant medications were tabulated via patient and caregiver reports. Only baseline data were analyzed. Direct and indirect costs per month were calculated per patient. The relationship between cost and explanatory variables was explored in a regression model.

RESULTS

The baseline monthly cost of care in this RCT population was £1,147 ± 2,483, with informal care costs accounting for 75% of costs. Gender, age, and functional status were significant predictors of costs (p ≤ 0.0001). The cost ratio was not impacted when the number of comorbidities was added to the model (cost ratio = 0.95; 95% CI 0.91-0.99) or when combined with the number of concomitant medications (cost ratio = 0.97; 95% CI 0.95-1.00). Inconsistent findings related to the impact of individual comorbidities on costs were noted in sensitivity analyses.

CONCLUSIONS

The number of comorbidities, alone or when combined with concomitant medications, did not impact baseline costs of care, perhaps because RCTs often enroll less severely ill and more medically stable patients. However, higher costs were consistently associated with greater functional impairment similar to non-RCT databases. Supplemental sources (e.g., claims databases) are likely needed to better estimate the effects of disease and treatment on costs of illness captured in RCTs for AD.

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.