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

Relationship between medication safety-related processes and medication use in residential aged care facilities

OBJECTIVE

To explore the association between the implementation of medication safety-related processes measured with the Medication Safety Self-Assessment for Long-Term Care (MSSA-LTC) tool and medication use in residential aged care facilities (RACFs).

METHODS

A descriptive cross-sectional study was conducted in Australian RACFs. Data on facility characteristics, aggregated medication use at the facility level for selected medications commonly associated with a high risk of harm and the MSSA-LTC were completed by clinical pharmacists providing clinical pharmacy services. The Spearman's correlation test was used to evaluate the association between the MSSA-LTC score and medication use. A scatter plot between the MSSA-LTC score and medication use data was generated, and a linear trend line was plotted using the least squares method.

RESULTS

Data were collected from 31 RACFs servicing 2986 residents. Most medication safety-related processes were implemented in Australian RACFs. A higher facility MSSA-LTC score was associated with a lower proportion of residents with polypharmacy (r = -.48, p = .01) and one or more benzodiazepines (r = -.41, p = .03). In addition, a negative linear trend was observed between the MSSA-LTC score and the average number of medications per resident, the proportion of residents with one or more anticonvulsants and the proportion of residents using one or more opioid analgesics.

CONCLUSIONS

This study indicates that implementing medication safety-related processes may improve medication use in RACFs.

Reducing the drug burden of sedative and anticholinergic medications in older adults: a scoping review of explicit decision criteria

OBJECTIVES

To describe the extent, characteristics, and knowledge gaps regarding explicit decision criteria for deprescribing drugs with anticholinergic or sedative properties (Ach/Sed) in older adults.

DESIGN

Scoping review.

SETTING AND PARTICIPANTS

Original studies, clinical trial protocols, grey literature, and Summaries of Product Characteristics.

METHODS

Searches targeting explicit decision criteria for deprescribing Ach/Sed were performed across MEDLINE, EMBASE, CINAHL, and Web of Science, including trial registries (clinicaltrials.gov, ICTRP, EU-CTR, ANZCTR) for pertinent articles, study protocols. Additionally, to encompass non-traditional or 'grey literature' sources, Google searches and relevant agency websites were explored, alongside the summary of product characteristics for Ach/Sed.

RESULTS

The initial literature search identified 8,192 unique data sources. After review, 188 original articles or books, 79 internet sources, and 127 SmPCs were included. Examining these sources for explicit criteria for 154 Ach/Sed, overall, 1,271 explicit criteria guidance for identifying clinical scenarios warranting deprescription of Ach/Sed across 145/154 Ach/Sed were identified. These criteria were identified mainly from qualitative research and Summaries of Product Characteristics. Additionally, 455 criteria-based recommendations suggesting approaches for tapering implementation across 76/154 Ach/Sed were identified, mostly from sources classified as expert opinions. Significant heterogeneity was found across the approaches for tapering Ach/Sed.

CONCLUSIONS

This scoping review provides a comprehensive overview of the literature providing guidance for clinical scenarios where Ach/Sed should be deprescribed and highlights the existing knowledge gaps regarding comprehensive guidance on tapering these drugs which warranties future research and development.

Development and validation of search filters to retrieve medication discontinuation articles in Medline and Embase

BACKGROUND

Medication discontinuation studies explore the outcomes of stopping a medication compared to continuing it. Comprehensively identifying medication discontinuation articles in bibliographic databases remains challenging due to variability in terminology.

OBJECTIVES

To develop and validate search filters to retrieve medication discontinuation articles in Medline and Embase.

METHODS

We identified medication discontinuation articles in a convenience sample of systematic reviews. We used primary articles to create two reference sets for Medline and Embase, respectively. The reference sets were equally divided by randomization in development sets and validation sets. Terms relevant for discontinuation were identified by term frequency analysis in development sets and combined to develop two search filters that maximized relative recalls. The filters were validated against validation sets. Relative recalls were calculated with their 95% confidences intervals (95% CI).

RESULTS

We included 316 articles for Medline and 407 articles for Embase, from 15 systematic reviews. The Medline optimized search filter combined 7 terms. The Embase optimized search filter combined 8 terms. The relative recalls were respectively 92% (95% CI: 87-96) and 91% (95% CI: 86-94).

CONCLUSIONS

We developed two search filters for retrieving medication discontinuation articles in Medline and Embase. Further research is needed to estimate precision and specificity of the filters.

Medication use among the oldest old in the Faroe Islands-A national cross-sectional study

Aging is often associated with an increasing number of comorbidities that warrant use of multiple drugs which increases the use of potentially inappropriate medications (PIMs), drug-drug interactions (DDIs) and drug-related problems (DRPs). The aim is to assess the prevalence of polypharmacy, PIMs, DDIs and DRPs among Faroese residents aged ≥90 years. In this population-based cross-sectional study, 494 individuals ≥90 years were invited and 298 (60%) participated. A pharmacist-led medication review was performed based on self-information, electronic patient journal and the Faroese Prescription Registry. The prevalence of polypharmacy was 74% with no sex-difference. Approximately 60% of participants used PIMs, primarily benzodiazepines and proton pump inhibitors, the latter being a frequently implicated medication in DRPs. Opioid use was low compared with other Nordic studies. DRPs were observed for 79% with discrepancies in the medication lists as the most common cause, and DDIs were identified for 47% of participants, mostly moderately clinically relevant DDIs. In conclusion, the medication use among the oldest old Faroese resembled that in other Nordic countries with a high prevalence of polypharmacy and use of PIMs, especially PPIs and benzodiazepines. However, no sex-difference was noted in medication use and the use of opioids was low.

Person-centred medicine in the care home setting: development of a complex intervention

BACKGROUND

Person-centred medicine is recommended in the care of older patients. Yet, involvement of care home residents and relatives in medication processes remains limited in routine care. Therefore, we aimed to develop a complex intervention focusing on resident and relative involvement and interprofessional communication to support person-centred medicine in the care home setting.

METHODS

The development took place from October 2021 to March 2022 in the Municipality of Aarhus, Denmark. The study followed the Medical Research Council guidance on complex intervention development using a combination of theoretical, evidence-based, and partnership approaches. The patient involvement tool, the PREparation of Patients for Active Involvement in medication Review (PREPAIR), was included in a preliminary intervention model. Study activities included developing programme theory, engaging stakeholders, and exploring key uncertainties through interviews, co-producing workshops, and testing with end-users to develop the intervention and an implementation strategy. The Consolidated Framework for Implementation Research and the Interprofessional Shared Decision Making Model were used. Data were analysed using a rapid analysis approach.

RESULTS

Before the workshops, six residents and four relatives were interviewed. Based on their feedback, PREPAIR was modified to the PREPAIR care home to fit the care home population. In total, ten persons participated in the co-producing workshops, including health care professionals and municipal managerial and quality improvement staff. The developed intervention prototype was tested for three residents and subsequently refined to the final intervention, including two fixed components (PREPAIR care home and an interprofessional medication communication template) delivered in a flexible three-stage workflow. Additionally, a multi-component implementation strategy was formed. In line with the developed programme theory, the intervention supported health care professionals´ awareness about resident and relative involvement. It provided a structure for involvement, empowered the residents to speak, and brought new insights through dialogue, thereby supporting involvement in medication-related decisions. The final intervention was perceived to be relevant, acceptable, and feasible in the care home setting.

CONCLUSION

Our results indicate that the final intervention may be a viable approach to facilitate person-centred medicine through resident and relative involvement. This will be further explored in a planned feasibility study.

Factors Associated With PIM use in the Frail Elderly: A Cross-sectional Study

Background: The use of potentially inappropriate medications (PIM) by the elderly is commonly studied, but studies evaluating the use of PIM by frail elderly covered by prepaid health plans are still lacking. Objective: To identify the prevalence of use and the factors associated with the use of PIM by the elderly patients with high and moderate risk of clinical-functional vulnerability, according to the Beers criteria 2019. Methods: A cross-sectional study was developed with elderly people from a private health plan in Vitória-ES, Brazil. Socioeconomic, demographic and clinical data were collected through a digital platform and a structured questionnaire through an interview, from October 2018 to June 2019. The association between the use of PIM and independent variables was verified by univariate logistic regression with their respective confidence intervals (CI) 95%. The Multiple Model included the variables with P ≤ .20. Results: 332 elderly patients were interviewed (mean age 81.5 years, gender 237 female, 95 male). A 65% prevalence of PIM use was identified. In the multiple logistic regression model, the variables associated with the use of PIM were self-medication (P = .004), high risk of clinical-functional vulnerability (P = .022), use of psychotropic medications (P = .000001), musculoskeletal medications (P = .04) and alimentary tract medications (P = .03). Physical exercises were considered a protection factor (P = .02). Conclusion: The high prevalence of PIM use indicates the need for improvement in elderly private health care, to increase pharmacotherapy safety for this population.

Clinician and Family Caregiver Perspectives on Deprescribing Chronic Disease Medications in Older Nursing Home Residents Near the End of Life

INTRODUCTION

Nursing home (NH) residents with limited life expectancy (LLE) who are intensely treated for hyperlipidemia, hypertension, or diabetes may benefit from deprescribing.

OBJECTIVE

This study sought to describe NH clinician and family caregiver perspectives on key influences on deprescribing decisions for chronic disease medications in NH residents near the end of life.

METHODS

We recruited family caregivers of veterans who recently died in a Veterans Affairs (VA) NH, known as community living centers (CLCs), and CLC healthcare clinicians (physicians, nurse practitioners, physician assistants, pharmacists, registered nurses). Respondents completed semi-structured interviews about their experiences with deprescribing statin, antihypertensive, and antidiabetic medications for residents near end of life. We conducted thematic analysis of interview transcripts to identify key themes regarding influences on deprescribing decisions.

RESULTS

Thirteen family caregivers and 13 clinicians completed interviews. Key themes included (1) clinicians and caregivers both prefer to minimize drug burden; (2) clinical factors strongly influence deprescribing of chronic disease medications, with differences in how clinicians and caregivers weigh specific factors; (3) caregivers trust and rely on clinicians to make deprescribing decisions; (4) clinicians perceive caregiver involvement and buy-in as essential to deprescribing decisions, which requires time and effort to obtain; and (5) clinicians perceive conflicting care from other clinicians as a barrier to deprescribing.

CONCLUSIONS

Findings suggest a need for efforts to encourage communication with and education for family caregivers of residents with LLE about deprescribing, and to foster better collaboration among clinicians in CLC and non-CLC settings.

Assessing deprescribing tools for implementation in care homes: A qualitative study of the views of care home staff

BACKGROUND

Care home residents often experience polypharmacy (defined as taking five or more regular medicines). Therefore, we need to ensure that residents only take the medications that are appropriate or provide value (also known as medicines optimisation). To achieve this, deprescribing, or the reduction or stopping of prescription medicines that may no longer be providing benefit, can help manage polypharmacy and improve outcomes. Various tools, guides, and approaches have been developed to help support health professionals to deprescribe in regular practice. Little evaluation of these tools has been conducted and no work has been done in the care home setting.

OBJECTIVE

This qualitative study aimed to assess distinct types of deprescribing tools for acceptability, feasibility, and suitability for the care home setting.

METHODS

Cognitive (think-aloud) interviews with care home staff in England were conducted (from December 2021 to June 2022) to assess five different deprescribing tools. The tools included a general deprescribing guidance, a generic (non-drug specific) deprescribing framework, a drug-specific deprescribing guideline/guide, a tool for identifying potentially inappropriate medications, and an electronic clinical decision support tool. Participants were recruited via their participation in another deprescribing study. The Consolidated Framework for Implementation Research informed the data collection and analysis.

RESULTS

Eight care home staff from 7 different care homes were interviewed. The five deprescribing tools were reviewed and assessed as not acceptable, feasible, or suitable for the care home setting. All would require significant modifications for use in the care home setting (e.g., language, design, and its function or use with different stakeholders).

CONCLUSIONS

As none of the tools were deemed acceptable, feasible, and suitable, future work is warranted to develop and tailor deprescribing tools for the care home setting, considering its specific context and users. Deprescribing implemented safely and successfully in care homes can benefit residents and the wider health economy.

Medication review and deprescribing in different healthcare settings: a position statement from an Italian scientific consortium

Recent medical advancements have increased life expectancy, leading to a surge in patients affected by multiple chronic diseases and consequent polypharmacy, especially among older adults. This scenario increases the risk of drug interactions and adverse drug reactions, highlighting the need for medication review and deprescribing to reduce inappropriate medications and optimize therapeutic regimens, with the ultimate goal to improving patients' health and quality of life. This position statement from the Italian Scientific Consortium on medication review and deprescribing aims to describe key elements, strategies, tools, timing, and healthcare professionals to be involved, for the implementation of medication review and deprescribing in different healthcare settings (i.e., primary care, hospital, long-term care facilities, and palliative care). Challenges and potential solutions for the implementation of medication review and deprescribing are also discussed.

Thinking strategies used by registered nurses during drug administration in nursing homes-An observational study

AIM

To explore registered nurses' thinking strategies during the drug administration process in nursing homes.

DESIGN

An exploratory qualitative design.

METHODS

Eight registered nurses, one male and seven female, in five nursing home wards in Mid-Norway were observed during 15 drug dispensing rounds (175 drug dispensing episodes). Think Aloud sessions with follow-up individual interviews were conducted. The Think Aloud data were analysed using deductive qualitative content analysis based on Marsha Fonteyn's description of 17 thinking strategies. Interview data were used to clarify missing information and validate the content of Think Aloud data.

RESULTS

The registered nurses used all 17 thinking strategies described by Fonteyn, including several variants of each strategy. The three most frequent were 'providing explanations', 'setting priorities' and 'drawing conclusions'. In addition, we found two novel thinking strategies that did not fit into Fonteyn's template, which were labelled 'controlling' and 'interacting'. Among all strategies, 'controlling' was by far the most used, serving as a means for the registered nurses to stay on track and navigate through various interruptions, while also minimising errors during drug dispensing.

CONCLUSION

The study highlights the diverse thinking strategies employed by registered nurses in nursing homes during medication administration. The findings emphasise the multifaceted nature of medication administration and underscore the importance of skilled personnel in ensuring medication safety. Recognising the significance of these findings is crucial for maintaining patient well-being and upholding medication safety standards in healthcare settings.

RELEVANCE TO CLINICAL PRACTICE

Understanding the thinking strategies employed by registered nurses can inform training programmes and enhance the clinical judgements of health care professionals involved in medication administration, ultimately leading to improved patient outcomes and reduced medication errors in practice.

PATIENT OR PUBLIC CONTRIBUTION

Patients were involved in this study as recipients of drugs which the nurses distributed during the observations. The patients were involved as a third party and consent to the observations was either given by the patients themselves or relatives in cases where the patient was not competent to consent. No personal information was collected about the patients.

REPORTING METHOD

The reporting of this study adhered to the COREQ checklist.

[Dementia Prevention]

Dementia is common and will continue to grow in importance and numbers in the future. However, as causal treatment is not possible in most cases, prevention is particularly important. This is not only aimed at cognitively healthy people, but is also a central element in all phases of the disease.

Potentially Inappropriate Prescribing in Long-Term Care and its Relationship With Probable Delirium

OBJECTIVES

This study examined potentially inappropriate prescribing (PIP) of medication and its association with probable delirium among long-term care (LTC) residents in Ontario, Canada.

DESIGN

Population-based cross-sectional study using provincial health administrative data, including LTC assessment data via the Resident Assessment Instrument-Minimum Dataset version 2.0 (RAI-MDS 2.0).

SETTING AND PARTICIPANTS

LTC residents in Ontario between January 1, 2016, and December 31, 2019.

METHODS

We used residents' first RAI-MDS 2.0 assessment in the study period as the index assessment. Probable delirium was identified via the delirium Clinical Assessment Protocol. Medication use in the 2 weeks preceding assessment was captured using medication claims data. PIP was measured using the STOPP/START criteria and 2015 Beers criteria, with residents classified as having 0, 1, 2, or 3+ instances of PIP. Relationships between PIP and probable delirium was assessed via bivariate and multivariable logistic regression models.

RESULTS

The study population included 171,190 LTC residents (mean age 84.5 years, 66.8% female, 62.9% with dementia). More than half (51.8%) of residents had 1+ instances of PIP and 21% had 3+ instances of PIP according to the STOPP/START criteria; PIP prevalence was slightly lower when assessed using Beers criteria (36.5% with 1+, 11.1% with 3+). Overall, 3.7% of residents had probable delirium. The prevalence of probable delirium increased as the number of instances of PIP increased, with residents with 3+ instances of STOPP/START PIP being 1.66 times more likely (95% CI 1.56-1.77) to have probable delirium compared to those with no instances of PIP. Similar findings were observed when PIP was measured using the Beers criteria. Central nervous system (CNS)-related PIP criteria showed a stronger association with probable delirium than non-CNS-related PIP criteria.

CONCLUSIONS AND IMPLICATIONS

This population-based study highlighted that PIP was highly prevalent in long-term care residents and was associated with an increased prevalence of probable delirium.

[Estimation of the risk of drug-related problems in nursing home residents : A retrospective analysis of routine data]

BACKGROUND

Polypharmacy and drug-related problems are major challenges in the care and treatment of nursing home residents. Many interventional studies showed disappointing results, which lead to the question if this could also be due to the selection of the target parameters of these studies.

MATERIAL AND METHODS

A routine data set from six long-term care facilities was retrospectively analyzed. The question is if the recently validated medication risk score (MERIS) is suitable for carrying out a risk assessment in a population of nursing home residents. Associations between MERIS and the dependent variables hospital admissions and falls over 12 months and a weight loss of ≥ 5% over 3 months were examined.

RESULTS

Out of 495 residents 38.6% (n = 191) have a high risk of drug-related problems according to MERIS. A univariate regression analysis showed a significantly increased risk of hospital admissions (OR 2.2; p < 0.001) and weight loss of ≥ 5% (OR 1.95; p = 0.041) with high MERIS, but no significant association with falls. In the multivariate regression the risk of hospitalization was increased by diabetes mellitus (OR 1.88; p = 0.004), falls in the same period (OR 1.91; p = 0.001), positive MERIS (OR 1.75; p = 0.006) and decreased with stable weight (OR 0.88; p = 0.004).

CONCLUSION

The results indicate the potential of the score for future research projects and individual risk assessment; however, due to the limitations of retrospective secondary analyses further studies are required.

Transitions of Care: Strategies for Medication Optimization and Deprescribing in Older Adults

Older adults have an increased risk of adverse drug events related to polypharmacy and potentially inappropriate medication (PIM) use. These patients are even more vulnerable as they transition through different health care settings. In 2023, the American Geriatrics Society published an updated version of the Beers Criteria®, providing updated guidance on identifying and managing PIMs. Nurses and nurse practitioners play important roles in medication management across the continuum of care. The current article aims to illustrate key concepts regarding medication safety and deprescribing for older adult patients during transitions of care. [Journal of Gerontological Nursing, 49(12), 5-10.].

Determinants of implementing deprescribing for older adults in English care homes: a qualitative interview study

OBJECTIVES

To explore the factors that may help or hinder deprescribing practice for older people within care homes.

DESIGN

Qualitative semistructured interviews using framework analysis informed by the Consolidated Framework for Implementation Research (CFIR).

SETTING

Participants were recruited from two care home provider organisations (a smaller independently owned organisation and a large organisation) in England.

PARTICIPANTS

A sample of 23 care home staff, 8 residents, 4 family members and 1 general practitioner were associated with 15 care homes.

RESULTS

Participants discussed their experiences and perceptions of implementing deprescribing within care homes. Major themes of (1) deprescribing as a complex process and (2) internal and external contextual factors influencing deprescribing practice (such as beliefs, abilities and relationships) were interrelated and spanned several CFIR constructs and domains. The quality of local relationships with and support from healthcare professionals were considered more crucial factors than the type of care home management structure.

CONCLUSIONS

Several influencing social and contextual factors need to be considered for implementing deprescribing for older adults in care homes. Additional training, tools, support and opportunities need to be made available to care home staff, so they can feel confident and able to question or raise concerns about medicines with prescribers. Further work is warranted to design and adopt a deprescribing approach which addresses these determinants to ensure successful implementation.

Co-existence of malnutrition and sarcopenia and its related factors in a long-term nursing care facility: A cross-sectional study

Objectives

Malnutrition and sarcopenia often co-exist in older patients. This condition, called co-MS, shows a worse prognosis than either condition alone but is often overlooked and undertreated. We aimed to clarify the prevalence of co-MS and its associated factors with a focus on prescription in a long-term nursing care facility in Japan.

Methods

Patients aged >65 years who resided in a long-term nursing care facility in Hyogo, Japan, were recruited for this cross-sectional study, which was conducted from July 1 to July 30, 2022. Sarcopenia and malnutrition were diagnosed using the Asian Working Group for Sarcopenia and Global Leadership Initiative on Malnutrition criteria, respectively. Patients who met both criteria were classified as having co-MS. Potentially associated factors, including age, sex, length of stay, activities of daily living, comorbidity, oral function and hygiene, swallowing ability, and the number and type of prescriptions, were assessed.

Results

The prevalence of sarcopenia was 92 % (72/78). All malnourished patients were sarcopenic (40.3 %) and were classified as having co-MS. Oral function and hygiene, swallowing ability, comorbidity, and the presence of potentially inappropriate medications showed significant associations in univariate analyses. Of particular note, potentially inappropriate medication was an independent factor in the multivariate analysis.

Conclusions

Co-MS is prevalent in long-term nursing care facilities; thus, healthcare workers should pay attention to relevant factors to identify patients at risk of co-MS and to provide appropriate care and intervention.

Assessing implementation fidelity of an on-site pharmacist intervention within Australian residential aged care facilities: A mixed methods study

BACKGROUND

An on-site pharmacist (OSP) intervention was implemented which sought to improve medication management within residential aged care facilities (RACFs) in the Australian Capital Territory, Australia. The objectives of this mixed methods study were to evaluate the implementation fidelity of the OSP intervention and to determine the moderating factors which influenced delivery of this intervention.

METHODS

This convergent parallel mixed methods study was underpinned by Hasson's conceptual framework for implementation fidelity. Implementation fidelity for seven intervention RACFs was quantitatively assessed using three quantitative data sets: (1) range of OSP intervention activities delivered; (2) random sample of 10% of medication reviews assessed for quality; (3) proportion of residents who received at least one medication review. Semi-structured interviews (n = 14) with managers and OSPs across the intervention RACFs were conducted to identify moderating factors which may have influenced OSP intervention delivery.

RESULTS

The OSP intervention was generally delivered as intended with overall medium levels of implementation fidelity. This delivery was supported by a range of facilitation strategies with most participants perceiving that the intervention was delivered to a high standard. RACF managers and OSPs were mostly well engaged and responsive. A number of potential barriers (including the part-time OSP role, COVID-19 pandemic, RACFs spread out over a large area with significant distance between resident dwellings) and facilitators (including the pharmacist support meetings, OSPs who took time to establish relationships, RACF managers who actively supported OSPs and worked with them) for OSP intervention delivery were identified which have potential implications for the roll out of OSPs within Australian RACFs.

CONCLUSION

In this study, the implementation fidelity of OSP intervention delivery was assessed with overall medium levels of fidelity found across the intervention RACFs. This suggested that the OSP intervention can generally be delivered as intended in real world RACFs. OSP intervention delivery was influenced by a range of moderating factors, some of which posed barriers and others which facilitated the OSP intervention being delivered as intended.

Impact of the publication of the Finnish Meds75+ database on the use of potentially inappropriate medications in older persons

AIMS

To evaluate the impact of the updated nationwide Meds75+ database and its linkage to the Finnish health portal on the use of potentially inappropriate medications (PIMs) among older persons. We also aimed to evaluate whether there is regional variation in trend changes of PIM use.

METHODS

Meds75+ was implemented at the population level in 2015, so randomization is unfeasible. We used a quasi-experimental interrupted time series analysis to evaluate the changes in levels and trends of PIM use. The data included all Finnish community-dwelling persons aged ≥75 years (N = 920 163) who had medication purchases in the Prescription Register during 2009-2020. Data were linked with the Care Registers for Health and Social Care and the cause of death register.

RESULTS

The prevalence of PIMs decreased from 20.2% in 2009 to 11.7% in 2020. The change of level of the monthly PIM users was negative (β -0.036, 95% confidence interval [CI] -0.202 to 0.131), but not statistically significant (P = .673) after the publication of the database. We found a small decrease (β -0.018, 95% CI -0.083 to 0.047, P = .593) in the slope of PIM users, but it was not statistically significant. The regional results were similar to the main findings.

CONCLUSIONS

Publication of the updated Meds75+ database did not decrease the level or trend of PIM users. In addition, this study did not show any significant regional variation in PIM use trends. Further research should focus on determining barriers and facilitators to the utilization of PIM criteria in clinical practice.

Policies Shaping Nursing Home Medication Practices: Involving Nurses to Advance Individualized Deprescribing

Deprescribing is a common practice in the care of older adults, including those living in nursing homes (NHs). Deprescribing represents an individualized approach to optimizing medication use; it considers the risks, benefits, and goals of an individual, and can mitigate the effects of polypharmacy and potentially inappropriate medications. In NH settings, prescribing practices are shaped directly and indirectly by historical and contemporaneous policies at federal, state, and local levels, which have primarily targeted chemical restraints and unnecessary medications. Understanding these policies, their impact, and potentially unintended consequences is essential for gerontological nursing to transition toward individualized practices and approaches to deprescribing. [Journal of Gerontological Nursing, 49(9), 15-20.].

The OptimaMed intervention to reduce medication burden in nursing home residents with severe dementia: results from a pragmatic, controlled study

BACKGROUND

Nursing home (NH) residents with severe dementia use many medications, sometimes inappropriately within a comfort care approach. Medications should be regularly reviewed and eventually deprescribed. This pragmatic, controlled trial assessed the effect of an interprofessional knowledge exchange (KE) intervention to decrease medication load and the use of medications of questionable benefit among these residents.

METHODS

A 6-month intervention was performed in 4 NHs in the Quebec City area, while 3 NHs, with comparable admissions criteria, served as controls. Published lists of "mostly", "sometimes" or "exceptionally" appropriate medications, tailored for NH residents with severe dementia, were used. The intervention included 1) information for participants' families about medication use in severe dementia; 2) a 90-min KE session for NH nurses, pharmacists, and physicians; 3) medication reviews by NH pharmacists using the lists; 4) discussions on recommended changes with nurses and physicians. Participants' levels of agitation and pain were evaluated using validated scales at baseline and the end of follow-up.

RESULTS

Seven (7) NHs and 123 participants were included for study. The mean number of regular medications per participant decreased from 7.1 to 6.6 in the intervention, and from 7.7 to 5.9 in the control NHs (p-value for the difference in differences test: < 0.05). Levels of agitation decreased by 8.3% in the intervention, and by 1.4% in the control NHs (p = 0.026); pain levels decreased by 12.6% in the intervention and increased by 7% in the control NHs (p = 0.049). Proportions of participants receiving regular medications deemed only exceptionally appropriate decreased from 19 to 17% (p = 0.43) in the intervention and from 28 to 21% (p = 0.007) in the control NHs (p = 0.22). The mean numbers of regular daily antipsychotics per participant fell from 0.64 to 0.58 in the intervention and from 0.39 to 0.30 in the control NHs (p = 0.27).

CONCLUSIONS

This interprofessional intervention to reduce inappropriate medication use in NH residents with severe dementia decreased medication load in both intervention and control NHs, without important concomitant increase in agitation, but mixed effects on pain levels. Practice changes and heterogeneity within these 7 NHs, and a ceiling effect in medication optimization likely interfered with the intervention.

TRIAL REGISTRATION

The study is registered at ClinicalTrials.gov: # NCT05155748 (first registration 03-10-2017).

Attitudes of Older Adult Patients and Caregivers Towards Deprescribing of Medications in Ethiopia

Background

Deprescribing is essential for reducing inappropriate medication use and polypharmacy. For a holistic approach, it is essential to know how older adult patients and their caregivers perceive deprescribing.

Objective

To assess the attitude of older adult patients and caregivers towards deprescribing medication at Ambo University Referral Hospital.

Methodology

Institutional-based cross-sectional study was conducted using the revised Patients' Attitude Towards Deprescribing tool (rPATD). The data was analyzed using the SPSS-25 software. Backward linear regression and logistic regression were used to measure association between outcome and determinant variables. The two-sided P-value ≤0.05 with 95% confidence interval was utilized for reporting significant factors.

Results

One hundred fifty-six (81.3%) of the respondents (ie, 85.0% of older adult and 77.2% of caregivers) agreed to stop one or more of their regular medications if the physician said it was possible despite 98 (51.0%) of them (ie, 49.0% of older adult and 53.3% of caregivers) being satisfied with their/their care recipient's medications. On the overall aggregate mean score, the respondents had a neutral position (2.6-3.59) regarding the burden and concerns of stopping medications whereas the majority of them disagree (1.0-2.59) with the inappropriateness of the medication they were taking and agreed (3.6-5.0) with the need for their involvement in treatment decision making. Concerns about stopping medicine scores (AOR = 0.440, 95% CI = 0.262-0.741, P = 0.035) and perceived levels of medication inappropriateness (AOR = 0.653, 95% CI = 0.456-0.936, P = 0.020) was significantly associated with the willingness to discontinue and overall satisfaction with their medicine regimen respectively.

Conclusion

The majority of older adult patients and caregivers would like to deprescribe if the physicians recommended it. The perceived concerns of stopping and inappropriateness of the medicines were associated with the willingness to deprescribe and overall satisfaction with their medicine respectively. Healthcare providers should prompt the deprescribing process with older adult patients and caregivers by addressing their concerns about stopping medications.

Global Mapping of Potentially Inappropriate Prescribing for Older Adults in Community Settings: An Umbrella Review

Potentially inappropriate prescribing (PIP) is a major public health concern with several undesirable health consequences for older adults. In this overview, we aimed to map and gather information from existing literature to provide a better insight into the prevalence of PIP among community dwellers. Electronic databases were searched from their inception to April 2022. The quality of the included systematic reviews (SRs) was assessed using the assessment of multiple systematic reviews checklist. The degree of overlap within the SRs was also evaluated (2% overlap). All SRs on the prevalence of PIP in older individuals in community settings were included, and a narrative approach was used to synthesize data. Nineteen SRs comprising 548 primary studies met the inclusion criteria, and the average quality of the included SRs was moderate. More than half (50.5%) of the primary studies were conducted in Europe, followed by the United States (22.8%), and Asia (18.9%). Thirty different criteria were used in the primary studies to estimate the prevalence of PIP. The most widely used criteria were those presented in Beers (41.8%) and STOPP (Screening Tool of Older Persons' Prescriptions)/START (Screening Tool to Alert to Right Treatment) (21.8%) criteria. Benzodiazepines, nonsteroidal anti-inflammatory drugs, and antidepressants were the most frequently reported PIPs. A considerable variation in the prevalence of PIP ranging from 0% to 98% was reported by SRs. However, there is a high degree of uncertainty regarding the extent of PIP in community settings. To identify knowledge-to-action gaps, SR authors should consider the differences in prevalence of PIP according to settings, applied tools, data sources, geographical areas, and specific pathologies. There is also a need for primary and SR studies from low- and middle-income countries regarding the prevalence of PIP.

Potentially Inappropriate Medication Use among Underserved Older Latino Adults

BACKGROUND

Previous studies identified alarming increases in medication use, polypharmacy, and the use of potentially inappropriate medications (PIMs) among minority older adults with multimorbidity. However, PIM use among underserved older Latino adults is still largely unknown. The main objective of this study is to examine the prevalence of PIM use among underserved, community-dwelling older Latino adults. This study examines both the complexity of polypharmacy in this community and identifies associations between PIM and multimorbidity, polypharmacy, and access to medical care among this segment of our population.

METHODS

This community-based, cross-sectional study included 126 community-dwelling Latinos aged 65 years and older. The updated 2019 AGS Beers Criteria was used to identify participants using PIMs. We used multinomial logistic regression to examine the independent association of PIM with several independent variables including demographic characteristics, the number of chronic conditions, the number of prescription medications used, level of pain, and sleep difficulty. In addition, we present five cases in order to offer greater insight into PIM use among our sample.

RESULTS

One-third of participants had at least one use of PIM. Polypharmacy (≥5 medications) was observed in 55% of our sample. In addition, 46% took drugs to be used with caution (UWC). In total, 16% were taking between 9 and 24 medications, whereas 39% and 46% were taking 5 to 8 and 1 to 4 prescription medications, respectively. The multinomial logit regression analysis showed that (controlling for demographic variables) increased PIM use was associated with an increased number of prescription medications, number of chronic conditions, sleep difficulty, lack of access to primary care, financial strains, and poor self-rated health.

DISCUSSION

Both qualitative and quantitative analysis revealed recurrent themes in the missed identification of potential drug-related harm among underserved Latino older adults. Our data suggest that financial strain, lack of access to primary care, as well as an increased number of medications and co-morbidity are inter-connected. Lack of continuity of care often leads to fragmented care, putting vulnerable patients at risk of polypharmacy and drug-drug interactions as clinicians lack access to a current and complete list of medications patients are using at any given time. Therefore, improving access to health care and thereby continuity of care among older Latino adults with multimorbidity has the potential to reduce both polypharmacy and PIM use. Programs that increase access to regular care and continuity of care should be prioritized among multimorbid, undeserved, Latino older adults in an effort toward improved health equity.

Potentially inappropriate medications in nursing homes and the community older adults using the French health insurance databases

PURPOSE

Potentially inappropriate medications (PIMs) have become a major issue in improving prescribing practices and reducing the risk of adverse drug events in older people. However, very few studies have compared exposition to PIMs controlling for differences in demographic and health between nursing home residents (NHRs) and community-dwelling older adults (CDOAs). This study aimed to assess the prescribing pattern of PIMs between NHRs and CDOAs.

METHODS

We conducted a cross-sectional study over three months in 2019 using the French Health Insurance databases. The study population included 274 971 NHRs and 4 893 721 CDOAs aged 75 years or over. The prevalence ratio (PR) between NHRs and CDOAs of 17 PIM indicators, based on the Beers and STOPP criteria lists, was assessed using multivariable robust Poisson regression adjusted for age, sex, diseases, and polypharmacy.

RESULTS

During the study period, 54% of NHRs and 29% of CDOAs received at least one PIM. After adjustment, the prevalence of PIMs was 33% higher among NHRs compared to CDOAs (aPR = 1.33; 95% CI [1.33-1.34]). NHRs received PIMs related to benzodiazepines (aPR = 1.43; 95% CI [1.42-1.43]), anticholinergic drugs (aPR = 1.29; 95% CI [1.27-1.31]), and at least three central nervous system-active drugs (aPR = 1.94; 95% CI [1.92-1.96]) more frequently. Prevalence of PIMs related to non-steroidal anti-inflammatory drugs (aPR = 0.50; 95% CI [0.48-0.52]) and long-acting benzodiazepines (aPR = 0.84; 95% CI [0.82-0.85]) was lower among NHRs.

CONCLUSION

The NHRs were at greater risk for PIM than CDOAs, although differences exist according to the category of PIMs. As the population is aging, it is essential to promote and evaluate interventions in NHs and the community to enhance medication optimization.

The association between socioeconomic status and use of potentially inappropriate medications in older adults

BACKGROUND

Potentially inappropriate medication (PIM) use is an important public health problem, particularly among older adults who may need multiple pharmacologic therapies for various chronic conditions. As socioeconomic status (SES) affects the quality of healthcare that individuals receive, SES may be associated with the use of PIM in older adults. This study aimed to determine whether low SES is associated with increased use of PIM.

METHODS

We studied 4927 participants (aged 66-90 years) who were on at least one medication at visit five (2011-2013) of the Atherosclerosis Risk in Communities Study. We created a cumulative SES score categorized as high (7-9), middle (3-6), and low (0-2) based on education, income, and area deprivation index. We use multivariable logistic regression to examine the associations between SES and use of two or more PIM for older adults, defined by the 2019 Beers Criteria.

RESULTS

A total of 31.0% and 6.9% of the participants used one or more PIM and two or more PIM, respectively. After adjusting for demographic characteristics and insurance type, low cumulative SES score was associated with significantly greater use of two or more PIM (odds ratio [OR] = 1.83 [95% confidence interval (CI) 1.18-2.86]), as was middle cumulative SES score (OR = 1.40 [95% CI 1.06-1.83]), compared to high cumulative SES score. The results remained significant after further adjusting for comorbidities and medication burden for low cumulative SES score (OR = 1.66 [95%CI 1.02-2.71]).

CONCLUSIONS

We found that lower SES was associated with greater use of PIM among older adults independent of their medication burden and comorbidities, suggesting socioeconomic disparities in quality of medication management. Focused efforts targeting older adults with low SES to reduce PIM use may be needed to prevent adverse drug events.

Deprescribing for older people living in residential aged care facilities: Pharmacist recommendations, doctor acceptance and implementation

BACKGROUND

Deprescribing is an intervention to address the high prevalence of inappropriate polypharmacy in older people living in residential aged care facilities (RACFs). Many deprescribing interventions are complex and involve several stages including initial pharmacist recommendation, subsequent acceptance of the recommendations by a prescriber and the patient, and then actual implementation.

OBJECTIVES

This study aimed to investigate pharmacist deprescribing recommendations for residents within RACFs, general practitioner (GP) acceptance, and the actual implementation of the accepted recommendations at 12-month.

METHODS

The intervention occurred as part of a randomised controlled trial and comprised a pharmacist-led medication review using an evidence-based algorithm, with the focus on identifying medications to potentially deprescribe. Consent to participate was obtained from residents (or surrogate decision-makers), RACF nursing staff and the resident's GP. Deprescribing recommendations were reviewed by GPs before implementation as part of the intervention and control arms of the trial, although control group participants continued to receive their usual medications in a blinded manner.

RESULTS

There were 303 participants enrolled in the study, and 77% (941/1222) of deprescribing recommendations suggested by the pharmacists were accepted by GPs. Of the recommendations accepted by GPs, 74% (692/ 941) were successfully implemented at the end of the follow-up visit at 12 months. The most common reason for deprescribing was because medications were no longer needed (42%, 513/ 1231).

CONCLUSION

Pharmacist-led deprescribing recommendations arising from an algorithm-based medication review are acceptable to doctors and can have a significant impact on reducing the number of inappropriate medications consumed by older people in RACFs.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12613001204730.

Developing a Warning Model of Potentially Inappropriate Medications in Older Chinese Outpatients in Tertiary Hospitals: A Machine-Learning Study

Due to multiple comorbid illnesses, polypharmacy, and age-related changes in pharmacokinetics and pharmacodynamics in older adults, the prevalence of potentially inappropriate medications (PIMs) is high, which affects the quality of life of older adults. Building an effective warning model is necessary for the early identification of PIMs to prevent harm caused by medication in geriatric patients. The purpose of this study was to develop a machine learning-based model for the warning of PIMs in older Chinese outpatients. This retrospective study was conducted among geriatric outpatients in nine tertiary hospitals in Chengdu from January 2018 to December 2018. The Beers criteria 2019 were used to assess PIMs in geriatric outpatients. Three problem transformation methods were used to tackle the multilabel classification problem in prescriptions. After the division of patient prescriptions into the training and test sets (8:2), we adopted six widely used classification algorithms to conduct the classification task and assessed the discriminative performance by the accuracy, precision, recall, F1 scores, subset accuracy (ss Acc), and Hamming loss (hm) of each model. The results showed that among 11,741 older patient prescriptions, 5816 PIMs were identified in 4038 (34.39%) patient prescriptions. A total of 41 types of PIMs were identified in these prescriptions. The three-problem transformation methods included label power set (LP), classifier chains (CC), and binary relevance (BR). Six classification algorithms were used to establish the warning models, including Random Forest (RF), Light Gradient Boosting Machine (LightGBM), eXtreme Gradient Boosting (XGBoost), CatBoost, Deep Forest (DF), and TabNet. The CC + CatBoost model had the highest accuracy value (97.83%), recall value (89.34%), F1 value (90.69%), and ss Acc value (97.79%) with a good precision value (92.18%) and the lowest hm value (0.0006). Therefore, the CC + CatBoost model was selected to predict the occurrence of PIM in geriatric Chinese patients. This study’s novelty establishes a warning model for PIMs in geriatric patients by using machine learning. With the popularity of electronic patient record systems, sophisticated computer algorithms can be implemented at the bedside to improve medication use safety in geriatric patients in the future.

Attitude towards deprescribing and its association with frailty and complexity of medication regimen: A survey of older inpatients in a district health board in New Zealand

BACKGROUND

Older inpatients, particularly those with frailty, have increased exposure to complex medication regimens. It is not known whether frailty and complexity of medication regimens influence attitudes toward deprescribing. This study aimed to investigate (1) older inpatients' attitudes toward deprescribing; (2) if frailty and complexity of medication regimen influence attitudes and willingness to deprescribe - a relationship that has not been investigated in previous studies.

METHODS

In this cross-sectional study, older adults (≥ 65 years) recruited from general medicine and geriatric services in a New Zealand hospital completed the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. Hospital frailty risk score (HFRS) was calculated using diagnostic codes and other relevant information present at the time of index hospital admission; higher scores indicate higher frailty risk. Medication regimen complexity was quantified using the medication regimen complexity index (MRCI); higher scores indicate greater complexity. Logistic regression analysis was used to identify predictors of attitudes and willingness to deprescribe.

RESULTS

A total of 222 patients were included in the study, the median age was 83 years and 63% were female. One in two patients reported feeling they were taking too many medications, and 1 in 5 considered their medications burdensome. Almost 3 in 4 (73%) wanted to be involved in decision-making about their medications, and 4 in 5 (84%) were willing to stop one or more of their medications if their prescriber said it was possible. Patients with higher MRCI had increased self-reported medication burden (adjusted odds ratio (AOR) 2.6, 95% CI 1.29, 5.29) and were more interested in being involved in decision-making about their medications (AOR 1.8, CI 0.99, 3.42) than those with lower MRCI. Patients with moderate HFRS had lower odds of willingness to deprescribe (AOR 0.45, CI 0.22,0.92) compared to the low-risk group. Female patients had a lower desire to be involved in decision-making. The oldest old age group( > 80 years) had lower self-reported medication burden and were less likely to want to try stopping their medications.

CONCLUSION

Most older inpatients wanted to be involved in decision-making about their medications and were willing to stop one or more medications if proposed by their prescriber. Medication complexity and frailty status influence patients' attitudes toward deprescribing and thus should be taken into consideration when making deprescribing decisions. Further research is needed to investigate the relationship between frailty and the complexity of medication regimens.

Socio-demographic differences in polypharmacy and potentially inappropriate drug use among older people with different care needs and in care settings in Stockholm, Sweden

AIMS

Polypharmacy and potentially inappropriate medications (PIM) are risk factors for negative health outcomes among older people. This study aimed to investigate socio-demographic differences in polypharmacy and PIM use among older people with different care needs in a standard versus an integrated care setting.

METHODS

Population-based register data on residents aged ⩾65 years in Stockholm County based on socio-demographic background and social care use in 2014 was linked to prescription drug use in 2015. A logistic regression analysis was used to estimate socio-demographic differences in polypharmacy and PIM, adjusting for education, age group, sex, country of birth, living alone, morbidity and dementia by care setting based on area and by care need (i.e. independent, home help or institutionalised).

RESULTS

The prevalence of polypharmacy and PIM was greater among home-help users (60.4% and 11.5% respectively) and institutional residents (74.4% and 11.9%, respectively). However, there were greater socio-demographic differences among the independent, with those with lower education, older age and females having higher odds of polypharmacy and PIM. Morbidity was a driver of polypharmacy (odds ratio (OR)=1.19, confidence interval (CI) 1.16-1.22) among home-help users. Dementia diagnosis was associated with reduced odds of polypharmacy and PIM among those in institutions (OR=0.78, CI 0.71-0.87 and OR 0.52, CI 0.45-0.59, respectively) and of PIM among home-help users (OR=0.53, 95% CI 0.42-0.67).

CONCLUSIONS

Polypharmacy and PIM were associated with care needs, most prevalent among home-help users and institutional residents, but socio-demographic differences were most prominent among those living independently, suggesting that municipal care might reduce differences between socio-demographic groups. Care setting had little effect on inappropriate drug use, indicating that national guidelines are followed.

Prevalence of Potentially Inappropriate Prescriptions According to the New STOPP/START Criteria in Nursing Homes: A Systematic Review

The demand for long-term care is expected to increase due to the rising life expectancy and the increased prevalence of long-term illnesses. Nursing home residents are at an increased risk of suffering adverse drug events due to inadequate prescriptions. The main objective of this systematic review is to collect and analyze the prevalence of potentially inadequate prescriptions based on the new version of STOPP/START criteria in this specific population. Databases (PubMed, Web of Science and Cochrane) were searched for inappropriate prescription use in nursing homes according to the second version of STOPP/START criteria. The risk of bias was assessed with the STROBE checklist. A total of 35 articles were assessed for eligibility. One hundred and forty nursing homes and more than 6900 residents were evaluated through the analysis of 13 studies of the last eight years. The reviewed literature returned prevalence ranges between 67.8% and 87.7% according to the STOPP criteria, according to START criteria prevalence ranged from 39.5% to 99.7%. The main factors associated with the presence of inappropriate prescriptions were age, comorbidities, and polypharmacy. These data highlight that, although the STOPP/START criteria were initially developed for community-dwelling older adults, its use in nursing homes may be a starting point to help detect more efficiently inappropriate prescriptions in institutionalized patients. We hope that this review will help to draw attention to the need for medication monitoring systems in this vulnerable population.

Medication-Related Acute Care Admission and Inappropriate Polypharmacy of Nursing Home Residents

OBJECTIVES

To evaluate the prevalence of medication-related admissions (MRAs) and their association with potentially inappropriate medications (PIMs) used by nursing home residents admitted to the geriatric center of a tertiary hospital.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Older patients admitted from nursing homes to the geriatric center of the Seoul National University Bundang Hospital who had undergone comprehensive geriatric assessment from January 1, 2016, to December 31, 2020.

METHODS

MRAs were determined and verified using a previously described MRA adjudication guide. The PIMs in the preadmission medication lists were identified according to each of the following criteria (as well as the combined criteria), the Beers, NORGEP-NH, STOPP/START-NH, and STOPPFrail criteria. Medication use factors associated with MRAs were analyzed using multivariate logistic regression.

RESULTS

Among the 304 acute care admissions, 32.2% were MRAs. The main cause of MRAs was acute kidney injury related with use of renin-angiotensin system inhibitors. Approximately 81% of the patients used at least 1 PIM according to the combined criteria. The use of 1 or more PIMs, renin-angiotensin system inhibitors, diuretics, nonsteroidal anti-inflammatory drugs, and benzodiazepines was significantly associated with MRAs. The combined criteria were able to predict MRAs better than the individual criteria.

CONCLUSIONS AND IMPLICATIONS

Approximately one-third of acute admissions of nursing home residents may be MRAs. Interventions for the optimal use of medication among nursing home residents are needed.

Research status and hotspots of medication safety in older adults: A bibliometric analysis

Background

Medication safety is a significant concern in healthcare. Research on medication safety for older adults has taken a broad approach, resulting in a range of proposals. At this juncture, it is necessary to identify the main contributors and establish the current developmental status of the principal research topics.

Objective

This study sets out to summarize the state-of-the-art in medication safety for older adults, identifying significant achievements, key topics, and emerging trends.

Methods

The Web of Science Core Collection (WOSCC) database was searched for relevant documentation over the interval 1st January 2000 to 31st December 2021. Annual outputs and citations were identified from the WOS citation reports. CiteSpace and VOSviewer were adopted for bibliometric analysis and visualization that included the distribution of countries/regions, organizations, authors and journals, and an analysis of co-cited references and keywords.

Results

A total of 1,638 documents were retrieved for bibliometric analysis, yielding 34.29 citations per document. Publications have increased over the past two decades, reaching 177 outputs in 2019. Our database encompasses 71 countries/regions, 2,347 organizations, and 7,040 authors. The United States ranks first in terms of scientific activity with 604 publications (36.87%). We have identified the University of Sydney as the most prolific organization (53 publications). J. T. Hanlon, J. H. Gurwitz, D. O'Mahony, and G. Onder are the most influential researchers in terms of publications and citations. The Journal of the American Geriatrics Society ranks first with 89 (5.43%) papers. In terms of major research directions, three topics have been identified from co-cited reference and keyword analysis: (1) estimation of the prevalence and variables associated with polypharmacy and potentially inappropriate medication; (2) analysis of interventions involving pharmacists and the associated impact; (3) patient experience and perception associated with medication use or pharmaceutical care.

Conclusion

Research on medication safety for older adults has progressed significantly over the past two decades. The United States, in particular, has made important contributions to this field. Polypharmacy and potentially inappropriate medication use, interventions involving pharmacists, patient experience and perception represent the current focus of research. Our findings suggest that these directions will continue as research hotspots in the future.

[Choosing Wisely in Patients with Polypharmacy]

Choosing Wisely in Patients with Polypharmacy Abstract. Polypharmacy and potentially inappropriate medication have a negative impact on health. For reducing or stopping medication (deprescribing) patient benefits are crucial. The following stepwise approach has turned out to be successful: a. ask patients to bring along all their medication and compare them with the current medication list; b. offer shared decision making; c. evaluate every drug for indication, balance between benefit and harm, side effects and dose; d. prioritize benefit and harm according to values, preferences and goals of the patient; e. decide together about deprescribing; f. track changes in the medication plan und arrange a follow-up consultation. We illustrate this approach by the example of an older, frail female patient with polypharmacy. Deprescribing is just as important for patients' well-being as is prescribing!

Exploring Australian pharmacists' perceptions and practices towards reducing the risk of medicines-related harm in aged care residents

Background: Older people living in residential aged care facilities frequently experience medicines-related harm. Evidence regarding the perception and practices towards reducing these harms may facilitate the development of customised educational programs for pharmacists providing services in RACFs. Objective: To explore Australian pharmacists' opinions and practices towards reducing the risk of medicines-related harm in aged care residents. Methods: An online survey was developed based on a literature review, expert opinion, and feedback from pharmacists providing services in RACFs. A web link for the survey was shared via professional pharmacy organisations and social media groups with Australian pharmacists providing services in RACFs. Results: A total of 209 pharmacists participated in the survey. Of these, 76% (n = 158) were residential medication management review embedded pharmacists, and 24% (n = 51) were supply pharmacists for RACFs. Most pharmacists believed that medicines-related harm is common in residents (n = 174, 83%), yet few agreed that pharmacists have enough time to participate in medicines-related harm reduction services (n = 60, 28%). There was a high level of agreement regarding the key risk factors (e.g., inappropriate medicines, anticholinergic drug use, and transitions of care) and potential strategies (e.g., embedded pharmacists in RACFs, educating aged care staff, and collaborative pharmacist-led medication reviews) for reducing medicines-related harm in residents. Conclusion: Pharmacists agreed that older residents often experience medicines-related harm, but they did not frequently participate in medicines-related harm reduction services. Initiatives to engage pharmacists in team-based harm reduction services and educate aged care staff regarding safe medication management may improve residents' safety and health outcomes.

Comparative analysis of potentially inappropriate medication use in long-term care facility residents and community-dwelling elders: A matched cohort study

As the population of the elderly in long-term care facilities has grown, the number of users of potentially inappropriate medication (PIM) is also increasing. With this study, we aimed to investigate the pattern of PIM usage and related factors among the elderly receiving long-term care services. Using the South Korean National Health Insurance Service Elderly Cohort Database, we conducted a retrospective matched cohort study. Elderly residents (n = 1980) in long-term care facilities in 2013 were selected and matched 1:1 with elderly persons living in the community applying propensity score method. The matching variables were sex, age, health insurance type, long-term care grade, Charlson's Comorbidity Index score, presence of dementia, cerebrovascular disease, or Parkinson's disease, and number of drugs prescribed. PIM use was assessed according to Beers criteria 2019. The prevalence of PIM was found to be higher among the elderly in long-term care facilities (86.77%) than among community-dwelling individuals (75.35%). Logistic regression showed that long-term care facility residents were 1.84 odds more likely to use PIM than community-dwelling older adults. We also confirmed that the average number of medications taken per day and the number of outpatient visits were the major influencing factors affecting PIM prescriptions. In addition, elders living in long-term care facilities were prescribed more PIM drugs acting on the central nervous system than community-dwelling older adults. The results of this study show that among those receiving long-term care services, older people in long-term care facilities use PIM more than do the elderly living at home. Medication management programs need to be developed to reduce the use of PIM in long-term care facilities.

Evaluation of potentially inappropriate medications in older patients admitted to the cardiac intensive care unit according to the 2019 Beers criteria, STOPP criteria version 2 and Chinese criteria

WHAT IS KNOWN AND OBJECTIVES

Potential inappropriate medications (PIMs) can increase the risk of medication-induced harm. However, there are no studies regarding PIMs in older and critically ill patients with cardiovascular diseases in China. Therefore, studies evaluating PIMs in these patients can help in the implementation of more effective interventions to reduce the risk of drug use. Our objective was to analyse the prevalence of PIMs in elderly patients admitted to the cardiac intensive care unit (CICU) comparing the 2019 Beers criteria (Beers criteria), Screening Tool of Older People's Potentially Inappropriate Prescriptions (STOPP) criteria version 2 (STOPP criteria) and criteria of potentially inappropriate medications for older adults in China (Chinese criteria); and analyse the factors influencing the PIMs.

METHODS

This cross-sectional and retrospective study was performed with elderly patients (≥65 years) admitted to the CICU of the Beijing Tongren Hospital in China from January 2019 to June 2020. The PIMs were identified based on the Chinese, STOPP and Beers criteria at admission and discharge. The three criteria were compared using the Kappa statistic. Multiple regression analysis was used to investigate the influencing factors associated with PIMs.

RESULTS AND DISCUSSION

A total of 369 patients who met the inclusion/exclusion criteria were included in this study. According to the three criteria used to evaluate the PIMs, the prevalence was 78.3% and 72.6% at admission and discharge, respectively. The prevalence rate of PIMs determined by the Chinese criteria was 62.1% at admission versus 56.6% at discharge (p = 0.134); the Beers criteria was 53.9% at admission versus 46.9% at discharge (p = 0.056); by the STOPP criteria was 20.6% at admission versus 13.8% at discharge (p = 0.015). Moreover, 28.9% (STOPP criteria), 56.8% (Beers criteria) and 73.4% (Chinese criteria) of patients taking PIMs on admission still had the same problem at discharge. The most common PIMs screened by the Beers, STOPP and Chinese criteria were diuretics, benzodiazepines and clopidogrel, respectively. Besides, the three criteria showed poor agreement. Finally, the stronger predictor of PIMs was the increased number of medications (p < 0.05).

WHAT IS NEW AND CONCLUSION

The prevalence of PIMs in elderly patients admitted to the CICU was high. The Chinese, STOPP and Beers criteria are effective screening tools to detect PIMs, but the consistency between them was poor. The increased number of medications was a significant predictor of PIMs.

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.

Pharmacotherapy Problems in Best Possible Medication History of Hospital Admission in the Elderly

Transfer of care is a sensitive process, especially for the elderly. Polypharmacy, potentially inappropriate medications (PIMs), drug-drug interactions (DDIs), and renal risk drugs (RRDs) are important issues in the elderly. The aim of the study was to expand the use of the Best Possible Medication History (BPMH) and to evaluate polypharmacy, PIMs, DDIs, and inappropriately prescribed RRDs on hospital admission, as well as to determine their mutual relationship and association with patients’ characteristics. An observational prospective study was conducted at the Internal Medicine Clinic of Clinical Hospital Dubrava. The study included 383 elderly patients. Overall, 49.9% of patients used 5−9 prescription medications and 31.8% used 10 or more medications. EU(7)-PIMs occurred in 80.7% (n = 309) of the participants. In total, 90.6% of participants had ≥1 potential DDI. In total, 43.6% of patients were found to have estimated glomerular filtration rate < 60 mL/min/1.73 m2, of which 64.7% of patients had one or more inappropriately prescribed RRDs. The clinical pharmacist detected a high incidence of polypharmacy, PIMs, DDIs, and inappropriately prescribed RRDs on hospital admission. This study highlights the importance of early detection of pharmacotherapy problems by using the BPMH in order to prevent their circulation during a hospital stay. The positive correlations between polypharmacy, PIMs, DDIs, and inappropriately prescribed RRDs indicate that they are not independent, but rather occur simultaneously.

Inappropriate drug use determined by TIME criteria and the relation with frailty

Amaç: Çalışmamızın amacı kırılganlık ile çoklu ilaç kullanımı, Potansiyel Uygunsuz İlaç Kullanımı (PUİK) ve Potansiyel Reçete İhmali (PRİ) ilişkisini değerlendirmektedir. Gereç ve Yöntem: Geriatri polikliniğine 1 Ekim 2021 ve 1 Nisan 2022 ayaktan başvuran 65 yaş ve üzeri hastalar retrospektif değerlendirildi. Hastaların demografik verileri, kullandıkları ilaçların etken maddeleri, komorbid hastalıkları ve Klinik Kırılganlık Skalası (KKS) skoru kayıt edildi. KKS skoruna göre hastalar kırılgan ve kırılgan olmayan olarak ikiye ayrıldı. Turkish Inappropriate Medication use in the Elderly (TIME) to STOP kriterleri PUİK değerlendirmek için, TIME to START ise PRİ’yi belirlemek için kullanıldı. Bulgular: Hastaların ortalama yaşı 75,9±8,7 olup, hastaların %63,1 kadın idi. Hastaların kullandığı ortanca ilaç sayısı 7 (0-17) iken, katılımcıların %79,6’sında polifarmasi mevcuttu. Kırılgan hastaların %69,5 (n=42)’ inde polifarmasi mevcut olup, kırılgan olmayan hastalarda bu oran %22,5 (n=18) idi. Kırılgan hastalarda oral beslenme ürünü, 3-hidroksi-3-metil-glutaril-KoA reduktaz inhibitörleri ve demans tedavisi reçete ihmali oranı anlamlı olarak normal popülasyondan daha fazla idi. Proton pompa inhibitörleri, antipsikotikler, asetilsalisilik asit ve betahistinin uygunsuz kullanım oranı kırılgan hastalarda, kırılgan olmayan hastalardan daha fazla idi. Sonuç: Polifarmasi, PRİ ve PUİK hastalarda değerlendirilirken kırılganlık göz önünde bulundurulmalıdır ve her ülkenin farklı reçeteleme alışkanlığı olmasından dolayı ülkemize özel olan TIME kriterlerinin kullanımı önemli bir avantaj sağlayabilir.

Potentially Inappropriate Medication Use among Nursing Home Residents: Medication Errors Associated with Pro re nata Medications and the Importance of Pill Burden

Background

The use of potentially inappropriate medications (PIM) has become more common among nursing home residents (NHR). This study focused on drugs initially prescribed as pro re nata (PRN) medications and pill burden in association with PIM among NHR.

Methods

This observational cross-sectional study was conducted between March and April 2019 on 225 adult NHR aged ≥60 years.

Results

The prevalence of PIM was 47.6% among NHR according to the Screening Tool of Older Persons' Prescriptions (STOPP) criteria version 2. The most frequent PIM was the use of any drug prescribed without evidence-based clinical indication; most medication errors were associated with PRN medications. The prevalence rates of PRN in non-PIM and PIM users were 12% and 62.4%, respectively. PRN medications that most commonly caused PIM were non-steroidal anti-inflammatory drugs and proton pump inhibitors. The cut-off value for both medications and pills to correctly identify participants with PIM was 5.5. Pill burden had a similar sensitivity to polypharmacy in identifying individuals with PIM.

Conclusion

Medication errors associated with PRN medications were overlooked as factors that increased the risk of PIMs. The most common error related to PRN medications was the continued daily use despite symptom resolution.

Quality Use of Medicines Indicators and Associated Factors in Residential Aged Care Facilities: Baseline Findings from the Pharmacists in RACF Study in Australia

Prescribing potentially inappropriate medications (PIMs), including antipsychotics and benzodiazepines, has been used as an indicator of the quality use of medicines in residential aged care facilities (RACFs). PIMs are associated with an increased risk of falls and hospitalisations in the elderly. The purpose of this study is to assess the extent of prescribing of PIMs in RACFs at baseline in the Pharmacists in residential aged care facilities (PiRACF) study and examine the association of resident and system factors with the number of PIMs. A cross-sectional analysis of 1368 participants from 15 Australian RACFs was performed to detect PIMs using the American Geriatrics Society 2019 Beers® criteria. Most residents (68.1%) were taking at least one regular PIM; 16.9% were taking regular antipsychotics and 11.1% were taking regular benzodiazepines. Long-term proton pump inhibitors were the most frequent class of PIMs. History of falls and higher Charlson Comorbidity Index were associated with an increased number of prescribed PIMs, while dementia diagnosis and older age (85 years or more) were associated with decreased number of PIMs (p-value <0.05). Residents in facilities with lower nurse-to-resident ratios were more likely to have an increased number of PIMs (p value = 0.001). This study indicates that potentially inappropriate prescribing is common in RACFs and interventions to target residents at highest risk are needed.

Assessment of Potentially Inappropriate Medications Using the EU (7)-PIM List, in a Sample of Portuguese Older Adults' Residents in Nursing Homes

Abstract

Prescription of potentially inappropriate medication (PIM) in older adults is associated with poor clinical outcomes. The EU (7)-PIM list was created for the European market to improve pharmacotherapy in older adults.

Purpose

This work aims to characterize the medication profile and assess the presence of PIM, using the EU (7)-PIM list in older adults’ residents at nursing homes.

Methods

Retrospective data were collected from the anonymized nursing home records. After PIM identification, a descriptive analysis was performed, and a generalized linear model for dependent negative binomial-type variables was constructed to assess the risk of PIM.

Results

Of the 210 participants (mean age 85.10), 82.40% were polymedicated. PIM was observed in 86.4% participants (mean per patient = 2.30± 0.10). The most common PIM were proton pump inhibitors (n = 121, 57.62%), followed by anxiolytics (n = 96, 45.71%). 64.30% of all patients take 2–4 PIM and 5.80% take five or more PIM. The occurrence of PIM is influenced by the number of prescribed medicines (RR 1.14; 95% CI 1.1.-1.17) and the presence of digestive system diseases (RR 1.05; 95% CI 1.0–1.09).

Conclusion

The high prevalence of PIM observations highlights the necessity of the implementation of guidelines to prevent PIM.

Provision of a comprehensive medicines review is associated with lower mortality risk for residents of aged care facilities: a retrospective cohort study

Background

no studies have examined the impact of residential medication management review (RMMR, a 24-year government subsidised comprehensive medicines review program) in Australian residential aged care facilities (RACFs) on hospitalisation or mortality.

Objective

to examine associations between RMMR provision in the 6–12 months after RACF entry and the 12-month risk of hospitalisation and mortality among older Australians in RACFs.

Design

retrospective cohort study.

Subjects

individuals aged 65–105 years taking at least one medicine, who entered an RACF in three Australian states between 1 January 2012 and 31 December 2015 and spent at least 6 months in the RACF (n = 57,719).

Methods

Cox regression models estimated adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) for associations between RMMR provision and mortality. Adjusted subdistribution hazard ratios were estimated for associations between RMMR provision and next (i) emergency department (ED) presentation or unplanned hospitalisation or (ii) fall-related ED presentation or hospitalisation.

Results

there were 12,603 (21.8%) individuals who received an RMMR within 6–12 months of RACF entry, of whom 22.2% (95%CI 21.4–22.9) died during follow-up, compared with 23.3% (95%CI 22.9–23.7) of unexposed individuals. RMMR provision was associated with a lower risk of death due to any cause over 12-months (aHR 0.96, 95%CI 0.91–0.99), but was not associated with ED presentations or hospitalisations for unplanned events or falls.

Conclusions

provision of an RMMR in the 6–12 months after RACF entry is associated with a 4.4% lower mortality risk over 12-months but was not associated with changes in hospitalisations for unplanned events or falls.

Potentially Inappropriate Medication and Polypharmacy in Nursing Home Residents: A Cross-Sectional Study

Inappropriate prescribing in the elderly is a risk factor for higher adverse drugs reactions, hospitalisation, and mortality rates. Therefore, it is necessary to identify irrational prescriptions and implement interventions to improve geriatric clinical practices in nursing homes. This study aimed to examine and compare the prevalence of potentially inappropriate medications in nursing home residents using three different updated criteria: 2019 Beers criteria, PRISCUS list, and v2 STOPP criteria, and to determine the prevalence of potential prescribing omissions according to v2 START criteria. A descriptive, observational, and cross-sectional study design was used. A total of 218 residents were involved in this study. Data on drug use were collected from medical charts. Information was screened with the software CheckTheMeds. Potentially inappropriate medications were present in 96.3%, 90.8%, and 35.3% of residents, according to the STOPP, Beers, and PRISCUS criteria or list, respectively. Inappropriate medication was found to be significantly associated with polypharmacy and severe or moderate drug–drug interactions with the three tools and with pathologies and unnecessary drugs only for STOPP criteria. The most frequent inappropriate medications were benzodiazepines and proton pump inhibitors. A regular use of software to review medications in nursing home residents would help to reduce the risk of these drug-related problems.

Medicines use before and after comprehensive medicines review among residents of long-term care facilities: a retrospective cohort study

Background

Residential Medication Management Review (RMMR) is a subsidized comprehensive medicines review program for individuals in Australian residential aged care facilities (RACFs). This study examined weekly trends in medicines use in the four months before and after an RMMR and among a comparison group of residents who did not receive an RMMR.

Methods

This retrospective cohort study included individuals aged 65 to 105 years who first entered permanent care between 1/1/2012 and 31/12/2016 in South Australia, Victoria, or New South Wales, and were taking at least one medicine. Individuals with an RMMR within 12 months of RACF entry were classified into one of three groups: (i) RMMR within 0 to 3 months, (ii) 3 to 6 months, or (iii) within 6 to 12 months of RACF entry. Individuals without RMMRs were included in the comparison group. Weekly trends in the number of defined daily doses per 1000 days were determined in the four months before and after the RMMR (or assigned index date in the comparison group) for 14 medicine classes.

Results

113909 individuals from 1979 RACFs were included, of whom 55021 received an RMMR. Across all three periods examined, decreased use of statins and proton pump inhibitors was observed post-RMMR in comparison to those without RMMRs. Decreases in calcium channel blockers, benzodiazepines/zopiclone, and antidepressants were observed following RMMR provision in the 3–6 and 6–12 months after RACF entry. Negligible changes in antipsychotic use were also observed following an RMMR in the 6–12 months after RACF entry by comparison to those without RMMRs. No changes in use of opioids, ACE inhibitors/sartans, beta blockers, loop diuretics, oral anticoagulants, or medicines for osteoporosis, diabetes or the cognitive symptoms of dementia were observed post-RMMR.

Conclusions

For six of the 14 medicine classes investigated, modest changes in weekly trends in use were observed after the provision of an RMMR in the 6–12 months after RACF entry compared to those without RMMRs. Findings suggest that activities such as medicines reconciliation may be prioritized when an RMMR is provided on RACF entry, with deprescribing more likely after an RMMR the longer a resident has been in the RACF.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03187-0.

Medication Review in Turkish Older Adults at Community Pharmacy: A Pilot Study by Using Medication Appropriateness Index

Objective: The study aimed to evaluate medication review in older adults (≥65 years) at a community pharmacy by identifying the prevalence of potentiality inappropriate medication and calculating medication appropriateness index. Methods: This descriptive study was carried out in a community pharmacy for six months. The older adults (≥65 years) using one or more medications were included. During clinical pharmacist-led medication review; the medication appropriateness index was calculated for each medication of older adults. Potentially inappropriate medications were evaluated according to the 2019 American Geriatrics Society Beers Criteria®. Result: Among a hundred older adults, 46.0% were female. The median age of the patients was 75.5 (IQR, 68.0-78.8). The median number of medications was 9.0 (7.0-10.0). Polypharmacy has been detected in 97.0% of the patients. At least one potentially inappropriate medication was detected in 63.0% of them. The median score of medication appropriateness index score was 53.0 (IQR: 38.6-67.9). Conclusion: To best our knowledge, this is the first study of clinical pharmacist-led medication review by calculating the medication appropriateness index carried out at a community pharmacy in Turkey. There was a high rate of potentially inappropriate medication with a higher score of medication appropriateness in older adults. This study highlights the importance of medication review led by the clinical pharmacist at community pharmacy to optimize medication usage in older adults.

Cost-effectiveness of an educational intervention to reduce potentially inappropriate medication

Background

Educational interventions can reduce potentially inappropriate medication (PIM) use in older people. Their effectiveness has been measured mainly as changes in PIM use. In this economic evaluation, we analyse the impact of an educational intervention in terms of costs and quality-adjusted life years (QALYs).

Methods

The educational intervention consisted of activating and interactive training sessions for nursing staff and consulting physicians, and was compared with treatment as usual (TAU). Participants (n = 227) in a cluster randomised trial (cRCT) were residents living permanently in assisted living facilities (n = 20 wards). For economic evaluation, participants’ healthcare service use costs and costs for the intervention were estimated for a 12 month period.

Incremental cost-effectiveness ratios (ICERs) were estimated for QALYs per participant. Cost-effectiveness analysis was conducted from a healthcare perspective. A bootstrapped cost-effectiveness plane and one-way sensitivity analysis were undertaken to analyse the uncertainty surrounding the estimates.

Results

The educational intervention was estimated to be less costly and less effective in terms of QALYs than TAU at the 12 month follow-up [incremental costs –€1,629, confidence interval (CI) –€5,489 to €2,240; incremental effect −0.02, CI –0.06 to 0.02]. The base case ICER was >€80,000/QALY.

Conclusion

The educational intervention was estimated to be less costly and less effective in terms of QALYs compared with TAU, but the results are subject to some uncertainties. Reduction in PIM use or benefits in quality of life did not seem to translate into improvements in QALYs. Our findings emphasise the need for better understanding of the impact of decreasing PIM use on health outcomes.

Characterization of potentially inappropriate medications use in Indian elderly population and their impact on quality of life using Beers criteria

Background

Methods

Results

Conclusion