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Esumi S, Ushio S, Zamami Y. Polypharmacy in Older Adults with Alzheimer’s Disease. Medicina (B Aires) 2022; 58:medicina58101445. [PMID: 36295605 PMCID: PMC9608980 DOI: 10.3390/medicina58101445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/23/2022] [Accepted: 09/28/2022] [Indexed: 11/28/2022] Open
Abstract
The number of patients with Alzheimer’s disease is increasing annually. Most of these patients are older adults with comorbid physical illnesses, which means that they are often treated with a combination of medications for the disease they have and those for Alzheimer’s disease. Thus, older adults with Alzheimer’s disease are potentially at risk for polypharmacy. In addition, the drug interactions between Alzheimer’s disease medications and those for the treatment of physical illnesses may reduce their efficacy and increase side effects. This article reviews polypharmacy and drug interactions in elderly patients with Alzheimer’s disease, with a focus on psychotropic drugs.
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Affiliation(s)
- Satoru Esumi
- Department of Pharmacy, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
- The Faculty of Pharmaceutical Science, Kobe Gakuin University, 1-1-3 Minatojima, Chuo-ku, Kobe 650-8586, Japan
- Correspondence: ; Tel.: +81-78-974-1551
| | - Soichiro Ushio
- Department of Pharmacy, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Yoshito Zamami
- Department of Pharmacy, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
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Quality Use of Medicines Indicators and Associated Factors in Residential Aged Care Facilities: Baseline Findings from the Pharmacists in RACF Study in Australia. J Clin Med 2022; 11:jcm11175189. [PMID: 36079117 PMCID: PMC9457045 DOI: 10.3390/jcm11175189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 12/02/2022] Open
Abstract
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.
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Kosari S, Koerner J, Naunton M, Peterson GM, Haider I, Lancsar E, Wright D, Niyonsenga T, Davey R. Integrating pharmacists into aged care facilities to improve the quality use of medicine (PiRACF Study): protocol for a cluster randomised controlled trial. Trials 2021; 22:390. [PMID: 34116708 PMCID: PMC8193166 DOI: 10.1186/s13063-021-05335-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 05/21/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Medication management in residential aged care facilities is an ongoing concern. Numerous studies have reported high rates of inappropriate prescribing and medication use in aged care facilities, which contribute to residents' adverse health outcomes. There is a need for new models of care that enhance inter-disciplinary collaboration between residential aged care facility staff and healthcare professionals, to improve medication management. Pilot research has demonstrated the feasibility and benefits of integrating a pharmacist into the aged care facility team to improve the quality use of medicines. This protocol describes the design and methods for a cluster randomised controlled trial to evaluate the outcomes and conduct economic evaluation of a service model where on-site pharmacists are integrated into residential aged care facility healthcare teams to improve medication management. METHODS Intervention aged care facilities will employ on-site pharmacists to work as part of their healthcare teams 2 to 2.5 days per week for 12 months. On-site pharmacists, in collaboration with facility nurses, prescribers, community pharmacists, residents and families will conduct medication management activities to improve the quality use of medicines. Aged care facilities in the control group will continue usual care. The target sample size is 1188 residents from a minimum of 13 aged care facilities. The primary outcome is the appropriateness of prescribing, measured by the proportion of residents who are prescribed at least one potentially inappropriate medicine according to the 2019 Beers Criteria. Secondary outcomes include hospital and emergency department presentations, fall rates, prevalence and dose of antipsychotics and benzodiazepines, Anticholinergic Cognitive Burden Score, staff influenza vaccination rate, time spent on medication rounds, appropriateness of dose form modification and completeness of resident's allergy and adverse drug reaction documentation. A cost-consequence and cost-effectiveness analysis will be embedded in the trial. DISCUSSION The results of this study will provide information on clinical and economic outcomes of a model that integrates on-site pharmacists into Australian residential aged care facilities. The results will provide policymakers with recommendations relevant to further implementation of this model. TRIAL REGISTRATION ACTRN12620000430932 . Registered on 1 April 2020 with ANZCTR.
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Affiliation(s)
- Sam Kosari
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, ACT, Australia.
| | - Jane Koerner
- Health Research Institute, Faculty of Health, University of Canberra, Bruce, ACT, Australia
| | - Mark Naunton
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, ACT, Australia
| | - Gregory M Peterson
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, ACT, Australia.,School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
| | - Ibrahim Haider
- Health Research Institute, Faculty of Health, University of Canberra, Bruce, ACT, Australia
| | - Emily Lancsar
- Department of Health Services Research and Policy, Research School of Population Health, Australian National University, Acton, ACT, Australia
| | - David Wright
- School of Pharmacy, University of East Anglia, Norwich, UK
| | - Theo Niyonsenga
- Health Research Institute, Faculty of Health, University of Canberra, Bruce, ACT, Australia
| | - Rachel Davey
- Health Research Institute, Faculty of Health, University of Canberra, Bruce, ACT, Australia
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Murphy C, Dyer AH, Lawlor B, Kennelly SP. Potentially inappropriate medication use in older adults with mild-moderate Alzheimer's disease: prevalence and associations with adverse events. Age Ageing 2020; 49:580-587. [PMID: 32474584 DOI: 10.1093/ageing/afaa067] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Indexed: 11/14/2022] Open
Abstract
AIM Potentially inappropriate medication (PIM) use is prevalent in older adults and is associated with adverse events, hospitalisation and mortality. We assessed the patterns and associations of PIM use in older adults with mild-to-moderate Alzheimer's Disease (AD), who may represent a particularly vulnerable group. DESIGN Analysis of data from NILVad, an 18-month Randomised Control Trial of Nilvadapine in mild-to-moderate AD. The v2 STOPP criteria were applied in duplicate to identify PIM use. Associations between PIM use and adverse events/unscheduled healthcare visits in addition to the associations between PIM use and AD progression were evaluated. SETTING AND PARTICIPANTS 448 older adults with mild-to-moderate AD from 23 centres in nine European countries. RESULTS Of 448 participants (mean age: 72.56 ± 8.19 years), over half (55.8%) were prescribed a PIM with 30.1% being prescribed 2+ PIMs. The most frequent PIMs were (i) long-term benzodiazepines (11.6% N = 52/448), (ii) selective serotonin reuptake inhibitors without appropriate indication (11.1% N = 50/448), and (iii) Proton-Pump Inhibitors (PPIs) without appropriate indication (10.7% N = 48/448). Increasing number of PIMs was associated with a greater risk of adverse events (IRR 1.17, 1.13-1.19, P < 0.001), serious adverse events (IRR 1.27; 1.17-1.37, P < 0.001), unscheduled hospitalisations (IRR 1.16, 1.03-1.30, P = 0.016) and GP visits (IRR 1.22, 1.15-1.28, P < 0.001). PIM use was not associated with dementia progression. CONCLUSIONS AND IMPLICATIONS PIM use is highly prevalent in mild-to-moderate AD and is associated with adverse events and unscheduled healthcare utilisation. Further attention to de-prescribing in this vulnerable group is warranted.
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Affiliation(s)
- Claire Murphy
- Department of Age-Related Healthcare, Tallaght University Hospital, Dublin, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Adam H Dyer
- Department of Age-Related Healthcare, Tallaght University Hospital, Dublin, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Brian Lawlor
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
- Mercer’s Institute for Research on Ageing, St James’s Hospital, Dublin, Ireland
| | - Sean P Kennelly
- Department of Age-Related Healthcare, Tallaght University Hospital, Dublin, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
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Cross AJ, Etherton-Beer CD, Clifford RM, Potter K, Page AT. Exploring stakeholder roles in medication management for people living with dementia. Res Social Adm Pharm 2020; 17:707-714. [PMID: 33722353 DOI: 10.1016/j.sapharm.2020.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Therapeutic decision making, prescribing, administering and managing medications can be difficult for people with dementia. OBJECTIVES To explore stakeholder roles in medication management for people with dementia, including barriers and enablers to achieving those roles. METHODS Focus groups were held with stakeholders (consumers, general practitioners, nurses and pharmacists) from both rural and metropolitan communities in two Australian states. Focus groups were audio-recorded, transcribed and thematically analysed using an inductive approach. RESULTS Nine focus groups were held with 55 participants. Four major themes were identified: supporting the role of the person with dementia, carer roles and challenges, health professional roles, and process and structure barriers to medication management. Stakeholders discussed the importance of advance care planning, and the potential benefits of early implementation of dose administration aids to support patients in self-managing their medication. Carers were seen to have a vital role as patient advocates, but carer burden and changes in the patient-carer roles acted as barriers to this role. General practitioners were perceived as the main care coordinator for a person with dementia, with effective interprofessional collaboration and communication with allied health professionals and specialists further enabling optimisation of medication use. A lack of evidence, guidelines and practitioner training to guide prescribing and deprescribing decisions in people with dementia were mentioned as barriers to medication management. CONCLUSION Medication management is increasingly challenging for people with dementia and each stakeholder perceives that they have a different role and faces different barriers and enablers. Future research should focus on improving the evidence base to guide prescribing, facilitating stakeholder communication and ensuring early documentation of patient wishes for the future.
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Affiliation(s)
- Amanda J Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.
| | - Christopher D Etherton-Beer
- Western Australian Centre for Health and Ageing, School of Medicine, University of Western Australia, Perth, Australia
| | - Rhonda M Clifford
- School of Allied Health, University of Western Australia, Perth, Australia
| | - Kathleen Potter
- Western Australian Centre for Health and Ageing, School of Medicine, University of Western Australia, Perth, Australia
| | - Amy T Page
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; School of Allied Health, University of Western Australia, Perth, Australia; Pharmacy Department, Alfred Health, Australia
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Šola KF, Mucalo I, Brajković A, Jukić I, Verbanac D, Vladimir Knežević S. Drug therapy problems identified among older adults placed in a nursing home: the Croatian experience. J Int Med Res 2020; 48:300060520928791. [PMID: 32493090 PMCID: PMC7273786 DOI: 10.1177/0300060520928791] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 04/30/2020] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE The aim of this study was to determine the frequency and type of drug therapy problems (DTPs) in older institutionalized adults. METHOD We conducted a cross-sectional observational study from February to June 2016 at a 150-bed public nursing home in Croatia, where comprehensive medication management (CMM) services were provided. A rational decision-making process, referred to as the Pharmacotherapy Workup method, was used to classify DTPs. RESULTS Data were prospectively collected from 73 residents, among which 71% were age 75 years or older. The median number of prescribed medications per patient was 7 (2-16) and polypharmacy (> 4) was recorded for 54 (74.0%) patients. A total 313 DTPs were identified, with an average of 4.3 ± 2 DTPs per patient. The most frequent DTP was needing additional drug therapy (n = 118; 37.7%), followed by adverse drug reaction (n = 55; 17.6%). Lactulose (14.4%), tramadol (6.7%), and potassium (6.4%) were the medications most frequently related to DTPs. CONCLUSION The high prevalence of DTPs identified among older institutionalized adults strongly suggests the need to incorporate new pharmacist-led CMM services within existing institutional care facilities, to improve the care provided to nursing home residents.
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Affiliation(s)
| | - Iva Mucalo
- University of Zagreb Faculty of Pharmacy and Biochemistry, Zagreb, Croatia
| | - Andrea Brajković
- University of Zagreb Faculty of Pharmacy and Biochemistry, Zagreb, Croatia
| | - Ivona Jukić
- Community Pharmacy Mandis Pharm, Zagreb, Croatia
| | - Donatella Verbanac
- University of Zagreb Faculty of Pharmacy and Biochemistry, Zagreb, Croatia
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Comparison of Potentially Inappropriate Medications for People with Dementia at Admission and Discharge during An Unplanned Admission to Hospital: Results from the SMS Dementia Study. Healthcare (Basel) 2019; 7:healthcare7010008. [PMID: 30634548 PMCID: PMC6473531 DOI: 10.3390/healthcare7010008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 01/04/2019] [Accepted: 01/07/2019] [Indexed: 11/16/2022] Open
Abstract
People with dementia (PWD) and cognitive impairment are particularly vulnerable to medication problems, and unplanned admission to hospital presents an opportunity to address polypharmacy, potentially inappropriate medications (PIMs) and anticholinergic burden. This study aimed to compare PIMS and other medication data for PWD to determine whether these changed during hospitalization. Medications documented in patient’s records at admission and discharge were evaluated for PWD recruited to phase one of a prospective quasi-experimental pre/post-controlled trial that was conducted at two regional hospitals in NSW, Australia. The study sample included PWD or cognitive impairment having an unplanned admission to hospital. Data were collected using a purpose developed audit tool for medications and PIMs, and a Modified Anticholinergic Burden Scale. Total participants were 277, and results determined that the cognitive status of PWD is not always detected during an unplanned admission. This may make them more vulnerable to medication problems and poor outcomes. Polypharmacy and PIMS for PWD were high at admission and significantly reduced at discharge. However, PWD should be routinely identified as high risk at admission; and there is potential to further reduce polypharmacy and PIMs during admission to hospital, particularly psychotropic medications at discharge. Future studies should focus on evaluating targeted interventions designed to increase medication safety for PWD.
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