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Pepper A, Dening KH. Dementia, comorbidity and multimorbidity. Br J Community Nurs 2024; 29:321-325. [PMID: 38963276 DOI: 10.12968/bjcn.2024.0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
Many people living with dementia will also have multimorbidity comprising several other intercurrent, long-term and comorbid conditions. This article examines the relationship between such conditions in the context of dementia, giving an overview of the literature, including prevalence and some of the common conditions that can coexist with dementia. The theory and evidence-base will be tied together using a case study approach, to illustrate the complexity of managing comorbid conditions and multimorbidity alongside dementia, and explore some of the approaches that can be used by community nurses to support the overall health of people living with dementia that they work with.
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Inglis JM, Caughey G, Thynne T, Brotherton K, Liew D, Mangoni AA, Shakib S. Association of Drug-Disease Interactions with Mortality or Readmission in Hospitalised Middle-Aged and Older Adults: A Systematic Review and Meta-Analysis. Drugs Real World Outcomes 2024:10.1007/s40801-024-00432-3. [PMID: 38852118 DOI: 10.1007/s40801-024-00432-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2024] [Indexed: 06/10/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Multimorbidity is common in hospitalised adults who are at increased risk of inappropriate prescribing including drug-disease interactions. These interactions occur when a medicine being used to treat one condition exacerbates a concurrent medical condition and may lead to adverse health outcomes. The aim of this review was to examine the association between drug-disease interactions and the risk of mortality and readmission in hospitalised middle-aged and older adults. METHODS A systematic review was conducted on drug-disease interactions in hospitalised middle-aged (45-64 years) and older adults (≥65 years). The study protocol was prospectively registered with PROSPERO (Registration Number: CRD42022341998). Drug-disease interactions were defined as a medicine being used to treat one condition with the potential to exacerbate a concurrent medical condition or that were inappropriate based on a comorbid medical condition. Both observational and interventional studies were included. The outcomes of interest were mortality and readmissions. The databases searched included MEDLINE, CINAHL, EMBASE, Web of Science, SCOPUS and the Cochrane Library from inception to 12 July, 2022. A meta-analysis was performed to pool risk estimates using the random-effects model. RESULTS A total of 563 studies were identified and four met the inclusion criteria. All were observational studies in older adults, with no studies identified in middle-aged adults. Most of the studies were at risk of bias because of an inadequate adjustment for covariates and a lack of clarity around individuals lost to follow-up. There were various definitions of drug-disease interactions within these four studies. Two studies assessed drugs that were contraindicated based on renal function, one assessed an individual drug-disease combination, and one was based on the clinical judgement of a pharmacist. There were two studies that showed an association between drug-disease interactions and the outcomes of interest. One reported that the use of diltiazem in patients with heart failure was associated with an increased risk of readmissions. The second reported that the use of medicines contraindicated according to renal function were associated with increased risk of all-cause mortality and a composite of mortality and readmission. Three of the studies (total study population = 5705) were amenable to a meta-analysis, which showed no significant association between drug-disease interactions and readmissions (odds ratio = 1.0, 95% confidence interval 0.80-1.38). CONCLUSIONS Few studies were identified examining the risk of drug-disease interactions and mortality and readmission in hospitalised adults. Most of the identified studies were at risk of bias. There is no universal accepted definition of drug-disease interactions in the literature. Further studies are needed to develop a standardised and accepted definition of these interactions to guide further research in this area.
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Affiliation(s)
- Joshua M Inglis
- Department of Clinical Pharmacology, Flinders Medical Centre, Flinders University, Adelaide, SA, Australia.
- Adelaide Medical School, University of Adelaide, North Terrace, Adelaide, SA, 5000, Australia.
| | - Gillian Caughey
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Tilenka Thynne
- Department of Clinical Pharmacology, Flinders Medical Centre, Flinders University, Adelaide, SA, Australia
| | - Kate Brotherton
- Department of Clinical Pharmacology, Flinders Medical Centre, Flinders University, Adelaide, SA, Australia
| | - Danny Liew
- Adelaide Medical School, University of Adelaide, North Terrace, Adelaide, SA, 5000, Australia
- Department of General Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Arduino A Mangoni
- Department of Clinical Pharmacology, Flinders Medical Centre, Flinders University, Adelaide, SA, Australia
| | - Sepehr Shakib
- Adelaide Medical School, University of Adelaide, North Terrace, Adelaide, SA, 5000, Australia
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, SA, Australia
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Alageel NA, Hughes CM, Alwhaibi M, Alkeridy W, Barry HE. Potentially inappropriate prescribing for people with dementia in ambulatory care: a cross-sectional observational study. BMC Geriatr 2024; 24:328. [PMID: 38600444 PMCID: PMC11008018 DOI: 10.1186/s12877-024-04949-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 04/04/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Studies have shown that potentially inappropriate prescribing (PIP) is highly prevalent among people with dementia (PwD) and linked to negative outcomes, such as hospitalisation and mortality. However, there are limited data on prescribing appropriateness for PwD in Saudi Arabia. Therefore, we aimed to estimate the prevalence of PIP and investigate associations between PIP and other patient characteristics among PwD in an ambulatory care setting. METHODS A cross-sectional, retrospective analysis was conducted at a tertiary hospital in Saudi Arabia. Patients who were ≥ 65 years old, had dementia, and visited ambulatory care clinics between 01/01/2019 and 31/12/2021 were included. Prescribing appropriateness was evaluated by applying the Screening Tool of Older Persons Potentially Inappropriate Prescriptions (STOPP) criteria. Descriptive analyses were used to describe the study population. Prevalence of PIP and the prevalence per each STOPP criterion were calculated as a percentage of all eligible patients. Logistic regression analysis was used to investigate associations between PIP, polypharmacy, age and sex; odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Analyses were conducted using SPSS v27. RESULTS A total of 287 PwD were identified; 56.0% (n = 161) were female. The mean number of medications prescribed was 9.0 [standard deviation (SD) ± 4.2]. The prevalence of PIP was 61.0% (n = 175). Common instances of PIP were drugs prescribed beyond the recommended duration (n = 90, 31.4%), drugs prescribed without an evidence-based clinical indication (n = 78, 27.2%), proton pump inhibitors (PPIs) for > 8 weeks (n = 75, 26.0%), and acetylcholinesterase inhibitors with concurrent drugs that reduce heart rate (n = 60, 21.0%). Polypharmacy was observed in 82.6% (n = 237) of patients and was strongly associated with PIP (adjusted OR 24.1, 95% CI 9.0-64.5). CONCLUSIONS Findings have revealed a high prevalence of PIP among PwD in Saudi Arabia that is strongly associated with polypharmacy. Future research should aim to explore key stakeholders' experiences and perspectives of medicines management to optimise medication use for this vulnerable patient population.
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Affiliation(s)
- Nahla A Alageel
- Primary Care Research Group, School of Pharmacy, Medical Biology Centre, Queen's University Belfast, 97 Lisburn Road, BT9 7BL, Belfast, UK
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Carmel M Hughes
- Primary Care Research Group, School of Pharmacy, Medical Biology Centre, Queen's University Belfast, 97 Lisburn Road, BT9 7BL, Belfast, UK
| | - Monira Alwhaibi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Walid Alkeridy
- Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Department of Medicine, Geriatric Division, University of British Columbia, Vancouver, Canada
- General Administration of Home Health Care, Therapeutic Affairs Deputyship, Riyadh, Saudi Arabia
| | - Heather E Barry
- Primary Care Research Group, School of Pharmacy, Medical Biology Centre, Queen's University Belfast, 97 Lisburn Road, BT9 7BL, Belfast, UK.
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Niznik JD, Kelley CJ, Fasth L, Colón-Emeric C, Thorpe CT, Gilliam MA, Lund JL, Hanson LC. Deprescribing bisphosphonates for older adults with dementia: perspectives of caregivers. Osteoporos Int 2024; 35:589-598. [PMID: 37980284 PMCID: PMC11145563 DOI: 10.1007/s00198-023-06967-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/01/2023] [Indexed: 11/20/2023]
Abstract
Little is known about caregivers' perspectives on deprescribing bisphosphonates for older adults with dementia. Caregivers agreed that fracture prevention was important for maintaining functional independence but acknowledged that changing goals of care may justify deprescribing. Conversations grounded in "what matters most" can align fracture prevention treatment with goals of care. PURPOSE The long-term fracture prevention benefits of bisphosphonates may begin to be overshadowed by the potential burden of adverse effects and polypharmacy for older adults living with dementia as the disease progresses. We characterized factors that influence caregiver decision-making for continuing versus deprescribing bisphosphonates for persons living with dementia. METHODS We conducted 11 interviews with family or informal caregivers of older adults living with dementia in the community or in long-term care who had been treated with bisphosphonates. Interviews focused on experiences caring for someone who has experienced a fracture, perceived benefits and harms of bisphosphonates, and experiences with deprescribing. Analyses were conducted using a qualitative framework methodology guided by the Health Belief Model. RESULTS Most caregivers were male (n = 8), younger than 65 (n = 8) and were an adult child caregiver (n = 8). Three caregivers were Black and five were Latino/a. Attempts to maintain functional independence despite high likelihood of falls was frequently discussed as contributing to fracture risk, in this population. Many caregivers perceived fracture prevention treatment as important, while several noted that it may become less important near the end of life. Perceived benefits of fracture prevention treatment for persons with dementia included improved quality of life and maintaining independence. Although most indicated that bisphosphonates were well tolerated, gastrointestinal adverse effects, preference for fewer treatments, and dementia-related behaviors that interfere with medication administration may be reasons for deprescribing. CONCLUSION Conversations grounded in caregiver experiences and "what matters most" may help optimize fracture prevention treatment for older adults with dementia.
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Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA.
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic CB#7550, Chapel Hill, NC, 27599, USA.
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA.
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Casey J Kelley
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic CB#7550, Chapel Hill, NC, 27599, USA
| | - Lauren Fasth
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Cathleen Colón-Emeric
- Division of Geriatrics, Duke University School of Medicine, Durham, NC, USA
- Durham VA Geriatric Research Education and Clinical Center, Durham, NC, USA
| | - Carolyn T Thorpe
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Meredith A Gilliam
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic CB#7550, Chapel Hill, NC, 27599, USA
| | - Jennifer L Lund
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic CB#7550, Chapel Hill, NC, 27599, USA
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Singh S, Cocoros NM, Li X, Mazor KM, Antonelli MT, Parlett L, Paullin M, Harkins TP, Zhou Y, Rochon PA, Platt R, Dashevsky I, Massino C, Saphirak C, Crawford SL, Gurwitz JH. Developing a PRogram to Educate and Sensitize Caregivers to Reduce the Inappropriate Prescription Burden in the Elderly with Alzheimer's Disease (D-PRESCRIBE-AD): Trial protocol and rationale of an open-label pragmatic, prospective randomized controlled trial. PLoS One 2024; 19:e0297562. [PMID: 38346025 PMCID: PMC10861034 DOI: 10.1371/journal.pone.0297562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 11/02/2023] [Indexed: 02/15/2024] Open
Abstract
CONTEXT Potentially inappropriate prescribing of medications in older adults, particular those with dementia, can lead to adverse drug events including falls and fractures, worsening cognitive impairment, emergency department visits, and hospitalizations. Educational mailings from health plans to patients and their providers to encourage deprescribing conversations may represent an effective, low-cost, "light touch", approach to reducing the burden of potentially inappropriate prescription use in older adults with dementia. OBJECTIVES The objective of the Developing a PRogram to Educate and Sensitize Caregivers to Reduce the Inappropriate Prescription Burden in Elderly with Alzheimer's Disease (D-PRESCRIBE-AD) trial is to evaluate the effect of a health plan based multi-faceted educational outreach intervention to community dwelling patients with dementia who are currently prescribed sedative/hypnotics, antipsychotics, or strong anticholinergics. METHODS The D-PRESCRIBE-AD is an open-label pragmatic, prospective randomized controlled trial (RCT) comparing three arms: 1) educational mailing to both the health plan patient and their prescribing physician (patient plus physician arm, n = 4814); 2) educational mailing to prescribing physician only (physician only arm, n = 4814); and 3) usual care (n = 4814) among patients with dementia enrolled in two large United States based health plans. The primary outcome is the absence of any dispensing of the targeted potentially inappropriate prescription during the 6-month study observation period after a 3-month black out period following the mailing. Secondary outcomes include dose-reduction, polypharmacy, healthcare utilization, mortality and therapeutic switching within targeted drug classes. CONCLUSION This large pragmatic RCT will contribute to the evidence base on promoting deprescribing of potentially inappropriate medications among older adults with dementia. If successful, such light touch, inexpensive and highly scalable interventions have the potential to reduce the burden of potentially inappropriate prescribing for patients with dementia. ClinicalTrials.gov Identifier: NCT05147428.
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Affiliation(s)
- Sonal Singh
- Department of Family Medicine and Community Health, Division of Health Systems Science, Umass Chan Medical School, Worcester, Massachusetts, United States of America
| | - Noelle M. Cocoros
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Xiaojuan Li
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Kathleen M. Mazor
- Division of Health Systems Science, UMass Chan Medical School, Worcester, Massachusetts, United States of America
| | - Mary T. Antonelli
- Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, Worcester, Massachusetts, United States of America
| | - Lauren Parlett
- Carelon Research, Wilmington, Delaware, United States of America
| | - Mark Paullin
- Carelon Research, Wilmington, Delaware, United States of America
| | - Thomas P. Harkins
- Humana Healthcare Research, Inc., (Humana), Louisville, Kentucky, United States of America
| | - Yunping Zhou
- Humana Healthcare Research, Inc., (Humana), Louisville, Kentucky, United States of America
| | - Paula A. Rochon
- Women’s Age Lab and Women’s College Research Institute, Women’s College Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Richard Platt
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Inna Dashevsky
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Carly Massino
- Division of Health Systems Science, UMass Chan Medical School, Worcester, Massachusetts, United States of America
| | - Cassandra Saphirak
- Division of Health Systems Science, UMass Chan Medical School, Worcester, Massachusetts, United States of America
| | - Sybil L. Crawford
- Division of Health System Science, UMass Chan Medical School, Tan Chingfen Graduate School of Nursing, Worcester, Massachusetts, United States of America
| | - Jerry H. Gurwitz
- Division of Geriatric Medicine and Division of Health Systems Science, UMass Chan Medical School, Worcester, Massachusetts, United States of America
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Bergman H, Borson S, Jessen F, Krolak-Salmon P, Pirani A, Rasmussen J, Rodrigo J, Taddeo D. Dementia and comorbidities in primary care: a scoping review. BMC PRIMARY CARE 2023; 24:277. [PMID: 38097969 PMCID: PMC10720181 DOI: 10.1186/s12875-023-02229-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 11/30/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND People with dementia (PwD) are known to have more chronic conditions compared to those without dementia, which can impact the clinical presentation of dementia, complicate clinical management and reduce overall quality of life. While primary care providers (PCPs) are integral to dementia care, it is currently unclear how PCPs adapt dementia care practices to account for comorbidities. This scoping review maps recent literature that describes the role for PCPs in the prevention, detection/diagnosis and management of dementia in the context of comorbidities, identifies critical knowledge gaps and proposes potential avenues for future research. METHODS We searched for peer-reviewed literature published between 2017-2022 in MEDLINE, Cochrane Library, and Scopus using key terms related to dementia, primary care, and comorbidity. The literature was screened for relevance by title-abstract screening and subsequent full-text screening. The prioritized papers were categorized as either 'Risk Assessment and Prevention', 'Screening, Detection, and Diagnosis' or 'Management' and were further labelled as either 'Tools and Technologies', 'Recommendations for Clinical Practice' or 'Programs and Initiatives'. RESULTS We identified 1,058 unique records in our search and respectively excluded 800 and 230 publications during title-abstract and full-text screening. Twenty-eight articles were included in our review, where ~ 50% describe the development and testing of tools and technologies that use pre-existing conditions to assess dementia risk. Only one publication provides official dementia screening guidelines for PCPs in people with pre-existing conditions. About 30% of the articles discuss managing the care of PwD, where most were anchored around models of multidisciplinary care and mitigating potentially inappropriate prescribing. CONCLUSION To our knowledge, this is the first scoping review that examines the role for PCPs in the prevention, detection/diagnosis and management of dementia in the context of comorbidities. Given our findings, we recommend that future studies: 1) further validate tools for risk assessment, timely detection and diagnosis that incorporate other health conditions; 2) provide additional guidance into how comorbidities could impact dementia care (including prescribing medication) in primary care settings; 3) incorporate comorbidities into primary care quality indicators for dementia; and 4) explore how to best incorporate dementia and comorbidities into models/frameworks of holistic, person-centred care.
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Affiliation(s)
- Howard Bergman
- Department of Family Medicine, McGill University, 5858 Ch. de La Côte-Des-Neiges, Suite 300, Montreal, QC, H3S 1Z1, Canada.
| | - Soo Borson
- Department of Family Medicine, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Frank Jessen
- Department of Psychiatry, Medical Faculty, University of Cologne, Cologne, Germany
| | | | | | | | - Jesus Rodrigo
- Spanish Alzheimer's Confederation (Confederación Española de Alzheimer), Pamplona, Spain
| | - Daiana Taddeo
- Italian College of General Practitioners and Primary Care (SIMG - Società Italiana Di Medicina Genrale E Cure Primarie), Florence, Italy
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Lu L, Wang S, Chen J, Yang Y, Wang K, Zheng J, Guo P, Cai Y, Zhang Q. Associated adverse health outcomes of polypharmacy and potentially inappropriate medications in community-dwelling older adults with diabetes. Front Pharmacol 2023; 14:1284287. [PMID: 38035029 PMCID: PMC10687175 DOI: 10.3389/fphar.2023.1284287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 10/31/2023] [Indexed: 12/02/2023] Open
Abstract
Aim: This study aimed to identify the association of chronic polypharmacy and potentially inappropriate medications (PIMs) with adverse health outcomes (AHOs) in community-dwelling older adults with diabetes in China. Methods: A 2-year retrospective cohort study was conducted using 11,829 community-followed older adults with diabetes and medical records from 83 hospitals and 702 primary care centers in Shenzhen, China. Chronic polypharmacy and PIMs were identified from prescription records using Beers' criteria, and their associated AHO was analyzed using multivariable logistic regression analysis. Results: The prevalence of chronic polypharmacy and at least one PIM exposure was 46.37% and 55.09%, respectively. The top five PIMs were diuretics, benzodiazepines, first-generation antihistamines, sulfonylureas, and insulin (sliding scale). Chronic polypharmacy was positively associated with all-cause hospital admission, admission for coronary heart disease, admission for stroke, admission for dementia, and emergency department visits. Exposure to PIMs was positively associated with all-cause hospital admission, admission for heart failure (PIMs ≥2), admission for stroke (PIMs ≥3), emergency department visits, bone fracture, constipation, and diarrhea. Conclusion: Chronic polypharmacy and PIMs were prevalent in older adults with diabetes in Chinese communities. Iatrogenic exposure to chronic polypharmacy and PIMs is associated with a higher incidence of different AHOs. This observational evidence highlights the necessity of patient-centered medication reviews for chronic polypharmacy and PIMs use in older patients with diabetes in primary care facilities in China and draws attention to the caution of polypharmacy, especially PIM use in older adults with diabetes in clinical practice.
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Affiliation(s)
- Lvliang Lu
- Department of Preventive Medicine, Shantou University Medical College, Shantou, Guangdong, China
| | - Shuang Wang
- Shenzhen Health Development Research and Data Management Center, Shenzhen, Guangdong, China
| | - Jiaqi Chen
- Department of Preventive Medicine, Shantou University Medical College, Shantou, Guangdong, China
| | - Yujie Yang
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, Guangdong, China
| | - Kai Wang
- Department of Preventive Medicine, Shantou University Medical College, Shantou, Guangdong, China
| | - Jing Zheng
- Shenzhen Health Development Research and Data Management Center, Shenzhen, Guangdong, China
| | - Pi Guo
- Department of Preventive Medicine, Shantou University Medical College, Shantou, Guangdong, China
| | - Yunpeng Cai
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, Guangdong, China
| | - Qingying Zhang
- Department of Preventive Medicine, Shantou University Medical College, Shantou, Guangdong, China
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Deardorff WJ, Jing B, Growdon ME, Yaffe K, Boscardin WJ, Boockvar KS, Steinman MA. Medication misuse and overuse in community-dwelling persons with dementia. J Am Geriatr Soc 2023; 71:3086-3098. [PMID: 37272899 PMCID: PMC10592653 DOI: 10.1111/jgs.18463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/26/2023] [Accepted: 05/16/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Persons with dementia (PWD) have high rates of polypharmacy. While previous studies have examined specific types of problematic medication use in PWD, we sought to characterize a broad spectrum of medication misuse and overuse among community-dwelling PWD. METHODS We included community-dwelling adults aged ≥66 in the Health and Retirement Study from 2008 to 2018 linked to Medicare and classified as having dementia using a validated algorithm. Medication usage was ascertained over the 1-year prior to an HRS interview date. Potentially problematic medications were identified by: (1) medication overuse including over-aggressive treatment of diabetes/hypertension (e.g., insulin/sulfonylurea with hemoglobin A1c < 7.5%) and medications inappropriate near end of life based on STOPPFrail and (2) medication misuse including medications that negatively affect cognition and medications from 2019 Beers and STOPP Version 2 criteria. To contextualize, we compared medication use to people without dementia through a propensity-matched cohort by age, sex, comorbidities, and interview year. We applied survey weights to make our results nationally representative. RESULTS Among 1441 PWD, median age was 84 (interquartile range = 78-89), 67% female, and 14% Black. Overall, 73% of PWD were prescribed ≥1 potentially problematic medication with a mean of 2.09 per individual in the prior year. This was notable across several domains, including 41% prescribed ≥1 medication that negatively affects cognition. Frequently problematic medications included proton pump inhibitors (PPIs), non-steroidal anti-inflammatory drugs (NSAIDs), opioids, antihypertensives, and antidiabetic agents. Problematic medication use was higher among PWD compared to those without dementia with 73% versus 67% prescribed ≥1 problematic medication (p = 0.002) and mean of 2.09 versus 1.62 (p < 0.001), respectively. CONCLUSION Community-dwelling PWD frequently receive problematic medications across multiple domains and at higher frequencies compared to those without dementia. Deprescribing efforts for PWD should focus not only on potentially harmful central nervous system-active medications but also on other classes such as PPIs and NSAIDs.
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Affiliation(s)
- W. James Deardorff
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Bocheng Jing
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Matthew E. Growdon
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Kristine Yaffe
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California
- Department of Neurology, University of California, San Francisco, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - W. John Boscardin
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Kenneth S. Boockvar
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama, Birmingham, Alabama
| | - Michael A. Steinman
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
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9
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Zhao M, Chen Z, Xu T, Fan P, Tian F. Global prevalence of polypharmacy and potentially inappropriate medication in older patients with dementia: a systematic review and meta-analysis. Front Pharmacol 2023; 14:1221069. [PMID: 37693899 PMCID: PMC10483131 DOI: 10.3389/fphar.2023.1221069] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/03/2023] [Indexed: 09/12/2023] Open
Abstract
Background: Older patients with dementia always need multiple drugs due to comorbidities and cognitive impairment, further complicating drug treatment and increasing the risk of potentially inappropriate medication. The objective of our study is to estimate the global prevalence of polypharmacy and potentially inappropriate medication (PIM) and explore the factors of PIM for older patients with dementia. Methods: We searched PubMed, Embase (Ovid), and Web of Science databases to identify eligible studies from inception to 16 June 2023. We conducted a meta-analysis for observational studies reporting the prevalence of potentially inappropriate medication and polypharmacy in older patients with dementia using a random-effect model. The factors associated with PIM were meta-analyzed. Results: Overall, 62 eligible studies were included, of which 53 studies reported the prevalence of PIM and 28 studies reported the prevalence of polypharmacy. The pooled estimate of PIM and polypharmacy was 43% (95% CI 38-48) and 62% (95% CI 52-71), respectively. Sixteen studies referred to factors associated with PIM use, and 15 factors were further pooled. Polypharmacy (2.83, 95% CI 1.80-4.44), diabetes (1.31, 95% CI 1.04-1.65), heart failure (1.17, 95% CI 1.00-1.37), depression (1.45, 95% CI 1.14-1.88), history of cancer (1.20, 95% CI 1.09-1.32), hypertension (1.46, 95% CI 1.05-2.03), ischemic heart disease (1.55, 95% CI 0.77-3.12), any cardiovascular disease (1.11, 95% CI 1.06-1.17), vascular dementia (1.09, 95% CI 1.03-1.16), chronic obstructive pulmonary disease (1.39, 95% CI 1.13-1.72), and psychosis (1.91, 95% CI 1.04-3.53) are positively associated with PIM use. Conclusion: PIM and polypharmacy were highly prevalent in older patients with dementia. Among different regions, the pooled estimate of PIM use and polypharmacy varied widely. Increasing PIM in older patients with dementia was closely associated with polypharmacy. For other comorbidities such as heart failure and diabetes, prescribing should be cautioned.
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Affiliation(s)
| | | | | | - Ping Fan
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fangyuan Tian
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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10
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Ayre MJ, Lewis PJ, Keers RN. Understanding the medication safety challenges for patients with mental illness in primary care: a scoping review. BMC Psychiatry 2023; 23:417. [PMID: 37308835 DOI: 10.1186/s12888-023-04850-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/06/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Mental illness and medication safety are key priorities for healthcare systems around the world. Despite most patients with mental illness being treated exclusively in primary care, our understanding of medication safety challenges in this setting is fragmented. METHOD Six electronic databases were searched between January 2000-January 2023. Google Scholar and reference lists of relevant/included studies were also screened for studies. Included studies reported data on epidemiology, aetiology, or interventions related to medication safety for patients with mental illness in primary care. Medication safety challenges were defined using the drug-related problems (DRPs) categorisation. RESULTS Seventy-nine studies were included with 77 (97.5%) reporting on epidemiology, 25 (31.6%) on aetiology, and 18 (22.8%) evaluated an intervention. Studies most commonly (33/79, 41.8%) originated from the United States of America (USA) with the most investigated DRP being non-adherence (62/79, 78.5%). General practice was the most common study setting (31/79, 39.2%) and patients with depression were a common focus (48/79, 60.8%). Aetiological data was presented as either causal (15/25, 60.0%) or as risk factors (10/25, 40.0%). Prescriber-related risk factors/causes were reported in 8/25 (32.0%) studies and patient-related risk factors/causes in 23/25 (92.0%) studies. Interventions to improve adherence rates (11/18, 61.1%) were the most evaluated. Specialist pharmacists provided the majority of interventions (10/18, 55.6%) with eight of these studies involving a medication review/monitoring service. All 18 interventions reported positive improvements on some medication safety outcomes but 6/18 reported little difference between groups for certain medication safety measures. CONCLUSION Patients with mental illness are at risk of a variety of DRPs in primary care. However, to date, available research exploring DRPs has focused attention on non-adherence and potential prescribing safety issues in older patients with dementia. Our findings highlight the need for further research on the causes of preventable medication incidents and targeted interventions to improve medication safety for patients with mental illness in primary care.
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Affiliation(s)
- Matthew J Ayre
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.
| | - Penny J Lewis
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, Academic Health Science Centre (MAHSC), The University of Manchester, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Richard N Keers
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, Academic Health Science Centre (MAHSC), The University of Manchester, Manchester, UK
- Suicide, Risk and Safety Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
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11
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Martín-Díaz M, Pino-Merlo G, Bueno-Cabanillas A, Khan KS. [Longitudinality in Primary Care and Polypharmacy. A Systematic Review]. Semergen 2023; 49:101994. [PMID: 37276757 DOI: 10.1016/j.semerg.2023.101994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 04/14/2023] [Accepted: 04/26/2023] [Indexed: 06/07/2023]
Abstract
The aim of this work was to collect, evaluate and interpret the available evidence on the relationship between continuity in primary care (i.e., longitudinality), and the prevalence of polypharmacy and its associated problems. Following the PRISMA reporting statement, we carried out a systematic review of the literature searching PubMed and Scopus databases. The screening of titles and summaries and the review of references carried out independently by two authors detected 16 works of potential interest, of which 4 were discarded after the independent review of all the originals because they did not meet inclusion criteria. The 12 papers selected studied the relationship between Longitudinality, measured with various quantitative indices, and the rate of polypharmacy or various associated problems, such as duplicate drugs, inadequate prescriptions or drug interactions. They all showed a significant relationship, often strong (RR>2 or<0.5), between longitudinality indicators and the various dependent variables. Although our knowledge could be improved by prospective studies that more directly evaluate longitudinality and its impact on problems due to excess medication, with the existing evidence, we can affirm that the protection and promotion of continuity in primary care can be a key element for the control of polypharmacy and associated problems.
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Affiliation(s)
- M Martín-Díaz
- Cirugía General y del Aparato Digestivo, Hospital General Básico Santa Ana de Motril, Área de Gestión Sanitaria Sur de Granada, Motril, Granada, España.
| | - G Pino-Merlo
- Unidad de Calidad y Seguridad del Paciente, Área de Gestión Sanitaria Sur de Granada, Granada, España
| | - A Bueno-Cabanillas
- Departamento de Medicina Preventiva y Salud Pública, Universidad de Granada, Granada, España; CIBER de Epidemiología y Salud Pública (CIBERESP), España; Instituto de Investigación BioSanitaria de Granada (IBS-Granada), Granada, España
| | - K S Khan
- Departamento de Medicina Preventiva y Salud Pública, Universidad de Granada, Granada, España; CIBER de Epidemiología y Salud Pública (CIBERESP), España
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12
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Liu AK, Possin KL, Cook KM, Lynch S, Dulaney S, Merrilees JJ, Braley T, Kiekhofer RE, Bonasera SJ, Allen IE, Chiong W, Clark AM, Feuer J, Ewalt J, Guterman EL, Gearhart R, Miller BL, Lee KP. Effect of collaborative dementia care on potentially inappropriate medication use: Outcomes from the Care Ecosystem randomized clinical trial. Alzheimers Dement 2023; 19:1865-1875. [PMID: 36331050 PMCID: PMC10156873 DOI: 10.1002/alz.12808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/11/2022] [Accepted: 08/29/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Potentially inappropriate medications (PIMs) cause adverse events and death. We evaluate the Care Ecosystem (CE) collaborative dementia care program on medication use among community-dwelling persons living with dementia (PLWD). METHODS Secondary analysis of a randomized clinical trial (RCT) comparing CE to usual care (UC) on changes in PIMs, over 12 months between March 2015 and May 2020. Secondary outcomes included change in number of medications, clinically relevant PIMs, and anti-dementia medications. RESULTS Of 804 PLWD, N = 490 had complete medication data. The CE resulted in significantly fewer PIMs compared to UC (-0.35; 95% CI, -0.49 to -0.20; P < 0.0001). Number needed to prevent an increase in 1 PIM was 3. Total medications, PIMs for dementia or cognitive impairment, CNS-active PIMs, anticholinergics, benzodiazepines, and opioids were also fewer. Anti-dementia medication regimens were modified more frequently. CONCLUSION The CE medication review intervention embedded in collaborative dementia care optimized medication use among PLWD. HIGHLIGHTS Compared to usual care (UC), the Care Ecosystem (CE) medication review intervention prevented increases in potentially inappropriate medications (PIMs). Use of anticholinergics, benzodiazepines, and opioids were significantly reduced, with a trend for antipsychotics. Anti-dementia medications were adjusted more frequently. The CE medication review intervention embedded in collaborative dementia care optimized medication use.
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Affiliation(s)
- Amy K. Liu
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California, USA
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Katherine L. Possin
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California, USA
| | - Kristen M. Cook
- Department of Pharmacy Practice and Science, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Shalini Lynch
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California, USA
| | - Sarah Dulaney
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer J. Merrilees
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Tamara Braley
- Division of Geriatrics, Gerontology, and Palliative Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Rachel E. Kiekhofer
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Stephen J. Bonasera
- Division of Geriatrics, Gerontology, and Palliative Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Isabel E. Allen
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Winston Chiong
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Amy M. Clark
- Division of Geriatrics, Gerontology, and Palliative Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Julie Feuer
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Joan Ewalt
- Division of Geriatrics, Gerontology, and Palliative Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Elan L. Guterman
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
| | - Rosalie Gearhart
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Bruce L. Miller
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Kirby P. Lee
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California, USA
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13
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Bogaerts JMK, Warmerdam LA, Achterberg WP, Gussekloo J, Poortvliet RKE. Proxy Decision-Making for Clinical Research in Nursing Home Residents With Dementia: A Qualitative Analysis. J Am Med Dir Assoc 2023; 24:541-547.e2. [PMID: 36924797 DOI: 10.1016/j.jamda.2023.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/16/2023] [Accepted: 02/16/2023] [Indexed: 03/14/2023]
Abstract
OBJECTIVES The benefit-risk ratio of many interventions remains unclear in older adults with dementia. Efforts for more representative trial inclusion are made; however, recruiting and particularly gaining informed consent remains complex. For research participation, dementia compels the designation of a legal guardian (LG) to give proxy consent. To advance future trial development, we aimed to provide more insights into the factors that affect the proxy decision-making process in dementia research. DESIGN A qualitative analysis of semi-structured interviews about proxy decision-making on participation in dementia research. SETTING AND PARTICIPANTS LGs of nursing home residents that gave (n = 19) and refrained from giving (n = 18) proxy consent for a clinical trial (the ∗∗∗BLINDED∗∗∗ study) in the Netherlands. METHODS Verbatim transcripts were thematically analyzed by using a preliminary deductive framework with room for induction of additional emerging themes, being an overall abductive approach. Based on that theme list, related factors of the decision-making process were grouped into overarching levels and merged into a step-by-step process. RESULTS When discussing proxy decision-making on the participation of an older adult with dementia in a clinical trial, LGs described interconnected factors on the level of the study and patient. Past experiences and attitudes of the LG influenced the weighing of these study- and patient-related factors, leading to a preliminary decision. Other proxies and treating health care professionals (HCPs) were named as important other stakeholders of the decision-making process. CONCLUSIONS AND IMPLICATIONS When giving proxy consent for research participation, LGs weigh study- and patient-related factors, leading to an initial benefit-risk evaluation. This weighing process is influenced by LG-related factors and can be modulated by other proxies or treating HCPs, leading to a definitive decision. Although insights into these underlying mechanisms could facilitate the proxy decision-making process for both LGs and researchers, treating HCPs could act as an independent party.
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Affiliation(s)
- Jonathan M K Bogaerts
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands.
| | - Laurie A Warmerdam
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Wilco P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands; University Network for the Care sector South Holland, Leiden University Medical Center, Leiden, the Netherlands
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands; Department of Internal Medicine, Section Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Rosalinde K E Poortvliet
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands; University Network for the Care sector South Holland, Leiden University Medical Center, Leiden, the Netherlands
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14
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Xue Qin QN, Ming LC, Abd Wahab MS, Tan CS, Yuda A, Hermansyah A. Drug-related problems among older people with dementia: A systematic review. Res Social Adm Pharm 2023; 19:873-881. [PMID: 36914513 DOI: 10.1016/j.sapharm.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/11/2023] [Accepted: 02/25/2023] [Indexed: 03/05/2023]
Abstract
INTRODUCTION Dementia is a disorder that causes a decline of cognitive function, and it affects millions of people worldwide. Increased availability of medications used to treat dementia will inevitably increase the likelihood of drug-related problems (DRPs). OBJECTIVE This systematic review sought to identify DRPs due to medication misadventures, including adverse drug reactions (ADRs), and use of inappropriate medications, among patients with dementia or cognitive impairments. METHODS The included studies were retrieved from the electronic databases PubMed and SCOPUS, and a preprint platform (MedRXiv) which were searched from their inception through August 2022. The English-language publications that reported DRPs among dementia patients were included. The JBI Critical Appraisal Tool for quality assessment was used to evaluate the quality of studies included in the review. RESULTS Overall, 746 distinct articles were identified. Fifteen studies met the inclusion criteria and reported the most common DRPs, which comprised medication misadventures (n = 9), such as ADRs, inappropriate prescription use, and potentially inappropriate medication use (n = 6). CONCLUSION This systematic review provides evidence that DRPs are prevalent among dementia patients, particularly the older people. It indicates that medication misadventures such as ADRs and inappropriate drug use, as well as potentially inappropriate medications, are the most prevalent DRPs among older people with dementia. Due to the small number of included studies, however, additional studies are required to improve comprehension about the issue.
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Affiliation(s)
- Qlaementine Ng Xue Qin
- Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah Institute of Health Sciences, Universiti Brunei Darussalam, Gadong, BE1410, Brunei Darussalam.
| | - Long Chiau Ming
- Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah Institute of Health Sciences, Universiti Brunei Darussalam, Gadong, BE1410, Brunei Darussalam; Department of Pharmacy Practice, Faculty of Pharmacy, Universitas Airlangga, Surabaya 60115, Indonesia; School of Medical and Life Sciences, Sunway University, Sunway City, Malaysia.
| | - Mohd Shahezwan Abd Wahab
- Department of Pharmacy Practice, Faculty of Pharmacy, Puncak Alam Campus, Universiti Teknologi MARA Cawangan Selangor, Bandar Puncak Alam 45350, Malaysia; Cardiology Therapeutics Research Group, Universiti Teknologi MARA, Bandar Puncak Alam 45350, Malaysia
| | - Ching Siang Tan
- School of Pharmacy, KPJ Healthcare University College, Nilai, Malaysia
| | - Ana Yuda
- Department of Pharmacy Practice, Faculty of Pharmacy, Universitas Airlangga, Surabaya 60115, Indonesia
| | - Andi Hermansyah
- Department of Pharmacy Practice, Faculty of Pharmacy, Universitas Airlangga, Surabaya 60115, Indonesia.
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15
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Liang CK, Chou MY, Hsu YH, Wang YC, Liao MC, Chen MT, Hsiao PY, Chen LK, Lin YT. The association of potentially inappropriate medications, polypharmacy and anticholinergic burden with readmission and emergency room revisit after discharge: A hospital-based retrospective cohort study. Br J Clin Pharmacol 2023; 89:187-200. [PMID: 35821614 DOI: 10.1111/bcp.15457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 06/05/2022] [Accepted: 06/30/2022] [Indexed: 11/30/2022] Open
Abstract
AIMS While certain drug-use indicators are known to be associated with clinical outcomes, the relationship is unclear for some highly prevalent conditions in in patients aged ≥65 years. We examine correlations between 3 drug-use indicators and postdischarge healthcare services use by older patients according to the presence of dementia, advanced age and frailty. METHODS This retrospective cohort study analysed data collected from hospital electronic health records between April and December 2017. Potentially inappropriate medications (PIMs) and anticholinergic burden were assessed using the 2015 Beers Criteria and anticholinergic cognitive burden scale (ACBS) score. Minor and major polypharmacy were defined as the use of 5-9 and ≥10 drugs, respectively. Outcomes were set as emergency room revisits and readmissions at 1, 3 and 6 months postdischarge. The correlation between drug-use indicators and outcomes was analysed by multivariable logistic regression. RESULTS The final cohort included 3061 patients for the analysis, and 2930, 2671 and 2560 patients were followed up to 1, 3 and 6 months after discharge. After controlling for confounders, all 3 drug-use indicators were significantly associated with readmission and emergency room revisits except for the relationship between PIMs and readmission within 6 months. These associations were significantly observed among patients without dementia, aged >80 years and with frailty. CONCLUSION PIMs, polypharmacy and anticholinergic burden are common at discharge and correlate with future use of healthcare services. In older patients, the absence of dementia, advanced age and frailty should be given extra consideration with regard to medication safety.
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Affiliation(s)
- Chih-Kuang Liang
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan.,Aging and Health Research Center, National Yang Ming Chiao Tung University, Taipei City, Taiwan.,Department of Geriatric Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan.,Division of Neurology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
| | - Ming-Yueh Chou
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan.,Aging and Health Research Center, National Yang Ming Chiao Tung University, Taipei City, Taiwan.,Department of Geriatric Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Ying-Hsin Hsu
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan.,Division of Neurology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan.,Chia Nan University, Tainan City, Taiwan
| | - Yu-Chun Wang
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
| | - Mei-Chen Liao
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
| | - Miao-Ting Chen
- Department of Pharmacy, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
| | - Pei-Yu Hsiao
- Department of Pharmacy, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
| | - Liang-Kung Chen
- Aging and Health Research Center, National Yang Ming Chiao Tung University, Taipei City, Taiwan.,Department of Geriatric Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan.,Taipei Municipal Gan-Dau Hospital, Taipei, Taiwan.,Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Yu-Te Lin
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan.,Division of Neurology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan.,Department of Pharmacy, Tajen University, Yanpu Township, Pingtung County, Taiwan
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16
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Potentially inappropriate medication use and mortality in patients with cognitive impairment. Eur J Clin Pharmacol 2022; 78:2013-2020. [DOI: 10.1007/s00228-022-03410-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 10/24/2022] [Indexed: 11/05/2022]
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17
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Zhu G, Tong Q, Ye X, Li J, Zhou L, Sun P, Liang F, Zhong S, Cheng R, Zhang J. Phototherapy for Cognitive Function in Patients With Dementia: A Systematic Review and Meta-Analysis. Front Aging Neurosci 2022; 14:936489. [PMID: 35847661 PMCID: PMC9284896 DOI: 10.3389/fnagi.2022.936489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 06/10/2022] [Indexed: 12/01/2022] Open
Abstract
Background Dementia is a major health burden worldwide. As numerous pharmacological trials for dementia have failed, emerging phototherapy studies have evaluated the efficacy of alternative therapies for cognition. Objective The objective of this study was to evaluate the association between phototherapy and changes in cognitive deficits in patients with dementia. Methods PubMed, Embase, Web of Science, PsycINFO, CINAHL, and Cochrane Central Register of Controlled Trials were searched from inception to 27 March 2022. Inclusion criteria were controlled clinical trials of phototherapy interventions reporting pre-post changes in global cognitive function and subdomains in patients with dementia. Data were extracted by two independent reviewers and pooled in random-effects models. Subgroup and meta-regression analyses were conducted to investigate the sources of heterogeneity. Results Our analyses included 13 studies enrolling a total of 608 participants. Phototherapy showed significant associations with improvements of global cognitive function (standardized mean difference [SMD], 0.63; 95% confidence interval [CI], 0.33-0.94; P < 0.001) and subdomains, especially with respect to attention, executive function, and working memory. Near-infrared (NIR) light-emitting diodes (LEDs) photobiomodulation (SMD, 0.91; 95% CI, 0.46-1.36; P < 0.001) and lasers (SMD, 0.99; 95% CI, 0.56-1.43; P < 0.001) showed more significant associations with improved cognitive functions when compared with normal visible light. In addition, the effect sizes of short-term effects (SMD, 0.63; 95% CI, 0.33-0.94; P < 0.001) were larger than effects assessed in long-term follow-up (SMD, 0.49; 95% CI, -0.24-1.21; P = 0.189). Conclusion In this meta-analysis, phototherapy interventions were associated with cognitive improvement in patients with dementia. NIR LEDs and lasers had advantages over normal visible light. Domain-specific effects were indicated for attention, executive function, and working memory. Short-term improvement after phototherapy was supported, while evidence for long-term benefits was lacking. Stronger evidence for individualized parameters, such as optimal dosing, is needed in the future. Systematic Review Registration [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=267596], identifier [CRD42021267596].
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Affiliation(s)
- Genying Zhu
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, China
- Department of Neurology & Brain Medical Centre, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qifeng Tong
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, China
- College of Rehabilitation, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiangming Ye
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, China
| | - Juebao Li
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, China
| | - Liang Zhou
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, China
| | - Peng Sun
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, China
| | - Feng Liang
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, China
| | - Shuchang Zhong
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, China
| | - Ruidong Cheng
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, China
- Department of Neurology & Brain Medical Centre, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jie Zhang
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, China
- Department of Neurology & Brain Medical Centre, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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18
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Growdon ME, Espejo E, Jing B, Boscardin WJ, Zullo AR, Yaffe K, Boockvar KS, Steinman MA. Attitudes toward deprescribing among older adults with dementia in the United States. J Am Geriatr Soc 2022; 70:1764-1773. [PMID: 35266141 DOI: 10.1111/jgs.17730] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 02/09/2022] [Accepted: 02/18/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND People with dementia (PWD) take medications that may be unnecessary or harmful. This problem can be addressed through deprescribing, but it is unclear if PWD would be willing to engage in deprescribing with their providers. Our goal was to investigate attitudes toward deprescribing among PWD. METHODS This was a cross-sectional study of 422 PWD aged ≥65 years who completed the medications attitudes module of the National Health and Aging Trends Study (NHATS) in 2016. Proxies provided responses when a participant was unable to respond due to health or cognitive problems. Attitudinal outcomes comprised responses to two statements from the patients' attitudes toward deprescribing questionnaire and its revised version (representing belief about the necessity of one's medications and willingness to deprescribe); another elicited the maximum number of pills that a respondent would be comfortable taking. RESULTS The weighted sample represented over 1.8 million PWD; 39% were 75 to 84 years old and 38% were 85 years or older, 60% were female, and 55% reported six or more regular medications. Proxies provided responses for 26% of PWD. Overall, 22% believed that they may be taking one or more medicines that they no longer needed, 87% were willing to stop one or more of their medications, and 50% were uncomfortable taking five or more medications. Attitudinal outcomes were similar across sociodemographic and clinical factors. PWD taking ≥6 medications were more likely to endorse a belief that at least one medication was no longer necessary compared to those taking <6 (adjusted probability 29% [95% confidence interval (CI), 22%-38%] vs. 13% [95% CI, 8%-20%]; p = 0.004); the same applied for willingness to deprescribe (92% [95% CI, 87%-95%] vs. 83% [95% CI, 76%-89%]; p = 0.04). CONCLUSIONS A majority of PWD are willing to deprescribe, representing an opportunity to improve quality of life for this vulnerable population.
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Affiliation(s)
- Matthew E Growdon
- Division of Geriatrics, University of California-San Francisco, San Francisco, California, USA.,San Francisco VA Medical Center, San Francisco, California, USA
| | - Edie Espejo
- Division of Geriatrics, University of California-San Francisco, San Francisco, California, USA.,San Francisco VA Medical Center, San Francisco, California, USA
| | - Bocheng Jing
- Division of Geriatrics, University of California-San Francisco, San Francisco, California, USA.,San Francisco VA Medical Center, San Francisco, California, USA
| | - W John Boscardin
- San Francisco VA Medical Center, San Francisco, California, USA.,Department of Medicine, University of California-San Francisco, San Francisco, California, USA.,Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA.,Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA.,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA.,Department of Pharmacy, Lifespan-Rhode Island Hospital, Providence, Rhode Island, USA
| | - Kristine Yaffe
- San Francisco VA Medical Center, San Francisco, California, USA.,Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA.,Department of Psychiatry, University of California-San Francisco, San Francisco, California, USA.,Department of Neurology, University of California-San Francisco, San Francisco, California, USA
| | - Kenneth S Boockvar
- The New Jewish Home, New York, New York, USA.,Icahn School of Medicine at Mount Sinai, New York, New York, USA.,James J. Peters VA Medical Center, Bronx, New York, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California-San Francisco, San Francisco, California, USA.,San Francisco VA Medical Center, San Francisco, California, USA
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19
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Koria LG, Sawan MJ, Redston MR, Gnjidic D. The Prevalence of Frailty Among Older Adults Living With Dementia: A Systematic Review. J Am Med Dir Assoc 2022; 23:1807-1814. [DOI: 10.1016/j.jamda.2022.01.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 01/11/2022] [Accepted: 01/31/2022] [Indexed: 11/29/2022]
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20
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Continuity of GP care for patients with dementia: impact on prescribing and the health of patients. Br J Gen Pract 2022; 72:e91-e98. [PMID: 35074796 PMCID: PMC8803082 DOI: 10.3399/bjgp.2021.0413] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 11/03/2021] [Indexed: 12/31/2022] Open
Abstract
Background Higher continuity of GP care (CGPC), that is, consulting the same doctor consistently, can improve doctor–patient relationships and increase quality of care; however, its effects on patients with dementia are mostly unknown. Aim To estimate the associations between CGPC and potentially inappropriate prescribing (PIP), and with the incidence of adverse health outcomes (AHOs) in patients with dementia. Design and setting A retrospective cohort study with 1 year of follow-up anonymised medical records from 9324 patients with dementia, aged ≥65 years living in England in 2016. Method CGPC measures include the Usual Provider of Care (UPC), Bice–Boxerman Continuity of Care (BB), and Sequential Continuity (SECON) indices. Regression models estimated associations with PIPs and survival analysis with incidence of AHOs during the follow-up adjusted for age, sex, deprivation level, 14 comorbidities, and frailty. Results The highest quartile (HQ) of UPC (highest continuity) had 34.8% less risk of delirium (odds ratio [OR] 0.65, 95% confidence interval [CI] = 0.51 to 0.84), 57.9% less risk of incontinence (OR 0.42, 95% CI = 0.31 to 0.58), and 9.7% less risk of emergency admissions to hospital (OR 0.90, 95% CI = 0.82 to 0.99) compared with the lowest quartile. Polypharmacy and PIP were identified in 81.6% (n = 7612) and 75.4% (n = 7027) of patients, respectively. The HQ had fewer prescribed medications (HQ: mean 8.5, lowest quartile (LQ): mean 9.7, P<0.01) and had fewer PIPs (HQ: mean 2.1, LQ: mean 2.5, P<0.01), including fewer loop diuretics in patients with incontinence, drugs that can cause constipation, and benzodiazepines with high fall risk. The BB and SECON measures produced similar findings. Conclusion Higher CGPC for patients with dementia was associated with safer prescribing and lower rates of major adverse events. Increasing continuity of care for patients with dementia may help improve treatment and outcomes.
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21
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Lu L, Yao K, Chen J, Yang Y, Wang K, Zheng J, Guo P, Cai Y, Zhang Q. Prevalence of potentially inappropriate medications and association with comorbidities in older adults with diabetes in an outpatient visitation setting. Front Public Health 2022; 10:995948. [PMID: 36203703 PMCID: PMC9530933 DOI: 10.3389/fpubh.2022.995948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 08/25/2022] [Indexed: 02/05/2023] Open
Abstract
AIMS Potentially inappropriate medications had been found associated with adverse drug events such as falls, emergency department admissions and hospital readmissions. There is lack of information about the prevalence of potentially inappropriate medications and associated chronic conditions in older patients with diabetes in China. This study aimed to assess the prevalence of potentially inappropriate medications in older adults with diabetes in an outpatient visitation setting and the association with polypharmacy due to comorbidities. MATERIALS AND METHODS This was a 3-year repeated cross-sectional study which conducted in outpatient setting of 52 hospitals in Shenzhen, China, using 2019 Beers criteria. The prevalence of potentially inappropriate medications, polypharmacy and comorbidities in older adults with diabetes in an outpatient setting was expressed as percentages. Logistic models were used to investigate the association between potentially inappropriate medication exposure and age, sex, polypharmacy and comorbidities. RESULTS Among the 28,484 older adults with diabetes in 2015, 31,757 in 2016 and 24,675 in 2017, the prevalence of potentially inappropriate medications was 43.2%, 44.88% and 42.40%, respectively. The top five potentially inappropriate medications were diuretics (20.56%), benzodiazepines (13.85%), androgens (13.18%), non-steroidal anti-inflammatory drugs (12.94%) and sulfonylureas (6.23%). After adjustment for age and polypharmacy, the probability of potentially inappropriate medication exposure was associated with chronic gastrointestinal diseases, followed by osteoarthritis and rheumatoid arthritis, chronic pulmonary disease, chronic kidney disease, tumor, dementia, chronic liver disease, hypertension, cardiovascular disease, cerebrovascular disease and hyperlipemia. CONCLUSION Potentially inappropriate medications were common in older patients with diabetes in an outpatient visitation setting. Higher probability of potentially inappropriate medication exposure was associated with the comorbidity chronic gastrointestinal diseases as well as osteoarthritis and rheumatoid arthritis. To ensure that iatrogenic risks remain minimal for older adults with diabetes, the clinical comorbidities should be considered.
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Affiliation(s)
- Lvliang Lu
- Department of Preventive Medicine, Shantou University Medical College, Shantou, China
| | - Keqin Yao
- Shenzhen Health Development Research and Data Management Center, Shenzhen, China
| | - Jiaqi Chen
- Department of Preventive Medicine, Shantou University Medical College, Shantou, China
| | - Yujie Yang
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Kai Wang
- Department of Preventive Medicine, Shantou University Medical College, Shantou, China
| | - Jing Zheng
- Shenzhen Health Development Research and Data Management Center, Shenzhen, China
| | - Pi Guo
- Department of Preventive Medicine, Shantou University Medical College, Shantou, China
| | - Yunpeng Cai
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
- Yunpeng Cai
| | - Qingying Zhang
- Department of Preventive Medicine, Shantou University Medical College, Shantou, China
- *Correspondence: Qingying Zhang
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22
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Leniz J, Higginson IJ, Yi D, Ul-Haq Z, Lucas A, Sleeman KE. Identification of palliative care needs among people with dementia and its association with acute hospital care and community service use at the end-of-life: A retrospective cohort study using linked primary, community and secondary care data. Palliat Med 2021; 35:1691-1700. [PMID: 34053356 PMCID: PMC8532216 DOI: 10.1177/02692163211019897] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hospital admissions among people dying with dementia are common. It is not known whether identification of palliative care needs could help prevent unnecessary admissions. AIM To examine the proportion of people with dementia identified as having palliative care needs in their last year of life, and the association between identification of needs and primary, community and hospital services in the last 90 days. DESIGN Retrospective cohort study using Discover, an administrative and clinical dataset from 365 primary care practices in London with deterministic individual-level data linkage to community and hospital records. SETTING/PARTICIPANTS People diagnosed with dementia and registered with a general practitioner in North West London (UK) who died between 2016 and 2019. The primary outcome was multiple non-elective hospital admissions in the last 90 days of life. Secondary outcomes included contacts with primary and community care providers. We examined the association between identification of palliative care needs with outcomes. RESULTS Among 5804 decedents with dementia, 1953 (33.6%) were identified as having palliative care needs, including 1141 (19.7%) identified before the last 90 days of life. Identification of palliative care needs before the last 90 days was associated with a lower risk of multiple hospital admissions (Relative Risk 0.70, 95% CI 0.58-0.85) and more contacts with the primary care practice, community nurses and palliative care teams in the last 90 days. CONCLUSIONS Further investigation of the mechanisms underlying the association between identification of palliative care needs and reduced hospital admissions could help reduce reliance on acute care for this population.
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Affiliation(s)
- Javiera Leniz
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Zia Ul-Haq
- Discover-Now, Imperial College Health Partners, London, UK
| | - Amanda Lucas
- Discover-Now, Imperial College Health Partners, London, UK
| | - Katherine E Sleeman
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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23
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van der Velde N, Minhas JS. Appropriate deprescribing in older people: a challenging necessityCommentary to accompany themed collection on deprescribing. Age Ageing 2021; 50:1516-1519. [PMID: 34260681 DOI: 10.1093/ageing/afab142] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 05/18/2021] [Indexed: 01/08/2023] Open
Abstract
Older people are often taking several medications for a number of different medical conditions. Although physicians prescribe medications to treat diseases and symptoms, there may be also harmful side effects, especially so in older people taking several medications. Unfortunately, regular review of the benefits or risks of prescribed medications is as of yet not part of standard care. Also, data on how and in whom to stop medications in older people are scarce. The reason this is an important area of work is that medication related issues in older people are a common cause of harm, including both expected and unexpected effects of medications. Research to date tells us that to ensure successful implementation of structured and appropriate deprescribing, careful planning within hospital systems is needed. This includes involving different members of the team to ensure the patients truly benefit. The themed collection published on the Age and Ageing journal website offers key articles providing tools to assist decision-making, implementation strategies and multidisciplinary interventions-all with the aim of improving patient outcome and sustainability of deprescribing approaches.
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Affiliation(s)
- Nathalie van der Velde
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jatinder S Minhas
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester, UK
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24
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Manias E, Kabir MZ, Maier AB. Inappropriate medications and physical function: a systematic review. Ther Adv Drug Saf 2021; 12:20420986211030371. [PMID: 34349978 PMCID: PMC8287273 DOI: 10.1177/20420986211030371] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 06/17/2021] [Indexed: 01/10/2023] Open
Abstract
Background and aims: Inappropriate medication prescription is highly prevalent in older adults and is associated with adverse health outcomes. The aim of this study was to examine the associations between potentially inappropriate medications (PIMS) and potential prescribing omissions with physical function in older adults situated in diverse environments. Methods: A systematic search was completed using the following databases: MEDLINE, CINAHL, PsycINFO, EMBASE and COCHRANE. Results were extracted from the included studies. Results: In total, 55 studies reported on 2,767,594 participants with a mean age of 77.1 years (63.5% women). Study designs comprised 26 retrospective cohort studies, 21 prospective cohort studies and 8 cross-sectional studies. Inappropriate medications in community and hospital settings were significantly associated with higher risk of falls (21 out of 30 studies), higher risk of fractures (7 out of 9 studies), impaired activities of daily living (ADL; 8 out of 10 studies) and impaired instrumental ADL (IADL) score (4 out of 6 studies). Five out of seven studies also showed that PIMs were associated with poorer physical performance comprising the Timed Up and Go test, walking speed, grip strength, time to functional recovery, functional independence and scale of functioning. Many medication classes were implicated as PIMs in falls, fractures and impairment in physical performance including antipsychotic, sedative, anti-anxiety, anticholinergic, antidiabetic, opioid and antihypertensive medications. For patients not receiving musculoskeletal medications, such as calcium, vitamin D and bisphosphonates, older adults were found to be at risk of a hospital admission for a fall or fracture. Conclusion: Inappropriate medication prescriptions are associated with impaired physical function across longitudinal and cross-sectional studies in older adults situated in diverse settings. It is important to support older people to reduce their use of inappropriate medications and prevent prescribing omissions. Plain language summary Inappropriate medications and physical function Background and aims: The use of inappropriate medications is very common in older adults and is associated with harmful health problems. The aim was to examine associations between potentially inappropriate medications and potential prescribing omissions with physical function in older adults situated in diverse environments. Methods: Library databases were examined for possible studies to include and a systematic search was completed. Relevant information was obtained from the included studies. Results: In total, 55 studies reported on 2,767,594 participants who were an average age of 77.1 years and about 6 out of 10 were women. A variety of different study designs were used. Inappropriate medication prescriptions in community and hospital settings were significantly associated with higher risk of falls (21 out of 30 studies), higher risk of fractures (7 out of 9 studies), problems with activities of daily living (ADL), such as eating, bathing, dressing, grooming, walking and toileting (8 out of 10 studies) and problems with instrumental ADL such as managing medications, house cleaning and shopping (4 out of 6 studies). Five out of seven studies also showed that inappropriate medications were associated with poorer physical performance involving the Timed Up and Go test, walking speed, grip strength, time to functional recovery, functional independence and scale of functioning. Many types of medication classes were shown to be associated with a risk of falls, fractures and problems with physical performance. Omitted medications were also associated with falls and fractures. Conclusion: Inappropriate medication prescriptions are associated with problems relating to physical function. It is important to support older people to reduce their use of inappropriate medications and prevent prescribing omissions.
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Affiliation(s)
- Elizabeth Manias
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, 221 Burwood Highway, Burwood, VIC 3125, Australia
| | - Md Zunayed Kabir
- Department of Medicine and Aged Care, The Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Andrea B Maier
- Department of Medicine and Aged Care, @ Age Melbourne, The Royal Melbourne Hospital, The University of Melbourne, VIC, Australia
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25
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Growdon ME, Gan S, Yaffe K, Steinman MA. Polypharmacy among older adults with dementia compared with those without dementia in the United States. J Am Geriatr Soc 2021; 69:2464-2475. [PMID: 34101822 DOI: 10.1111/jgs.17291] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/27/2021] [Accepted: 05/01/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES In older persons with dementia (PWD), extensive medication use is often unnecessary, discordant with goals of care, and possibly harmful. The objective of this study was to determine the prevalence and medication constituents of polypharmacy among older PWD attending outpatient visits in the United States. DESIGN Cross-sectional analysis. SETTING AND PARTICIPANTS PWD and persons without dementia (PWOD) aged ≥65 years attending outpatient visits recorded in the nationally representative National Ambulatory Medical Care Survey (NAMCS), 2014-2016. MEASUREMENTS PWD were identified as those with a diagnosis of dementia on the NAMCS encounter form and/or those receiving an anti-dementia medication. Visits with PWD and PWOD were compared in terms of sociodemographic, practice/physician factors, comorbidities, and prescribing outcomes. Regression analyses examined the effect of dementia diagnosis on contributions by clinically relevant medication categories to polypharmacy (defined as being prescribed ≥5 prescription and/or nonprescription medications). RESULTS The unweighted sample involved 918 visits for PWD and 26,543 visits for PWOD, representing 29.0 and 780 million outpatient visits. PWD had a median age of 81 and on average had 2.8 comorbidities other than dementia; 63% were female. The median number of medications in PWD was eight compared with three in PWOD (p < 0.001). After adjustment, PWD had significantly higher odds of being prescribed ≥5 medications (AOR 3.0; 95% CI: 2.1-4.3) or ≥10 medications (AOR 2.8; 95% CI: 2.0-4.2) compared with PWOD. The largest sources of medications among PWD were cardiovascular and central nervous system medications; usage from other categories was generally elevated in PWD compared with PWOD. PWD had higher odds of receiving at least one highly sedating or anticholinergic medication (AOR 2.5; 95% CI: 1.6-3.9). CONCLUSION In a representative sample of outpatient visits, polypharmacy was extremely common among PWD, driven by a wide array of medication categories. Addressing polypharmacy in PWD will require cross-cutting and multidisciplinary approaches.
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Affiliation(s)
- Matthew E Growdon
- Division of Geriatrics, University of California, San Francisco, California, USA.,San Francisco VA Medical Center, San Francisco, California, USA
| | - Siqi Gan
- Division of Geriatrics, University of California, San Francisco, California, USA.,San Francisco VA Medical Center, San Francisco, California, USA
| | - Kristine Yaffe
- San Francisco VA Medical Center, San Francisco, California, USA.,Departments of Neurology, Psychiatry, and Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco, California, USA.,San Francisco VA Medical Center, San Francisco, California, USA
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26
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Renom-Guiteras A. Potentially inappropriate medication among people with dementia: towards individualized decision-making. Eur Geriatr Med 2021; 12:569-575. [PMID: 34003481 DOI: 10.1007/s41999-021-00502-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 04/15/2021] [Indexed: 12/18/2022]
Abstract
AIM The aims of this manuscript are to report on several aspects that may deserve special consideration when individualizing decisions on the prescription appropriateness among people with dementia, and to discuss current research needs in relation to these aspects. METHODS Review article based on selective literature. RESULTS The aspects that may deserve special consideration are: the prescription of pychotropic medications, for being commonly inappropriately prescribed; the presence of advanced stage of dementia, comorbidities or multi-morbidity and/or frailty, as they can determine the prognosis and goals of care; the values and wishes of the person with dementia, as they may prioritize different goals of care; and medication adherence, as it may be poorer compared with persons without dementia. Further research on these aspects including representative participants is necessary as evidence base to guide clinical practice. CONCLUSION Individualised decisions on prescription appropriateness among people with dementia may require a comprehensive evaluation of the person in order to establish a shared care plan. Further research will probably support this process.
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Affiliation(s)
- Anna Renom-Guiteras
- Department of Geriatric Medicine. Parc de Salut Mar, Barcelona, Spain. .,Health Services Research on Chronic Patients Network (REDISSEC), Madrid, Spain.
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27
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Bablok I, Binder H, Stelzer D, Kaier K, Graf E, Wangler J, Jansky M, Löhr M, Schulz M, Kockläuner M, Geschke K, Wuttke-Linnemann A, Fellgiebel A, Farin E. Primary dementia care based on the individual needs of the patient: study protocol of the cluster randomized controlled trial, DemStepCare. BMC Geriatr 2021; 21:222. [PMID: 33794789 PMCID: PMC8012747 DOI: 10.1186/s12877-021-02114-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/24/2021] [Indexed: 11/27/2022] Open
Abstract
Background Most people with dementia (PwD) are cared for at home, with general practitioners (GPs) playing a key part in the treatment. However, primary dementia care suffers from a number of shortcomings: Often, diagnoses are made too late and therapies by GPs do not follow the guidelines. In cases of acute crises, PwD are too often admitted to hospital with adverse effects on the further course of the disease. The aim of this study is to implement and evaluate a new GP-based, complex dementia care model, DemStepCare. DemStepCare aims to ensure demand-oriented, stepped care for PwD and their caregivers. Methods/design In a cluster randomized controlled trial, the care of PwD receiving a complex intervention, where the GP is supported by a multi-professional team, is compared to (slightly expanded) usual care. GPs are clustered by GP practice, with 120 GP practices participating in total. GP practices are randomized to an intervention or a control group. 800 PwD are to be included per group. Recruitment takes place in Rhineland-Palatinate, Germany. In addition, a second control group with at least 800 PwD will be formed using aggregated routine data from German health insurance companies. The intervention comprises the training of GPs, case management including repeated risk assessment of the patients’ care situation, the demand-oriented service of an outpatient clinic, an electronic case record, external medication analyses and a link to regional support services. The primary aims of the intervention are to positively influence the quality of life for PwD, to reduce the caregivers’ burden, and to reduce the days spent in hospital. Secondary endpoints address medication adequacy and GPs’ attitudes and sensitivity towards dementia, among others. Discussion The GP-based dementia care model DemStepCare is intended to combine a number of promising interventions to provide a complex, stepped intervention that follows the individual needs of PwD and their caregivers. Its effectiveness and feasibility will be assessed in a formative and a summative evaluation. Trial registration German Register of Clinical Trials (Deutsches Register Klinischer Studien, DRKS), DRKS00023560. Registered 13 November 2020 - Retrospectively registered. HTML&TRIAL_ID=DRKS00023560.
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Affiliation(s)
- Isabella Bablok
- Institute of Medical Biometry and Statistics, Section of Health Care Research and Rehabilitation Research, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany.
| | - Harald Binder
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Dominikus Stelzer
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Erika Graf
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Julian Wangler
- Center for General and Geriatric Medicine, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Michael Jansky
- Center for General and Geriatric Medicine, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Michael Löhr
- Landschaftsverband Westfalen-Lippe, Hospital Gütersloh, Gütersloh, Germany.,Diakonie University of Applied Sciences, Bielefeld, Germany
| | - Michael Schulz
- Landschaftsverband Westfalen-Lippe, Hospital Gütersloh, Gütersloh, Germany.,Diakonie University of Applied Sciences, Bielefeld, Germany
| | - Marie Kockläuner
- Department of Pharmacy, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Katharina Geschke
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany.,Center for Mental Health in Old Age, Landeskrankenhaus (AöR), Mainz, Germany
| | - Alexandra Wuttke-Linnemann
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany.,Center for Mental Health in Old Age, Landeskrankenhaus (AöR), Mainz, Germany
| | - Andreas Fellgiebel
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany.,Center for Mental Health in Old Age, Landeskrankenhaus (AöR), Mainz, Germany
| | - Erik Farin
- Institute of Medical Biometry and Statistics, Section of Health Care Research and Rehabilitation Research, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
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