Detection and prevention of adverse drug reactions in multi-morbid older patients

Pre-clinical Models for Geriatric Pharmacotherapy

With ageing of the population worldwide and discovery of new medications for prevention and management of age-related conditions, there is increasing use of medications by older adults. There are international efforts to increase the representativeness of participants in clinical trials to match the intended real-world users of the medications across a range of characteristics including age, multimorbidity, polypharmacy and frailty. Currently, much of the data on medication-related harm in older adults are from pharmacovigilance studies. New methods in pre-clinical models have allowed for measurement of exposures (such as chronic exposure, polypharmacy and deprescribing) and outcomes (such as health span functional measures and frailty) that are highly relevant to geriatric pharmacotherapy. Here we describe opportunities for design and implementation of pre-clinical models that can better predict drug effects in geriatric patients. This could improve the translation of new drugs from bench to bedside and improve outcomes of pharmacotherapy in older adults.

Potentially Inappropriate Prescribing and Potential Prescribing Omissions and Their Association with Adverse Drug Reaction-Related Hospital Admissions

BACKGROUND

This study aimed to determine the prevalence of potentially inappropriate prescribing (PIP) and potential prescribing omissions (PPOs) and their association with ADR-related hospital admissions in patients aged ≥ 65 years admitted acutely to the hospital.

METHODS

Information on medications and morbidities was extracted from the Adverse Drug Reactions in an Ageing Population (ADAPT) cohort (N = 798: N = 361 ADR-related admissions; 437 non-ADR-related admissions). PIP and PPOs were assessed using Beers Criteria 2019 and STOPP/START version 2. Multivariable logistic regression (adjusted odds ratios (aOR), 95%CI) was used to examine the association between PIP, PPOs and ADR-related admissions, adjusting for covariates (age, gender, comorbidity, polypharmacy).

RESULTS

In total, 715 (90%; 95% CI 87-92%) patients had ≥1 Beers Criteria, 555 (70%; 95% CI 66-73%) had ≥ 1 STOPP criteria and 666 patients (83%; 95% CI 81-86%) had ≥ 1 START criteria. Being prescribed at least one Beers (aOR = 1.66, 95% CI = 1.00-2.77), or meeting STOPP (aOR = 1.07, 95% CI = 0.79-1.45) or START (aOR = 0.72; 95%CI = 0.50-1.06) criteria or the number of PIP/PPO criteria met was not significantly associated with ADR-related admissions. Patients prescribed certain drug classes (e.g., antiplatelet agents, diuretics) per individual PIP criteria were more likely to have an ADR-related admission.

CONCLUSION

There was a high prevalence of PIP and PPOs in this cohort but no association with ADR-related admissions.

Reports of Symptoms Associated with Supraventricular Arrhythmias as a Serious Adverse Drug Reaction in the Spanish Pharmacovigilance Database

This study aimed to determine the type of drugs reported as suspected of causing severe supraventricular arrhythmias from the Spanish Human Pharmacovigilance System database. A total of 1053 reports were analysed, of which 526 (50%) were on men and 516 (49%) were on women. The most affected age group was the over-65s, with 593 reports (56%). Of the 1613 drugs, those belonging to the cardiovascular system (ATC Group C) were the most numerous (414 reports, 26%), with digoxin being the most frequent drug (49 reports, 12%). Other common groups were antiinfectives for systemic use (ATC Group J; 306 reports, 19%), antineoplastic and immunomodulating agents (ATC Group L; 198 reports, 12%), and nervous system drugs (ATC Group N; 185 reports, 11%). The most common supraventricular arrhythmia was atrial fibrillation (561 reports, 51%). Regarding outcomes, 730 (66%) patients recovered, 76 (7%) did not recover, 25 (3%) recovered but with sequelae, and 23 (2%) resulted in death. This study revealed that certain drugs have reported to be associated more frequently to supraventricular arrhythmias as serious adverse reactions, especially in the older population. Proper clinical management and effective strategies to ensure medication appropriateness should always be considered to improve patient safety when prescribing drugs.

Adverse drug reactions in an ageing PopulaTion (ADAPT) study: Prevalence and risk factors associated with adverse drug reaction-related hospital admissions in older patients

Background: Older people experience greater morbidity with a corresponding increase in medication use resulting in a potentially higher risk of adverse drug reactions (ADRs). Objectives: The aim of this study was to; 1) determine the prevalence and characteristics of ADR-related hospital admissions among older patients (≥65 years) in Ireland; and 2) identify the risk factors associated with ADR-related hospital admissions. Methods: A cross-sectional study of ADR prevalence in patients aged ≥65 years admitted acutely to hospital in Ireland over a 8 month period (November 2016- June 2017). A multifaceted review of each hospital admission was undertaken to assess the likelihood of an ADR being a reason for admission (cause of admission or contributing to admission) in the context of the patient's medication, clinical conditions, comorbidities and investigations. A number of decision aids were applied by two independent reviewers to assess ADR causality, avoidability and severity. A random sample of patients, determined not to have a suspected ADR on screening, were assigned to a non-ADR control group. Multivariable logistic regression was used to assess the association between potential risk factors for ADR-related admissions compared with non-ADR-related admissions. Results: In total, 3,760 hospital admission episodes (in 3,091 patients) were screened and 377 admissions were considered ADR-related (10.0%, 95% CI 9.1%, 11.0%). 219 (58.1%) ADR-related admissions were caused by an ADR, while ADRs contributed to 158 (41.9%) admissions. 268 (71.1%) of all ADR-related admissions were deemed definitely or possibly preventable/avoidable. 350 (92.8%) ADRs were classified as being of moderate severity, with 27 (7.2%) classified as severe. Antithrombotic agents, mainly aspirin and warfarin, were the drugs most frequently associated with ADR-related admissions (gastrointestinal and vascular haemorrhagic disorders). In multivariable analysis, immobility, frailty, having delirium or ulcer disease and taking anticoagulant and antiplatelet medication on admission were significantly associated with an ADR-related hospital admission. Conclusion: One in ten hospital admissions, among those aged 65 + years, were considered ADR-related, with approximately 70% potentially avoidable. Reliable and validated ADR detection and prediction tools are needed to develop prevention strategies.

Development and Validation of ‘Prediction of Adverse Drug Reactions in Older Inpatients (PADROI)’ Risk Assessment Tool

Background

Adverse drug reactions (ADR) detection and prediction methods in hospitalized older adults remain imprecise. The identification of the risk factors for ADRs in this group of patients is crucial to develop plausible prediction models.

Objective

This study aimed at developing and validating a “Prediction of ADR in Older Inpatients (PADROI)” risk assessment tool in hospitalized older adults.

Methods and Materials

We had previously conducted a derivational study that aimed to determine the risk factors of ADRs in hospitalized older adults. We developed the PADROI model as a potential ADR risk assessment tool incorporating 8 predictors each given a score by rounding off the respective adjusted odds ratios (AORs) to the nearest whole number. Subsequently, we conducted another prospective cohort among adults aged 60 years and older admitted to Gynecology and Obstetrics, Medical, Oncology, Surgery, and Psychiatry wards at Mbarara Regional Referral Hospital (MRRH) from July 5 to September 17, 2021.

Results

A total of 124 participants, 70 females and 54 males aged 60–95 years, were included in this validation cohort; 62 of them experienced 90 ADRs. When applied to the derivational cohort, the area under receiver operating characteristic curve (AUROC) for the PADROI model was shown to be 0.896 (0.869–0.923; at 95% CI). In the validation study, AUROC of PADROI was 0.917 (0.864–0.971 at 95% CI; p < 0.001). Overall, PADROI correctly predicted 91.7% of those who experienced an ADR.

Conclusion

Using the adjusted odds ratios from our derivational cohort, we developed an ADR prediction tool (PADROI) that achieved an excellent AUROC (0.917), high sensitivity (87.1%) and specificity (90.3%). The current model demonstrated a high potential for clinical applicability which can be strengthened if similar results are reproduced in larger and multi-centered studies.

Pharmacogenomics in Older Adults: An Integrative Review

Through pharmacogenomics testing, identifying genetic variants that influence how individuals respond to medications could potentially decrease the "trial and error" approach to prescribing medications, maximize beneficial effects, and reduce risks of adverse drug events. Yet, pharmacogenomics testing is still subject to an ongoing debate over its clinical validity and utility. The purpose of the current integrative review was to examine and synthesize evidence on the clinical application of pharmacogenomics in medication management among older adults. Gaps were found, such as lack of studies investigating the prospective use of pharmacogenomics testing to improve clinical outcomes and lack of strong evidence on the clinical validity and utility of pharmacogenomics testing in the medication management of older adults. However, the review identified evidence for the potential benefits of pharmacogenomics testing to improve older adults' clinical outcomes that warrant further investigation. [Research in Gerontological Nursing, 14(4), 211-220.].

Nobody ever questions-Polypharmacy in care homes: A mixed methods evaluation of a multidisciplinary medicines optimisation initiative

BACKGROUND

Nurse-led monitoring of patients for signs and symptoms associated with documented 'undesirable effects' of medicines has potential to prevent avoidable harm, and optimise prescribing.

INTERVENTION

The Adverse Drug Reaction Profile for polypharmacy (ADRe-p) identifies and documents putative adverse effects of medicines commonly prescribed in primary care. Nurses address some problems, before passing ADRe-p to pharmacists and prescribers for review, in conjunction with prescriptions.

OBJECTIVES

We investigated changes in: the number and nature of residents' problems as recorded on ADRe-p; prescription regimens; medicines optimisation: and healthcare costs. We explored aetiologies of problems identified and stakeholders' perspectives.

SETTING AND PARTICIPANTS

In three UK care homes, 19 residents completed the study, December 2018 to May 2019. Two service users, three pharmacists, six nurses gave interviews.

METHODS

This mixed-method process evaluation integrated data from residents' ADRe-ps and medicines charts, at the study's start and 5-10 weeks later.

RESULTS

We recruited three of 27 homes approached and 26 of 45 eligible residents; 19 completed ADRe-p at least twice. Clinical gains were identified for 17/19 residents (mean number of symptoms 3 SD 1.67, range 0-7). Examples included management of: pain (six residents), seizures (three), dyspnoea (one), diarrhoea (laxatives reduced, two), falls (two of five able to stand). One or more medicine was de-prescribed or dose reduced for 12/19 residents. ADRe administration and review cost ~£30 in staff time. ADRe-p helped carers and nurses bring residents' problems to the attention of prescribers.

IMPLICATIONS

ADRe-p relieved unnecessary suffering. It supported carers and nurses by providing a tool to engage with pharmacists and prescribers, and was the only observable strategy for multidisciplinary team working around medicines optimisation. ADRe-p improved care by: a) regular systematic checks and problem documentation; b) information transfer from care home staff to prescribers and pharmacists; c) recording changes.

REGISTRATION

NLM Identifier NCT03955133; ClinicalTrials.gov.

Appropriate use of essential medicines in the elderly: a comparison of the WHO essential medicines list and PIM criteria

PURPOSE

The elderly are not only threatened by bad medicines (overtreatment) but also by undertreatment with "good" medicines. Symmetry is required in any patient-centred approach to properly treat older people. The purpose of this study was to perfect the development of an EML and criteria according to the advantages of each and promote the appropriate use of essential medicines in the elderly.

METHOD

We compared the EML with four PIM criteria and calculated the proportion of essential medicines included in the criteria. We also summarized the rationale for including medicines in each criterion and analysed higher risk drugs and drug risks.

RESULTS

Of essential medicines, 26% are included in at least one criterion as PIM. In 11 drug categories of the EML, more than 50% of drugs of each category are included in at least one criterion, and in four categories, all drugs are included. The potentially inappropriate essential medicines (PIEMs) for the elderly focus on cardiovascular drugs and central nervous system drugs. Fifty-nine drugs have been explicitly identified as increasing the risk of falls, increasing mortality and/or having inappropriate long-term use, and the main risk of PIEMs is falls (30.3% of PIEMs). Additionally, 17.9% of essential medicines are labelled as positive drugs in START and/or FORTA (A/B).

CONCLUSION

Improving medication information for the elderly in the EML and establishing an essential medicines list for the elderly will promote appropriate drug use in older people worldwide.

Medication-related problems encountered in the Program of All-Inclusive Care for the Elderly: An observational study

OBJECTIVE

To evaluate pharmacist-encountered medication-related problems (MRPs) among the participants of the Program of All-Inclusive Care for the Elderly (PACE).

DESIGN

This was a retrospective analysis of proprietary pharmacy records detailing pharmacist encounters with PACE clinical staff.

SETTING AND PARTICIPANTS

A national provider of pharmacy services to more than 75 PACE organizations. In total, 1057 PACE participants at 69 PACE sites across the United States with documented pharmacist encounters between March and May 2018.

OUTCOME MEASURES

MRPs were classified using the Hepler-Strand taxonomy, and pharmacists' recommendations made to prescribers to resolve these MRPs were classified using a modified Hoth taxonomy. In addition, pharmacists' communication methods and prescribers' responses were analyzed.

RESULTS

Overall, 2004 MRPs were encountered. The most frequent MRPs identified were related to medication safety concerns, including drug interactions (720, 35.9%), adverse drug reactions (ADRs, 356, 17.8%), high doses (270, 13.5%), and unindicated drugs (252, 12.6%). Drug interactions frequently involved competitive inhibition, 3 or more drugs, opioids, anticoagulants, antiplatelets, and antidepressants. Deprescribe medication (561, 24.8%), start alternative therapy (553, 24.4%), change doses (457, 20.2%), and monitor (243, 10.7%) were the top 4 types of recommendations made by pharmacists. Among 1730 responses obtained from PACE prescribers, 78.1% (n = 1351) of pharmacists' recommendations were accepted. Compared with electronic communication, telephonic communication was associated with more acceptance and less prescriber nonresponse (χ² = 78.5, P < 0.001).

CONCLUSION

Pharmacists identified a substantial number of MRPs in PACE, especially those related to medication safety such as drug interactions and ADRs. In this practice setting, significant collaboration occured between pharmacists and PACE prescribers, as evidenced by the rate of prescribers' acceptance of pharmacists' recommendations. Further research is needed to fully evaluate the economic, clinical, and humanistic outcomes associated with pharmacists' encounters in PACE.

Medication-related harm: a geriatric syndrome

The WHO Global Patient Safety Challenge: Medication Without Harm recognises medication-related harm (MRH) as a global public health issue. Increased life-expectancy coupled with multimorbidity and polypharmacy leads to an increased incidence of MRH, especially in older adults: at a cost of approximately £400 million to the National Health Service (NHS) in England. Harm from medicines has long been recognised by geriatricians, and strategies have been developed to mitigate harm. In general, these have focused on the challenges of polypharmacy and appropriateness of medicines, but impact on the quality of life, clinical and economic outcomes has been variable and often disappointing. The problem of MRH in older adults will continue to grow unless a new approach is adopted. Emerging evidence suggests that we need to take a broader approach as described in our conceptual model, where well-recognised physiological changes are incorporated, as well as other rarely considered psychosocial issues that influences MRH. Parallels may be drawn between this approach and the management of geriatric syndromes. We propose there must be a greater emphasis on MRH, and it, of itself, should be considered as a geriatric syndrome, to bring the spotlight onto the problem and to send a clear signal from geriatric experts that this is an important issue that needs to be addressed using a co-ordinated and tailored approach across health and social care boundaries. This requires a more proactive approach to monitor and review the medicines of older adults in response to their changing need.

Nurse-led medicines' monitoring in care homes, implementing the Adverse Drug Reaction (ADRe) Profile improvement initiative for mental health medicines: An observational and interview study

Introduction

Preventable adverse effects of medicines often pass unnoticed, but lead to real harm.

Intervention

Nurse-led monitoring using the structured Adverse Drug Reaction (ADRe) Profile identifies and addresses adverse effects of mental health medicines.

Objectives

This study investigated the implementation and clinical impact of ADRe, and barriers to and facilitators of sustained utilisation in routine practice.

Methods

Administration of ADRe was observed for 30 residents prescribed mental health medicines in ten care homes. The study pharmacist reviewed completed ADRes against medication records. Policy context was explored in 30 interviews with service users, nurse managers and strategic leads in Wales.

Results

Residents were aged 60–95, and prescribed 1–17 (median 9 [interquartile range (IQR) 7–13]) medicines. ADRe identified a median of 18 [IQR 11.5–23] problems per resident and nurses made 2 [1–2] changes to care per resident. For example: falls were reported for 9 residents, and care was modified for 5; pain was identified in 8 residents, and alleviated for 7; all 6 residents recognised as dyspnoeic were referred to prescribers. Nurses referred 17 of 30 residents to prescribers. Pharmacists recommended review for all 30. Doubts about administering ADRe, sometimes expressed by people who had not yet used it, diminished as it became familiar. ADRe was needed to bridge communication between resident, nurses and prescribers. When barriers of time, complacency, and doctors’ non-availability were overcome, reporting with ADRe made prescribers more likely to heed nurses’ concerns regarding residents’ welfare. Clinical gains were facilitated by one-to-one time, staff-resident relationships, and unification of documentation.

Implications

To our knowledge, ADRe is the only instrument that brings a full account of patients’ problems to medication reviews. This juxtaposition of signs and symptoms against prescriptions facilitates dose adjustments and de-prescribing and leads to: reduced pain and sedation; early identification of problems linked to ADRs, such as falls; and timely medication reviews e.g. for dyspnoea.