Decreasing polypharmacy in clients most at risk

Deprescribing medicines in older people living with multimorbidity and polypharmacy: the TAILOR evidence synthesis

BACKGROUND

Tackling problematic polypharmacy requires tailoring the use of medicines to individual needs and circumstances. This may involve stopping medicines (deprescribing) but patients and clinicians report uncertainty on how best to do this. The TAILOR medication synthesis sought to help understand how best to support deprescribing in older people living with multimorbidity and polypharmacy.

OBJECTIVES

We identified two research questions: (1) what evidence exists to support the safe, effective and acceptable stopping of medication in this patient group, and (2) how, for whom and in what contexts can safe and effective tailoring of clinical decisions related to medication use work to produce desired outcomes? We thus described three objectives: (1) to undertake a robust scoping review of the literature on stopping medicines in this group to describe what is being done, where and for what effect; (2) to undertake a realist synthesis review to construct a programme theory that describes 'best practice' and helps explain the heterogeneity of deprescribing approaches; and (3) to translate findings into resources to support tailored prescribing in clinical practice.

DATA SOURCES

Experienced information specialists conducted comprehensive searches in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials), Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (targeted searches).

REVIEW METHODS

The scoping review followed the five steps described by the Joanna Briggs Institute methodology for conducting a scoping review. The realist review followed the methodological and publication standards for realist reviews described by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) group. Patient and public involvement partners ensured that our analysis retained a patient-centred focus.

RESULTS

Our scoping review identified 9528 abstracts: 8847 were removed at screening and 662 were removed at full-text review. This left 20 studies (published between 2009 and 2020) that examined the effectiveness, safety and acceptability of deprescribing in adults (aged ≥ 50 years) with polypharmacy (five or more prescribed medications) and multimorbidity (two or more conditions). Our analysis revealed that deprescribing under research conditions mapped well to expert guidance on the steps needed for good clinical practice. Our findings offer evidence-informed support to clinicians regarding the safety, clinician acceptability and potential effectiveness of clinical decision-making that demonstrates a structured approach to deprescribing decisions. Our realist review identified 2602 studies with 119 included in the final analysis. The analysis outlined 34 context-mechanism-outcome configurations describing the knowledge work of tailored prescribing under eight headings related to organisational, health-care professional and patient factors, and interventions to improve deprescribing. We conclude that robust tailored deprescribing requires attention to providing an enabling infrastructure, access to data, tailored explanations and trust.

LIMITATIONS

Strict application of our definition of multimorbidity during the scoping review may have had an impact on the relevance of the review to clinical practice. The realist review was limited by the data (evidence) available.

CONCLUSIONS

Our combined reviews recognise deprescribing as a complex intervention and provide support for the safety of structured approaches to deprescribing, but also highlight the need to integrate patient-centred and contextual factors into best practice models.

FUTURE WORK

The TAILOR study has informed new funded research tackling deprescribing in sleep management, and professional education. Further research is being developed to implement tailored prescribing into routine primary care practice.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018107544 and PROSPERO CRD42018104176.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 32. See the NIHR Journals Library website for further project information.

Antioxidant Supplementation: A Linchpin in Radiation-Induced Enteritis

Radiation enteritis is one of the most feared complications of abdominal and pelvic regions. Thus, radiation to abdominal or pelvic malignancies unavoidably injures the intestine. Because of rapid cell turnover, the intestine is highly sensitive to radiation injury, which is the limiting factor in the permissible dosage of irradiation. Bowel injuries such as fistulas, strictures, and chronic malabsorption are potentially life-threatening complications and have an impact on patient quality of life. The incidence of radiation enteritis is increasing because of the current trend of combined chemotherapy and radiation. The consequences of radiation damage to the intestine may result in considerable morbidity and even mortality. The observed effects of ionizing radiation are mediated mainly by oxygen-free radicals that are generated by its action on water and are involved in several steps of signal transduction cascade, leading to apoptosis. The oxyradicals also induce DNA strand breaks and protein oxidation. An important line of defense against free radical damage is the presence of antioxidants. Therefore, administration of antioxidants may ameliorate the radiation-induced damage to the intestine.

A Profile of Calls to a Poison Information Center Regarding Older Adults

Objectives: The authors sought to examine the nature of calls to poison information centers by adults ages 50 and over. Methods: The authors used data from the national Toxic Exposure Surveillance System and conducted a retrospective review of all cases reported to an American Association of Poison Control Centers Certified Regional Poison Information Center in 1998 and 1999 ( N = 6,365). Results: The results indicated that females’ poison experiences were more likely the result of therapeutic error, adverse drug reactions, ingestions, and the acute-on-chronic class. The authors found that older age was inversely associated with acute class, suspected suicide, food poisoning, and inhalation and dermal exposures. Discussion: Older adults are the greatest consumers of over-the-counter drugs, take multiple medications for various medical conditions, and are experiencing biological changes that affect drug metabolism. Older women may be at especially high risk because of high drug use. Poison prevention education should target older adults.

Prevalence and predictors of polypharmacy among Korean elderly

OBJECTIVE

Polypharmacy is widespread in the elderly because of their multiple chronic health problems. The objective of this study was to investigate the prevalence and predictors associated with polypharmacy in a nationally representative sample of Korean elderly individuals.

METHODS

We used the Korea Health Insurance Review and Assessment Service - National Patient Sample (HIRA-NPS) data from 2010 and 2011. We used information on 319,185 elderly patients (aged 65 years or older) between January 1, 2010 and December 31, 2011 from the HIRA-NPS database. We defined 'polypharmacy' as the concurrent use of 6 medications or more per person, 'major polypharmacy' as 11 medications or more, and 'excessive polypharmacy' as 21 medications or more. The frequency and proportion (%) and their 95% confidence intervals were presented according to the polypharmacy definition. Polypharmacy was visualized by the Quantum Geographic Information Systems (QGIS) program to describe regional differences in patterns of drug use. Multivariate ordinal logistic regression was performed to estimate odds ratios (ORs) and their 95% confidence intervals (CI) to investigate the risk factors for polypharmacy.

RESULTS

Of the Korean elderly studied, 86.4% had polypharmacy, 44.9% had major polypharmacy and 3.0% had excessive polypharmacy. Polypharmacy was found to be primarily concentrated in the Southwest region of the country. Significant associations between polypharmacy and the lower-income Medical Aid population (OR = 1.52, 95% CI 1.47, 1.56) compared with National Health Insurance patients was observed.

CONCLUSIONS

Nationwide efforts are needed for managing polypharmacy among Korean elderly patients. In particular, a national campaign and education to promote appropriate use of medicines for the Medical Aid population is needed.

The impact of polypharmacy on the health of Canadian seniors

BACKGROUND

Prescription medication use increases with age. Seniors face an increased risk of adverse drug reactions from medications, partly because the kidneys and liver can lose functional ability with increasing age, resulting in the need for changes in dosage.

OBJECTIVE

To use population survey data to understand the extent and impact of multiple medication use and adverse drug events among Canadian seniors.

METHODS

This study consists of analysis of data from the Canadian Survey of Experiences with Primary Health Care, which was conducted through telephone by Statistics Canada in 2008. These analyses focussed on the 3132 respondents who were ≥ 65 years of age.

RESULTS

Twenty-seven per cent of seniors reported taking five or more medications on a regular basis. Within the past year, 12% of seniors taking five or more medications experienced a side effect that required medical attention compared with 5% of seniors taking only one or two medications. Even when controlling for age and number of chronic conditions, the number of prescription medications was associated with the rate of emergency department use. Less than half of all seniors reported having received medication reviews and having the possible side effects of their prescription medications explained to them by their physician.

CONCLUSIONS

Many Canadian seniors have an elevated risk of adverse events due to taking a high number of prescription medications and not having the potential side effects and drug interactions explained to them. There are interventions that can potentially reduce polypharmacy and adverse events, including routine medication reviews.

Drug treatment in the elderly: an intervention in primary care to enhance prescription quality and quality of life

OBJECTIVE

The aim of the study was to assess the effect on prescription quality and quality of life after intervention with prescription reviews and promotion of patient participation in primary care.

DESIGN

A randomized controlled study with three groups: (A) controls, (B) prescription review sent to physician, and (C) as in B and with a current comprehensive medication record sent to the patient.

SETTING

The municipality of Örebro, Sweden (130 000 inhabitants).

INTERVENTION

The study focused on the easiest possible intervention to increase prescription quality and thereby increase quality of life. The intervention should be cost-efficient, focus on colleague-to-colleague advice, and be possible to perform in the primary health care centre without additional resources such as a pharmacist.

SUBJECTS

150 patients recently discharged from hospital. Inclusion criteria were: ≥ 75 years, ≥ five drugs and living in ordinary homes.

MAIN OUTCOME MEASURES

Quality of life (EQ-5D index, EQ VAS) and quality of prescriptions.

RESULTS

Extreme polypharmacy was common and persistent in all three groups and this was accompanied by an unchanged frequency of drug-risk indicators. There was a low EQ-5D index and EQ VAS in all three groups throughout the study. No statistically significant differences were found anywhere between the groups.

CONCLUSION

The intervention seems to have had no effect on quality of prescriptions or quality of life. This underlines the major challenge of finding new strategies for improving prescription quality to improve patient outcome measures such as quality of life and reduce the known risks of polypharmacy for the elderly.

Medication quality and quality of life in the elderly, a cohort study

BACKGROUND

Modern drugs have made large contributions to better health and quality of life. Increasing proportions of negative side effects due to extensive pharmacological treatment are however observed especially among elderly patients who have multiple health problems. The aim of our study was to see if there is an association between medication quality and quality of life.

METHODS

150 patients discharged from hospital. Inclusion criteria were: living in ordinary homes, ≥ 75 years and ≥ 5 drugs. Home visits were performed to all, including prescription reviews and calculation of medication appropriateness index. The patients were divided into three groups depending on index score and followed for 12 months. The validated and recognized EQ-5D and EQ VAS instruments were used to assess quality of life.

RESULTS

A lower medication quality was associated with a lower quality of life. EQ-5D index was statistically significantly different (declining for each group) among the groups (p = 0.001 at study start, p = 0.001 at 6 months and p = 0.013 at 12 months) as was EQ VAS (p = 0.026 at study start, p = 0.003 at 6 months and p = 0.007 at 12 months).

CONCLUSIONS

This study has shown the validity of the basic principle in prescribing: the more appropriate medication the better quality of life. Since drug quality is related to the patients' quality of life, there is immense reason to continuously evaluate every prescription and treatment. The evaluation and if possible deprescribing should be done as a process where both the patient and physician are involved.

Clinical effectiveness of telmisartan alone or in combination therapy for controlling blood pressure and vascular risk in the elderly

Elderly patients (age ≥ 65 years) with hypertension are at high risk for vascular complications, especially when diabetes is present. Antihypertensive drugs that inhibit the renin-angiotensin system have been shown to be effective for controlling blood pressure in adult and elderly patients. Importantly, renin-angiotensin system inhibitors were shown to have benefits beyond their classic cardioprotective and vasculoprotective effects, including reducing the risk of new-onset diabetes and associated cardiovascular effects. The discovery that the renin-angiotensin system inhibitor and angiotensin II type 1 (AT(1)) receptor blocker (ARB), telmisartan, can selectively activate the peroxisome proliferator-activated receptor-γ (PPARγ, an established antidiabetic drug target) provides the unique opportunity to prevent and treat cardiovascular complications in high-risk elderly patients with hypertension and new-onset diabetes. Two large clinical trials, ONTARGET (Ongoing Telmisartan Alone in combination with Ramipril Global Endpoint Trial) and TRANSCEND (Telmisartan Randomized AssessmeNt Study in ACE-I iNtolerant subjects with cardiovascular disease) have assessed the cardioprotective and antidiabetic effects of telmisartan. The collective data suggest that telmisartan is a promising drug for controlling hypertension and reducing vascular risk in high-risk elderly patients with new-onset diabetes.

Discrepancies between home medications listed at hospital admission and reported medical conditions

BACKGROUND

One of the Joint Commission on Accreditation of Healthcare Organization's National Patient Safety Goals is for hospitals to accurately and completely reconcile patients' medications. Unfortunately, medication histories in charts might bc inaccurate and incomplete. In a thorough medication history, each medication should match a particular reported medical condition. The use of medications without a clear reported indication is of particular concern and has been associated with inappropriate use and polypharmacy.

OBJECTIVES

The purposes of this study were to evaluate the occurrence of discrepancies between home medications listed in hospital admission notes and patients' reported medical conditions and to describe the types of medications most often identified as not having a corresponding indication.

METHODS

In this retrospective observational study, data were included from adult patients (> or =18 years of age) who were receiving > or =3 home medications on admission to medical wards at a university hospital during a 6-month period. Each home medication listed in the admission note, together with any preadmission paperwork, was matched with an indication listed in the note. Medications were deemed unspecified if an indicated disease state or condition for the medication was not reported.

RESULTS

Data from 121 patients were included. The majority (91.7%) of the patients were admitted to an internal medicine service. Eighty-four patients (69.4%) had > or =1 unspecified medication listed in the admission note. Patients with > or =1 unspecified home medication reported taking a significantly higher number of home medications (10.2 [4.5] vs 7.5 [3.5] in those without unspecified medications; P = 0.007). Thirty-two patients (26.4%) were receiving proton pump inhibitors or histamine type 2 antagonists without a reported indication. Seventeen patients (14.0%) were receiving selective serotonin reuptake inhibitors without a reported indication.

CONCLUSIONS

Nearly 70% of patients admitted to a medical ward had > or =1 unspecified medication listed in the admission note. Based on these results, health care professionals must bc careful to obtain and document complete medication histories with matching indications.

Polypharmacy: misleading, but manageable

The percentage of the population described as elderly is growing, and a higher prevalence of multiple, chronic disease states must be managed concurrently. Healthcare practitioners must appropriately use medication for multiple diseases and avoid risks often associated with multiple medication use such as adverse effects, drug/drug interactions, drug/disease interactions, and inappropriate dosing. The purpose of this study is to identify a consensus definition for polypharmacy and evaluate its prevalence among elderly outpatients. The authors also sought to identify or develop a clinical tool which would assist healthcare practitioners guard against inappropriate drug therapy in elderly patients. The most commonly cited definition was a medication not matching a diagnosis. Inappropriate was part of definitions used frequently. Some definitions placed a numeric value on concurrent medications. Two common definitions (ie, 6 or more medications or a potentially inappropriate medication) were used to evaluate polypharmacy in elderly South Carolinians (n = 1027). Data analysis demonstrates that a significant percentage of this population is prescribed six or more concomitant drugs and/or uses a potentially inappropriate medication. The findings are 29.4% are prescribed 6 or more concurrent drugs, 15.7% are prescribed one or more potentially inappropriate drugs, and 9.3% meet both definitions of polypharmacy used in this study. The authors recommend use of less ambiguous terminology such as hyperpharmacotherapy or multiple medication use. A structured approach to identify and manage inappropriate polypharmacy is suggested and a clinical tool is provided.

Polymedicine and aging. Enhancing older adult care through advanced practitioners. GNPs and elder care pharmacists can help provide optimal pharmaceutical care

Approximately one third of all drugs prescribed in the United States are considered unnecessary. Polymedicine, polypharmacy, medication nonadherence, and adverse drug reactions are among the top five causes of acute care hospitalizations in persons older than age 65. These conditions significantly increase health care costs and will continue to do so at an alarming rate as America's population ages. Although medications are an important factor in improving and maintaining the quality of life for older adults, polymedicine places them at risk of an acute care admission for medication-related problems and other complications. This article reviews polymedicine and common medication errors, explores the depth of the problem in aging clients, and advocates for the use of gerontological nurse practitioners as advanced practice nurses and specialty-trained elder care pharmacists as active members of the interdisciplinary health care team.

AIDES to improving medication adherence in older adults

Medication regimens for older adults are often complex and costly. Designing, implementing, and maintaining an appropriate treatment regimen is challenging. The AIDES method is built on the principles of completing a comprehensive medication Assessment; partnering with patients to ensure Individualization of the regimen; choosing appropriate Documentation; providing accurate and ongoing Education tailored to the age group and needs of the individual; and continuing Supervision after initiation.

Health outcomes and polypharmacy in elderly individuals: an integrated literature review

The purpose of this integrated literature review was to determine the extent of research available related to polypharmacy and its effect on the health outcomes of the elderly population. A search of the Cumulative Index of Nursing and Allied Health Literature and Medline was conducted for studies published between 1995 and 2003 that linked polypharmacy and outcomes in the elderly population. The 16 studies in this integrative literature review were conducted in the United States, Canada, Australia, and Europe. Polypharmacy was shown to be a statistically significant predictor of hospitalization, nursing home placement, death, hypoglycemia, fractures, impaired mobility, pneumonia, and malnutrition. The effect of polypharmacy on elderly individuals is significant as demonstrated by this literature review. Nurses are in a unique position to monitor and potentially eliminate adverse effects of a complex medication regimen. Nursing research on polypharmacy and its effects on nursing-sensitive outcomes will help define guidelines for prevention and intervention.

Polypharmacy and elderly patients

Medication therapy in elderly patients is difficult to manage and always has the potential of being hazardous. With the age-related changes that affect the pharmacokinetics and pharmacodynamics of a medication, prescribing medications is further complicated. Similarly, assessment of a medication's efficacy is difficult. The situation becomes more complicated when the patient is taking multiple medications. Nurses in the perioperative area need to be cognizant of a patient's preoperative medication regime and the medications that have been prescribed in the perioperative setting. As medication interactions increase substantially with the number of medications taken, the most pertinent nursing intervention is accurate assessment of the patient. Early recognition of potentially harmful medication effects is critical.

Lymphoma at the extremes of age

OBJECTIVES

To provide a review of the unique features of both Hodgkin's and non-Hodgkin's lymphoma in pediatric and geriatric patient populations. Treatment approaches and nursing care interventions at the extremes of age will be discussed.

DATA SOURCES

Review articles, research studies, and book chapters.

CONCLUSIONS

Lymphoma is a highly heterogeneous malignancy whose classification and management have undergone significant evolution. Of particular concern has been lymphoma's prevalence and treatment at the extremes of age. Appropriate treatment by age and subtype remains controversial.

IMPLICATIONS FOR NURSING PRACTICE

The nursing care of pediatric and geriatric patients with lymphoma presents numerous challenges in education, symptom management, and supportive care.