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Schleiden LJ, Klima G, Rodriguez KL, Ersek M, Robinson JE, Hickson RP, Smith D, Cashy J, Sileanu FE, Thorpe CT. Clinician and Family Caregiver Perspectives on Deprescribing Chronic Disease Medications in Older Nursing Home Residents Near the End of Life. Drugs Aging 2024; 41:367-377. [PMID: 38575748 PMCID: PMC11021174 DOI: 10.1007/s40266-024-01110-3] [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] [Accepted: 03/07/2024] [Indexed: 04/06/2024]
Abstract
INTRODUCTION Nursing home (NH) residents with limited life expectancy (LLE) who are intensely treated for hyperlipidemia, hypertension, or diabetes may benefit from deprescribing. OBJECTIVE This study sought to describe NH clinician and family caregiver perspectives on key influences on deprescribing decisions for chronic disease medications in NH residents near the end of life. METHODS We recruited family caregivers of veterans who recently died in a Veterans Affairs (VA) NH, known as community living centers (CLCs), and CLC healthcare clinicians (physicians, nurse practitioners, physician assistants, pharmacists, registered nurses). Respondents completed semi-structured interviews about their experiences with deprescribing statin, antihypertensive, and antidiabetic medications for residents near end of life. We conducted thematic analysis of interview transcripts to identify key themes regarding influences on deprescribing decisions. RESULTS Thirteen family caregivers and 13 clinicians completed interviews. Key themes included (1) clinicians and caregivers both prefer to minimize drug burden; (2) clinical factors strongly influence deprescribing of chronic disease medications, with differences in how clinicians and caregivers weigh specific factors; (3) caregivers trust and rely on clinicians to make deprescribing decisions; (4) clinicians perceive caregiver involvement and buy-in as essential to deprescribing decisions, which requires time and effort to obtain; and (5) clinicians perceive conflicting care from other clinicians as a barrier to deprescribing. CONCLUSIONS Findings suggest a need for efforts to encourage communication with and education for family caregivers of residents with LLE about deprescribing, and to foster better collaboration among clinicians in CLC and non-CLC settings.
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Affiliation(s)
- Loren J Schleiden
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA.
| | - Gloria Klima
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
| | - Keri L Rodriguez
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
| | - Mary Ersek
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Jacob E Robinson
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Ryan P Hickson
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Dawn Smith
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- Center for Health Equity Research and Promotion (CHERP), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - John Cashy
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Research Office Building #30, University Drive (151C), Pittsburgh, PA, 15240, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC, USA
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Carlson DM, Yarns BC. Managing medical and psychiatric multimorbidity in older patients. Ther Adv Psychopharmacol 2023; 13:20451253231195274. [PMID: 37663084 PMCID: PMC10469275 DOI: 10.1177/20451253231195274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 07/14/2023] [Indexed: 09/05/2023] Open
Abstract
Aging increases susceptibility both to psychiatric and medical disorders through a variety of processes ranging from biochemical to pharmacologic to societal. Interactions between aging-related brain changes, emotional and psychological symptoms, and social factors contribute to multimorbidity - the presence of two or more chronic conditions in an individual - which requires a more patient-centered, holistic approach than used in traditional single-disease treatment guidelines. Optimal treatment of older adults with psychiatric and medical multimorbidity necessitates an appreciation and understanding of the links between biological, psychological, and social factors - including trauma and racism - that underlie physical and psychiatric multimorbidity in older adults, all of which are the topic of this review.
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Affiliation(s)
- David M. Carlson
- Department of Psychiatry/Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | - Brandon C. Yarns
- Department of Psychiatry/Mental Health, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Bldg. 401, Rm. A236, Mail Code 116AE, Los Angeles, CA 90073, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
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Lee JW, Boyd CM, Leff B, Green A, Hornstein E, LaFave S, Seau Q, Nkodo A, Kachur S, Williams N, Riser T, Szanton SL. Tailoring a home-based, multidisciplinary deprescribing intervention through clinicians and community-dwelling older adults. J Am Geriatr Soc 2023; 71:1663-1666. [PMID: 36515689 PMCID: PMC10175124 DOI: 10.1111/jgs.18186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 11/20/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Ji Won Lee
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD 21205
| | - Cynthia M. Boyd
- Johns Hopkins School of Medicine, Center for Transformative Geriatric Research, 5200 Eastern Avenue, MFL Building, 3 Floor, Baltimore, MD 21224
| | - Bruce Leff
- Johns Hopkins School of Medicine, Center for Transformative Geriatric Research, 5200 Eastern Avenue, MFL Building, 3 Floor, Baltimore, MD 21224
| | - Ariel Green
- Johns Hopkins School of Medicine, Center for Transformative Geriatric Research, 5200 Eastern Avenue, MFL Building, 3 Floor, Baltimore, MD 21224
| | - Erika Hornstein
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD 21205
| | - Sarah LaFave
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD 21205
| | - Quinn Seau
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD 21205
| | - Amelie Nkodo
- Virginia Commonwealth University School of Medicine, 1201 E Marshall street, Richmond, VA 23298
| | - Sarah Kachur
- Johns Hopkins School of Medicine, Center for Transformative Geriatric Research, 5200 Eastern Avenue, MFL Building, 3 Floor, Baltimore, MD 21224
| | - Nicole Williams
- Johns Hopkins School of Medicine, Center for Transformative Geriatric Research, 5200 Eastern Avenue, MFL Building, 3 Floor, Baltimore, MD 21224
| | - Tiffany Riser
- Johns Hopkins School of Medicine, Center for Transformative Geriatric Research, 5200 Eastern Avenue, MFL Building, 3 Floor, Baltimore, MD 21224
| | - Sarah L. Szanton
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD 21205
- Johns Hopkins Bloomberg School of Public Health, 525 N. Wolfe St., #515, Baltimore, MD 21205
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Agyapomah R, Boateng EA, Amankwaa I, Dzomeku VM, Peprah LO. "She is My Work": Caregiving for Older Adults With Hypertension and Diabetes Mellitus. Clin Nurs Res 2023; 32:886-894. [PMID: 37060299 DOI: 10.1177/10547738231165886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
To explore the lived experiences of informal caregivers of older adults with hypertension and/or diabetes mellitus in Kumasi, Ghana. A qualitative research approach was used to conduct the study using informal caregivers of older adults with hypertension and/or diabetes mellitus at a teaching hospital in Ghana. In all, 20 participants were purposively sampled, interviewed, and data were analyzed using thematic analysis. Three main themes emerged: "Experience with care demands," "Coping with care demands," and "Motivation for caregiving." Older adults with hypertension and/or diabetes mellitus had needs that placed a burden on informal caregivers' work life, health, and social life. Informal caregivers of older adults with hypertension and/or diabetes mellitus are under strain. Caregiving is a difficult task, requiring a lot of time, effort, attention, and devotion. Nurses should plan the care of older adults with hypertension and/or diabetes mellitus in collaboration with their informal caregivers.
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Affiliation(s)
| | - Edward Appiah Boateng
- Department of Nursing, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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Low CE, Sanchez Pellecer DE, Santivasi WL, Thompson VH, Elwood T, Davidson AJ, Tlusty JA, Feely MA, Ingram C. Deprescribing in Hospice Patients: Discontinuing Aspirin, Multivitamins, and Statins. Mayo Clin Proc Innov Qual Outcomes 2021; 5:721-726. [PMID: 34355129 PMCID: PMC8325098 DOI: 10.1016/j.mayocpiqo.2021.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Objective To facilitate deprescribing of aspirin, multivitamins, and statins in hospice patients enrolled in Mayo Clinic Hospice, Rochester, Minnesota. Patients and Methods During the fall of 2019, we conducted a quality improvement project to improve care of Mayo Clinic Hospice patients by decreasing the percentage of patients taking aspirin, multivitamins, or statins. Project interventions included the addition of a palliative medicine fellow to the hospice interdisciplinary team, nurse education, and implementation of an evidence-based deprescribing resource tool. The resource tool included a communication framework to guide deprescribing conversations and a literature summary supporting deprescribing. The project team recorded the number of patients taking 1 of these medications by intermittently surveying the hospice census. Process and counterbalance measures were tracked with online surveys of hospice nursing staff. Results At the start of the project, 22 of 69 patients (32%) were taking aspirin, a multivitamin, or a statin. After introduction of the deprescribing resource tool and the addition of a palliative medicine fellow to the interdisciplinary team, this was reduced to 20 of 83 patients (24%), a 24% decrease. Results appeared to be driven primarily by a reduction in multivitamin use (33% decrease). Self-reported comfort and knowledge about deprescribing improved among the hospice nursing staff, as did satisfaction in their workflow from 5.4 to 6.0 (maximum, 7). Conclusion The addition of a dedicated team member to address medication issues and provision of an evidence-based deprescribing resource tool appear to reduce the use of unnecessary and potentially harmful medications in ambulatory hospice patients.
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Affiliation(s)
- Cari E Low
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Daniel E Sanchez Pellecer
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Wil L Santivasi
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, MN
| | | | | | | | | | - Molly A Feely
- Center for Palliative Medicine, Mayo Clinic, Rochester, MN
| | - Cory Ingram
- Center for Palliative Medicine, Mayo Clinic, Rochester, MN
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Mardani A, Griffiths P, Vaismoradi M. The Role of the Nurse in the Management of Medicines During Transitional Care: A Systematic Review. J Multidiscip Healthc 2020; 13:1347-1361. [PMID: 33154651 PMCID: PMC7608001 DOI: 10.2147/jmdh.s276061] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/04/2020] [Indexed: 01/22/2023] Open
Abstract
PURPOSE To synthesise knowledge and to explore the role of the nurse in medicines management during transitional care. METHODS An integrative systematic review was conducted. Electronic databases such as PubMed [including Medline], Web of Knowledge, Scopus, and Cinahl from January 2010 to April 2020 were searched. Original qualitative and quantitative studies written in English that focused on the role of the nurse in medicines management during transitional care, which included movement between short-term, long-term, and community healthcare settings were included. RESULTS The search process led to the retrieval of 10 studies, which were published in English from 2014 to 2020. They focused on the role of the nurse in patients' medicines management during transitional care in various healthcare settings. Given variations in the aims and methods of selected studies, the review findings were presented narratively utilizing three categories developed by the authors. In the first category as 'medication reconciliation process' the nurse participated in obtaining medication history, performing medication review, identifying medication discrepancies, joint medication reconciliation and adjustment. The second category as 'collaboration with other healthcare providers' highlighted the nurses' role in clarifying medicines' concerns, interdisciplinary communication and consultation, discharge planning and monitoring. In the third category as 'provision of support to healthcare recipients', the nurse was responsible for interpersonal communication with patients, education about medicines, and simplification of medication regimens, and symptoms management during transitional care. CONCLUSION Nurses play a crucial role in the safety of medicines management during transitional care. Therefore, they should be empowered and more involved in medicines management initiatives in the healthcare system. Patient safety and avoidance of medication errors during transitional care require that medicines management becomes a multidisciplinary collaboration with effective communication between healthcare providers.
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Affiliation(s)
- Abbas Mardani
- Nursing Care Research Center, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
| | - Pauline Griffiths
- Department of Nursing, College of Human and Health Sciences, Swansea University, Swansea, Wales, UK
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Alves A, Green S, James DH. Deprescribing of Medicines in Care Homes-A Five-Year Evaluation of Primary Care Pharmacist Practices. PHARMACY 2019; 7:pharmacy7030105. [PMID: 31382582 PMCID: PMC6789793 DOI: 10.3390/pharmacy7030105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/24/2019] [Accepted: 08/01/2019] [Indexed: 12/18/2022] Open
Abstract
(1) Background: This project evaluates the outcomes of a novel pharmacy-led model of deprescribing unnecessary medications for care home patients. A feasibility study was conducted in 2015 to explore exposure to inappropriate polypharmacy in patients residing in care homes over a one-year timescale. The aim of this study was to present the results of this ongoing service evaluation over a five-year period. (2) Methods: Data collection and risk assessment tools developed during the feasibility study were used to measure the prevalence, nature, and impact of deprescribing interventions by primary care pharmacists over a five-year period. A random sample of approximately 5% of safety interventions were screened twice yearly by the pharmacist leads as part of standard practice. (3) Results: Over a period of five years there were 23,955 interventions (mean 2.3 per patient) reported from the 10,405 patient reviews undertaken. Deprescribing accounted for 53% of total estimated financial drug savings, equating to £431,493; and 16.1% of all interventions were related to safety. (4) Conclusions: Medication reviews in care homes, undertaken by primary care pharmacists who are linked to GP practices, generate a wide range of interventions commonly involving deprescribing, which contributes significantly to the continuous optimisation of the prescribing and monitoring of medicines.
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Affiliation(s)
- Ana Alves
- NHS Somerset Clinical Commissioning Group, Yeovil BA22 8HR, UK.
| | - Shaun Green
- NHS Somerset Clinical Commissioning Group, Yeovil BA22 8HR, UK
| | - Delyth H James
- Department of Applied Psychology, Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Llandaf Campus, Cardiff CF5 2YB, UK
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