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Alharkan KS, Alfarea AM, Alkhateeb AF, Alsousi SA, Althwaiqb SA, Alshammari MO. Are primary care physicians familiar enough with potentially inappropriate medications in geriatric care? A cross-sectional study in the Eastern Province of Saudi Arabia. J Family Community Med 2024; 31:251-256. [PMID: 39176015 PMCID: PMC11338396 DOI: 10.4103/jfcm.jfcm_238_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 04/24/2024] [Accepted: 05/07/2024] [Indexed: 08/24/2024] Open
Abstract
BACKGROUND Potentially inappropriate medications (PIMs) and polypharmacy constitute increasing healthcare costs and significant risk for adverse outcomes in older adults. The American Geriatrics Society Beers Criteria form a screening tool for the identification of PIMs and guidance for healthcare providers in prescribing appropriate medications. However, primary care physicians' knowledge of screening tools, of Beers Criteria, in particular, is not known. Therefore, this study was to investigate primary care physicians in the Eastern Province of Saudi Arabia and their awareness of Beers Criteria and knowledge of PIMs. MATERIALS AND METHODS This cross-sectional study was conducted among primary care physicians working in the Eastern Province of Saudi Arabia. Data were collected using an online self-administered questionnaire that consisted of sections on the general characteristics of respondents and their knowledge of Beers Criteria as a screening tool. Eight clinical-based vignettes concerning different therapeutic areas of medication use in the elderly were included, with a score of 1 and 0 for correct and wrong answers, respectively. Data presented as frequency and percentage. Chi-square test was used to determine the association between duration of practice and the level of awareness about Beers criteria. RESULTS Of the 121 physicians who returned completed questionnaires, 41.3% of respondents knew about Beers Criteria. Most respondents (52.9%) were confident in prescribing appropriately for elderly patients. The association between the duration of practice and confidence level was statistically significant (P = 0.040). Respondents showed an above-average knowledge of the clinical vignettes with a correct answer rate >50% in all clinical scenarios. Online search (84.2%) and physician colleagues' knowledge and experiences (39.2%) were the primary source of information reported by the respondents. CONCLUSION Awareness of Beers Criteria of primary care physicians in Saudi Arabia's Eastern Province is low. Therefore, our results will educate healthcare workers on the importance of Beers Criteria in Geriatric patients' prescriptions, in order to significantly improve the well-being of the elderly.
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Affiliation(s)
- Khalid S. Alharkan
- Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Abdulaziz M. Alfarea
- Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | | | - Safaa A. Alsousi
- Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Sarah A. Althwaiqb
- Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- Family Medicine, Academy, Eastern Health Cluster, Khobar, Saudi Arabia
| | - Malak O. Alshammari
- Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Waldron C, Hughes J, Wallace E, Cahir C, Bennett K. Contexts and mechanisms relevant to General Practitioner (GP) based interventions to reduce adverse drug events (ADE) in community dwelling older adults: a rapid realist review. HRB Open Res 2023; 5:53. [PMID: 38283368 PMCID: PMC10811420 DOI: 10.12688/hrbopenres.13580.2] [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] [Accepted: 12/19/2023] [Indexed: 01/30/2024] Open
Abstract
Background Older adults in Ireland are at increased risk of adverse drug events (ADE) due, in part, to increasing rates of polypharmacy. Interventions to reduce ADE in community dwelling older adults (CDOA) have had limited success, therefore, new approaches are required.A realist review uses a different lens to examine why and how interventions were supposed to work rather than if, they worked. A rapid realist review (RRR) is a more focused and accelerated version.The aim of this RRR is to identify and examine the contexts and mechanisms that play a role in the outcomes relevant to reducing ADE in CDOA in the GP setting that could inform the development of interventions in Ireland. Methods Six candidate theories (CT) were developed, based on knowledge of the field and recent literature, in relation to how interventions are expected to work. These formed the search strategy. Eighty full texts from 633 abstracts were reviewed, of which 27 were included. Snowballing added a further five articles, relevant policy documents increased the total number to 45. Data were extracted relevant to the theories under iteratively developed sub-themes using NVivo software. Results Of the six theories, three theories, relating to GP engagement in interventions, relevance of health policy documents for older adults, and shared decision-making, provided data to guide future interventions to reduce ADEs for CDOA in an Irish setting. There was insufficient data for two theories, a third was rejected as existing barriers in the Irish setting made it impractical to use. Conclusions To improve the success of Irish GP based interventions to reduce ADEs for CDOA, interventions must be relevant and easily applied in practice, supported by national policy and be adequately resourced. Future research is required to test our theories within a newly developed intervention.
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Affiliation(s)
- Catherine Waldron
- Data Science Centre, School of Population Health, RCSI University of Medicine and Health Sciences, Dublin 2, D02 DH60, Ireland
| | - John Hughes
- Data Science Centre, School of Population Health, RCSI University of Medicine and Health Sciences, Dublin 2, D02 DH60, Ireland
| | - Emma Wallace
- Department of General Practice, University College Cork, Cork, Ireland
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin 2, D02 DH60, Ireland
| | - Caitriona Cahir
- Data Science Centre, School of Population Health, RCSI University of Medicine and Health Sciences, Dublin 2, D02 DH60, Ireland
| | - K. Bennett
- Data Science Centre, School of Population Health, RCSI University of Medicine and Health Sciences, Dublin 2, D02 DH60, Ireland
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Akande-Sholabi W, Fafemi A. Potentially inappropriate medication use in the elderly: physicians' and hospital pharmacists knowledge, practice, confidence, and barriers. J Pharm Health Care Sci 2022; 8:36. [PMID: 36494676 PMCID: PMC9733080 DOI: 10.1186/s40780-022-00267-6] [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: 06/21/2022] [Accepted: 11/19/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Inappropriate medication prescribing and dispensing by physicians and pharmacists is a preventable cause of morbidity and mortality in the elderly. Signifying the importance of healthcare professionals' knowledge of potentially inappropriate prescribing tools/ guidelines which would improve overall health outcomes. Beers Criteria is one of the most used guidelines that list specific potentially inappropriate medications (PIMs). This study aimed to investigate physicians' and hospital pharmacists' awareness, knowledge, practice, confidence, and barriers to the use of Beers criteria. METHODS A cross-sectional survey was carried out among 66 hospital pharmacists and 31 family medicine physicians working in a teaching hospital in Nigeria, between May and September 2021 using a self-administered questionnaire. Knowledge of PIMs was assessed using 11 clinical vignettes based on the 2019 Beers Criteria. Practice behavior towards elderly patients was assessed using a 5-item statement with a 5-point Likert scale. Perceived barriers to the appropriate use of Beers Criteria were assessed using a 15-item statement. Descriptive and inferential statistics were used to analyze the data. RESULTS A total of 66 hospital pharmacists and 31 family medicine physicians participated in the study. Only (24; 36.4%) pharmacists and (4; 12.9%) physicians knew guidelines that listed specific PIMs. In all (21; 31.8%) pharmacists and (11; 35.4%) physicians demonstrated good knowledge of Beers Criteria, while most pharmacists (55; 83.3%) and physicians (29; 93.5%) reported good practice when dealing with elderly patients in terms of asking relevant questions and considering their ages while dispensing medications. Knowledge scores were not significantly associated with hospital pharmacists' socio-demographics. Most of the physicians and pharmacists were confident in the care provided for geriatric patients. The majority (66; 100.0%) pharmacists and (28; 93.5%) physicians suggested training through seminar presentations as a measure to improve the use of Beers' criteria. Lack of time to counsel patients was a major barrier recounted by both physicians and pharmacists. CONCLUSION Healthcare professionals that participated in this study had satisfactory practice, although a gap in the knowledge of hospital pharmacists and family medicine physicians was noted. In addition to creating awareness among healthcare professionals and training on PIMs and Beers' criteria, a multidisciplinary approach to reduce potentially inappropriate prescribing and dispensing would greatly help reduce the incidence of potentially inappropriate medication use among elderly patients.
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Affiliation(s)
- Wuraola Akande-Sholabi
- grid.9582.60000 0004 1794 5983Department of Clinical Pharmacy and Pharmacy Administration, Faculty of Pharmacy, University of Ibadan, Ibadan, Nigeria
| | - Adeola Fafemi
- grid.9582.60000 0004 1794 5983Department of Clinical Pharmacy and Pharmacy Administration, Faculty of Pharmacy, University of Ibadan, Ibadan, Nigeria
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Waldron C, Hughes J, Wallace E, Cahir C, Bennett K. Contexts and mechanisms relevant to General Practitioner (GP) based interventions to reduce adverse drug events (ADE) in community dwelling older adults: a rapid realist review. HRB Open Res 2022. [DOI: 10.12688/hrbopenres.13580.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Older adults in Ireland are at increased risk of adverse drug events (ADE) due, in part, to increasing rates of polypharmacy. Interventions to reduce ADE in community dwelling older adults (CDOA) have had limited success, therefore, new approaches are required. A realist review uses a different lens to examine why and how interventions were supposed to work rather than if, they worked. A rapid realist review (RRR) is a more focused and accelerated version. The aim of this RRR is to identify and examine the contexts and mechanisms that play a role in the outcomes relevant to reducing ADE in CDOA in the GP setting that could inform the development of interventions in Ireland. Methods: Six candidate theories (CT) were developed, based on knowledge of the field and recent literature, in relation to how interventions are expected to work. These formed the search strategy. Eighty full texts from 633 abstracts were reviewed, of which 27 were included. Snowballing added a further five articles, relevant policy documents increased the total number to 45. Data were extracted relevant to the theories under iteratively developed sub-themes using NVivo software. Results: Of the six theories, three theories, relating to GP engagement in interventions, relevance of health policy documents for older adults, and shared decision-making, provided data to guide future interventions to reduce ADEs for CDOA in an Irish setting. There was insufficient data for two theories, a third was rejected as existing barriers in the Irish setting made it impractical to use. Conclusions: To improve the success of Irish GP based interventions to reduce ADEs for CDOA, interventions must be relevant and easily applied in practice, supported by national policy and be adequately resourced. Future research is required to test our theories within a newly developed intervention.
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Xu Z, Liang X, Zhu Y, Lu Y, Ye Y, Fang L, Qian Y. Factors associated with potentially inappropriate prescriptions and barriers to medicines optimisation among older adults in primary care settings: a systematic review. Fam Med Community Health 2021; 9:e001325. [PMID: 34794961 PMCID: PMC8603289 DOI: 10.1136/fmch-2021-001325] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To identify factors that likely contribute to potentially inappropriate prescriptions (PIPs) among older adults in primary care settings, as well as barriers to medicines optimisation and recommended potential solutions. DESIGN Systematic review. ELIGIBILITY CRITERIA Quantitative studies that analysed the factors associated with PIPs among older adults (≥65 years) in primary care settings, and qualitative studies that explored perceived barriers and potential solutions to medicines optimisation for this population. INFORMATION SOURCES PubMed, EMBASE, Scopus, CINAHL, PsycINFO, Web of Science, CNKI and Wanfang. RESULTS Of the 13 167 studies identified, 50 were included (14 qualitative, 34 cross-sectional and 2 cohort). Nearly all quantitative studies examined patient-related non-clinical factors (eg, age) and clinical factors (eg, number of medications) and nine studies examined prescriber-related factors (eg, physician age). A greater number of medications were identified as positively associated with PIPs in 25 quantitative studies, and a higher number of comorbidities, physical comorbidities and psychiatric comorbidities were identified as patient-related clinical risk factors for PIPs. However, other factors showed inconsistent associations with the PIPs. Barriers to medicines optimisation emerged within four analytical themes: prescriber related (eg, inadequate knowledge, concerns of adverse consequences, clinical inertia, lack of communication), patient related (eg, limited understanding, patient non-adherence, drug dependency), environment related (eg, lack of integrated care, insufficient investment, time constraints) and technology related (eg, complexity of implementation and inapplicable guidance). Recommended potential solutions were based on each theme of the barriers identified accordingly (eg, prescriber-related factors: incorporating training courses into continuing medical education). CONCLUSIONS Older adults with more drugs prescribed and comorbidities may have a greater risk of receiving PIPs in the primary care setting, but it remains unclear whether other factors are related. Barriers to medicines optimisation among primary care older adults comprise multiple factors, and evidence-based and targeted interventions are needed to address these difficulties. PROSPERO REGISTRATION NUMBER CRD42020216258.
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Affiliation(s)
- Zhijie Xu
- Department of General Practice, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xujian Liang
- Department of General Practice, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
| | - Yue Zhu
- Department of General Practice, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
| | - Yiting Lu
- Zhongdai Community Healthcare Center, Huzhou, China
| | - Yuanqu Ye
- Baili Community Healthcare Center, The People's Hospital of Longhua, Shenzhen, China
| | - Lizheng Fang
- Department of General Practice, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
| | - Yi Qian
- School of Public Health, Hangzhou Normal University, Hangzhou, Zhejiang, China
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Cairo Notari S, Sader J, Caire Fon N, Sommer JM, Pereira Miozzari AC, Janjic D, Nendaz M, Audétat M. Understanding GPs' clinical reasoning processes involved in managing patients suffering from multimorbidity: A systematic review of qualitative and quantitative research. Int J Clin Pract 2021; 75:e14187. [PMID: 33783098 PMCID: PMC8459259 DOI: 10.1111/ijcp.14187] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/25/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Most consultations in primary care involve patients suffering from multimorbidity. Nevertheless, few studies exist on the clinical reasoning processes of general practitioners (GPs) during the follow-up of these patients. The aim of this systematic review is to summarise published evidence on how GPs reason and make decisions when managing patients with multimorbidity in the long term. METHODS A search of the relevant literature from Medline, Embase, PsycINFO, and ERIC databases was conducted in June 2019. The search terms were selected from five domains: primary care, clinical reasoning, chronic disease, multimorbidity, and issues of multimorbidity. Qualitative, quantitative, and mixed-methods studies published in English and French were included. Quality assessment was performed using the Mixed Methods Appraisal Tool. RESULTS A total of 2 165 abstracts and 362 full-text articles were assessed. Thirty-two studies met the inclusion criteria. Results showcased that GPs' clinical reasoning during the long-term management of multimorbidity is about setting intermediate goals of care in an ongoing process that adapts to the patients' constant evolution and contributes to preserve their quality of life. In the absence of guidelines adapted to multimorbidity, there is no single correct plan, but competing priorities and unavoidable uncertainties. Thus, GPs have to consider and weigh multiple factors simultaneously. In the context of multimorbidity, GPs describe their reasoning as essentially intuitive and seem to perceive it as less accurate. These clinical reasoning processes are nevertheless more analytical as they might think and rooted in deep knowledge of the individual patient. CONCLUSIONS Although the challenges GPs are facing in the long-term follow-up of patients suffering from multimorbidity are increasingly known, the literature currently offers limited information about GPs' clinical reasoning processes at play. GPs tend to underestimate the complexity and richness of their clinical reasoning, which may negatively impact their practice and their teaching.
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Affiliation(s)
- Sarah Cairo Notari
- Primary Care UnitFaculty of MedicineUniversity of GenevaGenevaSwitzerland
- Faculty of Psychology and Educational SciencesUniversity of GenevaGenevaSwitzerland
| | - Julia Sader
- Unit of Development and Research in Medical EducationFaculty of MedicineUniversity of GenevaGenevaSwitzerland
| | - Nathalie Caire Fon
- Department of Family Medicine and Emergency MedicineFaculty of MedicineUniversité de MontréalMontrealQCCanada
| | | | | | - Danilo Janjic
- Primary Care UnitFaculty of MedicineUniversity of GenevaGenevaSwitzerland
| | - Mathieu Nendaz
- Unit of Development and Research in Medical EducationFaculty of MedicineUniversity of GenevaGenevaSwitzerland
- Department of Internal MedicineUniversity Hospitals of GenevaGenevaSwitzerland
| | - Marie‐Claude Audétat
- Primary Care UnitFaculty of MedicineUniversity of GenevaGenevaSwitzerland
- Unit of Development and Research in Medical EducationFaculty of MedicineUniversity of GenevaGenevaSwitzerland
- Department of Family Medicine and Emergency MedicineFaculty of MedicineUniversité de MontréalMontrealQCCanada
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Magin P, Quain D, Tapley A, van Driel M, Davey A, Holliday E, Ball J, Kaniah A, Turner R, Spike N, FitzGerald K, Hilmer S. Deprescribing in older patients by early-career general practitioners: Prevalence and associations. Int J Clin Pract 2021; 75:e14325. [PMID: 33960089 DOI: 10.1111/ijcp.14325] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 12/09/2020] [Accepted: 05/03/2021] [Indexed: 11/30/2022] Open
Abstract
RATIONALE AND AIMS Deprescribing is the health-professional-supervised process of withdrawal of an inappropriate medication to manage polypharmacy and improve patient outcomes. Given the harms of polypharmacy and associated inappropriate medicines, practitioners, especially general practitioners (GPs), are encouraged to take a proactive role in deprescribing in older patients. While trial evidence for benefits of deprescribing is accumulating, there is currently little epidemiologic evidence of clinicians' (including GPs') deprescribing behaviours. We aimed to establish the prevalence and explore associations of deprescribing of inappropriate medicines by early-career GPs. METHODS A cross-sectional analysis of the ReCEnT study of GP registrars' in-consultation experience, 2016-18. Participants recorded 60 consecutive consultations, three times at 6-month intervals, including medicines ceased (our measure of deprescribing). The outcome was deprescribing of an inappropriate medicine (defined by a synthesis of three accepted classification systems) in patients 65 years or older. Logistic regression determined the associations of deprescribing inappropriate medicines. RESULTS One thousand one hundred and thirteen registrars reported 19 581 consultations with patients 65 years and older. Inappropriate medicines were deprescribed in 2.6% (95% CIs 2.4%-2.9%) of consultations. Of deprescribed medicines, 43% had been prescribed for three months or longer. Most commonly deprescribed were opioids (19%), proton pump inhibitors (9.2%), anti-inflammatory drugs (9.0%), statins (7.8%), and antidepressants (6.6%). The most common reason for deprescribing was: "no longer indicated" (38%). Significant adjusted associations of deprescribing included patients identifying as Aboriginal or Torres Strait Islander (OR 2.86); continuity-of-care (ORs 0.71 and 0.20 for the patient being new to practice and to the registrar, respectively); inner-regional compared to major-city location (OR 1.33); the problem/diagnosis being chronic (OR 1.90); and longer consultations (OR 1.03 per minute increase in duration). CONCLUSION These findings will have important implications for the education of GPs in deprescribing as a clinical skill.
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Affiliation(s)
- Parker Magin
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, NSW, Australia
| | - Debbie Quain
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, NSW, Australia
| | - Amanda Tapley
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, NSW, Australia
| | - Mieke van Driel
- Discipline of General Practice and Primary Care Clinical Unit, Faculty of Medicine, School of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - Andrew Davey
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- NSW & ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Newcastle, NSW, Australia
| | - Elizabeth Holliday
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- Clinical Research Design IT and Statistical Support Unit (CReDITSS), Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Jean Ball
- Clinical Research Design IT and Statistical Support Unit (CReDITSS), Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Ashwin Kaniah
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Rachel Turner
- Faculty of Health, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- Medical Education, GP Synergy Regional Training Organisation, Newcastle, NSW, Australia
| | - Neil Spike
- Eastern Victoria General Practice Training (EVGPT) Churchill, Churchill, Vic, Australia
- Department of General Practice and Primary Health Care Carlton, University of Melbourne, Melbourne, Vic, Australia
| | | | - Sarah Hilmer
- University of Sydney and Royal North Shore Hospital, Kolling Institute, St Leonards, NSW, Australia
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Dinh TS, González-González AI, Meid AD, Snell KIE, Rudolf H, Brueckle MS, Blom JW, Thiem U, Trampisch HJ, Elders PJM, Donner-Banzhoff N, Gerlach FM, Harder S, van den Akker M, Glasziou PP, Haefeli WE, Muth C. Are Anticholinergic Symptoms a Risk Factor for Falls in Older General Practice Patients With Polypharmacy? Study Protocol for the Development and Validation of a Prognostic Model. Front Pharmacol 2021; 11:577747. [PMID: 33519441 PMCID: PMC7845421 DOI: 10.3389/fphar.2020.577747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 11/23/2020] [Indexed: 12/23/2022] Open
Abstract
Background: Cumulative anticholinergic exposure, also known as anticholinergic burden, is associated with a variety of adverse outcomes. However, studies show that anticholinergic effects tend to be underestimated by prescribers, and anticholinergics are the most frequently prescribed potentially inappropriate medication in older patients. The grading systems and drugs included in existing scales to quantify anticholinergic burden differ considerably and do not adequately account for patients’ susceptibility to medications. Furthermore, their ability to link anticholinergic burden with adverse outcomes such as falls is unclear. This study aims to develop a prognostic model that predicts falls in older general practice patients, to assess the performance of several anticholinergic burden scales, and to quantify the added predictive value of anticholinergic symptoms in this context. Methods: Data from two cluster-randomized controlled trials investigating medication optimization in older general practice patients in Germany will be used. One trial (RIME, n = 1,197) will be used for the model development and the other trial (PRIMUM, n = 502) will be used to externally validate the model. A priori, candidate predictors will be selected based on a literature search, predictor availability, and clinical reasoning. Candidate predictors will include socio-demographics (e.g. age, sex), morbidity (e.g. single conditions), medication (e.g. polypharmacy, anticholinergic burden as defined by scales), and well-being (e.g. quality of life, physical function). A prognostic model including sociodemographic and lifestyle-related factors, as well as variables on morbidity, medication, health status, and well-being, will be developed, whereby the prognostic value of extending the model to include additional patient-reported symptoms will be also assessed. Logistic regression will be used for the binary outcome, which will be defined as “no falls” vs. “≥1 fall” within six months of baseline, as reported in patient interviews. Discussion: As the ability of different anticholinergic burden scales to predict falls in older patients is unclear, this study may provide insights into their relative importance as well as into the overall contribution of anticholinergic symptoms and other patient characteristics. The results may support general practitioners in their clinical decision-making and in prescribing fewer medications with anticholinergic properties.
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Affiliation(s)
- Truc Sophia Dinh
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt, Germany
| | - Ana Isabel González-González
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt, Germany.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Kym I E Snell
- Centre for Prognosis Research, School of Medicine, Keele University, Staffordshire, United Kingdom
| | - Henrik Rudolf
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum, Bochum, Germany
| | | | - Jeanet W Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
| | - Ulrich Thiem
- Chair of Geriatrics and Gerontology, University Clinic Eppendorf, Hamburg, Germany.,Department of Geriatrics, Immanuel Albertinen Diakonie, Albertinen-Haus, Hamburg, Germany
| | - Hans-Joachim Trampisch
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum, Bochum, Germany
| | - Petra J M Elders
- Amsterdam UMC, General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Norbert Donner-Banzhoff
- Department of General Practice/Family Medicine, Philipps University Marburg, Marburg, Germany
| | - Ferdinand M Gerlach
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt, Germany
| | - Sebastian Harder
- Institute of Clinical Pharmacology, Goethe-University Frankfurt am Main, Frankfurt am Main, Germany
| | | | - Paul P Glasziou
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christiane Muth
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt, Germany.,Department of General Practice and Family Medicine, Medical Faculty OWL, University of Bielefeld, Bielefeld, Germany
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9
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Goldberg EM, Marks SJ, Resnik LJ, Long S, Mellott H, Merchant RC. Can an Emergency Department-Initiated Intervention Prevent Subsequent Falls and Health Care Use in Older Adults? A Randomized Controlled Trial. Ann Emerg Med 2020; 76:739-750. [PMID: 32854965 PMCID: PMC7686139 DOI: 10.1016/j.annemergmed.2020.07.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 12/28/2022]
Abstract
STUDY OBJECTIVE We determine whether an emergency department (ED)-initiated fall-prevention intervention can reduce subsequent fall-related and all-cause ED visits and hospitalizations in older adults. METHODS The Geriatric Acute and Post-acute Fall Prevention intervention was a randomized controlled trial conducted from January 2018 to October 2019. Participants at 2 urban academic EDs were randomly assigned (1:1) to an intervention or usual care arm. Intervention participants received a brief, tailored, structured, pharmacy and physical therapy consultation in the ED, with automated communication of the recommendations to their primary care physicians. RESULTS Of 284 study-eligible participants, 110 noninstitutionalized older adults (≥65 years) with a recent fall consented to participate; median age was 81 years, 67% were women, 94% were white, and 16.3% had cognitive impairment. Compared with usual care participants (n=55), intervention participants (n=55) were half as likely to experience a subsequent ED visit (adjusted incidence rate ratio 0.47 [95% CI 0.29 to 0.74]) and one third as likely to have fall-related ED visits (adjusted incidence rate ratio 0.34 [95% CI 0.15 to 0.76]) within 6 months. Intervention participants experienced half the rate of all hospitalizations (adjusted incidence rate ratio 0.57 [95% CI 0.31 to 1.04]), but confidence intervals were wide. There was no difference in fall-related hospitalizations between groups (adjusted incidence rate ratio 0.99 [95% CI 0.31 to 3.27]). Self-reported adherence to pharmacy and physical therapy recommendations was moderate; 73% of pharmacy recommendations were adhered to and 68% of physical therapy recommendations were followed. CONCLUSION Geriatric Acute and Post-acute Fall Prevention, a postfall, in-ED, multidisciplinary intervention with pharmacists and physical therapists, reduced 6-month ED encounters in 2 urban EDs. The intervention could provide a model of care to other health care systems aiming to reduce costly and burdensome fall-related events in older adults.
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Affiliation(s)
- Elizabeth M Goldberg
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI; Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI.
| | - Sarah J Marks
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, MA
| | - Linda J Resnik
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI; Providence VA Medical Center, Providence, RI
| | - Sokunvichet Long
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Hannah Mellott
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Roland C Merchant
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, MA
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10
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Fadare JO, Obimakinde AM, Enwere OO, Desalu OO, Ibidapo RO. Physician's Knowledge of Appropriate Prescribing for the Elderly-A Survey Among Family and Internal Medicine Physicians in Nigeria. Front Pharmacol 2019; 10:592. [PMID: 31214031 PMCID: PMC6554676 DOI: 10.3389/fphar.2019.00592] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 05/08/2019] [Indexed: 02/02/2023] Open
Abstract
Background: Prescription and use of inappropriate medications have been identified as a major cause of morbidity among the elderly. Several screening tools have been developed to identify inappropriate medications prescribed for elderly patients. There is dearth of information about the knowledge of Nigerian physicians regarding these screening tools and appropriate prescribing for the elderly in general. The primary objective of this study was to assess the knowledge of Nigerian physicians about these screening tools and appropriate prescribing of medications for the elderly. Methods: The study was a cross-sectional questionnaire-based study conducted among physicians working in Family Medicine and Internal Medicine departments of four tertiary health care facilities in Nigeria. The questionnaire consisted of sections on general characteristics of respondents and their knowledge of four selected screening tools for inappropriate medications in the elderly. Ten clinical vignettes representing different therapeutic areas (using the best option type questions) about medicine use in the elderly were included with a score of 1 and 0 for correct and wrong answers, respectively. The knowledge of respondents was classified as (total score, over 10): poor (score, < 5), average (score, 5-6), and good (score, 7-10). Results: One hundred and five physicians returned completed questionnaires. Twenty percent of respondents knew about Beers criteria, whereas 15.6% were familiar with the STOPP criteria. Majority (83; 84.7%) of the respondents were confident of their ability to prescribeappropriately for elderly patients. The mean knowledge score was 5.3 ± 2.0 with 32 (30.5%), 41 (39%), and 32 (30.5%) having low, average, and good scores, respectively. The association between the knowledge score, duration of practice, and seniority was statistically significant (OR, 3.6, p = .004 and OR, 3; p = .012), respectively. Conclusion: There are significant gaps in the knowledge of Nigerian physicians about screening tools for inappropriate medications. There is a need for stakeholders involved in the care of elderly Nigerian patients to develop new strategies to improve services being offered. These may include introduction of modules on appropriate prescribing in the curriculum of undergraduate and postgraduate medical education and the routine use of some screening tools for inappropriate medications in daily clinical practice.
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Affiliation(s)
- Joseph O Fadare
- Department of Pharmacology and Therapeutics, Ekiti State University College of Medicine, Ado-Ekiti, Nigeria
| | - Abimbola Margaret Obimakinde
- Family Medicine Unit, Department of Community Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Family Medicine Department, University College Hospital, Ibadan, Nigeria
| | | | - Olufemi O Desalu
- Department of Medicine, College of Health Sciences, University of Ilorin, Ilorin, Nigeria
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11
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Lundby C, Graabaek T, Ryg J, Søndergaard J, Pottegård A, Nielsen DS. Health care professionals' attitudes towards deprescribing in older patients with limited life expectancy: A systematic review. Br J Clin Pharmacol 2019; 85:868-892. [PMID: 30630219 DOI: 10.1111/bcp.13861] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/19/2018] [Accepted: 12/26/2018] [Indexed: 12/20/2022] Open
Abstract
AIMS The aim of this systematic review was to explore health care professionals' attitudes towards deprescribing in older people with limited life expectancy. METHODS A systematic literature search was conducted from inception to December 2017 using MEDLINE, EMBASE and CINAHL. Studies were included if they specifically concerned older people (≥65 years) with limited life expectancy, including those residing in any type of aged care facility, or were based on representative patient profiles. Results were analyzed inspired by the Joanna Briggs Institute's method for synthesis of qualitative data. Studies were characterized using a checklist for reporting of qualitative research. RESULTS Eight studies were included. Six studies explored health care professionals' views on deprescribing in general, and two studies focused specifically on psychotropic agents. All eight studies explored the views of physicians, mostly general practitioners, while three studies also considered other health care professionals. Four themes related to health care professionals' attitudes towards deprescribing were identified: (i) patient and relative involvement; (ii) the importance of teamwork; (iii) health care professionals' self-assurance and skills; and (iv) the impact of organizational factors. Within each of these themes, 3-4 subthemes were identified and analysed. CONCLUSIONS Our results suggest that health care professionals' decisions to engage in deprescribing activities with older people with limited life expectancy depend on multiple factors which are highly interdependent. Consequently, there is an urgent need for more research on how to approach deprescribing in clinical practice within this population.
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Affiliation(s)
- Carina Lundby
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark.,Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Trine Graabaek
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark.,Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense C, Denmark.,Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Anton Pottegård
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark.,Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Dorthe Susanne Nielsen
- Migrant Health Clinic, Odense University Hospital, Odense C, Denmark.,Centre for Global Health, University of Southern Denmark, Odense C, Denmark.,Health Sciences Research Center, University College Lillebaelt, Odense M, Denmark
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12
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Comparison of Potentially Inappropriate Medications for People with Dementia at Admission and Discharge during An Unplanned Admission to Hospital: Results from the SMS Dementia Study. Healthcare (Basel) 2019; 7:healthcare7010008. [PMID: 30634548 PMCID: PMC6473531 DOI: 10.3390/healthcare7010008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 01/04/2019] [Accepted: 01/07/2019] [Indexed: 11/16/2022] Open
Abstract
People with dementia (PWD) and cognitive impairment are particularly vulnerable to medication problems, and unplanned admission to hospital presents an opportunity to address polypharmacy, potentially inappropriate medications (PIMs) and anticholinergic burden. This study aimed to compare PIMS and other medication data for PWD to determine whether these changed during hospitalization. Medications documented in patient’s records at admission and discharge were evaluated for PWD recruited to phase one of a prospective quasi-experimental pre/post-controlled trial that was conducted at two regional hospitals in NSW, Australia. The study sample included PWD or cognitive impairment having an unplanned admission to hospital. Data were collected using a purpose developed audit tool for medications and PIMs, and a Modified Anticholinergic Burden Scale. Total participants were 277, and results determined that the cognitive status of PWD is not always detected during an unplanned admission. This may make them more vulnerable to medication problems and poor outcomes. Polypharmacy and PIMS for PWD were high at admission and significantly reduced at discharge. However, PWD should be routinely identified as high risk at admission; and there is potential to further reduce polypharmacy and PIMs during admission to hospital, particularly psychotropic medications at discharge. Future studies should focus on evaluating targeted interventions designed to increase medication safety for PWD.
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13
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Hilmer SN. Calculating and using the drug burden index score in research and practice. Expert Rev Clin Pharmacol 2018; 11:1053-1055. [DOI: 10.1080/17512433.2018.1528145] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Sarah N Hilmer
- Head of Department of Clinical Pharmacology and Senior Staff Specialist Aged Care, Royal North Shore Hospital, Sydney, Australia
- Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Kolling Institute, Royal North Shore Hospital and University of Sydney, Sydney, Australia
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14
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Raguz Lucic N, Jakab J, Smolic M, Milas AM, Omanovic Kolaric T, Nincevic V, Bojanic K, Kralik K, Miskulin M, Wu GY, Smolic R. Primary Care Provider Counseling Practices about Adverse Drug Reactions and Interactions in Croatia. J Clin Med 2018; 7:jcm7090231. [PMID: 30135390 PMCID: PMC6162839 DOI: 10.3390/jcm7090231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/20/2018] [Accepted: 08/20/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Prescribing medications is one of the most common medical decisions that is made by primary care providers (PCPs). In the Republic of Croatia, PCPs hold a key position in prescribing and evaluating the medications that are provided for patients. Accordingly, providing advice for patients regarding the potential adverse drug reactions (ADRs) and drug-drug interactions (DDIs) is frequently the responsibility of the PCPs. The aim of the current study was to assess the knowledge, attitudes, and counseling practices of PCPs regarding drug interactions and adverse effects. METHODS After enrolling 195 PCPs that were selected at random, a survey was conducted while using an anonymous questionnaire that was created based on previously published studies, adjusted in a way that includes the most commonly prescribed medications in Croatia. RESULTS Of the 10 questions on knowledge about DDIs and ADRs, the median number of correct responses by PCPs was 5 (interquartile range 4 to 7). More than half of respondents (56%) agreed with the claim that knowledge of drug side effects facilitated their work in family medicine. Almost all of the respondents (92.8%) explained side effects and drug interactions to special groups of patients (pregnant women, elderly patients etc.). CONCLUSION The results show a need for additional education in the field of drug prescribing. However, PCPs were aware of the importance of counseling practices about adverse drug reactions and interactions and counseling practices among special patients populations are satisfactory.
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Affiliation(s)
- Nikola Raguz Lucic
- Faculty of Medicine, University of Osijek, Josipa Huttlera 4, HR-31000 Osijek, Croatia.
- Faculty of Dental Medicine and Health, University of Osijek, Crkvena 21, HR-31000 Osijek, Croatia.
| | - Jelena Jakab
- Faculty of Medicine, University of Osijek, Josipa Huttlera 4, HR-31000 Osijek, Croatia.
- Faculty of Dental Medicine and Health, University of Osijek, Crkvena 21, HR-31000 Osijek, Croatia.
| | - Martina Smolic
- Faculty of Medicine, University of Osijek, Josipa Huttlera 4, HR-31000 Osijek, Croatia.
- Faculty of Dental Medicine and Health, University of Osijek, Crkvena 21, HR-31000 Osijek, Croatia.
| | - Ana-Maria Milas
- Faculty of Medicine, University of Osijek, Josipa Huttlera 4, HR-31000 Osijek, Croatia.
| | - Tea Omanovic Kolaric
- Faculty of Medicine, University of Osijek, Josipa Huttlera 4, HR-31000 Osijek, Croatia.
- Faculty of Dental Medicine and Health, University of Osijek, Crkvena 21, HR-31000 Osijek, Croatia.
| | - Vjera Nincevic
- Faculty of Medicine, University of Osijek, Josipa Huttlera 4, HR-31000 Osijek, Croatia.
- Faculty of Dental Medicine and Health, University of Osijek, Crkvena 21, HR-31000 Osijek, Croatia.
| | - Kristina Bojanic
- Faculty of Medicine, University of Osijek, Josipa Huttlera 4, HR-31000 Osijek, Croatia.
- Faculty of Dental Medicine and Health, University of Osijek, Crkvena 21, HR-31000 Osijek, Croatia.
| | - Kristina Kralik
- Faculty of Medicine, University of Osijek, Josipa Huttlera 4, HR-31000 Osijek, Croatia.
| | - Maja Miskulin
- Faculty of Medicine, University of Osijek, Josipa Huttlera 4, HR-31000 Osijek, Croatia.
| | - George Y Wu
- Division of Gastroenterology-Hepatology, Department of Medicine, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06032, USA.
| | - Robert Smolic
- Faculty of Medicine, University of Osijek, Josipa Huttlera 4, HR-31000 Osijek, Croatia.
- Division of Gastroenterology-Hepatology, Department of Medicine, Osijek University Hospital, Josipa Huttlera 4, HR-31000 Osijek, Croatia.
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15
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Gillespie RJ, Harrison L, Mullan J. Deprescribing medications for older adults in the primary care context: A mixed studies review. Health Sci Rep 2018; 1:e45. [PMID: 30623083 PMCID: PMC6266366 DOI: 10.1002/hsr2.45] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/27/2018] [Accepted: 04/03/2018] [Indexed: 12/20/2022] Open
Abstract
AIMS This review investigates the factors that influence deprescribing of medications in primary care from the perspective of general practitioners (GPs) and community-living older adults. METHODS A mixed studies review structure was adopted searching Scopus, CINAHL, PsychINFO, ProQuest, and PubMed from January 2000 to December 2017. A manual search of reference lists was also conducted. Studies were included if they were original research available in English and explored general deprescribing rather than deprescribing of a specific class of medications. The Mixed Methods Assessment Tool was used to assess the quality of studies, and content analysis generated common categories across studies. RESULTS Thirty-eight articles were included, and 7 key categories were identified. The review found that the factors that influence deprescribing are similar across and within health systems and mostly act as barriers. These factors remained unchanged across the review period. The structural organisation of health systems remains poorly suited to facilitate deprescribing. Individual knowledge gaps of both GPs and older adults influence practices and attitudes towards deprescribing, and significant communication gaps occur between GPs and specialists and between GPs and older adults. As a result, deprescribing decision making is characterised by uncertainty, and deprescribing is often considered only when medication problems have already arisen. Trust plays a complex role, acting as both a barrier and facilitator of deprescribing. CONCLUSIONS Deprescribing is influenced by many factors. Despite recent interest, little change has occurred. Multilevel strategies aimed at reforming aspects of the health system and managing uncertainty at the practice and individual level, notably reducing knowledge limitations and closing communications gaps, may achieve change.
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Affiliation(s)
- Robyn J. Gillespie
- School of Medicine, Faculty of Science, Medicine and HealthUniversity of WollongongWollongongAustralia
| | - Lindsey Harrison
- School of Health and Society, Faculty of Social SciencesUniversity of WollongongWollongongAustralia
| | - Judy Mullan
- School of Medicine, Faculty of Science, Medicine and HealthUniversity of WollongongWollongongAustralia
- Centre for Health Research Illawarra Shoalhaven Population (CHRISP), Australian Health Services Research InstituteUniversity of WollongongNSW2522Australia
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16
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GPs' views and experiences of prescribing non-steroidal anti-inflammatory drugs: a qualitative study. BJGP Open 2017; 1:bjgpopen17X100869. [PMID: 30564663 PMCID: PMC6169948 DOI: 10.3399/bjgpopen17x100869] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Non-steroidal anti-inflammatory drugs (NSAIDs) are widely prescribed in primary care despite being a high-risk drug group causing significant adverse events, yet little is known about GPs’ perceptions of NSAID risks and benefits. Aim To explore GPs’ experiences with NSAID prescribing and views about the risks and benefits of this group of medicines. Design & setting A qualitative, inductive study in general practice. Method Individual interviews with 15 GPs using a semi-structured interview guide. Interviews were audiorecorded and transcribed. An inductive, thematic approach was used for analysis. Sampling continued until data saturation was achieved. Results Three main themes illustrate GPs’ key concerns with managing NSAID risks. The first theme was perceptions of risks and benefits of NSAIDs: GPs expressed differing attitudes towards prescribing medication generally. GPs were aware of the general risks of NSAIDs but weighed these up against specific risk factors and potential benefits for particular patients. They were most concerned about long-term use, risks for children, older people, and patients with comorbidities. The second theme was assessing and mitigating risks when prescribing NSAIDs: GPs considered gastric, cardiac, and renal risks of patients as well as drug interactions. Mitigation strategies included alternative treatment, choice and dose of NSAID, and use of gastroprotective agents. The final theme was other factors impacting on NSAID risks: particularly patient expectations and over-the-counter (OTC) availability. Conclusion NSAID prescribing is a complex balance between pragmatism and potential adverse events. Given the costs of morbidity, hospitalisation, and patient demand there is an urgent need to secure a more detailed evidence base and develop practical pathways to support safer prescribing.
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17
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Pohontsch NJ, Heser K, Löffler A, Haenisch B, Parker D, Luck T, Riedel-Heller SG, Maier W, Jessen F, Scherer M. General practitioners' views on (long-term) prescription and use of problematic and potentially inappropriate medication for oldest-old patients-A qualitative interview study with GPs (CIM-TRIAD study). BMC FAMILY PRACTICE 2017; 18:22. [PMID: 28212616 PMCID: PMC5395870 DOI: 10.1186/s12875-017-0595-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 01/26/2017] [Indexed: 12/13/2022]
Abstract
Background Potentially inappropriate medication (PIM) is defined as medication with uncertain therapeutic effects and/or potential adverse drug reactions outweighing the clinical benefits. The prescription rate of PIM for oldest-old patients is high despite the existence of lists of PIM (e.g. the PRISCUS list) and efforts to raise awareness. This study aims at identifying general practitioners’ views on PIM and aspects affecting the (long-term) use of PIM. Methods As part of the CIM-TRIAD study, we conducted semi-structured, qualitative interviews with 47 general practitioners, discussing 25 patients with and 22 without PIM (according to the PRISCUS list). The interview guideline included generic and patient-specific questions. Interviews were digitally recorded and transcribed verbatim. We content analyzed the interviews using deductive and inductive category development. Results The majority of the general practitioners were not aware of the PRISCUS list. Agents deemed potentially inappropriate from the general practitioners’ point of view and the PRISCUS list are not completely superimposable. General practitioners named their criteria to identify appropriate medication for elderly patients (e.g. renal function, cognitive state) and emphasized the importance of monitoring. We identified prescription- (e.g. benzodiazepines on alternative private prescription), medication- (e.g. subjective perception that PIM has no alternative), general practitioner- (e.g. general practitioner relies on specialists), patient- (e.g. “demanding high-user”, positive subjective benefit-risk-ratio) and system-related aspects (e.g. specialists lacking holistic view, interface problems) related to the (long term) use of PIM. Conclusions While the PRISCUS list does not seem to play a decisive role in general practice, general practitioners are well aware of risks associated with PIM. Our study identifies some starting points for a safer handling of PIM, e.g. stronger dissemination of the PRISCUS list, better compensation of medication reviews, “positive lists”, adequate patient information, multifaceted interventions and improved communication between general practitioners and specialists. Electronic supplementary material The online version of this article (doi:10.1186/s12875-017-0595-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nadine Janis Pohontsch
- Department of General Practice/Primary Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Kathrin Heser
- Department of Psychiatry and Psychotherapy, University of Bonn, Sigmund-Freud-Straße 25, 53105, Bonn, Germany
| | - Antje Löffler
- Institute of Health, Brandenburg University of Technology, Großenhainer Straße 57, 01968, Senftenberg, Germany
| | - Britta Haenisch
- German Center for Neurodegenerative Diseases (DZNE), Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Germany
| | - Debora Parker
- German Center for Neurodegenerative Diseases (DZNE), Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Germany
| | - Tobias Luck
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany
| | - Steffi G Riedel-Heller
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany
| | - Wolfgang Maier
- Department of Psychiatry and Psychotherapy, University of Bonn, Sigmund-Freud-Straße 25, 53105, Bonn, Germany
| | - Frank Jessen
- German Center for Neurodegenerative Diseases (DZNE), Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Germany.,Clinic and polyclinic for psychiatry and psychotherapy, University Medical Center Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Martin Scherer
- Department of General Practice/Primary Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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18
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Mori ALPM, Carvalho RC, Aguiar PM, de Lima MGF, Rossi MDSPN, Carrillo JFS, Dórea EL, Storpirtis S. Potentially inappropriate prescribing and associated factors in elderly patients at hospital discharge in Brazil: a cross-sectional study. Int J Clin Pharm 2017; 39:386-393. [PMID: 28188508 DOI: 10.1007/s11096-017-0433-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 01/31/2017] [Indexed: 01/27/2023]
Abstract
Background The Screening Tool of Older Persons' Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) criteria is used to identify instances of potentially inappropriate prescribing in a patient's medication regimen. Objective To determine the prevalence and predictors of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) among elderly patients at hospital discharge. Setting A university hospital medical clinic in Brazil. Method Discharge prescriptions were examined using the STOPP/START criteria. Subjects were inpatients aged ≥60 years receiving at least one medication prior to hospitalization and with a history of cardiovascular disease. The prevalence of PIMs and PPOs was determined and a multivariable binary regression analysis was performed to identify independent predictors associated with PIMs or PPOs. Main outcome measure Prevalence of PIMs and PPOs. Results Of the 230 subjects, 13.9% were prescribed at least one PIM. The most frequently prescribed PIMs were glibenclamide or chlorpropamide prescribed for type 2 diabetes mellitus (31.0%), and aspirin at doses >150 mg/day (14.3%). Ninety patients had at least one PPO (39.1%). The most prevalent PPOs were statins (29.8%) and antiplatelet therapy (13.7%) for diabetes mellitus when coexisting major cardiovascular risk factors were present. No predictors for PIMs were found. In contrast, diabetes was a risk factor while dyslipidaemia was a protective factor for PPOs. Conclusion PIMs and PPOs commonly occur with elderly people at hospital discharge. Diabetes and dyslipidaemia were significantly associated with PPOs. Our findings show the need for interventions to reduce potentially inappropriate prescribing, such as a pharmacist medication review process at hospital discharge.
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Affiliation(s)
| | - Renata Cunha Carvalho
- Department of Pharmacy, Faculty of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
| | - Patricia Melo Aguiar
- Department of Pharmacy, Faculty of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil.
| | | | | | | | | | - Sílvia Storpirtis
- Department of Pharmacy, Faculty of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
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19
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Clyne B, Cooper JA, Hughes CM, Fahey T, Smith SM. 'Potentially inappropriate or specifically appropriate?' Qualitative evaluation of general practitioners views on prescribing, polypharmacy and potentially inappropriate prescribing in older people. BMC FAMILY PRACTICE 2016; 17:109. [PMID: 27515854 PMCID: PMC4982127 DOI: 10.1186/s12875-016-0507-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 08/03/2016] [Indexed: 11/12/2022]
Abstract
Background Potentially inappropriate prescribing (PIP) is common in older people in primary care, as evidenced by a significant body of quantitative research. However, relatively few qualitative studies have investigated the phenomenon of PIP and its underlying processes from the perspective of general practitioners (GPs). The aim of this paper is to explore qualitatively, GP perspectives regarding prescribing and PIP in older primary care patients. Method Semi-structured qualitative interviews were conducted with GPs participating in a randomised controlled trial (RCT) of an intervention to decrease PIP in older patients (≥70 years) in Ireland. Interviews were conducted with GP participants (both intervention and control) from the OPTI-SCRIPT cluster RCT as part of the trial process evaluation between January and July 2013. Interviews were conducted by one interviewer and audio recorded. Interviews were transcribed verbatim and a thematic analysis was conducted. Results Seventeen semi-structured interviews were conducted (13 male; 4 female). Three main, inter-related themes emerged (complex prescribing environment, paternalistic doctor-patient relationship, and relevance of PIP concept). Patient complexity (e.g. polypharmacy, multimorbidity), as well as prescriber complexity (e.g. multiple prescribers, poor communication, restricted autonomy) were all identified as factors contributing to a complex prescribing environment where PIP could occur, as was a paternalistic-doctor patient relationship. The concept of PIP was perceived to be of variable usefulness to GPs and the criteria to measure it may be at odds with the complex processes of prescribing for this patient population. Conclusions Several inter-related factors contributing to the occurrence of PIP were identified, some of which may be amenable to intervention. Improvement strategies focused on improved management of polypharmacy and multimorbidity, and communication across primary and secondary care could result in substantial improvements in PIP. Trial registration Current controlled trials ISRCTN41694007
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Affiliation(s)
- Barbara Clyne
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland.
| | - Janine A Cooper
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland.,School of Pharmacy, Queen's University Belfast (QUB), 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
| | - Carmel M Hughes
- School of Pharmacy, Queen's University Belfast (QUB), 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland
| | - Susan M Smith
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland
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20
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Magin PJ, Morgan S, Tapley A, McCowan C, Parkinson L, Henderson KM, Muth C, Hammer MS, Pond D, Mate KE, Spike NA, McArthur LA, van Driel ML. Anticholinergic medicines in an older primary care population: a cross-sectional analysis of medicines' levels of anticholinergic activity and clinical indications. J Clin Pharm Ther 2016; 41:486-92. [PMID: 27349795 DOI: 10.1111/jcpt.12413] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 06/02/2016] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Adverse clinical outcomes have been associated with cumulative anticholinergic burden (to which low-potency as well as high-potency anticholinergic medicines contribute). The clinical indications for which anticholinergic medicines are prescribed (and thus the 'phenotype' of patients with anticholinergic burden) have not been established. We sought to establish the overall prevalence of prescribing of anticholinergic medicines, the prevalence of prescribing of low-, medium- and high-potency anticholinergic medicines, and the clinical indications for which the medicines were prescribed in an older primary care population. METHODS This was a cross-sectional analysis of a cohort study of Australian early-career general practitioners' (GPs') clinical consultations - the Registrar Clinical Encounters in Training (ReCEnT) study. In ReCEnT, GPs collect detailed data (including medicines prescribed and their clinical indication) for 60 consecutive patients, on up to three occasions 6 months apart. Anticholinergic medicines were categorized as levels 1 (low-potency) to 3 (high-potency) using the Anticholinergic Drug Scale (ADS). RESULTS During 2010-2014, 879 early-career GPs (across five of Australia's six states) conducted 20 555 consultations with patients aged 65 years or older, representing 35 506 problems/diagnoses. Anticholinergic medicines were prescribed in 10·4% [95% CIs 9·5-10·5] of consultations. Of the total anticholinergic load of prescribed medicines ('community anticholinergic load') 72·7% [95% CIs 71·0-74·3] was contributed by Level 1 medicines, 0·8% [95% CIs 0·5-1·3] by Level 2 medicines and 26·5% [95% CIs 24·8-28·1] by Level 3 medicines. Cardiac (40·0%), Musculoskeletal (16·9%) and Respiratory (10·6%) were the most common indications associated with Level 1 anticholinergic prescription. For Level 2 and 3 medicines (combined data), Psychological (16·1%), Neurological (16·1%), Musculoskeletal (15·7%) and Urological (11·1%) indications were most common. WHAT IS NEW AND CONCLUSION Anticholinergic medicines are frequently prescribed in Australian general practice, and the majority of the 'community' anticholinergic burden is contributed by 'low'-anticholinergic potency medicines whose anticholinergic effects may be largely 'invisible' to prescribing GPs. Furthermore, the clinical 'phenotype' of the patient with high anticholinergic burden may be very different to common stereotypes (patients with urological, psychological or neurological problems), potentially making recognition of risk of anticholinergic adverse effects additionally problematic for GPs.
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Affiliation(s)
- P J Magin
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - S Morgan
- Elermore Vale General Practice, Newcastle, NSW, Australia
| | - A Tapley
- GP Synergy, Newcastle, NSW, Australia
| | | | - L Parkinson
- School of Human Health and Social Sciences, Central Queensland University, Rockhampton, QLD, Australia
| | | | - C Muth
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | - M S Hammer
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | - D Pond
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - K E Mate
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, NSW, Australia
| | - N A Spike
- Eastern Victoria GP Training, Melbourne, VIC, Australia
| | | | - M L van Driel
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
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Kydd A, Fleming A. What doctors need to know: Prescribing or not for the oldest old. Maturitas 2016; 90:9-16. [PMID: 27282788 DOI: 10.1016/j.maturitas.2016.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 05/02/2016] [Accepted: 05/03/2016] [Indexed: 02/07/2023]
Abstract
Given the global increase in the number of people over the age of 85, there is a growing body of work concerning this group, termed the oldest old. Much of this work is confined to the literature specialising in geriatrics and the more generic health care papers refer to 'older people' with little definition of what is meant by 'older'. Iatrogenesis (ill health caused by doctors) is a major issue and general practitioners (GPs) need practical help in prescribing for the oldest old. This paper presents a narrative review of the literature on prescribing and the oldest old. The results showed that all papers sourced referred to prescribing for the 'old' as those aged over 65, with only scant mention of oldest old. Yet prescribing for the oldest old involves clinical judgement and knowledge of the patient. It includes weighing up what will do good, cause no harm and is acceptable to the individual. GPs have to make treatment choices mostly in isolation from colleagues, during time-limited consultations and with few relevant guidelines on managing multi-morbidities in the oldest old. A major issue in prescribing for people over the age of 85 is that guidelines for diseases are based on trials with younger adults, outline the best practice for one disease in isolation (i.e. not in the presence of other diseases) and take little account of the interactions between the drugs used in managing several diseases in frail older people. There is a growing body of work, however, calling for specialist services for the oldest old.
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Affiliation(s)
- Angela Kydd
- School of Nursing Midwifery and Social Care, Edinburgh Napier University, Edinburgh EH11 4BN, United Kingdom.
| | - Anne Fleming
- School of Nursing Midwifery and Social Care, Edinburgh Napier University, Edinburgh EH11 4BN, United Kingdom
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Mate KE, Kerr KP, Pond D, Williams EJ, Marley J, Disler P, Brodaty H, Magin PJ. Impact of multiple low-level anticholinergic medications on anticholinergic load of community-dwelling elderly with and without dementia. Drugs Aging 2016; 32:159-67. [PMID: 25566958 DOI: 10.1007/s40266-014-0230-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Elderly people, particularly those with dementia, are sensitive to adverse anticholinergic drug effects. This study examines the prevalence of anticholinergic medication, and anticholinergic load and its predictors, in community-dwelling elderly patients (aged 75 years and older) in Australia. METHODS A research nurse visited the home of each participant (n = 1,044), compiled a list of current medications, and assessed participants' cognitive status using a subsection of the revised Cambridge Examination for Mental Disorders of the Elderly (CAMCOG-R). Anticholinergic load was determined for each patient using the Anticholinergic Drug Scale (ADS). RESULTS Multivariate analysis identified several patient factors that were associated with higher anticholinergic burden, including polypharmacy (i.e. taking five or more medications) (p < 0.001), increasing age (p = 0.018), CAMCOG-R dementia (p = 0.003), depression (p = 0.003), and lower physical quality of life (p < 0.001). The dementia group (n = 86) took a significantly higher number of medications (4.6 vs. 3.9; p = 0.04), and had a significantly higher anticholinergic load (1.5 vs. 0.8; p = 0.002) than those without dementia (n = 958). Approximately 60% of the dementia group and 40% of the non-dementia group were receiving at least one anticholinergic drug. This difference was due to the higher proportion of dementia patients taking level 1 (potentially anticholinergic) (p = 0.002) and level 3 (markedly anticholinergic) (p = 0.005) drugs. CONCLUSIONS There is considerable scope for the improvement of prescribing practices in the elderly, and particularly those with dementia. Importantly, level 1 anticholinergics have been identified as major contributors to the anticholinergic load in people with dementia. Longitudinal studies are required to determine the effects of increased and decreased anticholinergic load on cognitive function and other clinical outcomes for people with dementia.
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Affiliation(s)
- Karen E Mate
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, NSW, 2308, Australia,
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Kennedy MC, Henman MC, Cousins G. General Practitioners and Chronic Non-Malignant Pain Management in Older Patients: A Qualitative Study. PHARMACY 2016; 4:E15. [PMID: 28970388 PMCID: PMC5419349 DOI: 10.3390/pharmacy4010015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 02/25/2016] [Accepted: 02/29/2016] [Indexed: 12/28/2022] Open
Abstract
Chronic non-malignant pain (CNMP) is commonly managed by General Practitioners (GPs) in primary care. Analgesics are the mainstay of CNMP management in this setting. Selection of medications by GPs may be influenced by micro factors which are relevant to the practice setting, meso factors which relate to the local or regional environment or macro factors such as those arising from national or international influences. The aim of this study is to explore influences on GP practises in relation to pain management for older adults with CNMP. Semi-structured interviews were conducted with 12 GPs. Transcripts were organised using the Framework Method of Data Management while an applied thematic analysis was used to identify the themes emerging from the data. Clinical considerations such as the efficacy of analgesics, adverse effects and co-morbidities strongly influence prescribing decisions. The GPs interviewed identified the lack of guidance on this subject in Ireland and described the impact of organisational and structural barriers of the Irish healthcare system on the management of CNMP. Changes in practice behaviours coupled with health system reforms are required to improve the quality and consistency of pharmacotherapeutic management of CNMP in primary care.
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Affiliation(s)
| | - Martin C Henman
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland.
| | - Gráinne Cousins
- School of Pharmacy, Royal College of Surgeons in Ireland, St. Stephens Green, Dublin , Ireland.
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Steinman MA, Beizer JL, DuBeau CE, Laird RD, Lundebjerg NE, Mulhausen P. How to Use the American Geriatrics Society 2015 Beers Criteria-A Guide for Patients, Clinicians, Health Systems, and Payors. J Am Geriatr Soc 2015; 63:e1-e7. [PMID: 26446776 PMCID: PMC5325682 DOI: 10.1111/jgs.13701] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The Beers Criteria are a valuable tool for clinical care and quality improvement but may be misinterpreted and implemented in ways that cause unintended harms. This article describes the intended role of the 2015 American Geriatrics Society (AGS) Beers Criteria and provides guidance on how patients, clinicians, health systems, and payors should use them. A key theme underlying these recommendations is to use common sense and clinical judgment in applying the 2015 AGS Beers Criteria and to remain mindful of nuances in the criteria. The criteria serve as a "warning light" to identify medications that have an unfavorable balance of benefits and harms in many older adults, particularly when compared with pharmacological and nonpharmacological alternatives. However, there are situations in which use of medications included in the criteria can be appropriate. As such, the 2015 AGS Beers Criteria work best not only when they identify potentially inappropriate medications, but also when they educate clinicians and patients about the reasons those medications are included and the situations in which their use may be more or less problematic. The criteria are designed to support, rather than supplant, good clinical judgment.
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Affiliation(s)
- Michael A Steinman
- Division of Geriatrics, University of California at San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Judith L Beizer
- College of Pharmacy and Health Sciences, St. John's University, Queens, New York
| | - Catherine E DuBeau
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
- Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, Massachusetts
- Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worcester, Massachusetts
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Specialist discharge, child psychiatry, PIMs, and Facebook. Br J Gen Pract 2014; 64:468. [DOI: 10.3399/bjgp14x681445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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