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Faulkner L, Hughes CM, Barry HE. 'I think we could probably do more': an interview study to explore community pharmacists' experiences and perspectives of frailty and optimising medicines use in frail older adults. Age Ageing 2024; 53:afae089. [PMID: 38706393 PMCID: PMC11070721 DOI: 10.1093/ageing/afae089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Indexed: 05/07/2024] Open
Abstract
BACKGROUND Community pharmacists potentially have an important role to play in identification of frailty and delivery of interventions to optimise medicines use for frail older adults. However, little is known about their knowledge or views about this role. AIM To explore community pharmacists' knowledge of frailty and assessment, experiences and contact with frail older adults, and perceptions of their role in optimising medicines use for this population. METHODS Semi-structured interviews conducted between March and December 2020 with 15 community pharmacists in Northern Ireland. Interviews were transcribed verbatim and analysed thematically. RESULTS Three broad themes were generated from the data. The first, 'awareness and understanding of frailty', highlighted gaps in community pharmacists' knowledge regarding presentation and identification of frailty and their reluctance to broach potentially challenging conversations with frail older patients. Within the second theme, 'problem-solving and supporting medication use', community pharmacists felt a large part of their role was to resolve medicines-related issues for frail older adults through collaboration with other primary healthcare professionals but feedback on the outcome was often not provided upon issue resolution. The third theme, 'seizing opportunities in primary care to enhance pharmaceutical care provision for frail older adults', identified areas for further development of the community pharmacist role. CONCLUSIONS This study has provided an understanding of the views and experiences of community pharmacists about frailty. Community pharmacists' knowledge deficits about frailty must be addressed and their communication skills enhanced so they may confidently initiate conversations about frailty and medicines use with older adults.
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Affiliation(s)
- Lucy Faulkner
- Primary Care Research Group, School of Pharmacy, Queen’s University Belfast, Belfast, UK
| | - Carmel M Hughes
- Primary Care Research Group, School of Pharmacy, Queen’s University Belfast, Belfast, UK
| | - Heather E Barry
- Primary Care Research Group, School of Pharmacy, Queen’s University Belfast, Belfast, UK
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2
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Anlay DZ, Paque K, Van Leeuwen E, Cohen J, Dilles T. Tools and guidelines to assess the appropriateness of medication and aid deprescribing: An umbrella review. Br J Clin Pharmacol 2024; 90:12-106. [PMID: 37697479 DOI: 10.1111/bcp.15906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/24/2023] [Accepted: 08/29/2023] [Indexed: 09/13/2023] Open
Abstract
AIMS The aim of this umbrella review was to identify tools and guidelines to aid the deprescribing process of potentially inappropriate medications (PIMs), evaluate development and validation methods, and describe evidence levels for medication inclusion. METHODS Searches were conducted on MEDLINE (Ovid), Embase.com, Cochrane CDSR, CINAHL (EBSCO), Web of Science Core Collection and guideline databases from the date of inception to 7 July 2022. Following the initial search, an additional search was conducted to identify an updated versions of tools on 17 July 2023. We analysed the contents of tools and guidelines. RESULTS From 23 systematic reviews and guidelines, we identified 95 tools (72 explicit, 12 mixed and 11 implicit) and nine guidelines. Most tools (83.2%) were developed to use for older persons, including 14 for those with limited life expectancy. Seven tools were for children <18 years (7.37%). Most explicit/mixed tools (78.57%) and all guidelines were validated. We found 484 PIMs and 202 medications with different appropriateness independent of disease for older persons with normal and limited life expectancy, respectively. Only two tools and eight guidelines reported the evidence level, and a quarter of medications had high-quality evidence. CONCLUSIONS Tools are available for a diversity of populations. There were discrepancies, with the same medication being classified as inappropriate in some tools and appropriate in others, possibly due to low-quality evidence. In particular, tools for patients with limited life expectancy were developed based on very limited evidence, and research to generate this evidence is urgently needed. Our medication lists, along with the level of evidence, could facilitate efforts to strengthen the evidence.
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Affiliation(s)
- Degefaye Zelalem Anlay
- End-of-life Care Research Group, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
- Centre for Research and Innovation in Care, Nurse and Pharmaceutical Care, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Kristel Paque
- Centre for Research and Innovation in Care, Nurse and Pharmaceutical Care, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- HAST, Hasselt, Belgium
| | - Ellen Van Leeuwen
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences & Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Joachim Cohen
- End-of-life Care Research Group, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Tinne Dilles
- Centre for Research and Innovation in Care, Nurse and Pharmaceutical Care, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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3
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Sargent L, Zimmerman KM, Mohammed A, Barrett MJ, Nawaz H, Wyman-Chick K, Mackiewicz M, Roman Y, Slattum P, Russell S, Dixon DL, Lageman SK, Hobgood S, Thacker LR, Price ET. Low-Income Older Adults' Vulnerability to Anticholinergic Medication-Associated Frailty. Drugs Aging 2023; 40:1123-1131. [PMID: 37856064 DOI: 10.1007/s40266-023-01069-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND A growing body of research supports the negative impact of anticholinergic drug burden on physical frailty. However, prior research has been limited to homogeneous white European populations, and few studies have evaluated how anticholinergic burden tools compare in their measurement function and reliability with minority community-dwelling adult populations. This study investigated the association between anticholinergic drug exposure and frailty by conducting a sensitivity analysis using multiple anticholinergic burden tools in a diverse cohort. METHODS A comprehensive psychometric approach was used to assess the performance of five clinical Anticholinergic Burden Tools: Anticholinergic Cognitive Burden Scale (ACB), Anticholinergic Drug Scale (ADS), average daily dose, total standardized daily doses (TSDD), and Cumulative Anticholinergic Burden scale (CAB). Spearman correlation matrix and intraclass correlation coefficients (ICC) were used to determine the association among the variables. Ordinal logistic regression is used to evaluate the anticholinergic burden measured by each scale to determine the prediction of frailty. Model performance is determined by the area under the curve (AUC). RESULTS The cohort included 80 individuals (mean age 69 years; 55.7% female, 71% African American). All anticholinergic burden tools were highly correlated (p < 0.001), ICC3 0.66 (p < 0.001, 95% confidence interval (CI) 0.53-0.73). Among individuals prescribed anticholinergics, 33% were robust, 44% were prefrail, and 23% were frail. All five tools predicted prefrail and frail status (p < 0.05) with low model misclassification rates for frail individuals (AUC range 0.78-0.85). CONCLUSION Anticholinergic burden tools evaluated in this cohort of low-income African American older adults were highly correlated and predicted prefrail and frail status. Findings indicate that clinicians can select the appropriate instrument for the clinic setting and research question while maintaining confidence that all five tools will produce reliable results. Future anticholinergic research is needed to unravel the association between interventions such as deprescribing on incident frailty in longitudinal data.
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Affiliation(s)
- Lana Sargent
- School of Nursing, Virginia Commonwealth University, 1100 E Leigh St., Richmond, VA, 23298, USA.
- Geriatric Pharmacotherapy Program, School of Pharmacy, Virginia Commonwealth University, 410 N 12th St., Richmond, VA, 23298, USA.
- Institute for Inclusion, Inquiry, and Innovation (iCubed): Health and Wellness in Aging Populations Core, Richmond, VA, 23298, USA.
| | - Kristin M Zimmerman
- Institute for Inclusion, Inquiry, and Innovation (iCubed): Health and Wellness in Aging Populations Core, Richmond, VA, 23298, USA
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, 410 N 12th St., Richmond, VA, 23298, USA
| | - Almutairi Mohammed
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, 51452, Buraydah, Saudi Arabia
| | - Matthew J Barrett
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - Huma Nawaz
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | | | - Marissa Mackiewicz
- Geriatric Pharmacotherapy Program, School of Pharmacy, Virginia Commonwealth University, 410 N 12th St., Richmond, VA, 23298, USA
- Institute for Inclusion, Inquiry, and Innovation (iCubed): Health and Wellness in Aging Populations Core, Richmond, VA, 23298, USA
| | - Youssef Roman
- Geriatric Pharmacotherapy Program, School of Pharmacy, Virginia Commonwealth University, 410 N 12th St., Richmond, VA, 23298, USA
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, 410 N 12th St., Richmond, VA, 23298, USA
| | - Patricia Slattum
- Geriatric Pharmacotherapy Program, School of Pharmacy, Virginia Commonwealth University, 410 N 12th St., Richmond, VA, 23298, USA
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, 410 N 12th St., Richmond, VA, 23298, USA
- Virginia Center on Aging, Virginia Commonwealth University, 900 E Leigh St, Richmond, VA, 23298, USA
| | - Sally Russell
- School of Nursing, Virginia Commonwealth University, 1100 E Leigh St., Richmond, VA, 23298, USA
| | - Dave L Dixon
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, 410 N 12th St., Richmond, VA, 23298, USA
| | - Sarah K Lageman
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, 23298, USA
| | - Sarah Hobgood
- School of Medicine, Department of Geriatrics, Virginia Commonwealth University, 1101 E. Marshall St., Richmond, VA, 23298, USA
| | - Leroy R Thacker
- School of Medicine, Department of Biostatistics, Virginia Commonwealth University, 830 East Main Street, Richmond, VA, 23298, USA
| | - Elvin T Price
- Geriatric Pharmacotherapy Program, School of Pharmacy, Virginia Commonwealth University, 410 N 12th St., Richmond, VA, 23298, USA
- Institute for Inclusion, Inquiry, and Innovation (iCubed): Health and Wellness in Aging Populations Core, Richmond, VA, 23298, USA
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, 410 N 12th St., Richmond, VA, 23298, USA
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Positive Patient Postoperative Outcomes with Pharmacotherapy: A Narrative Review including Perioperative-Specialty Pharmacist Interviews. J Clin Med 2022; 11:jcm11195628. [PMID: 36233497 PMCID: PMC9572852 DOI: 10.3390/jcm11195628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/15/2022] [Accepted: 09/21/2022] [Indexed: 11/19/2022] Open
Abstract
The influence of pharmacotherapy regimens on surgical patient outcomes is increasingly appreciated in the era of enhanced recovery protocols and institutional focus on reducing postoperative complications. Specifics related to medication selection, dosing, frequency of administration, and duration of therapy are evolving to optimize pharmacotherapeutic regimens for many enhanced recovery protocolized elements. This review provides a summary of recent pharmacotherapeutic strategies, including those configured within electronic health record (EHR) applications and functionalities, that are associated with the minimization of the frequency and severity of postoperative complications (POCs), shortened hospital length of stay (LOS), reduced readmission rates, and cost or revenue impacts. Further, it will highlight preventive pharmacotherapy regimens that are correlated with improved patient preparation, especially those related to surgical site infection (SSI), venous thromboembolism (VTE), nausea and vomiting (PONV), postoperative ileus (POI), and emergence delirium (PoD) as well as less commonly encountered POCs such as acute kidney injury (AKI) and atrial fibrillation (AF). The importance of interprofessional collaboration in all periprocedural phases, focusing on medication management through shared responsibilities for drug therapy outcomes, will be emphasized. Finally, examples of collaborative care through shared mental models of drug stewardship and non-medical practice agreements to improve operative throughput, reduce operative stress, and increase patient satisfaction are illustrated.
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5
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Pharmacist-led home medication review for older adults: A stepwise process and algorithm for face to face and online approach. Res Social Adm Pharm 2022; 19:1-4. [DOI: 10.1016/j.sapharm.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 09/21/2022] [Indexed: 11/22/2022]
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6
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Development, validation and evaluation of an online medication review tool (MedReview). PLoS One 2022; 17:e0269322. [PMID: 35657965 PMCID: PMC9165870 DOI: 10.1371/journal.pone.0269322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 05/19/2022] [Indexed: 11/19/2022] Open
Abstract
Objectives To develop, validate and evaluate a computerized clinical decision support system (MedReview) that aids medication reviewers with pharmacological decision-making. Methods This study included three phases; the development phase included computerizing a consolidated medication review algorithm (MedReview), followed by validation and evaluation of MedReview and responding to a web-based survey designed using patient scenarios. Participants had to be ‘fully registered’ with the Malaysian Pharmacy Board and work full-time at a community pharmacy. Results MedReview was developed as a web app. It was validated among 100 community pharmacists from May-July 2021 using the Technology Acceptance Model (TAM). There was acceptable content validity and fair inter-rater agreement, and good convergent and discriminant validity. Exploratory factor analysis resulted in five domains to determine the attitude of pharmacists about using MedReview: perceived ease of use, perceived usefulness, intention to use, trust, and personal initiatives and characteristics; the total variance explained by five factors was 76.36%. The survey questionnaire had a high overall reliability value of 0.96. Evaluation of MedReview was based on mean scores of survey items. Of all items included in the survey, the highest mean score (out of 7) was achieved for ‘I could use MedReview if it is meaningful/relevant to my daily tasks’ (5.78 ± 1.10), followed by ‘I could use MedReview if I feel confident that the data returned by MedReview is reliable’ (5.77 ± 1.21), and ‘I could use MedReview if it protects the privacy of its users’ (5.73 ± 1.20). Conclusion Community pharmacists generally had a positive attitude towards MedReview. They found that MedReview is trustworthy and they had the intention to use it when conducting medication reviews. The adaptation of the TAM in the survey instrument was reliable and internally valid.
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7
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Virnes RE, Tiihonen M, Karttunen N, van Poelgeest EP, van der Velde N, Hartikainen S. Opioids and Falls Risk in Older Adults: A Narrative Review. Drugs Aging 2022; 39:199-207. [PMID: 35288864 PMCID: PMC8934763 DOI: 10.1007/s40266-022-00929-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 02/07/2023]
Abstract
Pain treatment is important in older adults but may result in adverse events such as falls. Opioids are effective for nociceptive pain but the evidence for neuropathic pain is weak. Nevertheless, both pain and opioids may increase the risk of falls. This narrative literature review aims to summarize the existing knowledge on the opioid-related fall risk in older adults, including the pharmacokinetics and pharmacodynamics, and assist clinicians in prescribing and deprescribing opioids in older persons. We systematically searched relevant literature on opioid-related fall risk in older adults in PubMed and Scopus in December 2020. We reviewed the literature and evaluated fall-related adverse effects of opioids, explaining how to optimally approach deprescribing of opioids in older adults. Opioid use increases fall risk through drowsiness, (orthostatic) hypotension and also through hyponatremia caused by weak opioids. When prescribing, opioids should be started with low dosages if possible, keeping in mind their metabolic genetic variation. Falls are clinically significant adverse effects of all opioids, and the risk may be dose dependent and highest with strong opioids. The risk is most prominent in older adults prone to falls. To reduce the risk of falls, both pain and the need for opioids should be assessed on a regular basis, and deprescribing or changing to a lower dosage or safer alternative should be considered if the clinical condition allows. Deprescribing should be done by reducing the dosage gradually and by assessing and monitoring the pain and withdrawal symptoms at the same time. Weighing the risks and benefits is necessary before prescribing opioids, especially to older persons at high risk of falls. Clinical decision tools assist prescribers in clinical decisions regarding (de-) prescribing.
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Affiliation(s)
- Roosa-Emilia Virnes
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland
| | - Miia Tiihonen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland. .,Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.
| | - Niina Karttunen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland
| | - Eveline P van Poelgeest
- Department of Internal Medicine, Geriatrics, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Natalie van der Velde
- Department of Internal Medicine, Geriatrics, Amsterdam University Medical Centers, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Sirpa Hartikainen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland
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8
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Gonçalves JR, Sleath BL, Lopes MJ, Cavaco AM. Prescribing-Assessment Tools for Long-Term Care Pharmacy Practice: Reaching Consensus through a Modified RAND/UCLA Appropriateness Method. PHARMACY 2021; 9:194. [PMID: 34941626 PMCID: PMC8708836 DOI: 10.3390/pharmacy9040194] [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: 11/15/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 11/20/2022] Open
Abstract
Medicines are the most used health technology in Long-Term Care. The prevalence of potentially inappropriate medicines amongst Long-Term Care patients is high. Pharmacists, assisted by prescribing-assessment tools, can play an important role in optimizing medication use at this level of care. Through a modified RAND/UCLA Appropriateness Method, 13 long-term care and hospital pharmacists assessed as 'appropriate', 'uncertain', or 'inappropriate' a collection of commonly used prescribing-assessment tools as to its suitability in assisting pharmacy practice in institutional long-term care settings. A qualitative analysis of written or transcribed comments of participants was pursued to identify relevant characteristics of prescribing-assessment tools and potential hinders in their use. From 24 different tools, pharmacists classified 9 as 'appropriate' for pharmacy practice targeted to long-term care patients, while 3 were classified as 'inappropriate'. The tools feature most appreciated by study participants was the indication of alternatives to potentially inappropriate medication. Lack of time and/or pharmacists and limited access to clinical information seems to be the most relevant hinders for prescribing-assessment tools used in daily practice.
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Affiliation(s)
- João R. Gonçalves
- iMed.ULisboa, Social Pharmacy Department, Faculty of Pharmacy, University of Lisbon, 1649-003 Lisboa, Portugal;
| | - Betsy L. Sleath
- Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA;
| | - Manuel J. Lopes
- College of Nursing S. João de Deus, University of Évora, 7000-811 Évora, Portugal;
| | - Afonso M. Cavaco
- iMed.ULisboa, Social Pharmacy Department, Faculty of Pharmacy, University of Lisbon, 1649-003 Lisboa, Portugal;
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Thiruchelvam K, Byles J, Hasan SS, Egan N, Kairuz T. Frailty and potentially inappropriate medications using the 2019 Beers Criteria: findings from the Australian Longitudinal Study on Women's Health (ALSWH). Aging Clin Exp Res 2021; 33:2499-2509. [PMID: 33449339 DOI: 10.1007/s40520-020-01772-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/03/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Frailty is an essential consideration with potentially inappropriate medications (PIMs), especially among older women. AIMS This study determined the use of potentially inappropriate medications according to frailty status using the Beers Criteria 2019, identified medications that should be flagged as potentially inappropriate and harmful depending on individual health factors, and determined the association between frailty and PIMs, adjusted for characteristics associated with PIMs. METHODS This prospective longitudinal study included 9355 participants aged 77-82 years at baseline (2003). Frailty was measured using the FRAIL (fatigue, resistance, ambulation, illness and loss of weight) scale. Generalised estimating equations using log-binomial regressions determined the association between frailty and risk of using PIMs. RESULTS Among participants who were frail and non-frail at baseline, the majority used ≥ 3 PIMs (74.2% and 58.5%, respectively). At 2017, the proportion using ≥ 3 PIMs remained constant in the frail group (72.0%) but increased in the non-frail group (66.0%). Commonly prescribed medications that may be potentially inappropriate in both groups included benzodiazepines, proton-pump inhibitors and non-steroidal anti-inflammatory drugs, and risperidone was an additional contributor in the non-frail group. When adjusted for other characteristics, frail women had a 2% higher risk of using PIMs (RR 1.02; 95% CI 1.01, 1.03). CONCLUSION Given that the majority of frail women were using medications that may have been potentially inappropriate, it is important to consider both frailty and PIMs as indicators of health outcomes, and to review the need for PIMs for women aged 77-96 years who are frail.
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Affiliation(s)
- Kaeshaelya Thiruchelvam
- University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
- International Medical University, 126 Jalan Jalil Perkasa 19, Bukit Jalil, 57000, Kuala Lumpur, Malaysia.
| | - Julie Byles
- University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Priority Research Centre for Generational Health and Ageing, Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
| | - Syed Shahzad Hasan
- University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- University of Huddersfield, Queensgate, Huddersfield, HD1 3DH, UK
| | - Nicholas Egan
- University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Priority Research Centre for Generational Health and Ageing, Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
| | - Therese Kairuz
- University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- International Medical University, 126 Jalan Jalil Perkasa 19, Bukit Jalil, 57000, Kuala Lumpur, Malaysia
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Thiruchelvam K, Byles J, Hasan SS, Kairuz T. Innovating medication reviews through a technology-enabled process. Res Social Adm Pharm 2021; 18:2700-2705. [PMID: 34326004 PMCID: PMC8847068 DOI: 10.1016/j.sapharm.2021.07.019] [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: 03/24/2021] [Revised: 07/06/2021] [Accepted: 07/20/2021] [Indexed: 10/31/2022]
Abstract
Medication reviews are effective in improving the quality of medication use among older people. However, they are conducted to various standards resulting in a wide range of outcomes which limit generalisability of findings arising from research studies. There also appear to be funding and time constraints, lack of data storage for quality improvement purposes, and non-standardised reporting of outcomes, especially clinically relevant outcomes. Furthermore, the coronavirus disease-19 (COVID-19) pandemic has restricted many face-to-face activities, including medication reviews. This article introduces a technology-enabled approach to medication reviews that may overcome some limitations with current medication review processes, and also make it possible to conduct medication reviews during the COVID-19 pandemic by providing an alternate platform. The possible advantages of this technology-enabled approach, legislative considerations and possible implementation in practice are discussed.
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Affiliation(s)
- Kaeshaelya Thiruchelvam
- University of Newcastle, University Drive, Callaghan, New South Wales, 2308, Australia; International Medical University, 126 Jalan Jalil Perkasa 19, Bukit Jalil, 57000, Kuala Lumpur, Malaysia.
| | - Julie Byles
- University of Newcastle, University Drive, Callaghan, New South Wales, 2308, Australia; Priority Research Centre for Generational Health and Ageing, Hunter Medical Research Institute, New Lambton Heights, New South Wales, 2305, Australia.
| | - Syed Shahzad Hasan
- University of Newcastle, University Drive, Callaghan, New South Wales, 2308, Australia; University of Huddersfield, Queensgate, Huddersfield, HD1 3DH, United Kingdom.
| | - Therese Kairuz
- University of Newcastle, University Drive, Callaghan, New South Wales, 2308, Australia; International Medical University, 126 Jalan Jalil Perkasa 19, Bukit Jalil, 57000, Kuala Lumpur, Malaysia.
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11
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Bengaard AK, Iversen E, Kallemose T, Juul-Larsen HG, Rasmussen LJH, Dalhoff KP, Andersen O, Eugen-Olsen J, Houlind MB. Using soluble urokinase plasminogen activator receptor to stratify patients for medication review in the emergency department. Br J Clin Pharmacol 2021; 88:1679-1690. [PMID: 34242432 DOI: 10.1111/bcp.14982] [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: 04/07/2021] [Revised: 06/25/2021] [Accepted: 06/27/2021] [Indexed: 11/30/2022] Open
Abstract
AIMS To investigate whether the association between levels of medication use (including polypharmacy and potentially inappropriate medications [PIMs]) and health outcomes such as readmission and mortality is dependent on baseline soluble urokinase plasminogen activator receptor (suPAR). METHODS This registry-based cohort study included medical patients admitted to the emergency department at Copenhagen University Hospital Hvidovre, Denmark. Patients were grouped according to their admission suPAR levels: low (0-3 ng/mL), intermediate (3-6 ng/mL), or high (>6 ng/mL). Hyper-polypharmacy was defined as ≥10 prescribed medications. PIMs were identified based on the EU(7)-PIM list, and data on admissions and mortality were obtained from national registries. Risk of 90-day readmission and mortality was assessed by Cox regression analysis adjusted for sex, age and Charlson comorbidity index. Results were reported as hazard ratios within 90 days of index discharge. RESULTS In total, 26 291 patients (median age 57.3 y; 52.7% female) were included. Risk of 90-day readmission and mortality increased significantly for patients with higher suPAR or higher number of medications. Among patients with low suPAR, patients with ≥10 prescribed medications had a hazard ratio of 2.41 (95% confidence interval = 2.09-2.78) for 90-day readmission and 8.46 (95% confidence interval = 2.53-28.28) for 90-day mortality compared to patients with 0 medications. Patients with high suPAR generally had high risk of readmission and mortality, and the impact of medication use was less pronounced in this group. Similar, but weaker, association patterns were observed between suPAR and PIMs. CONCLUSION The association between levels of medication use and health outcomes is dependent on baseline suPAR.
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Affiliation(s)
- Anne Kathrine Bengaard
- Department of Clinical Research, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark.,The Capital Region Pharmacy, Herlev, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Esben Iversen
- Department of Clinical Research, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark.,Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Thomas Kallemose
- Department of Clinical Research, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark
| | - Helle Gybel Juul-Larsen
- Department of Clinical Research, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark
| | - Line Jee Hartmann Rasmussen
- Department of Clinical Research, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark.,Department of Psychology and Neuroscience, Duke University, Durham, North Carolina, USA
| | - Kim Peder Dalhoff
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Pharmacology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Ove Andersen
- Department of Clinical Research, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Emergency Department, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark
| | - Jesper Eugen-Olsen
- Department of Clinical Research, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark
| | - Morten Baltzer Houlind
- Department of Clinical Research, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark.,The Capital Region Pharmacy, Herlev, Denmark.,Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
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Roux B, Berthou-Contreras J, Beuscart JB, Charenton-Blavignac M, Doucet J, Fournier JP, de la Gastine B, Gautier S, Gonthier R, Gras V, Grau M, Noize P, Polard E, Rudelle K, Valnet-Rabier MB, Tannou T, Laroche ML. REview of potentially inappropriate MEDIcation pr[e]scribing in Seniors (REMEDI[e]S): French implicit and explicit criteria. Eur J Clin Pharmacol 2021; 77:1713-1724. [PMID: 34115158 DOI: 10.1007/s00228-021-03145-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 04/15/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE To establish a consensus on both explicit and implicit criteria in order to identify potentially inappropriate prescribing (PIP) in French older people aged 75 years and over or 65 years and over with multimorbidity. METHODS Fifteen experts in geriatrics, general practice, pharmacy, and clinical pharmacology were involved in a two-round Delphi survey to assess preliminary explicit and implicit criteria based on an extensive literature review and up-to-date evidence data. Experts were asked to rate their level of agreement using a 5-level Likert scale for inclusion of criteria and also for rationale and therapeutic alternatives. A consensus was considered as reached if at least 75% of the experts rated criteria as "strongly agreed" or "agreed." RESULTS The new tool included a seven-step algorithm (implicit criteria) encompassing the three main domains that define PIP (i.e. overprescribing, underprescribing, and misprescribing) and 104 explicit criteria. Explicit criteria were divided into 6 tables related to inappropriate drug duplications (n = 7 criteria), omissions of medications and/or medication associations (n = 16), medications with an unfavourable benefit/risk ratio and/or a questionable efficacy (n = 39), medications with an unsuitable dose (n = 4) or duration (n = 6), drug-disease (n = 13), and drug-drug interactions (n = 19). CONCLUSION The REMEDI[e]S tool (REview of potentially inappropriate MEDIcation pr[e]scribing in Seniors) is an original mixed tool, adapted to French medical practices, aimed at preventing PIP both at the individual level in clinical practice and the population level in large-scale studies. Therefore, its use could contribute to an improvement in healthcare professionals' prescribing practices and safer care in older adults.
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Affiliation(s)
- Barbara Roux
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Pharmacology Toxicology and Centre of Pharmacovigilance, University Hospital of Limoges, Limoges, France. .,INSERM UMR 1248, Faculty of Medicine, University of Limoges, Limoges, France.
| | - Julie Berthou-Contreras
- Department of Pharmacy, Clinical Pharmacy Unit, University Hospital of Besançon, Besançon, France
| | - Jean-Baptiste Beuscart
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Evaluation des technologies de santé et des pratiques médicales, F-59000, Lille, France
| | | | - Jean Doucet
- Department of Internal Medicine, Geriatrics and Therapeutics, Saint Julien Hospital, Rouen University Hospital, 76031, Rouen Cedex, France
| | - Jean-Pascal Fournier
- Department of General Practice, Faculty of Medicine, University of Nantes, Nantes, France
| | - Blandine de la Gastine
- Geriatric Department, Institut du Vieillissement, Hospices Civils de Lyon, Hôpital Pierre Garraud, Lyon, France
| | - Sophie Gautier
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Medical Pharmacology, University Hospital of Lille, Lille, France
| | - Régis Gonthier
- Département de Gérontologie Clinique, CHU de Saint Etienne, Hôpital de La Charité, 44 rue Pointe Cadet, 42000, Saint-Etienne, France
| | - Valérie Gras
- Centre of Pharmacovigilance, Department of Clinical Pharmacology, University Hospital of Amiens, Amiens, France
| | - Muriel Grau
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Pharmacology Toxicology and Centre of Pharmacovigilance, University Hospital of Limoges, Limoges, France
| | - Pernelle Noize
- Department of Clinical Pharmacology, University Hospital of Bordeaux, Bordeaux, France.,Univ. Bordeaux, INSERM, BPH, U1219, F-33000, Bordeaux, France
| | - Elisabeth Polard
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Medical Pharmacology, University Hospital of Rennes, Rennes, France
| | - Karen Rudelle
- University Department of General Medicine, Faculty of Medicine, Limoges, France
| | - Marie-Blanche Valnet-Rabier
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Medical Pharmacology, University Hospital of Besançon, Besançon, France
| | - Thomas Tannou
- Geriatric Departement, University Hospital of Besançon, Besançon, France
| | - Marie-Laure Laroche
- Centre of Pharmacovigilance and Pharmacoepidemiology, Department of Pharmacology Toxicology and Centre of Pharmacovigilance, University Hospital of Limoges, Limoges, France.,INSERM UMR 1248, Faculty of Medicine, University of Limoges, Limoges, France.,Laboratoire Vie-Santé (Vieillissement Fragilité Prévention, E-Santé), IFR GEIST, Université de Limoges, Limoges, France
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13
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Drug interactions for elderly people with mental and behavioral disorders: a systematic scoping review. Arch Gerontol Geriatr 2020; 93:104283. [PMID: 33227533 DOI: 10.1016/j.archger.2020.104283] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/08/2020] [Accepted: 10/09/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To identify drug interactions of potentially inappropriate medications and mental and behavioral disorders, according to explicit potentially inappropriate medications criteria-based tools. METHODOLOGY A systematic scoping review was conducted in February 2020. Study characteristics, potentially inappropriate medications, drug interactions, rationale, and therapeutic management proposed were extracted. The commercialization and potentially inappropriate medications standard as essential in Brazil and in the world were identified. Therapeutic management was proposed for the most cited potentially inappropriate medications. RESULTS 36 tools including 151 drug interactions, in addition to 132 potentially inappropriate medications with concerns related to six mental and behavioral disorders were identified. Cognitive impairment and dementia were the most frequently disorders reported and antipsychotics, anticholinergics, and benzodiazepines were the pharmacological classes more involved in the drug interactions. Despite the tools recommended risperidone and quetiapine when the use of antipsychotics were inevitable; levodopa + carbidopa for Parkinson's disease; and short and intermediate half-life benzodiazepines; the quality of the evidence needs to be assessed. In this review, sleep hygiene; deprescription; medication review; and clinical monitoring of adverse drug reactions are strongly recommended. In addition, to consider agomelatine, bupropion, moclobemide and melatonin as potential safer options for benzodiazepines. CONCLUSION Knowing the clinical conditions or risk morbidities associated with the use of potentially inappropriate medications and management of these medications for safer therapeutic equivalents or non-pharmacotherapeutic alternatives are relevant for patient safety.
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Barry HE, Hughes CM. Managing medicines in the time of COVID-19: implications for community-dwelling people with dementia. Int J Clin Pharm 2020; 43:275-279. [PMID: 32803555 PMCID: PMC7429133 DOI: 10.1007/s11096-020-01116-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 07/25/2020] [Indexed: 11/25/2022]
Abstract
COVID-19 has changed life beyond recognition for millions of individuals, as countries implement social distancing measures to prevent disease transmission. For certain patient groups, such as community-dwelling older people with dementia (PwD), these restrictions may have far-reaching consequences. Medicines management may be adversely affected and deserves careful thought. PwD face unique challenges with medicines management compared to other older people, often relying upon support from family/carers and primary healthcare professionals. This article considers potential issues that PwD may face with each component of medicines management (prescribing, dispensing, administration, adherence, review), and based on previous research, highlights strategies to support PwD and their carers during this time. Primary healthcare professionals must be attentive to medicines-related needs of community-dwelling PwD, particularly those living alone, both during the pandemic and as restrictions are lifted. Carers of PwD continue to have a critical role to play in medicines management, and also require support.
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Affiliation(s)
- Heather E Barry
- Primary Care Research Group, School of Pharmacy, Medical Biology Centre, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK.
| | - Carmel M Hughes
- Primary Care Research Group, School of Pharmacy, Medical Biology Centre, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK
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15
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Khera S, Abbasi M, Dabravolskaj J, Sadowski CA, Yua H, Chevalier B. Appropriateness of Medications in Older Adults Living With Frailty: Impact of a Pharmacist-Led Structured Medication Review Process in Primary Care. J Prim Care Community Health 2020; 10:2150132719890227. [PMID: 31808725 PMCID: PMC6900606 DOI: 10.1177/2150132719890227] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: Older persons with frailty take multiple medications and
are vulnerable to inappropriate prescribing. Objective: This study
assesses the impact of a team-based, pharmacist-led structured medication review
process in primary care on the appropriateness of medications taken by older
adults living with frailty. Methods: This was a quasi-experimental
pretest-posttest design in 6 primary care practices within an academic clinic in
Edmonton, Alberta, Canada. We enrolled community dwelling older adults 65 years
and older with frailty who have polypharmacy and/or 2 or more chronic conditions
(ie, high-risk group for drug-related issues). The intervention was a structured
pharmacist-led medication review using evidence-based explicit criteria (ie,
Beers and STOPP/START criteria) and implicit criteria (ie, pharmacist expertise)
for potentially inappropriate prescribing, done in the context of a primary care
team-based seniors’ program. We measured the changes in the number of
medications pre- and postmedication review, number of medications satisfying
explicit criteria of START and STOPP/Beers and determined the association with
frailty level. Data were analyzed using descriptive and inferential statistics
(a priori significance level of P < .05).
Results: A total of 54 participants (61.1% females, mean age
81.7 years [SD = 6.74]) enrolled April 2017 to May 2018 and 52 participants
completed the medication review process (2 lost to hospitalization).
Drug-related problems noted on medication review were untreated conditions
(61.1%), inappropriate medications (57.4%), and unnecessary therapy (40.7%). No
significant changes in total number of medications taken by patients before and
after, but the intervention significantly decreased number of inappropriate
medications (1.15 meds pre to 0.9 meds post; P = .006).
Conclusion: A pharmacist-led medication review is a strategy
that can be implemented in primary care to address inappropriate
medications.
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Affiliation(s)
- Sheny Khera
- University of Alberta, Edmonton, Alberta, Canada
| | | | | | | | - Hannah Yua
- Edmonton Oliver Primary Care Network, Edmonton, Alberta, Canada
| | - Bernadette Chevalier
- University of Alberta, Edmonton, Alberta, Canada.,University of Queensland, Brisbane, Queensland, Australia
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16
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Michiels-Corsten M, Gerlach N, Schleef T, Junius-Walker U, Donner-Banzhoff N, Viniol A. Generic instruments for drug discontinuation in primary care: A systematic review. Br J Clin Pharmacol 2020; 86:1251-1266. [PMID: 32216066 PMCID: PMC7319012 DOI: 10.1111/bcp.14287] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 02/14/2020] [Accepted: 02/25/2020] [Indexed: 11/26/2022] Open
Abstract
Aims The aim of this systematic review was to identify generic instruments for drug discontinuation in patients with polypharmacy in the primary care setting. Methods We systematically searched PubMed and EMBASE, 8 guideline databases (AWMF, NICE, NGC, SIGN, NHMRC, CPG, KCE), the Cochrane Library and grey literature (Google) in 2016 and 2017. Two independent researchers screened and analysed data. The drug discontinuation instruments of the included publications were described and classified. Results We identified 16 relevant publications. Here we found complex algorithms as well as instruments composed of distinct sequential steps. Two guidelines are constructed as electronic web‐applications. Instruments revealed diverging emphases on the stages of deprescribing, i.e. preparation, drug evaluation, decision‐making and implementation. Accordingly, 3 types of instruments emerged: general frameworks, detailed drug assessment tools and comprehensive discontinuation guidelines. Conclusion Diverse generic instruments exist for different areas of applications in regard to drug discontinuation. However, there is still a need for practical and user‐friendly tools that support physicians in communicational aspects, visualise trade‐offs and also enhance patient involvement.
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Affiliation(s)
| | - Navina Gerlach
- Department of General Practice/Family Medicine, Philipps University of Marburg, Marburg, Germany
| | - Tanja Schleef
- Institute for General Practice, Hannover Medical School, Hannover, Germany
| | | | - Norbert Donner-Banzhoff
- Department of General Practice/Family Medicine, Philipps University of Marburg, Marburg, Germany
| | - Annika Viniol
- Department of General Practice/Family Medicine, Philipps University of Marburg, Marburg, Germany
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17
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Mino-León D, Sánchez-García S, Giraldo-Rodríguez L, Reyes-Morales H. Potentially inappropriate prescribing to older adults in ambulatory care: prevalence and associated patient conditions. Eur Geriatr Med 2019; 10:639-647. [PMID: 34652727 DOI: 10.1007/s41999-019-00181-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 03/08/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE To analyze potentially inappropriate prescribing (PIP), its prevalence and patient conditions associated with this phenomenon, in a cohort of older adults receiving outpatient care in Mexico. METHODS Data from 1252 adults ≥ 60 years of age, from primary care centers were analyzed. Information included sociodemographic data, medications, chronic diseases, polypharmacy (≥ 5 medications), functional dependence, cognitive impairment and frailty. Three logistic regression models were employed to identify associations between PIP (according to the Beers criteria) and different variable combinations. RESULTS A total of 41.8% of participants had at least one PIP. The most frequently identified PIPs involved nonsteroidal anti-inflammatory drugs (NSAIDs) and glibenclamide; clonazepam in patients with cognitive impairment; and interactions of warfarin with NSAIDs. In the multivariate analyses, Model 1 showed that frailty and polypharmacy were associated with PIP. In Model 2, only polypharmacy was associated with PIP. For Model 3, lower educational levels, taking hypoglycemics, nervous system disease drugs, antiasthmatics, gastrointestinal disease drugs and anti-inflammatories-antirheumatics and analgesics, were associated with PIP. CONCLUSION PIP is common in outpatient treatment of health care services in Mexico. Its association with medical and nonmedical factors highlights the need to improve drug treatment quality focused on implementation of effective strategies, such as educative interventions, electronic medication safety alerts, and inclusion of pharmacists in the health team.
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Affiliation(s)
- Dolores Mino-León
- Clinical Epidemiology Research Unit, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Sergio Sánchez-García
- Epidemiology and Health Services Research Unit, Aging Area, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Liliana Giraldo-Rodríguez
- Research Division, Demographic Epidemiology and Social Determinants Department, Instituto Nacional de Geriatría, Secretaría de Salud, Mexico City, Mexico
| | - Hortensia Reyes-Morales
- Center for Health Systems Research, Instituto Nacional de Salud Pública, Avenida Universidad #655, Santa María Ahuacatitlán, 62100, Cuernavaca, Morelos, Mexico.
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18
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Thiruchelvam K, Wong PS, Kairuz T, Babar ZUD, Hasan SS. Consolidated Medication Review Algorithm to Improve Medications Use in Older Adults: Components, Scoring Scheme, and Implementation. J Am Med Dir Assoc 2018; 19:717-718. [DOI: 10.1016/j.jamda.2018.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 03/10/2018] [Indexed: 10/17/2022]
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Abstract
Avoiding inappropriate polypharmacy has become increasingly recognised as a safety imperative for older patient care. Deprescribing is an active process of reviewing all medications being used by individual patients that prompts clinicians to consider which medications have unfavourable risk-benefit trade-offs in the context of illness severity, advanced age, multi-morbidity, physical and emotional capacity, life expectancy, care goals and personal preferences. Structured guides to deprescribing include algorithms, flow charts or tables which are patient-directed and aim to guide the clinician through sequential steps in deciding which medications should be targeted for discontinuation. In this narrative review, we describe seven structured deprescribing guides whose stated purpose included the reduction of polypharmacy, their use was not restricted to a single drug or drug class and they had undergone some form of efficacy testing. There was considerable heterogeneity in guide design and content, with some guides constituting little more than a set of principles while others entail detailed processes and sub-steps which addressed multiple determinants of drug appropriateness. Evidence of effectiveness for each guide was limited in that none have been evaluated in randomised controlled trials, that pilot or feasibility studies have involved relatively small patient samples, that intra-rater and inter-rater reliabilities have not been determined and that most have been studied in hospital settings. Which is most useful to clinicians is unknown in the absence of head-to-head comparisons. While most guides have face validity, more research is needed for determining effectiveness and ease of use in routine clinical practice, especially in primary care settings.
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Affiliation(s)
- Ian Scott
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.,Centre of Research Excellence in Quality & Safety in Integrated Primary-Secondary Care, School of Medicine, The University of Queensland, Brisbane, Australia
| | - Kristen Anderson
- Centre of Research Excellence in Quality & Safety in Integrated Primary-Secondary Care, School of Medicine, The University of Queensland, Brisbane, Australia
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