Managing sleep problems using non-prescription medications and the role of community pharmacists: older adults' perspectives

Conceptualizing Sleep Satisfaction: A Rapid Review

Good, satisfying, sleep is a key indicator and determinant of health and wellness. However, there is no consensus about how to define and measure good sleep. The present research aimed to define sleep satisfaction through the extant literature and disentangle it from sleep quality, a conceptually similar construct. Systematic review methods were adapted for a rapid review approach. The entire review was completed in eight weeks. Tabulation coding with content analysis was used to identify key categories and synthesize findings. A systematic process for generating construct definitions was followed. Database search yielded 51 eligible studies (N > 218,788), representing diverse adult populations, in 20 countries. Designs varied in rigour. Sleep satisfaction was defined as a personal, introspective, and global judgment about one's feelings of contentment with one's sleep, at a particular point in time. Sleep satisfaction was understood as an indicator of general health, impacted by and varied as a function of one's sleep environment and individual-level characteristics. This rapid review contributes to the literature by providing the first systematically generated definition of sleep satisfaction, with strong implications for measurement, research, and practice.

Using Protection Motivation Theory to develop a survey of over-the-counter decision-making by older adults

BACKGROUND

Older adults (aged 65+) are responsible for 30% of the over-the-counter (OTC) medication use in the US. Each year, over 175,000 older adults are hospitalized due to OTC-related adverse drug events (ADEs). A major barrier to improving OTC use has been the dearth of actionable research on factors that affect older adult decision-making during OTC selection. Risk perception and health literacy are two such factors known to impact health behavior. However, to date no studies have characterized risk perceptions of OTCs nor how they relate to health literacy in the decision-making processes of older adults.

OBJECTIVE

This paper presents the development and validation of a survey instrument to measure older adults' risk perception toward over-the-counter medications. The survey also explores the relation of risk perception to health literacy efficacy.

METHODS

The Protection Motivation Theory (PMT) and the Tripartite Risk Perception Model (TRIRISK model) formed the basis for conceptualizing relationships between this study's constructs of interest. The utility of the PMT and the TRIRISK model in the context of OTC medication safety was tested in a survey of 103 older adults; exploratory factor analysis (EFA) and Spearman's correlation coefficients were used to test construct validity.

RESULTS

The EFA yielded a 4-factor model of protection motivation, which included deliberative risk perception, emotional risk perception, perceived threat severity, and perceived coping efficacy. The EFA-based item reduction resulted in a final 14-item OTC Protection Motivation survey.

CONCLUSION

The survey generated through this study is a tool for characterizing older adult risk perceptions of OTCs. The development of a measure of OTC risk perceptions is a promising step toward designing and evaluating patient-centered interventions to improve older adult medication safety.

Pharmacists' Counseling and Benzodiazepines Dispensing for Sleep Disorders: A Simulated Patient Study in Iran

Objective

Sleep is critical for good health and quality of life, but many people struggle with sleep disorders. Pharmacists are on the front lines, helping patients manage these problems. However, there is growing concern that some pharmacists are dispensing benzodiazepines over-the-counter and failing to provide proper counseling. This study examined how pharmacists in Iran performed in these areas.

Methods

Between January and April 2022, we conducted a cross-sectional study in three major Iranian cities, using a "simulated patient" to observe how pharmacists interacted with them. In total, 431 pharmacies participated, and we used detailed forms to record the pharmacists' behavior. We then analyzed the data using descriptive statistics and the Chi-square tests.

Findings

Of 549 visits, 78.5% were managed by pharmacists, whereas the remainder were managed by other pharmacy staff. 79.7% of pharmacists evaluated the patient before deciding whether or not to prescribe the medication and 58.9% provided a kind of counseling for their offered medication, but just 10.6% of pharmacies had a private counseling area. Despite regulations that require a valid prescription for benzodiazepines, 9.2% of pharmacies dispensed diazepam, and 13.2% dispensed alprazolam without requesting one, and when counseling was offered, it often lacked critical details.

Conclusion

These findings raise serious concerns. There are deficiencies in how pharmacists and patients interact, with many pharmacists spending minimal time assessing patient needs. The high rates of benzodiazepine dispensing without valid prescriptions and inadequate counseling point to a need for stricter protocols and more training. To address these issues, health-care professionals and policymakers must collaborate to improve the quality and safety of sleep disorder treatment in community pharmacies.

Pharmacists' perspectives and attitudes towards the 2021 down-scheduling of melatonin in Australia using the Theoretical Domains Framework: a mixed-methods study

BACKGROUND

In Australia, prescription melatonin became a 'Pharmacist Only Medicine' for people over 55 with insomnia from June 2021. However, little is known about pharmacists' views on melatonin down-scheduling and perceived impacts on practice.

AIM

To explore Australian community pharmacists' views on and attitudes towards the down-scheduling of melatonin.

METHOD

A convenience sample of community pharmacists and pharmacy interns were recruited. Participants completed a survey capturing demographic and professional practice details, and rated their knowledge, beliefs and attitudes towards melatonin. This was followed by an online semi-structured interview. Interviews were guided by a schedule of questions developed using the Theoretical Domains Framework and explored the perceived role of melatonin, preparation/response to down-scheduling, practice changes and patient interactions. Interviews continued until data saturation and were digitally recorded, transcribed verbatim and analysed using the Framework Approach.

RESULTS

Twenty-four interviews were conducted with community pharmacists (n = 19) and intern pharmacists (n = 5), all practicing in metropolitan areas. Pharmacists/intern pharmacists welcomed the increased accessibility of melatonin for patients. However, pharmacists perceived a disconnect between the guidelines, supply protocols and pack sizes with practice, making it difficult to monitor patient use of melatonin. The miscommunication of eligibility also contributed to patient-pharmacist tension when supply was denied. Importantly, most participants indicated their interest in upskilling their knowledge in melatonin use in sleep, specifically formulation differences and dosage titration.

CONCLUSION

While pharmacists welcomed the down-scheduling of melatonin, several challenges were noted, contributing to pharmacist-patient tensions in practice. Findings highlight the need to refine and unify melatonin supply protocols and amend pack sizes to reflect guideline recommendations as well as better educating the public about the risk-benefits of melatonin.

Elevating Safe Use of Over-The-Counter Medications in Older Adults: A Narrative Review of Pharmacy Involved Interventions and Recommendations for Improvement

Over-the-counter (OTC) medications are products that have been made easily accessible to allow patients to treat common ailments without a prescription and the cost of a doctor's visit. These medications are generally considered safe; however, there is still a potential for these medications to lead to adverse health outcomes. Older adults (ages 50+) are especially susceptible to these adverse health outcomes, due to age-related physiological changes, a higher prevalence of comorbidities, and prescription medication use. Many OTC medications are sold in pharmacies, which provides pharmacists and technicians with the opportunity to help guide safe selection and use for these medications. Therefore, community pharmacies are the ideal setting for OTC medication safety interventions. This narrative review summarizes the findings of pharmacy-involved interventions that promote safe OTC medication use for older adults.

Prevalence of self-medication among the elderly: A systematic review and meta-analysis

BACKGROUND

Self-medication is the use of unprescribed drugs to treat a disease. Elderly self-medication can be more dangerous compared to other age groups because of changes in organ functions that occur due to senescence. This study aimed to estimate the prevalence of self-medication in the elderly, its related factors, and common drugs used in this regard.

MATERIALS AND METHODS

Electronic databases such as PubMed, Scopus, and Web of Science were searched between January 2016 and June 2021. The search strategy was built on two core concepts: "self-medication" and "aged". The search was limited to original articles in the English language. A random effect model was used to estimate the pooled prevalence of self-medication. Heterogeneity among studies was assessed using both the I² statistic and the χ ² test. Also, a meta-regression model was used to investigate the potential sources of heterogeneity of the studies.

RESULTS

Out of 520 non-duplicate studies, 38 were included in the meta-analysis. Self-medication in the elderly ranged from 0.3% to 82%. The pooled proportion of self-medication was 36% (95% CI: 27%-45%). The result of the χ ² test and the I² index (P < 0.001, I²= 99.90%) revealed notable heterogeneity among the included studies in the meta-analysis. The meta-regression showed a significant association between the sample size (adjusted β = -0.01; P = 0.043) and the pooled proportion of self-medication.

CONCLUSION

The prevalence of self-medication in the elderly is high. Education through mass media to raise awareness about the dangers of self-medication can help solve this problem.

Insomnia Is Not a Normal Part of Aging: The Challenges of Safely and Effectively Managing Insomnia in Older People

Almost everyone has sleep problems from time to time, and often, simple nonpharmacologic interventions can improve sleep hygiene. When nonpharmacologic interventions fail, patients often request and may even require treatment with hypnotics. Insomnia is a heterogeneous disorder. Patients with insomnia may have trouble falling asleep, staying asleep, or waking too early. Sleep disturbances are especially common in older people because of changes in sleep architecture. Though this population may benefit from hypnotics to improve sleep, these drugs increase the risk of polypharmacy, drug interactions, and adverse drug effects, such as falls and cognitive impairment. Pharmacists must consider patient-specific factors to ensure older patients who require hypnotics receive an appropriate drug for an appropriate duration.

Experience of Patients with COPD of Pharmacists' Provided Care: A Qualitative Study

Chronic obstructive pulmonary disease (COPD) is associated with high global morbidity and mortality. Pharmacists are uniquely positioned to provide services which may reduce the burden of this disease on the health system, patients, and their families. The study aimed to understand the perceptions and experiences of patients living with COPD with pharmacists’ provided care in COPD diagnosis and management. The study was guided by qualitative description methodology and reported using the consolidated criteria for reporting qualitative research (COREQ) checklist. We conducted semi-structured interviews with 12 participants who were recruited from community pharmacies, seniors’ centres, a general practice clinic, and a pulmonary rehabilitation centre. Using qualitative content analysis, we identified categories that revealed great variation in participants’ experience of pharmacy care based on the depth of patient–pharmacist engagement. Participants who regarded their pharmacists as an essential member of their healthcare team and those who did not, had contrasting experiences with education, communication, and ability to form connections with their pharmacists. For patients with COPD, it is important that the pharmacist is proactive in engaging patients through effective communication, education/provision of relevant information, identification of patient needs, and consistent provision of care with empathy.

A Systematic Review of the Efficacy and Safety of Over-the-Counter Medications Used in Older People for the Treatment of Primary insomnia

OBJECTIVE: The purpose of this systematic review is to evaluate the available evidence for safety and efficacy of over-the-counter (OTC) sleep aids used for the treatment of insomnia in older people.<br/> DATA SOURCES: PubMed, EBSCO, and International Pharmaceutical Abstracts.<br/> STUDY SELECTION: Five studies were included that involved humans 65 years of age and older being evaluated on OTC sleep aids in the outpatient setting.<br/> DATA EXTRACTION: Data extraction from each study included primary and secondary efficacy endpoints, such as differences in the mean total sleep time, sleep latency, sleep efficiency, and number of awakenings, along with safety endpoints, such as psychomotor ability, cognitive ability, and adverse effect profiles. Both subjective and objective measures of changes in sleep and adverse effects were included.<br/> DATA SYNTHESIS: Diphenhydramine had a statistically significant increase in sedation and decrease in number of awakenings but was not shown to be any less or more safe than compared products. Despite lacking safety issues, valerian was found to have no effect on subjective or objective sleep outcomes. Overall, melatonin had the most evidence and was found to have a statistically significant positive impact on sleep measures without safety issues.<br/> CONCLUSION: Diphenhydramine and melatonin appear to be efficacious in improving some sleep measures while causing minimal adverse effects. However, there are very few studies that examine the use of over-the-counter sleep aids in those 65 years of age and older with primary insomnia. Additional studies are needed in this population.

Bioavailability of Triprolidine as a Single Agent or in Combination With Pseudoephedrine: A Randomized, Open-Label Crossover Study in Healthy Volunteers

Antihistamines have been in clinical use for more than 70 years to treat allergic and nonallergic symptoms including relief from cold and flu symptoms. Despite their widespread use, pharmacokinetic (PK) data are sparse for older, first-generation antihistamines. This phase 1 single-center open-label, randomized, single-dose, 3-way crossover trial evaluated the PK profiles of 2 doses of film-coated triprolidine caplets (2.5 and 5 mg) compared with a reference combination tablet (triprolidine 2.5 mg + pseudoephedrine 60 mg) in 24 healthy adults. Blood samples were collected predose and at specified intervals across a 24-hour period after administration, and triprolidine was quantified using liquid chromatography-tandem mass spectrometry. Maximum plasma concentration of triprolidine for the 2.5 mg and dose-normalized 5 mg single-agent tablets were comparable (8.4 versus 7.1 ng/mL, respectively) and higher for the combination tablet (9.5 ng/mL). PK parameters, including time to maximum plasma concentration (∼1.5 hours) and elimination half-life (∼4 hours), were comparable between the 3 treatment arms. The safety profile of this sedating antihistamine was as expected; however, adverse effects were reported in a markedly higher proportion of women than men. There were no significant sex differences in any of the measured PK parameters.

Cannabis Expectancies for Sleep

Up to 35% of adults in the United States suffer from sleep disturbances, which covary with a host of negative mental and physical health outcomes. Previous research suggests that cannabis' sedative effects may be associated with improved sleep. The present study examined the self-reported effect of cannabis use on individual's sleep-related problems. Participants included 311 individuals recruited online, who reported both sleep-related problems and cannabis use. Analyses revealed that participants expected cannabis to decrease the incidence of sleep-related problems, including allowing participants to have an earlier bedtime, to fall asleep more quickly, and to have a longer night's sleep. Moreover, expectancies about the influence of cannabis on sleep negatively covaried with cannabis-related problems. These findings suggest that individuals believe using cannabis might positively influence their sleep quality and believing so may be protective against cannabis problems. Randomized control trials of cannabis for insomnia appear justified.

Exploring how pharmacists engage with patients about over-the-counter medications

OBJECTIVE

This study used an innovative information-gathering approach to provide insight into the nature and structure of pharmacy staff encounters with patients seeking over-the-counter (OTC) medications and revealed specific activities of pharmacy staff around these encounters.

METHODS

A multistep process was used to develop and standardize an 8-item OTC Encounter Form to document the characteristics of pharmacy staff-patient encounters. The OTC Form contained several domains, including topics discussed and the problems or symptoms identified during the encounter, staff functions during the encounter, and approximate time spent with the patient. Nine pharmacists and 8 technicians used the OTC Form to document patient encounters over 7 consecutive days. Frequency distributions for each OTC Form item are reported.

RESULTS

One hundred eleven OTC Forms were completed. Adults aged 65 years or older were involved in 46% of all encounters. Pharmacists provided the only assistance in 41% of encounters and worked in partnership with other pharmacy staff for another 25% of encounters. Many encounters required the pharmacy staff to leave the prescription department, involved discussions about a variety of problems or symptoms, and lasted less than 3 minutes. Although the most prevalent encounter topic was locations of a particular product, about one-third of encounters involved either recommendations about a product or providing information about a product, and 41% involved communications about 2 or more topics. Finally, 11% of encounters generated a nondrug recommendation, and 8% resulted in a referral to a physician.

CONCLUSION

Pharmacists play a key role in ensuring that the benefits of OTC medications outweigh the risks, thereby providing an important resource for patient engagement about safe medication selection and use. Examining the features of OTC encounters creates an evidence base to promote best practices for OTC encounters, increasing pharmacists' ability to help people, especially older adults, navigate the intricacies of OTC medication use, without significantly increasing pharmacy staff workload.

Preferences and attitudes of older adults of Bialystok, Poland toward the use of over-the-counter drugs

Purpose

The aim of the study was to assess preferences and attitudes toward the use of over-the-counter (OTC) drugs among residents of Bialystok aged 60 or older.

Patients and methods

The study included 170 people, inhabitants of Bialystok aged over 60: 85 students of the University of a Healthy Senior and the University of Psychogeriatric Prophylaxis, and 85 students of the University of the Third Age in Bialystok. The study made use of a diagnostic survey conducted via a questionnaire prepared by the authors.

Results

The vast majority of respondents bought OTC drugs for own use. About one-third of the respondents from each analyzed group bought OTC drugs less often than once every 3 months. Over half of the respondents bought OTC drugs due to a cold. A majority of the respondents were of the opinion that OTC drugs should be sold only in pharmacies. Over 40% of seniors took 1 OTC drug regularly. Most respondents also took vitamins and supplements. The main sources of information on OTC drugs for the studied seniors were their doctor and pharmacist. Respondents did not always consult the treatment method with a doctor or pharmacist. Over half of the respondents familiarized themselves with the contents of the OTC drug package leaflet. Over three-quarters of the respondents were familiar with drug disposal methods; however, despite declarations of being familiar with these principles, a significant percentage did not bring back medication to a pharmacy or clinic, or threw the drugs into the trash.

Conclusion

Our study found that in our sample there were many OTC drug consumers who did not always demonstrate responsible attitudes toward using this group of drugs. Thus, older people should be educated on the possible adverse effects of taking OTC drugs without consulting a doctor or pharmacist as well as basic drug disposal principles. Furthermore, legislation should be introduced that will limit the wide availability of OTC drugs, particularly to the elderly; and thus, lower the costs of hospitalization and outpatient treatment of this age group. Also, a wider-reaching study should be conducted. It should include a larger group of elderly people as well as information on intake of prescribed medications in order to be able to determine the frequency of drug consumption in this population, as well as seniors' preferences and attitudes in this regard.

Change of sleep quality from pre- to 3 years post-solid organ transplantation: The Swiss Transplant Cohort Study

BACKGROUND

Poor sleep quality (SQ) is common after solid organ transplantation; however, very little is known about its natural history. We assessed the changes in SQ from pre- to 3 years post-transplant in adult heart, kidney, liver and lung recipients included in the prospective nation-wide Swiss Transplant Cohort Study. We explored associations with selected variables in patients suffering persistent poor SQ compared to those with good or variable SQ.

METHODS

Adult single organ transplant recipients enrolled in the Swiss Transplant Cohort Study with pre-transplant and at least 3 post-transplant SQ assessment data were included. SQ was self-reported pre-transplant (at listing), then at 6, 12, 24 and 36 months post-transplant. A single SQ item was used to identify poor (0-5) and good sleepers (6-10). Between organ groups, SQ was compared via logistic regression analysis with generalized estimating equations. Within the group reporting persistently poor SQ, we used logistic regression or Kaplan-Meier analysis as appropriate to check for differences in global quality of life and survival.

RESULTS

In a sample of 1173 transplant patients (age: 52.1±13.2 years; 65% males; 66% kidney, 17% liver, 10% lung, 7% heart) transplanted between 2008 and 2012, pre- transplant poor SQ was highest in liver (50%) and heart (49%) recipients. Overall, poor SQ decreased significantly from pre-transplant (38%) to 24 months post-transplant (26%) and remained stable at 3 years (29%). Patients reporting persistently poor SQ had significantly more depressive symptomatology and lower global quality of life.

CONCLUSION

Because self-reported poor SQ is related to poorer global quality of life, these results emphasize the need for further studies to find suitable treatment options for poor SQ in transplant recipients.