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O'Leary CET, Wilkinson TJ, Hanger HC. A comparison of changes in drug burden index between older inpatients who fell and people who have not fallen: A case-control study. Australas J Ageing 2024. [PMID: 38770595 DOI: 10.1111/ajag.13333] [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: 10/31/2023] [Revised: 03/03/2024] [Accepted: 04/28/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVE Older inpatients who fall are often frail, with multiple co-morbidities and polypharmacy. Although the causes of falls are multifactorial, sedating and delirium-inducing drugs increase that risk. The aims were to determine whether people who fell had a change in their sedative and anticholinergic medication burden during an admission compared to people who did not fall. A secondary aim was to determine the factors associated with change in drug burden. METHODS A retrospective, observational, case-control study of inpatients who fell. Two hundred consecutive people who fell were compared with 200 randomly selected people who had not fallen. Demographics, functional ability, frailty and cognition were recorded. For each patient, their total medications and anticholinergic and sedative burden were calculated on admission and on discharge, using the drug burden index (DBI). RESULTS People who fell were more dependent and cognitively impaired than people who did not fallen. People who fell had a higher DBI on admission, than people who had not fall (mean: .69 vs .43, respectively, p < .001) and discharge (.66 vs .38, p < .001). For both cohorts, the DBI decreased between admission and discharge (-.03 and -.05), but neither were clinically significant. Higher total medications and a higher number DBI medications on admission were both associated with greater DBI changes (p = .003 and <.001, respectively). However, the presence (or absence) of cognitive impairment, dependency, frailty and single vs multiple falls were not significantly associated with DBI changes. CONCLUSIONS In older people, DBI medications and falls are both common and have serious consequences, yet this study was unable to demonstrate any clinically relevant reduction in average DBI either in people who fell or people who had not fallen during a hospital admission.
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Affiliation(s)
- Claire E T O'Leary
- Older Persons Health, Te Whatu Ora (Health New Zealand)-Waitaha, Burwood Hospital, Christchurch, New Zealand
| | - Timothy J Wilkinson
- Older Persons Health, Te Whatu Ora (Health New Zealand)-Waitaha, Burwood Hospital, Christchurch, New Zealand
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - H Carl Hanger
- Older Persons Health, Te Whatu Ora (Health New Zealand)-Waitaha, Burwood Hospital, Christchurch, New Zealand
- Department of Medicine, University of Otago, Christchurch, New Zealand
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Turner JP, Newport K, McEvoy AM, Smith T, Tannenbaum C, Kelly DV. Strategies to guide the successful implementation of deprescribing in community practice: Lessons learned from the front line. Can Pharm J (Ott) 2024; 157:133-142. [PMID: 38737354 PMCID: PMC11086729 DOI: 10.1177/17151635241240737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 12/19/2023] [Accepted: 01/25/2024] [Indexed: 05/14/2024]
Abstract
Background Sustainable implementation of new professional services into clinical practice can be difficult. In 2019, a population-wide initiative called SaferMedsNL was implemented across the province of Newfoundland and Labrador (NL), to promote appropriate medication use. Two evidence-based interventions were adapted to the context of NL to promote deprescribing of proton pump inhibitors and sedatives. The objective of this study was to identify and prioritize which actions supported the implementation of deprescribing in community practice for pharmacists, physicians and nurse practitioners across the province. Methods Community pharmacists, physicians and nurse practitioners were invited to participate in virtual focus groups. Nominal Group Technique was used to elicit responses to the question: "What actions support the implementation of deprescribing into the daily workflow of your practice?" Participants prioritized actions within each group while thematic analysis permitted comparison across groups. Results Five focus groups were held in fall 2020 involving pharmacists (n = 11), physicians (n = 7) and nurse practitioners (n = 4). Participants worked in rural (n = 10) and urban (n = 12) settings. The different groups agreed on what the top 5 actions were, with the top 5 receiving 68% of the scores: (1) providing patient education, (2) allocating time and resources, (3) building interprofessional collaboration and communication, (4) fostering patient relationships and (5) aligning with public awareness strategies. Conclusion Pharmacists, physicians and nurse practitioners identified similar actions that supported implementing evidence-based deprescribing into routine clinical practice. Sharing these strategies may help others embed deprescribing into daily practice and assist the uptake of medication appropriateness initiatives by front-line providers. Can Pharm J (Ott) 2024;157:xx-xx.
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Affiliation(s)
- Justin P. Turner
- Centre for Medicines Use and Safety, Memorial University of Newfoundland, Newfoundland and Labrador
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria, Australia; the Faculty of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
- Université de Montréal, Québec; the Centre de recherche, Institut universitaire de gériatrie de Montréal, Memorial University of Newfoundland, Newfoundland and Labrador
- Québec; the Faculté de Pharmacie, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Kelda Newport
- Laval Université, Québec; and the School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Aisling M. McEvoy
- Centre for Medicines Use and Safety, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Tara Smith
- Laval Université, Québec; and the School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Cara Tannenbaum
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria, Australia; the Faculty of Pharmacy and Medicine, Memorial University of Newfoundland, Newfoundland and Labrador
- Université de Montréal, Québec; the Centre de recherche, Institut universitaire de gériatrie de Montréal, Memorial University of Newfoundland, Newfoundland and Labrador
| | - Deborah V. Kelly
- Laval Université, Québec; and the School of Pharmacy, Memorial University of Newfoundland, Newfoundland and Labrador
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Robinson M, Mokrzecki S, Mallett AJ. Attitudes and barriers towards deprescribing in older patients experiencing polypharmacy: a narrative review. NPJ AGING 2024; 10:6. [PMID: 38263176 PMCID: PMC10806180 DOI: 10.1038/s41514-023-00132-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 11/28/2023] [Indexed: 01/25/2024]
Abstract
Polypharmacy, commonly defined as ≥5 medications, is a rising public health concern due to its many risks of harm. One commonly recommended strategy to address polypharmacy is medication reviews, with subsequent deprescription of inappropriate medications. In this review, we explore the intersection of older age, polypharmacy, and deprescribing in a contemporary context by appraising the published literature (2012-2022) to identify articles that included new primary data on deprescribing medications in patients aged ≥65 years currently taking ≥5 medications. We found 31 articles were found which describe the current perceptions of clinicians towards deprescribing, the identified barriers, key enabling factors, and future directions in approaching deprescribing. Currently, clinicians believe that deprescribing is a complex process, and despite the majority of clinicians reporting feeling comfortable in deprescribing, fewer engage with this process regularly. Common barriers cited include a lack of knowledge and training around the deprescribing process, a lack of time, a breakdown in communication, perceived 'abandonment of care', fear of adverse consequences, and resistance from patients and/or their carers. Common enabling factors of deprescribing include recognition of key opportunities to instigate this process, regular medication reviews, improving lines of communication, education of both patients and clinicians and a multidisciplinary approach towards patient care. Addressing polypharmacy requires a nuanced approach in a generally complex group of patients. Key strategies to reducing the risks of polypharmacy include education of patients and clinicians, in addition to improving communication between healthcare providers in a multidisciplinary approach.
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Affiliation(s)
- Michael Robinson
- Townsville Institute of Health Research and Innovation, Townsville University Hospital, Douglas, QLD, Australia
- College of Medicine and Dentistry, James Cook University, Douglas, QLD, Australia
| | - Sophie Mokrzecki
- Townsville Institute of Health Research and Innovation, Townsville University Hospital, Douglas, QLD, Australia
- College of Medicine and Dentistry, James Cook University, Douglas, QLD, Australia
- Department of Pharmacy, Townsville University Hospital, Douglas, QLD, Australia
| | - Andrew J Mallett
- Townsville Institute of Health Research and Innovation, Townsville University Hospital, Douglas, QLD, Australia.
- College of Medicine and Dentistry, James Cook University, Douglas, QLD, Australia.
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, Australia.
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Sibille FX, de Saint-Hubert M, Henrard S, Aubert CE, Goto NA, Jennings E, Dalleur O, Rodondi N, Knol W, O'Mahony D, Schwenkglenks M, Spinewine A. Benzodiazepine Receptor Agonists Use and Cessation Among Multimorbid Older Adults with Polypharmacy: Secondary Analysis from the OPERAM Trial. Drugs Aging 2023; 40:551-561. [PMID: 37221407 DOI: 10.1007/s40266-023-01029-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Benzodiazepine receptor agonists (BZRAs) are commonly prescribed in older adults despite an unfavorable risk-benefit ratio. Hospitalizations may provide a unique opportunity to initiate BZRA cessation, yet little is known about cessation during and after hospitalization. We aimed to measure the prevalence of BZRA use before hospitalization and the rate of cessation 6 months later, and to identify factors associated with these outcomes. METHODS We conducted a secondary analysis of a cluster randomized controlled trial (OPtimising thERapy to prevent Avoidable hospital admissions in the Multimorbid elderly [OPERAM]), comparing usual care and in-hospital pharmacotherapy optimization in adults aged 70 years or over with multimorbidity and polypharmacy in four European countries. BZRA cessation was defined as taking one or more BZRA before hospitalization and not taking any BZRA at the 6-month follow-up. Multivariable logistic regression was performed to identify factors associated with BZRA use before hospitalization and with cessation at 6 months. RESULTS Among 1601 participants with complete 6-month follow-up data, 378 (23.6%) were BZRA users before hospitalization. Female sex (odds ratio [OR] 1.52 [95% confidence interval 1.18-1.96]), a higher reported level of depression/anxiety (OR up to 2.45 [1.54-3.89]), a higher number of daily drugs (OR 1.08 [1.05-1.12]), use of an antidepressant (OR 1.74 [1.31-2.31]) or an antiepileptic (OR 1.46 [1.02-2.07]), and trial site were associated with BZRA use. Diabetes mellitus (OR 0.60 [0.44-0.80]) was associated with a lower probability of BZRA use. BZRA cessation occurred in 86 BZRA users (22.8%). Antidepressant use (OR 1.74 [1.06-2.86]) and a history of falling in the previous 12 months (OR 1.75 [1.10-2.78]) were associated with higher BZRA cessation, and chronic obstructive pulmonary disease (COPD) (OR 0.45 [0.20-0.91]) with lower BZRA cessation. CONCLUSION BZRA prevalence was high among included multimorbid older adults, and BZRA cessation occurred in almost a quarter of them within 6 months after hospitalization. Targeted BZRA deprescribing programs could further enhance cessation. Specific attention is needed for females, central nervous system-acting co-medication, and COPD co-morbidity. REGISTRATION ClinicalTrials.gov identifier: NCT02986425. December 8, 2016.
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Affiliation(s)
- François-Xavier Sibille
- Department of Geriatric Medicine, CHU UCL Namur, Avenue Dr Gaston Therasse, 1, 5530, Yvoir, Belgium.
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium.
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium.
| | - Marie de Saint-Hubert
- Department of Geriatric Medicine, CHU UCL Namur, Avenue Dr Gaston Therasse, 1, 5530, Yvoir, Belgium
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
| | - Séverine Henrard
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
| | - Carole Elodie Aubert
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Namiko Anna Goto
- Department of Geriatric Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Emma Jennings
- Department of Medicine, School of Medicine, University College Cork, Cork, Republic of Ireland
| | - Olivia Dalleur
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
- Department of Pharmacy, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Wilma Knol
- Department of Geriatric Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Denis O'Mahony
- Department of Medicine, School of Medicine, University College Cork, Cork, Republic of Ireland
| | | | - Anne Spinewine
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
- Department of Pharmacy, CHU UCL Namur, Yvoir, Belgium
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Muhandiramge J, Dev T, Kong J, Hall K, Wadhwa V. In‐hospital deprescribing in the real world – a clinician‐led approach to hyperpolypharmacy. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2023. [DOI: 10.1002/jppr.1844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Jaidyn Muhandiramge
- Faculty of Medicine, Nursing and Health Sciences Monash University Melbourne Australia
- Austin Health Heidelberg, Melbourne Australia
- Eastern Health Clinical School Monash University & Deakin University Melbourne Australia
| | - Tara Dev
- Faculty of Medicine, Nursing and Health Sciences Monash University Melbourne Australia
- Eastern Health Clinical School Monash University & Deakin University Melbourne Australia
| | - Jason Kong
- Department of General Medicine Maroondah Hospital, Eastern Health Melbourne Australia
| | - Kylie Hall
- Department of General Medicine Maroondah Hospital, Eastern Health Melbourne Australia
| | - Vikas Wadhwa
- Eastern Health Clinical School Monash University & Deakin University Melbourne Australia
- Department of General Medicine Maroondah Hospital, Eastern Health Melbourne Australia
- Rural Clinical School University of Melbourne Shepparton Australia
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Scott IA, Reeve E, Hilmer SN. Establishing the worth of deprescribing inappropriate medications: are we there yet? Med J Aust 2022; 217:283-286. [PMID: 36030510 DOI: 10.5694/mja2.51686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/14/2022] [Accepted: 06/21/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Ian A Scott
- Princess Alexandra Hospital, Brisbane, QLD
- University of Queensland, Brisbane, QLD
| | | | - Sarah N Hilmer
- Royal North Shore Hospital, Sydney, NSW
- University of Sydney, Sydney, NSW
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