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Kummer I, Reissigová J, Lukačišinová A, Ortner Hadžiabdić M, Stuhec M, Liperoti R, Finne-Soveri H, Onder G, van Hout H, Fialová D. Polypharmacy and potentially inappropriate prescribing of benzodiazepines in older nursing home residents. Ann Med 2024; 56:2357232. [PMID: 38833339 DOI: 10.1080/07853890.2024.2357232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 04/30/2024] [Indexed: 06/06/2024] Open
Abstract
INTRODUCTION Previous research has raised concerns about high prevalence of drug-related problems, polypharmacy and inappropriate benzodiazepine prescribing in nursing homes (NHs) and confirmed lack of studies from Central and South-Eastern Europe. The aim of our study was to determine the prevalence and characteristics of polypharmacy, hyperpolypharmacy and inappropriate benzodiazepine prescribing in NH residents in Croatia. METHODS Data from 226 older NH residents from five Croatian NHs were collected using the InterRAI Long-Term Care Facilities assessment form. The prevalence and determinants of polypharmacy/hyperpolypharmacy and patterns of inappropriate benzodiazepine prescribing were documented. RESULTS The prevalence of polypharmacy (49.6%) and hyperpolypharmacy (25.7%) among NH residents was high. In our study, 72.1% of NH residents were prescribed at least one psychotropic agent, 36.7% used 2-3 psychotropics and 6.6% used 4+ psychotropics. Among benzodiazepine users (55.8%), 28% of residents were prescribed benzodiazepines in higher than recommended geriatric doses, 75% used them for the long term and 48% were prescribed concomitant interacting medications. The odds of being prescribed polypharmacy/hyperpolypharmacy were significantly higher for older patients with polymorbidity (6+ disorders, proportional odds ratio (POR) = 19.8), type II diabetes (POR = 5.2), ischemic heart disease (POR = 4.6), higher frailty (Clinical Frailty Scale (CFS ≥5); POR = 4.3) and gastrointestinal problems (POR = 4.8). CONCLUSIONS Our research underscores the persistent challenge of inappropriate medication use and drug-related harms among older NH residents, despite existing evidence and professional campaigns. Effective regulatory and policy interventions, including the implementation of geriatrician and clinical pharmacy services, are essential to address this critical issue and ensure optimal medication management for vulnerable NH populations.
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Affiliation(s)
- Ingrid Kummer
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, The Czech Republic
| | - Jindra Reissigová
- Department of Statistical Modelling, Institute of Computer Science of the Czech Academy of Sciences, Prague, The Czech Republic
| | - Anna Lukačišinová
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, The Czech Republic
| | - Maja Ortner Hadžiabdić
- Center for Applied Pharmacy, Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
| | - Matej Stuhec
- Department of Pharmacology, Faculty of Medicine Maribor, University of Maribor, Maribor, Slovenia
- Department of Clinical Pharmacy, Ormoz Psychiatric Hospital, Ormoz, Slovenia
| | - Rosa Liperoti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Graziano Onder
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Hein van Hout
- Departments of General Practice and Medicine for Older People, Amsterdam University Medical Center, location Vrije Universiteit, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Daniela Fialová
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, The Czech Republic
- Department of Geriatrics and Gerontology, 1st Faculty of Medicine, Charles University, Prague, The Czech Republic
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Talwar A, Chatterjee S, Sherer J, Abughosh S, Johnson M, Aparasu RR. Cumulative Anticholinergic Burden and its Predictors among Older Adults with Alzheimer's Disease Initiating Cholinesterase Inhibitors. Drugs Aging 2024; 41:339-355. [PMID: 38467994 DOI: 10.1007/s40266-024-01103-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Cumulative anticholinergic burden refers to the cumulative effect of multiple medications with anticholinergic properties. However, concomitant use of cholinesterase inhibitors (ChEIs) and anticholinergic burden can nullify the benefit of the treatment and worsen Alzheimer's disease (AD). A literature gap exists regarding the extent of the cumulative anticholinergic burden and associated risk factors in AD. Therefore, this study evaluated the prevalence and predictors of cumulative anticholinergic burden among patients with AD initiating ChEIs. METHODS A retrospective longitudinal cohort study was conducted using the Medicare claims data involving parts A, B, and D from 2013 to 2017. The study sample included older adults (65 years and older) diagnosed with AD and initiating ChEIs (donepezil, rivastigmine, or galantamine). The cumulative anticholinergic burden was calculated based on the Anticholinergic Cognitive Burden scale and patient-specific dosing using the defined daily dose over the 1 year follow-up period after ChEI initiation. Incremental anticholinergic burden levels were dichotomized into moderate-high (sum of standardized daily anticholinergic exposure over a year (TSDD) score ≥ 90) versus low-no (score 0-89). The Andersen Behavioral Model was used as the conceptual framework for selecting the predictors under the predisposing, enabling, and need categories. A multivariable logistic regression model was used to evaluate the predictors of high-moderate versus low-no cumulative anticholinergic burden. A multinomial logistic regression model was also used to determine the factors associated with patients having moderate and high burdens compared to low/no burdens. RESULTS The study included 222,064 older adults with AD with incident ChEI use (mean age 82.24 ± 7.29, 68.9% females, 83.6% White). Overall, 80.48% had some anticholinergic burden during the follow-up, with 36.26% patients with moderate (TSDD scores 90-499), followed by 24.76% high (TSDD score > 500), and 19.46% with low (TSDD score 1-89) burden categories. Predisposing factors such as age; African American, Asian, or Hispanic race; and need factors included comorbidities such as dyslipidemia, syncope, delirium, fracture, pneumonia, epilepsy, and claims-based frailty index were less likely to be associated with the moderate-high anticholinergic burden. The factors that increased the odds of moderate-high burden were predisposing factors such as female sex; enabling factors such as dual eligibility and diagnosis year; and need factors such as baseline burden, behavioral and psychological symptoms of dementia, depression, insomnia, urinary incontinence, irritable bowel syndrome, anxiety, muscle spasm, gastroesophageal reflux disease, heart failure, and dysrhythmia. Most of these findings remained consistent with multinomial logistic regression. CONCLUSION: Four out of five older adults with AD had some level of anticholinergic burden, with over 60% having moderate-high anticholinergic burden. Several predisposing, enabling, and need factors were associated with the cumulative anticholinergic burden. The study findings suggest a critical need to minimize the cumulative anticholinergic burden to improve AD care.
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Affiliation(s)
- Ashna Talwar
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX, USA
| | | | - Jeffrey Sherer
- Department of Pharmacy Practice and Translational Research, College of Pharmacy, University of Houston, Houston, TX, USA
| | - Susan Abughosh
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX, USA
| | - Michael Johnson
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX, USA
| | - Rajender R Aparasu
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX, USA.
- Department of Pharmaceutical Health Outcomes and Policy, Adjunct Professor of Geriatrics, UTHealth McGovern Medical School, Health and Biomedical Sciences Building 2 - Office 4052, College of Pharmacy, University of Houston, 4349 Martin Luther King Boulevard, Houston, TX, 77204-5047, USA.
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Vandergrift JL, Weng W, Leff B, Gray BM. Geriatricians, general internists, and potentially inappropriate medications for a national sample of older adults. J Am Geriatr Soc 2024; 72:37-47. [PMID: 37350649 DOI: 10.1111/jgs.18489] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 05/22/2023] [Accepted: 05/30/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Older adults are often prescribed medications that are potentially dangerous and geriatricians have specialized training in treating polypharmacy that may benefit these patients. To examine this, we compared potentially inappropriate medication (PIM) prescribing rates between geriatricians and similar general internists in the United States. METHODS Using national cross-sectional data from 2013 to 2019, we compared annual PIM prescribing rates between 2815 outpatient geriatricians certified by the American Board of Internal Medicine in 1994-2018 and general internists matched 1:1 on IM certification exam score and year, residency exam pass rate, gender, and US birth and/or US medical school. PIM prescribing was based on the Healthcare Effectiveness Data and Information Set (HEDIS) PIM physician annual prescribing measures which consider medications flagged as potentially inappropriate in the American Geriatric Society Beers Criteria® guideline. We also examined prescribing of appropriate alternative medications. Prescribing rates were calculated as the percentage a physician's patients with Medicare fee-for-service part D enrollment seen in the outpatient setting in a given year (mean: 150 patients per physician) with a PIM prescription they prescribed. RESULTS Across 30,677 physician-year observations, geriatricians were 16.7% less likely (95% confidence interval (CI): -19.8 to -13.7, p < 0.001) to prescribe a PIM (7.2% versus 8.7% of patients respectively) and 2.7% more likely (95% CI: 0.8 to 4.5, p = 0.004) to prescribe an appropriate alternative medication (52.0% versus 50.7% of patients respectively). Lower PIM prescribing was observed for most medication sub-types including central nervous system, anticholinergic, pain, and endocrine medications. In sensitivity analyses, differences in prescribing were similar when comparing recently trained physicians with more experienced physicians. CONCLUSION Findings suggest geriatricians in the United States prescribe PIMs at lower rates than general internists. This highlights the value geriatricians provide as well as opportunities to embed key principles of geriatric care into internal medicine training and health care delivery systems.
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Affiliation(s)
- Jonathan L Vandergrift
- Assessment and Research, American Board of Internal Medicine, Philadelphia, Pennsylvania, USA
| | - Weifeng Weng
- Assessment and Research, American Board of Internal Medicine, Philadelphia, Pennsylvania, USA
| | - Bruce Leff
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bradley M Gray
- Assessment and Research, American Board of Internal Medicine, Philadelphia, Pennsylvania, USA
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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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Lee S, Howard MA, Han JH. Delirium and Delirium Prevention in the Emergency Department. Clin Geriatr Med 2023; 39:535-551. [PMID: 37798064 DOI: 10.1016/j.cger.2023.05.006] [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] [Indexed: 10/07/2023]
Abstract
This article covers the epidemiology of delirium and the overlapping condition of altered mental status and encephalopathy that is relevant to those who practice in the emergency department.
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Affiliation(s)
- Sangil Lee
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, 312 Oxford House, Nashville, TN 37232-4700, USA; Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, 1310 24th Avenue South, Nashville, TN 37212-2637, USA
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Hall RK, Muzaale AD, Bae S, Steal SM, Rosman LM, Segev DL, McAdams-DeMarco M. Association of Potentially Inappropriate Medication Classes with Mortality Risk Among Older Adults Initiating Hemodialysis. Drugs Aging 2023; 40:741-749. [PMID: 37378815 PMCID: PMC10441684 DOI: 10.1007/s40266-023-01039-z] [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: 05/24/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND AND OBJECTIVE Older adults initiating dialysis have a high risk of mortality and that risk may be related to potentially inappropriate medications (PIMs). Our objective was to identify and validate mortality risk associated with American Geriatrics Society Beers Criteria PIM classes and concomitant PIM use. METHODS We used US Renal Data System data to establish a cohort of adults aged ≥ 65 years initiating dialysis (2013-2014) and had no PIM prescriptions in the 6 months prior to dialysis initiation. In a development cohort (40% sample), adjusted Cox proportional hazards models were performed to determine which of 30 PIM classes were associated with mortality (or "high-risk" PIMs). Adjusted Cox models were performed to assess the association of the number of "high-risk" PIM fills/month with mortality. All models were repeated in the validation cohort (60% sample). RESULTS In the development cohort (n = 15,570), only 13 of 30 PIM classes were associated with a higher mortality risk. Compared with those with no "high-risk" PIM fills/month, patients having one "high-risk" PIM fill/month had a 1.29-fold (95% confidence interval 1.21-1.38) increased risk of death; those with two or more "high-risk" PIM fills/month had a 1.40-fold (95% confidence interval 1.24-1.58) increased risk. These findings were similar in the validation cohort (n = 23,569). CONCLUSIONS Only a minority of Beers Criteria PIM classes may be associated with mortality in the older dialysis population; however, mortality risk increases with concomitant use of "high-risk" PIMs. Additional studies are needed to confirm these associations and their underlying mechanisms.
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Affiliation(s)
- Rasheeda K Hall
- Department of Medicine, Duke University School of Medicine, Rasheeda Hall, 2424 Erwin Road, Suite 605, Durham, NC, 27705, USA.
- Durham Veterans Affairs Medical Center, Durham, NC, USA.
| | - Abimereki D Muzaale
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, USA, MD
| | - Sunjae Bae
- Department of Surgery, New York University School of Medicine, New York City, NY, USA
| | - Stella M Steal
- Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lori M Rosman
- Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, New York University School of Medicine, New York City, NY, USA
| | - Mara McAdams-DeMarco
- Department of Surgery, New York University School of Medicine, New York City, NY, USA
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Overactive Bladder and Cognitive Impairment: The American Urogynecologic Society and Pelvic Floor Disorders Research Foundation State-of-the-Science Conference Summary Report. UROGYNECOLOGY (HAGERSTOWN, MD.) 2023; 29:S1-S19. [PMID: 36548636 DOI: 10.1097/spv.0000000000001272] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Overactive bladder (OAB) is prevalent in older adults in whom management is complicated by comorbidities and greater vulnerability to the cognitive effects of antimuscarinic medications. OBJECTIVES The aim of this study is to provide a comprehensive evidence-based summary of the 2021 State-of-the-Science (SOS) conference and a multidisciplinary expert literature review on OAB and cognitive impairment. STUDY DESIGN The American Urogynecologic Society and the Pelvic Floor Disorders Research Foundation convened a 3-day collaborative conference. Experts from multidisciplinary fields examined cognitive function, higher neural control of the OAB patient, risk factors for cognitive impairment in older patients, cognitive effects of antimuscarinic medications for OAB treatment, OAB phenotyping, conservative and advanced OAB therapies, and the need for a multidisciplinary approach to person-centered treatment. Translational topics included the blood-brain barrier, purine metabolome, mechanotransduction, and gene therapy for OAB targets. RESULTS Research surrounding OAB treatment efficacy in cognitively impaired individuals is limited. Short- and long-term outcomes regarding antimuscarinic effects on cognition are mixed; however, greater anticholinergic burden and duration of use influence risk. Oxybutynin is most consistently associated with negative cognitive effects in short-term, prospective studies. Although data are limited, beta-adrenergic agonists do not appear to confer the same cognitive risk. CONCLUSIONS The 2021 SOS summary report provides a comprehensive review of the fundamental, translational, and clinical research on OAB with emphasis on cognitive impairment risks to antimuscarinic medications. Duration of use and antimuscarinic type, specifically oxybutynin when examining OAB treatments, appears to have the most cognitive impact; however, conclusions are limited by the primarily cognitively intact population studied. Given current evidence, it appears prudent to minimize anticholinergic burden by emphasizing nonantimuscarinic therapeutic regimens in the older population and/or those with cognitive impairment.
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Lo-Ciganic WH, Hincapie-Castillo J, Wang T, Ge Y, Jones BL, Huang JL, Chang CY, Wilson DL, Lee JK, Reisfield GM, Kwoh CK, Delcher C, Nguyen KA, Zhou L, Shorr RI, Guo J, Marcum ZA, Harle CA, Park H, Winterstein A, Yang S, Huang PL, Adkins L, Gellad WF. Dosing profiles of concurrent opioid and benzodiazepine use associated with overdose risk among US Medicare beneficiaries: group-based multi-trajectory models. Addiction 2022; 117:1982-1997. [PMID: 35224799 DOI: 10.1111/add.15857] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 02/11/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS One-third of opioid (OPI) overdose deaths involve concurrent benzodiazepine (BZD) use. Little is known about concurrent opioid and benzodiazepine use (OPI-BZD) most associated with overdose risk. We aimed to examine associations between OPI-BZD dose and duration trajectories, and subsequent OPI or BZD overdose in US Medicare. DESIGN Retrospective cohort study. SETTING US Medicare. PARTICIPANTS Using a 5% national Medicare data sample (2013-16) of fee-for-service beneficiaries without cancer initiating OPI prescriptions, we identified 37 879 beneficiaries (age ≥ 65 = 59.3%, female = 71.9%, white = 87.6%, having OPI overdose = 0.3%). MEASUREMENTS During the 6 months following OPI initiation (i.e. trajectory period), we identified OPI-BZD dose and duration patterns using group-based multi-trajectory models, based on average daily morphine milligram equivalents (MME) for OPIs and diazepam milligram equivalents (DME) for BZDs. To label dose levels in each trajectory, we defined OPI use as very low (< 25 MME), low (25-50 MME), moderate (51-90 MME), high (91-150 MME) and very high (>150 MME) dose. Similarly, we defined BZD use as very low (< 10 DME), low (10-20 DME), moderate (21-40 DME), high (41-60 DME) and very high (> 60 DME) dose. Our primary analysis was to estimate the risk of time to first hospital or emergency department visit for OPI overdose within 6 months following the trajectory period using inverse probability of treatment-weighted Cox proportional hazards models. FINDINGS We identified nine distinct OPI-BZD trajectories: group A: very low OPI (early discontinuation)-very low declining BZD (n = 10 598; 28.0% of the cohort); B: very low OPI (early discontinuation)-very low stable BZD (n = 4923; 13.0%); C: very low OPI (early discontinuation)-medium BZD (n = 4997; 13.2%); D: low OPI-low BZD (n = 5083; 13.4%); E: low OPI-high BZD (n = 3906; 10.3%); F: medium OPI-low BZD (n = 3948; 10.4%); G: very high OPI-high BZD (n = 1371; 3.6%); H: very high OPI-very high BZD (n = 957; 2.5%); and I: very high OPI-low BZD (n = 2096; 5.5%). Compared with group A, five trajectories (32.3% of the study cohort) were associated with increased 6-month OPI overdose risks: E: low OPI-high BZD [hazard ratio (HR) = 3.27, 95% confidence interval (CI) = 1.61-6.63]; F: medium OPI-low BZD (HR = 4.04, 95% CI = 2.06-7.95); G: very high OPI-high BZD (HR = 6.98, 95% CI = 3.11-15.64); H: very high OPI-very high BZD (HR = 4.41, 95% CI = 1.51-12.85); and I: very high OPI-low BZD (HR = 6.50, 95% CI = 3.15-13.42). CONCLUSIONS Patterns of concurrent opioid and benzodiazepine use most associated with overdose risk among fee-for-service US Medicare beneficiaries initiating opioid prescriptions include very high-dose opioid use (MME > 150), high-dose benzodiazepine use (DME > 40) or medium-dose opioid with low-dose benzodiazepine use.
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Affiliation(s)
- Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA.,Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Juan Hincapie-Castillo
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA.,Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Ting Wang
- Agricultural Information Institute, Chinese Academy of Agricultural Sciences, Beijing, China.,Key Laboratory of Agricultural Big Data, Ministry of Agriculture and Rural Affairs, Beijing, China
| | - Yong Ge
- Department of Management Information Systems, University of Arizona, Tucson, AZ, USA
| | - Bobby L Jones
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - James L Huang
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Ching-Yuan Chang
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Debbie L Wilson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Jeannie K Lee
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Gary M Reisfield
- Divisions of Addiction Medicine & Forensic Psychiatry, Departments of Psychiatry & Anesthesiology, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Chian K Kwoh
- University of Arizona Arthritis Center, College of Medicine, University of Arizona, Tucson, AZ, USA.,Division of Rheumatology, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Chris Delcher
- Pharmacy Practice & Science, Institute for Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Khoa A Nguyen
- Department of Pharmacotherapy & Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Lili Zhou
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Ronald I Shorr
- North Florida/South Georgia Veterans Health System Geriatric Research Education and Clinical Center, Gainesville, FL, USA
| | - Jingchuan Guo
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA.,Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville, FL, USA
| | | | - Christopher A Harle
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Haesuk Park
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA.,Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Almut Winterstein
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA.,Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville, FL, USA.,Department of Epidemiology, Colleges of Medicine and Public Health and Health Professions, University of Florida, Gainesville, FL, USA
| | - Seonkyeong Yang
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Pei-Lin Huang
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Lauren Adkins
- Health Science Center Libraries, University of Florida, Gainesville, FL, USA
| | - Walid F Gellad
- Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Center for Health Equity Research Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
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Anand P, Katyal J, Dey AB, Gupta YK. Characterization of potentially inappropriate medications use in Indian elderly population and their impact on quality of life using Beers criteria. Aging Med (Milton) 2022; 5:45-52. [PMID: 35309155 PMCID: PMC8917262 DOI: 10.1002/agm2.12194] [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: 10/25/2021] [Revised: 01/19/2022] [Accepted: 01/19/2022] [Indexed: 11/12/2022] Open
Abstract
Background Polypharmacy is principal cause of potentially inappropriate medications (PIMs) in elderly patients, which include over prescribing, under prescribing, and misprescribing. Methods Elderly subjects (≥60 years), of either sex, receiving two or more medications for one or more chronic ailments, attending Geriatrics Outpatient Department (OPD), at All India Institute of Medical Sciences (AIIMS) New Delhi, were included. Their prescriptions were assessed for PIMs by using Beers criteria 2015 and were further followed up at least once in 6 months for adverse events, telephonically. The results were analyzed by using suitable regression models and correlation analysis. Results Three hundred eighty patients average age of 65.4 ± 4.7 years were enrolled. Eighty-eight percent of the people were having greater than or equal to two ailments. Each patient was prescribed 6.7 ± 2.1 medications with 65% of prescriptions having one or more PIMs. Out of the total prescribed drugs, 15% were satisfying Beers criteria for PIMs. There were 63 adverse drug reactions (ADRs) reported. A statistically significant correlation was observed among comorbidities, number of prescribed medications, PIMs, and ADRs. Quality of life (QOL) of the elderly patients was negatively corelated with polypharmacy and female sex. Conclusion A risk-benefit analysis of prescribed medications is part and parcel of prescribing, especially in elderly patients. In order to decrease further risks associated with inappropriate prescribing, there is need for indigenous guidelines and intensive training.
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Affiliation(s)
- Pooja Anand
- Department of PharmacologyAll India Institute of Medical Sciences (AIIMS)New DelhiIndia
| | - Jatinder Katyal
- Department of PharmacologyAll India Institute of Medical Sciences (AIIMS)New DelhiIndia
| | - Aparajit Ballav Dey
- Department of Geriatric MedicineAll India Institute of Medical Sciences (AIIMS)New DelhiIndia
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Pecce Bento A, Costa Pereira L, Ramos Garcia K, Ramos Ferreira LF, da Silva EV, Karnikowski M. Inclusion of Potentially Inappropriate Medicines for the Older Adults in the Brazilian Consensus in Accordance with International Criteria. Clin Interv Aging 2022; 17:151-161. [PMID: 35210761 PMCID: PMC8859540 DOI: 10.2147/cia.s318578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/15/2021] [Indexed: 11/23/2022] Open
Abstract
AIM The use of potentially inappropriate medications (PIM) can impair the safety and effectiveness of pharmacotherapy in the older adults. Thus, several countries have lists and criteria to indicate these drugs, in order to promote the safety of prescription and the rational use of drugs in geriatric practice. OBJECTIVE This study sought to contribute to the inclusion of PIM for the older adults in the Brazilian criterion (BCPIM/2016) - current list used in Brazil and reference in Latin American countries - through expert approval, comparing convergences with international AGS lists BEERS/2019, STOPP/START/2015, PRISCUS/2010 and EU (7)-PIM List/2015. METHODS This is a critical analysis of potentially inappropriate medications for use in the older adults present in the list of Brazilian criteria, together with their absence of some drugs that are on international lists (BEERS/2019; Priscus/2010; Stopp/Start/2015; EU7-PIM list/2015). This study was subdivided in 6 stages: selection of national criteria, classification of drugs according to Anatomic Therapeutic Chemical, comparison between BCPIM/2016 with international lists, selection of drugs not included in the Brazilian list, selection of experts for evaluation and suggestions about drugs not included in the Brazilian list and the synthesis of the analysis carried out by the specialists. RESULTS We cataloged 66 drugs marketed in Brazil that are on international lists, but not in the Brazilian consensus, of which 24 were validated by experts as necessary for inclusion in this consensus, considering the risks and benefits in health care for the older adults. However, the lists have divergences and similarities between them. We observed that eight drugs were common to all criteria studied, mainly related to the nervous system. CONCLUSION The results suggest the need for periodic validation of PIM against research clinics, new drugs and the inclusion of this agenda by the Ministry of Health in the revision of the National List of Essential Drugs and other Clinical Protocols and Therapeutic Prescription Guidelines for the older adults.
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Affiliation(s)
- Andréa Pecce Bento
- Sciences and Health Technologies Program, University of Brasilia, Brasilia, DF, Brazil
| | | | - Kerolyn Ramos Garcia
- Sciences and Health Technologies Program, University of Brasilia, Brasilia, DF, Brazil
| | | | | | - Margô Karnikowski
- Sciences and Health Technologies Program, University of Brasilia, Brasilia, DF, Brazil
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Novak J, Goldberg A, Dharmarajan K, Amini A, Maggiore RJ, Presley CJ, Nightingale G. Polypharmacy in older adults with cancer undergoing radiotherapy: A review. J Geriatr Oncol 2022; 13:778-783. [DOI: 10.1016/j.jgo.2022.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 12/09/2021] [Accepted: 02/10/2022] [Indexed: 01/09/2023]
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Eshetie TC, Marcum ZA, Schmader KE, Gray SL. Medication use quality and safety in older adults: 2020 update. J Am Geriatr Soc 2022; 70:389-397. [PMID: 34897654 PMCID: PMC8821136 DOI: 10.1111/jgs.17603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 11/03/2021] [Accepted: 11/13/2021] [Indexed: 02/03/2023]
Abstract
Improving the quality of medication use and medication safety are important priorities for prescribers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2020. We selected high-quality studies that moved the field of research forward and were not merely replication studies. The chosen articles cover domains related to deprescribing, medication safety, and optimizing medication use. The first study, a noninferiority randomized clinical trial in England, evaluated whether antihypertensive medication reduction is possible without significant changes in systolic blood pressure control or adverse events over the 12-week follow-up (domain: deprescribing). The second study, a prospective cohort study of women at Kaiser Permanente Southern, California, examined the association between bisphosphonate use and atypical femur fracture (domain: medication safety). The third study examined the effectiveness and safety of a multifaceted antimicrobial stewardship and quality improvement initiative in reducing unnecessary antimicrobial use for unlikely cystitis cases in noncatheterized residents in 25 nursing homes across the United States (domain: optimizing medication use). Lastly, the fourth study, a population-based cohort study in the United Kingdom, examined the association of tramadol use with risk of hip fracture (domain: medication safety). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens.
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Affiliation(s)
- Tesfahun C. Eshetie
- Plein Center for Geriatric Pharmacy Research, Education and Outreach, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Zachary A. Marcum
- Plein Center for Geriatric Pharmacy Research, Education and Outreach, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Kenneth E. Schmader
- Department of Medicine (Geriatrics), School of Medicine, Duke University Medical Center, Durham, NC
- Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, NC
| | - Shelly L. Gray
- Plein Center for Geriatric Pharmacy Research, Education and Outreach, School of Pharmacy, University of Washington, Seattle, Washington, USA
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Martins UCDM, Ramalho-de-Oliveira D, Nascimento MMGD, Nascimento YA, Oliveira GCBD, Cid AS, Lima MG. Potentially inappropriate medication use in a comprehensive therapy management service: clinical outcomes and interventions. BRAZ J PHARM SCI 2022. [DOI: 10.1590/s2175-97902022e19191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Li M, Yuan J, Dezfuli C, Lu ZK. Impact of Medicare prescription drug (Part D) coverage expansion on utilisation and financial burden of benzodiazepines among older adults: an interrupted time series analysis. BMJ Open 2021; 11:e053717. [PMID: 34911718 PMCID: PMC8679099 DOI: 10.1136/bmjopen-2021-053717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Benzodiazepines were excluded from Medicare Part D coverage since its introduction in 2006. Part D expanded coverage for benzodiazepines in 2013. The objective was to examine the impact of Medicare Part D coverage expansion on the utilisation and financial burden of benzodiazepines in older adults. DESIGN Interrupted time series with a control group. SETTING Nationally representative sample. PARTICIPANTS 53 150 468 users of benzodiazepines and 21 749 749 users of non-benzodiazepines (an alternative therapy) from the Medicare Current Beneficiary Survey between the pre-expansion (2006-2012) and post-expansion (2013-2017) periods. INTERVENTION Medicare Part D coverage expansion on benzodiazepines. PRIMARY AND SECONDARY OUTCOME MEASURES Annual rate of benzodiazepines and non-benzodiazepines, average number of benzodiazepines and non-benzodiazepines and average cost of benzodiazepines and non-benzodiazepines. RESULTS After Medicare Part D coverage expansion, the level of the annual rate of benzodiazepines increased by 8.20% (95% CI: 6.07% to 10.32%) and the trend decreased by 1.03% each year (95% CI: -1.77% to -0.29%). The trend of the annual rate of non-benzodiazepines decreased by 0.72% each year (95% CI: -1.11% to -0.33%). For the average number of benzodiazepines, the level increased by 0.67 (95% CI: 0.52 to 0.82) and the trend decreased by 0.10 each year (95% CI: -0.15 to -0.05). For the average number of non-benzodiazepines, the level decreased by 0.11 (95% CI: -0.21 to -0.01) and the trend decreased by 0.04 each year (95% CI: -0.08 to -0.01). No significant level and trend changes were identified for the average cost of benzodiazepines and non-benzodiazepines. CONCLUSIONS After Medicare Part D coverage expansion, there was a sudden increase in the utilisation of benzodiazepines and a decreasing trend in the long-term. The increase in the utilisation of benzodiazepines did not add a financial burden to older adults. As an alternative therapy, the utilisation of non-benzodiazepines decreased following the coverage expansion.
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Affiliation(s)
- Minghui Li
- Department of Clinical Pharmacy and Translational Science, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Jing Yuan
- Department of Clinical Pharmacy and Pharmacy Administration, Fudan University, Shanghai, China
| | - Chelsea Dezfuli
- Department of Clinical Pharmacy and Translational Science, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Z Kevin Lu
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina, Columbia, Columbia, USA
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Anand TV, Wallace BK, Chase HS. Prevalence of potentially harmful multidrug interactions on medication lists of elderly ambulatory patients. BMC Geriatr 2021; 21:648. [PMID: 34798832 PMCID: PMC8603594 DOI: 10.1186/s12877-021-02594-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/27/2021] [Indexed: 12/04/2022] Open
Abstract
Background It has been hypothesized that polypharmacy may increase the frequency of multidrug interactions (MDIs) where one drug interacts with two or more other drugs, amplifying the risk of associated adverse drug events (ADEs). The main objective of this study was to determine the prevalence of MDIs in medication lists of elderly ambulatory patients and to identify the medications most commonly involved in MDIs that amplify the risk of ADEs. Methods Medication lists stored in the electronic health record (EHR) of 6,545 outpatients ≥60 years old were extracted from the enterprise data warehouse. Network analysis identified patients with three or more interacting medications from their medication lists. Potentially harmful interactions were identified from the enterprise drug-drug interaction alerting system. MDIs were considered to amplify the risk if interactions could increase the probability of ADEs. Results MDIs were identified in 1.3 % of the medication lists, the majority of which involved three interacting drugs (75.6 %) while the remainder involved four (15.6 %) or five or more (8.9 %) interacting drugs. The average number of medications on the lists was 3.1 ± 2.3 in patients with no drug interactions and 8.6 ± 3.4 in patients with MDIs. The prevalence of MDIs on medication lists was greater than 10 % in patients prescribed bupropion, tramadol, trazodone, cyclobenzaprine, fluoxetine, ondansetron, or quetiapine and greater than 20 % in patients prescribed amiodarone or methotrexate. All MDIs were potentially risk-amplifying due to pharmacodynamic interactions, where three or more medications were associated with the same ADE, or pharmacokinetic, where two or more drugs reduced the metabolism of a third drug. The most common drugs involved in MDIs were psychotropic, comprising 35.1 % of all drugs involved. The most common serious potential ADEs associated with the interactions were serotonin syndrome, seizures, prolonged QT interval and bleeding. Conclusions An identifiable number of medications, the majority of which are psychotropic, may be involved in MDIs in elderly ambulatory patients which may amplify the risk of serious ADEs. To mitigate the risk, providers will need to pay special attention to the overlapping drug-drug interactions which result in MDIs. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02594-z.
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Affiliation(s)
- Tara V Anand
- Department of Biomedical informatics, Columbia University Medical Center, 622 West 168th Street, New York, NY, 10032, USA
| | - Brendan K Wallace
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, 10032, USA
| | - Herbert S Chase
- Department of Biomedical informatics, Columbia University Medical Center, 622 West 168th Street, New York, NY, 10032, USA.
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Ward LM, Stanley B, Greenlaw N, Cooper SA, Pacitti C, Henderson A, Gibson J, Kinnear D. Risk of anticholinergic burden in adults with intellectual disabilities: a Scottish retrospective cohort study of n = 17 220. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2021; 65:813-830. [PMID: 34169610 DOI: 10.1111/jir.12861] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/25/2021] [Accepted: 05/26/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Several drugs have anticholinergic side effects that are associated with adverse health outcomes. Anticholinergic burden studies in adults with intellectual disabilities (ID) have focused exclusively on older adults. This study investigates anticholinergic burden and its associations in adults with ID of all ages (17-94 years). METHODS Adults with ID (n = 4 305), each with three general population age-sex-neighbourhood-matched controls (n = 12 915), were linked to their prescribed medications with anticholinergic effects between 2009 and 2017. Analyses were undertaken using logistic regression models. RESULTS Adults with ID were more likely to be prescribed any anticholinergic medicines, odds ratio (OR) = 1.49 (1.38-1.59), especially 'very strong' risk medicines, OR = 2.59 (2.39-2.81); 48.5% had very high total anticholinergic burden (3+) compared with 35.4% of the general population, OR = 1.77 (1.64-1.90). This group difference was greater for males, OR = 2.02 (1.84-2.22), than females, OR = 1.48 (1.33-1.65). Adults with ID had significantly higher odds of having very high total anticholinergic burden up to 75 years old, with the greatest group effect occurring in younger ages, 17-24-year-olds, OR = 3.05 (2.39-3.89), and the extent of the difference decreased as age increased. The main effect of neighbourhood deprivation showed greater group differences with increasing affluence of neighbourhood. Results examining only the ID group showed that very high total anticholinergic burden was greatest for females, OR = 1.21 (1.07-1.37), and those over age 55, and extent of neighbourhood deprivation was not significant. CONCLUSIONS Adults with ID are at higher risk of anticholinergic burden than the general population, especially young adults. Overall anticholinergic burden increased with age, but burden was high across all ages in the ID group. Very high total anticholinergic burden is prevalent across all types of neighbourhoods for the adults with ID, in contrast to the steeper gradient seen in the general population. Adults with ID have increased likelihood of unintended adverse effects, regardless of potential confounds, so clinicians undertaking medication reviews need to consider anticholinergic side effects and cumulative burden across concomitant medications, including in young adults with ID, not just older adults, and particularly women.
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Affiliation(s)
- L M Ward
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK
| | - B Stanley
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - N Greenlaw
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - S-A Cooper
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK
| | - C Pacitti
- NHS Greater Glasgow & Clyde, Leverndale Hospital, Glasgow, UK
| | - A Henderson
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK
| | - J Gibson
- School of Medicine, Dentistry and Nursing, Glasgow Dental Hospital and School, Glasgow, UK
| | - D Kinnear
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK
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Vandergrift JL, Weng W, Gray BM. The association between physician knowledge and inappropriate medications for older populations. J Am Geriatr Soc 2021; 69:3584-3594. [PMID: 34459494 DOI: 10.1111/jgs.17413] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/21/2021] [Accepted: 07/25/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Older patients are often prescribed potentially inappropriate medications (PIMs) given their age. We measured the association between a physician's general knowledge and their PIM prescribing. METHODS Using a 2013-2017 cross-sectional design, we related a general internist's knowledge (n = 8196) to their prescribing of PIMs to fee-for-service Medicare beneficiaries, age ≥ 66 years with part D coverage, which they saw in the outpatient setting the year after their exam (n = 875,132). Physician knowledge was based on the American Board of Internal Medicine's (ABIM) Internal Medicine Maintenance of Certification (IM-MOC) exam scores. Medications included 72 PIMs from the American Geriatric Society's Beers Criteria and appropriate alternatives to these medications. Logistic regressions controlled for physicians practice/training characteristics and patient-risk factors. RESULTS Annually, 11.0% of patients received a PIM and 57.2% received an appropriate alternative medication. Patients seen by physicians scoring in the top versus bottom quartile were 8.6% less likely (95% confidence interval [CI]: -12.7 to -4.5, p < 0.001) to be prescribed a PIM and 4.7% more likely (95% CI: 1.7 to 7.6, p = 0.001) to be prescribed an appropriate alternative medication. The difference in PIM prescribing grew to 12.1% fewer (95% CI: -15.1 to -9.1) patients when limiting the sample to the 58.9% of patients being prescribed a PIM or appropriate alternative medication. Among patients receiving any medication, this was similar to the percent difference in PIM prescribing between solo and large practices (≥50 physicians, -10.2%, 95% CI: 13.6-6.5, p < 0.001) or between group and academic practices (-11.7%, 95% CI: -15.3 to -7.9, p < 0.001). PIM prescribing was more positively associated with patient characteristics including age, gender, and total number of medications prescribed. CONCLUSIONS Better physician general knowledge, as measured by an ABIM exam, was associated with fewer PIM prescriptions. Future research should examine whether general educational interventions, such as MOC, effect PIM prescribing.
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Affiliation(s)
| | - Weifeng Weng
- American Board of Internal Medicine, Philadelphia, Pennsylvania, USA
| | - Bradley M Gray
- American Board of Internal Medicine, Philadelphia, Pennsylvania, USA
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Mohottige D, Manley HJ, Hall RK. Less is More: Deprescribing Medications in Older Adults with Kidney Disease: A Review. KIDNEY360 2021; 2:1510-1522. [PMID: 35373095 PMCID: PMC8786141 DOI: 10.34067/kid.0001942021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/08/2021] [Indexed: 02/04/2023]
Abstract
Due to age and impaired kidney function, older adults with kidney disease are at increased risk of medication-related problems and related hospitalizations. One proa ctive approach to minimize this risk is deprescribing. Deprescribing refers to the systematic process of reducing or stopping a medication. Aside from preventing harm, deprescribing can potentially optimize patients' quality of life by aligning medications with their goals of care. For some patients, deprescribing could involve less aggressive management of their diabetes and/or hypertension. In other instances, deprescribing targets may include potentially inappropriate medications that carry greater risk of harm than benefit in older adults, medications that have questionable efficacy, including medications that have varying efficacy by degree of kidney function, and that increase medication regimen complexity. We include a guide for clinicians to utilize in deprescribing, the List, Evaluate, Shared Decision-Making, Support (LESS) framework. The LESS framework provides key considerations at each step of the deprescribing process that can be tailored for the medications and context of individu al patients. Patient characteristics or clinical events that warrant consideration of deprescribing include limited life expectancy, cognitive impairment, and health status changes, such as dialysis initiation or recent hospitalization. We acknowledge patient-, clinician-, and system-level challenges to the depre scribing process. These include patient hesitancy and challenges to discussing goals of care, clinician time constraints and a lack of evidence-based guidelines, and system-level challenges of interoperable electronic health records and limited incentives for deprescribing. However, novel evidence-based tools designed to facilitate deprescribing and future evidence on effectiveness of deprescribing could help mitigate these barriers. This review provides foundational knowledge on deprescribing as an emerging component of clinical practice and research within nephrology.
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Affiliation(s)
- Dinushika Mohottige
- Renal Section, Durham Veterans Affairs Healthcare System, Durham, North Carolina,Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Rasheeda K. Hall
- Renal Section, Durham Veterans Affairs Healthcare System, Durham, North Carolina,Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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Oudewortel L, van der Roest HG, Onder G, Wijnen VJM, Liperoti R, Denkinger M, Finne-Soveri H, Topinková E, Henrard JC, van Gool WA. The Association of Anticholinergic Drugs and Delirium in Nursing Home Patients With Dementia: Results From the SHELTER Study. J Am Med Dir Assoc 2021; 22:2087-2092. [PMID: 34197793 DOI: 10.1016/j.jamda.2021.05.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 05/12/2021] [Accepted: 05/29/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Drugs with anticholinergic properties are associated with an increased prevalence of delirium, especially in older persons. The aim of this study was to evaluate the association between the use of this class of drugs in nursing home (NH) patients and prevalence of delirium, particularly in people with dementia. DESIGN Cross-sectional multicenter study. SETTING AND PARTICIPANTS 3924 nursing home patients of 57 nursing homes in 7 European countries participating in the Services and Health for Elderly in Long TERmcare (SHELTER) project. METHODS Descriptive statistics, calculation of percentage, and multivariable logistic analysis were applied to describe the relationship between anticholinergic drug use and prevalence of delirium in NH patients. The Anticholinergic Risk Scale (ARS) and the Anticholinergic Burden Scale (ACB) were used to calculate the anticholinergic load. RESULTS 54% of patients with dementia and 60% without dementia received at least 1 anticholinergic drug according to the ACB. The prevalence of delirium was higher in the dementia group (21%) compared with the nondementia group (11%). Overall, anticholinergic burden according to the ACB and ARS was associated with delirium both in patients with and without dementia, with odds ratios ranging from 1.07 [95% confidence interval (CI) 0.94-1.21] to 1.26 (95% CI 1.11-1.44). These associations reached statistical significance only in the group of patients with dementia. Among patients with dementia, delirium prevalence increased only modestly with increasing anticholinergic burden according to the ACB, from 20% (with none or minimal anticholinergic burden) to 25% (with moderate burden) and 27% delirium (with strong burden scores). CONCLUSIONS AND IMPLICATIONS The ACB scale is relatively capable to detect anticholinergic side effects, which are positively associated with prevalence of delirium in NH patients. Given the modest nature of this association, strong recommendations are currently not warranted, and more longitudinal studies are needed.
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Affiliation(s)
- Letty Oudewortel
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Amsterdam, the Netherlands.
| | - Henriëtte G van der Roest
- Department on Aging, Netherlands Institute of Mental Health and Addiction (Trimbos Institute), Utrecht, the Netherlands
| | - Graziano Onder
- Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Viona J M Wijnen
- Psychogeriatric Observation Unit, Institution for Mental Health Care, Parnassia Groep, the Netherlands
| | - Rosa Liperoti
- Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Michael Denkinger
- Agaplesion Bethesda Clinic, Geriatric Centre Ulm/Alb-Donau, Ulm University, Ulm, Germany
| | - Harriet Finne-Soveri
- Department of Welfare, National Institute for Health and Welfare, Helsinki, Finland
| | - Eva Topinková
- Department of Geriatrics, First Faculty of Medicine, Charles University, Prague, Czech Republic; Faculty of Health and Social Sciences, University of South Bohemia, Ceske Budejovice, Czech Republic
| | - Jean-Claude Henrard
- Research Unit Health-Environment-Ageing, Versailles-Saint-Quentin en Yvelines University, Paris, France
| | - Willem A van Gool
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Hall RK, Morton S, Wilson J, Ephraim PL, Boulware LE, St Peter WL, Colón-Emeric C, Pendergast J, Scialla JJ. Risks associated with continuation of potentially inappropriate antihypertensive medications in older adults receiving hemodialysis. BMC Nephrol 2021; 22:232. [PMID: 34147085 PMCID: PMC8214789 DOI: 10.1186/s12882-021-02438-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/31/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND OBJECTIVES After dialysis initiation, older adults may experience orthostatic or post-dialysis hypotension. Some orthostasis-causing antihypertensives (i.e., central alpha agonists and alpha blockers), are considered potentially inappropriate medications (PIMs) for older adults because they carry more risk than benefit. We sought to (1) describe antihypertensive PIM prescribing patterns before and after dialysis initiation and (2) ascertain the potential risk of adverse outcomes when these medications are continued after dialysis initiation. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS Using United States Renal Data System data, we evaluated monthly prevalence of antihypertensive PIM claims in the period before and after dialysis initiation among older adults aged ≥66 years initiating in-center hemodialysis in the US between 2013 and 2014. Patients with an antihypertensive PIM prescription at hemodialysis initiation and who survived for 120 days were classified as 'continuers' or 'discontinuers' based on presence or absence of a refill within the 120 days after initiation. We compared rates of hospitalization and risk of death across these groups from day 121 through 24 months after dialysis initiation. RESULTS Our study included 30,760 total patients, of whom 5981 (19%) patients had an antihypertensive PIM claim at dialysis initiation and survived ≥120 days. Most [65% (n = 3920)] were continuers. Those who continued (versus discontinued) were more likely to be black race (26% versus 21%), have dual Medicare-Medicaid coverage (31% versus 27%), have more medications on average (12 versus 9) and have no functional limitations (84% versus 80%). Continuers experienced fewer all-cause hospitalizations and deaths, but neither were statistically significant after adjustment (Hospitalization: RR 0.93, 95% CI 0.86, 1.00; Death: HR 0.89, 95% CI: 0.78-1.02). CONCLUSIONS Nearly one in five older adults had an antihypertensive PIM at dialysis initiation. Among those who survived ≥120 days, continuation of an antihypertensive PIM was not associated with increased risk of all-cause hospitalization or mortality.
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Affiliation(s)
- Rasheeda K Hall
- Department of Medicine, Duke University School of Medicine, Box DUMC 2747, 2424 Erwin Road Suite 605, Durham, NC, 27710, USA.
- Durham Veterans Affairs Medical Center, Durham, NC, USA.
| | - Sarah Morton
- Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Jonathan Wilson
- Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Patti L Ephraim
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - L Ebony Boulware
- Department of Medicine, Duke University School of Medicine, Box DUMC 2747, 2424 Erwin Road Suite 605, Durham, NC, 27710, USA
| | - Wendy L St Peter
- Department of Pharmaceutical Care and Health Systems, University of Minnesota College of Pharmacy, Minneapolis, MN, USA
| | - Cathleen Colón-Emeric
- Department of Medicine, Duke University School of Medicine, Box DUMC 2747, 2424 Erwin Road Suite 605, Durham, NC, 27710, USA
- Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Jane Pendergast
- Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Julia J Scialla
- Departments of Medicine and Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
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21
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Vickers LE, Martinez AI, Wallem AM, Johnson C, Moga DC. Potentially Inappropriate Medication Use in Older Adults with Alzheimer's Disease and Related Dementias Living in the Community: A Cross-Sectional Analysis. Drugs Real World Outcomes 2021; 8:519-526. [PMID: 34114133 PMCID: PMC8605947 DOI: 10.1007/s40801-021-00265-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND With the older adult population in the USA increasing, so is the population of those with Alzheimer's disease and related dementias (ADRD). Older adults are vulnerable to the effects of potentially inappropriate medications as established by the Beers Criteria; however, some medications continue to be prescribed against recommendations. OBJECTIVES Our objectives were to describe potentially inappropriate medication (PIM) use linked to cognitive impairment or decline (referred to as Cog-PIM) in older adults with and without ADRD and to investigate whether the odds of Cog-PIM report differ by ADRD status in ambulatory care (i.e., outpatient care) in the USA. METHODS A cross-sectional analysis was performed using a nationally representative sample of non-perioperative, office-based ambulatory care visits by adults aged ≥ 65 years in 2016 (n = 218,182,131). Data were collected from the National Ambulatory Medical Care Survey. Cog-PIMs were identified as defined in the 2015 Beers Criteria recommendations for medications that may be potentially inappropriate in older adults with cognitive impairment or dementia. ADRD status was determined by clinician report using free text, the ADRD flag, or the presence of a diagnosis code indicating dementia. Multivariable logistic regressions were used to estimate the odds of Cog-PIM use overall and by medication class. RESULTS In 2016, 2.1% (n = 4,651,563) of outpatient visits were made by older adults with ADRD, 33.2% of which reported at least one Cog-PIM. Anticholinergic Cog-PIMs were noted in 20.5% of ADRD visits compared with 8.1% of non-ADRD visits. Antipsychotic PIMs were noted in 15.5% of ADRD visits compared with 0.8% of non-ADRD visits. Benzodiazepine and non-benzodiazepine receptor agonist hypnotic (Z drug) Cog-PIMs were reported in 10.9% of ADRD visits and 10.7% of non-ADRD visits. ADRD status was a significant predictor of Cog-PIM report overall (adjusted odds ratio [aOR] 2.74 [95% confidence interval {CI} 1.20-6.27]) and for anticholinergics and antipsychotics specifically (aOR 3.35 [95% CI 1.24-9.03] and aOR 22.80 [95% CI 5.80-89.50], respectively). CONCLUSION This study demonstrated a high prevalence of Cog-PIM use and increased odds of Cog-PIM use in older adults with ADRD. Future work should investigate opportunities in the ambulatory care setting for safer prescribing and de-escalation of Cog-PIMs.
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Affiliation(s)
| | | | | | - Clare Johnson
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Daniela C Moga
- University of Kentucky College of Pharmacy, Lexington, KY, USA. .,University of Kentucky College of Public Health, Lexington, KY, USA. .,University of Kentucky Institute for Pharmaceutical Outcomes and Policy, Lexington, KY, USA. .,Sanders-Brown Center on Aging, Lexington, KY, USA.
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22
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The prevalence and prescribing patterns of benzodiazepines and Z-drugs in older nursing home residents in different European countries and Israel: retrospective results from the EU SHELTER study. BMC Geriatr 2021; 21:277. [PMID: 33902474 PMCID: PMC8077828 DOI: 10.1186/s12877-021-02213-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 04/06/2021] [Indexed: 11/11/2022] Open
Abstract
Background Benzodiazepines (BZDs) and Z-drugs have high potential for developing frequent adverse drug events in older adults (e.g., psychomotor sedation, drug-related dementia, deliria, drug dependence, etc.). Knowledge of the prevalence and patterns of the use of BZDs/Z-drugs in vulnerable older patients is important in order to prevent and reduce the burden caused by their drug-related complications. Our study focused on international comparisons of the prevalence, country-specific prescribing patterns and risk factors of regular BZD/Z-drug use in nursing home (NH) residents. Methods This cross-sectional study retrospectively analysed data of 4156 NH residents, prospectively assessed in the Services and Health in the Elderly in Long TERm care (SHELTER) project conducted from 2009 to 2014. Residents aged 65+ in 57 NHs in 7 European countries and Israel were assessed by the InterRAI Long-Term Care Facilities instrument. Descriptive statistics and multiple logistic regression models were used to describe the country-specific prevalence, patterns and risk factors of BZD/Z-drug use. Results The mean age of the participants was 83.4 ± 9.4 years, 73% were female and 27.7% used BZDs/Z-drugs. The prevalence of BZD/Z-drug use differed significantly across countries, ranging from 44.1% in Israel to 14.5% in Germany. The most frequently prescribed were zopiclone (17.8%), lorazepam (17.1%) and oxazepam (16.3%). Lorazepam, oxazepam and diazepam were used in most of the countries. Brotizolam, temazepam and zolpidem showed highest prevalence in Israel (99.4% of all regular users of this medication in the sample), the Netherlands (72.6%) and France (50.0%), respectively. Residing in Israel was the most significant factor associated with the use of BZDs/Z-drugs or BZDs only (odds ratio [OR] 6.7; 95% confidence interval [CI] 4.8–9.2 and OR 9.7, 95%CI 6.5–14.5, respectively). The use of Z-drugs only was most significantly associated with residing in France (OR 21.0, 95%CI 9.0–48.9). Conclusions Despite global recommendations and warnings, the preference for and extent of use of individual BZDs and Z-drugs in vulnerable NH residents differ significantly across countries. The strong association with country of residence compared to clinical and functional factors denotes that prescribing habits, social, cultural, behavioural, and regulatory factors still play an important role in the current diverse use of these medications. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02213-x.
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23
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Alessi CA, Fung CH, Dzierzewski JM, Fiorentino L, Stepnowsky C, Rodriguez Tapia JC, Song Y, Zeidler MR, Josephson K, Mitchell MN, Jouldjian S, Martin JL. Randomized controlled trial of an integrated approach to treating insomnia and improving the use of positive airway pressure therapy in veterans with comorbid insomnia disorder and obstructive sleep apnea. Sleep 2021; 44:zsaa235. [PMID: 33221910 PMCID: PMC8033453 DOI: 10.1093/sleep/zsaa235] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/26/2020] [Indexed: 12/11/2022] Open
Abstract
STUDY OBJECTIVES Cognitive behavioral therapy for insomnia (CBTI) for comorbid insomnia and obstructive sleep apnea (OSA) has had mixed results. We integrated CBTI with a positive airway pressure (PAP) adherence program and tested effects on sleep and PAP use. METHODS 125 veterans (mean age 63.2, 96% men, 39% non-Hispanic white, 26% black/African American, 18% Hispanic/Latino) with comorbid insomnia and newly-diagnosed OSA (apnea-hypopnea index ≥ 15) were randomized to 5-weekly sessions integrating CBTI with a PAP adherence program provided by a "sleep coach" (with behavioral sleep medicine supervision), or 5-weekly sleep education control sessions. Participants and assessment staff were blinded to group assignment. Outcomes (baseline, 3 and 6 months) included Pittsburgh Sleep Quality Index (PSQI), 7-day sleep diary (sleep onset latency [SOL-D], wake after sleep onset [WASO-D], sleep efficiency [SE-D]), 7-day actigraphy (SE-A), and objective PAP use (hours/night and nights ≥ 4 h). Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), and Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10) were also collected. RESULTS Compared to controls, intervention participants showed greater improvement (baseline to 3 and 6 months, respectively) in PSQI (-3.2 and -1.7), SOL-D (-16.2 and -15.5 minutes), SE-D (10.5% and 8.5%), SE-A (4.4% and 2.6%) and more 90-day PAP use (1.3 and 0.9 more hours/night, 17.4 and 11.3 more nights PAP ≥ 4 h). 90-day PAP use at 3 months was 3.2 and 1.9 h/night in intervention versus controls. Intervention participants also had greater improvements in ISI, ESS, and FOSQ-10 (all p < 0.05). CONCLUSIONS An intervention integrating CBTI with a PAP adherence program delivered by a supervised sleep coach improved sleep and PAP use in adults with comorbid insomnia and OSA. TRIAL REGISTRATION ClinicalTrials.govStudy name: Novel Treatment of Comorbid Insomnia and Sleep Apnea in Older VeteransURL: https://clinicaltrials.gov/ct2/results?cond=&term=NCT02027558&cntry=&state=&city=&dist=Registration: NCT02027558.
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Affiliation(s)
- Cathy A Alessi
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Constance H Fung
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | | | - Lavinia Fiorentino
- Department of Psychiatry, University of California, San Diego, San Diego, CA
| | - Carl Stepnowsky
- Department of Medicine, University of California, San Diego, San Diego, CA
- VA San Diego Healthcare System, San Diego, CA
| | | | - Yeonsu Song
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
- School of Nursing, University of California Los Angeles, Los Angeles, CA
| | - Michelle R Zeidler
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
- Pulmonary, Critical Care and Sleep Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Karen Josephson
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Michael N Mitchell
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Stella Jouldjian
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Jennifer L Martin
- Geriatric Research, Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
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24
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Ailabouni NJ, Marcum ZA, Schmader KE, Gray SL. Medication Use Quality and Safety in Older Adults: 2019 Update. J Am Geriatr Soc 2021; 69:336-341. [PMID: 33438206 PMCID: PMC11057223 DOI: 10.1111/jgs.17018] [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: 08/18/2020] [Revised: 12/09/2020] [Accepted: 12/17/2020] [Indexed: 11/29/2022]
Abstract
Improving the quality of medication use and medication safety are important priorities for prescribers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2019. We selected high-quality studies that moved the field of research forward and were not merely replication studies. The chosen articles cover domains related to aspects of suboptimal prescribing and medication safety. The first study used a nationally representative sample of Medicare beneficiaries to examine the continuation of medications with limited benefit in patients admitted for cancer and non-cancer diagnoses in hospice (domain: potentially inappropriate medications). The second study, a retrospective cohort study of older adults in Ontario, Canada, assessed the association between prescribing oral anticoagulants in an emergency department relative to not prescribing anticoagulants in the emergency department and their persistence at 6 months (domain: underuse of medications). The third study, a cluster randomized trial in Quebec, Canada, evaluated the effect of conducting electronic medication reconciliation on several outcomes including adverse drug events and medication discrepancies (domain: medication safety). Lastly, the fourth study, a retrospective study using national inpatient and outpatient Veteran Health Administration combined with clinical and Medicare Claims data, examined the effects of intensification of antihypertensive medications on older adults' likelihood for hospital re-admission and other important clinical outcomes (domain: medication safety). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens.
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Affiliation(s)
- Nagham J. Ailabouni
- Quality Use of Medicine and Pharmacy Research Centre, UniSA: Clinical & Health Sciences, University of South Australia, Adelaide, Australia
- Department of Pharmacy, University of Washington, Seattle, Washington
| | - Zachary A. Marcum
- Quality Use of Medicine and Pharmacy Research Centre, UniSA: Clinical & Health Sciences, University of South Australia, Adelaide, Australia
- Department of Pharmacy, University of Washington, Seattle, Washington
| | - Kenneth E. Schmader
- Department of Medicine (Geriatrics), School of Medicine, Duke University Medical Center, Durham, North Carolina
- Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Shelly L. Gray
- Department of Pharmacy, University of Washington, Seattle, Washington
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25
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Friebe MP, LeGrand JR, Shepherd BE, Breeden EA, Nelson SD. Reducing Inappropriate Outpatient Medication Prescribing in Older Adults across Electronic Health Record Systems. Appl Clin Inform 2020; 11:865-872. [PMID: 33378781 DOI: 10.1055/s-0040-1721398] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND The American Geriatrics Society recommends against the use of certain potentially inappropriate medications (PIMs) in older adults. Prescribing of these medications correlates with higher rates of hospital readmissions, morbidity, and mortality. Vanderbilt University Medical Center previously deployed clinical decision support (CDS) to decrease PIM prescribing rates, but recently transitioned to a new electronic health record (EHR). OBJECTIVE The goal of this study was to evaluate PIM prescribing rates for older adults before and after migration to the new EHR system. METHODS We reviewed prescribing rates of PIMs in adults 65 years and older, normalized per 100 total prescriptions from the legacy and new EHR systems between July 1, 2014 and December 31, 2019. The PIM prescribing rates before and after EHR migration during November 2017 were compared using a U-chart and Poisson regression model. Secondary analysis descriptively evaluated the frequency of prescriber acceptance rates in the new EHR. RESULTS Prescribing rates of PIMs decreased 5.2% (13.5 per 100 prescriptions to 12.8 per 100 prescriptions; p < 0.0001) corresponding to the implementation of alternatives CDS in the legacy EHR. After migration of the alternative CDS from the legacy to the new EHR system, PIM prescribing rates dropped an additional 18.8% (10.4 per 100 prescriptions; p < 0.0001). Acceptance rates of the alternative recommendations for PIMs was low overall at 11.1%. CONCLUSION The prescribing rate of PIMs in adults aged 65 years and older was successfully decreased with the implementation of prescribing CDS. This decrease was not only maintained but strengthened by the transition to a new EHR system.
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Affiliation(s)
- Michael P Friebe
- Lipscomb University College of Pharmacy and Health Sciences, Nashville, Tennessee, United States
| | - Joseph R LeGrand
- HealthIT, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Bryan E Shepherd
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Elizabeth A Breeden
- Lipscomb University College of Pharmacy and Health Sciences, Nashville, Tennessee, United States
| | - Scott D Nelson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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26
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Alshehri S, Alshibani M, Magboul G, Albandar A, Nasser R, Yaqoub RM, Alzuhayri J, Aljabri A. Adherence to Beers Criteria in Geriatrics: A Retrospective Study in a Saudi Teaching Hospital. Geriatrics (Basel) 2020; 5:geriatrics5040097. [PMID: 33233330 PMCID: PMC7709682 DOI: 10.3390/geriatrics5040097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 11/16/2022] Open
Abstract
Background: The aging process makes geriatric populations more prone to various chronic diseases. Such diseases require older patients to be on more medications than any other age group and make them more susceptible to adverse drug events related to potentially inappropriate medications (PIMs). Aim: To identify the prevalence of potentially inappropriate medications among older people and explore the most commonly prescribed PIMs in hospitalized patients. Design and Setting: A retrospective study conducted in a large tertiary hospital among patients hospitalized in a 4 year period from January 2015 to December 2018. Methods: The 2019 Beers Criteria were used to assess PIMs in all inpatient prescribed medications focusing on the first class (i.e., drug/drug class to be avoided in older adults). Results: The mean age was 75.17 ± 7.66 years. A total of 684 (80.6%) patients were prescribed at least one medication listed in the first-class category of the 2019 Beers Criteria. Top five drugs were proton pump inhibitors (40.3%), nonsteroidal anti-inflammatory drugs (10.2%), metoclopramide (9.3%), benzodiazepines (8.4%), and insulin (5.4%). Conclusions: The prevalence of PIMs is high among older patients admitted to the hospital. More efforts are needed to investigate the potential reasons and develop action plans to improve concordance to Beers Criteria among healthcare providers.
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Affiliation(s)
- Samah Alshehri
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz Univeristy, Jeddah 21589, Saudi Arabia; (M.A.); (A.A.)
- Faculty of Pharmacy, University of Arizona, Tucson, AZ 85721, USA
- Correspondence: ; Tel.: +96-65-6436-2332
| | - Mohannad Alshibani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz Univeristy, Jeddah 21589, Saudi Arabia; (M.A.); (A.A.)
- Faculty of Pharmacy, University of Arizona, Tucson, AZ 85721, USA
| | - Ghaydaa Magboul
- Faculty of Medicine, King Abdulaziz Univeristy, Jeddah 21589, Saudi Arabia; (G.M.); (A.A.); (R.N.); (R.M.Y.)
| | - Albandari Albandar
- Faculty of Medicine, King Abdulaziz Univeristy, Jeddah 21589, Saudi Arabia; (G.M.); (A.A.); (R.N.); (R.M.Y.)
| | - Roaa Nasser
- Faculty of Medicine, King Abdulaziz Univeristy, Jeddah 21589, Saudi Arabia; (G.M.); (A.A.); (R.N.); (R.M.Y.)
| | - Roaya M. Yaqoub
- Faculty of Medicine, King Abdulaziz Univeristy, Jeddah 21589, Saudi Arabia; (G.M.); (A.A.); (R.N.); (R.M.Y.)
| | - Jumana Alzuhayri
- Faculty of Science, King Abdulaziz Univeristy, Jeddah 21589, Saudi Arabia;
| | - Ahmed Aljabri
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz Univeristy, Jeddah 21589, Saudi Arabia; (M.A.); (A.A.)
- Department of Pharmacy Practice, Faculty of Pharmacy, University of Tabuk, Tabuk 71491, Saudi Arabia
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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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Saka SA, Oosthuizen F, Nlooto M. Expert consensus on clinical applicability of the American Geriatrics Society-Beers Criteria to older persons in Africa: An exploratory validation study. J Eval Clin Pract 2020; 26:1522-1529. [PMID: 31908081 DOI: 10.1111/jep.13339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 12/02/2019] [Accepted: 12/06/2019] [Indexed: 02/06/2023]
Abstract
RATIONALE, AIMS AND OBJECTIVES There are currently no criteria to guide appropriate prescribing to older persons in Africa. Although the American Geriatrics Society-Beers (AGS-Beers) Criteria appear to be favoured by African researchers, there is a need to adapt its recommendations to the continent's health care systems. This study aimed to adapt the AGS-Beers recommendations to Nigerian and South African health care contexts. METHODS A modified Delphi technique was used to explore Nigerian and South African experts' consensus on the applicability of the 2015 AGS-Beers Criteria recommendations to older persons in Africa. Thirty-two recommendations, 21 from the parent Criteria and 11 modified, were explored among 10 purposively selected medical and pharmacy experts in a predetermined two-round survey that utilized a 5-point Likert scale. Consensus was defined as a lower-limit 95% CI mean ratings of ≥3.0. RESULTS Overall, the experts reached consensus on 62.5% (20/32) of the recommendations and 76.2% (16/21) of the parent AGS-Beers' recommendations specifically. While the experts consensually agreed that medications with strong anticholinergic effects should be generally avoided in older persons, mean = 4.11 (SD = ±1.27, 95% CI, 3.14-5.09), they could not reach a consensus on the context-specific recommendation to avoid amitriptyline in neuropathic pain mean = 3.11 (SD = ±1.05, 95% CI, 2.30-3.92). CONCLUSIONS The 2015 AGS-Beers Criteria were adapted to the Nigerian and South African health care contexts. The adapted and the parent recommendations differed in their context specificity. The recommendations may serve as a guide to clinicians when prescribing medications to older persons in Nigeria and South Africa.
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Affiliation(s)
- Sule Ajibola Saka
- Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Westville Campus, Durban, South Africa
| | - Frasia Oosthuizen
- Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Westville Campus, Durban, South Africa
| | - Manimbulu Nlooto
- Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Westville Campus, Durban, South Africa
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Saka SA, Oosthuizen F, Nlooto M, Odusan O. The knowledge, awareness, and perception of healthcare professionals about appropriate prescribing in the elderly: Findings from Nigeria and South Africa. J Eval Clin Pract 2020; 26:1512-1521. [PMID: 31898394 DOI: 10.1111/jep.13347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 12/18/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Inappropriate prescribing is associated with preventable morbidity and mortality in the elderly. The American Geriatrics-Beers (AGS-Beers) Criteria was developed to guide healthcare professionals (HCPs) to prescribe medications appropriately in the elderly. However, there is a dearth of information about the knowledge and awareness of HCPs of these criteria, and their perceptions of appropriate prescribing in the elderly. This study aimed to evaluate the knowledge and perceptions of Nigerian and South African HCPs about appropriate prescribing in the elderly. METHOD A 32-item questionnaire was self-administered among consecutively selected HCPs (physicians, nurses, and pharmacists) in one teaching hospital each in Nigeria and South Africa. Seven questions including six clinical vignettes from the 2015 AGS-Beers Criteria were used to assess the participants' knowledge.The participants' knowledge was classified based on the total score as poor (0-3), fair (4, 5), and good (6, 7). The HCPs' perceptions of appropriate prescribing in the elderly were evaluated using a 5-point Likert scale. Mann-Whitney U test was used to evaluate ranked variables at P < .05. RESULTS A total of 369 participants, 62.9% (232/369) mean age 42.75(9.35) years in Nigeria and 37.1% (137/369), mean age 38.66 (7.76) years, (CI = 2.32-5.87, P < .001) in South Africa were evaluated. Many participants in Nigeria (52.6%) and 48.2% in South Africa had scores (4, 5).The majority of the participants (57.3%) in Nigeria and 67.2% in South Africa were not aware of any explicit criteria for prescribing to the elderly while 45.8% of the total participants with no significant difference between the groups (P = .332) "strongly agreed" or "agreed" that the basic professional training is adequate for prescribing medicines to the elderly. CONCLUSIONS Many HCPs in Nigeria and South Africa had a fair knowledge of appropriate prescribing to the elderly and considered basic professional training as adequate for appropriate prescribing to the elderly.
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Affiliation(s)
- Sule A Saka
- Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Frasia Oosthuizen
- Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Manimbulu Nlooto
- Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Olatunde Odusan
- Department of Medicine, Obafemi Awolowo College of Health Sciences, Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria
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Reducing high-risk medication use through pharmacist-led interventions in an outpatient setting. J Am Pharm Assoc (2003) 2020; 60:e86-e92. [DOI: 10.1016/j.japh.2020.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 01/09/2020] [Accepted: 01/20/2020] [Indexed: 11/23/2022]
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Moebs I, Abeln E, Siefert A, Barak Y. Potentially Inappropriate Medications in a Psychogeriatric Inpatient Ward: An Audit Based on Beers Criteria. Neurol Ther 2020; 9:151-157. [PMID: 32304025 PMCID: PMC7229050 DOI: 10.1007/s40120-020-00188-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Older adults are often prescribed a high number of medications. Overcoming inaction in health care is difficult but essential to deprescribing potentially inappropriate medications (PIMs). Curbing the use of PIMs is urgent in older adults suffering from psychiatric illness, as cognitive, emotional and psychosocial adversity makes them an especially vulnerable group. We aimed to audit PIM usage and deprescribing in an old-age psychiatry inpatient service of a university-affiliated public hospital. METHODS The 2015 American Geriatrics Society (AGS) Beers Criteria were used in the present study. Computerized medical records were reviewed for all patients discharged from the Dunedin Public Hospital Inpatient Psychogeriatric Ward during the period January 2017 to December 2017. RESULTS During the 1-year study period, 136 patients were discharged from our psychogeriatrics inpatient ward, including 87 women and 49 men, with a mean age of 75.4 ± 8.6 years (range: 59-95). The mean number of medications prescribed per patient at the time of admission was 7.7. At discharge, a mean of 8.9 medications were recorded. Analysis focused on 120 complete patient records. Of the 49 patients with 63 high-risk medications, 16 patients (prescribed 19 high-risk medications) had their high-risk medication stopped, 23 patients (prescribed 24 high-risk medications) had high-risk medications started and 10 (prescribed 20 high-risk medications) had no change to high-risk medications between admission and discharge. In 56 of 120 patients (47%), benzodiazepines (BZDs) were started, stopped or unchanged. CONCLUSION Older adults suffering from severe psychiatric disorders are frequently prescribed PIMs. However, clinical decision-making for this vulnerable population needs to take into account safety as reflected by the Beers Criteria, but also the complexity of managing psychogeriatric problems.
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Affiliation(s)
| | - Esther Abeln
- Southern District Health Board, Dunedin, New Zealand
| | | | - Yoram Barak
- Southern District Health Board, Dunedin, New Zealand.
- Department Psychological Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
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Peng J, Zhu L, Wang Y, Chen J. Mining Relationships among Multiple Entities in Biological Networks. IEEE/ACM TRANSACTIONS ON COMPUTATIONAL BIOLOGY AND BIOINFORMATICS 2020; 17:769-776. [PMID: 30872239 DOI: 10.1109/tcbb.2019.2904965] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Identifying topological relationships among multiple entities in biological networks is critical towards the understanding of the organizational principles of network functionality. Theoretically, this problem can be solved using minimum Steiner tree (MSTT) algorithms. However, due to large network size, it remains to be computationally challenging, and the predictive value of multi-entity topological relationships is still unclear. We present a novel solution called Cluster-based Steiner Tree Miner (CST-Miner) to instantly identify multi-entity topological relationships in biological networks. Given a list of user-specific entities, CST-Miner decomposes a biological network into nested cluster-based subgraphs, on which multiple minimum Steiner trees are identified. By merging all of them into a minimum cost tree, the optimal topological relationships among all the user-specific entities are revealed. Experimental results showed that CST-Miner can finish in nearly log-linear time and the tree constructed by CST-Miner is close to the global minimum.
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Burningham Z, Jackson GL, Kelleher J, Stevens M, Morris I, Cohen J, Maloney G, Vaughan CP. The Enhancing Quality of Prescribing Practices for Older Veterans Discharged From the Emergency Department (EQUIPPED) Potentially Inappropriate Medication Dashboard: A Suitable Alternative to the In-person Academic Detailing and Standardized Feedback Reports of Traditional EQUIPPED? Clin Ther 2020; 42:573-582. [DOI: 10.1016/j.clinthera.2020.02.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/15/2020] [Accepted: 02/20/2020] [Indexed: 11/25/2022]
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Brown JD. Potential Adverse Drug Events with Tetrahydrocannabinol (THC) Due to Drug-Drug Interactions. J Clin Med 2020; 9:jcm9040919. [PMID: 32230864 PMCID: PMC7231229 DOI: 10.3390/jcm9040919] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/16/2020] [Accepted: 03/23/2020] [Indexed: 12/13/2022] Open
Abstract
Tetrahydrocannabinol (THC) is the primary psychoactive ingredient in cannabis. While the safety of THC and cannabis has been extrapolated from millennia of recreational use, medical marijuana programs have increased exposure among medically complex individuals with comorbid conditions and many co-prescribed medications. Thus, THC should be recognized as a pharmacologically complex compound with potential for drug–drug interactions and adverse drug events. This review summarizes potential adverse drug events related to THC when combined with other medications. Metabolic drug–drug interactions are primarily due to THC conversion by CYP3A4 and CYP2C9, which can be impacted by several common medications. Further, CYP2C9 polymorphisms are highly prevalent in certain racial groups (up to 35% in Caucasians) and increase the bioavailability of THC. THC also has broad interactions with drug-metabolizing enzymes and can enhance adverse effects of other medications. Pharmacodynamic interactions include neurological effects, impact on the cardiovascular system, and risk of infection. General clinical recommendations for THC use include starting with low doses and titrating to desired effects. However, many interactions may be unavoidable, dose-limiting, or a barrier to THC-based therapy. Future work and research must establish sufficient data resources to capture medical marijuana use for such studies. Meanwhile, clinicians should balance the potential risks of THC and cannabis and the lack of strong evidence of efficacy in many conditions with patient desires for alternative therapy.
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Affiliation(s)
- Joshua D Brown
- Center for Drug Evaluation & Safety, Consortium for Medical Marijuana Clinical Outcomes Research, Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, FL 32610, USA
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Moga DC, Beech BF, Abner EL, Schmitt FA, El Khouli RH, Martinez AI, Eckmann L, Huffmyer M, George R, Jicha GA. INtervention for Cognitive Reserve Enhancement in delaying the onset of Alzheimer's Symptomatic Expression (INCREASE), a randomized controlled trial: rationale, study design, and protocol. Trials 2019; 20:806. [PMID: 31888732 PMCID: PMC6937673 DOI: 10.1186/s13063-019-3993-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 12/11/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The course of Alzheimer's disease (AD) includes a 10-20-year preclinical period with progressive accumulation of amyloid β (Aβ) plaques and neurofibrillary tangles in the absence of symptomatic cognitive or functional decline. The duration of this preclinical stage in part depends on the rate of pathologic progression, which is offset by compensatory mechanisms, referred to as cognitive reserve (CR). Comorbid medical conditions, psychosocial stressors, and inappropriate medication use may lower CR, hastening the onset of symptomatic AD. Here, we describe a randomized controlled trial (RCT) designed to test the efficacy of a medication therapy management (MTM) intervention to reduce inappropriate medication use, bolster cognitive reserve, and ultimately delay symptomatic AD. METHODS/DESIGN Our study aims to enroll 90 non-demented community-dwelling adults ≥ 65 years of age. Participants will undergo positron emission tomography (PET) scans, measuring Aβ levels using standardized uptake value ratios (SUVr). Participants will be randomly assigned to MTM intervention or control, stratified by Aβ levels, and followed for 12 months via in-person and telephone visits. Outcomes of interest include: (1) medication appropriateness (measured with the Medication Appropriateness Index (MAI)); (2) scores from Trail Making Test B (TMTB), Montreal Cognitive Assessment (MoCA), and California Verbal Learning Test (CVLT); (3) perceived health status (measured with the SF-36). We will also evaluate pre- to post-intervention change in: (1) use of inappropriate medications as measured by MAI; 2) CR Change Score (CRCS), defined as the difference in scopolamine-challenged vs unchallenged cognitive scores at baseline and follow-up. Baseline Aβ SUVr will be used to examine the relative impact of preclinical AD (pAD) pathology on CRCS, as well as the interplay of amyloid burden with inappropriate medication use. DISCUSSION This manuscript describes the protocol of INCREASE ("INtervention for Cognitive Reserve Enhancement in delaying the onset of Alzheimer's Symptomatic Expression"): a randomized controlled trial that investigates the impact of deprescribing inappropriate medications and optimizing medication regimens on potentially delaying the onset of symptomatic AD and AD-related dementias. TRIAL REGISTRATION ClinicalTrials.gov, NCT02849639. Registered on 29 July 2016.
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Affiliation(s)
- Daniela C Moga
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA.
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY, USA.
- Sanders-Brown Center on Aging, Lexington, KY, USA.
| | | | - Erin L Abner
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY, USA
- Sanders-Brown Center on Aging, Lexington, KY, USA
| | - Frederick A Schmitt
- Sanders-Brown Center on Aging, Lexington, KY, USA
- Department of Neurology, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Riham H El Khouli
- Department of Radiology, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Ashley I Martinez
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Lynne Eckmann
- PRO2RX LLC Pharmacy Consulting Services, Lexington, KY, USA
| | - Mark Huffmyer
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
- PRO2RX LLC Pharmacy Consulting Services, Lexington, KY, USA
| | - Rosmy George
- Sanders-Brown Center on Aging, Lexington, KY, USA
| | - Gregory A Jicha
- Sanders-Brown Center on Aging, Lexington, KY, USA
- Department of Neurology, College of Medicine, University of Kentucky, Lexington, KY, USA
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Motter FR, Hilmer SN, Paniz VMV. Pain and Inflammation Management in Older Adults: A Brazilian Consensus of Potentially Inappropriate Medication and Their Alternative Therapies. Front Pharmacol 2019; 10:1408. [PMID: 31849664 PMCID: PMC6901010 DOI: 10.3389/fphar.2019.01408] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 11/05/2019] [Indexed: 12/19/2022] Open
Abstract
Purpose: The aim of the present study was to develop and validate a Potentially Inappropriate Medications (PIM) list and alternative therapies for treatment of pain and inflammation in older people adapted to the Brazilian context. Methods: A preliminary PIM list suitable for the Brazilian market was developed on the basis of three published international PIM lists [Beers 2015, Screening Tool of Older People’s Potentially Inappropriate Prescriptions - 2015, European Union (7) PIM list]. We used the modified Delphi technique (two-round) to validate concerns of use and alternative therapies related to PIM for treatment of pain and inflammation in older adults ≥65 years in Brazil. The panel involved nine Brazilian experts in geriatric pharmacotherapy. All items with mean Likert scale score ≥4.0 (agree) and the lower limit of 95% confidence interval ≥4.0 were considered validated in this study. Results: At the end of the consensus process, 94 (65.3%) items of 144 were validated. In total, consensus was reached for 33/35 (94.3%) concerns about drugs that should be avoided in older patients regardless of diagnosis, for 22/23 (95.7%) concerns about drugs that should be avoided in older patients with specific conditions or diseases, for 11/23 (47.8%) with special considerations of use, and for 28/63 (44.4%) of therapeutic alternatives. Conclusion: Although these criteria are not designed to replace clinical judgement, PIM and alternative therapies lists can be useful to inform prescribers, pharmacists, and health care planners and may serve as a starting point for safe and effective use of medications in older people.
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Affiliation(s)
- Fabiane Raquel Motter
- Postgraduate Program in Collective Health, University of Vale do Rio dos Sinos (UNISINOS), São Leopoldo, Brazil.,Kolling Institute of Medical Research, Royal North Shore 83 Hospital, St. Leonards, NSW, Australia
| | - Sarah Nicole Hilmer
- Kolling Institute of Medical Research, Royal North Shore 83 Hospital, St. Leonards, NSW, Australia
| | - Vera Maria Vieira Paniz
- Postgraduate Program in Collective Health, University of Vale do Rio dos Sinos (UNISINOS), São Leopoldo, Brazil
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Mantri S, Fullard M, Gray SL, Weintraub D, Hubbard RA, Hennessy S, Willis AW. Patterns of Dementia Treatment and Frank Prescribing Errors in Older Adults With Parkinson Disease. JAMA Neurol 2019; 76:41-49. [PMID: 30285047 DOI: 10.1001/jamaneurol.2018.2820] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Importance Dementia is common in Parkinson disease, but few data exist on dementia treatment patterns or the concurrent use of acetylcholinesterase inhibitors (ACHEIs) and anticholinergic medications, a frank prescribing error. Objectives To describe dementia treatment patterns, and to determine the extent to which the concurrent use of ACHEIs and drugs with strong anticholinergic activity occurs among individuals with Parkinson disease in the United States. Design, Setting, and Participants This cross-sectional analysis included adult Medicare beneficiaries (aged 65 years or older) with Parkinson disease diagnosis with 12 consecutive months of inpatient, outpatient, and prescription drug coverage from January 1, 2014, through December 31, 2014. Beneficiaries with other parkinsonian syndromes were excluded. Demographic, geographic, prescription claims, and other data were extracted from the 2014 Carrier, Beneficiary Summary, and Prescription Drug Event research identifiable files of the Centers for Medicare & Medicaid Services. Data analysis was conducted from August 1, 2017, to November 30, 2017. Main Outcomes and Measures Primary outcomes were use of dementia drug, specific dementia medication, and concurrent exposure to a high-potency anticholinergic drug and an ACHEI. Descriptive analyses and multivariable logistic regression models determined the extent to which patient characteristics and comorbid conditions were associated with dementia treatment or with a high-potency anticholinergic and ACHEI never event. Results Of 268 407 Medicare beneficiaries with Parkinson disease (mean [SD] age, 78.9 [7.5]; 134 575 male [50.1%]), most were identified in the files as white (232 831 [86.7%]), followed by black (14 629 [5.5%]), Hispanic (7176 [2.7%]), Asian (7115 [2.7%]), and Native American (874 [0.3%]). Among these beneficiaries, 73 093 (27.2%) were given a prescription for at least 1 antidementia medication. The most commonly prescribed medication was donepezil hydrochloride (46 027 [63.0%] users), followed by memantine hydrochloride (30 578 [41.8%] users) and rivastigmine tartrate (19 278 [26.4%] users). Dementia drugs were more likely to be prescribed to black (adjusted odds ratio [AOR], 1.33; 95% CI, 1.28-1.38) and Hispanic (AOR, 1.28; 95% CI, 1.22-1.35) beneficiaries and less likely for Native American beneficiaries (AOR, 0.62; 95% CI, 0.51-0.74). Women were less likely than men to be given a prescription for dementia medication (AOR, 0.85; 95% CI, 0.84-0.87). Of the 64 017 beneficiaries receiving an ACHEI, 28 495 (44.5%) experienced at least 1 high-potency anticholinergic-ACHEI event. Hispanic (AOR, 1.11; 95% CI, 1.00-1.23) and women (AOR, 1.30; 95% CI, 1.25-1.35) beneficiaries had greater odds of experiencing this never event. Statistically significant clusters of the prevalence of this prescribing error were observed across the United States (Moran I = 0.24; P < .001), with clusters of high prevalence in the southern and midwestern states. Conclusions and Relevance Dementia medication use by persons with Parkinson disease varies by race/ethnicity and sex; potentially inappropriate prescribing is common among those being treated for cognitive impairment and varies by race/ethnicity, sex, and geography. These findings may serve as national and local targets for improving care quality and outcomes for persons with Parkinson disease.
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Affiliation(s)
- Sneha Mantri
- Parkinson's Disease Research, Education, and Clinical Center, Philadelphia VA Medical Center, Philadelphia, Pennsylvania.,Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Michelle Fullard
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Shelly L Gray
- School of Pharmacy, University of Washington, Seattle
| | - Daniel Weintraub
- Department of Psychiatry, The Hospital at the University of Pennsylvania, Philadelphia
| | - Rebecca A Hubbard
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Allison W Willis
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,School of Pharmacy, University of Washington, Seattle.,Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Ailabouni NJ, Marcum ZA, Schmader KE, Gray SL. Medication Use Quality and Safety in Older Adults: 2018 Update. J Am Geriatr Soc 2019; 67:2458-2462. [PMID: 31765004 DOI: 10.1111/jgs.16243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/20/2019] [Accepted: 10/04/2019] [Indexed: 01/04/2023]
Abstract
Improving the quality of medication use and medication safety is an important priority for prescribers who care for older adults. The objective of this article was to identify key articles from 2018 that address these issues. In addition, we selected four of these articles to annotate, critique, and discuss their broader implications for clinical practice. The first study highlights a cluster-randomized trial that utilized a pharmacist-led education-based intervention delivered to both patients and physicians to deprescribe four types of inappropriate medications (sedative-hypnotics, first-generation antihistamines, selective nonsteroidal anti-inflammatory drugs, and glyburide). The second study, a nested case-control study using data from within the UK Clinical Practice Research Datalink, examined the association between anticholinergic exposure, overall and by anticholinergic medication class, and dementia risk in 40 770 older adults. The third study, a longitudinal cohort study of 1028 Swedish older adults, examined the association between antihypertensive medications and incident dementia. The last study was a randomized, double-blind, placebo-controlled trial that investigated the effect of daily low-dose aspirin (100 mg) for primary prevention on cardiovascular events and major hemorrhage in 19 144 community-dwelling older adults. Collectively, this current article provides insight into the pertinent topics of medication use quality and safety in older adults and helps raise awareness about optimal prescribing in older adults. J Am Geriatr Soc 67:2458-2462, 2019.
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Affiliation(s)
| | - Zachary A Marcum
- Department of Pharmacy, University of Washington, Seattle, Washington
| | - Kenneth E Schmader
- Department of Medicine (Geriatrics), School of Medicine, Duke University Medical Center, Durham, North Carolina.,Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Shelly L Gray
- Department of Pharmacy, University of Washington, Seattle, Washington
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Vatcharavongvan P, Puttawanchai V. Potentially inappropriate medications among the elderly in primary care in Thailand from three different sets of criteria. Pharm Pract (Granada) 2019; 17:1494. [PMID: 31592037 PMCID: PMC6763309 DOI: 10.18549/pharmpract.2019.3.1494] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 08/05/2019] [Indexed: 11/17/2022] Open
Abstract
Objective: The primary objective was to examine potentially inappropriate medications
(or PIMs) in the elderly using three different criteria: Beers 2015, STOPP
version 2, and Winit-Watjana (for Thai elderly patients). The secondary
objective was to examine PIM-related factors. Methods: This is a retrospective cross-sectional study. Eligible patients were aged
≥65 years in a primary care unit. Demographic data, medical
prescriptions in the past year, clinical data and diagnoses were collected
from electronic medical records. PIMs, including the use of ≥2
medications, were identified using the three criteria. Descriptive and
analytical statistics were conducted. The type I error was 0.05. Multiple
logistic regression analysis was used to examine associations between PIMs
and other factors. Results: A total of 400 patients were recruited, and 1,640 prescriptions were
reviewed. The median age was 70.5 years, and the median numbers of diseases,
medications, and prescriptions were 3 (interquartile range or IQR=2), 11
(IQR=20), and 3 (IQR=4), respectively. Of all the patients, 213
(53.3%) showed a use of ≥5 medications, and 301 (75.3%)
were prescribed PIMs. Of the 1,640 prescriptions, 60% had at least
one PIM. The Winit-Watjana criteria, Beers 2015 criteria and STOPP version 2
identified 66.8%, 59.0% and 40.3% of the patients
receiving PIMs, respectively. Approximately 16% of the patients
showed at least one potential drug-drug interaction. The use of duplicate
drug classes accounted for the highest proportion of potential drug-drug
interactions (41.3%). Polypharmacy (odds ratio or OR 3.93, 95%
confidence interval or 95%CI 2.17-71.2) and the presence of ≥4
diseases (OR 2.78, 95%CI 1.39-5.56) were associated with PIMs. Conclusions: PIMs are common among the elderly patients in primary care in Thailand.
Prescriptions of the elderly with polypharmacy or multiple concurrent
diagnoses should be reviewed for PIMs because they have a high chance of
receiving PIMs.
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Affiliation(s)
- Pasitpon Vatcharavongvan
- Department of Community Medicine and Family Medicine, Faculty of Medicine, Thammasat University. Pathum-Thani (Thailand).
| | - Viwat Puttawanchai
- Department of Community Medicine and Family Medicine, Faculty of Medicine, Thammasat University. Pathum-Thani (Thailand).
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Santos TOD, Nascimento MMGD, Nascimento YA, Oliveira GCBD, Martins UCDM, Silva DFD, Oliveira DRD. Drug interactions among older adults followed up in a comprehensive medication management service at Primary Care. EINSTEIN-SAO PAULO 2019; 17:eAO4725. [PMID: 31460618 PMCID: PMC6706225 DOI: 10.31744/einstein_journal/2019ao4725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 02/27/2019] [Indexed: 11/25/2022] Open
Abstract
Objective: To estimate the prevalence of drug interactions and associated factors among older adults followed up in a Comprehensive Medication Management Service at Primary Care. Methods: Firstly, the Beers criteria 2015 was used to define drug interactions; later, drug interactions proposed by Dumbreck for patients with diabetes, depression, and heart failure were evaluated. The associated factors were assessed by univariate (Pearson's χ2) and multivariate analyses (logistic regression). The significance level of 5% was set for all analyses. Results: The mean age of the studied population was 70.2±7.8 years; 52.2% were between 60 and 69 years, and 61.3% were female. Among the older adults, 94.5% used two or more drugs (condition for the occurrence of drug-drug interaction). The prevalence of drug interaction according to the Beers criteria was 4.9%. After multivariate analysis, diseases of the central nervous system, arrhythmia, number of medications, and female sex were positively associated with drug interaction. The prevalence of drug interaction according to Dumbreck was 27.2%. After multivariate analysis, the number of medications, the presence of heart failure, and Charlson comorbidity index greater than 1 were conditions positively associated with drug interactions. Conclusion: The holistic and individualized approach used in comprehensive medication management services for older patients is important, considering the prevalence of drug interactions and the need to minimize adverse events.
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Affiliation(s)
- Tayane Oliveira Dos Santos
- Centro de Estudos em Atenção Farmacêutica, Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | | | - Yone Almeida Nascimento
- Centro de Estudos em Atenção Farmacêutica, Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | | | | | - Danielle Fernandes da Silva
- Centro de Estudos em Atenção Farmacêutica, Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Djenane Ramalho de Oliveira
- Centro de Estudos em Atenção Farmacêutica, Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
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Anticholinergic and sedative medications exposure in older patients: a cross-sectional study. Int J Clin Pharm 2019; 41:1152-1158. [DOI: 10.1007/s11096-019-00885-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 07/27/2019] [Indexed: 10/26/2022]
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Blanco-Reina E, Valdellós J, Aguilar-Cano L, García-Merino MR, Ocaña-Riola R, Ariza-Zafra G, Bellido-Estévez I. 2015 Beers Criteria and STOPP v2 for detecting potentially inappropriate medication in community-dwelling older people: prevalence, profile, and risk factors. Eur J Clin Pharmacol 2019; 75:1459-1466. [PMID: 31338540 DOI: 10.1007/s00228-019-02722-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 07/11/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE To comparatively assess the prevalence rates of potentially inappropriate medications (PIMs) obtained by the former and latest versions of American Geriatrics Society Beers Criteria (AGS BC) and screening tool of older person's potentially inappropriate prescriptions (STOPP), and analyze the factors of influence on PIM. METHODS Cross-sectional study including 582 community-dwelling older adults over the age of 65. Sociodemographic, clinical, functional, and comprehensive drug therapy data were collected. The primary endpoint was the percentage of patients receiving at least one PIM. RESULTS A total of 3626 prescriptions were analyzed. PIMs were detected in 35.4% and 47.9% of patients according to the STOPP v1 and the 2012 AGS BC, respectively. This percentage rose to 54% when 2015 AGS BC were used and reached 66.8% with STOPP v2. The kappa coefficient between STOPP v2 and its former version was lower than the one between the updated Beers Criteria and their former version (0.41 vs 0.85). The agreement was good (0.65) between both latest criteria. The number of medications, psychological disorders, and insomnia were predictors of PIM. A novel finding was that bone and joint disorders increased the odds for PIM by 78%. CONCLUSIONS The 2015 AGS BC showed high sensitivity and good applicability to the European older patients. Both updated tools identified some pharmacological groups (benzodiazepines, PPIs, and opioids, among others) and certain health problems (insomnia, psychological disorders, and osteoarticular diseases) as factors of influence on PIM. Based on these findings, interventions aimed at promoting appropriate use of medications should be developed.
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Affiliation(s)
- Encarnación Blanco-Reina
- Pharmacology and Therapeutics Department, School of Medicine, Instituto de Investigación Biomédica de Málaga-IBIMA, University of Málaga, Campus de Teatinos, Boulevard Louis Pasteur, 32, 29071, Málaga, Spain.
| | | | | | | | | | - Gabriel Ariza-Zafra
- Geriatrics Department, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Inmaculada Bellido-Estévez
- Pharmacology and Therapeutics Department, School of Medicine, Instituto de Investigación Biomédica de Málaga-IBIMA, University of Málaga, Campus de Teatinos, Boulevard Louis Pasteur, 32, 29071, Málaga, Spain
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43
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Abstract
Appropriate selection and dosing of medications is essential when prescribing for older adults. Opioids are commonly employed to treat pain but must be approached with caution due to potentially dangerous adverse reactions. This article provides strategies for safely prescribing opioids for pain in older adults.
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44
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Mecca MC, Thomas JM, Niehoff KM, Hyson A, Jeffery SM, Sellinger J, Mecca AP, Van Ness PH, Fried TR, Brienza R. Assessing an Interprofessional Polypharmacy and Deprescribing Educational Intervention for Primary Care Post-graduate Trainees: a Quantitative and Qualitative Evaluation. J Gen Intern Med 2019; 34:1220-1227. [PMID: 30972554 PMCID: PMC6614292 DOI: 10.1007/s11606-019-04932-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 11/30/2018] [Accepted: 02/26/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Polypharmacy and potentially inappropriate medications (PIMs) are increasingly common and associated with adverse health effects. However, post-graduate education in polypharmacy and complex medication management for older adults remain limited. OBJECTIVE The Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) polypharmacy clinic was created to provide a platform for teaching internal medicine (IM) and nurse practitioner (NP) residents about outpatient medication management and deprescribing for older adults. We aimed to assess residents' knowledge of polypharmacy and perceptions of this interprofessional education intervention. DESIGN A prospective cohort study with an internal comparison group. PARTICIPANTS IM residents and NP residents; Veterans ≥ 65 years and taking ≥ 10 medications. INTERVENTION IMPROVE consists of a pre-clinic conference, shared medical appointment, individual appointment, and interprofessional precepting model. MAIN MEASURES We assessed residents' performance on a pre-post knowledge test, residents' qualitative assessment of the educational impact of IMPROVE, and the number and type of medications discontinued or decreased. KEY RESULTS The IMPROVE intervention group (n = 18) had a significantly greater improvement in test scores than the control group (n = 18) (14% ± 15% versus - 1.3% ± 16%) over a period of 6 months (Wilcoxon rank sum, p = 0.019). In focus groups, residents (n = 17) reported perceived improvements in knowledge and skills, noting that the experience changed their practice in other clinical settings. In addition, residents valued the unique interprofessional experience. Veterans (n = 71) had a median of 15 medications (IQR 12-19), and a median of 2 medications (IQR 1-3) was discontinued. Vitamins, supplements, and cardiovascular medications were the most commonly discontinued medications, and cardiovascular medications were the most commonly decreased in dose or frequency. CONCLUSIONS Overall, IMPROVE is an effective model of post-graduate primary care training in complex medication management and deprescribing that improves residents' knowledge and skills, and is perceived by residents to influence their practice outside the program.
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Affiliation(s)
- Marcia C Mecca
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA.
- Center of Excellence in Primary Care Education, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, USA.
| | - John M Thomas
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
- Center of Excellence in Primary Care Education, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Dominican House of Studies, Pontifical Faculty of the Immaculate Conception, Washington, DC, USA
| | - Kristina M Niehoff
- Vanderbilt University Medical Center, Nashville, TN, USA
- Integrated Care Partners, Hartford HealthCare Group, Wethersfield, CT, USA
| | - Anne Hyson
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Sean M Jeffery
- Integrated Care Partners, Hartford HealthCare Group, Wethersfield, CT, USA
- University of Connecticut School of Pharmacy, Storrs, CT, USA
| | - John Sellinger
- Center of Excellence in Primary Care Education, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Psychology, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Adam P Mecca
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Peter H Van Ness
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
- Program on Aging, Yale School of Medicine, New Haven, CT, USA
| | - Terri R Fried
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
- Integrated Care Partners, Hartford HealthCare Group, Wethersfield, CT, USA
- Program on Aging, Yale School of Medicine, New Haven, CT, USA
| | - Rebecca Brienza
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
- Center of Excellence in Primary Care Education, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
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45
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Sobieraj DM, Martinez BK, Hernandez AV, Coleman CI, Ross JS, Berg KM, Steffens DC, Baker WL. Adverse Effects of Pharmacologic Treatments of Major Depression in Older Adults. J Am Geriatr Soc 2019; 67:1571-1581. [DOI: 10.1111/jgs.15966] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/12/2019] [Accepted: 03/15/2019] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Adrian V. Hernandez
- University of Connecticut School of Pharmacy Storrs Connecticut
- Vicerrectorado de Investigacion, Universidad SanIgnacio de Loyola (USIL) Lima Peru
| | | | - Joseph S. Ross
- Yale University School of Medicine and School of Public Health New Haven Connecticut
| | - Karina M. Berg
- University of Connecticut School of Medicine Farmington Connecticut
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46
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Magnuson A, Sattar S, Nightingale G, Saracino R, Skonecki E, Trevino KM. A Practical Guide to Geriatric Syndromes in Older Adults With Cancer: A Focus on Falls, Cognition, Polypharmacy, and Depression. Am Soc Clin Oncol Educ Book 2019; 39:e96-e109. [PMID: 31099668 DOI: 10.1200/edbk_237641] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Geriatric syndromes are multifactorial conditions that are prevalent in older adults. Geriatric syndromes are believed to develop when an individual experiences accumulated impairments in multiple systems that compromise their compensatory ability. In older adults with cancer, the presence of a geriatric syndrome is common and may increase the complexity of cancer treatment. In addition, the physiologic stress of cancer and cancer treatment may precipitate or exacerbate geriatric syndromes. Common geriatric syndromes include falls, cognitive syndromes and delirium, depression, and polypharmacy. In the oncology setting, the presence of geriatric syndromes is relevant; falls and cognitive problems have been shown to be predictive of chemotherapy toxicity and overall survival. Polypharmacy and depression are more common in older adults with cancer compared with the general geriatric population. Multiple screening tools exist to identify falls, cognitive problems, polypharmacy, and depression in older adults and can be applied to the oncology setting to identify patients at risk. When recognized, several interventions exist that could be considered for this vulnerable population. We review the available evidence of four geriatric syndromes in the oncology setting, including clinical implications, validated screening tools, potential supportive care, and therapeutic interventions.
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Affiliation(s)
- Allison Magnuson
- 1 Department of Medicine, Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, NY
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47
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Characteristic of drug-related problems and pharmacists' interventions in a stroke unit in Thailand. Int J Clin Pharm 2019; 41:880-887. [PMID: 31054061 DOI: 10.1007/s11096-019-00832-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 04/10/2019] [Indexed: 01/01/2023]
Abstract
Background Little information is available regarding pharmacist's intervention to solve drug-related problems (DRPs) in a stroke unit. Objective To investigate the nature and frequency of DRPs along with the role of pharmacists in a stroke unit. Setting The study was conducted at the stroke unit of Siriraj hospital, a university affiliated tertiary care hospital in Thailand. Method A retrospective descriptive study of DRPs and pharmacists' interventions for stroke patients was performed during July 2015 to December 2016. Data were collected from patient's medical records and pharmacist's intervention record forms. DRPs were categorized using the Hepler-Strand classification. The stroke pharmacist team, consisting of a board-certified pharmacotherapy specialist, neurology pharmacy residents and stroke unit pharmacists, participated in the multidisciplinary ward round in the stroke unit 5 days a week. All patients were visited by a member of the stroke pharmacist team within the first two days of their admission to conduct a thorough review of drug therapy for every patient and provided appropriate recommendation to the multidisciplinary team either verbally during the ward round or with written information in the patients' medical charts, as appropriate. Main Outcome Measure (a) incidence and characteristics of DRPs (b) types and the acceptance of pharmacists' interventions. Results A total of 859 patients were admitted, of those, 768 patients had ≥ 1 DRPs and a total of 796 DRPs were identified. Clinical pharmacists provided 659 interventions to the multidisciplinary team. The most common DRPs identified were "untreated indications" (22.6%) and "non-compliance" (21.0%). Of all DRPs, 74.6% were stroke related issues. The most implicated drugs were antihypertensive drugs, followed by antithrombotic therapies. The multidisciplinary team accepted 84.7% of pharmacists' interventions. Conclusion DRP in a stroke unit is common. Clinical pharmacists in a stroke unit can effectively reduce and prevent DRPs with the focus on performing medication reconciliation, providing recommendation on dosage adjustment and proper drug selection for stroke patients.
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48
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Antidepressant Induced Hallucinations, Rhabdomyolysis, and Hyperkalemia in the Geriatric Population: A Case Overview. J Emerg Nurs 2019; 45:312-315. [DOI: 10.1016/j.jen.2018.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 07/20/2018] [Accepted: 08/25/2018] [Indexed: 11/21/2022]
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Green AR, Reifler LM, Bayliss EA, Weffald LA, Boyd CM. Drugs Contributing to Anticholinergic Burden and Risk of Fall or Fall-Related Injury among Older Adults with Mild Cognitive Impairment, Dementia and Multiple Chronic Conditions: A Retrospective Cohort Study. Drugs Aging 2019; 36:289-297. [PMID: 30652263 DOI: 10.1007/s40266-018-00630-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND It is not known whether drugs with different anticholinergic ratings contribute proportionately to overall anticholinergic score. OBJECTIVES Our objective was to assess the risk of falls or fall-related injuries as a function of the overall anticholinergic score resulting from drugs with different anticholinergic ratings among people with impaired cognition. METHODS This was a retrospective cohort study of adults aged ≥ 65 years with mild cognitive impairment (MCI) or dementia and two or more additional chronic conditions (N = 10,698) in an integrated delivery system. Electronic health record data, including pharmacy fills and diagnosis claims, were used to assess anticholinergic medication use, quantified using the anticholinergic cognitive burden (ACB) scale, falls and fall-related injuries. RESULTS During a median follow-up of 366 days, 63% of the cohort used one or more ACB drug; 2015 (18.8%) people experienced a fall or fall-related injury. Among patients with a daily ACB score of 5, the greatest increase in risk of falls or fall-related injuries was seen when level 2 and level 3 drugs were used in combination [hazard ratio (HR) 2.06; 95% confidence interval (CI) 1.51-2.83]. Multiple ACB level 1 drugs taken together also increased the hazard of a fall or fall-related injury (HR 1.16; 95% CI 1.03-1.32). The risk of fall or fall-related injury as a function of exposure to ACB level 2 drugs (HR 1.56; 95% CI 1.16-2.10) was higher than that for ACB level 1 or 3 drugs. CONCLUSIONS The same daily ACB score was associated with a different degree of risk, depending on the ACB ratings of the individual drugs comprising the score. Combinations of level 2 and level 3 drugs had the greatest risk of fall or fall-related injury relative to other individuals with the same daily ACB score. Low-potency anticholinergic drugs taken together modestly increased the hazard of a fall or fall-related injury.
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Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Mason F. Lord Center Tower, 7th Floor, 5200 Eastern Avenue, Baltimore, MD, 21224, USA.
| | - Liza M Reifler
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA.,Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Linda A Weffald
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA.,University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Mason F. Lord Center Tower, 7th Floor, 5200 Eastern Avenue, Baltimore, MD, 21224, USA. .,Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
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50
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Steinman MA, Fick DM. Using Wisely: A Reminder on How to Properly Use the American Geriatrics Society Beers Criteria
®. J Gerontol Nurs 2019; 45:3-6. [DOI: 10.3928/00989134-20190211-01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Michael A. Steinman
- Division of Geriatrics, University of California, San Francisco, San Francisco VA Medical Center, San Francisco, California
| | - Donna M. Fick
- Elouise Ross Eberly Endowed Professor College of Nursing and College of Medicine, Pennsylvania State University Director, Center of Geriatric Nursing Excellence State College, Pennsylvania, Editor, Journal of Gerontological Nursing
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