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Peixoto C, Choudhri Y, Francoeur S, McCarthy LM, Fung C, Dowlatshahi D, Lemay G, Barry A, Goyal P, Pan J, Bjerre LM, Thompson W. Discontinuation versus continuation of statins: A systematic review. J Am Geriatr Soc 2024. [PMID: 39051828 DOI: 10.1111/jgs.19093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/23/2024] [Accepted: 06/27/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Clinicians and patients often face a decision to continue or discontinue statins. We examined the impact of discontinuation of statins compared with continuation on clinical outcomes (all-cause mortality, cardiovascular [CV] mortality, CV events, and quality of life). METHODS We conducted a systematic review. Randomized controlled trials (RCTs), cohort studies, case-control studies, and quasi-randomized studies among people ≥18 years were eligible. We searched MEDLINE, Embase, and Cochrane Central Registry (inception to August 2023). Two independent reviewers performed screening and extracted data. Quality assessment was performed by one author and verified by another. We summarized results narratively, performed meta-analysis for a subset of studies, and used GRADE to assess certainty of evidence. We summarized findings in the subgroup of persons ≥75 years. RESULTS We retrieved 8369 titles/abstracts; 37 reports from 36 studies were eligible. This comprised 35 non-randomized studies (n = 1,708,684) and 1 RCT (n = 381). The 1 RCT was conducted among persons with life expectancy <1 year and showed there is probably no difference in 60-day mortality (risk difference = 3.5%, 90% CI -3.5 to 10.5) for statin discontinuation compared with continuation. Non-randomized studies varied in terms of population and setting, but consistently suggested that statin discontinuation might be associated with a relative increased risk of mortality (hazard ratio (HR) 1.92, 95% CI 1.52 to 2.44, nine studies), CV mortality (HR 1.63, 95% CI 1.27 to 2.10, five reports), and CV events (HR 1.31, 95% CI 1.23 to 1.39, eight reports). Findings in people ≥75 years were consistent with main results. There was a high degree of uncertainty in findings from non-randomized studies due to methodological limitations. CONCLUSIONS Statin discontinuation does not appear to affect short-term mortality near end-of-life based on one RCT. Outside of this population, findings from non-randomized studies consistently suggested statin discontinuation may be associated with worse outcomes, though this is uncertain.
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Affiliation(s)
| | | | | | - Lisa M McCarthy
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
- Women's College Research Institute, Toronto, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Celeste Fung
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Geneviève Lemay
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Arden Barry
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Parag Goyal
- Program for the Care and Study of the Aging Heart, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Jeffrey Pan
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lise M Bjerre
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Carollo M, Boccardi V, Crisafulli S, Conti V, Gnerre P, Miozzo S, Omodeo Salè E, Pieraccini F, Zamboni M, Marengoni A, Onder G, Trifirò G. Medication review and deprescribing in different healthcare settings: a position statement from an Italian scientific consortium. Aging Clin Exp Res 2024; 36:63. [PMID: 38459218 PMCID: PMC10923734 DOI: 10.1007/s40520-023-02679-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 12/17/2023] [Indexed: 03/10/2024]
Abstract
Recent medical advancements have increased life expectancy, leading to a surge in patients affected by multiple chronic diseases and consequent polypharmacy, especially among older adults. This scenario increases the risk of drug interactions and adverse drug reactions, highlighting the need for medication review and deprescribing to reduce inappropriate medications and optimize therapeutic regimens, with the ultimate goal to improving patients' health and quality of life. This position statement from the Italian Scientific Consortium on medication review and deprescribing aims to describe key elements, strategies, tools, timing, and healthcare professionals to be involved, for the implementation of medication review and deprescribing in different healthcare settings (i.e., primary care, hospital, long-term care facilities, and palliative care). Challenges and potential solutions for the implementation of medication review and deprescribing are also discussed.
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Affiliation(s)
- Massimo Carollo
- Department of Diagnostics and Public Health, University of Verona, P.Le L.A. Scuro 10, 37124, Verona, Italy
| | - Virginia Boccardi
- Institute of Gerontology and Geriatrics, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Salvatore Crisafulli
- Department of Diagnostics and Public Health, University of Verona, P.Le L.A. Scuro 10, 37124, Verona, Italy
| | - Valeria Conti
- Clinical Pharmacology Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Salerno, Italy
| | | | - Simonetta Miozzo
- Italian Society of General Medicine and Primary Care, Florence, Italy
| | - Emanuela Omodeo Salè
- Division of Pharmacy, IEO European Institute of Oncology IRCCS, Milan, Italy
- IRCCS Centro Cardiologico Monzino, Milan, Italy
| | | | - Mauro Zamboni
- Department of Medicine-Geriatric Division, University of Verona, Verona, Italy
| | - Alessandra Marengoni
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Graziano Onder
- Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Gemelli IRCCS, Rome, Italy
| | - Gianluca Trifirò
- Department of Diagnostics and Public Health, University of Verona, P.Le L.A. Scuro 10, 37124, Verona, Italy.
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3
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Martínez-Aguilar L, Sanz-Valero J, Martínez-Martínez F, Faus MJ. Suitability of indexing terms in the MEDLINE bibliographic database on drug-related problems. Res Social Adm Pharm 2023; 19:1440-1445. [PMID: 37481351 DOI: 10.1016/j.sapharm.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 06/26/2023] [Accepted: 07/12/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND For years, there has been controversy about the meaning of medication-related problems (MRPs). This has led several authors to attempt to redefine and classify this term with the aim of using it correctly in the healthcare setting. So far without achieving the desired objective, resulting in erroneous results in the sources of information and thus in malpractice in the sector. OBJECTIVE To describe and analyze the appropriateness of the existing indexing of scientific publications in the MEDLINE bibliographical database with respect to drug-related problems (DRPs) and to determine whether the descriptors used fulfilled the function of suitably representing this concept. METHODS A descriptive study was conducted, using the following search terms: Medication Errors; Drug Interactions; Drug Overdose; Drug-Related Side Effects and Adverse Reactions; Contraindications, Drug. The sample size was calculated by estimating population parameters in an infinite population (expected value = 0.05; precision of interval = 0.05; level of confidence = 0.95) and the selection method was simple random sampling without replacement, taking the total number of bibliographical references in the database as the basis. The agreement of the indexing with DRPs was evaluated with the coefficient of determination (R2), and the Cohen kappa coefficient was used for the association between the definition of the descriptors and the objective of the article. RESULTS The 1930 records analyzed showed a total of 2888 different major topics. These major topics were present, with at least one of the five descriptors studied, in 482 (25.0%; 95% CI 23.0-27.0) documentary files, with statistically significant differences between the two phases analyzed (χ2 = 183.8; degrees of freedom (df) = 1; p < 0.001): 1st phase, 295 (13.3%; 95% CI 13.7-16.9) and 2nd phase, 187 (9.7%; 95% CI 8.4-11.0). Overall scientific output with the five descriptors showed a coefficient of determination (R2) of 0.9 (p < 0.001) and the relationship between the objective of the study and the definitions of the five descriptors was 0.9 (p < 0.001). CONCLUSIONS There was a very good direct exponential trend of the overall scientific output retrieved with the terms associated with DRPs, although the progression of the five descriptors separately did not show a growth model conforming to expectations. There was a moderate agreement between the objective of the study and the definition of each of the five descriptors used and a low relationship between the objective of the study and the concept of DRPs used for this investigation. It is essential to have a descriptor that unifies the terminological diffusion that has existed up till now, since process (causes) and effects (outcomes) have been mixed together under the various definitions and classifications of DRPs found in the studies.
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Affiliation(s)
- Laura Martínez-Aguilar
- Pharmaceutical Research Group of the University of Granada, Faculty of Pharmacy, University of Granada, Granada, Spain
| | - Javier Sanz-Valero
- Carlos III Health Institute, National School of Occupational Medicine, Madrid, Spain.
| | - Fernando Martínez-Martínez
- Pharmaceutical Research Group of the University of Granada, Faculty of Pharmacy, University of Granada, Granada, Spain
| | - María J Faus
- Pharmaceutical Research Group of the University of Granada, Faculty of Pharmacy, University of Granada, Granada, Spain
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Thompson W, McCarthy LM, Galley E, Homan L, Farrell B. Using Shared Decision-Making Resources in Long-Term Care: a Qualitative Study. Can Geriatr J 2023; 26:253-258. [PMID: 37265981 PMCID: PMC10198683 DOI: 10.5770/cgj.26.657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
Background Shared decision-making (SDM) incorporates people's individual preferences and context into individualized, person-centred decisions. Persons living in long-term care (LTC) should only take medications that are a good fit for them as individuals. Methods We conducted a pilot study to understand experiences of two LTC homes in Ontario as they tested implementing SDM resources to support medication decisions. LTC homes conducted two Plan-Do-Study-Act (PDSA) cycles supported by an Advisory Group composed of LTC home representatives and stakeholders involved in resource design. Rapid qualitative analysis of transcripts and field notes from Advisory Group meetings elucidated how SDM resources were used. Results Each site was positively engaged but implemented resources differently. The pharmacist and physicians at Site 1 introduced proton-pump inhibitor (PPI) deprescribing as their primary intervention, identifying suitable residents, informing residents and families of the deprescribing process, and providing selected SDM resources to residents, caregivers and staff. Representatives reported limited engagement with SDM resources and difficulty measuring the impact of PPI deprescribing. Representatives from Site 2 disseminated the SDM resources to residents and caregivers for use at care conferences and focused on front-line staff education and involvement. This site reported that some residents/caregivers were interested in participating in SDM and using the resources, while others were not. The impact of the resources on SDM at this site was unclear. Conclusions Within the context of LTC, further research is needed to clarify the meaning and importance of SDM in medication decision-making. Implementation of SDM will likely require a multi-faceted approach.
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Affiliation(s)
- Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC
- Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Lisa M. McCarthy
- Institute for Better Health, Trillium Health Partners, Mississauga, ON
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON
- Bruyère Research Institute, Ottawa, ON
- Women’s College Research Institute, Toronto, ON
- School of Pharmacy, University of Waterloo, Waterloo, ON
| | - Emily Galley
- Bruyère Research Institute, Ottawa, ON
- School of Public Policy, University of Calgary, Calgary, AB
| | | | - Barbara Farrell
- Bruyère Research Institute, Ottawa, ON
- School of Pharmacy, University of Waterloo, Waterloo, ON
- Department of Family Medicine, University of Ottawa, Ottawa, ON
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5
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Engell AE, Bathum L, Andersen JS, Thompson W, Lind BS, Jørgensen HL, Nexøe J. Factors associated with statin discontinuation near end of life in a Danish primary health care cohort. Fam Pract 2022; 40:300-307. [PMID: 35950318 DOI: 10.1093/fampra/cmac090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Long-term preventive treatment such as treatment with statins should be reassessed among patients approaching end of life. The aim of the study was to describe the rate of discontinuation of statin treatment and factors associated with discontinuation in the 6 months before death. METHODS This study is a retrospective cohort study using national registers and blood test results from primary health care patients. Patients in the Copenhagen municipality, Denmark who died between 1997 and 2018 and were statin users during the 10-year period before death were included. We calculated the proportion who remained statin users in the 6-month period before death. Factors associated with discontinuation were tested using logistic regression. RESULTS A total of 55,591 decedents were included. More patients continued treatment (64%, n = 35,693) than discontinued (36%, n = 19,898) the last 6 months of life. The 70 and 80 age groups had the lowest odds of discontinuing compared to the 90 (OR 1.59, 95% CI 0.93-2.72) and 100 (OR 3.11, 95% CI 2.79-3.47) age groups. Increasing comorbidity score (OR 0.89, 95% CI 0.87; 0.90 per 1-point increase) and use of statins for secondary prevention (OR 0.89, 95% CI 0.85; 0.93) reduced the likelihood of discontinuation as did a diagnosis of dementia, heart failure, or cancer. CONCLUSION A substantial portion of patients continued statin treatment near end of life. Efforts to promote rational statin use and discontinuation are required among patients with limited life expectancy, including establishing clear, practical recommendations about statin discontinuation, and initiatives to translate recommendations into clinical practice.
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Affiliation(s)
- Anna E Engell
- Department of Clinical Biochemistry, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Lise Bathum
- Department of Clinical Biochemistry, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - John S Andersen
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Wade Thompson
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.,Hospital Pharmacy of Funen, Odense University Hospital, Odense, Denmark.,Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Bent S Lind
- Department of Clinical Biochemistry, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Henrik L Jørgensen
- Department of Clinical Biochemistry, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Jørgen Nexøe
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
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6
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Niznik JD, Zhao X, Slieanu F, Mor MK, Aspinall SL, Gellad WF, Ersek M, Hickson RP, Springer SP, Schleiden LJ, Hanlon JT, Thorpe JM, Thorpe CT. Effect of Deintensifying Diabetes Medications on Negative Events in Older Veteran Nursing Home Residents. Diabetes Care 2022; 45:1558-1567. [PMID: 35621712 PMCID: PMC9274227 DOI: 10.2337/dc21-2116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 04/17/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Guidelines advocate against tight glycemic control in older nursing home (NH) residents with advanced dementia (AD) or limited life expectancy (LLE). We evaluated the effect of deintensifying diabetes medications with regard to all-cause emergency department (ED) visits, hospitalizations, and death in NH residents with LLE/AD and tight glycemic control. RESEARCH DESIGN AND METHODS We conducted a national retrospective cohort study of 2,082 newly admitted nonhospice veteran NH residents with LLE/AD potentially overtreated for diabetes (HbA1c ≤7.5% and one or more diabetes medications) in fiscal years 2009-2015. Diabetes treatment deintensification (dose decrease or discontinuation of a noninsulin agent or stopping insulin sustained ≥7 days) was identified within 30 days after HbA1c measurement. To adjust for confounding, we used entropy weights to balance covariates between NH residents who deintensified versus continued medications. We used the Aalen-Johansen estimator to calculate the 60-day cumulative incidence and risk ratios (RRs) for ED or hospital visits and deaths. RESULTS Diabetes medications were deintensified for 27% of residents. In the subsequent 60 days, 28.5% of all residents were transferred to the ED or acute hospital setting for any cause and 3.9% died. After entropy weighting, deintensifying was not associated with 60-day all-cause ED visits or hospitalizations (RR 0.99 [95% CI 0.84, 1.18]) or 60-day mortality (1.52 [0.89, 2.81]). CONCLUSIONS Among NH residents with LLE/AD who may be inappropriately overtreated with tight glycemic control, deintensification of diabetes medications was not associated with increased risk of 60-day all-cause ED visits, hospitalization, or death.
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Affiliation(s)
- Joshua D Niznik
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina School of Medicine, Chapel Hill, NC.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Florentina Slieanu
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Sherrie L Aspinall
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,VA Center for Medication Safety, Hines, Illinois.,University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Mary Ersek
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA.,School of Nursing, University of Pennsylvania, Philadelphia, PA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Ryan P Hickson
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Sydney P Springer
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,University of New England School of Pharmacy, Portland, ME
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA.,Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC
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Soo JEJ, Chan MY, Bte Adb Rashid NAB, Bte Mohamad Yusri LI, Wynn YY, Noda M, Tewani K. Medication chart review at end of life of paediatric palliative patients. J Paediatr Child Health 2022; 58:392-396. [PMID: 34553811 DOI: 10.1111/jpc.15719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 02/18/2021] [Accepted: 08/10/2021] [Indexed: 11/28/2022]
Abstract
AIM This study aimed to review the use of medications in a paediatric palliative care (PPC) population during the last two weeks of life. METHODS This is a retrospective observational cohort study that included 50 consecutive patients who were referred to KK Hospital PPC service from 2011 to 2015. Those who died after two weeks from discharge date were excluded. Medication charts were reviewed and relevant data were extracted. RESULTS The study population included 42 patients and consists predominantly oncological and neurological diagnoses. The median number of medications used was 11.5. Ninety-five percent (40 out of 42) of study population required analgesia where 81% (34 out of 42) were opioid. There was prevalent use of antibiotics (86% of study population, 36 out of 42). Less frequently used medications included steroids, sedatives, laxatives and antiemetics (48%, 52%, 48% and 38% of study population respectively). CONCLUSION Significant number of medications was used in PPC during the last two weeks of life. Apart from significant use of analgesia, there is also notable use of antibiotics. Future directions in education such as prescription of laxatives with opioid are proposed.
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Affiliation(s)
| | - Mei Yoke Chan
- KK Women's and Children's Hospital, Singapore, Singapore
| | | | | | - Yi Yi Wynn
- KK Women's and Children's Hospital, Singapore, Singapore
| | - Misa Noda
- KK Women's and Children's Hospital, Singapore, Singapore
| | - Komal Tewani
- KK Women's and Children's Hospital, Singapore, Singapore
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8
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Navia RO, Constantine LA. Palliative care for patients with advanced dementia. Nursing 2022; 52:19-26. [PMID: 35196277 DOI: 10.1097/01.nurse.0000820024.83629.ee] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Dementia is currently the seventh leading cause of death and one of the major causes of disability and dependency among older adults globally. Its final stages are complicated by a multitude of problems that can cause immense suffering. This article explores the interconnection between advanced dementia and palliative care and the role of nurses in providing end-of-life care for these patients.
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Affiliation(s)
- R Osvaldo Navia
- R. Osvaldo Navia is the chief of Geriatrics, Palliative Medicine and Hospice; the Grace Kinney Mead Chair of Geriatrics; an attending at the Rockefeller Neuroscience Institute; and an assistant professor at West Virginia University School of Medicine
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Honinx E, Van den Block L, Piers R, Van Kuijk SMJ, Onwuteaka-Philipsen BD, Payne SA, Szczerbińska K, Gambassi GG, Finne-Soveri H, Deliens L, Smets T. Potentially Inappropriate Treatments at the End of Life in Nursing Home Residents: Findings From the PACE Cross-Sectional Study in Six European Countries. J Pain Symptom Manage 2021; 61:732-742.e1. [PMID: 32916262 DOI: 10.1016/j.jpainsymman.2020.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/28/2020] [Accepted: 09/01/2020] [Indexed: 12/15/2022]
Abstract
CONTEXT Certain treatments are potentially inappropriate when administered to nursing homes residents at the end of life and should be carefully considered. An international comparison of potentially inappropriate treatments allows insight into common issues and country-specific challenges of end-of-life care in nursing homes and helps direct health-care policy in this area. OBJECTIVES To estimate the prevalence of potentially inappropriate treatments in the last week of life in nursing home residents and analyze the differences in prevalence between countries. METHODS A cross-sectional study of deceased residents in nursing homes (2015) in six European countries: Belgium (Flanders), England, Finland, Italy, The Netherlands, and Poland. Potentially inappropriate treatments included enteral administration of nutrition, parental administration of nutrition, artificial fluids, resuscitation, artificial ventilation, blood transfusion, chemotherapy/radiotherapy, dialysis, surgery, antibiotics, statins, antidiabetics, new oral anticoagulants. Nurses were questioned about whether these treatments were administered in the last week of life. RESULTS We included 1384 deceased residents from 322 nursing homes. In most countries, potentially inappropriate treatments were rarely used, with a maximum of 18.3% of residents receiving at least one treatment in Poland. Exceptions were antibiotics in all countries (between 11.3% in Belgium and 45% in Poland), artificial nutrition and hydration in Poland (54.3%) and Italy (41%) and antidiabetics in Poland (19.7%). CONCLUSION Although the prevalence of potentially inappropriate treatments in the last week of life was generally low, antibiotics were frequently prescribed in all countries. In Poland and Italy, the prevalence of artificial administration of food/fluids in the last week of life was high, possibly reflecting country differences in legislation, care organization and culture, and the palliative care competences of staff.
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Affiliation(s)
- Elisabeth Honinx
- End-of-Life Care Research Group, Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.
| | - Lieve Van den Block
- End-of-Life Care Research Group, Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Ruth Piers
- Clinic of Geriatric Medicine, Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | - Sander M J Van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), MUMC, Maastricht, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Vrije Universiteit Amsterdam Medisch Centrum, Amsterdam, The Netherlands
| | - Sheila A Payne
- Faculty of Health And Medicine, Lancaster University, Lancaster, UK
| | - Katarzyna Szczerbińska
- Laboratory for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine, Medical Faculty, Jagiellonian University Medical College, Kraków, Poland
| | - Giovanni G Gambassi
- Department of Internal Medicine, Istituto di Medicina Interna e Geriatria, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Harriet Finne-Soveri
- Geriatric Medicine, Department of Welfare, Ageing Disability and Functioning Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Luc Deliens
- End-of-Life Care Research Group, Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Tinne Smets
- End-of-Life Care Research Group, Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
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10
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Impact of Dementia on Health Service Use in the Last 2 Years of Life for Women with Other Chronic Conditions. J Am Med Dir Assoc 2020; 21:1651-1657.e1. [DOI: 10.1016/j.jamda.2020.02.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 02/21/2020] [Accepted: 02/21/2020] [Indexed: 01/17/2023]
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11
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Thorpe CT, Sileanu FE, Mor MK, Zhao X, Aspinall S, Ersek M, Springer S, Niznik JD, Vu M, Schleiden LJ, Gellad WF, Hunnicutt J, Thorpe JM, Hanlon JT. Discontinuation of Statins in Veterans Admitted to Nursing Homes near the End of Life. J Am Geriatr Soc 2020; 68:2609-2619. [PMID: 32786004 DOI: 10.1111/jgs.16727] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND/OBJECTIVES Geriatric guidelines recommend against statin use in older adults with limited life expectancy (LLE) or advanced dementia (AD). This study examined resident and facility factors predicting statin discontinuation after nursing home (NH) admission in veterans with LLE/AD taking statins for secondary prevention. DESIGN Retrospective cohort study of Veterans Affairs (VA) bar code medication administration records, Minimum Data Set (MDS) assessments, and utilization records linked to Medicare claims. SETTING VA NHs, known as community living centers (CLCs). PARTICIPANTS Veterans aged 65 and older with coronary artery disease, stroke, or diabetes mellitus, type II, admitted in fiscal years 2009 to 2015, who met criteria for LLE/AD on their admission MDS and received statins in the week after admission (n = 13,110). MEASUREMENTS Residents were followed until statin discontinuation (ie, gap in statin use ≥14 days), death, or censoring due to discharge, day 91 of the stay, or end of the study period. Competing risk models assessed cumulative incidence and predictors of discontinuation, stratified by whether the resident had their end-of-life (EOL) status designated or used hospice at admission. RESULTS Overall cumulative incidence of statin discontinuation was 31% (95% confidence interval [CI] = 30%-32%) by day 91, and it was markedly higher in those with (52%; 95% CI = 50%-55%) vs without (25%; 95% CI = 24%-26%) EOL designation/hospice. In patients with EOL designation/hospice (n = 2,374), obesity, congestive heart failure, and admission from nonhospital settings predicted decreased likelihood of discontinuation; AD, dependency in activities of daily living, greater number of medications, and geographic region predicted increased likelihood of discontinuation. In patients without EOL designation/hospice (n = 10,736), older age and several specific markers of poor prognosis predicted greater discontinuation, whereas obesity/overweight predicted decreased discontinuation. CONCLUSION Most veterans with LLE/AD taking statins for secondary prevention do not discontinue statins following CLC admission. Designating residents as EOL status, hospice use, and individual clinical factors indicating poor prognosis may prompt deprescribing.
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Affiliation(s)
- Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Sherrie Aspinall
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,VA Center for Medication Safety, Hines, Illinois.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Mary Ersek
- Veterans Experience Center and the Center for Health Equity Research and Promotion; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sydney Springer
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,University of New England College of Pharmacy, Portland, Maine
| | - Joshua D Niznik
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina.,Division of Geriatric Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Michelle Vu
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,VA Center for Medication Safety, Hines, Illinois
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jacob Hunnicutt
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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12
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Dunning TL. Palliative and End-of-Life Care: Vital Aspects of Holistic Diabetes Care of Older People With Diabetes. Diabetes Spectr 2020; 33:246-254. [PMID: 32848346 PMCID: PMC7428665 DOI: 10.2337/ds20-0014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Palliative and end-of-life care and advance care planning are important components of holistic diabetes management, especially for older people with a long duration of diabetes and comorbidities who experience unpleasant symptoms and remediable suffering. Many diabetes clinicians do not have conversations about advance care planning with people with diabetes, often because they are reluctant to discuss these issues and are not familiar with palliative care. This article outlines palliative, terminal, and end-of-life care for older people with type 1 or type 2 diabetes and suggests when to consider changing the focus on tight blood glucose control to a focus on safety and comfort. It proposes strategies to incorporate palliative and end-of-life care into personalized holistic diabetes care, determined with older people with diabetes and their families through shared decision-making.
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Affiliation(s)
- Trisha Lynette Dunning
- Centre for Quality and Patient Safety Research, Barwon Health Partnership, School of Nursing and Midwifery, Deakin University, Geelong, Australia
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13
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Aitken C, Boyd M, Nielsen L, Collier A. Medication use in aged care residents in the last year of life: A scoping review. Palliat Med 2020; 34:832-850. [PMID: 32286162 DOI: 10.1177/0269216320911596] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND A substantial number of older adults die in residential aged care facilities, yet little is known about the characteristics of and how best to optimise medication use in the last year of life. AIM The aim of this review was to map characteristics of medication use in aged care residents during the last year of life in order to examine key concepts related to medication safety and draw implications for further research and service provision. DESIGN A scoping review following Arskey and O'Malley's framework was conducted using a targeted keyword search, followed by assessments of eligibility based on title and content of abstracts and full papers. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the scoping review protocol was prospectively registered to the Open Science Framework on 27 November 2018. DATA SOURCES We searched MEDLINE, EMBASE, AMED, CINAHL and Cochrane databases to identify peer-reviewed studies published between 1937 and 2018, written in English and looking at medication use in individuals living in aged care facilities within their last year of life. RESULTS A total of 30 papers were reviewed. Five key overarching themes were derived from the analysis process: (1) access to medicines at the end of life, (2) categorisation and classes: medicines and populations, (3) polypharmacy and total medication numbers, (4) use of symptomatic versus preventive medications and (5) 'inappropriate' medications. CONCLUSION Number of prescriptions or blunt categorisations of medications to assess their appropriateness are unlikely to be sufficient to promote well-being and medication safety for older people in residential aged care in the final stages of life.
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Affiliation(s)
| | - Michal Boyd
- The University of Auckland, Auckland, New Zealand
| | | | - Aileen Collier
- The University of Auckland, Auckland, New Zealand.,Flinders University, Adelaide, SA, Australia.,University of Tasmania, Hobart, TAS, Australia
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14
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Rausch C, Hoffmann F. Prescribing medications of questionable benefit prior to death: a retrospective study on older nursing home residents with and without dementia in Germany. Eur J Clin Pharmacol 2020; 76:877-885. [PMID: 32219538 PMCID: PMC7239800 DOI: 10.1007/s00228-020-02859-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 03/11/2020] [Indexed: 12/04/2022]
Abstract
Purpose We studied the prevalence of medications of questionable benefit in the last 6 months of life among older nursing home residents with and without dementia in Germany. Methods A retrospective cohort study was conducted on claims data from 67,328 deceased nursing home residents aged 65+ years who were admitted between 2010 and 2014. We analyzed prescription regimens of medications of questionable benefit in the 180–91-day period and the 90-day period prior to death for residents with dementia (n = 29,052) and without dementia (n = 38,276). Factors associated with new prescriptions of medications of questionable benefit prior to death were analyzed using logistic regression models among all nursing home residents and stratified by dementia. Results A higher proportion of nursing home residents with dementia were prescribed at least one medication of questionable benefit in the 180–91-day (29.6%) and 90-day (26.8%) periods prior to death, compared with residents without dementia (180–91 days, 22.8%; 90 days, 20.1%). Lipid-lowering agents were the most commonly prescribed medications. New prescriptions of medications of questionable benefit were more common among residents with dementia (9.8% vs. 8.7%). When excluding anti-dementia medication, new prescriptions of these medications were more common among residents without dementia (6.4% vs. 8.0%). The presence of dementia (odds ratio [OR] 1.40, 95% confidence interval [95%CI] 1.32–1.48) and excessive polypharmacy were associated with new prescriptions of medications of questionable benefit prior to death (OR 4.74, 95%CI 4.15–5.42). Conclusion Even when accounting for anti-dementia prescriptions, the prevalence of nursing home residents with dementia receiving medications of questionable benefit is considerable and may require further attention. Electronic supplementary material The online version of this article (10.1007/s00228-020-02859-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christian Rausch
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Ammerländer Heerstraße 140, 26129, Oldenburg, Germany.
- Department of Health Sciences, Community and Occupational Medicine, University of Groningen, University Medical Center Groningen, Antonius Deusinglaan 1, FA10, 9713 AV, Groningen, The Netherlands.
- Department of Global Public Health, Karolinska Institutet, Widerströmska huset, Tomtebodavägen 18A, SE, 17177, Stockholm, Sweden.
| | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Ammerländer Heerstraße 140, 26129, Oldenburg, Germany
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15
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Ouslander JG. Improving Drug Therapy for Patients With Life‐Limiting Illnesses: Letʼs Take Care of Some Low Hanging Fruit. J Am Geriatr Soc 2020; 68:682-685. [DOI: 10.1111/jgs.16395] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 02/03/2020] [Indexed: 01/07/2023]
Affiliation(s)
- Joseph G. Ouslander
- Clinical Biomedical Science Charles E. Schmidt College of Biomedical Science Boca Raton Florida
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16
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Stall NM, Fischer HD, Fung K, Giannakeas V, Bronskill SE, Austin PC, Matlow JN, Quinn KL, Mitchell SL, Bell CM, Rochon PA. Sex-Specific Differences in End-of-Life Burdensome Interventions and Antibiotic Therapy in Nursing Home Residents With Advanced Dementia. JAMA Netw Open 2019; 2:e199557. [PMID: 31418809 PMCID: PMC6704739 DOI: 10.1001/jamanetworkopen.2019.9557] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 06/29/2019] [Indexed: 01/11/2023] Open
Abstract
Importance Nursing home residents with advanced dementia have limited life expectancies yet are commonly subjected to burdensome interventions at the very end of life. Whether sex-specific differences in the receipt of these interventions exist and what levels of physical restraints and antibiotics are used in this terminal setting are unknown. Objective To evaluate the population-based frequency, factors, and sex differences in burdensome interventions and antibiotic therapy among nursing home residents with advanced dementia. Design, Setting, and Participants This population-based cohort study from Ontario, Canada, used linked administrative databases held at ICES, including the Continuing Care Resident Reporting System Long-Term Care database, which contains data from the Resident Assessment Instrument Minimum Data Set, version 2.0. Nursing home residents (n = 27 243) with advanced dementia who died between June 1, 2010, and March 31, 2015, at 66 years or older were included in the analysis. Initial statistical analysis was completed in May 2017, and analytical revisions were conducted from November 2018 to January 2019. Exposure Sex of the nursing home resident. Main Outcomes and Measures Burdensome interventions (transitions of care, invasive procedures, and physical restraints) and antibiotic therapy in the last 30 days of life. Results The final cohort included 27 243 nursing home residents with advanced dementia (19 363 [71.1%] women) who died between June 1, 2010, and March 31, 2015, at the median (interquartile range) age of 88 (83-92) years. In the last 30 days of life, burdensome interventions were common, especially among men: 5940 (21.8%) residents were hospitalized (3661 women [18.9%] vs 2279 men [28.9%]; P < .001), 2433 (8.9%) had an emergency department visit (1579 women [8.2%] vs 854 men [10.8%]; P < .001), and 3701 (13.6%) died in an acute care facility (2276 women [11.8%] vs 1425 men [18.1%]; P < .001). Invasive procedures were also common; 2673 residents (9.8%) were attended for life-threatening critical care (1672 women [8.6%] vs 1001 men [12.7%]; P < .001), and 210 (0.8%) received mechanical ventilation (113 women [0.6%] vs 97 men [1.2%]; P < .001). Among the 9844 residents (36.1%) who had a Resident Assessment Instrument Minimum Data Set, version 2.0, completed in the last 30 days of life, 2842 (28.9%) were physically restrained (2002 women [28.3%] vs 840 men [30.4%]; P = .005). More than one-third (9873 [36.2%]) of all residents received an antibiotic (6599 women [34.1%] vs 3264 men [41.4%]; P < .001). In multivariable models, men were more likely to have a transition of care (adjusted odds ratio, 1.41; 95% CI, 1.33-1.49; P < .001) and receive antibiotics (adjusted odds ratio, 1.33; 95% CI, 1.26-1.41; P < .001). Only 3309 residents (12.1%; 2382 women [12.3%] vs 927 men [11.8%]) saw a palliative care physician in the year before death, but those who did experienced greater than 50% lower odds of an end-of-life transition of care (adjusted odds ratio, 0.48; 95% CI, 0.43-0.54); P < .001) and greater than 25% lower odds of receiving antibiotics (adjusted odds ratio, 0.74; 95% CI, 0.68-0.81; P < .001). Conclusions and Relevance In this study, many nursing home residents with advanced dementia, especially men, received burdensome interventions and antibiotics in their final days of life. These findings appear to emphasize the need for sex-specific analysis in dementia research as well as the expansion of palliative care and end-of-life antimicrobial stewardship in nursing homes.
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Affiliation(s)
- Nathan M. Stall
- ICES, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine and Geriatrics, Sinai Health System, Toronto, Ontario, Canada
| | | | | | - Vasily Giannakeas
- ICES, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Susan E. Bronskill
- ICES, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Peter C. Austin
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jeremy N. Matlow
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kieran L. Quinn
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine and Geriatrics, Sinai Health System, Toronto, Ontario, Canada
| | - Susan L. Mitchell
- Hebrew SeniorLife Institute for Aging Research, Boston, Massachusetts
| | - Chaim M. Bell
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine and Geriatrics, Sinai Health System, Toronto, Ontario, Canada
| | - Paula A. Rochon
- ICES, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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17
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Griffiths AW, Surr CA, Alldred DP, Baker J, Higham R, Spilsbury K, Thompson CA. Pro re nata prescribing and administration for neuropsychiatric symptoms and pain in long-term care residents with dementia and memory problems: a cross-sectional study. Int J Clin Pharm 2019; 41:1314-1322. [PMID: 31342248 PMCID: PMC6800850 DOI: 10.1007/s11096-019-00883-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 07/10/2019] [Indexed: 11/30/2022]
Abstract
Background Prescribing, dispensing and administering pro re nata (PRN; as needed or necessary, as determined by an individual) medicines to people with intermittent or short-term conditions is a potential area for medication errors and inappropriate prescribing and administration. In people with dementia, regular PRN medicines use can demonstrate good practice when appropriate or poor in situations where their use is not recommended. However, the frequency of PRN prescription and administration within long-term care settings (care homes) for people with dementia is largely unknown. A limited number of studies worldwide suggest variation between countries. Objective To describe the prescription and administration rates of PRN medicines for people with dementia in UK care homes. Setting Fifty UK care homes. Method Medication details were collected from review of residents’ medicines records within the care home for the previous month. Main outcome measure Prescription and administration of PRN medicines for the treatment of behaviours associated with neuropsychiatric symptoms and pain. Results The most commonly prescribed PRN medicines were analgesics (35.3%), although lower levels of PRN prescription were observed compared to recent studies. The percentage of residents receiving PRN administrations varied, with 20% for antipsychotics, 50% for benzodiazepines, 59% for analgesics, and 85.7% for nonbenzodiazepine hypnotics being administered. Conclusion Further research is needed to understand the decision making in PRN prescription and administration within long-term care. The prescribing of potentially inappropriate medicines remains a problem in long-term care settings and pharmacists have a key role in reducing inappropriate polypharmacy by undertaking medication reviews that consider both regular and PRN medicines.
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Affiliation(s)
- Alys W Griffiths
- Centre for Dementia Research, School of Health and Community Studies, Leeds Beckett University, City Campus, Leeds, LS1 3HE, UK.
| | - Claire A Surr
- Centre for Dementia Research, School of Health and Community Studies, Leeds Beckett University, City Campus, Leeds, LS1 3HE, UK
| | - David P Alldred
- School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds, LS2 9JT, UK
| | - John Baker
- School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds, LS2 9JT, UK
| | - Ruchi Higham
- School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds, LS2 9JT, UK
| | - Karen Spilsbury
- School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds, LS2 9JT, UK
| | - Carl A Thompson
- School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds, LS2 9JT, UK
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18
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Pop P, Bronskill SE, Piggott KL, Stall NM, Savage RD, Visentin JD, McCarthy LM, Giannakes V, Wu W, Gruneir A, Gatley JM, Rochon PA. Management of Sleep Disorders in Community-Dwelling Older Women and Men at the Time of Diagnosis. J Am Geriatr Soc 2019; 67:2094-2101. [PMID: 31225914 DOI: 10.1111/jgs.16038] [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: 02/20/2019] [Revised: 05/10/2019] [Accepted: 05/21/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Sedative and hypnotic medications are associated with harm, and guidelines suggest limiting their use. Only limited evidence has described how older adults are managed following an initial sleep disorder diagnosis. We aimed to describe clinical management patterns of sleep disorders in older women and men at the time of initial diagnosis. DESIGN Population-based retrospective cohort study using linked administrative databases. SETTING Ontario, Canada. PARTICIPANTS Community-dwelling adults aged 66 and older, diagnosed with a new sleep disorder by a primary care provider (n = 30 729; 56% women and 44% men). We compared women and men for each outcome. MEASUREMENTS The primary outcome was prescription of a medication used for sleep within 30 days of a new sleep disorder diagnosis. Additional analysis included medical investigations such as sleep studies and visits to specialists who manage obstructive sleep disorders within 90 days of diagnosis. RESULTS Among the 30 729 older adults with a new sleep disorder diagnosis, 5512 (17.9% total; 18.8% of women and 16.9% of men) were prescribed a medication used for sleep. Compared with men, women were somewhat more likely to be prescribed at least one sedative medication (adjusted odds ratio = 1.09; 95% confidence interval = 1.03-1.16). A total of 2573 (8.4%) older adults underwent a sleep study, and 3743 (12.2%) were evaluated by a specialist; both occurred more commonly in men. CONCLUSION In our cohort, almost 1 in 5 older adults with a new sleep disorder diagnosis were prescribed a medication used for sleep; of these, a higher proportion were women. Comparatively few older adults were further evaluated; of these, a higher proportion were men. Our study highlights the high rates at which medications are prescribed to older adults with a new sleep disorder diagnosis and identifies potential sex differences in the management of such diagnoses. J Am Geriatr Soc 1-8, 2019. J Am Geriatr Soc 67:2094-2101, 2019.
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Affiliation(s)
- Paula Pop
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Susan E Bronskill
- Women's College Research Institute, Women's College Hospital, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,ICES, Toronto, Ontario, Canada
| | - Katrina L Piggott
- Department of Medicine, Division of Geriatric Medicine, University of Toronto, Toronto, Canada
| | - Nathan M Stall
- Women's College Research Institute, Women's College Hospital, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Department of Medicine, Division of Geriatric Medicine, University of Toronto, Toronto, Canada
| | - Rachel D Savage
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
| | - Jessica D Visentin
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
| | - Lisa M McCarthy
- Women's College Research Institute, Women's College Hospital, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Vasily Giannakes
- Women's College Research Institute, Women's College Hospital, Toronto, Canada.,ICES, Toronto, Ontario, Canada
| | - Wei Wu
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
| | - Andrea Gruneir
- Women's College Research Institute, Women's College Hospital, Toronto, Canada.,ICES, Toronto, Ontario, Canada.,Department of Family Medicine, University of Alberta, Edmonton, Canada
| | | | - Paula A Rochon
- Women's College Research Institute, Women's College Hospital, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,ICES, Toronto, Ontario, Canada.,Department of Medicine, Division of Geriatric Medicine, University of Toronto, Toronto, Canada
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19
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Roux B, Morin L, Papon A, Laroche ML. Prescription and deprescription of medications for older adults receiving palliative care during the last 3 months of life: a single-center retrospective cohort study. Eur Geriatr Med 2019; 10:463-471. [PMID: 34652792 DOI: 10.1007/s41999-019-00175-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/18/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Near the end of life, drugs to ensure comfort and improve quality of life should be prioritized, and unnecessary drugs should be avoided. The aim was to assess the evolution and quality of drug therapy throughout the last 3 months of life of older adults in need of palliative care. METHODS A single-center retrospective cohort study included older adults (≥ 65 years) who died in a teaching hospital between 1 January 2014 and 30 June 2014 and had been identified as patients in need of palliative care in their last 3 months of life. Drugs were collected from electronic medical records and defined as 'unnecessary' or 'essential' based on a review of the literature. RESULTS A total of 149 patients were included [age: 82.1 (SD 8.6) years, women: 46.3%]. The mean number of medications varied from 6.7 (SD 3.3) drugs 90 days before death, to 7.5 (SD 4.1) 7 days before death, to 5.6 (SD 3.6) on the day of death. During the final week of life, one additional prescription of essential drugs was observed for 75.2% of patients and 79.3% of patients had at least one unnecessary drug deprescribed. The most prescribed and deprescribed drug classes were, respectively, analgesics (56.4%) and antithrombotic agents (38.2%) during the last week of life. CONCLUSIONS Near the end of life, medication therapy is adapted to the goals of palliative care. However, this only occurs during the last week of life. Earlier transition to palliative care is necessary to avoid exposure to unnecessary drugs.
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Affiliation(s)
- Barbara Roux
- Department of Pharmacology, Toxicology and Pharmacovigilance, University Hospital of Limoges, 2 avenue Martin Luther King, 87042, Limoges Cedex, France. .,INSERM UMR 1248, University of Limoges, Limoges, France.
| | - Lucas Morin
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Arnaud Papon
- Department of Geriatric Medicine, University Hospital of Limoges, Limoges, France
| | - Marie-Laure Laroche
- Department of Pharmacology, Toxicology and Pharmacovigilance, University Hospital of Limoges, 2 avenue Martin Luther King, 87042, Limoges Cedex, France.,INSERM UMR 1248, University of Limoges, Limoges, France
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20
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Ofori-Asenso R, Ilomaki J, Tacey M, Curtis AJ, Zomer E, Bell JS, Zoungas S, Liew D. Prevalence and Incidence of Statin Use and 3-Year Adherence and Discontinuation Rates Among Older Adults With Dementia. Am J Alzheimers Dis Other Demen 2018; 33:527-534. [PMID: 29991271 PMCID: PMC10852509 DOI: 10.1177/1533317518787314] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To examine the patterns of statin use and determine the 3-year adherence and discontinuation rates among a cohort of Australians aged ≥65 years with dementia. METHODS The yearly prevalence and incidence of statin use were compared via Poisson regression modeling using 2007 as the reference year. People with dementia were identified according to dispensing of antidementia medications. A cohort of 589 new statin users was followed longitudinally. Adherence was estimated via the proportion of days covered (PDC). Discontinuation was defined as ≥90 days without statin coverage. RESULTS The annual prevalence of statin use among older Australians with dementia increased from 20.6% in 2007 to 31.7% in 2016 (aged-sex adjusted rate ratio: 1.51, 95% confidence interval: 1.35-1.69). Among the new users, the proportion adherent (PDC ≥ 0.80) decreased from 60.3% at 6 months to 31.0% at 3 years. During the 3-year follow-up, 58.7% discontinued their statin. CONCLUSIONS Despite increased use of statins among older Australians with dementia, adherence is low and discontinuation is high, which may point to intentional cessation.
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Affiliation(s)
- Richard Ofori-Asenso
- Centre of cardiovascular Research and Education in therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Epidemiological Modelling Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jenni Ilomaki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Mark Tacey
- Centre of cardiovascular Research and Education in therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrea J. Curtis
- Division of Metabolism, Ageing, and Genomics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ella Zomer
- Centre of cardiovascular Research and Education in therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - J. Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Hornsby, New South Wales, Australia
| | - Sophia Zoungas
- Division of Metabolism, Ageing, and Genomics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Danny Liew
- Centre of cardiovascular Research and Education in therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Thompson W, Lundby C, Graabaek T, Nielsen DS, Ryg J, Søndergaard J, Pottegård A. Tools for Deprescribing in Frail Older Persons and Those with Limited Life Expectancy: A Systematic Review. J Am Geriatr Soc 2018; 67:172-180. [DOI: 10.1111/jgs.15616] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/13/2018] [Accepted: 08/19/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Wade Thompson
- Research Unit of General Practice, Department of Public Health; University of Southern Denmark; Odense Denmark
| | - Carina Lundby
- Hospital Pharmacy Funen, Odense University Hospital; Odense Denmark
- Clinical Pharmacology and Pharmacy, Department of Public Health; University of Southern Denmark; Odense Denmark
| | - Trine Graabaek
- Hospital Pharmacy Funen, Odense University Hospital; Odense Denmark
- Clinical Pharmacology and Pharmacy, Department of Public Health; University of Southern Denmark; Odense Denmark
| | - Dorthe S. Nielsen
- Migrant Health Clinic; Odense University Hospital; Odense Denmark
- Centre for Global Health; University of Southern Denmark; Odense Denmark
- Health Sciences Research Center; University College Lillebaelt; Odense Denmark
| | - Jesper Ryg
- Department of Geriatric Medicine; Odense University Hospital; Odense Denmark
- Geriatric Research Unit, Department of Clinical Research; University of Southern Denmark; Odense Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health; University of Southern Denmark; Odense Denmark
| | - Anton Pottegård
- Hospital Pharmacy Funen, Odense University Hospital; Odense Denmark
- Clinical Pharmacology and Pharmacy, Department of Public Health; University of Southern Denmark; Odense Denmark
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Disalvo D, Luckett T, Luscombe G, Bennett A, Davidson P, Chenoweth L, Mitchell G, Pond D, Phillips J, Beattie E, Goodall S, Agar M. Potentially Inappropriate Prescribing in Australian Nursing Home Residents with Advanced Dementia: A Substudy of the IDEAL Study. J Palliat Med 2018; 21:1472-1479. [PMID: 30106321 DOI: 10.1089/jpm.2018.0070] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Prescribing medications for nursing home residents with advanced dementia should focus on optimizing function and comfort, reducing unnecessary harms and aligning care goals with a palliative approach. OBJECTIVE The aim of the study was to estimate the proportion of Australian nursing home residents with advanced dementia receiving potentially inappropriate medications, and identify those most commonly prescribed and factors associated with their use. DESIGN Data were collected through retrospective audit of medication charts. SETTING/SUBJECTS Two hundred eighteen nursing home residents with advanced dementia from 20 nursing homes participated in a cluster-randomized controlled trial of case conferencing (the IDEAL Study) from June 2013 to December 2014. MEASUREMENTS Inappropriate drug use was defined as medications classified as "never appropriate" by the Palliative Excellence in Alzheimer Care Efforts (PEACE) program criteria. Generalized linear mixed models were used to identify variables predicting use of "never" appropriate medications. RESULTS Over a quarter (n = 65, 30%) of residents received at least one medication classed as "never" appropriate, the most common being lipid-lowering agents (n = 38, 17.4%), antiplatelet agents (n = 18, 8.3%), and acetylcholinesterase inhibitors (n = 16, 7.3%). Residents who had been at the nursing home for ≤10 months (odds ratio [OR] 5.60, 95% confidence interval [CI] 1.74-18.06) and 11-21 months (OR 5.41, 95% CI 1.67-17.75) had significantly greater odds of receiving a never appropriate medication compared with residents who had been at the nursing home for >5 years. CONCLUSIONS Use of potentially inappropriate medications in Australian nursing home residents with advanced dementia is common. A greater understanding of the rationale that underpins prescribing of medications is required.
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Affiliation(s)
- Domenica Disalvo
- 1 Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney , Ultimo, New South Wales, Australia
| | - Tim Luckett
- 1 Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney , Ultimo, New South Wales, Australia
| | - Georgina Luscombe
- 2 Sydney Medical School, The University of Sydney , Ultimo, New South Wales, Australia
| | - Alexandra Bennett
- 3 NSW Therapeutic Advisory Group , Sydney, New South Wales, Australia
| | | | - Lynnette Chenoweth
- 5 Centre for Healthy Brain Ageing, University of New South Wales , Sydney, New South Wales, Australia
| | - Geoffrey Mitchell
- 6 Faculty of Medicine, The University of Queensland , St. Lucia, Queensland, Australia
| | - Dimity Pond
- 7 School of Medicine and Public Health, The University of Newcastle , Newcastle, New South Wales, Australia
| | - Jane Phillips
- 1 Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney , Ultimo, New South Wales, Australia
| | - Elizabeth Beattie
- 8 School of Nursing, Queensland University of Technology , Herston, Queensland, Australia
| | - Stephen Goodall
- 9 Centre for Health Research and Evaluation (CHERE), Faculty of Business, University of Technology , Haymarket, New South Wales, Australia
| | - Meera Agar
- 1 Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney , Ultimo, New South Wales, Australia .,10 South Western Sydney Clinical School, University of New South Wales , Sydney, New South Wales, Australia .,11 Ingham Institute of Applied Medical Research , Liverpool, New South Wales, Australia
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Green AR, Reifler LM, Boyd CM, Weffald LA, Bayliss EA. Medication Profiles of Patients with Cognitive Impairment and High Anticholinergic Burden. Drugs Aging 2018; 35:223-232. [PMID: 29404965 DOI: 10.1007/s40266-018-0522-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Drugs with anticholinergic properties are considered potentially inappropriate in patients with cognitive impairment because harms-including delirium, falls, and fractures-may outweigh benefits. OBJECTIVE To highlight opportunities to improve clinical decision making and care for patients with cognitive impairment and multiple chronic conditions, we identified distinct subgroups of patients with mild cognitive impairment (MCI) and dementia who had high cumulative anticholinergic burden and specific patterns of anticholinergic use. PATIENTS AND METHODS We conducted a retrospective cohort study in a not-for-profit, integrated delivery system. Participants included community-dwelling adults aged 65 years and older (n = 13,627) with MCI or dementia and at least two other chronic diseases. We calculated the Anticholinergic Cognitive Burden (ACB) score for each participant from pharmacy and electronic health record (EHR) data. Among individuals with a mean 12-month ACB score ≥ 2, we used agglomerative hierarchical clustering to identify groups or clusters of individuals with similar anticholinergic prescription patterns. RESULTS Twenty-four percent (3257 participants) had high anticholinergic burden, defined as an ACB score ≥ 2. Clinically meaningful clusters based upon anchoring medications or drug classes included a cluster of cardiovascular medications (n = 1497; 46%); two clusters of antidepressant medications (n = 633; 20%); and a cluster based on use of bladder antimuscarinics (n = 431; 13%). Several clusters comprised multiple central nervous system (CNS)-active drugs. CONCLUSIONS Cardiovascular and CNS-active medications comprise a substantial portion of anticholinergic burden in people with cognitive impairment and multiple chronic conditions. Antidepressants were highly prevalent. Clinical profiles elucidated by these clusters of anticholinergic medications can inform targeted approaches to care.
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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, 10065 E. Harvard Ave. Suite 300, Denver, CO, 80207, 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
| | - Linda A Weffald
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Ave. Suite 300, Denver, CO, 80207, USA
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Ave. Suite 300, Denver, CO, 80207, USA.
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
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McCloskey B, Hughes C, Parsons C. A qualitative exploration of proxy decision makers' expectations of prescribed medications for people with advanced dementia. Palliat Med 2018; 32:1114-1123. [PMID: 29485337 DOI: 10.1177/0269216318757163] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background: Proxy decision makers often have to make decisions for people with advanced dementia. Their expectations regarding prescribed medications have the potential to influence prescription or withdrawal of medications. However, few studies to date have explored this. Aim: To explore proxy decision makers’ expectations of prescribed medications for people with advanced dementia and to consider how these change with changing goals of care and dementia progression. Design: This is a qualitative semi-structured interview study. Setting/participants: In total, 15 proxy decision makers of people with advanced dementia were recruited via general practitioners ( n = 9), Join Dementia Research ( n = 3) and the Alzheimer’s Society Northern Ireland ( n = 3). Results: Five key themes emerged: the role as advocate, attitudes to medicines and medicine taking, uncertainty over the benefit of anti-dementia medications, stopping medications, and communication and decision-making. Proxy decision makers desired more information about prescribed medicines, particularly the indications, benefits and risks of treatment. Despite uncertainty about the benefits of anti-dementia medications, proxy decision makers were reluctant for these medications to be withdrawn. Reluctance to stop other prescribed medicines was also expressed but reduced with changing goals of care and dementia progression. Although some proxy decision makers expected to be involved in medication-related decisions, the majority preferred to delegate these decisions to healthcare professionals. However, they expected to be informed of any medication-related decisions made. Conclusion: Proxy decision makers vary in terms of their desire for active involvement in the medication decision-making process. Healthcare professionals should facilitate proxy decision maker involvement if desired. Further research is required to consider the impact of proxy decision maker involvement in decision-making.
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Affiliation(s)
| | - Carmel Hughes
- 2 School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Carole Parsons
- 2 School of Pharmacy, Queen's University Belfast, Belfast, UK
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25
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Inter-rater reliability of STOPPFrail [Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy] criteria amongst 12 physicians. Eur J Clin Pharmacol 2017; 74:331-338. [DOI: 10.1007/s00228-017-2376-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 11/12/2017] [Indexed: 01/25/2023]
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26
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Füeßl HS. [Not Available]. MMW Fortschr Med 2017; 159:32. [PMID: 28656422 DOI: 10.1007/s15006-017-9833-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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