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Mohanty S, Lindroth H, Timsina L, Holler E, Jenkins P, Ortiz D, Hur J, Gillio A, Zarzaur B, Boustani M. A Mediation Analysis Examining High Risk, Anticholinergic Medication Use, Delirium, and Dementia After Major Surgery. J Surg Res 2024; 298:222-229. [PMID: 38626720 PMCID: PMC11144094 DOI: 10.1016/j.jss.2024.03.018] [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: 08/29/2023] [Revised: 01/29/2024] [Accepted: 03/18/2024] [Indexed: 04/18/2024]
Abstract
INTRODUCTION Anticholinergic medications are known to cause adverse cognitive effects in community-dwelling older adults and medical inpatients, including dementia. The prevalence with which such medications are prescribed in older adults undergoing major surgery is not well described nor is their mediating relationship with delirium and dementia. We sought to determine the prevalence of high-risk medication use in major surgery patients and their relationship with the subsequent development of dementia. METHODS This was a retrospective cohort study which used data between January 2013 and December 2019, in a large midwestern health system, including sixteen hospitals. All patients over age 50 undergoing surgery requiring an inpatient stay were included. The primary exposure was the number of doses of anticholinergic medications delivered during the hospital stay. The primary outcome was a new diagnosis of Alzheimer's disease and related dementias at 1-y postsurgery. Regression methods and a mediation analysis were used to explore relationships between anticholinergic medication usage, delirium, and dementia. RESULTS There were 39,665 patients included, with a median age of 66. Most patients were exposed to anticholinergic medications (35,957/39,665; 91%), and 7588/39,665 (19.1%) patients received six or more doses during their hospital stay. Patients with at least six doses of these medications were more likely to be female, black, and with a lower American Society of Anesthesiologists class. Upon adjusted analysis, high doses of anticholinergic medications were associated with increased odds of dementia at 1 y relative to those with no exposure (odds ratio 2.7; 95% confidence interval 2.2-3.3). On mediation analysis, postoperative delirium mediated the effect of anticholinergic medications on dementia, explaining an estimated 57.6% of their association. CONCLUSIONS High doses of anticholinergic medications are common in major surgery patients and, in part via a mediating relationship with postoperative delirium, are associated with the development of dementia 1 y following surgery. Strategies to decrease the use of these medications and encourage the use of alternatives may improve long-term cognitive recovery.
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Affiliation(s)
- Sanjay Mohanty
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Center for Health Innovation and Implementation Science, Indianapolis, Indiana.
| | - Heidi Lindroth
- Nursing Research Division, Department of Nursing, Mayo Clinic, Rochester, Minnesota
| | - Lava Timsina
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Emma Holler
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health, Bloomington, Indiana
| | - Peter Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Damaris Ortiz
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Center for Health Innovation and Implementation Science, Indianapolis, Indiana
| | - Jennifer Hur
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Anna Gillio
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ben Zarzaur
- Division of Acute Care and Regional General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Malaz Boustani
- Center for Health Innovation and Implementation Science, Indianapolis, Indiana; Regenstrief Institute, Indiana University Center of Aging Research, Indianapolis, Indiana
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Lee JW, Hollingsworth EK, Shah AS, Szanton SL, Perrin N, Mixon AS, Vasilevskis EE, Boyd CM, Han HR, Green AR, Taylor JL, Simmons SF. Emergency department visits and hospital readmissions after a deprescribing intervention among hospitalized older adults. J Am Geriatr Soc 2024. [PMID: 38725307 DOI: 10.1111/jgs.18945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 04/01/2024] [Accepted: 04/14/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Deprescribing is the planned/supervised method of dose reduction or cessation of medications that might be harmful, or no longer be beneficial. Though benefits of deprescribing are debatable in improving clinical outcomes, it has been associated with decreased number of potentially inappropriate medications, which may potentially reduce the risk of adverse events among hospitalized older adults. With unclear evidence for deprescribing in this population, this study aimed to examine time-to-first unplanned healthcare utilization, which included 90-day emergency department (ED) visits or hospital readmission and associated predictors, during a deprescribing intervention. METHODS A secondary data analysis of a clinical trial (Shed-MEDS NCT02979353) was performed. Cox regression was used to compare the time-to-first 90-day ED visit/readmission/death from hospital discharge for the intervention and control groups. Additionally, we performed exploratory analysis of predictors (comorbidities, functional health status, drug burden index (DBI), hospital length of stay, health literacy, food insecurity, and financial burden) associated with the time-to-first 90-day ED visit/readmission/death. RESULTS The hazard of first 90-day ED visits/readmissions/death was 15% lower in the intervention versus the control group (95% CI: 0.61-1.19, p = 0.352, respectively); however, this difference was not statistically significant. For every additional number of comorbidities (Hazard ratio (HR): 1.12, 95% CI: 1.04-1.21) and each additional day of hospital length of stay (HR: 1.04, 95% CI: 1.01-1.07) were significantly associated with a higher hazard of 90-day ED visit/readmission/death in the intervention group; whereas for each unit of increase in pre-hospital DBI score (HR: 1.08 and HR 1.16, respectively) was significantly associated with a higher hazard of 90-day ED visit/readmission/death in the control group. CONCLUSIONS The intervention and control groups had comparable time-to-first 90-day ED visit/readmission/death during a deprescribing intervention. This finding suggests that deprescribing did not result in a higher risk of ED visit/readmission/death during the 90-day period following hospital discharge.
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Affiliation(s)
- Ji Won Lee
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
- Columbia University School of Nursing, New York, USA
| | - Emily Kay Hollingsworth
- Division of Geriatrics, Vanderbilt Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Avantika Saraf Shah
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Nancy Perrin
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Amanda S Mixon
- Division of Geriatrics, Vanderbilt Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, Tennessee, USA
| | - Eduard Eric Vasilevskis
- Division of Geriatrics, Vanderbilt Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, Tennessee, USA
- Division of Hospital Medicine, School of Medicine and Public Health, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Cynthia M Boyd
- Johns Hopkins School of Medicine, Center for Transformative Geriatric Research, Baltimore, Maryland, USA
| | - Hae-Ra Han
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Ariel R Green
- Johns Hopkins School of Medicine, Center for Transformative Geriatric Research, Baltimore, Maryland, USA
| | | | - Sandra Faye Simmons
- Division of Geriatrics, Vanderbilt Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, Tennessee, USA
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Taylor-Rowan M, Alharthi AA, Noel-Storr AH, Myint PK, Stewart C, McCleery J, Quinn TJ. Anticholinergic deprescribing interventions for reducing risk of cognitive decline or dementia in older adults with and without prior cognitive impairment. Cochrane Database Syst Rev 2023; 12:CD015405. [PMID: 38063254 PMCID: PMC10704558 DOI: 10.1002/14651858.cd015405.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
BACKGROUND Anticholinergics are medications that block the action of acetylcholine in the central or peripheral nervous system. Medications with anticholinergic properties are commonly prescribed to older adults. The cumulative anticholinergic effect of all the medications a person takes is referred to as the anticholinergic burden. A high anticholinergic burden may cause cognitive impairment in people who are otherwise cognitively healthy, or cause further cognitive decline in people with pre-existing cognitive problems. Reducing anticholinergic burden through deprescribing interventions may help to prevent onset of cognitive impairment or slow the rate of cognitive decline. OBJECTIVES Primary objective • To assess the efficacy and safety of anticholinergic medication reduction interventions for improving cognitive outcomes in cognitively healthy older adults and older adults with pre-existing cognitive issues. Secondary Objectives • To compare the effectiveness of different types of reduction interventions (e.g. pharmacist-led versus general practitioner-led, educational versus audit and feedback) for reducing overall anticholinergic burden. • To establish optimal duration of anticholinergic reduction interventions, sustainability, and lessons learnt for upscaling • To compare results according to differing anticholinergic scales used in medication reduction intervention trials • To assess the efficacy of anticholinergic medication reduction interventions for improving other clinical outcomes, including mortality, quality of life, clinical global impression, physical function, institutionalisation, falls, cardiovascular diseases, and neurobehavioral outcomes. SEARCH METHODS We searched CENTRAL on 22 December 2022, and we searched MEDLINE, Embase, and three other databases from inception to 1 November 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) of interventions that aimed to reduce anticholinergic burden in older people and that investigated cognitive outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data, and assessed the risk of bias of included studies. The data were not suitable for meta-analysis, so we summarised them narratively. We used GRADE methods to rate our confidence in the review results. MAIN RESULTS We included three trials with a total of 299 participants. All three trials were conducted in a cognitively mixed population (some cognitively healthy participants, some participants with dementia). Outcomes were assessed after one to three months. One trial reported significantly improved performance on the Digit Symbol Substitution Test (DSST) in the intervention group (treatment difference 0.70, 95% confidence interval (CI) 0.11 to 1.30), although there was no difference between the groups in the proportion of participants with reduced anticholinergic burden. Two trials successfully reduced anticholinergic burden in the intervention group. Of these, one reported no significant difference between the intervention versus control in terms of their effect on cognitive performance measured by the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) immediate recall (mean between-group difference 0.54, 95% CI -0.91 to 2.05), CERAD delayed recall (mean between-group difference -0.23, 95% CI-0.85 to 0.38), CERAD recognition (mean between-group difference 0.77, 95% CI -0.39 to 1.94), and Mini-Mental State Examination (mean between-group difference 0.39, 95% CI -0.96 to 1.75). The other trial reported a significant correlation between anticholinergic burden and a test of working memory after the intervention (which suggested reducing the burden improved performance), but reported no effect on multiple other cognitive measures. In GRADE terms, the results were of very low certainty. There were no reported between-group differences for any other clinical outcome we investigated. It was not possible to investigate differences according to type of reduction intervention or type of anticholinergic scale, to measure the sustainability of interventions, or to establish lessons learnt for upscaling. No trials investigated safety outcomes. AUTHORS' CONCLUSIONS There is insufficient evidence to reach any conclusions on the effects of anticholinergic burden reduction interventions on cognitive outcomes in older adults with or without prior cognitive impairment. The evidence from RCTs was of very low certainty so cannot support or refute the hypothesis that actively reducing or stopping prescription of medications with anticholinergic properties can improve cognitive outcomes in older people. There is no evidence from RCTs that anticholinergic burden reduction interventions improve other clinical outcomes such as mortality, quality of life, clinical global impression, physical function, institutionalisation, falls, cardiovascular diseases, or neurobehavioral outcomes. Larger RCTs investigating long-term outcomes are needed. Future RCTs should also investigate potential benefits of anticholinergic reduction interventions in cognitively healthy populations and cognitively impaired populations separately.
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Affiliation(s)
- Martin Taylor-Rowan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Ahmed A Alharthi
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Department of Clinical Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
| | | | - Phyo K Myint
- Division of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | | | | | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Ashkanani FZ, Rathbone AP, Lindsey L. The role of pharmacists in deprescribing benzodiazepines: A scoping review. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 12:100328. [PMID: 37743854 PMCID: PMC10511800 DOI: 10.1016/j.rcsop.2023.100328] [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: 05/23/2023] [Revised: 07/14/2023] [Accepted: 09/01/2023] [Indexed: 09/26/2023] Open
Abstract
Background Polypharmacy can increase the risk of adverse drug events, hospitalisation, and unnecessary healthcare costs. Evidence indicates that discontinuing certain medications, such as benzodiazepines, can improve health outcomes, by resolving adverse drug effects. This scoping review aims to explore the pharmacists' role in deprescribing benzodiazepines. Method A scoping review has been conducted to distinguish and map the literature, discover research gaps, and focus on targeted areas for future studies and research. A systematic search strategy was conducted to identify relevant studies from PubMed, Medline, and EMBASE databases. The eligibility criteria involved studies that focused on the role of pharmacists in benzodiazepine deprescribing, quantitative and qualitative studies conducted in humans, full-text articles published in English. Results Twenty studies were identified, revealing three themes: 1) pharmacists' involvement in benzodiazepine deprescribing, 2) the impact of their involvement, and 3) obstacles impeding the process. Pharmacists involved in deprescribing procedures, mainly through completing medication reviews, collaborative work with other healthcare providers, and education. Pharmacists' involvement in benzodiazepine deprescribing intervention led to better health and economic outcomes. Withdrawal symptoms after medication discontinuation, dependence on medication, and lack of time and guidelines were identified in the literature as barriers to deprescribing. Conclusion Pharmacists' involvement in deprescribing benzodiazepines is crucial for optimizing medication therapy. This scoping review examines the pharmacists' role in benzodiazepine deprescribing. The findings contribute to enhancing healthcare outcomes and guiding future research in this area.
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Affiliation(s)
- Fatemah Zakariya Ashkanani
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, King George VI Building, Newcastle upon Tyne, Tyne and Wear NE2 7RU, United Kingdom
| | - Adam Pattison Rathbone
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, King George VI Building, Newcastle upon Tyne, Tyne and Wear NE2 7RU, United Kingdom
| | - Laura Lindsey
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, King George VI Building, Newcastle upon Tyne, Tyne and Wear NE2 7RU, United Kingdom
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Mehta J, Williams C, Holden RJ, Taylor B, Fowler NR, Boustani M. The methodology of the Agile Nudge University. FRONTIERS IN HEALTH SERVICES 2023; 3:1212787. [PMID: 38093811 PMCID: PMC10716213 DOI: 10.3389/frhs.2023.1212787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/10/2023] [Indexed: 02/01/2024]
Abstract
Introduction The Agile Nudge University is a National Institute on Aging-funded initiative to engineer a diverse, interdisciplinary network of scientists trained in Agile processes. Methods Members of the network are trained and mentored in rapid, iterative, and adaptive problem-solving techniques to develop, implement, and disseminate evidence-based nudges capable of addressing health disparities and improving the care of people living with Alzheimer's disease and other related dementias (ADRD). Results Each Agile Nudge University cohort completes a year-long online program, biweekly coaching and mentoring sessions, monthly group-based problem-solving sessions, and receives access to a five-day Bootcamp and the Agile Nudge Resource Library. Discussion The Agile Nudge University is evaluated through participant feedback, competency surveys, and tracking of the funding, research awards, and promotions of participating scholars. The Agile Nudge University is compounding national innovation efforts in overcoming the gaps in the ADRD discovery-to-delivery translational cycle.
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Affiliation(s)
- Jade Mehta
- Center for Health Innovation and Implementation Science, School of Medicine, Indiana University, Indianapolis, IN, United States
| | - Christopher Williams
- Center for Health Innovation and Implementation Science, School of Medicine, Indiana University, Indianapolis, IN, United States
- Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, IN, United States
- Department of Health and Wellness Design, School of Public Health - Bloomington, Indiana University, Bloomington, IN, United States
| | - Richard J. Holden
- Center for Health Innovation and Implementation Science, School of Medicine, Indiana University, Indianapolis, IN, United States
- Department of Health and Wellness Design, School of Public Health - Bloomington, Indiana University, Bloomington, IN, United States
- Department of Medicine, School of Medicine, Indiana University, Indianapolis, IN, United States
- Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, United States
| | - Britain Taylor
- Center for Health Innovation and Implementation Science, School of Medicine, Indiana University, Indianapolis, IN, United States
- Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, United States
| | - Nicole R. Fowler
- Center for Health Innovation and Implementation Science, School of Medicine, Indiana University, Indianapolis, IN, United States
- Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, IN, United States
- Department of Medicine, School of Medicine, Indiana University, Indianapolis, IN, United States
- Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, United States
| | - Malaz Boustani
- Center for Health Innovation and Implementation Science, School of Medicine, Indiana University, Indianapolis, IN, United States
- Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, IN, United States
- Department of Medicine, School of Medicine, Indiana University, Indianapolis, IN, United States
- Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, United States
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Khan SH, Perkins AJ, Eltarras AM, Chi R, Athar AA, Wang S, Campbell NL, Gao S, Boustani MA, Khan BA. Association between Change in the peripheral biomarkers of inflammation, astrocyte activation, and neuroprotection at one week of critical illness and hospital mortality in patients with delirium: A prospective cohort study. PLoS One 2023; 18:e0290298. [PMID: 37656731 PMCID: PMC10473496 DOI: 10.1371/journal.pone.0290298] [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] [Received: 01/24/2023] [Accepted: 08/04/2023] [Indexed: 09/03/2023] Open
Abstract
OBJECTIVE In critically ill adults with delirium, biomarkers of systemic inflammation, astrocyte activation, neuroprotection, and systemic inflammation measured at one week of critical illness may be associated with mortality. DESIGN Prospective observational study. SETTING Intensive care unit (ICU). PATIENTS 178 ICU patients with delirium, alive and remaining in ICU at one week. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Blood samples collected for a pair of previously published, negative, clinical trials were utilized. Samples were collected at study enrollment/ICU admission (Day 1 sample) and one week later (Day 8 sample), and analyzed for interleukins (IL)-6, 8, 10, Insulin-like Growth Factor (IGF), S100 Binding Protein (S100B), Tumor Necrosis Factor Alpha (TNF-A) and C-Reactive Protein (CRP). Delirium, delirium severity, and coma were assessed twice daily using Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), CAM-ICU-7, and Richmond Agitation-Sedation Scale (RASS), respectively. Mortality was assessed until discharge using the electronic medical record. Logistic regression models adjusting for age, sex, severity of illness, comorbidities, sepsis, and randomization status, were used to assess the relationship among biomarkers and mortality. Higher IL-10 quartiles at day 8 were associated with increased odds of hospital mortality (IL-10: OR 2.00 95%CI: 1.1-3.65, p = 0.023). There was a significant interaction between day 1 and day 8 biomarker quartiles only for IL-6. Patients with IL-6 values in the first three quartiles on admission to the ICU that transitioned to higher IL-6 quartiles at day 8 had increased probability of hospital mortality. CONCLUSION In this hypothesis-generating study, higher IL-6 and IL-10 quartiles at one week, and increase in IL-6 from day 1 to day 8 were associated with increased hospital mortality. Studies with larger sample sizes are needed to confirm the mechanisms for these observations.
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Affiliation(s)
- Sikandar H. Khan
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
- Regenstrief Institute, IU Center of Aging Research, Indianapolis, IN, United States of America
| | - Anthony J. Perkins
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Ahmed M. Eltarras
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Rosalyn Chi
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Ammar A. Athar
- Regenstrief Institute, IU Center of Aging Research, Indianapolis, IN, United States of America
| | - Sophia Wang
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Noll L. Campbell
- Department of Pharmacy, Purdue University, Lafayette, IN, United States of America
| | - Sujuan Gao
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Malaz A. Boustani
- Regenstrief Institute, IU Center of Aging Research, Indianapolis, IN, United States of America
| | - Babar A. Khan
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
- Regenstrief Institute, IU Center of Aging Research, Indianapolis, IN, United States of America
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Nizet P, Evin A, Brociero E, Vigneau CV, Huon JF. Outcomes in deprescribing implementation trials and compliance with expert recommendations: a systematic review. BMC Geriatr 2023; 23:428. [PMID: 37438697 DOI: 10.1186/s12877-023-04155-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 07/05/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Deprescribing, defined as discontinuing or reducing the dose of medications that are no longer needed or for which the risks outweigh the benefits is a way to reduce polypharmacy. In 2022, the US Deprescribing Research Network (USDeN) published recommendations concerning the measurement of outcomes for deprescribing intervention studies. The objectives of this systematic review were to identify the outcome categories used in deprescribing intervention trials and to relate them to the previously published recommendations. METHODS We searched MEDLINE, Embase, PsychInfo, and the Cochrane library from January 2012 through January 2022. Studies were included if they were randomized controlled trials evaluating a deprescribing intervention. After data extraction, outcomes were categorized by type: medication outcomes, clinical outcomes, system outcomes, implementation outcomes, and other outcomes based on the previously published recommendations. RESULTS Thirty-six studies were included. The majority of studies focused on older adults in nursing homes and targeted inappropriate medications or polypharmacy. In 20 studies, the intervention was a medication review; in seven studies, the intervention was educational or informative; and three studies based their intervention on motivational interviewing or patient empowerment. Thirty-one studies presented a medication outcome (primary outcome in 26 studies), 25 a clinical outcome, 18 a system outcome, and seven an implementation outcome. Only three studies presented all four types of outcomes, and 10 studies presented three types of outcomes. CONCLUSIONS This review provides an update on the implementation of gold standard deprescribing studies in clinical practice. Implementation outcomes need to be developed and specified to facilitate the implementation of these practices on a larger scale and clinical outcome need to be prioritized. Finally, this review provides new elements for future real-life deprescribing studies.
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Affiliation(s)
- Pierre Nizet
- Nantes Université, CHU Nantes, 44000, Pharmacie, France.
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France.
| | - Adrien Evin
- Nantes Université, CHU Nantes, Service de Soins Palliatifs Et de Support, 44000, Nantes, France
| | - Emma Brociero
- Nantes Université, CHU Nantes, 44000, Pharmacie, France
| | - Caroline Victorri Vigneau
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France
- Nantes Université, CHU Nantes, Service de Pharmacologie Clinique, 44000, Nantes, France
| | - Jean-François Huon
- Nantes Université, CHU Nantes, 44000, Pharmacie, France
- U1246 SPHERE "methodS in Patient-Centered Outcomes and HEalth ResEarch", Université de Nantes, Université de Tours, INSERM, Nantes, France
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Mulkey MA, Khan S, Perkins A, Gao S, Wang S, Campbell N, Khan B. Relationship between angiotensin-converting enzyme inhibitors and angiotensin receptor blockers prescribing and delirium in the ICU-A secondary analysis. J Am Geriatr Soc 2023; 71:1873-1880. [PMID: 36905601 PMCID: PMC10258121 DOI: 10.1111/jgs.18285] [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: 07/05/2022] [Revised: 01/14/2023] [Accepted: 01/25/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Studies suggest Angiotensin-Converting Enzyme inhibitors (ACEI) and Angiotensin Receptor Blockers (ARB) may slow the decline of memory function in individuals with mild to moderate Alzheimer's disease by regulating migroglial activation and oxidative stress within the brain's reticular activating system. Therefore, we evaluated the relationship between delirium prevalence and being prescribed ACEI and ARB in participants admitted to the intensive care units (ICU). METHODS A secondary analysis of data from two parallel pragmatic randomized controlled trials was performed. ACEI and ARB exposure was defined as being prescribed an ACEI or an ARB within six months prior to the ICU admission. The primary endpoint was the first positive delirium assessment based on Confusion Assessment Method for the ICU (CAM-ICU) for up to thirty days. RESULTS A total of 4791 patients admitted to the medical, surgical, and progressive ICU and screened for eligibility for the parent studies between February 2009 and January 2015 from two level 1 trauma and one safety net hospital in a large urban academic health system were included. Delirium rates in the ICU were not significantly different among participants with no exposure to ACEI/ARB (12.6%), or exposure to ACEI (14.4%), ARB (11.8%), or ACEI and ARB in combination (15.4%) in six months prior to the ICU admission. Exposure to ACEI (OR = 0.97[0.77, 1.22]), ARB (OR = 0.70 [0.47, 1.05]), or both (OR = 0.97 [0.33, 2.89]) in six months prior to ICU admission was not significantly associated with odds of delirium during the ICU admission after adjusting for age, gender, race, co-morbidities, and insurance status. CONCLUSIONS While the impact of ACEI and ARB exposure prior to the ICU admission was not associated with the prevalence of delirium in this study, further research is needed to fully understand the impact of antihypertensive medications on delirium.
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Affiliation(s)
- Malissa A Mulkey
- College of Nursing, University of South Carolina, Columbia, South Carolina, USA
| | - Sikandar Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University-Purdue University, Indianapolis, Indiana, USA
- School of Medicine, Indiana University, Indianapolis, Indiana, USA
- Center for Aging Research, Indiana University, Indianapolis, Indiana, USA
- Indiana University Center of Aging Research, Regenstrief Institute, Indianapolis, Indiana, USA
| | - Anthony Perkins
- School of Medicine, Indiana University, Indianapolis, Indiana, USA
- Department of Biostatistics and Health Data Science, Indiana University-Purdue University, Indianapolis, Indiana, USA
| | - Sujuan Gao
- School of Medicine, Indiana University, Indianapolis, Indiana, USA
- Department of Biostatistics and Health Data Science, Indiana University-Purdue University, Indianapolis, Indiana, USA
| | - Sophia Wang
- School of Medicine, Indiana University, Indianapolis, Indiana, USA
- Department of Psychiatry, Department of Biostatistics and Health Data Science, Indianapolis, Indiana, USA
| | - Noll Campbell
- Center for Aging Research, Indiana University, Indianapolis, Indiana, USA
- Indiana University Center of Aging Research, Regenstrief Institute, Indianapolis, Indiana, USA
- Department of Pharmacy Practice, Purdue University, Lafayette, Indiana, USA
| | - Babar Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University-Purdue University, Indianapolis, Indiana, USA
- School of Medicine, Indiana University, Indianapolis, Indiana, USA
- Center for Aging Research, Indiana University, Indianapolis, Indiana, USA
- Indiana University Center of Aging Research, Regenstrief Institute, Indianapolis, Indiana, USA
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Campbell NL. Building Demand for Deprescribing Expertise: Pharmacists as Deprescribing Care Coordinators. Sr Care Pharm 2023; 38:3-4. [PMID: 36751920 DOI: 10.4140/tcp.n.2023.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A number of barriers to deprescribing exist, with knowledge, skills, and self-efficacy often highlighted by prescribers within an interrupted, siloed nature of the existing health care system. Thus, deprescribing is not likely to occur without a change in the system. Pharmacists are extremely well positioned to positively impact the deprescribing process, and particularly senior care pharmacists given familiarity with population-specific pharmacodynamic and pharmacokinetic characteristics of medications. Similarly, our health care partners have endorsed pharmacists to not only collaborate but to drive the deprescribing trials. Therefore, no other profession is better positioned to advocate for the value of deprescribing as a core component of the pharmaceutical care process.
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Affiliation(s)
- Noll L Campbell
- Department of Pharmacy Practice Purdue University College of Pharmacy West Lafayette, Indiana Indiana University Center for Aging Research Regenstrief Institute Indiana University Center for Healthcare Innovation and Implementation Science Indianapolis, Indiana
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10
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Kleiman MJ, Plewes AD, Owora A, Grout RW, Dexter PR, Fowler NR, Galvin JE, Miled ZB, Boustani M. Digital detection of dementia (D 3): a study protocol for a pragmatic cluster-randomized trial examining the application of patient-reported outcomes and passive clinical decision support systems. Trials 2022; 23:868. [PMID: 36221141 PMCID: PMC9552361 DOI: 10.1186/s13063-022-06809-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 09/30/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Early detection of Alzheimer's disease and related dementias (ADRD) in a primary care setting is challenging due to time constraints and stigma. The implementation of scalable, sustainable, and patient-driven processes may improve early detection of ADRD; however, there are competing approaches; information may be obtained either directly from a patient (e.g., through a questionnaire) or passively using electronic health record (EHR) data. In this study, we aim to identify the benefit of a combined approach using a pragmatic cluster-randomized clinical trial. METHODS We have developed a Passive Digital Marker (PDM), based on machine learning algorithms applied to EHR data, and paired it with a patient-reported outcome (the Quick Dementia Rating Scale or QDRS) to rapidly share an identified risk of impairment to a patient's physician. Clinics in both south Florida and Indiana will be randomly assigned to one of three study arms: 1200 patients in each of the two populations will be administered either the PDM, the PDM with the QDRS, or neither, for a total of 7200 patients across all clinics and populations. Both incidence of ADRD diagnosis and acceptance into ADRD diagnostic work-up regimens is hypothesized to increase when patients are administered both the PDM and QDRS. Physicians performing the work-up regimens will be blind to the study arm of the patient. DISCUSSION This study aims to test the accuracy and effectiveness of the two scalable approaches (PDM and QDRS) for the early detection of ADRD among older adults attending primary care practices. The data obtained in this study may lead to national early detection and management program for ADRD as an efficient and beneficial method of reducing the current and future burden of ADRD, as well as improving the annual rate of newly documented ADRD in primary care practices. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05231954 . Registered February 9, 2022.
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Affiliation(s)
- Michael J Kleiman
- Comprehensive Center for Brain Health, Department of Neurology, University of Miami Miller School of Medicine, 7700 W Camino Real, Suite 200, Boca Raton, FL, 33433, USA.
| | - Abbi D Plewes
- Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- Center for Health Innovation and Implementation Science, Indiana Clinical and Translational Science Institute, Indianapolis, IN, 46202, USA
| | - Arthur Owora
- Indiana University Bloomington School of Public Health, Bloomington, IN, 47405, USA
| | - Randall W Grout
- Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- Regenstrief Institute, Inc., Indianapolis, IN, 46202, USA
| | - Paul Richard Dexter
- Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- Regenstrief Institute, Inc., Indianapolis, IN, 46202, USA
| | - Nicole R Fowler
- Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- Center for Health Innovation and Implementation Science, Indiana Clinical and Translational Science Institute, Indianapolis, IN, 46202, USA
- Regenstrief Institute, Inc., Indianapolis, IN, 46202, USA
- Indiana University Center for Aging Research, Indianapolis, IN, 46202, USA
| | - James E Galvin
- Comprehensive Center for Brain Health, Department of Neurology, University of Miami Miller School of Medicine, 7700 W Camino Real, Suite 200, Boca Raton, FL, 33433, USA
| | - Zina Ben Miled
- Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Malaz Boustani
- Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- Center for Health Innovation and Implementation Science, Indiana Clinical and Translational Science Institute, Indianapolis, IN, 46202, USA
- Regenstrief Institute, Inc., Indianapolis, IN, 46202, USA
- Indiana University Center for Aging Research, Indianapolis, IN, 46202, USA
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11
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Campbell NL, Pitts C, Corvari C, Kaehr E, Alamer K, Chand P, Nanagas K, Callahan CM, Boustani MA. Deprescribing anticholinergics in primary care older adults: Experience from two models and impact on a continuous measure of exposure. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022; 5:1039-1047. [PMID: 36620097 PMCID: PMC9796793 DOI: 10.1002/jac5.1682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 01/11/2023]
Abstract
Background Deprescribing interventions delivered through the electronic medical record have not significantly reduced the use of high-risk anticholinergics in prior trials. Pharmacists have been identified as ideal practitioners to conduct deprescribing; however, little experience beyond collaborative consult models has been published. Objective To evaluate the impact of two pilot pharmacist-based advanced practice models nested within primary care. Methods Pilot studies of a collaborative clinic-based pharmacist deprescribing intervention and a telephone-based pharmacist deprescribing intervention were conducted. Patients receiving the clinic-based pharmacy model were aged 55 years and older and referred for deprescribing at a specialty clinic. Patients receiving the telephone-based pharmacy model were aged 65 years and older and called by a clinical pharmacist for deprescribing without referral. Deprescribing was defined as a discontinuation or dose reduction reported either in clinical records or through self-reporting. Results The 18 patients receiving clinic-based deprescribing had a mean age of 68 years and 78% were female. Among 24 medications deemed eligible for deprescribing, 23 (96%) were deprescribed. The clinic-based deprescribing model resulted in a 93% reduction in median annualized total standardized dose (TSD), 56% lowered their annualized exposure below a cognitive risk threshold, and 4 (17%) of medications were represcribed within 6 months. The 24 patients receiving telephone-based deprescribing had a mean age of 73 years and 92% were female. Among 24 medications deemed eligible for deprescribing, 12 (50%) were deprescribed. There was no change in the median annualized TSD, the annualized TSD was lowered below a cognitive risk threshold in 46%, and no medications were represcribed within 6 months. Few withdrawal symptoms or adverse events were reported in both groups. Conclusions Pharmacist-based deprescribing successfully reduced exposure to high-risk anticholinergics in primary care older adults, yet further work is needed to understand the impact on clinical outcomes.
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Affiliation(s)
- Noll L. Campbell
- Department of Pharmacy PracticePurdue University College of PharmacyWest LafayetteIndianaUSA
- Indiana University Center for Aging Research, Regenstrief Institute, Inc.IndianapolisIndianaUSA
- Center for Health Innovation and Implementation ScienceIndiana University School of MedicineIndianapolisIndianaUSA
- Sandra Eskenazi Center for Brain Care InnovationEskenazi HealthIndianapolisIndianaUSA
| | | | - Claire Corvari
- Department of PharmacyFranciscan HealthIndianapolisIndianaUSA
| | - Ellen Kaehr
- Sandra Eskenazi Center for Brain Care InnovationEskenazi HealthIndianapolisIndianaUSA
- Department of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Khalid Alamer
- Department of Pharmacy PracticePurdue University College of PharmacyWest LafayetteIndianaUSA
| | - Parveen Chand
- Ascenscion St. Vincent North RegionEvansvilleIndianaUSA
| | - Kristine Nanagas
- Ascenscion St. Vincent North RegionEvansvilleIndianaUSA
- Department of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Christopher M. Callahan
- Indiana University Center for Aging Research, Regenstrief Institute, Inc.IndianapolisIndianaUSA
- Center for Health Innovation and Implementation ScienceIndiana University School of MedicineIndianapolisIndianaUSA
- Sandra Eskenazi Center for Brain Care InnovationEskenazi HealthIndianapolisIndianaUSA
- Department of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Malaz A. Boustani
- Indiana University Center for Aging Research, Regenstrief Institute, Inc.IndianapolisIndianaUSA
- Center for Health Innovation and Implementation ScienceIndiana University School of MedicineIndianapolisIndianaUSA
- Sandra Eskenazi Center for Brain Care InnovationEskenazi HealthIndianapolisIndianaUSA
- Department of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
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Ortiz D, Lindroth HL, Braly T, Perkins AJ, Mohanty S, Meagher AD, Khan SH, Boustani MA, Khan BA. Delirium severity does not differ between medical and surgical intensive care units after adjusting for medication use. Sci Rep 2022; 12:14447. [PMID: 36002562 PMCID: PMC9402532 DOI: 10.1038/s41598-022-18429-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 08/11/2022] [Indexed: 11/10/2022] Open
Abstract
Severe delirium is associated with an increased risk of mortality, institutionalization, and length of stay. Few studies have examined differences in delirium severity between different populations of critically ill patients. The objective of the study was to compare delirium severity and the presence of the four core features between adults in the surgical intensive care unit (SICU) and medical intensive care unit (MICU) while controlling for variables known to be associated with delirium. This is a secondary analysis of two parallel randomized multi-center trials conducted from March 2009 to January 2015 at 3 Indianapolis hospitals. A total of 474 adults with delirium were included in the analysis. Subjects were randomized in a 1:1 ratio in random blocks of 4 by a computer program. Patients were randomized to either haloperidol prescribing or de-prescribing regimen vs usual care. Delirium severity was assessed daily or twice-daily using the CAM-ICU-7 beginning after 24 h of ICU admission and until discharge from the hospital, death, or 30 days after enrollment. Secondary outcomes included hospital length of stay, hospital and 30-day mortality, and delirium-related adverse events. These outcomes were compared between SICU and MICU settings for this secondary analysis. Out of 474 patients, 237 were randomized to intervention. At study enrollment, the overall cohort had a mean age of 59 (SD 16) years old, was 54% female, 44% African-American, and 81% were mechanically ventilated upon enrollment. MICU participants were significantly older and severely ill with a higher premorbid cognitive and physical dysfunction burden. In univariate analysis, SICU participants had significantly higher mean total CAM-ICU-7 scores, corresponding to delirium severity, (4.15 (2.20) vs 3.60 (2.32), p = 0.02), and a lower mean RASS score (- 1.79 (1.28) vs - 1.53 (1.27), p < 0.001) compared to MICU participants. Following adjustment for benzodiazepines and opioids, delirium severity did not significantly differ between groups. The presence of Feature 3, altered level of consciousness, was significantly associated with the SICU participants, identifying as Black, premorbid functional impairment, benzodiazepines, opioids, and dexmedetomidine. In this secondary analysis examining differences in delirium severity between MICU and SICU participants, we did not identify a difference between participant populations following adjustment for administered benzodiazepines and opioids. We did identify that an altered level of consciousness, core feature 3 of delirium, was associated with SICU setting, identifying as Black, activities of daily living, benzodiazepines and opioid medications. These results suggest that sedation practice patterns play a bigger role in delirium severity than the underlying physiologic insult, and expression of core features of delirium may vary based on individual factors.Trial registration CT#: NCT00842608.
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Affiliation(s)
- Damaris Ortiz
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall, Indianapolis, IN, 46202, USA.
- Sidney & Lois Eskenazi Hospital Smith Level 1 Trauma Center, 720 Eskenazi Ave, Indianapolis, IN, 46202, USA.
- Center of Health Innovation and Implementation Science, Center for Translational Science and Innovation, Indiana University, 410 W. 10th St, Indianapolis, IN, 46202, USA.
- Indiana University Health Methodist Hospital, 1701 N Senate Blvd, Indianapolis, IN, 46202, USA.
- Sidney & Lois Eskenazi Hospital Smith Level 1 Trauma Center, 720 Eskenazi Avenue, 2nd floor Room 431, Indianapolis, IN, 46202, USA.
| | - Heidi L Lindroth
- Department of Nursing, Mayo Clinic Nursing Research Division, 200 First Street SW, Rochester, MN, 55905, USA
| | - Tyler Braly
- Indiana University School of Medicine, Fort Wayne Campus, 2101 East Coliseum Blvd, Fort Wayne, IN, 46805, USA
| | - Anthony J Perkins
- Indiana University Center of Aging Research, Regenstrief Institute, 1101 W. 10th Street, Indianapolis, IN, 46202, USA
| | - Sanjay Mohanty
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall, Indianapolis, IN, 46202, USA
- Center of Health Innovation and Implementation Science, Center for Translational Science and Innovation, Indiana University, 410 W. 10th St, Indianapolis, IN, 46202, USA
- Indiana University Health Methodist Hospital, 1701 N Senate Blvd, Indianapolis, IN, 46202, USA
| | - Ashley D Meagher
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall, Indianapolis, IN, 46202, USA
- Indiana University Health Methodist Hospital, 1701 N Senate Blvd, Indianapolis, IN, 46202, USA
| | - Sikandar H Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, 1120 W. Michigan St., CL 260, Indianapolis, IN, 46202, USA
| | - Malaz A Boustani
- Indiana University Health Methodist Hospital, 1701 N Senate Blvd, Indianapolis, IN, 46202, USA
- Indiana University Center of Aging Research, Regenstrief Institute, 1101 W. 10th Street, Indianapolis, IN, 46202, USA
| | - Babar A Khan
- Sidney & Lois Eskenazi Hospital Smith Level 1 Trauma Center, 720 Eskenazi Ave, Indianapolis, IN, 46202, USA
- Indiana University Center of Aging Research, Regenstrief Institute, 1101 W. 10th Street, Indianapolis, IN, 46202, USA
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, 1120 W. Michigan St., CL 260, Indianapolis, IN, 46202, USA
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13
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Cadogan CA. Pharmacist interventions to deprescribe benzodiazepines in older adults: A missed opportunity? Res Social Adm Pharm 2022; 18:4012-4015. [PMID: 35768308 DOI: 10.1016/j.sapharm.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/17/2022] [Accepted: 05/25/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Cathal A Cadogan
- (a)School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, Ireland.
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14
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Niznik JD, Collins BJ, Armistead LT, Larson CK, Kelley CJ, Hughes TD, Sanders KA, Carlson R, Ferreri SP. Pharmacist interventions to deprescribe opioids and benzodiazepines in older adults: A rapid review. Res Social Adm Pharm 2022; 18:2913-2921. [PMID: 34281786 PMCID: PMC8836277 DOI: 10.1016/j.sapharm.2021.07.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Many older adults are prescribed opioids and benzodiazepines (BZDs), despite increased susceptibility to adverse events. Challenges of deprescribing include fragmented care and lack of knowledge or time. Pharmacists are well-positioned to overcome these challenges and facilitate deprescribing of these medications. OBJECTIVES We sought to evaluate interventions utilizing pharmacists to deprescribe opioids and BZDs in older adults. METHODS We conducted a rapid review following a comprehensive literature search to identify interventions with pharmacist involvement for deprescribing opioids and BZDs in older adults. Studies were included based on: (1) inclusion of patients ≥ 65 years old receiving BZDs and/or opioids, (2) evaluation of feasibility or outcomes following deprescribing (3) pharmacists as part of the intervention. We included randomized, observational, cohort, and pilot studies. Studies that did not report specific results for BZD or opioids were excluded. RESULTS We screened 687 abstracts and included 17 studies. Most (n = 13) focused on BZD deprescribing. Few studies focused on opioids (n = 2) or co-prescribing of opioids and BZDs (n = 2). The most common intervention was educational brochures (n = 8), majority being the EMPOWER brochure for deprescribing BZDs. Other interventions included chart review with electronic notes (n = 4), pharmacist-led programs/services (n = 2), and multifactorial interventions (n = 3). Many studies were underpowered or lacked suitable control groups. Generally speaking, interventions utilizing educational materials and those in which pharmacists engaged with patients and providers were more effective. Interventions relying on electronic communication by pharmacists were less successful, due to low acceptance or acknowledgement. CONCLUSIONS We identified a number of feasible interventions to reduce BZD use, but fewer interventions to reduce opioid use in older adults. An optimal approach for deprescribing likely requires pharmacists to engage directly with patients and providers. Larger well-designed studies are needed to evaluate the effectiveness of deprescribing interventions beyond feasibility.
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Affiliation(s)
- Joshua D Niznik
- University of North Carolina School of Medicine, Division of Geriatric Medicine and Center for Aging and Health, Chapel Hill, NC, USA; University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA; VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.
| | - Brendan J Collins
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Lori T Armistead
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Claire K Larson
- University of North Carolina School of Medicine, Division of Geriatric Medicine and Center for Aging and Health, Chapel Hill, NC, USA
| | - Casey J Kelley
- University of North Carolina School of Medicine, Division of Geriatric Medicine and Center for Aging and Health, Chapel Hill, NC, USA
| | - Tamera D Hughes
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Kimberly A Sanders
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Rebecca Carlson
- University of North Carolina, Health Sciences Library, Chapel Hill, NC, USA
| | - Stefanie P Ferreri
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
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Differential Effects of Gamma-Aminobutyric Acidergic Sedatives on Risk of Post-Extubation Delirium in the ICU: A Retrospective Cohort Study From a New England Health Care Network. Crit Care Med 2022; 50:e434-e444. [PMID: 34982739 DOI: 10.1097/ccm.0000000000005425] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate whether different gamma-aminobutyric acidergic (GABAergic) sedatives such as propofol and benzodiazepines carry differential risks of post-extubation delirium in the ICU. DESIGN Retrospective cohort study. SETTING Seven ICUs in an academic hospital network, Beth Israel Deaconess Medical Center (Boston, MA). PATIENTS Ten thousand five hundred and one adult patients mechanically ventilated for over 24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We tested the hypothesis that benzodiazepine versus propofol-based sedation is associated with fewer delirium-free days within 14 days after extubation. Further, we hypothesized that the measured sedation level evoked by GABAergic drugs is a better predictor of delirium than the drug dose administered. The proportion of GABAergic drug-induced deep sedation was defined as the ratio of days with a mean Richmond Agitation-Sedation Scale of less than or equal to -3 during mechanical ventilation. Multivariable regression and effect modification analyses were used. Delirium-free days were lower in patients who received a high proportion of deep sedation using benzodiazepine compared with propofol-based sedation (adjusted absolute difference, -1.17 d; 95% CI, -0.64 to -1.69; p < 0.001). This differential effect was magnified in elderly patients (age > 65) and in patients with liver or kidney failure (p-for-interaction < 0.001) but not observed in patients who received a low proportion of deep sedation (p = 0.95). GABAergic-induced deep sedation days during mechanical ventilation was a better predictor of post-extubation delirium than the GABAergic daily average effective dose (area under the curve 0.76 vs 0.69; p < 0.001). CONCLUSIONS Deep sedation during mechanical ventilation with benzodiazepines compared with propofol is associated with increased risk of post-extubation delirium. Our data do not support the view that benzodiazepine-based compared with propofol-based sedation in the ICU is an independent risk factor of delirium, as long as deep sedation can be avoided in these patients.
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Rana R, Choi J, Vordenberg SE. Older adults’ willingness to consider deprescribing when experiencing hyperpolypharmacy. J Am Pharm Assoc (2003) 2022; 62:1189-1196. [DOI: 10.1016/j.japh.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/19/2021] [Accepted: 01/12/2022] [Indexed: 11/16/2022]
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DeMaagd GA, DeMaagd DR, Philip A. Delirium and its Pharmacological Causes in Older People, Part Two. Sr Care Pharm 2021; 36:534-547. [PMID: 34717785 DOI: 10.4140/tcp.n.2021.534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Delirium is a syndrome that can arise from many causes or underlying conditions, and though it has been reported in younger patients, it is more prevalent in older people, though it can occur in other age groups as well. Identifying delirium is challenging in older people because of the coexistence of underlying dementia or depression, which may further complicate the presentation. Drug-induced delirium is one of the major causes of delirium, and evaluation of this potential cause or contribution is an important component of the evaluation process, since it can lead to poor patient outcomes. Part one of this three part series reviewed the epidemiology, pathophysiology, evaluation, diagnostic process, and causes of delirium in older people, with a focus on the pharmacological causes. Part two of this series continues to review drugs and drug classes that can cause or contribute to delirium in older people.
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Affiliation(s)
| | | | - Ashok Philip
- Union University College of Pharmacy, Jackson, Tennessee
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Dynamic Delirium Severity Trajectories and Their Association With 2-Year Healthcare Utilization and Mortality Outcomes. Crit Care Explor 2021; 3:e0524. [PMID: 34589712 PMCID: PMC8437216 DOI: 10.1097/cce.0000000000000524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. Delirium severity has been associated with a higher risk of mortality and an increasing morbidity burden. Recently defined delirium severity trajectories were predictive of 30-day mortality in a critically ill patient population. No studies to date have examined associations between delirium severity trajectories and 2-year mortality and healthcare utilization outcomes.
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Delirium Severity Trajectories and Outcomes in ICU Patients. Defining a Dynamic Symptom Phenotype. Ann Am Thorac Soc 2021; 17:1094-1103. [PMID: 32383964 DOI: 10.1513/annalsats.201910-764oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Rationale: Delirium severity and duration are independently associated with higher mortality and morbidity. No studies to date have described a delirium trajectory by integrating both severity and duration.Objectives: The primary aim was to develop delirium trajectories by integrating symptom severity and duration. The secondary aim was to investigate the association among trajectory membership, clinical characteristics, and 30-day mortality.Methods: A secondary analysis of the PMD (Pharmacologic Management of Delirium) randomized control trial (ClinicalTrials.gov Identifier: NCT00842608; N = 531) was conducted. The presence of delirium and symptom severity were measured at least daily for 7 days using the Confusion Assessment Method for the intensive care unit (CAM-ICU) and CAM-ICU-7 (on a scale of 0-7, with 7 being the most severe). Delirium trajectories were defined using an innovative, data-driven statistical method (group-based trajectory modeling [GBTM]) and SAS v9.4.Results: A total of 531 delirious participants (mean age 60 yr [standard deviation = 16], 55% female, and 46% African American) were analyzed. Five distinct delirium trajectories were described (CAM-ICU-7: mean [standard deviation]); mild-brief (CAM-ICU-7: 0.5 [0.5]), severe-rapid recovers (CAM-ICU-7: 2.1 [1.0]), mild-accelerating (CAM-ICU-7: 2.2 [0.9]), severe-slow recovers (CAM-ICU-7: 3.9 [0.9]), and severe-nonrecovers (CAM-ICU-7: 5.9 [1.0]). Baseline cognition and race were associated with trajectory membership. Trajectory membership independently predicted 30-day mortality while controlling for age, sex, race, cognition, illness severity, and comorbidities.Conclusions: This secondary analysis described five distinct delirium trajectories based on delirium symptom severity and duration using group-based trajectory modeling. Trajectory membership predicted 30-day mortality.
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Kang J, An JH, Jeon HJ, Park YJ. Association between ankle brachial index and development of postoperative intensive care unit delirium in patients with peripheral arterial disease. Sci Rep 2021; 11:12744. [PMID: 34140560 PMCID: PMC8211748 DOI: 10.1038/s41598-021-91990-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 06/03/2021] [Indexed: 12/24/2022] Open
Abstract
Patients with vascular diseases are prone to developing postoperative delirium (POD). Ankle brachial index (ABI) is a non-invasive clinical indicator of lower-extremities peripheral arterial disease (PAD) and has been identified as an indicator of cognitive impairment. We investigated the association between ABI and POD. 683 PAD patients who underwent elective leg arterial bypass surgery between October 1998 and August 2019 were collected for retrospective analysis. Demographic information, comorbidities, preoperative ABI and the Rutherford classification within one month prior to surgery were obtained. POD was assessed using the Confusion assessment method -intensive care unit. Logistic regression and receiver operating characteristics (ROC) curve analysis were used to assess the association between ABI and POD. The mean value of ABI was significantly lower in patients with POD than it was those without POD. Older age, more medical comorbidities, longer length of surgery, decreased ABI, and higher Rutherford class were all significantly associated with POD. The area under ROC (0.74) revealed that ABI below 0.35 was associated with development of POD. Lower preoperative ABI was associated with POD in PAD patients who underwent arterial bypass surgery.
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Affiliation(s)
- Jihee Kang
- Division of Vascular Surgery, Department of Surgery, Inha University Hospital, Inha University School of Medicine, #27 Inhang-ro, Joong-gu, Incheon, 22332, Korea
| | - Ji Hyun An
- Department of Psychiatry, Depression Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, #81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Hong Jin Jeon
- Department of Psychiatry, Depression Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, #81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea. .,Department of Health Sciences & Technology, Department of Medical Device Management & Research, and Department of Clinical Research Design & Evaluation, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, #81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea.
| | - Yang Jin Park
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, #81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea.
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Colantuoni E, Koneru M, Akhlaghi N, Li X, Hashem MD, Dinglas VD, Neufeld KJ, Harhay MO, Needham DM. Heterogeneity in design and analysis of ICU delirium randomized trials: a systematic review. Trials 2021; 22:354. [PMID: 34016134 PMCID: PMC8136095 DOI: 10.1186/s13063-021-05299-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 04/27/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND There is a growing number of randomized controlled trials (RCTs) evaluating interventions to prevent or treat delirium in the intensive care unit (ICU). Efforts to improve the conduct of delirium RCTs are underway, but none address issues related to statistical analysis. The purpose of this review is to evaluate heterogeneity in the design and analysis of delirium outcomes and advance methodological recommendations for delirium RCTs in the ICU. METHODS Relevant databases, including PubMed and Embase, were searched with no restrictions on language or publication date; the search was conducted on July 8, 2019. RCTs conducted on adult ICU patients with delirium as the primary outcome were included where trial results were available. Data on frequency and duration of delirium assessments, delirium outcome definitions, and statistical methods were independently extracted in duplicate. The review was registered with PROSPERO (CRD42020141204). RESULTS Among 65 eligible RCTs, 44 (68%) targeted the prevention of delirium. The duration of follow-up varied, with 31 (48%) RCTs having ≤7 days of follow-up, and only 24 (37%) conducting delirium assessments after ICU discharge. The incidence of delirium was the most common outcome (50 RCTs, 77%) for which 8 unique statistical methods were applied. The most common method, applied to 51 of 56 (91%) delirium incidence outcomes, was the two-sample test comparing the proportion of patients who ever experienced delirium. In the presence of censoring of patients at ICU discharge or death, this test may be misleading. The impact of censoring was also not considered in most analyses of the duration of delirium, as evaluated in 24 RCTs, with 21 (88%) delirium duration outcomes analyzed using a non-parametric test or two-sample t test. Composite outcomes (e.g., rank-based delirium- and coma-free days), used in 11 (17%) RCTs, seldom explicitly defined how ICU discharge, and death were incorporated into the definition and were analyzed using non-parametric tests (11 of 13 (85%) composite outcomes). CONCLUSIONS To improve delirium RCTs, outcomes should be explicitly defined. To account for censoring due to ICU discharge or death, survival analysis methods should be considered for delirium incidence and duration outcomes; non-parametric tests are recommended for rank-based delirium composite outcomes. TRIAL REGISTRATION PROSPERO CRD42020141204 . Registration date: 7/3/2019.
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Affiliation(s)
- Elizabeth Colantuoni
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
- Outcomes After Critical Illness and Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Mounica Koneru
- Outcomes After Critical Illness and Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Narjes Akhlaghi
- Outcomes After Critical Illness and Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ximin Li
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | - Victor D Dinglas
- Outcomes After Critical Illness and Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karin J Neufeld
- Outcomes After Critical Illness and Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Michael O Harhay
- Department of Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- PAIR (Palliative and Advanced Illness Research) Center Clinical Trials Methods and Outcomes Lab, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Campbell NL, Holden RJ, Tang Q, Boustani MA, Teal E, Hillstrom J, Tu W, Clark DO, Callahan CM. Multicomponent behavioral intervention to reduce exposure to anticholinergics in primary care older adults. J Am Geriatr Soc 2021; 69:1490-1499. [PMID: 33772749 DOI: 10.1111/jgs.17121] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 02/10/2021] [Accepted: 02/13/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To test the impact of a multicomponent behavioral intervention to reduce the use of high-risk anticholinergic medications in primary care older adults. DESIGN Cluster-randomized controlled trial. SETTING AND PARTICIPANTS Ten primary care clinics within Eskenazi Health in Indianapolis. INTERVENTION The multicomponent intervention included provider- and patient-focused components. The provider-focused component was computerized decision support alerting of the presence of a high-risk anticholinergic and offering dose- and indication-specific alternatives. The patient-focused component was a story-based video providing education and modeling an interaction with a healthcare provider resulting in a medication change. Alerts within the medical record triggered staff to play the video for a patient. Our design intended for parallel, independent priming of both providers and patients immediately before an outpatient face-to-face interaction. MEASUREMENT Medication orders were extracted from the electronic medical record system to evaluate the prescribing behavior and population prevalence of anticholinergic users. The intervention was introduced April 1, 2019, through March 31, 2020, and a preintervention observational period of April 1, 2018, through March 31, 2019, facilitated difference in difference comparisons. RESULTS A total of 552 older adults had visits at primary care sites during the study period, with mean age of 72.1 (SD 6.4) years and 45.3% African American. Of the 259 provider-focused alerts, only three (1.2%) led to a medication change. Of the 276 staff alerts, 4.7% were confirmed to activate the patient-focused intervention. The intervention resulted in no significant differences in either the number of discontinue orders for anticholinergics (intervention: two additional orders; control: five fewer orders, p = 0.7334) or proportion of the population using anticholinergics following the intervention (preintervention: 6.2% and postintervention: 5.1%, p = 0.6326). CONCLUSION This multicomponent intervention did not reduce the use of high-risk anticholinergics in older adults receiving primary care. Improving nudges or a policy-focused component may be necessary to reduce use of high-risk medications.
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Affiliation(s)
- Noll L Campbell
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, Indiana, USA.,Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Center for Health Innovation and Implementation Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Richard J Holden
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Center for Health Innovation and Implementation Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Qing Tang
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Malaz A Boustani
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Center for Health Innovation and Implementation Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Evgenia Teal
- Data Core, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Jennifer Hillstrom
- Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA
| | - Wanzhu Tu
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Daniel O Clark
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Christopher M Callahan
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Hanlon JT, Tjia J. Avoiding Adverse Drug Withdrawal Events When Stopping Unnecessary Medications According to the STOPPFrail Criteria. Sr Care Pharm 2021; 36:136-141. [PMID: 33662236 DOI: 10.4140/tcp.n.2021.136] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide clinicians with information about avoiding adverse drug withdrawal events (ADWEs) when discontinuing unnecessary medications as per the STOPPFrail criteria. DATA SOURCES Searches of MEDLINE (1970-June 2020), the Cochrane Database of Systematic Reviews (through June 2020), Google Scholar (through June 2020). STUDY SELECTION Reviews and original studies of ADWEs. DATA EXTRACTION Tapering protocols for specific drugs/ classes from randomized controlled deprescribing trials. DATA SYNTHESIS Six drug classes were identified as being high risk for physiological ADWEs. CONCLUSION The occurrence of ADWEs is rare in comparison to adverse drug reactions in older adults. Few drugs/classes have been reported to have physiological ADWEs with abrupt discontinuation. For these we provide information about tapering protocols and symptom monitoring to avoid ADWEs.
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Affiliation(s)
- Joseph T Hanlon
- 1University of Pittsburgh, Department of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer Tjia
- 3University of Massachusetts Medical School, Department of Population and Quantitative Health Sciences, Worcester, Massachusetts
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Assessment and management of agitation, sleep, and mental illness in the surgical ICU. Curr Opin Crit Care 2021; 26:634-639. [PMID: 33002972 DOI: 10.1097/mcc.0000000000000762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Increased focus on patient-centered outcomes, mental health, and delirium prevention makes this review timely and relevant for critical care. RECENT FINDINGS This review focuses on patient-centered outcomes in the ICU, highlighting the latest research to promote brain health and psychological recovery during and after perioperative critical illness. Topics include sedation in the obese patient, delirium severity assessments, the role of the Psychiatry Consultation-Liaison in the ICU, Post-intensive care syndrome, and the importance of family engagement in the COVID era. SUMMARY Highlighting new research, such as novel implementation strategies in addition to a lack of research in certain areas like sleep in the ICU may lead to innovation and establishment of evidence-based practices in critical care. Perioperative brain health is multifaceted, and an increase in multidisciplinary interventions may help improve outcomes and decrease morbidity in ICU survivors.
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Andrews PS, Wang S, Perkins AJ, Gao S, Khan S, Lindroth H, Boustani M, Khan B. Relationship Between Intensive Care Unit Delirium Severity and 2-Year Mortality and Health Care Utilization. Am J Crit Care 2020; 29:311-317. [PMID: 32607574 DOI: 10.4037/ajcc2020498] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Critical care patients with delirium are at an increased risk of functional decline and mortality long term. OBJECTIVE To determine the relationship between delirium severity in the intensive care unit and mortality and acute health care utilization within 2 years after hospital discharge. METHODS A secondary data analysis of the Pharmacological Management of Delirium and Deprescribe randomized controlled trials. Patients were assessed twice daily for delirium or coma using the Richmond Agitation-Sedation Scale and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Delirium severity was measured using the CAM-ICU-7. Mean delirium severity (from time of randomization to discharge) was categorized as rapidly resolving, mild to moderate, or severe. Cox proportional hazards regression was used to model time to death, first emergency department visit, and rehospitalization. Analyses were adjusted for age, sex, race, Charlson Comorbidity Index, Acute Physiology and Chronic Health Evaluation II score, discharge location, diagnosis, and intensive care unit type. RESULTS Of 434 patients, those with severe delirium had higher mortality risk than those with rapidly resolving delirium (hazard ratio 2.21; 95% CI, 1.35-3.61). Those with 5 or more days of delirium or coma had higher mortality risk than those with less than 5 days (hazard ratio 1.52; 95% CI, 1.07-2.17). Delirium severity and number of days of delirium or coma were not associated with time to emergency department visits and rehospitalizations. CONCLUSION Increased delirium severity and days of delirium or coma are associated with higher mortality risk 2 years after discharge.
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Affiliation(s)
- Patricia S. Andrews
- About the Authors: Patricia S. Andrews is an assistant professor, Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sophia Wang
- Sophia Wang is an assistant professor, Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana
| | - Anthony J. Perkins
- Anthony J. Perkins is a staff biostatistician, Department of Biostatistics, Indiana University School of Medicine
| | - Sujuan Gao
- Sujuan Gao is a professor, Department of Biostatistics, Indiana University School of Medicine
| | - Sikandar Khan
- Sikandar Khan is an assistant professor, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine; and a research scientist, Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana
| | - Heidi Lindroth
- Heidi Lindroth is a postdoctoral fellow, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine; and an affiliate at the Indiana University Center for Aging Research, Regenstrief Institute
| | - Malaz Boustani
- Malaz Boustani is a professor, Department of Medicine, Indiana University School of Medicine; the founding director, Center for Health Innovation and Implementation Science at Indiana Clinical Translational Science Institute; director of senior care innovation, Eskenazi Hospital; and a research scientist, Indiana University Center for Aging Research, Regen strief Institute
| | - Babar Khan
- Babar Khan is an associate professor, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine; and a research scientist, Indiana University Center for Aging Research, Regenstrief Institute
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Donaghy J. ITU patients with delirium did not benefit from electronic and pharmacist support encouraging the deprescribing of benzodiazepines and anticholinergics. Evid Based Nurs 2020; 23:52. [PMID: 31285247 DOI: 10.1136/ebnurs-2019-103090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2019] [Indexed: 06/09/2023]
Affiliation(s)
- Juliet Donaghy
- Emergency Assessment Unit, Ipswich Hospital NHS Trust, Ipswich, UK
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27
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Time trends of delirium rates in the intensive care unit. Heart Lung 2020; 49:572-577. [PMID: 32220395 DOI: 10.1016/j.hrtlng.2020.03.006] [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: 10/17/2019] [Revised: 03/04/2020] [Accepted: 03/06/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Effects of clinical practice changes on ICU delirium are not well understood. OBJECTIVES Determine ICU delirium rates over time. METHODS Data from a previously described screening cohort of the Pharmacological Management of Delirium trial was analyzed. Richmond Agitation-Sedation Scale (RASS) and Confusion Assessment Method for the ICU (CAM-ICU) were assessed twice daily. We defined: Any delirium (positive CAM-ICU at any time during ICU stay) and ICU-acquired delirium (1st CAM-ICU negative with a subsequent positive CAM-ICU). Mixed-effects logistic regression models were used to test for differences. RESULTS 2742 patient admissions were included. Delirium occurred in 16.5%, any delirium decreased [22.7% to 10.2% (p < 0.01)], and ICU-acquired delirium decreased [8.4% to 4.4% (p = 0.01)]. Coma decreased from 24% to 17.4% (p = 0.04). Later ICU years and higher mean RASS scores were associated with lower odds of delirium. CONCLUSIONS Delirium rates were not explained by the measured variables and further prospective research is needed.
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Khan BA, Perkins AJ, Prasad NK, Shekhar A, Campbell NL, Gao S, Wang S, Khan SH, Marcantonio ER, Twigg HL, Boustani MA. Biomarkers of Delirium Duration and Delirium Severity in the ICU. Crit Care Med 2020; 48:353-361. [PMID: 31770149 PMCID: PMC7242000 DOI: 10.1097/ccm.0000000000004139] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Both delirium duration and delirium severity are associated with adverse patient outcomes. Serum biomarkers associated with delirium duration and delirium severity in ICU patients have not been reliably identified. We conducted our study to identify peripheral biomarkers representing systemic inflammation, impaired neuroprotection, and astrocyte activation associated with delirium duration, delirium severity, and in-hospital mortality. DESIGN Observational study. SETTING Three Indianapolis hospitals. PATIENTS Three-hundred twenty-one critically ill delirious patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We analyzed the associations between biomarkers collected at delirium onset and delirium-/coma-free days assessed through Richmond Agitation-Sedation Scale/Confusion Assessment Method for the ICU, delirium severity assessed through Confusion Assessment Method for the ICU-7, and in-hospital mortality. After adjusting for age, gender, Acute Physiology and Chronic Health Evaluation II score, Charlson comorbidity score, sepsis diagnosis and study intervention group, interleukin-6, -8, and -10, tumor necrosis factor-α, C-reactive protein, and S-100β levels in quartile 4 were negatively associated with delirium-/coma-free days by 1 week and 30 days post enrollment. Insulin-like growth factor-1 levels in quartile 4 were not associated with delirium-/coma-free days at both time points. Interleukin-6, -8, and -10, tumor necrosis factor-α, C-reactive protein, and S-100β levels in quartile 4 were also associated with delirium severity by 1 week. At hospital discharge, interleukin-6, -8, and -10 retained the association but tumor necrosis factor-α, C-reactive protein, and S-100β lost their associations with delirium severity. Insulin-like growth factor-1 levels in quartile 4 were not associated with delirium severity at both time points. Interleukin-8 and S-100β levels in quartile 4 were also associated with higher in-hospital mortality. Interleukin-6 and -10, tumor necrosis factor-α, and insulin-like growth factor-1 were not found to be associated with in-hospital mortality. CONCLUSIONS Biomarkers of systemic inflammation and those for astrocyte and glial activation were associated with longer delirium duration, higher delirium severity, and in-hospital mortality. Utility of these biomarkers early in delirium onset to identify patients at a higher risk of severe and prolonged delirium, and delirium related complications during hospitalization needs to be explored in future studies.
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Affiliation(s)
- Babar A. Khan
- Indiana University School of Medicine, Indianapolis, IN
- Indiana University Center for Aging Research, Indianapolis, IN
- Regenstrief Institute, Inc., Indianapolis, IN
- Indiana University Center for Health Innovation and Implementation Science; Indiana Clinical and Translational Sciences Institute, Indianapolis, IN
| | | | | | | | - Noll L. Campbell
- Indiana University School of Medicine, Indianapolis, IN
- Indiana University Center for Aging Research, Indianapolis, IN
- Regenstrief Institute, Inc., Indianapolis, IN
- Indiana University Center for Health Innovation and Implementation Science; Indiana Clinical and Translational Sciences Institute, Indianapolis, IN
- Sandra Eskenazi Center for Brain Care Innovation at Eskenazi Health, Indianapolis, IN
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, IN
| | - Sujuan Gao
- Indiana University School of Medicine, Indianapolis, IN
| | - Sophia Wang
- Indiana University School of Medicine, Indianapolis, IN
| | | | - Edward R. Marcantonio
- Divisions of General Medicine and Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston MA
| | | | - Malaz A. Boustani
- Indiana University School of Medicine, Indianapolis, IN
- Indiana University Center for Aging Research, Indianapolis, IN
- Regenstrief Institute, Inc., Indianapolis, IN
- Indiana University Center for Health Innovation and Implementation Science; Indiana Clinical and Translational Sciences Institute, Indianapolis, IN
- Sandra Eskenazi Center for Brain Care Innovation at Eskenazi Health, Indianapolis, IN
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