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O'Conor R, Russell AM, Pack A, Oladejo D, Filec S, Rogalski E, Morhardt D, Lindquist LA, Wolf MS. Managing medications among individuals with mild cognitive impairment and dementia: Patient-caregiver perspectives. J Am Geriatr Soc 2024. [PMID: 39007450 DOI: 10.1111/jgs.19065] [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: 04/03/2024] [Revised: 06/05/2024] [Accepted: 06/13/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND With changing cognitive abilities, individuals with mild cognitive impairment (MCI) and dementia face challenges in successfully managing multidrug regimens. We sought to understand how individuals with MCI or dementia and their family caregivers manage multidrug regimens and better understand patient-to-caregiver transitions in medication management responsibilities. METHODS We conducted qualitative interviews among patient-caregiver dyads. Eligibility included: patients with a diagnosis of MCI, mild or moderate dementia, managing ≥3 chronic conditions, ≥5 prescription medications, who also had a family caregiver ≥18 years old. Semi-structured interview guides, informed by the Medication Self-Management model, ascertained roles and responsibilities for medication management and patient-to-caregiver transitions in medication responsibilities. RESULTS We interviewed 32 patient-caregiver dyads. Older adults and caregivers favored older adult autonomy in medication management, and individuals with MCI and mild dementia largely managed their medications independently using multiple strategies (e.g., establishing daily routines, using pillboxes). Among individuals with moderate dementia, caregivers assumed all medication-related responsibilities except when living separately. In those scenarios, caregivers set up organizers and made reminder calls, but did not observe family members taking medications. Patient-to-caregiver transitions in medication responsibilities frequently occurred after caregivers observed older adults making errors with medications. As caregivers sought to assume greater responsibilities with family members' medicines, they faced multiple barriers. Most barriers were dyadic; they affected both the older adult and the caregiver and/or the relationship. Some barriers were specific to caregivers; these included caregivers' competing responsibilities or inaccurate perceptions of dementia, while other barriers were related to the healthcare system. CONCLUSIONS To ease medication management transitions, balance must be sought between preservation of older adult autonomy and early family caregiver involvement. Clinicians should work to initiate conversations with family caregivers and individuals living with MCI or dementia about transitioning medication responsibilities as memory loss progresses, simplify regimens, and deprescribe, as appropriate.
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Affiliation(s)
- Rachel O'Conor
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois, USA
| | - Andrea M Russell
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois, USA
| | - Allison Pack
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dianne Oladejo
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sarah Filec
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois, USA
| | - Emily Rogalski
- Healthy Aging & Alzheimer's Research Care (HAARC) Center, The University of Chicago, Chicago, Illinois, USA
| | - Darby Morhardt
- Mesulam Center for Cognitive Neurology and Alzheimer's Disease, Northwestern University, Chicago, Illinois, USA
| | - Lee A Lindquist
- Division of Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Michael S Wolf
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois, USA
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Pan S, Li S, Jiang S, Shin JI, Liu GG, Wu H, Lyu B. Trends in Number and Appropriateness of Prescription Medication Utilization Among Community-Dwelling Older Adults in the United States: 2011-2020. J Gerontol A Biol Sci Med Sci 2024; 79:glae108. [PMID: 38644631 DOI: 10.1093/gerona/glae108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Indexed: 04/23/2024] Open
Abstract
BACKGROUND Contemporary data on the quantity and quality of medication use among older adults are lacking. This study examined recent trends in the number and appropriateness of prescription medication use among older adults in the United States. METHODS Data from the National Health and Nutrition Examination Survey (NHANES) between 2011 and March 2020 were used, and 6 336 adult participants aged 65 and older were included. We examined the number of prescription medication, prevalence of polypharmacy (≥5 prescription drugs), use of potentially inappropriate medication (PIM), and use of recommended medications (angiotensin-converting enzyme inhibitor [ACEI]/angiotensin receptor blockers [ARBs] plus beta-blockers among patients with heart failure and ACEI/ARBs among patients with albuminuria). RESULTS There has been a slight increase in the prevalence of polypharmacy (39.3% in 2011-2012 to 43.8% in 2017-2020, p for trend = .32). Antihypertensive, antihyperlipidemic, antidiabetic medications, and antidepressants are the most commonly used medications. There was no substantial change in the use of PIM (17.0% to 14.7%). Less than 50% of older adults with heart failure received ACEI/ARBs plus beta-blockers (44.3% in 2017-2020) and approximately 50% of patients with albuminuria received ACEI/ARBs (54.0% in 2017-2020), with no improvement over the study period. Polypharmacy, older age, female, and lower socioeconomic status were generally associated with greater use of PIM but lower use of recommended medications. CONCLUSIONS The medication burden remained high among older adults in the United States and the appropriate utilization of medications did not improve in the recent decade. Our results underscore the need for greater attentions and interventions to the quality of medication use among older adults.
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Affiliation(s)
- Shaoxi Pan
- School of Public Health, The Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang 561113, China
- China Center for Health Economic Research, Peking University, Beijing, China
| | - Shanshan Li
- China Center for Health Economic Research, Peking University, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Shaoxiang Jiang
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Jung-Im Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
| | - Gordon G Liu
- Institute for Global Health and Development, Peking University, Beijing, China
- National School of Development, Peking University, Beijing, China
| | - Hongyan Wu
- School of Public Health, The Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang 561113, China
| | - Beini Lyu
- Institute for Global Health and Development, Peking University, Beijing, China
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Pickering AN, Anderson TS. Deprescribing for people living with dementia: ALIGNing interventions and outcomes. J Am Geriatr Soc 2024; 72:1949-1951. [PMID: 38751095 PMCID: PMC11226374 DOI: 10.1111/jgs.18946] [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: 03/22/2024] [Accepted: 04/06/2024] [Indexed: 07/06/2024]
Abstract
AbstractThis editorial comments on the article by Green et al.
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Affiliation(s)
- Aimee N. Pickering
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Timothy S. Anderson
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
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Alves J, Prendki V, Chedid M, Yahav D, Bosetti D, Rello J. Challenges of antimicrobial stewardship among older adults. Eur J Intern Med 2024; 124:5-13. [PMID: 38360513 DOI: 10.1016/j.ejim.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/06/2024] [Accepted: 01/15/2024] [Indexed: 02/17/2024]
Abstract
Older adults hospitalized in internal medicine wards or long-term care facilities (LTCF) are progressively increasing. Older adults with multimorbidity are more susceptible to infections, as well as to more vulnerable to adverse effects (and interactions) of antibiotics, resulting in a need for effective and safer strategies for antimicrobial stewardship (ASM), both in hospitalization wards and long-term care facilities. Studies on antimicrobial stewardship in older patients are scarce and guidelines are required. Given the peculiarities of the optimization of antimicrobial prescription in individual older adults for common infections, tactics to overcome barriers need an update. The use of rapid diagnosis tests, biomarkers, de-escalation and switching from intravenous to oral/subcutaneous therapy strategies are examples of successful AMS interventions. AMS interventions are associated with reduced side effects, lower mortality, shorter hospital stays, and reduced costs. The proposed AMS framework in LTCF should focus on five domains: strategic vision, team, interventions, patient-centred care and awareness. Internists can partner with geriatrists, pharmacists and infectious disease specialists to address barriers and to improve patient care.
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Affiliation(s)
- Joana Alves
- Infectious Diseases Specialist, Head of Local Unit of the Program for Prevention and Control of Infection and Antimicrobial Resistance, Hospital de Braga, Portugal.
| | - Virginie Prendki
- Department of Internal Medicine for the Aged, Department of Rehabilitation and Geriatrics, Geneva University Hospitals, Geneva, Switzerland; Department of Infectious Disease, Geneva University Hospital, Switzerland
| | - Marie Chedid
- Department of Infectious Disease, Geneva University Hospital, Switzerland
| | - Dafna Yahav
- Infectious Diseases Unit, Sheba Medical Centre, Ramat Gan, Israel
| | - Davide Bosetti
- Department of Infectious Disease, Geneva University Hospital, Switzerland; Infection Control Programme and WHO Collaborating Centre for Infection Prevention and Control and Antimicrobial Resistance, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Jordi Rello
- Medicine Department, Universitat Internacional de Catalunya, Spain; Clinical Research Pneumonia and Sepsis (CRIPS) Research Group-Vall d'Hebrón Institute Research (VHIR), Barcelona, Spain; Formation, Recherche, Evaluation (FOREVA), CHU Nîmes, Nîmes, France
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5
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Kim HL, Lee HJ. Polypharmacy and associated factors in South Korean elderly patients with dementia: An analysis using National Health Insurance claims data. PLoS One 2024; 19:e0302300. [PMID: 38662655 PMCID: PMC11045087 DOI: 10.1371/journal.pone.0302300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 04/01/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Dementia is accompanied by several symptoms, including cognitive function decline, as well as behavioral and psychological symptoms. Elderly patients with dementia often experience polypharmacy, the concurrent use of multiple medications, due to chronic comorbidities. However, research on polypharmacy in patients with dementia is limited. This study aimed to characterize polypharmacy and associated factors among elderly patients with dementia in South Korea, and compare the characteristics of patients with and without dementia patients. METHODS From the National Health Insurance Service (NHIS)-Senior cohort database, we extracted data on patients aged≥60 years who received outpatient treatment in 2019. Polypharmacy was defined as the concurrent use of five or more different oral medications for ≥90 days; excessive polypharmacy referred to the concurrent use of ten or more different oral medications for ≥90 days. We compared the prevalence of polypharmacy between patients with and without and identified the associated factors using a logistic regression model. RESULTS About 70.3% and 23.7% of patients with dementia exhibited polypharmacy and excessive polypharmacy, respectively. After adjusting for conditions such as age and Charlson's comorbidity index, the likelihood of polypharmacy and excessive polypharmacy significantly increased over time after the diagnosis of dementia. Additionally, under the same conditions, Medical Aid beneficiaries with dementia were more likely to experience polypharmacy and excessive polypharmacy compared to patients with dementia covered by National Health Insurance (NHI). CONCLUSION This study reports the latest evidence on the status and risk factors of polypharmacy in elderly patients with dementia. We proposed that careful monitoring and management are required for patients at high risk for polypharmacy.
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Affiliation(s)
- Hea-Lim Kim
- Department of Public Health Sciences, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
| | - Hye-Jae Lee
- Department of Environmental Health, Korea National Open University, Seoul, Republic of Korea
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Alageel NA, Hughes CM, Alwhaibi M, Alkeridy W, Barry HE. Potentially inappropriate prescribing for people with dementia in ambulatory care: a cross-sectional observational study. BMC Geriatr 2024; 24:328. [PMID: 38600444 PMCID: PMC11008018 DOI: 10.1186/s12877-024-04949-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 04/04/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Studies have shown that potentially inappropriate prescribing (PIP) is highly prevalent among people with dementia (PwD) and linked to negative outcomes, such as hospitalisation and mortality. However, there are limited data on prescribing appropriateness for PwD in Saudi Arabia. Therefore, we aimed to estimate the prevalence of PIP and investigate associations between PIP and other patient characteristics among PwD in an ambulatory care setting. METHODS A cross-sectional, retrospective analysis was conducted at a tertiary hospital in Saudi Arabia. Patients who were ≥ 65 years old, had dementia, and visited ambulatory care clinics between 01/01/2019 and 31/12/2021 were included. Prescribing appropriateness was evaluated by applying the Screening Tool of Older Persons Potentially Inappropriate Prescriptions (STOPP) criteria. Descriptive analyses were used to describe the study population. Prevalence of PIP and the prevalence per each STOPP criterion were calculated as a percentage of all eligible patients. Logistic regression analysis was used to investigate associations between PIP, polypharmacy, age and sex; odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Analyses were conducted using SPSS v27. RESULTS A total of 287 PwD were identified; 56.0% (n = 161) were female. The mean number of medications prescribed was 9.0 [standard deviation (SD) ± 4.2]. The prevalence of PIP was 61.0% (n = 175). Common instances of PIP were drugs prescribed beyond the recommended duration (n = 90, 31.4%), drugs prescribed without an evidence-based clinical indication (n = 78, 27.2%), proton pump inhibitors (PPIs) for > 8 weeks (n = 75, 26.0%), and acetylcholinesterase inhibitors with concurrent drugs that reduce heart rate (n = 60, 21.0%). Polypharmacy was observed in 82.6% (n = 237) of patients and was strongly associated with PIP (adjusted OR 24.1, 95% CI 9.0-64.5). CONCLUSIONS Findings have revealed a high prevalence of PIP among PwD in Saudi Arabia that is strongly associated with polypharmacy. Future research should aim to explore key stakeholders' experiences and perspectives of medicines management to optimise medication use for this vulnerable patient population.
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Affiliation(s)
- Nahla A Alageel
- Primary Care Research Group, School of Pharmacy, Medical Biology Centre, Queen's University Belfast, 97 Lisburn Road, BT9 7BL, Belfast, UK
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Carmel M Hughes
- Primary Care Research Group, School of Pharmacy, Medical Biology Centre, Queen's University Belfast, 97 Lisburn Road, BT9 7BL, Belfast, UK
| | - Monira Alwhaibi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Walid Alkeridy
- Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Department of Medicine, Geriatric Division, University of British Columbia, Vancouver, Canada
- General Administration of Home Health Care, Therapeutic Affairs Deputyship, Riyadh, Saudi Arabia
| | - Heather E Barry
- Primary Care Research Group, School of Pharmacy, Medical Biology Centre, Queen's University Belfast, 97 Lisburn Road, BT9 7BL, Belfast, UK.
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Rahman MS, Islam R, Bhuiyan MIH. Ion transporter cascade, reactive astrogliosis and cerebrovascular diseases. Front Pharmacol 2024; 15:1374408. [PMID: 38659577 PMCID: PMC11041382 DOI: 10.3389/fphar.2024.1374408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/21/2024] [Indexed: 04/26/2024] Open
Abstract
Cerebrovascular diseases and their sequalae, such as ischemic stroke, chronic cerebral hypoperfusion, and vascular dementia are significant contributors to adult disability and cognitive impairment in the modern world. Astrocytes are an integral part of the neurovascular unit in the CNS and play a pivotal role in CNS homeostasis, including ionic and pH balance, neurotransmission, cerebral blood flow, and metabolism. Astrocytes respond to cerebral insults, inflammation, and diseases through unique molecular, morphological, and functional changes, collectively known as reactive astrogliosis. The function of reactive astrocytes has been a subject of debate. Initially, astrocytes were thought to primarily play a supportive role in maintaining the structure and function of the nervous system. However, recent studies suggest that reactive astrocytes may have both beneficial and detrimental effects. For example, in chronic cerebral hypoperfusion, reactive astrocytes can cause oligodendrocyte death and demyelination. In this review, we will summarize the (1) roles of ion transporter cascade in reactive astrogliosis, (2) role of reactive astrocytes in vascular dementia and related dementias, and (3) potential therapeutic approaches for dementing disorders targeting reactive astrocytes. Understanding the relationship between ion transporter cascade, reactive astrogliosis, and cerebrovascular diseases may reveal mechanisms and targets for the development of therapies for brain diseases associated with reactive astrogliosis.
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Affiliation(s)
- Md Shamim Rahman
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Texas at El Paso, El Paso, TX, United States
| | | | - Mohammad Iqbal H. Bhuiyan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Texas at El Paso, El Paso, TX, United States
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Niznik JD, Kelley CJ, Fasth L, Colón-Emeric C, Thorpe CT, Gilliam MA, Lund JL, Hanson LC. Deprescribing bisphosphonates for older adults with dementia: perspectives of caregivers. Osteoporos Int 2024; 35:589-598. [PMID: 37980284 PMCID: PMC11145563 DOI: 10.1007/s00198-023-06967-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/01/2023] [Indexed: 11/20/2023]
Abstract
Little is known about caregivers' perspectives on deprescribing bisphosphonates for older adults with dementia. Caregivers agreed that fracture prevention was important for maintaining functional independence but acknowledged that changing goals of care may justify deprescribing. Conversations grounded in "what matters most" can align fracture prevention treatment with goals of care. PURPOSE The long-term fracture prevention benefits of bisphosphonates may begin to be overshadowed by the potential burden of adverse effects and polypharmacy for older adults living with dementia as the disease progresses. We characterized factors that influence caregiver decision-making for continuing versus deprescribing bisphosphonates for persons living with dementia. METHODS We conducted 11 interviews with family or informal caregivers of older adults living with dementia in the community or in long-term care who had been treated with bisphosphonates. Interviews focused on experiences caring for someone who has experienced a fracture, perceived benefits and harms of bisphosphonates, and experiences with deprescribing. Analyses were conducted using a qualitative framework methodology guided by the Health Belief Model. RESULTS Most caregivers were male (n = 8), younger than 65 (n = 8) and were an adult child caregiver (n = 8). Three caregivers were Black and five were Latino/a. Attempts to maintain functional independence despite high likelihood of falls was frequently discussed as contributing to fracture risk, in this population. Many caregivers perceived fracture prevention treatment as important, while several noted that it may become less important near the end of life. Perceived benefits of fracture prevention treatment for persons with dementia included improved quality of life and maintaining independence. Although most indicated that bisphosphonates were well tolerated, gastrointestinal adverse effects, preference for fewer treatments, and dementia-related behaviors that interfere with medication administration may be reasons for deprescribing. CONCLUSION Conversations grounded in caregiver experiences and "what matters most" may help optimize fracture prevention treatment for older adults with dementia.
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Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA.
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic CB#7550, Chapel Hill, NC, 27599, USA.
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA.
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Casey J Kelley
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic CB#7550, Chapel Hill, NC, 27599, USA
| | - Lauren Fasth
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Cathleen Colón-Emeric
- Division of Geriatrics, Duke University School of Medicine, Durham, NC, USA
- Durham VA Geriatric Research Education and Clinical Center, Durham, NC, USA
| | - Carolyn T Thorpe
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Meredith A Gilliam
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic CB#7550, Chapel Hill, NC, 27599, USA
| | - Jennifer L Lund
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic CB#7550, Chapel Hill, NC, 27599, USA
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Tat DP, Zullo AR, Mor V, Hayes KN. Sliding Scale Insulin Use in Nursing Homes Before and After Onset of the COVID-19 Pandemic. J Am Med Dir Assoc 2024; 25:459-464. [PMID: 38307122 PMCID: PMC10923121 DOI: 10.1016/j.jamda.2024.01.004] [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: 10/04/2023] [Revised: 01/08/2024] [Accepted: 01/08/2024] [Indexed: 02/04/2024]
Abstract
OBJECTIVE To characterize sliding-scale insulin (SSI) use in US nursing homes (NHs) before and after the COVID-19 pandemic. DESIGN Cross-sectional study. SETTING AND PARTICIPANTS A total of 129,829 US NH residents on SSI (01/2018-06/2022) across 12 NH chains with a common electronic health record system. METHODS Among all residents with at least 1 administration of SSI documented in the electronic medication administration record, we described resident demographics, frequency of SSI monotherapy vs combination therapy with another diabetes medication, number of daily capillary blood glucose readings ("fingersticks"), and hypoglycemia (capillary blood glucose <70 mg/dL) and hyperglycemia after first SSI use. We used interrupted time series analysis (ITS) with segmented linear regression models to examine whether the monthly prevalence of SSI use changed at and after the onset of the COVID-19 pandemic (March 2020). RESULTS There were 129,829 unique NH residents with SSI use [51% women, average age 71.3 (SD 11.7) years]. Of these, 36% of residents received SSI monotherapy and 64% received SSI combination therapy. Residents on SSI received an average of 3.96 (SD 1.41) fingersticks per day. Overall, 26% of SSI users experienced a hypoglycemic event within 30 days of the first SSI dose. The ITS analysis identified a step decrease in the rate of SSI use following the onset of the COVID-19 pandemic (43 fewer SSI users per 1000 insulin users) but no change in overall trend over time from before the onset of the pandemic. CONCLUSIONS AND IMPLICATIONS SSI use and fingerstick burden are high in NH residents. Hypoglycemia occurred commonly among residents on SSI. Future research should compare the safety and effectiveness of SSI monotherapy vs other diabetes medication regimens to guide person-centered prescribing decisions in NHs.
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Affiliation(s)
- Darlene P Tat
- Brown University School of Public Health, Center for Gerontology and Healthcare Research, Providence, RI, USA
| | - Andrew R Zullo
- Brown University School of Public Health, Center for Gerontology and Healthcare Research, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Vincent Mor
- Brown University School of Public Health, Center for Gerontology and Healthcare Research, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Kaleen N Hayes
- Brown University School of Public Health, Center for Gerontology and Healthcare Research, Providence, RI, USA.
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Sharma R, Gill JK, Carter C, Alkabbani W, Chhabra M, Vidyasagar K, Chang F, Lee L, Patel T. Use of Potentially Inappropriate Medications among Older Adults with Dementia or Cognitive Impairment Attending Memory Clinics: A Protocol for a Systematic Review and Meta-Analysis. Biomed Hub 2024; 9:83-88. [PMID: 39015200 PMCID: PMC11249799 DOI: 10.1159/000539074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 04/22/2024] [Indexed: 07/18/2024] Open
Abstract
Introduction Older adults with dementia who are on multiple medications are more vulnerable to the use of potentially inappropriate medications (PIMs), which can significantly increase the risk of adverse events and drug-related problems. PIMs use is prevalent and varies among older adults with dementia or cognitive impairment (CI) attending memory clinics. However, the prevalence of PIMs, polypharmacy, and hyper-polypharmacy among older adults with dementia or CI who are attending memory clinics is not well understood. We will conduct a systematic review and meta-analyses to examine the overall estimate of the prevalence of the PIMs, polypharmacy, and hyper-polypharmacy use among older adults attending memory clinics, with dementia or CI. The secondary objective of this study will be to compile a list of commonly implicated PIMs and to investigate factors that may be associated with using PIMs in this population. Methods Ovid MEDLINE, Ovid Embase, Scopus, Cochrane library, EBSCOhost CINAHL, and Ovid International Pharmaceutical Abstracts (IPA) will be systematically searched by a researcher (R.S.) with the help of a librarian (C.C.). All databases will be searched from inception to May 05, 2023. Cross-sectional, cohort, randomized clinical trials, quasi-experimental, and case-control studies will be included if they assess PIM's use among older adults with dementia and/or CI. A step-by-step guide by Pai et al. [Natl Med J India. 2004;17(2):86-95] will be followed when conducting this systematic review (S.R.). The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist will be followed for reporting this SR. Conclusion The findings from this SR/MA will identify the pooled prevalence of PIMs, providing a more precise estimate of the true prevalence of the PIMs, polypharmacy, hyper-polypharmacy in older adults with dementia or CI who are attending memory clinics at primary, secondary, or tertiary healthcare settings by considering the results of multiple studies.
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Affiliation(s)
- Rishabh Sharma
- School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
| | | | - Caitlin Carter
- School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
| | - Wajd Alkabbani
- School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
| | - Manik Chhabra
- Indo-Soviet Friendship College of Pharmacy, Moga, India
| | - Kota Vidyasagar
- Department of Pharmacy, University College of Pharmaceutical Sciences, Kakatiya University, Warangal, India
| | - Feng Chang
- School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
| | - Linda Lee
- Schlegel-UW Research Institute for Aging, Waterloo, ON, Canada
- CFFM MINT Memory Clinic, Kitchener, ON, Canada
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Tejal Patel
- School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
- Schlegel-UW Research Institute for Aging, Waterloo, ON, Canada
- CFFM MINT Memory Clinic, Kitchener, ON, Canada
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Muench U, Kim KM, Zimmer Z, Monroe TB. The association between cognitive ability and opioid prescribing in vulnerable older adults with chronic pain in ambulatory care: a secondary data analysis using the Medical Expenditure Panel Survey. BMC Med 2023; 21:446. [PMID: 37974164 PMCID: PMC10655447 DOI: 10.1186/s12916-023-03133-w] [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] [Received: 06/15/2023] [Accepted: 10/25/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Vulnerable older adults living with Alzheimer's disease or Alzheimer's disease and related dementia (AD/ADRD) and chronic pain generally receive fewer pain medications than individuals without AD/ADRD, especially in nursing homes. Little is known about pain management in older adults with AD/ADRD in the community. The aim of the study was to examine opioid prescribing patterns in individuals with chronic pain by levels of cognitive ability in ambulatory care. METHODS We used the Medical Expenditure Panel Survey (MEPS), years 2002-2017, and identified three levels of cognitive impairment: no cognitive impairment (NCI), individuals reporting cognitive impairment (CI) without an AD/ADRD diagnosis, and individuals with a diagnosis of AD/ADRD. We examined any receipt of an opioid prescription and the number of opioid prescriptions using a logistic and negative binomial regression adjusting for sociodemographic and health characteristics and stratifying by three types of chronic pain (any chronic pain, severe chronic pain, and chronic pain identified through ICD 9/10 chronic pain diagnoses). RESULTS Among people with any chronic pain, adjusted odds of receiving an opioid for people with CI (OR 1.41, 95% confidence interval 1.31-1.52) and AD/ADRD (OR 1.23, 95% confidence interval 1.04-1.45) were higher compared to NCI. Among people with chronic pain ICD 9/10 conditions, the odds of receiving an opioid were also higher for those with CI (OR 1.43, 95% confidence interval 1.34-1.56) and AD/ADRD (OR 1.48, 95% confidence interval 1.23-1.78) compared to NCI. Among those with severe chronic pain, people with CI were more likely to receive an opioid (OR 1.17, 95% confidence interval 1.07-1.27) relative to NCI (OR 0.89, 95% confidence interval 0.75-1.06). People with AD/ADRD experiencing severe chronic pain were not more likely to receive an opioid compared to the NCI group. Adjusted predicted counts of opioid prescriptions showed more opioids in CI and AD/ADRD in all chronic pain cohorts, with the largest numbers of opioid prescriptions in the severe chronic pain and ICD 9/10 diagnoses groups. CONCLUSIONS The results suggest increased opioid use in people living with CI and AD/ADRD in the ambulatory care setting and potentially indicate that these individuals either require more analgesics or that opioids may be overprescribed. Further research is needed to examine pain management in this vulnerable population.
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Affiliation(s)
- Ulrike Muench
- Department of Social and Behavioral Sciences, School of Nursing, University of California, 490 Illinois St., Floor 12, Box 0612, San FranciscoSan Francisco, CA, 94143, USA.
- Philip R. Lee Institute for Health Policy Studies, School of Medicine, University of California, San Francisco, USA.
- Healthforce Center, University of California, San Francisco, San Francisco, USA.
| | - Kyung Mi Kim
- Department of Social and Behavioral Sciences, School of Nursing, University of California, 490 Illinois St., Floor 12, Box 0612, San FranciscoSan Francisco, CA, 94143, USA
- Office of Research Patient Care Services, Stanford Health Care, Stanford, USA
- Clinical Excellence Research Center, School of Medicine, Stanford University, Stanford, USA
| | - Zachary Zimmer
- Global Aging and Community Initiative and Department of Family Studies & Gerontology, Mount Saint Vincent University, Halifax, Canada
| | - Todd B Monroe
- Center for Healthy Aging Self-Management, and Complex Care, College of Nursing, The Ohio State University, Columbus, USA
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Cámara-Calmaestra R, Martínez-Amat A, Aibar-Almazán A, Hita-Contreras F, De Miguel-Hernando N, Rodríguez-Almagro D, Fábrega-Cuadros R, Achalandabaso-Ochoa A. Falls and Sleep Disorders in Spanish Alzheimer's Disease in Nursing Homes: An Observational Study. Healthcare (Basel) 2023; 11:2852. [PMID: 37957998 PMCID: PMC10649919 DOI: 10.3390/healthcare11212852] [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: 09/24/2023] [Revised: 10/18/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
OBJECTIVE The main objective of this study was to establish a relationship between the number of falls and sleep problems experienced by patients with Alzheimer's disease. MATERIALS AND METHODS This was a cross-sectional study. A total of 114 Spanish aged people with Alzheimer's disease institutionalized in nursing homes and 80 independent Spanish aged people without neurodegenerative diseases living at home were enrolled in this study and completed in-person interviews and digital questionnaires. RESULTS The mean age was 78.98 ± 8.59 years. Sleep disorders were related to continuous stress (p = 0.001; OR = 4.729) and a high frequency of falls (p = 0.001; OR = 2.145), while predictor variables associated with falls in patients with Alzheimer's disease were continuous medical visits (β = 0.319, p < 0.001), family history of dementia (β = 0.212; p = 0.014), and sleep disorders (β = 0.235; p = 0.007). Second, the analysis showed that moderate physical activity (p = 0.001; OR = 0.147), continuous medical visits (p < 0.001; OR = 0.621), and high level of study (p = 0.011; OR = 0.334) were protective factors against Alzheimer's, while older age (p = 0.035; OR = 1.087), type II Diabetes Mellitus (p = 0.042; OR = 3.973), number of falls (p = 0.021; OR = 1.409), and daily drug intake (p = 0.001; OR = 1.437) were risk factors for Alzheimer's. CONCLUSIONS Sleep disturbances are related to stress and falls in a sample of 114 Spanish AD aged people institutionalized in nursing homes, and the falls they experience are related to ongoing medical visits, a history of dementia, and sleep disturbances. Therefore, a bidirectional relationship was established between falls and sleep disorders in these patients. Moreover, this study showed that a greater frequency of falls and high daily drug intake could constitute novel risk factors for Alzheimer's disease, in addition to already known factors, such as age and type II Diabetes Mellitus, while being physically active and a high level of studies are protective factors against Alzheimer's disease.
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Affiliation(s)
- Rubén Cámara-Calmaestra
- Department of Health Sciences, Faculty of Health Sciences, University of Jaén, 23071 Jaén, Spain (R.F.-C.)
| | - Antonio Martínez-Amat
- Department of Health Sciences, Faculty of Health Sciences, University of Jaén, 23071 Jaén, Spain (R.F.-C.)
| | - Agustín Aibar-Almazán
- Department of Health Sciences, Faculty of Health Sciences, University of Jaén, 23071 Jaén, Spain (R.F.-C.)
| | - Fidel Hita-Contreras
- Department of Health Sciences, Faculty of Health Sciences, University of Jaén, 23071 Jaén, Spain (R.F.-C.)
| | - Nerea De Miguel-Hernando
- Department of Surgery, Ophthalmology, Otolaryngology and Physiotherapy, University of Valladolid, 47002 Valladolid, Spain
| | | | - Raquel Fábrega-Cuadros
- Department of Health Sciences, Faculty of Health Sciences, University of Jaén, 23071 Jaén, Spain (R.F.-C.)
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Sharma R, Mahajan N, Fadaleh SA, Patel H, Ivo J, Faisal S, Chang F, Lee L, Patel T. Medication Reviews and Clinical Outcomes in Persons with Dementia: A Scoping Review. PHARMACY 2023; 11:168. [PMID: 37888512 PMCID: PMC10609910 DOI: 10.3390/pharmacy11050168] [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: 08/06/2023] [Revised: 10/10/2023] [Accepted: 10/16/2023] [Indexed: 10/28/2023] Open
Abstract
Persons diagnosed with dementia are often faced with challenges related to polypharmacy and inappropriate medication use and could benefit from regular medication reviews. However, the benefit of such reviews has not been examined in this population. Therefore, the current scoping review was designed to identify the gaps in the current knowledge regarding the impact of medication reviews on the clinical outcomes in older adults with dementia. Relevant studies were identified by searching three databases (Ovid MEDLINE, Ovid EMBASE, and Scopus) from inception to January 2022 with a combination of keywords and medical subject headings. After the removal of duplicates and ineligible articles, 22 publications of the initial 8346 were included in this review. A total of 57 outcomes were identified, including those pertaining to the evaluation of medication use (n = 17), drug-related interventions (n = 11), drug-related problems (n = 10), dementia-related behavioral symptoms (n = 8), cost-effectiveness (n = 2), drug-related hospital admissions (n = 1), as well as outcomes classified as other (n = 7). Gaps identified through this scoping review included the paucity of studies measuring the impact of medication reviews on the medication management capacity and medication adherence, quality of life, and mortality.
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Affiliation(s)
- Rishabh Sharma
- School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, ON N2G 1C5, Canada; (R.S.); (S.A.F.); (H.P.); (J.I.); (S.F.); (F.C.)
| | - Neil Mahajan
- Faculty of Health, Western University, 1151 Richmond St, London, ON N6A 5B9, Canada;
| | - Sarah Abu Fadaleh
- School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, ON N2G 1C5, Canada; (R.S.); (S.A.F.); (H.P.); (J.I.); (S.F.); (F.C.)
| | - Hawa Patel
- School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, ON N2G 1C5, Canada; (R.S.); (S.A.F.); (H.P.); (J.I.); (S.F.); (F.C.)
| | - Jessica Ivo
- School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, ON N2G 1C5, Canada; (R.S.); (S.A.F.); (H.P.); (J.I.); (S.F.); (F.C.)
| | - Sadaf Faisal
- School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, ON N2G 1C5, Canada; (R.S.); (S.A.F.); (H.P.); (J.I.); (S.F.); (F.C.)
| | - Feng Chang
- School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, ON N2G 1C5, Canada; (R.S.); (S.A.F.); (H.P.); (J.I.); (S.F.); (F.C.)
| | - Linda Lee
- CFFM MINT Memory Clinic, 25 Joseph St, Kitchener, ON N2G 4X6, Canada;
- Schlegel-UW Research Institute for Aging, 250 Laurelwood Dr, Waterloo, ON N2J 0E2, Canada
- Department of Family Medicine, McMaster University, 100 Main St W 5th Floor, Hamilton, ON L8P 1H6, Canada
| | - Tejal Patel
- School of Pharmacy, University of Waterloo, 10 Victoria St S A, Kitchener, ON N2G 1C5, Canada; (R.S.); (S.A.F.); (H.P.); (J.I.); (S.F.); (F.C.)
- CFFM MINT Memory Clinic, 25 Joseph St, Kitchener, ON N2G 4X6, Canada;
- Schlegel-UW Research Institute for Aging, 250 Laurelwood Dr, Waterloo, ON N2J 0E2, Canada
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14
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Deardorff WJ, Jing B, Growdon ME, Yaffe K, Boscardin WJ, Boockvar KS, Steinman MA. Medication misuse and overuse in community-dwelling persons with dementia. J Am Geriatr Soc 2023; 71:3086-3098. [PMID: 37272899 PMCID: PMC10592653 DOI: 10.1111/jgs.18463] [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: 02/21/2023] [Revised: 04/26/2023] [Accepted: 05/16/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Persons with dementia (PWD) have high rates of polypharmacy. While previous studies have examined specific types of problematic medication use in PWD, we sought to characterize a broad spectrum of medication misuse and overuse among community-dwelling PWD. METHODS We included community-dwelling adults aged ≥66 in the Health and Retirement Study from 2008 to 2018 linked to Medicare and classified as having dementia using a validated algorithm. Medication usage was ascertained over the 1-year prior to an HRS interview date. Potentially problematic medications were identified by: (1) medication overuse including over-aggressive treatment of diabetes/hypertension (e.g., insulin/sulfonylurea with hemoglobin A1c < 7.5%) and medications inappropriate near end of life based on STOPPFrail and (2) medication misuse including medications that negatively affect cognition and medications from 2019 Beers and STOPP Version 2 criteria. To contextualize, we compared medication use to people without dementia through a propensity-matched cohort by age, sex, comorbidities, and interview year. We applied survey weights to make our results nationally representative. RESULTS Among 1441 PWD, median age was 84 (interquartile range = 78-89), 67% female, and 14% Black. Overall, 73% of PWD were prescribed ≥1 potentially problematic medication with a mean of 2.09 per individual in the prior year. This was notable across several domains, including 41% prescribed ≥1 medication that negatively affects cognition. Frequently problematic medications included proton pump inhibitors (PPIs), non-steroidal anti-inflammatory drugs (NSAIDs), opioids, antihypertensives, and antidiabetic agents. Problematic medication use was higher among PWD compared to those without dementia with 73% versus 67% prescribed ≥1 problematic medication (p = 0.002) and mean of 2.09 versus 1.62 (p < 0.001), respectively. CONCLUSION Community-dwelling PWD frequently receive problematic medications across multiple domains and at higher frequencies compared to those without dementia. Deprescribing efforts for PWD should focus not only on potentially harmful central nervous system-active medications but also on other classes such as PPIs and NSAIDs.
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Affiliation(s)
- W. James Deardorff
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Bocheng Jing
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Matthew E. Growdon
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Kristine Yaffe
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California
- Department of Neurology, University of California, San Francisco, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - W. John Boscardin
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Kenneth S. Boockvar
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama, Birmingham, Alabama
| | - Michael A. Steinman
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
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Shabet CL, Bicket MC, Blair E, Hu HM, Langa KM, Kabeto MU, Levine DA, Waljee J. The Association of Cognitive Status and Post-Operative Opioid Prescribing in Older Adults. ANNALS OF SURGERY OPEN 2023; 4:e320. [PMID: 37746626 PMCID: PMC10513135 DOI: 10.1097/as9.0000000000000320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/14/2023] [Indexed: 09/26/2023] Open
Abstract
Objective To examine the differences in opioid prescribing by cognitive status following common elective surgical procedures among Medicare beneficiaries. Background Older individuals commonly experience changes in cognition with age. Although opioid prescribing is common after surgery, differences in opioid prescribing after surgery by cognitive status are poorly understood. Methods We conducted a retrospective analysis of patients ≥65 years participating in the Health and Retirement Study (HRS) linked with Medicare claims data who underwent surgeries between January 2007 and November 2016 and had cognitive assessments before the index operation. Cognitive status was defined as normal cognition, mild cognitive impairment (MCI), or dementia. Outcomes assessed were initial perioperative opioid fill rates, refill rates, and high-risk prescriptions fill rates. The total amount of opioids filled during the 30-day postdischarge period was also assessed. Adjusted rates were estimated for patient factors using the Cochran-Armitage test for trend. Results Among the 1874 patients included in the analysis, 68% had normal cognition, 21.3% had MCI, and 10.7% had dementia. Patients with normal cognition (58.1%) and MCI (54.5%) had higher initial preoperative fill rates than patients with dementia (33.5%) (P < 0.001). Overall, patients with dementia had similar opioid refill rates (21%) to patients with normal cognition (24.1%) and MCI (26.5%) (P = 0.322). Although prior opioid exposure did not differ by cognitive status (P = 0.171), among patients with high chronic preoperative use, those with dementia had lower adjusted prescription sizes filled within 30 days following discharge (281 OME) than patients with normal cognition (2147 OME) and MCI (774 OME) (P < 0.001; P = 0.009 respectively). Among opioid-naive patients, patients with dementia also filled smaller prescription sizes (97 OME) compared to patients with normal cognition (205 OME) and patients with MCI (173 OME) (P < 0.001 and P = 0.019, respectively). Conclusions Patients with dementia are less likely to receive postoperative prescriptions, less likely to refill prescriptions, and receive prescriptions of smaller sizes compared to patients with normal cognition or MCI. A cognitive assessment is an additional tool surgeons can use to determine a patient's individualized postoperative pain control plan.
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Affiliation(s)
- Christina L Shabet
- From the Department of Surgery, University of Michigan Medical School, University of Michigan, Ann Arbor
| | - Mark C Bicket
- Department of Anesthesiology, University of Michigan, Ann Arbor
- Michigan Opioid Prescribing Engagement Network (Michigan OPEN), Institute for Healthcare Policy and Innovation, Ann Arbor
| | - Emilie Blair
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan, Ann Arbor
| | - Hsou Mei Hu
- Michigan Opioid Prescribing Engagement Network (Michigan OPEN), Institute for Healthcare Policy and Innovation, Ann Arbor
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor
| | - Kenneth M Langa
- Michigan Opioid Prescribing Engagement Network (Michigan OPEN), Institute for Healthcare Policy and Innovation, Ann Arbor
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Social Research, University of Michigan, Ann Arbor
- VA Center for Clinical Management Research, Ann Arbor
| | | | - Deborah A Levine
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Jennifer Waljee
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor
- Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI
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16
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Zhao M, Chen Z, Xu T, Fan P, Tian F. Global prevalence of polypharmacy and potentially inappropriate medication in older patients with dementia: a systematic review and meta-analysis. Front Pharmacol 2023; 14:1221069. [PMID: 37693899 PMCID: PMC10483131 DOI: 10.3389/fphar.2023.1221069] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/03/2023] [Indexed: 09/12/2023] Open
Abstract
Background: Older patients with dementia always need multiple drugs due to comorbidities and cognitive impairment, further complicating drug treatment and increasing the risk of potentially inappropriate medication. The objective of our study is to estimate the global prevalence of polypharmacy and potentially inappropriate medication (PIM) and explore the factors of PIM for older patients with dementia. Methods: We searched PubMed, Embase (Ovid), and Web of Science databases to identify eligible studies from inception to 16 June 2023. We conducted a meta-analysis for observational studies reporting the prevalence of potentially inappropriate medication and polypharmacy in older patients with dementia using a random-effect model. The factors associated with PIM were meta-analyzed. Results: Overall, 62 eligible studies were included, of which 53 studies reported the prevalence of PIM and 28 studies reported the prevalence of polypharmacy. The pooled estimate of PIM and polypharmacy was 43% (95% CI 38-48) and 62% (95% CI 52-71), respectively. Sixteen studies referred to factors associated with PIM use, and 15 factors were further pooled. Polypharmacy (2.83, 95% CI 1.80-4.44), diabetes (1.31, 95% CI 1.04-1.65), heart failure (1.17, 95% CI 1.00-1.37), depression (1.45, 95% CI 1.14-1.88), history of cancer (1.20, 95% CI 1.09-1.32), hypertension (1.46, 95% CI 1.05-2.03), ischemic heart disease (1.55, 95% CI 0.77-3.12), any cardiovascular disease (1.11, 95% CI 1.06-1.17), vascular dementia (1.09, 95% CI 1.03-1.16), chronic obstructive pulmonary disease (1.39, 95% CI 1.13-1.72), and psychosis (1.91, 95% CI 1.04-3.53) are positively associated with PIM use. Conclusion: PIM and polypharmacy were highly prevalent in older patients with dementia. Among different regions, the pooled estimate of PIM use and polypharmacy varied widely. Increasing PIM in older patients with dementia was closely associated with polypharmacy. For other comorbidities such as heart failure and diabetes, prescribing should be cautioned.
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Affiliation(s)
| | | | | | - Ping Fan
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fangyuan Tian
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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17
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Liu AK, Possin KL, Cook KM, Lynch S, Dulaney S, Merrilees JJ, Braley T, Kiekhofer RE, Bonasera SJ, Allen IE, Chiong W, Clark AM, Feuer J, Ewalt J, Guterman EL, Gearhart R, Miller BL, Lee KP. Effect of collaborative dementia care on potentially inappropriate medication use: Outcomes from the Care Ecosystem randomized clinical trial. Alzheimers Dement 2023; 19:1865-1875. [PMID: 36331050 PMCID: PMC10156873 DOI: 10.1002/alz.12808] [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: 06/07/2022] [Revised: 08/11/2022] [Accepted: 08/29/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Potentially inappropriate medications (PIMs) cause adverse events and death. We evaluate the Care Ecosystem (CE) collaborative dementia care program on medication use among community-dwelling persons living with dementia (PLWD). METHODS Secondary analysis of a randomized clinical trial (RCT) comparing CE to usual care (UC) on changes in PIMs, over 12 months between March 2015 and May 2020. Secondary outcomes included change in number of medications, clinically relevant PIMs, and anti-dementia medications. RESULTS Of 804 PLWD, N = 490 had complete medication data. The CE resulted in significantly fewer PIMs compared to UC (-0.35; 95% CI, -0.49 to -0.20; P < 0.0001). Number needed to prevent an increase in 1 PIM was 3. Total medications, PIMs for dementia or cognitive impairment, CNS-active PIMs, anticholinergics, benzodiazepines, and opioids were also fewer. Anti-dementia medication regimens were modified more frequently. CONCLUSION The CE medication review intervention embedded in collaborative dementia care optimized medication use among PLWD. HIGHLIGHTS Compared to usual care (UC), the Care Ecosystem (CE) medication review intervention prevented increases in potentially inappropriate medications (PIMs). Use of anticholinergics, benzodiazepines, and opioids were significantly reduced, with a trend for antipsychotics. Anti-dementia medications were adjusted more frequently. The CE medication review intervention embedded in collaborative dementia care optimized medication use.
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Affiliation(s)
- Amy K. Liu
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California, USA
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Katherine L. Possin
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California, USA
| | - Kristen M. Cook
- Department of Pharmacy Practice and Science, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Shalini Lynch
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California, USA
| | - Sarah Dulaney
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer J. Merrilees
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Tamara Braley
- Division of Geriatrics, Gerontology, and Palliative Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Rachel E. Kiekhofer
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Stephen J. Bonasera
- Division of Geriatrics, Gerontology, and Palliative Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Isabel E. Allen
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Winston Chiong
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Amy M. Clark
- Division of Geriatrics, Gerontology, and Palliative Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Julie Feuer
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Joan Ewalt
- Division of Geriatrics, Gerontology, and Palliative Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Elan L. Guterman
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
| | - Rosalie Gearhart
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Bruce L. Miller
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Kirby P. Lee
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California, USA
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18
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Nijskens C, Henstra M, Rhodius-Meester H, Yasar S, van Poelgeest E, Peters M, Muller M. Cardiovascular Risk Management in Persons with Dementia. J Alzheimers Dis 2023:JAD230019. [PMID: 37125555 DOI: 10.3233/jad-230019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
The number of people living with dementia, such as Alzheimer's disease, is increasing worldwide. Persons with dementia often have a high risk of atherosclerotic cardiovascular disease and they are therefore theoretically eligible for treatment of hypertension and hyperlipidemia. However, in this population, beneficial and harmful effects of cardiovascular risk management (CVRM) may be different compared to older persons without cognitive impairment. Current CVRM guidelines are based on trials from which persons with dementia were excluded. In this narrative review, we will discuss how current guidelines can be translated to persons with dementia and which aspects should be taken into account when treating hypertension and hyperlipidemia to prevent major adverse cardiovascular events (MACE). Survival time is significantly shorter in persons with dementia. We therefore suggest that since the main goal of CVRM is prevention of MACE, first of all, the patient's life expectancy and treatment wishes should be evaluated. Risk assessment tools are to be used with care, as they tend to overestimate the 5- and 10-year risk of MACE and benefit from CVRM in the prevention of MACE in persons with dementia. When the clinician and patient have decided that treatment is initiated or intensified, patients should be closely monitored since they are at high risk for adverse drugs events and overtreatment due to the natural course of blood pressure in persons with dementia. In the event of intolerance or side effects, medication should be switched or withdrawn. For persons with dementia and limited life expectancy, deprescribing should be part of usual care.
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Affiliation(s)
- Charlotte Nijskens
- Department of Internal Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Geriatrics section, Amsterdam, The Netherlands
| | - Marieke Henstra
- Department of Internal Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Geriatrics section, Amsterdam, The Netherlands
| | - Hanneke Rhodius-Meester
- Department of Internal Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Geriatrics section, Amsterdam, The Netherlands
- Department of Neurology, Amsterdam UMC location Vrije Universiteit Amsterdam, Alzheimer Center Amsterdam, Amsterdam, The Netherlands
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Sevil Yasar
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins Schoolof Medicine, Baltimore, MD, USA
| | - Eveline van Poelgeest
- Department of Internal Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Geriatrics section, Amsterdam, The Netherlands
| | - Mike Peters
- Department of Internal and Geriatric Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Majon Muller
- Department of Internal Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Geriatrics section, Amsterdam, The Netherlands
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19
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Growdon ME, Gan S, Yaffe K, Lee AK, Anderson TS, Muench U, Boscardin WJ, Steinman MA. New psychotropic medication use among Medicare beneficiaries with dementia after hospital discharge. J Am Geriatr Soc 2023; 71:1134-1144. [PMID: 36514208 PMCID: PMC10089969 DOI: 10.1111/jgs.18161] [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: 07/06/2022] [Revised: 10/21/2022] [Accepted: 11/16/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hospitalizations among people with dementia (PWD) may precipitate behavioral changes, leading to the psychotropic medication use despite adverse outcomes and limited efficacy. We sought to determine the incidence of new psychotropic medication use among community-dwelling PWD after hospital discharge and, among new users, the proportion with prolonged use. METHODS This was a retrospective cohort study using a 20% random sample of Medicare claims in 2017, including hospitalized PWD with traditional and Part D Medicare who were 68 years or older. The primary outcome was incident prescribing at discharge of psychotropics including antipsychotics, sedative-hypnotics, antiepileptics, and antidepressants. This was defined as new prescription fills (i.e., from classes not used in 180 days preadmission) within 7 days of hospital or skilled nursing facility discharge. Prolonged use was defined as the proportion of new users who continued to fill newly prescribed medications beyond 90 days of discharge. RESULTS The cohort included 117,022 hospitalized PWD with a mean age of 81 years; 63% were female. Preadmission, 63% were using at least 1 psychotropic medication; 10% were using medications from ≥3 psychotropic classes. These included antidepressants (44% preadmission), antiepileptics (29%), sedative-hypnotics (21%), and antipsychotics (11%). The proportion of PWD discharged from the hospital with new psychotropics ranged from 1.9% (antipsychotics) to 2.9% (antiepileptics); 6.6% had at least one new class started. Among new users, prolonged use ranged from 36% (sedative-hypnotics) to 63% (antidepressants); across drug classes, prolonged use occurred in 51%. Predictors of newly initiated psychotropics included length of stay (≥median vs. CONCLUSIONS Hospitalized PWD have a high prevalence of preadmission psychotropic medication use; against this baseline, discharge from the hospital with new psychotropics is relatively uncommon. Nevertheless, prolonged use of newly initiated psychotropics occurs in a substantial proportion of this population.
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Affiliation(s)
- Matthew E Growdon
- Division of Geriatrics, University of California, San Francisco, California, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California, USA
| | - Siqi Gan
- Division of Geriatrics, University of California, San Francisco, California, USA
- Northern California Institute for Research and Education, San Francisco, California, USA
| | - Kristine Yaffe
- Mental Health, San Francisco VA Medical Center, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
- Departments of Neurology and Psychiatry, University of California, San Francisco, California, USA
| | - Alexandra K Lee
- Division of Geriatrics, University of California, San Francisco, California, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California, USA
| | - Timothy S Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ulrike Muench
- Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, California, USA
| | - W John Boscardin
- Division of Geriatrics, University of California, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco, California, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California, USA
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20
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Polypharmacy in older surgical patients: practical steps for managing perioperative medications. Int Anesthesiol Clin 2023; 61:16-22. [PMID: 36892983 DOI: 10.1097/aia.0000000000000395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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21
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Cho E, Kim MJ, Yang M, Jang J, Cho J, Lee JY. Symptom-specific non-pharmacological interventions for behavioural and psychological symptoms of dementia: protocol of an umbrella review of systematic reviews of randomised controlled trials. BMJ Open 2023; 13:e070317. [PMID: 36792326 PMCID: PMC9933668 DOI: 10.1136/bmjopen-2022-070317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
INTRODUCTION There are various non-pharmacological interventions for dementia care. However, healthcare providers continue to face challenges in determining the most suitable interventions for the behavioural and psychological symptoms of dementia (BPSD), which vary according to individuals. This umbrella review aims to identify and summarise the effective non-pharmacological interventions for each sub-symptom to provide individualised, evidence-based recommendations for clinical practice. METHODS AND ANALYSIS This review follows the guideline of the Cochrane methodology for umbrella reviews. It focuses only on systematic reviews (SRs) with or without a meta-analysis of randomised controlled trials. Five electronic databases: PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, PsycINFO and Cochrane Database, will be searched. The screened SRs will be determined for eligibility by the PICO formulation: (Population) older adults with dementia of any type; (Intervention) all types of non-pharmacological intervention; (Comparison) usual care or other non-pharmacological intervention; and (Outcome) BPSD and its sub-symptoms. The quality of the individual SRs will be appraised using A Measurement Tool to Assess Systematic Reviews 2. The overlap of primary studies will also be considered by eliminating an old-date SR conducted by the same authors with the same interest and calculating the Corrected Covered Area. Data will be extracted according to the pre-determined formula, which will organise non-pharmacological interventions according to the sub-symptoms of BPSD and not according to the type of intervention. ETHICS AND DISSEMINATION Since this is a review paper, ethical approval is not required. The findings of this review will be disseminated through publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42022340930.
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Affiliation(s)
- Eunhee Cho
- Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing, Yonsei University, Seoul, Korea (the Republic of)
| | - Min Jung Kim
- Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing, Yonsei University, Seoul, Korea (the Republic of)
| | - Minhee Yang
- College of Nursing and Brain Korea 21 FOUR Project, Yonsei University, Seoul, Korea (the Republic of)
| | - Jiyoon Jang
- College of Nursing and Brain Korea 21 FOUR Project, Yonsei University, Seoul, Korea (the Republic of)
| | - Jungwon Cho
- College of Nursing, Yonsei University, Seoul, Korea (the Republic of)
| | - Ji Yeon Lee
- Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing, Yonsei University, Seoul, Korea (the Republic of)
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22
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Goodhope NR, Anderson TS, Jung Y, McCarthy EP, Herzig SJ. Initiation of Psychotropic and Opioid Medications After Hospital Discharge in Older Adults with Dementia. J Gen Intern Med 2023; 38:824-827. [PMID: 36323826 PMCID: PMC9971384 DOI: 10.1007/s11606-022-07874-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 10/24/2022] [Indexed: 01/27/2023]
Affiliation(s)
- Nicholas R Goodhope
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Timothy S Anderson
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Yoojin Jung
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ellen P McCarthy
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
| | - Shoshana J Herzig
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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23
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Little MO, Hecker EJ, Colon-Emeric CS, Herndon L, McConnell ES, Xue TM, Berry SD. Perspectives on Deprescribing in long-term care: qualitative findings from nurses, aides, residents, and proxies. BMC Nurs 2023; 22:27. [PMID: 36721150 PMCID: PMC9890706 DOI: 10.1186/s12912-023-01179-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 01/12/2023] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Deprescribing initiatives in the long-term care (LTC) setting are often unsuccessful or not sustained. Prior research has considered how physicians and pharmacists feel about deprescribing, yet little is known about the perspectives of frontline nursing staff and residents. Our aim was to elicit perspectives from LTC nursing staff, patients, and proxies regarding their experiences and preferences for deprescribing in order to inform future deprescribing efforts in LTC. METHODS This study was a qualitative analysis of interviews with nurses, nurse aides, a nurse practitioner, residents, and proxies (family member and/or responsible party) from three LTC facilities. The research team used semi-structured interviews. Guides were designed to inform an injury prevention intervention. Interviews were recorded and transcribed. A qualitative framework analysis was used to summarize themes related to deprescribing. The full study team reviewed the summary to identify actionable, clinical implications. RESULTS Twenty-six interviews with 28 participants were completed, including 11 nurse aides, three residents, seven proxies, one nurse practitioner, and six nurses. Three themes emerged that were consistent across facilities: 1) build trust with team members, including residents and proxies; 2) identify motivating factors that lead to resident, proxy, nurse practitioner, and staff acceptance of deprescribing; 3) standardize supportive processes to encourage deprescribing. These themes suggest several actionable steps to improve deprescribing initiatives including: 1) tell stories about successful deprescribing, 2) provide deprescribing education to frontline staff, 3) align medication risk/benefit discussions with what matters most to the resident, 4) standardize deprescribing monitoring protocols, 5) standardize interprofessional team huddles and care plan meetings to include deprescribing conversations, and 6) strengthen non-pharmacologic treatment programs. CONCLUSIONS By interviewing LTC stakeholders, we identified three important themes regarding successful deprescribing: Trust, Motivating Factors, and Supportive Processes. These themes may translate into actionable steps for clinicians and researchers to improve and sustain person-centered deprescribing initiatives. TRIAL REGISTRATION NCT04242186.
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Affiliation(s)
- Milta O. Little
- grid.26009.3d0000 0004 1936 7961Duke University School of Medicine, Department of Medicine, Division of Geriatric Medicine, NC Durham, USA
| | - Emily J. Hecker
- grid.26009.3d0000 0004 1936 7961Duke University School of Medicine, Department of Medicine, Division of Geriatric Medicine, NC Durham, USA
| | - Cathleen S. Colon-Emeric
- grid.26009.3d0000 0004 1936 7961Duke University School of Medicine, Department of Medicine, Division of Geriatric Medicine, NC Durham, USA ,grid.281208.10000 0004 0419 3073Durham VA Geriatric Research Education and Clinical Center, NC Durham, USA
| | - Laurie Herndon
- grid.497274.b0000 0004 0627 5136Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA USA
| | - Eleanor S. McConnell
- grid.281208.10000 0004 0419 3073Durham VA Geriatric Research Education and Clinical Center, NC Durham, USA ,grid.26009.3d0000 0004 1936 7961Duke University School of Nursing, NC Durham, USA
| | - Tingzhong Michelle Xue
- grid.281208.10000 0004 0419 3073Durham VA Geriatric Research Education and Clinical Center, NC Durham, USA ,grid.26009.3d0000 0004 1936 7961Duke University School of Nursing, NC Durham, USA
| | - Sarah D. Berry
- grid.497274.b0000 0004 0627 5136Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA USA ,grid.38142.3c000000041936754XBeth Israel Deaconess Medical Center, Department of Medicine & Harvard Medical School, Boston, MA USA
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24
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Liang CK, Chou MY, Hsu YH, Wang YC, Liao MC, Chen MT, Hsiao PY, Chen LK, Lin YT. The association of potentially inappropriate medications, polypharmacy and anticholinergic burden with readmission and emergency room revisit after discharge: A hospital-based retrospective cohort study. Br J Clin Pharmacol 2023; 89:187-200. [PMID: 35821614 DOI: 10.1111/bcp.15457] [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: 12/08/2021] [Revised: 06/05/2022] [Accepted: 06/30/2022] [Indexed: 11/30/2022] Open
Abstract
AIMS While certain drug-use indicators are known to be associated with clinical outcomes, the relationship is unclear for some highly prevalent conditions in in patients aged ≥65 years. We examine correlations between 3 drug-use indicators and postdischarge healthcare services use by older patients according to the presence of dementia, advanced age and frailty. METHODS This retrospective cohort study analysed data collected from hospital electronic health records between April and December 2017. Potentially inappropriate medications (PIMs) and anticholinergic burden were assessed using the 2015 Beers Criteria and anticholinergic cognitive burden scale (ACBS) score. Minor and major polypharmacy were defined as the use of 5-9 and ≥10 drugs, respectively. Outcomes were set as emergency room revisits and readmissions at 1, 3 and 6 months postdischarge. The correlation between drug-use indicators and outcomes was analysed by multivariable logistic regression. RESULTS The final cohort included 3061 patients for the analysis, and 2930, 2671 and 2560 patients were followed up to 1, 3 and 6 months after discharge. After controlling for confounders, all 3 drug-use indicators were significantly associated with readmission and emergency room revisits except for the relationship between PIMs and readmission within 6 months. These associations were significantly observed among patients without dementia, aged >80 years and with frailty. CONCLUSION PIMs, polypharmacy and anticholinergic burden are common at discharge and correlate with future use of healthcare services. In older patients, the absence of dementia, advanced age and frailty should be given extra consideration with regard to medication safety.
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Affiliation(s)
- Chih-Kuang Liang
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan.,Aging and Health Research Center, National Yang Ming Chiao Tung University, Taipei City, Taiwan.,Department of Geriatric Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan.,Division of Neurology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
| | - Ming-Yueh Chou
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan.,Aging and Health Research Center, National Yang Ming Chiao Tung University, Taipei City, Taiwan.,Department of Geriatric Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Ying-Hsin Hsu
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan.,Division of Neurology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan.,Chia Nan University, Tainan City, Taiwan
| | - Yu-Chun Wang
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
| | - Mei-Chen Liao
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
| | - Miao-Ting Chen
- Department of Pharmacy, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
| | - Pei-Yu Hsiao
- Department of Pharmacy, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
| | - Liang-Kung Chen
- Aging and Health Research Center, National Yang Ming Chiao Tung University, Taipei City, Taiwan.,Department of Geriatric Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan.,Taipei Municipal Gan-Dau Hospital, Taipei, Taiwan.,Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Yu-Te Lin
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan.,Division of Neurology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan.,Department of Pharmacy, Tajen University, Yanpu Township, Pingtung County, Taiwan
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25
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Esumi S, Ushio S, Zamami Y. Polypharmacy in Older Adults with Alzheimer’s Disease. Medicina (B Aires) 2022; 58:medicina58101445. [PMID: 36295605 PMCID: PMC9608980 DOI: 10.3390/medicina58101445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/23/2022] [Accepted: 09/28/2022] [Indexed: 11/28/2022] Open
Abstract
The number of patients with Alzheimer’s disease is increasing annually. Most of these patients are older adults with comorbid physical illnesses, which means that they are often treated with a combination of medications for the disease they have and those for Alzheimer’s disease. Thus, older adults with Alzheimer’s disease are potentially at risk for polypharmacy. In addition, the drug interactions between Alzheimer’s disease medications and those for the treatment of physical illnesses may reduce their efficacy and increase side effects. This article reviews polypharmacy and drug interactions in elderly patients with Alzheimer’s disease, with a focus on psychotropic drugs.
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Affiliation(s)
- Satoru Esumi
- Department of Pharmacy, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
- The Faculty of Pharmaceutical Science, Kobe Gakuin University, 1-1-3 Minatojima, Chuo-ku, Kobe 650-8586, Japan
- Correspondence: ; Tel.: +81-78-974-1551
| | - Soichiro Ushio
- Department of Pharmacy, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
| | - Yoshito Zamami
- Department of Pharmacy, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558, Japan
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26
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Yoon K, Kim JT, Kwack WG, Kim D, Lee KT, Yang S, Lee S, Choi YJ, Chung EK. Potentially Inappropriate Medication Use in Patients with Dementia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11426. [PMID: 36141699 PMCID: PMC9517486 DOI: 10.3390/ijerph191811426] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 06/16/2023]
Abstract
The objective of this study was to characterize the epidemiology of using potentially inappropriate medications associated with dementia exacerbation (DPIMs) in elderly outpatients with dementia. Electronic medical records were retrospectively reviewed for geriatric patients with dementia who were prescribed at least one medication in 2016 at a tertiary, university-affiliated hospital. The 2015 Beers criteria were used to define DPIMs. Logistic regression was performed to identify factors associated with prescribing DPIMs in patients with dementia. Among 2100 patients included in our study, 987 (47.0%) patients were prescribed at least one DPIM. Benzodiazepines were the most frequently prescribed DPIM followed by anticholinergics, histamine H2-receptor blockers, and zolpidem. The risk of prescribing DPIMs was significantly increased in female patients (odds ratio (OR) 1.355) with polypharmacy (OR 5.146) and multiple comorbidities (OR 1.129) (p < 0.05 for all). Coexistence of Parkinson's disease (OR 1.799), mood disorder (OR 1.373), or schizophrenia (OR 4.116) in patients with dementia further increased the likelihood of receiving DPIMs. In conclusion, DPIMs were commonly used in elderly patients with dementia in Korea with benzodiazepines most frequently prescribed followed by anticholinergics. Female patients using polypharmacy with multiple comorbidities should be closely monitored to minimize unnecessary DPIM use and, ultimately, DPIM-related harms.
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Affiliation(s)
- Kyungwon Yoon
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, Seoul 02447, Korea
- Department of Pharmacy, Kyung Hee University Hospital, Seoul 02447, Korea
| | - Jung-Tae Kim
- Department of Pharmacy, Kyung Hee University Hospital at Gangdong, Seoul 05278, Korea
| | - Won-Gun Kwack
- Division of Pulmonary, Allergy and Critical Care Medicine, Kyung Hee University Hospital, Seoul 02447, Korea
| | - Donghyun Kim
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, Seoul 02447, Korea
| | - Kyung-Tae Lee
- Department of Biomedical and Pharmaceutical Sciences, Graduate School, Kyung Hee University, Seoul 02447, Korea
- Department of Pharmaceutical Biochemistry, College of Pharmacy, Kyung Hee University, Seoul 02447, Korea
| | - Seungwon Yang
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, Seoul 02447, Korea
- Department of Regulatory Science, College of Pharmacy, Graduate School, Kyung Hee University, Seoul 02447, Korea
| | - Sangmin Lee
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, Seoul 02447, Korea
- Department of Regulatory Science, College of Pharmacy, Graduate School, Kyung Hee University, Seoul 02447, Korea
| | - Yeo-Jin Choi
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, Seoul 02447, Korea
- Department of Regulatory Science, College of Pharmacy, Graduate School, Kyung Hee University, Seoul 02447, Korea
| | - Eun-Kyoung Chung
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, Seoul 02447, Korea
- Department of Pharmacy, Kyung Hee University Hospital at Gangdong, Seoul 05278, Korea
- Department of Regulatory Science, College of Pharmacy, Graduate School, Kyung Hee University, Seoul 02447, Korea
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27
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Growdon ME, Espejo E, Jing B, Boscardin WJ, Zullo AR, Yaffe K, Boockvar KS, Steinman MA. Attitudes toward deprescribing among older adults with dementia in the United States. J Am Geriatr Soc 2022; 70:1764-1773. [PMID: 35266141 DOI: 10.1111/jgs.17730] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 02/09/2022] [Accepted: 02/18/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND People with dementia (PWD) take medications that may be unnecessary or harmful. This problem can be addressed through deprescribing, but it is unclear if PWD would be willing to engage in deprescribing with their providers. Our goal was to investigate attitudes toward deprescribing among PWD. METHODS This was a cross-sectional study of 422 PWD aged ≥65 years who completed the medications attitudes module of the National Health and Aging Trends Study (NHATS) in 2016. Proxies provided responses when a participant was unable to respond due to health or cognitive problems. Attitudinal outcomes comprised responses to two statements from the patients' attitudes toward deprescribing questionnaire and its revised version (representing belief about the necessity of one's medications and willingness to deprescribe); another elicited the maximum number of pills that a respondent would be comfortable taking. RESULTS The weighted sample represented over 1.8 million PWD; 39% were 75 to 84 years old and 38% were 85 years or older, 60% were female, and 55% reported six or more regular medications. Proxies provided responses for 26% of PWD. Overall, 22% believed that they may be taking one or more medicines that they no longer needed, 87% were willing to stop one or more of their medications, and 50% were uncomfortable taking five or more medications. Attitudinal outcomes were similar across sociodemographic and clinical factors. PWD taking ≥6 medications were more likely to endorse a belief that at least one medication was no longer necessary compared to those taking <6 (adjusted probability 29% [95% confidence interval (CI), 22%-38%] vs. 13% [95% CI, 8%-20%]; p = 0.004); the same applied for willingness to deprescribe (92% [95% CI, 87%-95%] vs. 83% [95% CI, 76%-89%]; p = 0.04). CONCLUSIONS A majority of PWD are willing to deprescribe, representing an opportunity to improve quality of life for this vulnerable population.
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Affiliation(s)
- Matthew E Growdon
- Division of Geriatrics, University of California-San Francisco, San Francisco, California, USA.,San Francisco VA Medical Center, San Francisco, California, USA
| | - Edie Espejo
- Division of Geriatrics, University of California-San Francisco, San Francisco, California, USA.,San Francisco VA Medical Center, San Francisco, California, USA
| | - Bocheng Jing
- Division of Geriatrics, University of California-San Francisco, San Francisco, California, USA.,San Francisco VA Medical Center, San Francisco, California, USA
| | - W John Boscardin
- San Francisco VA Medical Center, San Francisco, California, USA.,Department of Medicine, University of California-San Francisco, San Francisco, California, USA.,Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA.,Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA.,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA.,Department of Pharmacy, Lifespan-Rhode Island Hospital, Providence, Rhode Island, USA
| | - Kristine Yaffe
- San Francisco VA Medical Center, San Francisco, California, USA.,Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA.,Department of Psychiatry, University of California-San Francisco, San Francisco, California, USA.,Department of Neurology, University of California-San Francisco, San Francisco, California, USA
| | - Kenneth S Boockvar
- The New Jewish Home, New York, New York, USA.,Icahn School of Medicine at Mount Sinai, New York, New York, USA.,James J. Peters VA Medical Center, Bronx, New York, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California-San Francisco, San Francisco, California, USA.,San Francisco VA Medical Center, San Francisco, California, USA
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28
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Shafir A, Ritchie CS, Garrett SB, Bernstein Sideman A, Naasan G, Merrilees J, Widera E, Flint L, Harrison KL. "Captive by the Uncertainty"-Experiences with Anticipatory Guidance for People Living with Dementia and Their Caregivers at a Specialty Dementia Clinic. J Alzheimers Dis 2022; 86:787-800. [PMID: 35124641 DOI: 10.3233/jad-215203] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND After a diagnosis of Alzheimer's disease and related disorders, people living with dementia (PWD) and caregivers wonder what disease trajectory to expect and how to plan for functional and cognitive decline. This qualitative study aimed to identify patient and caregiver experiences receiving anticipatory guidance about dementia from a specialty dementia clinic. OBJECTIVE To examine PWD and caregiver perspectives on receiving anticipatory guidance from a specialty dementia clinic. METHODS We conducted semi-structured interviews with PWD, and active and bereaved family caregivers, recruited from a specialty dementia clinic. Interviews were recorded, transcribed, and systematically summarized. Thematic analysis identified anticipatory guidance received from clinical or non-clinical sources and areas where respondents wanted additional guidance. RESULTS Of 40 participants, 9 were PWD, 16 were active caregivers, and 15 were bereaved caregivers. PWD had a mean age of 75 and were primarily male (n = 6/9); caregivers had a mean age of 67 and were primarily female (n = 21/31). Participants felt they received incomplete or "hesitant" guidance on prognosis and expected disease course via their clinicians and filled the gap with information they found via the internet, books, and support groups. They appreciated guidance on behavioral, safety, and communication issues from clinicians, but found more timely and advance guidance from other non-clinical sources. Guidance on legal and financial planning was primarily identified through non-clinical sources. CONCLUSION PWD and caregivers want more information about expected disease course, prognosis, and help planning after diagnosis. Clinicians have an opportunity to improve anticipatory guidance communication and subsequent care provision.
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Affiliation(s)
- Adi Shafir
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.,Department of Veterans Affairs Medical Center, San Francisco, CA, USA.,Division of General Internal Medicine and Geriatrics, Oregon Health and Sciences University, Portland, OR, USA
| | - Christine S Ritchie
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.,Division of Palliative Care and Geriatric Medicine and the Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Sarah B Garrett
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA
| | - Alissa Bernstein Sideman
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA.,UCSF Department of Humanities & Social Sciences, San Francisco, CA, USA.,Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Georges Naasan
- The Barbara and Maurice Deane Center for Wellness and Cognitive Health, Department of Neurology, Mount Sinai, Icahn School of Medicine, New York, NY, USA.,Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Jennifer Merrilees
- UCSF Memory and Aging Center, University of California, San Francisco, San Francisco, CA, USA
| | - Eric Widera
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.,Department of Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Lynn Flint
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.,Department of Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Krista L Harrison
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA.,Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, USA
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