Drug therapy problems identified among older adults placed in a nursing home: the Croatian experience

Polypharmacy and potentially inappropriate prescribing of benzodiazepines in older nursing home residents

INTRODUCTION

Previous research has raised concerns about high prevalence of drug-related problems, polypharmacy and inappropriate benzodiazepine prescribing in nursing homes (NHs) and confirmed lack of studies from Central and South-Eastern Europe. The aim of our study was to determine the prevalence and characteristics of polypharmacy, hyperpolypharmacy and inappropriate benzodiazepine prescribing in NH residents in Croatia.

METHODS

Data from 226 older NH residents from five Croatian NHs were collected using the InterRAI Long-Term Care Facilities assessment form. The prevalence and determinants of polypharmacy/hyperpolypharmacy and patterns of inappropriate benzodiazepine prescribing were documented.

RESULTS

The prevalence of polypharmacy (49.6%) and hyperpolypharmacy (25.7%) among NH residents was high. In our study, 72.1% of NH residents were prescribed at least one psychotropic agent, 36.7% used 2-3 psychotropics and 6.6% used 4+ psychotropics. Among benzodiazepine users (55.8%), 28% of residents were prescribed benzodiazepines in higher than recommended geriatric doses, 75% used them for the long term and 48% were prescribed concomitant interacting medications. The odds of being prescribed polypharmacy/hyperpolypharmacy were significantly higher for older patients with polymorbidity (6+ disorders, proportional odds ratio (POR) = 19.8), type II diabetes (POR = 5.2), ischemic heart disease (POR = 4.6), higher frailty (Clinical Frailty Scale (CFS ≥5); POR = 4.3) and gastrointestinal problems (POR = 4.8).

CONCLUSIONS

Our research underscores the persistent challenge of inappropriate medication use and drug-related harms among older NH residents, despite existing evidence and professional campaigns. Effective regulatory and policy interventions, including the implementation of geriatrician and clinical pharmacy services, are essential to address this critical issue and ensure optimal medication management for vulnerable NH populations.

Prescribers' approval rate of pharmacist-initiated interventions to optimise patients' clinical status of hypertension in the ambulatory care setting

This perspective, pre- and post-intervention study with a one-year follow-up primarily aimed to ascertain prescribers' approval rate of pharmacists' interventions and clinical status of hypertension following comprehensive medication management (CMM) intervention in the ambulatory care clinic. Between January 2018 and January 2022 overall 100 patients with hypertension and other comorbidities were referred to the CMM services at the Health Centre Zagreb - Centar (HCZC). Out of 275 interventions directed to prescribers, 73.1 % of interventions were approved, 12.4 % were rejected and 14.5 % were not reviewed. The percentage of patients with a blood pressure goal increased from 45 % at the initial consultation to 82.5 % at the patients' latest encounter (p < 0.001). The average number of drug therapy problems (DTPs) per patient totaled 3.53 ± 1.80, where 98 % of patients had one or more DTPs, 48 % had 4 or more DTPs, whereas 26 % had 5 or more DTPs. Sub-therapeutic dosage (32.6 %) and the need for additional drug therapy (30.9 %) were the two most commonly identified DTPs. These results reinforce the need to integrate pharmacy-led services in the primary care setting with the aim of improving patients' health outcomes.

Appropriateness of medication prescribing in nursing homes: A collaboration project between pharmacy and geriatric departments

PURPOSE

To evaluate the appropriateness of medication prescribing and to analyze interventions carried out in polymedicated elderly patients in nursing homes (NHs).

METHODS

Prospective study of potentially inappropriate medication prescribing in polymedicated older adults living in NHs, implemented via a collaborative project between NHs and the geriatric and pharmacy departments of a university hospital. The pharmacist reviewed patients' active medical prescriptions and prepared an individualized report with proposals aimed at therapeutic optimization that was sent for evaluation to the geriatrician in charge of the NH. The drug-related problems (DRPs) were classified according to the Third Consensus of Granada and the potentially inappropriate prescriptions (PIPs) were identified by explicit criteria (STOPP/START, BEERS, LESS-CHRON), implicit criteria (MAI) and CheckTheMeds® software. It was measured the degree of acceptance of the interventions carried out, and the economic impact was calculated from the direct costs of the discontinued drugs.

RESULTS

Of the 210 patients reviewed by the pharmacy department, 105 patients from 10 NHs were analyzed. A total of 510 prescriptions with possible DRPs were identified (38.5% of all prescribed drugs). According to STOPP/START/BEERS or LESS-CHRON criteria, 41.2% were PIPs. The main DRPs identified were: unfavorable risk-benefit ratio, inappropriate dose/regimen, inappropriate treatment duration, probability of adverse events, medication not indicated, and duplicate therapy. Interventions were proposed for 81.5% of the DRPs detected, of which 73.3% were accepted. This resulted in a 23.1% reduction in the number of drugs prescribed per patient and an economic saving of €16,218 per 6-month period.

CONCLUSION

The appropriateness of medication prescribing in polymedicated older adults living in NHs by the pharmacist has made it possible to reduce DRPs and PIPs and to save costs thanks to the high degree of acceptance by geriatricians.

Clinical Pharmacist Intervention on Drug-Related Problems among Elderly Patients Admitted to Medical Wards of Northwest Ethiopia Comprehensive Specialized Hospitals: A Multicenter Prospective, Observational Study

Background: Drug therapy in the elderly needs an emphasis on age-related changes in drug pharmacokinetics and pharmacodynamics profile. Hospitalized elderly patients are at risk of more than one disease and polypharmacy associated with these; they are at risk of drug-related problems. This study aimed to assess the role of clinical pharmacy on identifying and resolution of drug-related problems among elderly patients admitted to medical ward of Northwest Ethiopia comprehensive specialized hospitals. Methods: A multicenter prospective observational study was conducted. A systematic sampling technique was used. The identified drug-related problem was recorded and classified using Cipolle, and adverse drug reaction was assessed using Naranjo algorithm of adverse drug reaction probability scale, and Medscape was used for drug-drug interaction. Data were analyzed by using STATA software version 14.1. Logistic regression was used, and results were reported as odds ratios (ORs) with 95% Confidence intervals with $P\text{value}<0.05$ statistically significant. Result: A total of 389 study participants were included in the study. About 266 (68.4%) of the participants had at least a single drug-related problem. About 503 drug-related problems were identified with a mean of 1.32 (CI: 1.27-1.36) drug-related problem per patient. The three-leading categories of drug-related problems were dose too high 108 (21.5%), nonadherence 105 (20.9%), and adverse drug reaction 96 (19.1%). Alcohol use ( $\text{AOR}=2.2$ , 95CI%: 1.23-3.94), source of the drug ( $\text{AOR}=2.85$ , 95CI%: 1.63-4.98), length of hospitalization ( $\text{AOR}=2.32$ , 95CI%: 1.37-3.95), number of comorbidities ( $\text{AOR}=1.48$ , 95CI%: 1.09-1.99), and polypharmacy ( $\text{AOR}=3.06$ , 95CI%: 1.72-5.46) were important risk factors for drug-related problems. From the intervention provided, 84.7% were accepted by prescribers. Among the total drug-related problems 67.4% of the problem was totally solved. Conclusion: This study revealed that DRPs were high among elderly patients admitted to medical ward of Northwest Ethiopia. Comorbidity, length of hospitalization, ploy-pharmacy, payer, and alcohol drinker were more likely to developed drug-related problems. Treatment optimizations were also done by clinical pharmacists and interventions were well accepted by prescribers.

Identifying Potential Drug-Related Problems Among Geriatric Patients With Use of an Integrated Clinical Decision Support Tool

Background: Drug-related problems (DRPs) which arise from potentially inappropriate medications (PIMs) are a common problem in older people with multi-morbidity and polypharmacy.

Aim: To develop an integrated PIM clinical decision support tool for identification of DRPs in geriatric multi-morbid polypharmacy patients, using the EU(7)-PIM and EURO-FORTA lists, with a focus on high-risk medications.

Methods: The integrated PIM tool used the information on PIMs in both databases—the EU(7)-PIM and EURO-FORTA. PIMs were classified into four color groups based on risk profile: high-risk PIMs (should be avoided in older patients) as red, moderate-risk PIMs (require dose and/or treatment duration adjustment) as yellow, low-risk PIMs (low DRP risk) as green, and questionable PIMs (incomplete/missing information) as grey.

Results: The summarized list of the high-risk (red and some grey) PIMs contained 81 active substances and medication classes. According to the ATC classification, most of the high-risk PIMs (n = 60, 74.1%) belong to the A, C, and N medication groups and 50.6% (n = 41) of the high-risk PIMs have currently marketing authorization in Estonia. The preliminary list of the moderate- and low-risk (yellow, green, and other grey) PIMs contained 240 active substances and medication classes, but sub-classification of this category into one or another group depends mainly on an individual patient´s clinical characteristics in a concrete analyzed study sample and needs further research.

Conclusion: The integrated clinical decision support tool based on the EU(7)-PIM and EURO-FORTA criteria addresses the need for more efficient identification of DRPs. It can be applied to identify PIMs and geriatric prescribing problems in different health care settings, and also in a context of little clinical information available.