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Garfinkel D, Levy Y. Optimizing clinical outcomes in polypharmacy through poly-de-prescribing: a longitudinal study. Front Med (Lausanne) 2024; 11:1365751. [PMID: 38745740 PMCID: PMC11091405 DOI: 10.3389/fmed.2024.1365751] [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: 01/04/2024] [Accepted: 02/26/2024] [Indexed: 05/16/2024] Open
Abstract
Objectives To evaluate polypharmacy in older people to determine whether the number of medications de-prescribed correlates with the extent of improvement in quality of life (QoL) and clinical outcomes. Design A prospective longitudinal cohort study of polypharmacy in people living in a community in Israel. Setting Participants aged 65 years or older who took at least six prescription drugs followed up for at least 3 years (range 3-10 years) after poly-de-prescription (PDP) recommendations. Interventions PDP recommended at first home visit using the Garfinkel algorithm. Annual follow-up and end-of-study questionnaires used to assess clinical outcomes, QoL, and satisfaction from de-prescribing. All medications taken, complications, hospitalizations, and mortality recorded. In total, 307 participants met the inclusion criteria; 25 incomplete end-of-study questionnaires meant 282 participants for subjective analysis. Participants divided into two subgroups: (i) those who discontinued more than 50% of the drugs (PDP group) or (ii) those who discontinued less than 50% of the drugs (non-responders, NR). Main outcome measures Objective: 3-year survival rate and hospitalizations. Subjective: general satisfaction from de-prescribing; change in functional, mental, and cognitive status; improved sleep quality, appetite, and continence; and decreased pain. Results Mean age: 83 years (range 65-99 years). Mean number of drugs at baseline visit: 9.8 (range 6-20); 6.7 ± 2.0 de-prescribed in the PDP group (n = 146) and 2.2 ± 2.1 in the NR group (n = 161) (p < 0.001).No statistical difference between the groups in the 3-year survival rate and hospitalizations, but a significant improvement in functional and cognitive status and, in general, satisfaction from the intervention in the PDP group compared to the NR group. Improvement usually evident within the first 3 months and persists for several years. Conclusion Poly-de-prescribing in the older population has beneficial effects on several clinical outcomes with no detrimental effect on the rate of hospitalization and survival. The extent of improvement correlates with the extent of de-prescribing. Applying the Garfinkel algorithm globally may improve QoL in millions of patients, a clinical and economic win-win situation.
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Affiliation(s)
- Doron Garfinkel
- Center for Appropriate Medication Use, Sheba Medical Center, Ramat Gan, Israel
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Ho JMW, To E, Sammy R, Stoian M, Tung JMH, Bodkin RJ, Cox L, Antoniou T, Benjamin S. Outcomes of a Medication Optimization Virtual Interdisciplinary Geriatric Specialist (MOVING) Program: A Feasibility Study. Drugs Real World Outcomes 2024; 11:117-124. [PMID: 38007818 DOI: 10.1007/s40801-023-00403-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2023] [Indexed: 11/28/2023] Open
Abstract
BACKGROUND Adverse drug events among older adults result in significant mortality, morbidity and cost. This harm may be mitigated with appropriate prescribing and deprescribing. We sought to understand the prescribing outcomes of an interdisciplinary geriatric virtual consultation service. METHODS We conducted a retrospective, before-and-after feasibility study to measure prescribing outcomes for a medication optimization virtual interdisciplinary geriatric specialist (MOVING) programme comprised of expertise from geriatric clinical pharmacology, pharmacy and psychiatry for older adults (aged ≥ 65 years) between June and December 2018, Ontario, Canada. The primary outcome was the number of distinct prescriptions and the presence of polypharmacy (defined as ≥ 4 medications) before and after the service. Secondary outcomes included the number of as needed and regularly administered prescriptions, number of potentially inappropriate prescriptions as defined by the Beers and STOPP criteria, and number of prescriptions for psychotropics, long-acting opioids and diabetic medications. RESULTS We studied 40 patients with a mean age of 80.6 [standard deviation (SD) 8.8] years who received a MOVING consult. We found no significant change in the mean total number of prescriptions per patient before (12.02, SD 5.83) and after the intervention (11.58, SD 5.28), with a mean difference of -0.45 [95% confidence interval (CI) -0.94 to 0.04; p = 0.07]. We found statistically significant decreases in as needed prescriptions (mean difference - 0.30, 95% CI - 0.45 to - 0.15; p<0.001), and potentially harmful medications as identified by the Beers (mean difference -1.25, 95% CI -2.00 to -0.50; p = 0.002) and STOPP (mean difference -1.65, 95% CI -2.33 to -0.97; p < 0.001) scores. Without including the cost savings from hospital diversion by a MOVING consult, the costs of a MOVING consult were $545.80-$629.80 per person, compared with the costs associated with traditional in-person consults involving similar specialist clinical services ($904.89-$1270.69 per person). CONCLUSION A MOVING model of care is associated with decreases in prescriptions for potentially inappropriate medications in older adults. These findings support further evaluation to ascertain health system impacts.
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Affiliation(s)
- Joanne Man-Wai Ho
- Department of Medicine, McMaster University, Waterloo, ON, Canada.
- Schlegel Research Institute for Aging, Waterloo, ON, Canada.
- GeriMedRisk, Waterloo, ON, Canada.
| | - Eric To
- Department of Medicine, McMaster University, Waterloo, ON, Canada
- Department of Medicine, Western University, London, ON, Canada
| | - Rebecca Sammy
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Matei Stoian
- Department of Family Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jennifer Man-Han Tung
- Department of Pharmacy, Grand River Hospital, Kitchener, ON, Canada
- GeriMedRisk, Waterloo, ON, Canada
| | - Robert Jack Bodkin
- Department of Pharmacy, Grand River Hospital, Kitchener, ON, Canada
- GeriMedRisk, Waterloo, ON, Canada
| | - Lindsay Cox
- Schlegel Research Institute for Aging, Waterloo, ON, Canada
- GeriMedRisk, Waterloo, ON, Canada
| | - Tony Antoniou
- GeriMedRisk, Waterloo, ON, Canada
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Sophiya Benjamin
- Department of Pharmacy, Grand River Hospital, Kitchener, ON, Canada
- GeriMedRisk, Waterloo, ON, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Waterloo, ON, Canada
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Woo JL, Nash KA, Dragan K, Crook S, Neidell M, Cook S, Hannan EL, Jacobs M, Goldstone AB, Petit CJ, Vincent R, Walsh-Spoonhower K, Mosca R, Kumar TKS, Devejian N, Kamenir SA, Alfieris GM, Swartz MF, Meyer D, Paul EA, Newburger JW, Billings J, Davis MM, Anderson BR. Chronic Medication Burden After Cardiac Surgery for Pediatric Medicaid Beneficiaries. J Am Coll Cardiol 2023; 82:1331-1340. [PMID: 37730290 DOI: 10.1016/j.jacc.2023.06.046] [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: 03/03/2023] [Revised: 05/26/2023] [Accepted: 06/30/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Congenital heart defects are the most common and resource-intensive birth defects. As children with congenital heart defects increasingly survive beyond early childhood, it is imperative to understand longitudinal disease burden. OBJECTIVES The purpose of this study was to examine chronic outpatient prescription medication use and expenditures for New York State pediatric Medicaid enrollees, comparing children who undergo cardiac surgery (cardiac enrollees) and the general pediatric population. METHODS This was a retrospective cohort study of all Medicaid enrollees age <18 years using the New York State Congenital Heart Surgery Collaborative for Longitudinal Outcomes and Utilization of Resources database (2006-2019). Primary outcomes were total chronic medications per person-year, enrollees per 100 person-years using ≥1 and ≥3 medications, and medication expenditures per person-year. We described and compared outcomes between cardiac enrollees and the general pediatric population. Among cardiac enrollees, multivariable regression examined associations between outcomes and clinical characteristics. RESULTS We included 5,459 unique children (32,131 person-years) who underwent cardiac surgery and 4.5 million children (22 million person-years) who did not. More than 4 in 10 children who underwent cardiac surgery used ≥1 chronic medication compared with approximately 1 in 10 children who did not have cardiac surgery. Medication expenditures were 10 times higher per person-year for cardiac compared with noncardiac enrollees. Among cardiac enrollees, disease severity was associated with chronic medication use; use was highest among infants; however, nearly one-half of adolescents used ≥1 chronic medication. CONCLUSIONS Children who undergo cardiac surgery experience high medication burden that persists throughout childhood. Understanding chronic medication use can inform clinicians (both pediatricians and subspecialists) and policymakers, and ultimately the value of care for this medically complex population.
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Affiliation(s)
- Joyce L Woo
- Division of Pediatric Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Division of Pediatric Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Katherine A Nash
- Division of Pediatric Critical Care and Hospital Medicine, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Kacie Dragan
- Wagner Graduate School of Public Service, New York University, New York, New York, USA; Interfaculty Initiative in Health Policy, Graduate School of Arts and Sciences, Harvard University, Boston, Massachusetts, USA
| | - Sarah Crook
- Division of Pediatric Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Matthew Neidell
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Stephen Cook
- New York State Department of Health; Offices of Health Insurance Programs, Albany, New York, USA; Department of Pediatrics, Internal Medicine, and Center for Community Health, University of Rochester Medical Center, Rochester, New York, USA
| | - Edward L Hannan
- University at Albany School of Public Health, Rensselaer, New York, USA
| | - Marshall Jacobs
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrew B Goldstone
- Department of Cardiothoracic Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center and Weill Cornell Medical Center, New York, New York, USA
| | - Christopher J Petit
- Interfaculty Initiative in Health Policy, Graduate School of Arts and Sciences, Harvard University, Boston, Massachusetts, USA
| | - Robert Vincent
- Division of Pediatric Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | | | - Ralph Mosca
- Department of Cardiothoracic Surgery, New York University, New York, New York, USA
| | - T K Susheel Kumar
- Department of Cardiothoracic Surgery, New York University, New York, New York, USA
| | - Neil Devejian
- Division of Pediatric Cardiothoracic Surgery, Albany Medical College, Albany, New York, USA
| | - Steven A Kamenir
- Division of Pediatric Cardiology, Albany Medical College, Albany, New York, USA
| | - George M Alfieris
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York, USA; Department of Surgery, State University of New York Upstate Medical Center, Syracuse, New York, USA
| | - Michael F Swartz
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - David Meyer
- Departments of Cardiothoracic Surgery and Pediatrics, Hofstra-Northwell School of Medicine, Uniondale, New York, USA
| | - Erin A Paul
- Division of Pediatric Cardiology, Icahn School of Medicine at Mt Sinai, New York, New York, USA
| | - Jane W Newburger
- Department of Pediatric Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - John Billings
- Division of Pediatric Critical Care and Hospital Medicine, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Matthew M Davis
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Brett R Anderson
- Division of Pediatric Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA.
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Choi DW, Kang H, Zhang HS, Jhang H, Jeong W, Park S. Association of polypharmacy with all-cause mortality and adverse events among elderly colorectal cancer survivors. Cancer 2023; 129:2705-2716. [PMID: 37118834 DOI: 10.1002/cncr.34813] [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: 09/29/2022] [Revised: 03/14/2023] [Accepted: 03/15/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND The risk of inappropriate drug exposure in elderly colorectal cancer (CRC) survivors after the initial cancer treatment has not been well studied. This study investigated the association of polypharmacy (PP) with overall survival, hospitalization, and emergency room (ER) visits among older CRC survivors. METHODS A retrospective cohort study was conducted using the Korean National Health Insurance claims data follow-up from 2002 to 2017. Participants comprised those aged ≥65 years who were hospitalized with a diagnosis of CRC received cancer treatment and survived at least 2 years from the initial CRC diagnosis between 2003 and 2012. PP was defined based on the number of individual drugs during the third year, after 2 years of survival since the initial cancer treatment. PP was categorized as follows: non-PP (zero to four prescribed drugs); PP (five to nine drugs), and excessive PP (≥10 drugs). Main outcomes are all-cause mortality, hospitalization, and ER visits. RESULTS Of the 55,228 participants, 44.5% died, 83.1% were hospitalized, and 46.1% visited the ER. The PP and excess PP groups showed increased risk of all-cause mortality, hospitalization, and ER visit compared with the low PP group, and was highly associated among groups including patients aged 65 to 74 years and those in low-level frailty groups. CONCLUSIONS These risks can be minimized by increasing awareness and enhancing behaviors among health care professionals, especially clinician and pharmacists, to be aware of potential drug interactions, review, and ongoing monitoring. PLAIN LANGUAGE SUMMARY The risk of inappropriate drug exposure in older colorectal cancer (CRC) survivors after the initial cancer treatment has not been well studied. Polypharmacy was associated with adverse outcomes, including all-cause mortality, hospitalization, and emergency room visits among older CRC survivors and it was particularly associated with those who were 65 to 75 years and those with low risk of frailty. When prescribing drugs, physicians should be mindful of finding a balance between adequate treatment of diseases and avoiding adverse drug effects in survivors of CRC.
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Affiliation(s)
- Dong-Woo Choi
- Cancer Big Data Center, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea
| | - Hyejung Kang
- Department of Health Informatics & Biostatistics, Graduate School of Public Health, Yonsei University, Seoul, Korea
| | - Hyun-Soo Zhang
- Department of Health Informatics & Biostatistics, Graduate School of Public Health, Yonsei University, Seoul, Korea
- Department of Biomedical Informatics, College of Medicine, Yonsei University, Seoul, Korea
| | - Hoyol Jhang
- Department of Health Informatics & Biostatistics, Graduate School of Public Health, Yonsei University, Seoul, Korea
| | - Wonjeong Jeong
- Cancer Information & Education Center, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea
| | - Sohee Park
- Department of Health Informatics & Biostatistics, Graduate School of Public Health, Yonsei University, Seoul, Korea
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Kröger E, Wilchesky M, Morin M, Carmichael PH, Marcotte M, Misson L, Plante J, Voyer P, Durand P. The OptimaMed intervention to reduce medication burden in nursing home residents with severe dementia: results from a pragmatic, controlled study. BMC Geriatr 2023; 23:520. [PMID: 37641020 PMCID: PMC10464023 DOI: 10.1186/s12877-023-04222-4] [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: 10/05/2022] [Accepted: 08/07/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Nursing home (NH) residents with severe dementia use many medications, sometimes inappropriately within a comfort care approach. Medications should be regularly reviewed and eventually deprescribed. This pragmatic, controlled trial assessed the effect of an interprofessional knowledge exchange (KE) intervention to decrease medication load and the use of medications of questionable benefit among these residents. METHODS A 6-month intervention was performed in 4 NHs in the Quebec City area, while 3 NHs, with comparable admissions criteria, served as controls. Published lists of "mostly", "sometimes" or "exceptionally" appropriate medications, tailored for NH residents with severe dementia, were used. The intervention included 1) information for participants' families about medication use in severe dementia; 2) a 90-min KE session for NH nurses, pharmacists, and physicians; 3) medication reviews by NH pharmacists using the lists; 4) discussions on recommended changes with nurses and physicians. Participants' levels of agitation and pain were evaluated using validated scales at baseline and the end of follow-up. RESULTS Seven (7) NHs and 123 participants were included for study. The mean number of regular medications per participant decreased from 7.1 to 6.6 in the intervention, and from 7.7 to 5.9 in the control NHs (p-value for the difference in differences test: < 0.05). Levels of agitation decreased by 8.3% in the intervention, and by 1.4% in the control NHs (p = 0.026); pain levels decreased by 12.6% in the intervention and increased by 7% in the control NHs (p = 0.049). Proportions of participants receiving regular medications deemed only exceptionally appropriate decreased from 19 to 17% (p = 0.43) in the intervention and from 28 to 21% (p = 0.007) in the control NHs (p = 0.22). The mean numbers of regular daily antipsychotics per participant fell from 0.64 to 0.58 in the intervention and from 0.39 to 0.30 in the control NHs (p = 0.27). CONCLUSIONS This interprofessional intervention to reduce inappropriate medication use in NH residents with severe dementia decreased medication load in both intervention and control NHs, without important concomitant increase in agitation, but mixed effects on pain levels. Practice changes and heterogeneity within these 7 NHs, and a ceiling effect in medication optimization likely interfered with the intervention. TRIAL REGISTRATION The study is registered at ClinicalTrials.gov: # NCT05155748 (first registration 03-10-2017).
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Affiliation(s)
- Edeltraut Kröger
- Centre d'excellence sur le vieillissement de Québec, CIUSSSCN, Hôpital du Saint-Sacrement, 1050, Chemin Sainte-Foy, Québec (Québec), G1S 4L8, Canada.
- Université Laval, Faculté de pharmacie, Pavillon Ferdinand Vandry, 1050 Avenue de La Médecine, Québec, Québec, G1V 0A6, Canada.
- Institut sur le vieillissement et la participation sociale des aînés, Université Laval, Hôpital du Saint-Sacrement, bureau L2-42, 1050, Chemin Sainte-Foy, Québec (Québec), G1S 4L8, Canada.
| | - Machelle Wilchesky
- McGill University, Faculty of Medicine and Health Sciences, 3605, Chemin de La Montagne, Montreal (Québec), H3G 2M1, Canada
- Lady Davis Institute for Medical Research, Jewish General Hospital, 3755 Chem. de La Côte-Sainte-Catherine, Montréal, (Québec), H3T 1E2, Canada
| | - Michèle Morin
- Centre d'excellence sur le vieillissement de Québec, CIUSSSCN, Hôpital du Saint-Sacrement, 1050, Chemin Sainte-Foy, Québec (Québec), G1S 4L8, Canada
- Institut sur le vieillissement et la participation sociale des aînés, Université Laval, Hôpital du Saint-Sacrement, bureau L2-42, 1050, Chemin Sainte-Foy, Québec (Québec), G1S 4L8, Canada
- Donald Berman Maimonides Centre for Research in Aging, 5795 Av. Caldwell, Côte Saint-Luc, Montreal (Québec), H4W 1W3, Canada
| | - Pierre-Hugues Carmichael
- Centre d'excellence sur le vieillissement de Québec, CIUSSSCN, Hôpital du Saint-Sacrement, 1050, Chemin Sainte-Foy, Québec (Québec), G1S 4L8, Canada
| | - Martine Marcotte
- Centre d'excellence sur le vieillissement de Québec, CIUSSSCN, Hôpital du Saint-Sacrement, 1050, Chemin Sainte-Foy, Québec (Québec), G1S 4L8, Canada
| | - Lucie Misson
- Centre d'excellence sur le vieillissement de Québec, CIUSSSCN, Hôpital du Saint-Sacrement, 1050, Chemin Sainte-Foy, Québec (Québec), G1S 4L8, Canada
| | - Jonathan Plante
- Centre d'excellence sur le vieillissement de Québec, CIUSSSCN, Hôpital du Saint-Sacrement, 1050, Chemin Sainte-Foy, Québec (Québec), G1S 4L8, Canada
- Université Laval, Faculté de pharmacie, Pavillon Ferdinand Vandry, 1050 Avenue de La Médecine, Québec, Québec, G1V 0A6, Canada
| | - Philippe Voyer
- Centre d'excellence sur le vieillissement de Québec, CIUSSSCN, Hôpital du Saint-Sacrement, 1050, Chemin Sainte-Foy, Québec (Québec), G1S 4L8, Canada
- Université Laval, Faculté de pharmacie, Pavillon Ferdinand Vandry, 1050 Avenue de La Médecine, Québec, Québec, G1V 0A6, Canada
- Université Laval, Faculté de médecine, Pavillon Ferdinand Vandry, 1050 Avenue de La Médecine, Québec (Québec), G1V 0A6, Canada
| | - Pierre Durand
- Centre d'excellence sur le vieillissement de Québec, CIUSSSCN, Hôpital du Saint-Sacrement, 1050, Chemin Sainte-Foy, Québec (Québec), G1S 4L8, Canada
- Université Laval, Faculté de pharmacie, Pavillon Ferdinand Vandry, 1050 Avenue de La Médecine, Québec, Québec, G1V 0A6, Canada
- Donald Berman Maimonides Centre for Research in Aging, 5795 Av. Caldwell, Côte Saint-Luc, Montreal (Québec), H4W 1W3, Canada
- Université Laval, Faculté des sciences infirmières, Pavillon Ferdinand Vandry, 1050 Avenue de La Médecine, Québec (Québec), G1V 0A6, Canada
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İlhan B, Erdoğan T, Topinková E, Bahat G. Management of use of urinary antimuscarinics and alpha blockers for benign prostatic hyperplasia in older adults at risk of falls: a clinical review. Eur Geriatr Med 2023; 14:733-746. [PMID: 37245173 DOI: 10.1007/s41999-023-00798-7] [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: 10/07/2022] [Accepted: 05/10/2023] [Indexed: 05/29/2023]
Abstract
PURPOSE We aimed to outline the existing information and the underlying mechanisms of risk of falls associated with the use of urinary antimuscarinics for overactive bladder (OAB) or alpha-blockers for benign prostatic hyperplasia (BPH) in older adults. In addition, we aimed to provide assistance to clinicians in decision-making about (de-)prescribing these drugs in older adults. METHODOLOGY Based on a literature search in PubMed and Google Scholar, we reviewed the literature, and identified additional relevant articles from reference lists, with an emphasis on the most commonly prescribed drugs in OAB and BPH in older patients. We discussed the use of bladder antimuscarinics and alpha-blockers, their potential side effects related to falls, and the deprescribing of these drugs in older adults. RESULTS Urinary urgency or incontinence and lower urinary tract symptoms due to untreated OAB and BPH contribute to fall risk. On the other hand, the use of bladder antimuscarinics and alpha-blockers is also related to fall risk. They contribute to (or cause) falling through dizziness, somnolence, visual impairment, and orthostatic hypotension while they differ in their side-effect profiles regarding these problems. Falls are common and can cause a remarkable amount of morbidity and mortality. Thus, preventive measures should be taken to lower the risk. If the clinical condition allows, withdrawal of bladder antimuscarinics and alpha-blockers is recommended in fall-prone older adults. There are practical resources and algorithms that guide and assist clinicians in deprescribing these drug groups. CONCLUSIONS The decision to prescribe or deprescribe these treatments in patients at high risk of falls should be individualized. In addition to explicit tools that are helpful for clinical decision-making in (de-)prescribing these drugs, STOPPFall (a recently developed expert-based decision aid specifically aiming to prevent falls) is present to assist prescribers in attaining decisions.
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Affiliation(s)
- Birkan İlhan
- Internal Medicine, and Geriatrics Clinic, Liv Hospital Vadi Istanbul, Istanbul, Turkey
| | - Tuğba Erdoğan
- Geriatrics Clinic, Tekirdağ Dr. Ismail Fehmi Cumalıoglu City Hospital, Tekirdağ, Turkey
| | - Eva Topinková
- Department of Geriatric Medicine, 1st Faculty of Medicine, Charles University and General University Hospital, Prague and Faculty of Health and Social Sciences, University of South Bohemia, České Budejovice, Czechia
| | - Gülistan Bahat
- Division of Geriatrics, Department of Internal Medicine, Istanbul Medical School, Istanbul University, Istanbul, Turkey.
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Tjia J, Karakida M, Alcusky M, Furuno JP. Perspectives on deprescribing in palliative care. Expert Rev Clin Pharmacol 2023; 16:411-421. [PMID: 36995162 PMCID: PMC10192103 DOI: 10.1080/17512433.2023.2197592] [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: 10/07/2022] [Accepted: 03/28/2023] [Indexed: 03/31/2023]
Abstract
INTRODUCTION Pharmacotherapy plays a critical role in the delivery of high-quality palliative care, but the intersection of palliative care and deprescribing has received little attention. AREAS COVERED We conducted a scoping review of English language articles using PubMed to identify relevant publications between 1 January 2000 to 31 July 2022 using search terms of deprescribing, palliative care, end of life, and hospice. We summarize current definitions and developments in palliative care and deprescribing from both clinical and research perspectives. We highlight key challenges and outline proposed solutions and needed research. EXPERT OPINION The future of deprescribing in palliative care requires the development and adoption of individualized approaches to medication management, including a reconsidered approach to communication about deprescribing. Evidence from high-quality clinical outcomes studies is lacking, and the field needs new approaches to coordination of care delivery. This review article will be of interest to both clinical and research-based pharmacists, physicians, and nurses interested in improving care for patients with serious illness.
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Affiliation(s)
- Jennifer Tjia
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA
| | - Maki Karakida
- Department of Gerontology, McCormack Graduate School of Policy and Global Studies, UMass Boston, Boston, MA
| | - Matthew Alcusky
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA
| | - Jon P Furuno
- Oregon State University College of Pharmacy, Portland, OR
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Tse N, Parks RM, Holmes HM, Cheung KL. The Association Between Medication Use in Older Women with Early-Stage Operable Primary Breast Cancer and Decision Regarding Primary Treatment. Oncologist 2023; 28:e128-e135. [PMID: 36718086 PMCID: PMC10020815 DOI: 10.1093/oncolo/oyac278] [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: 06/27/2022] [Accepted: 11/14/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Polypharmacy is one factor contributing to increased mortality, hospitalization, and adverse drug reactions in older adults. The aim of this study was to measure the prevalence of polypharmacy in a cohort of older women with early-stage operable primary breast cancer and the relationship of polypharmacy to primary treatment decision and functional status. METHODS A total of 139 patients with a new diagnosis of early-stage operable primary breast cancer proven histologically were recruited as part of a prospective study. The average age was 77 years. Assessment using a cancer-specific Comprehensive Geriatric Assessment (CGA) tool was conducted within 6 weeks of diagnosis of breast cancer. Association was determined between number of medications and treatment decision and physical status as measured by the CGA outcomes. Additional analysis was performed to determine the associations above with polypharmacy defined by ≥5 daily medications, and if cardiovascular-related diseases have a role in the treatment decision. RESULTS Polypharmacy was present in 48% of patients (n = 139). CGA determined that polypharmacy was associated with greater comorbidity (P < .001), reduced physical status rated by physicians (P = .009) and patients (P = .019), and reduced ability to perform activities of instrumental ADLs (P = .008). Similar findings were present in the analysis of cardiovascular-related diseases. CONCLUSIONS This work suggests that patients with polypharmacy are more likely to be frail. The number of medications could help us screen patients who should go on to receive full CGA.
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Affiliation(s)
- Natalie Tse
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
- Nottingham Breast Cancer Research Centre, University of Nottingham, Nottingham, UK
| | - Ruth M Parks
- Nottingham Breast Cancer Research Centre, University of Nottingham, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Holly M Holmes
- Division of Geriatric and Palliative Medicine, University of Texas Health Science Center, McGovern Medical School, Houston, TX, USA
| | - Kwok-Leung Cheung
- Corresponding author: Kwok-Leung Cheung, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Uttoxeter Road, Derby, DE22 3DT, UK. Telephone: +44(0)1332 724881;
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9
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Ie K, Machino R, Albert SM, Tomita S, Kushibuchi M, Hirose M, Matsuda T, Okuse C, Ohira Y. Deprescribing as an Opportunity to Facilitate Patient-Centered Care: A Qualitative Study of General Practitioners and Pharmacists in Japan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3543. [PMID: 36834238 PMCID: PMC9962748 DOI: 10.3390/ijerph20043543] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/04/2023] [Accepted: 02/15/2023] [Indexed: 06/18/2023]
Abstract
Deprescribing has recently been applied to address polypharmacy, particularly among older adults. However, the characteristics of deprescribing that are likely to improve health outcomes have not been well studied. This study explored the experiences and perspectives of general practitioners and pharmacists with regard to deprescribing in older adults with multimorbidity. A qualitative study was conducted involving eight semi-structured focus group interviews with 35 physicians and pharmacists from hospitals, clinics, and community pharmacies. Thematic analysis was applied to identify themes using the theory of planned behavior as a guide. The results illustrated a metacognitive process, as well as influencing factors, through which healthcare providers commit to shared decision making for deprescribing. Healthcare providers acted on the basis of their attitudes and beliefs on deprescribing, the influence of subjective norms, and perceived behavioral control for deprescribing. These processes are influenced by factors such as drug class, prescribers, patients, deprescribing experience, and environment/education. Healthcare providers' attitudes, beliefs, and behavioral control (along with deprescribing strategies) evolve in a dynamic interplay with experience, environment, and education. Our results can serve as a foundation for the development of effective patient-centered deprescribing to improve the safety of pharmaceutical care for older adults.
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Affiliation(s)
- Kenya Ie
- Department of General Internal Medicine, St. Marianna University School of Medicine, Kawasaki 214-8525, Japan
- Department of General Internal Medicine, Kawasaki Municipal Tama Hospital, Kawasaki 214-8525, Japan
- Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15621, USA
| | - Reiko Machino
- Department of General Internal Medicine, St. Marianna University School of Medicine, Kawasaki 214-8525, Japan
- Department of General Internal Medicine, Kawasaki Municipal Tama Hospital, Kawasaki 214-8525, Japan
| | - Steven M. Albert
- Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15621, USA
| | - Shiori Tomita
- Tama Family Clinic, Kawasaki 214-0013, Japan
- Division of Clinical Epidemiology, Jikei University School of Medicine, Tokyo 105-8461, Japan
| | - Mio Kushibuchi
- Department of General Internal Medicine, St. Marianna University School of Medicine, Kawasaki 214-8525, Japan
- Department of General Internal Medicine, Kawasaki Municipal Tama Hospital, Kawasaki 214-8525, Japan
| | - Masanori Hirose
- Department of General Internal Medicine, St. Marianna University School of Medicine, Kawasaki 214-8525, Japan
- Department of General Internal Medicine, Kawasaki Municipal Tama Hospital, Kawasaki 214-8525, Japan
| | - Takahide Matsuda
- Department of General Internal Medicine, St. Marianna University School of Medicine, Kawasaki 214-8525, Japan
| | - Chiaki Okuse
- Department of General Internal Medicine, St. Marianna University School of Medicine, Kawasaki 214-8525, Japan
- Department of General Internal Medicine, Kawasaki Municipal Tama Hospital, Kawasaki 214-8525, Japan
| | - Yoshiyuki Ohira
- Department of General Internal Medicine, St. Marianna University School of Medicine, Kawasaki 214-8525, Japan
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10
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Drewelow E, Ritzke M, Altiner A, Icks A, Montalbo J, Kalitzkus V, Löscher S, Pashutina Y, Fleischer S, Abraham J, Thürmann P, Mann NK, Wiese B, Wilm S, Wollny A, Feldmeier G, Buuck T, Mortsiefer A. Development of a shared decision-making intervention to improve drug safety and to reduce polypharmacy in frail elderly patients living at home. PEC INNOVATION 2022; 1:100032. [PMID: 37213749 PMCID: PMC10194292 DOI: 10.1016/j.pecinn.2022.100032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/03/2022] [Accepted: 03/19/2022] [Indexed: 05/23/2023]
Abstract
Objectives For patients with geriatric frailty, reducing inappropriate medication is an important goal to improve patient safety in primary care. GP-side barriers include knowledge gaps, legal concerns, and lack of communication between the actors involved. The aim was to develop a multi-faceted intervention to facilitate deprescribing and shared prioritisation among frail elderlies with polypharmacy living at home. Methods Mixed methods study including: 1) scoping review on family conferences, expert panels; 2) group discussions with GPs, mapping of needs and challenges in Primary Care; 3) workshops and expert interviews with GPs, patient advocates, researchers as a basis for a theoretical intervention model; 4) piloting. Results A major challenge for GPs is to conduct a productive discussion with patients and family cares on deprescribing and drug safety. A guideline for a structured family conference with a medication check and geriatric assessment was developed and proved to be feasible in the pilot study. Conclusion The intervention developed to facilitate deprescribing and shared prioritisation of drug therapy based on family conferences seems suitable to be tested in a subsequent cRCT. Innovation Adapting family conferences to primary care for frail patients with polypharmacy.
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Affiliation(s)
- E. Drewelow
- Institute of General Practice, University Medical Center Rostock, Doberaner Straße 142, 18057 Rostock, Germany
- Corresponding author at: Institut für Allgemeinmedizin, Universitätsmedizin Rostock, Doberaner Straße 142, 18057 Rostock, DE, Germany.
| | - M. Ritzke
- Institute of General Practice, University Medical Center Rostock, Doberaner Straße 142, 18057 Rostock, Germany
| | - A. Altiner
- Institute of General Practice, University Medical Center Rostock, Doberaner Straße 142, 18057 Rostock, Germany
| | - A. Icks
- Institute for Health Services and Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - J. Montalbo
- Institute for Health Services and Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - V. Kalitzkus
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - S. Löscher
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Y. Pashutina
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - S. Fleischer
- Institute for Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112 Halle, Germany
| | - J. Abraham
- Institute for Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, Magdeburger Straße 8, 06112 Halle, Germany
| | - P. Thürmann
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Heusnerstraße 40, 42283 Wuppertal, Germany
| | - NK. Mann
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Heusnerstraße 40, 42283 Wuppertal, Germany
| | - B. Wiese
- WG Medical Statistics and IT-Infrastructure, Institute of General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - S. Wilm
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - A. Wollny
- Institute of General Practice, University Medical Center Rostock, Doberaner Straße 142, 18057 Rostock, Germany
| | - G. Feldmeier
- Institute of General Practice, University Medical Center Rostock, Doberaner Straße 142, 18057 Rostock, Germany
| | - T. Buuck
- Institute of General Practice, University Medical Center Rostock, Doberaner Straße 142, 18057 Rostock, Germany
| | - A. Mortsiefer
- Institute of General Practice and Primary Care, Faculty of Health, Department of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
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11
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Ouellet N, Bergeron AS, Gagnon E, Cossette B, Labrecque CA, Sirois C. Prescribing and deprescribing in very old age: perceptions of very old adults, caregivers and health professionals. Age Ageing 2022; 51:6827077. [PMID: 36413585 DOI: 10.1093/ageing/afac244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND although they are major consumers of medications, there is little evidence-based data to guide prescribing and deprescribing of medications for very old adults (80+ years). OBJECTIVES to discover the perceptions of very old adults, caregivers and health professionals in order to further examine the clinical and ethical issues raised by prescribing and deprescribing in very old age. METHODS individual interviews were conducted with very old adults (n = 10) and caregivers (n = 6), whereas group interviews were conducted with health professionals (n = 11). The themes covered included perceptions of medication use, polypharmacy, deprescribing and patient-health professional relationships. Thematic analysis was used to identify areas of convergence and divergence. RESULTS very old adults are satisfied with the medications they are taking, do not see the need to reduce their medication use and consider their doctor as the expert who should make the decisions regarding treatment. The perceptions of caregivers are similar to those of older adults, whereas health professionals believe that very old adults take a lot of inappropriate medications and list multiple barriers to deprescribing. All participants describe a normalisation of medication use with ageing. CONCLUSION there is a dichotomy between the perception of the very old adults/caregivers and that of health professionals regarding the safety of medication in very old age. A cultural change regarding medication use seems essential to optimise therapy and support deprescribing in clinical practice since the potential issues raised by researchers do not resonate with the main stakeholders.
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Affiliation(s)
- Nicole Ouellet
- Département des Sciences Infirmières, Université du Québec à Rimouski, Rimouski, Québec, Canada
| | - Anne-Sophie Bergeron
- Département des Sciences Infirmières, Université du Québec à Rimouski, Rimouski, Québec, Canada
| | - Eric Gagnon
- Centre d'excellence sur le vieillissement de Québec, Québec, Canada.,VITAM - Centre de Recherche en Santé Durable, Centre Intégré Universitaire de Santé et de Services Sociaux, Québec, Canada
| | - Benoit Cossette
- Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, Québec, Canada.,Research Center on Aging, Integrated University Health and Social Services Center of Estrie-Sherbrooke University Hospital Center, Sherbrooke, Québec, Canada
| | - Cory A Labrecque
- Faculté de Théologie et de Sciences Religieuses, Université Laval, Québec, Canada
| | - Caroline Sirois
- Centre d'excellence sur le vieillissement de Québec, Québec, Canada.,VITAM - Centre de Recherche en Santé Durable, Centre Intégré Universitaire de Santé et de Services Sociaux, Québec, Canada.,Faculté de Pharmacie, Université Laval, Laval, Québec, Canada
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12
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Herrington G, Riche DM. Part I: Interactive case: Hyperlipidemia management for special populations. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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13
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Bahat G, İlhan B, Tufan A, Kılıç C, Karan MA, Petrovic M. Hypotension Under Antihypertensive Treatment and Incident Hospitalizations of Nursing Home Residents. Drugs Aging 2022; 39:477-484. [PMID: 35701577 DOI: 10.1007/s40266-022-00951-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Hypertension is the most prevalent chronic disease in older adults. Antihypertensive drug use increases with aging. In some studies, hypotension developing under antihypertensive medication use has been indicated as a potential risk factor for morbidity and mortality in older adults. Our objective was to assess the relationship between hypotension under antihypertensive treatment and incident hospitalization of nursing home residents. METHODS We detailed blood pressure measurements of the previous 1-year period that were noted regularly at 2-week intervals and studied their mean values. The systolic blood pressure (SBP) and diastolic blood pressure (DBP) thresholds to define low SBP (≤ 110 mm Hg) and DBP (≤ 65 mm Hg) were derived from our previous study. We noted demographics, number of co-morbidities and regular medications, mobility status, and nutritional assessment via the Mini Nutritional Assessment Short Form. RESULTS We included 253 participants (66% male, mean age 75.7 ± 8.7 years). The prevalence of low SBP (≤ 110 mmHg) and low DBP (≤ 65 mmHg) was 34.8% and 15.8%, respectively. Among residents, 4% were bedridden, 15.8% wheelchair bound, 14.5% needing assistance for reduced mobility, and 62.7% were ambulatory. At a median of 15 months of follow-up, hospitalization incidence from any cause was 50.8% (n = 134). Incident hospitalization was more common in the group that had low DBP (odds ratio = 3.06; 95% confidence interval 1.02-9.15; p = 0.04) after adjusting for age, number of comorbidities and medications, mobility status, and nutritional status. Low SBP was not associated with hospitalization. CONCLUSIONS The low DBP (≤ 65 mm Hg) during the previous year was associated with incident hospitalization of nursing home residents after adjustment for several factors. These findings indicate that lower DBP may be a causative factor for incident hospitalization. We need further studies to explore whether a correction of diastolic hypotension may decrease the hospitalization risk in this vulnerable population.
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Affiliation(s)
- Gülistan Bahat
- Department of Internal Medicine, Division of Geriatrics, Istanbul Medical School, Istanbul University, Capa, Istanbul, 34390, Türkiye.
| | - Birkan İlhan
- Department of Internal Medicine, Division of Geriatrics, Sisli Hamidiye Etfal Teaching and Research Hospital, University of Health Sciences Türkiye, Istanbul, Türkiye
| | - Asli Tufan
- Department of Internal Medicine, Division of Geriatrics, Marmara University Medical School, Istanbul, Türkiye
| | - Cihan Kılıç
- Department of Internal Medicine, Division of Geriatrics, Istanbul Medical School, Istanbul University, Capa, Istanbul, 34390, Türkiye
| | - Mehmet Akif Karan
- Department of Internal Medicine, Division of Geriatrics, Istanbul Medical School, Istanbul University, Capa, Istanbul, 34390, Türkiye
| | - Mirko Petrovic
- Section of Geriatrics, Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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14
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van Poelgeest EP, Seppala LJ, Lee JM, Bahat G, Ilhan B, Lavan AH, Mair A, van Marum RJ, Onder G, Ryg J, Fernandes MA, Garfinkel D, Guðmundsson A, Hartikainen S, Kotsani M, Montero-Errasquín B, Neumann-Podczaska A, Pazan F, Petrovic M, Soulis G, Vankova H, Wehling M, Wieczorowska-Tobis K, van der Velde N. Deprescribing practices, habits and attitudes of geriatricians and geriatricians-in-training across Europe: a large web-based survey. Eur Geriatr Med 2022; 13:1455-1466. [PMID: 36319837 PMCID: PMC9722796 DOI: 10.1007/s41999-022-00702-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 09/26/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE To provide an overview of the current deprescribing attitudes, practices, and approaches of geriatricians and geriatricians-in-training across Europe. METHODS An online survey was disseminated among European geriatricians and geriatricians-in-training. The survey comprised Likert scale and multiple-choice questions on deprescribing approaches and practices, deprescribing education and knowledge, and facilitators/barriers of deprescribing. Responses to the survey questions and participant characteristics were quantified and differences evaluated between geriatricians and geriatricians-in-training and between European regions. RESULTS The 964 respondents (median age 42 years old; 64% female; 21% geriatricians-in-training) were generally willing to deprescribe (98%) and felt confident about deprescribing (85%). Despite differences across European regions, the most commonly reported reasons for deprescribing were functional impairment and occurrence of adverse drug reactions. The most important barriers for deprescribing were patients' unwillingness, fear of negative consequences, lack of time, and poor communication between multiple prescribers. Perceived risk of adverse drug reactions was highest for psychotropic drugs, nonsteroidal anti-inflammatory drugs, cardiovascular drugs, and opioid analgesics. Only one in four respondents (23% of geriatricians and 37% of geriatricians-in-training) think education in medical school had sufficiently prepared them for deprescribing in clinical practice. They reported that their future deprescribing activities would probably increase with improved information sharing between various prescribers, deprescribing recommendations in guidelines, and increased education and training. Approximately 90% think that a paradigm shift is required for prescribers and patients, increasing focus on the possible benefits of deprescribing (potentially) inappropriate medications. CONCLUSIONS Based on the outcomes of this survey, we recommend investing in improved inter-professional communication, better education and evidence-based recommendations to improve future patient-centered deprescribing practices.
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Affiliation(s)
- Eveline P van Poelgeest
- Department of Internal Medicine Section of Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands.
| | - Lotta J Seppala
- Department of Internal Medicine Section of Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands
| | - Jihoo M Lee
- Graduate School of Communication Science, University of Amsterdam, Amsterdam, The Netherlands
| | - Gülistan Bahat
- Division of Geriatrics, Department of Internal Medicine, Istanbul Medical School, Istanbul University, Capa, Istanbul, Turkey
| | - Birkan Ilhan
- Division of Geriatrics, Department of Internal Medicine, Sisli Hamidiye Etfal Training and Research Hospital, University of Medical Sciences, Istanbul, Turkey
| | - Amanda H Lavan
- Mercers Institute of Successful Ageing, St James's Hospital, Dublin, Ireland
- Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
| | - Alpana Mair
- Effective Prescribing and Therapeutics, Health and Social Care Directorate, Scottish Government, Edinburgh, Scotland, UK
| | - Rob J van Marum
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands
- Department of Elderly Care Medicine, Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands
| | - Graziano Onder
- Department of Cardiovascular, Endocrine-Metabolic Diseases and Aging, Istituto Superiore di Sanità, Rome, Italy
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Odense Deprescribing Initiative (ODIN), Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Marília Andreia Fernandes
- Department of Internal Medicine, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Doron Garfinkel
- Center for Appropriate Medication Use, Sheba Medical Center and Deputy Head, Homecare Hospice, Israel Cancer Association, 55 Ben Gurion Road, 5932210, Bat, Yam, Israel
| | - Aðalsteinn Guðmundsson
- Landspitali University Hospital, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | | | - Marina Kotsani
- Université de Lorraine, CHRU-Nancy, Pôle (Maladies du Vieillissement, Gérontologie et Soins Palliatifs), Nancy, France
| | | | | | - Farhad Pazan
- Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Mirko Petrovic
- Section of Geriatrics, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
| | - George Soulis
- Outpatient Geriatric Assessment Unit, Henry Dunant Hospital Center, Athens, Greece
- Hellenic Open University, Patras, Greece
| | - Hana Vankova
- Cooperatio 34 - Internal Disciplines, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Martin Wehling
- Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Nathalie van der Velde
- Department of Internal Medicine Section of Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands
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15
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Lun P, Law F, Ho E, Tan KT, Ang W, Munro Y, Ding YY. Optimising prescribing practices in older adults with multimorbidity: a scoping review of guidelines. BMJ Open 2021; 11:e049072. [PMID: 34907045 PMCID: PMC8671917 DOI: 10.1136/bmjopen-2021-049072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Inappropriate polypharmacy occurs when multiple medications are prescribed without clear indications or where harms outweigh their benefits. The aims of this scoping review are to (1) identify prescribing guidelines that are available for older adults with multimorbidity and (2) to identify cross-cutting themes used in these guidelines. DESIGN Scoping review. DATA SOURCES PubMed, Embase, Web of Science, the Cochrane Library databases, Cumulative Index to Nursing and Allied Health Literature, grey literature sources, six key geriatrics journals, and reference lists of identified review papers. The search was conducted in November 2018 and updated in September 2019. STUDY SELECTION General prescribing guidelines tailored to or for adults including older adults with multimorbidity. DATA EXTRACTION Data for publication description, guideline characteristics, information for users and criteria were extracted. The synthesis contains summarised qualitative descriptions of the studies and guideline characteristics as well as identified cross-cutting themes. RESULTS Our search strategy yielded 10 427 unique citations, of which 70 fulfilled the inclusion criteria for synthesis. Among these, there were 61 unique guidelines and tools which used implicit, explicit, mixed or other approaches in the prescriber decision-making process. There are 11 cross-cutting themes identified in the guidelines. Prescriber-related themes are: conduct a comprehensive assessment before prescribing, identify patients' needs, goals and priorities, adopt shared decision-making, consider evidence-based recommendations, use clinical prescribing tools, incorporate multidisciplinary inputs and embrace technology-enabled prescribing. Wider organisation-related and system-related themes related to education, training and the work environment are also identified. CONCLUSIONS From guidelines and tools identified, eleven cross-cutting themes provide a usable knowledge base when seeking to optimise prescribing among older adults with multimorbidity. Incorporating these themes in an approach that uses mixed criteria and implementation information could facilitate greater uptake of published prescribing recommendations.
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Affiliation(s)
- Penny Lun
- Geriatric Education and Research Institute, Singapore
| | - Felicia Law
- Geriatric Medicine, National Healthcare Group Woodlands Health Campus, Singapore
| | - Esther Ho
- Geriatric Medicine, Tan Tock Seng Hospital, Singapore
| | | | - Wendy Ang
- Pharmacy, Changi General Hospital, Singapore
| | - Yasmin Munro
- Medical Library, Lee Kong Chian School of Medicine, Singapore
| | - Yew Yoong Ding
- Geriatric Education and Research Institute, Singapore
- Geriatric Medicine, Tan Tock Seng Hospital, Singapore
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16
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Tian F, Liao S, Chen Z, Xu T. The prevalence and risk factors of potentially inappropriate medication use in older Chinese inpatients with multimorbidity and polypharmacy: a cross-sectional study. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1483. [PMID: 34734035 PMCID: PMC8506761 DOI: 10.21037/atm-21-4238] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/09/2021] [Indexed: 02/05/2023]
Abstract
Background Multimorbidity and polypharmacy are common problems among the older population globally. They not only reduce the quality of life of older adults but also increase the prevalence of potentially inappropriate medication (PIM) use. This study aimed to examine the prevalence and the predictors of PIMs in hospitalized geriatric patients with multimorbidity and polypharmacy in Chengdu based on the 2015 American Geriatric Society Beers Criteria (2015 AGS Beers Criteria) and 2019 American Geriatric Society Beers Criteria (2019 AGS Beers Criteria). Methods From 2016 to 2018, a cross-sectional study was conducted using electronic medical data from nine tertiary hospitals in Chengdu. The 2019 and 2015 AGS Beers Criteria were used to evaluate the PIM status of older inpatients (age ≥65 years), and logistic regression was used to identify the risk factors for PIM use. Results A total of 17,352 inpatients were included in the study between 2016 and 2018. The prevalence of PIM use based on the 2019 AGS Beers Criteria (72.54%) was slightly higher than that based on the 2015 AGS Beers Criteria (70.10%). Further, the prevalence of PIM use based on the 2019 AGS Beers Criteria showed an increasing trend, from 71.17% in 2016 to 73.39% in 2018. Logistic regression demonstrated that female, advanced age, and polypharmacy were positively associated with PIM use in older adults. The most frequently used PIMs in the inpatients were diuretics, benzodiazepines, non-steroidal anti-inflammatory drugs, antipsychotics, and selective serotonin reuptake inhibitors. Conclusions There is a high prevalence of PIM use in older inpatients with multimorbidity and polypharmacy in Chengdu. The 2019 AGS Beers Criteria is more sensitive for evaluating older adults in Chengdu than the 2015 AGS Beers Criteria. Further, based on the 2019 AGS Beers Criteria, the prevalence of PIM use is increasing year by year. Research on interventions rationing PIM use in the geriatric population in Chengdu are necessary in the future.
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Affiliation(s)
- Fangyuan Tian
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
| | - Shili Liao
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
| | - Zhaoyan Chen
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
| | - Ting Xu
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
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17
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Visser AGR, Schols JMGA, Prevoo MALM, Janknegt R, Winkens B. Deprescribing Statins and Proton Pump Inhibitors in Nursing Home Residents; a Pragmatic Exploratory Study. Gerontol Geriatr Med 2021; 7:23337214211050807. [PMID: 35187202 PMCID: PMC8851197 DOI: 10.1177/23337214211050807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/26/2021] [Accepted: 09/16/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Polypharmacy is common in the frail nursing home population and associated with an increased risk of adverse events, unplanned hospitalizations, and increased all-cause mortality. Deprescribing using a deprescribing algorithm might reduce unnecessary polypharmacy. This exploratory study was performed to determine the effect of this implicit deprescribing algorithm in deprescribing statins and proton pump inhibitors (PPIs) in nursing home residents. Method Multicenter, longitudinal, single-arm exploratory study. All participants received the same deprescribing intervention to identify and deprescribe potentially inappropriate statins and/or PPIs. Residents across 10 nursing homes in the Netherlands were included if they used a statin and/or PPI. Residents in hospices or short-stay wards were excluded. The intervention involved a deprescribing algorithm in which nursing home physicians identified and, if possible, deprescribed potentially inappropriate statins and/or PPIs. Results Sixty-seven residents participated in the study. At 3 months, deprescribing was successful in 52% of the residents. Six months after the intervention, all these residents still had their medication sustainably deprescribed. Conclusion Based on this study, deprescribing statins and PPIs using an implicit deprescribing algorithm is possible in a considerable number of nursing home residents.
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Affiliation(s)
| | - Jos M. G. A. Schols
- Department Health Services Research and Family Medicine, Maastricht University, Maastricht, The Netherlands
| | | | - Rob Janknegt
- Zuyderland Elderly Care, Sittard, The Netherlands
| | - Bjorn Winkens
- Department Health Services Research and Family Medicine, Maastricht University, Maastricht, The Netherlands
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Coe A, Kaylor-Hughes C, Fletcher S, Murray E, Gunn J. Deprescribing intervention activities mapped to guiding principles for use in general practice: a scoping review. BMJ Open 2021; 11:e052547. [PMID: 34489296 PMCID: PMC8422486 DOI: 10.1136/bmjopen-2021-052547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To identify and characterise activities for deprescribing used in general practice and to map the identified activities to pioneering principles of deprescribing. SETTING Primary care. DATA SOURCES Medline, EMBASE (Ovid), CINAHL, Australian New Zealand Clinical Trials Registry (ANZCTR), Clinicaltrials.gov, ISRCTN registry, OpenGrey, Annals of Family Medicine, BMC Family Practice, Family Practice and British Journal of General Practice (BJGP) from inception to the end of June 2021. STUDY SELECTION Included studies were original research (randomised controlled trial, quasi-experimental, cohort study, qualitative and case studies), protocol papers and protocol registrations. DATA EXTRACTION Screening and data extraction was completed by one reviewer; 10% of the studies were independently reviewed by a second reviewer. Coding of full-text articles in NVivo was conducted and mapped to five deprescribing principles. RESULTS Fifty studies were included. The most frequently used activities were identification of appropriate patients for deprescribing (76%), patient education (50%), general practitioners (GP) education (48%), and development and use of a tapering schedule (38%). Six activities did not align with the five deprescribing principles. As such, two principles (engage practice staff in education and appropriate identification of patients, and provide feedback to staff about deprescribing occurrences within the practice) were added. CONCLUSION Activities and guiding principles for deprescribing should be paired together to provide an accessible and comprehensive guide to deprescribing by GPs. The addition of two principles suggests that practice staff and practice management teams may play an instrumental role in sustaining deprescribing processes within clinical practice. Future research is required to determine the most of effective activities to use within each principle and by whom.
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Affiliation(s)
- Amy Coe
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Susan Fletcher
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth Murray
- Primary Care and Population Health, University College London, London, UK
| | - Jane Gunn
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
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Low CE, Sanchez Pellecer DE, Santivasi WL, Thompson VH, Elwood T, Davidson AJ, Tlusty JA, Feely MA, Ingram C. Deprescribing in Hospice Patients: Discontinuing Aspirin, Multivitamins, and Statins. Mayo Clin Proc Innov Qual Outcomes 2021; 5:721-726. [PMID: 34355129 PMCID: PMC8325098 DOI: 10.1016/j.mayocpiqo.2021.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Objective To facilitate deprescribing of aspirin, multivitamins, and statins in hospice patients enrolled in Mayo Clinic Hospice, Rochester, Minnesota. Patients and Methods During the fall of 2019, we conducted a quality improvement project to improve care of Mayo Clinic Hospice patients by decreasing the percentage of patients taking aspirin, multivitamins, or statins. Project interventions included the addition of a palliative medicine fellow to the hospice interdisciplinary team, nurse education, and implementation of an evidence-based deprescribing resource tool. The resource tool included a communication framework to guide deprescribing conversations and a literature summary supporting deprescribing. The project team recorded the number of patients taking 1 of these medications by intermittently surveying the hospice census. Process and counterbalance measures were tracked with online surveys of hospice nursing staff. Results At the start of the project, 22 of 69 patients (32%) were taking aspirin, a multivitamin, or a statin. After introduction of the deprescribing resource tool and the addition of a palliative medicine fellow to the interdisciplinary team, this was reduced to 20 of 83 patients (24%), a 24% decrease. Results appeared to be driven primarily by a reduction in multivitamin use (33% decrease). Self-reported comfort and knowledge about deprescribing improved among the hospice nursing staff, as did satisfaction in their workflow from 5.4 to 6.0 (maximum, 7). Conclusion The addition of a dedicated team member to address medication issues and provision of an evidence-based deprescribing resource tool appear to reduce the use of unnecessary and potentially harmful medications in ambulatory hospice patients.
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Affiliation(s)
- Cari E Low
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Daniel E Sanchez Pellecer
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Wil L Santivasi
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, MN
| | | | | | | | | | - Molly A Feely
- Center for Palliative Medicine, Mayo Clinic, Rochester, MN
| | - Cory Ingram
- Center for Palliative Medicine, Mayo Clinic, Rochester, MN
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Okpechi IG, Tinwala MM, Muneer S, Zaidi D, Ye F, Hamonic LN, Khan M, Sultana N, Brimble S, Grill A, Klarenbach S, Lindeman C, Molnar A, Nitsch D, Ronksley P, Shojai S, Soos B, Tangri N, Thompson S, Tuot D, Drummond N, Mangin D, Bello AK. Prevalence of polypharmacy and associated adverse health outcomes in adult patients with chronic kidney disease: protocol for a systematic review and meta-analysis. Syst Rev 2021; 10:198. [PMID: 34218816 PMCID: PMC8256607 DOI: 10.1186/s13643-021-01752-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 06/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Polypharmacy, often defined as the concomitant use of ≥ 5 medications, has been identified as a significant global public health threat. Aging and multimorbidity are key drivers of polypharmacy and have been linked to a broad range of adverse health outcomes and mortality. Patients with chronic kidney disease (CKD) are particularly at high risk of polypharmacy and use of potentially inappropriate medications given the numerous risk factors and complications associated with CKD. The aim of this systematic review will be to assess the prevalence of polypharmacy among adult patients with CKD, and the potential association between polypharmacy and adverse health outcomes within this population. METHODS/DESIGN We will search empirical databases such as MEDLINE, Embase, Cochrane Library, CINAHL, Web of Science, and PsycINFO and grey literature from inception onwards (with no language restrictions) for observational studies (e.g., cross-sectional or cohort studies) reporting the prevalence of polypharmacy in adult patients with CKD (all stages including dialysis). Two reviewers will independently screen all citations, full-text articles, and extract data. Potential conflicts will be resolved through discussion. The study methodological quality will be appraised using an appropriate tool. The primary outcome will be the prevalence of polypharmacy. Secondary outcomes will include any adverse health outcomes (e.g., worsening kidney function) in association with polypharmacy. If appropriate, we will conduct random effects meta-analysis of observational data to summarize the pooled prevalence of polypharmacy and the associations between polypharmacy and adverse outcomes. Statistical heterogeneity will be estimated using Cochran's Q and I2 index. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., sex, kidney replacement therapy, multimorbidity). DISCUSSION Given that polypharmacy is a major and a growing public health issue, our findings will highlight the prevalence of polypharmacy, hazards associated with it, and medication thresholds associated with adverse outcomes in patients with CKD. Our study will also draw attention to the prognostic importance of improving medication practices as a key priority area to help minimize the use of inappropriate medications in patients with CKD. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number: [ CRD42020206514 ].
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Affiliation(s)
- Ikechi G. Okpechi
- Department of Medicine, University of Alberta, Edmonton, AB Canada
- Division of Nephrology, University of Cape Town, Cape Town, South Africa
| | | | - Shezel Muneer
- Department of Medicine, University of Alberta, Edmonton, AB Canada
| | - Deenaz Zaidi
- Department of Medicine, University of Alberta, Edmonton, AB Canada
| | - Feng Ye
- Department of Medicine, University of Alberta, Edmonton, AB Canada
| | - Laura N. Hamonic
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, Alberta Canada
| | - Maryam Khan
- Faculty of Science, University of Alberta, Edmonton, Alberta Canada
| | - Naima Sultana
- Faculty of Science, University of Alberta, Edmonton, Alberta Canada
| | - Scott Brimble
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON Canada
| | - Allan Grill
- Department of Family and Community Medicine, University of Toronto, Toronto, ON Canada
| | - Scott Klarenbach
- Department of Medicine, University of Alberta, Edmonton, AB Canada
| | - Cliff Lindeman
- Department of Family Medicine, University of Alberta, Edmonton, AB Canada
| | - Amber Molnar
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario Canada
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Paul Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, AB Canada
| | - Soroush Shojai
- Department of Medicine, University of Alberta, Edmonton, AB Canada
| | - Boglarka Soos
- Department of Community Health Sciences, University of Calgary, Calgary, AB Canada
- Department of Family Medicine, University of Calgary, Calgary, AB Canada
| | - Navdeep Tangri
- Department of Medicine, Max Rady College of Medicine, Winnipeg, MB Canada
| | | | - Delphine Tuot
- Division of Nephrology, University of California, San Francisco, CA USA
- Kidney Health Research Institute, University of California, San Francisco, CA USA
| | - Neil Drummond
- Department of Family Medicine, University of Alberta, Edmonton, AB Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB Canada
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, ON Canada
| | - Aminu K. Bello
- Department of Medicine, University of Alberta, Edmonton, AB Canada
- Division of Nephrology and Immunology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta Canada
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Polypharmacy, inappropriate prescribing, and deprescribing in older people: through a sex and gender lens. LANCET HEALTHY LONGEVITY 2021; 2:e290-e300. [DOI: 10.1016/s2666-7568(21)00054-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/01/2021] [Accepted: 02/24/2021] [Indexed: 01/27/2023]
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Whitman A, Erdeljac P, Jones C, Pillarella N, Nightingale G. Managing Polypharmacy in Older Adults with Cancer Across Different Healthcare Settings. DRUG HEALTHCARE AND PATIENT SAFETY 2021; 13:101-116. [PMID: 33953612 PMCID: PMC8092848 DOI: 10.2147/dhps.s255893] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 03/25/2021] [Indexed: 11/23/2022]
Abstract
The care of older patients with cancer is becoming increasingly complex. Common challenges for this population include management of comorbidities, safe transitions of care, and appropriate medication use. In particular, polypharmacy-generally defined as the regular use of five or more medications-and inappropriate medication use can lead to adverse effects and poor outcomes in older adults with cancer, including falls, hospital readmissions, cognitive impairment, poor adherence to essential medications, chemotherapy toxicity, and increased mortality. Managing polypharmacy across different cancer care settings is often challenging. Providers face barriers to safe and successful medication management that may include lack of time, absence of reimbursement, underappreciation of the scale of polypharmacy-related harm, lack of ownership of deprescribing efforts, and poor communication across care settings. Existing literature on managing inappropriate medication use and polypharmacy in older adults with cancer has often focused on ideal state settings in which resources are plentiful and time is purposefully allocated for medication interventions. This paper presents a narrative, rather than a systematic review, of studies published in the past decade that provided detailed information on medication management and polypharmacy across cancer care settings. This review aims to also summarize different healthcare provider roles in taking action against inappropriate medication use and polypharmacy in older adults with cancer.
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Affiliation(s)
- Andrew Whitman
- Department of Pharmacy, University of Virginia Health, Charlottesville, VA, USA
| | - Paige Erdeljac
- Department of Pharmacy, James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Caroline Jones
- Department of Pharmacy, University of Virginia Health, Charlottesville, VA, USA
| | - Nicole Pillarella
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ginah Nightingale
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA
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International Validation of the Turkish Inappropriate Medication Use in the Elderly (TIME) Criteria Set: A Delphi Panel Study. Drugs Aging 2021; 38:513-521. [PMID: 33847948 PMCID: PMC8041618 DOI: 10.1007/s40266-021-00855-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2021] [Indexed: 01/14/2023]
Abstract
Objective Explicit screening tools and implicit evaluation methods have been developed to assist healthcare professionals in the management of pharmacotherapy in older adults. As prescribing habits and locally available medications vary considerably between countries, guides tailored to the needs of specific regions may be required. We aimed to report the results of the international Delphi validation study for the Turkish Inappropriate Medication use in the Elderly (TIME) criteria set, which aims to detect inappropriate prescribing in older adults in Eastern Europe. Methods The study was conducted between June 2019 and March 2020. Delphi rounds were conducted by the TIME international working group, which included 11 internationally recognized experts in geriatric pharmacotherapy as Delphi panelists. They were asked to indicate to what extent they agreed or disagreed with each TIME criterion, taking into account both the available evidence and their own experience. We used a five-point Likert scale from 1 (strongly agree) to 5 (strongly disagree) and an online software program (SurveyMonkey®) to grade the level of agreement. Criteria with a median value of 1 or 2 and a 75th centile value of 1 or 2 were accepted, and criteria with a median value > 2 were rejected. Those with a median value of 1 or 2 but a 75th centile value > 2 were retained, to be assessed in the following round. The initial list of Delphi criteria comprised 153 TIME items. Results After three Delphi rounds, 134 criteria were accepted and seven criteria were rejected, while 12 criteria did not achieve consensus, and so were not included in the final validated set of TIME criteria. Conclusion We developed the internationally validated TIME criteria set based on a Delphi process involving international experts. The validation study suggests that the TIME criteria set can be applied in both central and Eastern European settings. Further studies are needed to assess the utility and benefit of the TIME criteria in reducing inappropriate drug use and improving clinical outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s40266-021-00855-5.
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Plácido AI, Herdeiro MT, Simões JL, Amaral O, Figueiras A, Roque F. Health professionals perception and beliefs about drug- related problems on polymedicated older adults- a focus group study. BMC Geriatr 2021; 21:27. [PMID: 33413137 PMCID: PMC7792196 DOI: 10.1186/s12877-020-01972-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 12/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Polymedicated older patients are at greater risk of suffering from adverse events. For this reason, the detection of both inappropriate polypharmacy and polypharmacy-associated Drug-Related Problems (DRPs) are essential to improve the health and wellbeing of older adults and to reduce healthcare costs. This work aims to explore health professionals' perceptions and opinions about polypharmacy and the handling of medicines by polymedicated older adults. METHODS Thirteen focus groups with 94 health professionals (20 community pharmacists, 40 general practitioners and, 34 nurses) were conducted in primary healthcare centers of the center region of Portugal. Participants were asked to discuss their perceptions and beliefs concerning DRPs in polymedicated older adults. The sessions were audiotaped. After the transcription and coding of focus group sessions, a thematic analysis was done. RESULTS The following four main themes emerged from the 13 focus group sessions: poor compliance and polypharmacy- A perpetuated vicious cycle, organization of the healthcare system, interaction and communication between the health professionals, and strategies to prevent inappropriate polypharmacy. CONCLUSIONS The lack of both an efficient network of information and Interaction and communication between Health professionals makes the detection and/ or prevention of polypharmacy in older adults difficult. The implementation of new models to manage and/or prevent polypharmacy based on health professional perception and beliefs is essential to prevent DRPs and improve compliance among older adults.
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Affiliation(s)
- Ana Isabel Plácido
- Research Unit for Inland Development, Polytechnic of Guarda (UDI-IPG), Avenida Dr. Francisco Sá Carneiro, n. ° 50, 6300-559, Guarda, Portugal
| | - Maria Teresa Herdeiro
- Institute of Biomedicine (iBiMED) and Department of Medical Sciences, University of Aveiro, Campus Universitário de Santiago, 3810-193, Aveiro, Portugal
| | - João Lindo Simões
- Institute of Biomedicine (iBiMED) and School of Health Sciences, University of Aveiro, Campus Universitário de Santiago, 3810-193, Aveiro, Portugal
| | - Odete Amaral
- Health Sciences School, Polytechnic of Viseu, R. D. João Crisostomo Gomes de Almeida, n.° 102, 3500-843, Viseu, Portugal
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain.,Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Santiago de Compostela, Spain.,Institute of Health Research of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Fátima Roque
- Research Unit for Inland Development, Polytechnic of Guarda (UDI-IPG), Avenida Dr. Francisco Sá Carneiro, n. ° 50, 6300-559, Guarda, Portugal. .,Health Sciences Research Centre, University of Beira Interior (CICS-UBI), Av. Infante D. Henrique, 6200-506, Covilhã, Portugal. .,Escola Superior de Saúde, Instituto Politécnico da Guarda Rua da Cadeia, 6300-035, Guarda, Portugal.
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Korenvain C, MacKeigan LD, Dainty KN, Guilcher SJ, McCarthy LM. Exploring deprescribing opportunities for community pharmacists using the Behaviour Change Wheel. Res Social Adm Pharm 2020; 16:1746-1753. [DOI: 10.1016/j.sapharm.2020.01.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 01/30/2020] [Accepted: 01/30/2020] [Indexed: 01/05/2023]
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de Araújo NC, Silveira EA, Mota BG, Neves Mota JP, de Camargo Silva AEB, Alves Guimarães R, Pagotto V. Potentially inappropriate medications for the elderly: Incidence and impact on mortality in a cohort ten-year follow-up. PLoS One 2020; 15:e0240104. [PMID: 33112864 PMCID: PMC7592782 DOI: 10.1371/journal.pone.0240104] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 09/19/2020] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Pharmacological therapy plays an important role in disease control in the elderly; unfortunately, this comes with a high prevalence in the use of medications classified as potentially inappropriate. OBJECTIVE To analyze the incidence, risk factors, and survival of elderly people using potentially inappropriate medications (PIM). METHOD A ten-year follow-up assessment of elderly participants residing in a capital of Central Brazil was conducted. The initial assessment (baseline) included 418 elderly people. Data were collected through home interviews guided by a questionnaire covering socioeconomic, demographic, living conditions, and health variables. The medication information obtained comprised active ingredient, dosage, route, and regimen for the medications. The PIMs were classified according to 2019 Beers Criteria. The analyses were performed using STATA 15.0. For survival analysis, a Cox Regression was performed with the respective Kaplan Meier curve. RESULTS The incidence of PIM was 44.1 cases (95% CI: 35.2-54.7) per 1,000 people a year. The most used PIMs were nifedipine, glibenclamide, and sodium diclofenac. The risk factors were polypharmacy (aRR: 3.00; 95% CI: 1.31-6.88) and diabetes mellitus (aRR: 1.57; 95% CI: 1.03-2.39). We identified no statistically significant association between survival and the use of PIM. CONCLUSION The study highlights the high consumption of PIM among the elderly causing polypharmacy risks. Health professionals working in drug treatment need to be alert to polypharmacy risks to ensure the rational use of medications to prevent adverse reactions and other health problems.
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Affiliation(s)
| | - Erika Aparecida Silveira
- Faculty of Medicine, Postgraduate Program in Health Sciences, Federal University of Goiás, Goiânia, Goiás, Brazil
| | - Brenda Godoi Mota
- Faculty of Nursing, Federal University of Goiás, Goiânia, Goiás, Brazil
| | | | | | - Rafael Alves Guimarães
- Faculty of Nursing, Postgraduate Program in Nursing, Federal University of Goiás, Goiânia, Goiás, Brazil
| | - Valéria Pagotto
- Faculty of Nursing, Postgraduate Program in Nursing, Federal University of Goiás, Goiânia, Goiás, Brazil
- * E-mail:
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Farrell B, Grad R, Howell P, Quast T, Reeve E. Deprescribing Guidelines: Value of an Interactive Mobile Application. PRIMER : PEER-REVIEW REPORTS IN MEDICAL EDUCATION RESEARCH 2020; 4:26. [PMID: 33111053 DOI: 10.22454/primer.2020.349237] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Introduction We developed a new channel on a mobile app as a continuing education tool to augment the use of deprescribing guideline content in clinical practice. In this research brief, we describe the reach and adoption of channel content, as well as user feedback. Methods Using Google Analytics, we counted page views of the website (deprescribing.org) where the app was promoted. We calculated total app downloads, monthly active users, and guideline-specific page views. Users were invited to complete the embedded Information Assessment Method (IAM) Questionnaire to obtain feedback on the value of information presented on the Deprescribing Channel. Results Between March 2, 2019 and November 30, 2019, we documented 9,454 page views of the promotional web page across 40 countries. The Deprescribing Channel was downloaded 3,256 times with an average of 464 monthly users. In total, the guidelines on this channel were accessed 14,377 times with 49,721 views across all guideline pages. Thirty-seven IAM questionnaires were completed. Thirty-two responses indicated this deprescribing information was relevant for at least one of their patients. Regarding educational outcomes, 22 responses were of learning something new and/or being motivated to learn more. Conclusion We documented international interest in a mobile app providing continuing education on deprescribing. App users generated sustained page views over the study period. Feedback from a small number of users was positive with the majority finding the content relevant, educational, and applicable to patient care. Further work is needed to improve the usability of the embedded feedback questionnaire and to evaluate its value in supporting learning.
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Affiliation(s)
- Barbara Farrell
- Bruyère Research Institute and Department of Family Medicine, University of Ottawa, Ottawa, Canada
- and School of Pharmacy, University of Waterloo, Waterloo, Canada
| | - Roland Grad
- McGill University Department of Family Medicine, Montreal, Quebec, Canada
| | - Pam Howell
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Tammie Quast
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
- Geriatric Medicine Research, Faculty of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
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DeAngelis J, Lowry MF. Hospital Readmissions in Hospice Patients: Evaluation of Medication-Related Causes for Readmission. Am J Hosp Palliat Care 2020; 38:745-749. [PMID: 32935551 DOI: 10.1177/1049909120959641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
CONTEXT Hospital readmissions, frequent medication changes, and polypharmacy are common issues for hospice patients. It is important to consider if close monitoring of medications by pharmacists could help these patients avoid hospital readmissions. OBJECTIVE The objectives of this study were to determine the incidence and types of medication-related problems that contributed to hospital readmissions from hospice settings. METHODS A retrospective chart review was conducted from October 1, 2018 to January 31, 2020. Patients admitted from hospice settings (i.e. Home, ALF, LTCF) and who were seen by the palliative care teams at 9 Maryland and Washington DC MedStar hospitals were included. Demographic information was collected: age, gender, race, primary hospice diagnosis, prognosis determined by provider prior to hospice disposition, reason for readmission, and medication list at readmission. The primary outcomes were the incidence and types of medication-related problems. Secondary outcomes included patient characteristics associated with readmission, and classes/number of medications changed before readmission. Descriptive statistics were used to analyze data. RESULTS Seventy-five hospice patients were readmitted and seen by palliative care during the study period. Forty-three patients (57%) were found to have medication-related problems at readmission. The most common problem identified was needing additional drug therapy. Dose too low, dose too high, incorrect drugs, adverse drug reactions, and non-adherence were also identified. Additional reasons for readmission were: unanticipated new medical issue (n = 46, 61%) and uncontrolled symptoms (n = 34, 34%). CONCLUSIONS These findings suggest that deprescribing practices possibly contributeto readmissions from hospice settings.
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Rashid R, Chang C, Niu F, Deguzman L, Draves M, Awsare S, Hui R. Evaluation of a Pharmacist-Managed Nonsteroidal Anti-Inflammatory Drugs Deprescribing Program in an Integrated Health Care System. J Manag Care Spec Pharm 2020; 26:918-924. [PMID: 32584681 PMCID: PMC10391032 DOI: 10.18553/jmcp.2020.26.7.918] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat symptoms of chronic inflammatory diseases such as osteoarthritis and rheumatoid arthritis; however, they are also associated with various adverse effects, including gastrointestinal (GI) bleeding and renal harm. As patients get older, some medications may no longer be beneficial or may even cause harm. Deprescribing is defined as the planned and supervised process of dose reduction or discontinuation of medications. While there are studies showing that deprescribing strategies with several classes of medications positively affects outcomes in elderly patients, there is a lack of strong evidence and guidance to deprescribe NSAIDs. OBJECTIVE To evaluate the effectiveness, safety, and economic impact of pharmacists deprescribing NSAIDs under the guidance of a standardized deprescribing program compared with usual care within an integrated health care system. METHODS This retrospective, propensity score-matched cohort study included patients aged ≥ 65 years who were eligible for the NSAID deprescribing program from July 2016 to June 2018. Those patients in the deprescribing group were assessed by pharmacists and had their medications deprescribed. Patients who were eligible for the deprescribing program but did not receive any interventions were matched to the deprescribed group using propensity score matching at a 4:1 ratio and became the usual care group. Patients were followed for 6 months, until end of membership, or until death, whichever occurred first. The effectiveness and safety outcomes included rates of 3 adverse events: GI bleeds, acute kidney injuries (AKI), and exacerbation of pain triggering a hospitalization or emergency room visit. The economic outcome was the change in monthly NSAID cost. Descriptive statistics, t-tests, chi-square tests, and conditional logistic regression models were used for analysis. RESULTS There were 431 patients in the deprescribed group and 1,724 patients in the usual care group, with similar baseline characteristics after propensity score matching. The adjusted results showed no significant difference between the deprescribed and usual care groups for GI bleed events (OR = 0.65, 95% CI = 0.36-1.16, P = 0.15) and AKI (OR = 0.53, 95% CI = 0.24-1.16, P = 0.11). The deprescribed group experienced a significant 2-fold decrease in the odds of exacerbation of pain versus the deprescribed group (OR = 0.50, 95% CI = 0.33-0.77, P < 0.01). Finally, there was no significant difference in the change in monthly NSAIDs costs between the 2 groups (median change, IQR: -$0.29, -$2.37 to -$0.11 for deprescribed group; -$0.23, -2.59 to 0.00 for usual care group, P = 0.054). CONCLUSIONS Although this study did not find any difference in the rate of GI bleed or AKI, we found a significant decrease in the rate of exacerbation of pain in the deprescribed group versus the usual care group. This result suggests that deprescribing NSAIDs did not cause harm during the 6-month follow-up. Further long-term studies are necessary to validate these outcomes. DISCLOSURES No funding was provided to support this research study. The authors of this study have no actual or potential conflicts of interest to report. Parts of this study were presented in a nonreviewed resident poster at the AMCP Managed Care and Specialty Pharmacy Annual Meeting; March 25-28, 2019; San Diego, CA.
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Affiliation(s)
- Rezoana Rashid
- Ambulatory Care Pharmacy, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Christopher Chang
- Clinical Pharmacy Services, Kaiser Permanente Northern California Region, Oakland
| | - Fang Niu
- Pharmacy Outcomes Research Group, Kaiser Permanente California Regions, Downey
| | - Lynn Deguzman
- Clinical Pharmacy Services, Kaiser Permanente Northern California Region, Oakland
| | - Maisha Draves
- The Permanente Medical Group, Kaiser Permanente Northern California Region, Oakland
| | - Sameer Awsare
- The Permanente Medical Group, Kaiser Permanente Northern California Region, Oakland
| | - Rita Hui
- Pharmacy Outcomes Research Group, Kaiser Permanente California Regions, Oakland
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Affiliation(s)
- Doron Garfinkel
- Center for Appropriate Medication Use, Sheba Medical Center, Tel Hashomer, Israel
| | - Aaron Bilek
- Geriatric division, Tel Aviv Sourasky Medical Center, Israel
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Burghle A, Lundby C, Ryg J, Søndergaard J, Pottegård A, Nielsen D, Graabæk T. Attitudes Towards Deprescribing Among Older Adults with Limited Life Expectancy and Their Relatives: A Systematic Review. Drugs Aging 2020; 37:503-520. [DOI: 10.1007/s40266-020-00774-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Olry de Labry Lima A, Marcos Marcos J, Marquina Marquez A, González Vera MDLÁ, Matas Hoces A, Bermúdez Tamayo C. Evidence for deprescription in primary care through an umbrella review. BMC FAMILY PRACTICE 2020; 21:100. [PMID: 32513110 PMCID: PMC7278115 DOI: 10.1186/s12875-020-01166-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 05/14/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is a high prevalence of potentially inappropriate prescriptions in primary care. This is associated with more frequent adverse events, lower quality of life and more frequent visits to hospital accident & emergency departments. The aim of the present study is to summarise available evidence on the effectiveness of deprescription interventions in primary care, and to describe the barriers and enablers of the process from the point of view of patients and healthcare professionals. METHODS We designed an umbrella review which includes nine systematic reviews. More than 50% of included studies were performed with adults in primary care. Two reviewers independently performed data extraction and analysis. RESULTS In considering studies of the effectiveness of interventions, it can be observed that the educational component of deprescription procedures is a key factor, whilst procedures tailored towards the patient's situation offer better results. With regards to studies involving healthcare professionals, the main explored areas were the balance between risks and benefits, and the need to improve communication with patients as well as other colleagues involved in patient care. Amongst the identified barriers we found lack of time, inability to access all information, being stuck in a routine, resistance to change and a lack of willingness to question the prescription decisions made by healthcare colleagues. With regards to patients, it is clear that they have worries and doubts. In order to overcome these issues, a good relationship with healthcare professionals and receipt of their support is required during the process. CONCLUSIONS Optimizing medication through targeted deprescribing is an important part of managing chronic conditions, avoiding adverse effects and improving outcomes. The majority of deprescription interventions in primary care are effective. Good communication between healthcare professionals is a key element for success in the deprescription process.
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Affiliation(s)
- Antonio Olry de Labry Lima
- Andalusian School of Public Health (Spanish acronym EASP), Granada, Spain. .,Instituto de Investigación Biosanitaria ibs, GRANADA, Granada, Spain. .,CIBER en Epidemiología and Salud Pública (CIBERESP), Madrid, Spain.
| | - Jorge Marcos Marcos
- Andalusian School of Public Health (Spanish acronym EASP), Granada, Spain.,Public Health Research Group, University of Alicante, Alicante, Spain
| | - Alfonso Marquina Marquez
- Faculty of Education and Social Work, University of Valladolid, Valladolid, Spain.,GIESA, Applied Sociocultural Studies (SEJ208), University of Granada, Granada, Spain
| | | | - Antonio Matas Hoces
- Andalusian School of Public Health (Spanish acronym EASP), Granada, Spain.,Centro Andaluz de Información del Medicamento (CADIME), Campus Universitario de Cartuja, Granada, Spain
| | - Clara Bermúdez Tamayo
- Andalusian School of Public Health (Spanish acronym EASP), Granada, Spain.,Instituto de Investigación Biosanitaria ibs, GRANADA, Granada, Spain.,CIBER en Epidemiología and Salud Pública (CIBERESP), Madrid, Spain
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Alemtuzumab and prescription medication use in the MS population. Mult Scler Relat Disord 2020; 42:102086. [PMID: 32403069 DOI: 10.1016/j.msard.2020.102086] [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: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 11/23/2022]
Abstract
Medications are indicated to minimize adverse reactions with alemtuzumab treatment for multiple sclerosis, but polypharmacy can be problematic. We characterized prescriptions filled by 160 individuals before, during and after first infusion of alemtuzumab (Dec/2013-Jun/2017). Ninety-five percent of individuals filled ≥1 prescription(s) before alemtuzumab across 87 unique drug classes, averaging 5.3 prescriptions/person over 47 weeks. During the infusion period, 90% filled ≥1 prescription(s) for 40 new drug classes, averaging 2.2 prescriptions/person over 5 weeks. Twenty-four percent refilled ≥1 of these prescription(s) after alemtuzumab across 17 drug classes, averaging 0.3 refills/person over 24 weeks. There was substantial medication burden throughout the study.
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Mortsiefer A, Wilm S, Santos S, Löscher S, Wollny A, Drewelow E, Ritzke M, Thürmann P, Mann NK, Meyer G, Abraham J, Icks A, Montalbo J, Wiese B, Altiner A. Family conferences and shared prioritisation to improve patient safety in the frail elderly (COFRAIL): study protocol of a cluster randomised intervention trial in primary care. Trials 2020; 21:285. [PMID: 32197631 PMCID: PMC7082941 DOI: 10.1186/s13063-020-4182-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 02/18/2020] [Indexed: 01/19/2023] Open
Abstract
Background Frailty in elderly patients is associated with an increased risk of poor health outcomes, including falls, delirium, malnutrition, hospitalisation, and mortality. Because polypharmacy is recognised as a possible major contributor to the pathogenesis of geriatric frailty, reducing inappropriate medication exposure is supposed to be a promising approach to improve health-related quality of life and prevent adverse outcomes. A major challenge for the process of deprescribing of inappropriate polypharmacy is to improve the communication between general practitioner (GPs), patient and family carer. This study investigates the effects of a complex intervention in frail elderly patients with polypharmacy living at home. Methods This is a cluster randomised controlled trial including 136 GPs and 676 patients. Patients with a positive clinical screening for frailty are eligible if they are aged 70 years or older, receiving family or professional nursing care at home, and taking in five or more drugs per day. Exclusion criteria are higher grade of dementia and life expectancy of 6 months or less. The GPs of the intervention group receive an educational training promoting a deprescribing guideline and providing information on how to conduct a family conference focussing on prioritisation of treatment goals concerning drug therapy. During the 1-year intervention, GPs are expected to perform a total of three family conferences, each including a structured medication review with patients and their family carers. GPs of the control group will receive no training and will deliver care as usual. Geriatric assessment of all patients will be performed by study nurses during home visits at baseline and after 6 and 12 months. The primary outcome is the hospitalisation rate during the observation period of 12 months. Secondary outcomes are number and appropriateness of medications, mobility, weakness, cognition, depressive disorder, health-related quality of life, activities of daily living, weight, and costs of health care use. Discussion This study will provide evidence for a pragmatic co-operative and patient-centred educational intervention using family conferences to improve patient safety in frail elderly patients with polypharmacy. Trial registration German Clinical Trials Register, DRKS00015055 (WHO International Clinical Trials Registry Platform [ICTRP]). Registered on 6 February 2019.
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Affiliation(s)
- Achim Mortsiefer
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Stefan Wilm
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Sara Santos
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Susanne Löscher
- Institute of General Practice, Medical Faculty, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Anja Wollny
- Institute of General Practice, University Medical Center Rostock, Doberaner Str. 142, 18057, Rostock, Germany
| | - Eva Drewelow
- Institute of General Practice, University Medical Center Rostock, Doberaner Str. 142, 18057, Rostock, Germany
| | - Manuela Ritzke
- Institute of General Practice, University Medical Center Rostock, Doberaner Str. 142, 18057, Rostock, Germany
| | - Petra Thürmann
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Heusnerstr. 40, 42283, Wuppertal, Germany
| | - Nina-Kristin Mann
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Heusnerstr. 40, 42283, Wuppertal, Germany
| | - Gabriele Meyer
- Institute for Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany
| | - Jens Abraham
- Institute for Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany
| | - Andrea Icks
- Institute for Health Services and Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Joseph Montalbo
- Institute for Health Services and Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Birgitt Wiese
- WG Medical Statistics and IT-Infrastructure, Institute of General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Attila Altiner
- Institute of General Practice, University Medical Center Rostock, Doberaner Str. 142, 18057, Rostock, Germany
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Ross A, Gillett J. Confronting Medicine's Dichotomies: Older Adults' Use of Interpretative Repertoires in Negotiating the Paradoxes of Polypharmacy and Deprescribing. QUALITATIVE HEALTH RESEARCH 2020; 30:448-457. [PMID: 31451052 DOI: 10.1177/1049732319868981] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
To address the risks associated with polypharmacy, health care providers are investigating the feasibility of deprescribing programs as part of routine medical care to reduce medication burden to older adults. As older adults are enrolled in these programs, they are confronted with two dominant and legitimate accounts of medications, labeled the medication paradox: medications keep you healthy but they might be making you sick. We investigated how the medication paradox operates in the lives of older adults. In-depth qualitative interviews were conducted and analyzed with older adults aged 70+ to identify the various paradoxes that seniors live through regarding their medications and the narratives that they engage to negotiate these contradictions. Older adults were found to have established interpretative repertoires to make sense of the incongruent narratives of the medication paradox. In this article, we demonstrate older adults' efforts to carve out their unique place in the dichotomized institution of medicine.
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Affiliation(s)
- Alison Ross
- McMaster University, Hamilton, Ontario, Canada
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Ross A, Gillett J. "At 80 I Know Myself": Embodied Learning and Older Adults' Experiences of Polypharmacy and Perceptions of Deprescribing. Gerontol Geriatr Med 2020; 5:2333721419895617. [PMID: 31903412 PMCID: PMC6926975 DOI: 10.1177/2333721419895617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 11/25/2019] [Accepted: 11/26/2019] [Indexed: 11/17/2022] Open
Abstract
In response to the risks of polypharmacy for older adults, there are increasing calls for the development and implementation of deprescribing programs. This article examines the forms of expertise that inform older adults' decisions about how to use medications given concerns over polypharmacy and a clinical focus on deprescribing. In-depth interviews with older adults found that diverse knowledge sources underpin decisions regarding polypharmacy and deprescribing. Findings indicate that this knowledge is formed through a lifetime of embodied learning-the production of relevant knowledge through lived experiences of the body. By way of this embodied learning, older adults possess individualized knowledge bases that inform health and health care decisions, especially regarding the use of medications. If deprescribing programs are to be embedded into standard preventive medical care of older adults, then it is valuable for health care providers to be aware of and take seriously the contribution of embodied knowledge.
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Affiliation(s)
- Alison Ross
- McMaster University, Hamilton, Ontario, Canada
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Bilek AJ, Levy Y, Kab H, Andreev P, Garfinkel D. Teaching physicians the GPGP method promotes deprescribing in both inpatient and outpatient settings. Ther Adv Drug Saf 2019; 10:2042098619895914. [PMID: 31908757 PMCID: PMC6935879 DOI: 10.1177/2042098619895914] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/27/2019] [Indexed: 01/22/2023] Open
Abstract
Background In complex older patients, inappropriate medication use and polypharmacy (IMUP) are commonplace and increasing exponentially. Reducing IMUP is a challenge in multiple clinical contexts, including acute admission and family practice, due to several key barriers. In the global effort against this epidemic, educational programs geared toward changing physicians’ prescribing patterns represent an important means of promoting deprescribing. Methods This is a nonrandomized, controlled interventional study investigating polypharmacy outcomes and prescribing patterns in patients whose physicians were trained in the Good Palliative-Geriatric Practice (GPGP) method, an algorithm for the reduction of polypharmacy, with patients whose physicians were not. Training involved a one-time, full-day workshop led by a senior geriatrician. Two separate settings were examined. In the inpatient setting, one internal medicine ward was trained and compared with another ward which was not trained. In the family practice setting, 28 physicians were trained and compared with practices of 15 physicians not trained. Patients were above the age of 70, representative of the general geriatric population, and not terminally ill. Results In the inpatient arm, the intervention group (n = 100) experienced a decrease in medications prescribed from admission to discharge of 18.5%, compared with a decrease of 1.9% in the control group (n = 100, difference between groups p < 0.0001). In the outpatient arm, the intervention group (n = 100) experienced a decrease in medication number of 6.1% compared with 0.07% in the control group (n = 100, difference between groups p = 0.001) over a 6-month period. Preferential decreases in specific drug classes were observed in both groups, including benzodiazepines, psychotropics, and antihypertensives. Conclusions A one-time educational intervention based on GPGP can change prescribing patterns in both outpatient and inpatient settings leading to a moderate reduction in polypharmacy. Future work should focus on longitudinal interventions, and longer-term clinical outcomes such as morbidity, mortality, and quality of life.
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Affiliation(s)
- Aaron Jason Bilek
- Geriatrics Department, Tel Aviv Sourasky Medical Center, Weizmann Street 6, Tel Aviv 64239, Israel
| | - Yuval Levy
- Deputy Director General Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Haneen Kab
- Pharmacy Department at Hebrew University, Jerusalem, Israel
| | - Pavel Andreev
- Department of Medicine C, Wolfson Medical Center, Holon, Israel
| | - Doron Garfinkel
- Medical Center, Ramat Gan, Israel Homecare Hospice, Israel Cancer Association, Givatayim, Israel IGRIMUP (International Group for Reducing Inappropriate Medication Use and Polypharmacy), Bat Yam, Israel
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Kleipool EE, Dorresteijn JA, Smulders YM, Visseren FL, Peters MJ, Muller M. Treatment of hypercholesterolaemia in older adults calls for a patient-centred approach. Heart 2019; 106:261-266. [PMID: 31780523 PMCID: PMC7027025 DOI: 10.1136/heartjnl-2019-315600] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 10/01/2019] [Accepted: 10/16/2019] [Indexed: 12/21/2022] Open
Abstract
Due to an increasing number of older adults with (risk factors for) cardiovascular disease (CVD), the sum of older adults eligible for lipid-lowering drugs will increase. This has risen questions about benefits and harms of lipid-lowering therapy in older adults with a varying number of (cardiovascular) comorbidities and functional status. The heterogeneity in physical and functional health increases with age, leading to a much wider variety in cardiovascular risk and life expectancy than in younger adults. We suggest treatment decisions on hypercholesterolaemia in adults aged ≥75 years should shift from a strictly 10-year cardiovascular risk-driven approach to a patient-centred and lifetime benefit-based approach. With this, estimated 10-year risk of CVD should be placed into the perspective of life expectancy. Moreover, frailty and safety concerns must be taken into account for a risk–benefit discussion between clinician and patient. Based on the Dutch addendum ‘Cardiovascular Risk Management in (frail) older adults’, our approach offers more detailed information on when not to initiate or deprescribe therapy than standard guidelines. Instead of using traditional risk estimating tools which tend to overestimate risk of CVD in older adults, use a competing risk adjusted, older adults-specific risk score (available at https://u-prevent.com). By filling in a patient’s (cardiovascular) health profile (eg, cholesterol, renal function), the tool estimates risk of CVD and models the effect of medication in terms of absolute risk reduction for an individual patient. Using this tool can guide doctors and patients in making shared decisions on initiating, continuing or deprescribing lipid-lowering therapy.
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Affiliation(s)
- Emma Ef Kleipool
- Internal medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Yvo M Smulders
- Internal medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Frank Lj Visseren
- Vascular medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Mike Jl Peters
- Internal medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Majon Muller
- Internal medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Hawley CE, Roefaro J, Forman DE, Orkaby AR. Statins for Primary Prevention in Those Aged 70 Years and Older: A Critical Review of Recent Cholesterol Guidelines. Drugs Aging 2019; 36:687-699. [PMID: 31049807 DOI: 10.1007/s40266-019-00673-w] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The risk of atherosclerotic cardiovascular disease rises with age and remains the leading cause of death in older adults. Evidence for the use of statins for primary prevention in older adults is limited, despite the possibility that this population may derive significant clinical benefit given its increased cardiovascular risk. Until publication of the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the Management of Blood Cholesterol, and the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease, guidelines for statin prescription in older adults remained unchanged despite new evidence of possible benefit in older adults. In this review, we present key updates in the 2018 and 2019 guidelines and the evidence informing these updates. We compare the discordant recommendations of the seven major North American and European guidelines on cholesterol management released in the past 5 years and highlight gaps in the literature regarding primary prevention of cardiovascular disease in older adults. As most cardiovascular events in older adults are nonfatal, we ask how clinicians should weigh the risks and benefits of continuing a statin for primary prevention in older adults. We also reframe the concept of deprescribing of statins in the older population, using the Geriatrics 5Ms framework: Mind, Mobility, Medications, Multi-complexity, and what Matters Most to older adults. A recent call from the National Institute on Aging for a statin trial focusing on older adults extends from similar concerns.
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Affiliation(s)
- Chelsea E Hawley
- New England Geriatric Research, Education, and Clinical Center (GRECC), VA Boston Healthcare System, Boston, MA, USA. .,Pharmacy Department, VA Boston Healthcare System, Boston, MA, USA.
| | - John Roefaro
- Pharmacy Department, VA Boston Healthcare System, Boston, MA, USA
| | - Daniel E Forman
- Section of Geriatric Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Geriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Ariela R Orkaby
- New England Geriatric Research, Education, and Clinical Center (GRECC), VA Boston Healthcare System, Boston, MA, USA.,Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Hui RL, Chang CC, Niu F, Tang YK, Harano D, Deguzman L, Kao DJ, Awsare S, Draves M. Evaluation of a Pharmacist-Managed Antidiabetic Deprescribing Program in an Integrated Health Care System. J Manag Care Spec Pharm 2019; 25:927-934. [PMID: 31347983 PMCID: PMC10398140 DOI: 10.18553/jmcp.2019.25.8.927] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In the elderly, use of medications may increase the propensity for adverse drug events due to alterations in pharmacokinetic and pharmacodynamic profiles from normal aging processes. Deprescribing is the planned and supervised process of dose reduction or discontinuation of medications that may lead to harm or are no longer beneficial. While there are studies detailing strategies to deprescribe medications such as benzodiazepines and antipsychotics in nursing homes or for patients with dementia, there is a lack of guidance to safely deprescribe chronic medications, such as antidiabetics, for older patients in the community setting. OBJECTIVE To evaluate the risk of hypoglycemia and other outcomes of pharmacist-managed deprescribing on selected antidiabetic medications under the guidance of a standardized program compared with usual care within an integrated health care system. METHODS This was a retrospective propensity score-matched cohort study. The pharmacist-managed deprescribing group included patients who were enrolled in the deprescribing program between July 1, 2016, and June 30, 2017. The usual care group included eligible patients who did not receive the deprescribing intervention and were matched to the deprescribing group using propensity score matching (PSM). Baseline demographics and clinical variables were used for matching. Patients were followed for 6 months or the end of membership or death, whichever occurred first. Primary outcome was the risk of hypoglycemia. Secondary outcomes included risk of hyperglycemia, proportion of patients at goal (A1c), change in A1c, change in monthly antidiabetic drug cost, and all-cause mortality. Outcomes were analyzed using descriptive statistics and multivariant regression or Cox proportional hazard models when appropriate. RESULTS After PSM, 685 patients in the deprescribing group and 2,055 patients in the usual care group were similar in age, gender, weight, and comorbidity burden (mean [SD] age 82.4 [5.4] years, 48% female, mean [SD] weight 81.7 [19.2] kg, mean [SD] Charlson Comorbidity Index score 3.2 [1.6]). Compared with the usual care group, the deprescribing group had a lower risk of hypoglycemia (1.5% vs. 3.1%, P < 0.02; adjusted odds ratio 0.42, P < 0.01). As for the secondary outcomes, the deprescribing group had a greater change (SD) in A1c (0.3 [0.6] vs. 0.2 [0.7] P < 0.01) and lower all-cause mortality (2.3% vs 5.6%, P < 0.01; adjusted hazard ratio 0.35, P < 0.01). There were no differences observed in the risk of hyperglycemia, proportion of patients at goal A1c < 7%, and change in monthly antidiabetic drug costs between the 2 groups. CONCLUSIONS There are currently no studies to our knowledge that evaluate the outcomes of a pharmacist-managed deprescribing program targeting antidiabetic medications. The results of our study showed that deprescribing of selected antidiabetics reduced the risk of hypoglycemia and may have mortality benefit in elderly patients with well-controlled type 2 diabetes, who are taking medications that can cause hypoglycemia. Further and longer studies are needed to validate these benefits. DISCLOSURES No outside funding was provided to support this research study. The authors of this study have no actual or potential conflicts of interest to report. Parts of this study were presented in a nonreviewed resident poster at the Academy of Managed Care Pharmacy Managed Care and Specialty Pharmacy Annual Meeting; April 23-26, 2018; Boston, MA.
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Affiliation(s)
| | - Christopher C. Chang
- Clinical Pharmacy Services, Kaiser Permanente Northern California Region, Oakland
| | - Fang Niu
- Pharmacy Outcomes Research Group, Kaiser Permanente California Regions, Downey
| | - Yen K. Tang
- Clinical Pharmacy Services, Kaiser Permanente Santa Rosa Medical Center, Santa Rosa, California
| | - Denise Harano
- Clinical Pharmacy Services, Kaiser Permanente Northern California Region, Oakland
| | - Lynn Deguzman
- Clinical Pharmacy Services, Kaiser Permanente Northern California Region, Oakland
| | - Doris J. Kao
- Drug Information Services, Kaiser Permanente California Regions, Oakland
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Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, Braun LT, de Ferranti S, Faiella-Tommasino J, Forman DE, Goldberg R, Heidenreich PA, Hlatky MA, Jones DW, Lloyd-Jones D, Lopez-Pajares N, Ndumele CE, Orringer CE, Peralta CA, Saseen JJ, Smith SC, Sperling L, Virani SS, Yeboah J. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019; 139:e1082-e1143. [PMID: 30586774 PMCID: PMC7403606 DOI: 10.1161/cir.0000000000000625] [Citation(s) in RCA: 1108] [Impact Index Per Article: 221.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Scott M Grundy
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Neil J Stone
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Alison L Bailey
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Craig Beam
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Kim K Birtcher
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Roger S Blumenthal
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Lynne T Braun
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Sarah de Ferranti
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Joseph Faiella-Tommasino
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Daniel E Forman
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Ronald Goldberg
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Paul A Heidenreich
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Mark A Hlatky
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Daniel W Jones
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Donald Lloyd-Jones
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Nuria Lopez-Pajares
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Chiadi E Ndumele
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Carl E Orringer
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Carmen A Peralta
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Joseph J Saseen
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Sidney C Smith
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Laurence Sperling
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Salim S Virani
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Joseph Yeboah
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
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Abstract
In the United States, the adult population that will need hospice and palliative care is expected to double in the next 40 years. In primary care, providers are often faced with tough decisions on how to manage patients' medications at the end of life. This article describes how to deprescribe in the last year of life.
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43
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Greiver M, Dahrouge S, O'Brien P, Manca D, Lussier MT, Wang J, Burge F, Grandy M, Singer A, Twohig M, Moineddin R, Kalia S, Aliarzadeh B, Ivers N, Garies S, Turner JP, Farrell B. Improving care for elderly patients living with polypharmacy: protocol for a pragmatic cluster randomized trial in community-based primary care practices in Canada. Implement Sci 2019; 14:55. [PMID: 31171011 PMCID: PMC6551894 DOI: 10.1186/s13012-019-0904-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 05/13/2019] [Indexed: 01/17/2023] Open
Abstract
Background Elders living with polypharmacy may be taking medications that do not benefit them. Polypharmacy can be associated with elevated risks of poor health, reduced quality of life, high care costs, and persistently complex care needs. While many medications could be problematic, this project targets medications that should be deprescribed for most elders and for which guidelines and evidence-based deprescribing tools are available. These are termed potentially inappropriate prescriptions (PIPs) and are as follows: proton pump inhibitors, benzodiazepines, antipsychotics, and sulfonylureas. Implementation strategies for deprescribing PIPs in complex older patient populations are needed. Methods This will be a pragmatic cluster randomized controlled trial in community-based primary care practices across Canada. Eligible practices provide comprehensive primary care and have at least one physician that consents to participate. Community-dwelling patients aged 65 years and older with ten or more unique medication prescriptions in the past year will be included. The objective is to assess whether the intervention reduces targeted PIPs for these patients compared with usual care. The intervention, Structured Process Informed by Data, Evidence and Research (SPIDER), is a collaboration between quality improvement (QI) and research programs. Primary care teams will form interprofessional Learning Collaboratives and work with QI coaches to review electronic medical record data provided by their regional Practice Based Research Networks (PBRNs), identify areas of improvement, and develop and implement changes. The study will be tested for feasibility in three PBRNs (Toronto, Montreal, and Edmonton) using prospective single-arm mixed methods. Findings will then guide a pragmatic cluster randomized controlled trial in five PBRNs (Calgary, Winnipeg, Ottawa, Montreal, and Halifax). Seven practices per PBRN will be recruited for each arm. The analysis will be by intention to treat. Ten percent of patients who have at least one PIP at baseline will be randomly selected to participate in the assessment of patient experience and self-reported outcomes. Qualitative methods will be used to explore patient and physician experience and evaluate SPIDER’s processes. Conclusion We are testing SPIDER in a primary care population with complex care needs. This could provide a widely applicable model for care improvement. Trial registration Clinicaltrials.gov NCT03689049; registered September 28, 2018 Electronic supplementary material The online version of this article (10.1186/s13012-019-0904-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M Greiver
- North York General Hospital, 4001 Leslie Street, LE-140, Toronto, Ontario, M2K 1E1, Canada. .,Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 4001 Leslie Street, LE-140, Toronto, Ontario, M2K 1E1, Canada.
| | - S Dahrouge
- Department of Family Medicine, University of Ottawa, 85 Primrose Avenue, Ottawa, Ontario, K1R 6M1, Canada.,Bruyère Research Institute, 43 Bruyère Street, Ottawa, Ontario, K1N 5C8, Canada
| | - P O'Brien
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 4001 Leslie Street, LE-140, Toronto, Ontario, M2K 1E1, Canada
| | - D Manca
- Department of Family Medicine, University of Alberta, 8303 - 112 Street NW, 610 University Terrace, Edmonton, Alberta, T6G 2T4, Canada
| | - M T Lussier
- Department of Family Medicine and Emergency Medicine, University of Montreal, 1755 René Laennec, Bureau DS-079, Laval, Québec, H7M3L9, Canada
| | - J Wang
- North York General Hospital, 4001 Leslie Street, LE-140, Toronto, Ontario, M2K 1E1, Canada
| | - F Burge
- Department of Family Medicine, Dalhousie University, 8F, 8525 Abbie J Lane Building, 5909 Veterans' Memorial Lane, Halifax, Nova Scotia, B3H 2E2, Canada
| | - M Grandy
- Department of Family Medicine, Dalhousie University, 8F, 8525 Abbie J Lane Building, 5909 Veterans' Memorial Lane, Halifax, Nova Scotia, B3H 2E2, Canada
| | - A Singer
- Department of Family Medicine, University of Manitoba, D009 - 780 Bannatyne Ave, Winnipeg, Manitoba, R3T 2N2, Canada
| | - M Twohig
- North York General Hospital, 4001 Leslie Street, LE-140, Toronto, Ontario, M2K 1E1, Canada
| | - R Moineddin
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 4001 Leslie Street, LE-140, Toronto, Ontario, M2K 1E1, Canada.,ICES, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, 500 University Avenue, Toronto, Ontario, M5G 1V7, Canada
| | - S Kalia
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 4001 Leslie Street, LE-140, Toronto, Ontario, M2K 1E1, Canada
| | - B Aliarzadeh
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 4001 Leslie Street, LE-140, Toronto, Ontario, M2K 1E1, Canada
| | - N Ivers
- Family Practice Health Centre and Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, Ontario, M5S 1B2, Canada
| | - S Garies
- Department of family Medicine, Cumming School of Medicine, University of Calgary, G012 Health Sciences Centre, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - J P Turner
- Faculty of Pharmacy, University of Montreal, 2900 Edouard Montpetit Boulevard, Montreal, Quebec, H3T 1J4, Canada.,Centre de Recherche, Institut Universitaire de Geriatrie de Montreal, Montreal, Canada
| | - B Farrell
- Department of Family Medicine, University of Ottawa, 85 Primrose Avenue, Ottawa, Ontario, K1R 6M1, Canada.,Bruyère Research Institute, 43 Bruyère Street, Ottawa, Ontario, K1N 5C8, Canada.,School of Pharmacy, University of Waterloo, Waterloo, Canada
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44
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Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, Braun LT, de Ferranti S, Faiella-Tommasino J, Forman DE, Goldberg R, Heidenreich PA, Hlatky MA, Jones DW, Lloyd-Jones D, Lopez-Pajares N, Ndumele CE, Orringer CE, Peralta CA, Saseen JJ, Smith SC, Sperling L, Virani SS, Yeboah J. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol. J Am Coll Cardiol 2019; 73:e285-e350. [DOI: 10.1016/j.jacc.2018.11.003] [Citation(s) in RCA: 1113] [Impact Index Per Article: 222.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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45
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Nurses' Perspectives on Family Caregiver Medication Management Support and Deprescribing. J Hosp Palliat Nurs 2019; 21:312-318. [PMID: 31033645 DOI: 10.1097/njh.0000000000000574] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Nurses who care for patients with life-limiting illness operate at the interface of family caregivers (FCGs), patients, and prescribers and are uniquely positioned to guide late-life medication management, including challenging discussions about deprescribing. The study objective was to describe nurses' perspectives about their role in hospice FCG medication management. Content analysis was used to analyze qualitative interviews with nurses from a parent study exploring views on medication management and deprescribing for advanced cancer patients. Ten home and inpatient hospice nurses, drawn from 3 hospice agencies and their referring hospital systems in New England, were asked to describe current practices of medication management and deprescribing and to evaluate a pilot tool to standardize hospice medication review. Analysis of the 10 interviews revealed that hospice nurses are receptive to a standardized approach for comprehensive medication review upon hospice transition and responded favorably to opportunities to discuss medication discontinuation with FCGs and prescribers. Effective framing for discussions included focus on reducing harmful and nonessential medications and reducing caregiver burden. Results indicate that nurses who care for hospice-eligible and enrolled patients are willing to discuss deprescribing with FCGs and prescribers when conversations are framed around medication harms and their impact on quality of life.
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46
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Potter EL, Lew TE, Sooriyakumaran M, Edwards AM, Tong E, Aung AK. Evaluation of pharmacist‐led physician‐supported inpatient deprescribing model in older patients admitted to an acute general medical unit. Australas J Ageing 2019; 38:206-210. [DOI: 10.1111/ajag.12643] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 02/12/2019] [Accepted: 02/18/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Elizabeth Louise Potter
- Department of General MedicineAlfred HospitalAlfred Health Melbourne Victoria Australia
- School of Public Health and Preventive MedicineMonash University Melbourne Victoria Australia
| | - Thomas Eliot Lew
- Department of General MedicineAlfred HospitalAlfred Health Melbourne Victoria Australia
| | | | | | - Erica Tong
- Pharmacy DepartmentAlfred HospitalAlfred Health Melbourne Victoria Australia
| | - Ar Kar Aung
- Department of General MedicineAlfred HospitalAlfred Health Melbourne Victoria Australia
- School of Public Health and Preventive MedicineMonash University Melbourne Victoria Australia
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47
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Mangin D, Bahat G, Golomb BA, Mallery LH, Moorhouse P, Onder G, Petrovic M, Garfinkel D. International Group for Reducing Inappropriate Medication Use & Polypharmacy (IGRIMUP): Position Statement and 10 Recommendations for Action. Drugs Aging 2019; 35:575-587. [PMID: 30006810 PMCID: PMC6061397 DOI: 10.1007/s40266-018-0554-2] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Globally, the number of drug prescriptions is increasing causing more adverse drug events, which is now a significant cause of mortality, morbidity, and disability that has reached epidemic proportions. The risk of adverse drug events is correlated to very old age, multiple co-morbidities, dementia, frailty, and limited life expectancy, with the major contributor being polypharmacy. Each characteristic alters the risk-benefit balance of medications, typically reducing anticipated benefits and amplifying risk. Current clinical guidelines are based on evidence proven in younger/healthier adult populations using a single disease model and their application to older adults with multimorbidity, in whom testing has not been conducted, yields a different risk-benefit prospect and makes inappropriate medication use and polypharmacy inevitable. Applying inappropriate clinical practice guidelines to older adults is antithetical to good healthcare, is likely to increase health inequity, and is associated with substantial negative clinical, economic, and social implications for health systems. The casualties are on the scale of a war or epidemic, yet are usually invisible in measures of healthcare quality and formal recommendations. Radical and rapid action is required to achieve a better quality of life for older populations and to remain true to the principles of medical professionalism and evidence-based medicine that place patients' interests and autonomy at the fore. This first International Group for Reducing Inappropriate Medication Use & Polypharmacy position statement briefly details the causes, consequences, and extent of inappropriate medication use and polypharmacy. This article outlines current strategies to reduce inappropriate medication use, provides evidence for their effect, and then proposes recommendations for moving forward with 10 recommendations for action and 12 recommendations for research. We conclude that an urgent integrated effort to reduce inappropriate medication use and polypharmacy should be a leading global target of the highest priority. The cornerstone of this position statement from the International Group for Reducing Inappropriate Medication Use & Polypharmacy is the understanding that without evidence of definite relevant benefit, when it comes to prescribing, for many older patients 'less is more'. This approach differs from most other current recommendations and guidance in medical care, as the focus is on what, when, and how to stop, rather than on when to start medications/interventions. Disrupting the framework that indiscriminately applies standard guidelines to older adults requires a new approach that better serves patients with multimorbidity. This transition requires a shift in medical education, research, and diagnostic frameworks, and re-examination of the measures used as quality indicators. In achieving this objective, we promote a return to some of the original concepts of evidence-based medicine: which considers scientific data (where it exists), clinical judgment, patient/family preference, and context. A shift is needed: from the current model that focuses on single conditions to one that simultaneously considers multiple conditions and patient priorities. This approach reframes the clinician's role as a professional providing care, rather than a disease technician.
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Affiliation(s)
- Dee Mangin
- Department of Family Medicine, Faculty of Health Sciences, McMaster University, 100 Main Street West, Hamilton, ON, Canada. .,Department of General Practice, University of Otago, Christchurch, New Zealand.
| | - Gülistan Bahat
- Division of Geriatrics, Department of Internal Medicine, Istanbul Medical School, Istanbul University, Istanbul, Turkey
| | - Beatrice A Golomb
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Laurie Herzig Mallery
- Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Paige Moorhouse
- Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Graziano Onder
- Department of Geriatrics, Università Cattolica del Sacro Cuore, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Mirko Petrovic
- Department of Internal Medicine, Section of Geriatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Doron Garfinkel
- Wolfson Medical Center, Holon, Israel.,Homecare Hospice Israel Cancer Association, Holon, Israel
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48
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Whitman A, DeGregory K, Morris A, Mohile S, Ramsdale E. Pharmacist-led medication assessment and deprescribing intervention for older adults with cancer and polypharmacy: a pilot study. Support Care Cancer 2018; 26:4105-4113. [PMID: 29869294 PMCID: PMC6204077 DOI: 10.1007/s00520-018-4281-3] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 05/17/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE The aims of this study were to compare the application of three geriatric medication screening tools to the Beers Criteria alone for potentially inappropriate medication quantification and to determine feasibility of a pharmacist-led polypharmacy assessment in a geriatric oncology clinic. METHODS Adult patients with cancer aged 65 and older underwent a comprehensive geriatric assessment. A polypharmacy assessment was completed by a pharmacist and included a review of all drug therapies. Potentially inappropriate medications were screened using the Beers Criteria, Screening Tool to Alert doctors to Right Treatment/Screening Tool of Older Persons' Prescriptions, and the Medication Appropriateness Index. Deprescribing occurred after discussion with the pharmacist, geriatric oncologist, patient, and caregiver. RESULTS Data were collected for 26 patients. The mean number of medications was 12. The Beers Criteria alone identified 38 potentially inappropriate medications compared to 119 potentially inappropriate medications with the three-tool assessment; a mean of 5 potentially inappropriate medications were identified per patient. After the application of the three-tool assessment, 73% of potentially inappropriate medications identified were deprescribed, resulting in a mean of 3 medications deprescribed per patient. Approximately two thirds of patients reported a reduction in symptoms after the deprescribing intervention. Healthcare expenditures of $4282.27 per patient were potentially avoided as a result of deprescribing. CONCLUSIONS Our three-tool assessment identified three times more potentially inappropriate medications than the Beers Criteria alone. Pharmacist-led deprescribing interventions are feasible and may lead to improved patient outcomes and cost savings. This three-tool assessment process should be incorporated into interdisciplinary assessments of older patients with cancer and validated in future studies.
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Affiliation(s)
- Andrew Whitman
- Department of Pharmacy, University of Virginia Health System, Charlottesville, VA, USA.
| | - Kathlene DeGregory
- Department of Pharmacy, University of Virginia Health System, Charlottesville, VA, USA
| | - Amy Morris
- Department of Pharmacy, University of Virginia Health System, Charlottesville, VA, USA
| | - Supriya Mohile
- Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, NY, USA
| | - Erika Ramsdale
- Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, NY, USA
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49
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Wilchesky M, Mueller G, Morin M, Marcotte M, Voyer P, Aubin M, Carmichael PH, Champoux N, Monette J, Giguère A, Durand P, Verreault R, Arcand M, Kröger E. The OptimaMed intervention to reduce inappropriate medications in nursing home residents with severe dementia: results from a quasi-experimental feasibility pilot study. BMC Geriatr 2018; 18:204. [PMID: 30180821 PMCID: PMC6123948 DOI: 10.1186/s12877-018-0895-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 08/27/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Medication regimens in nursing home (NH) residents with severe dementia should be frequently reviewed to avoid inappropriate medication, overtreatment and adverse drug events, within a comfort care approach. This study aimed at testing the feasibility of an interdisciplinary knowledge exchange (KE) intervention using a medication review guidance tool categorizing medications as either "generally", "sometimes" or "exceptionally" appropriate for NH residents with severe dementia. METHODS A quasi-experimental feasibility pilot study with 44 participating residents aged 65 years or over with severe dementia was carried out in three NH in Quebec City, Canada. The intervention comprised an information leaflet for residents' families, a 90-min KE session for NH general practitioners (GP), pharmacists and nurses focusing on the medication review guidance tool, a medication review by the pharmacists for participating residents with ensuing team discussion on medication changes, and a post-intervention KE session to obtain feedback from team staff. Medication regimens and levels of pain and of agitation of the participants were evaluated at baseline and at 4 months post-intervention. A questionnaire for team staff explored perceived barriers and facilitators. Statistical differences in measures comparing pre and post-intervention were assessed using paired t-tests and Cochran's-Q tests. RESULTS The KE sessions reached 34 NH team staff (5 GP, 4 pharmacists, 6 heads of care unit and 19 staff nurses). Forty-four residents participated in the study and were followed for a mean of 104 days. The total number of regular medications was 372 pre and 327 post-intervention. The mean number of regular medications per resident was 7.86 pre and 6.81 post-intervention. The odds ratios estimating the risks of using any regular medication or a "sometimes appropriate" medication post-intervention were 0.81 (95% CI: 0.71-0.92) and 0.83 (95% CI: 0.74-0.94), respectively. CONCLUSION A simple KE intervention using a medication review guidance tool categorizing medications as being either "generally", "sometimes" or "exceptionally" appropriate in severe dementia was well received and accompanied by an overall reduction in medication use by NH residents with severe dementia. Levels of agitation were unaffected and there was no clinically significant changes in levels of pain. Staff feedback provided opportunities to improve the intervention.
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Affiliation(s)
- Machelle Wilchesky
- Department of Family Medicine and Division of Geriatric Medicine, McGill University, 5858, Chemin de la Côte-des-Neiges, Montreal, Quebec, H3S 1Z1, Canada.,Donald Berman Maimonides Centre for Research in Aging, 5795 Caldwell Avenue, Montreal, Quebec, H4W 1W3, Canada
| | - Gerhard Mueller
- Department of Nursing Science and Gerontology, UMIT-The Health & Life Sciences University, Eduard-Wallnoefer-Zentrum 1, A-6060, Hall in Tyrol, Tyrol, Austria
| | - Michèle Morin
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, 1050, Chemin Ste-Foy, room L2-30, Quebec City, Quebec, G1S 4L8, Canada.,Laval University, 1050, avenue de la Médecine, Quebec City, Quebec, G1V 0A6, Canada
| | - Martine Marcotte
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, 1050, Chemin Ste-Foy, room L2-30, Quebec City, Quebec, G1S 4L8, Canada
| | - Philippe Voyer
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, 1050, Chemin Ste-Foy, room L2-30, Quebec City, Quebec, G1S 4L8, Canada.,Laval University, 1050, avenue de la Médecine, Quebec City, Quebec, G1V 0A6, Canada
| | - Michèle Aubin
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, 1050, Chemin Ste-Foy, room L2-30, Quebec City, Quebec, G1S 4L8, Canada
| | - Pierre-Hugues Carmichael
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, 1050, Chemin Ste-Foy, room L2-30, Quebec City, Quebec, G1S 4L8, Canada
| | - Nathalie Champoux
- Faculté de médecine, Université de Montréal, 2900 Boulevard Edouard-Montpetit, Montreal, Quebec, H3T 1J4, Canada
| | - Johanne Monette
- Division of Geriatric Medicine, McGill University, Jewish General Hospital, 3755 Côte-Ste-Catherine, Montreal, Quebec, H3T 1E2, Canada
| | - Anik Giguère
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, 1050, Chemin Ste-Foy, room L2-30, Quebec City, Quebec, G1S 4L8, Canada.,Laval University, 1050, avenue de la Médecine, Quebec City, Quebec, G1V 0A6, Canada
| | - Pierre Durand
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, 1050, Chemin Ste-Foy, room L2-30, Quebec City, Quebec, G1S 4L8, Canada.,Laval University, 1050, avenue de la Médecine, Quebec City, Quebec, G1V 0A6, Canada
| | - René Verreault
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, 1050, Chemin Ste-Foy, room L2-30, Quebec City, Quebec, G1S 4L8, Canada.,Laval University, 1050, avenue de la Médecine, Quebec City, Quebec, G1V 0A6, Canada
| | - Marcel Arcand
- Centre de recherche sur le vieillissement, affilié à l'Université de Sherbrooke, 1036, rue Belvédère Sud, Sherbrooke, Quebec, J1H 4C4, Canada
| | - Edeltraut Kröger
- Centre d'excellence sur le vieillissement de Québec, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, 1050, Chemin Ste-Foy, room L2-30, Quebec City, Quebec, G1S 4L8, Canada. .,Laval University, 1050, avenue de la Médecine, Quebec City, Quebec, G1V 0A6, Canada.
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Gillespie RJ, Harrison L, Mullan J. Deprescribing medications for older adults in the primary care context: A mixed studies review. Health Sci Rep 2018; 1:e45. [PMID: 30623083 PMCID: PMC6266366 DOI: 10.1002/hsr2.45] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/27/2018] [Accepted: 04/03/2018] [Indexed: 12/20/2022] Open
Abstract
AIMS This review investigates the factors that influence deprescribing of medications in primary care from the perspective of general practitioners (GPs) and community-living older adults. METHODS A mixed studies review structure was adopted searching Scopus, CINAHL, PsychINFO, ProQuest, and PubMed from January 2000 to December 2017. A manual search of reference lists was also conducted. Studies were included if they were original research available in English and explored general deprescribing rather than deprescribing of a specific class of medications. The Mixed Methods Assessment Tool was used to assess the quality of studies, and content analysis generated common categories across studies. RESULTS Thirty-eight articles were included, and 7 key categories were identified. The review found that the factors that influence deprescribing are similar across and within health systems and mostly act as barriers. These factors remained unchanged across the review period. The structural organisation of health systems remains poorly suited to facilitate deprescribing. Individual knowledge gaps of both GPs and older adults influence practices and attitudes towards deprescribing, and significant communication gaps occur between GPs and specialists and between GPs and older adults. As a result, deprescribing decision making is characterised by uncertainty, and deprescribing is often considered only when medication problems have already arisen. Trust plays a complex role, acting as both a barrier and facilitator of deprescribing. CONCLUSIONS Deprescribing is influenced by many factors. Despite recent interest, little change has occurred. Multilevel strategies aimed at reforming aspects of the health system and managing uncertainty at the practice and individual level, notably reducing knowledge limitations and closing communications gaps, may achieve change.
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Affiliation(s)
- Robyn J. Gillespie
- School of Medicine, Faculty of Science, Medicine and HealthUniversity of WollongongWollongongAustralia
| | - Lindsey Harrison
- School of Health and Society, Faculty of Social SciencesUniversity of WollongongWollongongAustralia
| | - Judy Mullan
- School of Medicine, Faculty of Science, Medicine and HealthUniversity of WollongongWollongongAustralia
- Centre for Health Research Illawarra Shoalhaven Population (CHRISP), Australian Health Services Research InstituteUniversity of WollongongNSW2522Australia
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