1
|
Moles RJ, Perry L, Naylor JM, Center J, Ebeling P, Duque G, Major G, White C, Yates C, Jennings M, Kotowicz M, Tran T, Bliuc D, Si L, Gibson K, Basger BJ, Bolton P, Barnett S, Hassett G, Kelly A, Bazarnik B, Ezz W, Luckie K, Carter SR. Safer medicines To reduce falls and refractures for OsteoPorosis (#STOP): a study protocol for a randomised controlled trial of medical specialist-initiated pharmacist-led medication management reviews in primary care. BMJ Open 2023; 13:e072050. [PMID: 37620274 PMCID: PMC10450068 DOI: 10.1136/bmjopen-2023-072050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 07/31/2023] [Indexed: 08/26/2023] Open
Abstract
INTRODUCTION Minimal trauma fractures (MTFs) often occur in older patients with osteoporosis and may be precipitated by falls risk-increasing drugs. One category of falls risk-increasing drugs of concern are those with sedative/anticholinergic properties. Collaborative medication management services such as Australia's Home Medicine Review (HMR) can reduce patients' intake of sedative/anticholinergics and improve continuity of care. This paper describes a protocol for an randomised controlled trial to determine the efficacy of an HMR service for patients who have sustained MTF. METHOD AND ANALYSIS Eligible participants are as follows: ≥65 years of age, using ≥5 medicines including at least one falls risk-increasing drug, who have sustained an MTF and under treatment in one of eight Osteoporosis Refracture Prevention clinics in Australia. Consenting participants will be randomised to control (standard care) or intervention groups. For the intervention group, medical specialists will refer to a pharmacist for HMR focused on reducing falls risk predominately through making recommendations to reduce falls risk medicines, and adherence to antiosteoporosis medicines. Twelve months from treatment allocation, comparisons between groups will be made. The main outcome measure is participants' cumulative exposure to sedative and anticholinergics, using the Drug Burden Index. Secondary outcomes include medication adherence, emergency department visits, hospitalisations, falls and mortality. Economic evaluation will compare the intervention strategy with standard care. ETHICS AND DISSEMINATION Approval was obtained via the New South Wales Research Ethics and Governance Information System (approval number: 2021/ETH12003) with site-specific approvals granted through Human Research Ethics Committees for each research site. Study outcomes will be published in peer-reviewed journals. It will provide robust insight into effectiveness of a pharmacist-based intervention on medicine-related falls risk for patients with osteoporosis. We anticipate that this study will take 2 years to fully accrue including follow-up. TRIAL REGISTRATION NUMBER ACTRN12622000261718.
Collapse
Affiliation(s)
- Rebekah Jane Moles
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Lin Perry
- School of Nursing and Midwifery, University of Technology Sydney Faculty of Health, Sydney, New South Wales, Australia
| | - Justine M Naylor
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
- Southwestern Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Jacqueline Center
- Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
| | - Peter Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Gustavo Duque
- Australian Institute for Musculoskeletal Science, The University of Melbourne, Melbourne, Victoria, Australia
| | - Gabor Major
- Department of Rheumatology, Bone and Joint Centre, Royal Newcastle Centre, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
- School of Medicine and Public Health, The University of Newcastle Faculty of Health and Medicine, Callaghan, New South Wales, Australia
| | - Christopher White
- Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Prince of Wales Hospital and Community Health Services, Randwick, New South Wales, Australia
| | - Christopher Yates
- Department of Diabetes and Endocrinology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Matthew Jennings
- Physiotherapy, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Mark Kotowicz
- Epi-Centre for Healthy Ageing, Deakin University - Geelong Campus at Waurn Ponds, Geelong, Victoria, Australia
- Barwon Health, Geelong, Victoria, Australia
| | - Thach Tran
- Bone Biology Division, Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
| | - Dana Bliuc
- Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
| | - Lei Si
- The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Kathryn Gibson
- Liverpool Hospital, Liverpool, New South Wales, Australia
- Ingham Institute, Liverpool, New South Wales, Australia
| | - Benjamin Joseph Basger
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Patrick Bolton
- Public Health and Community Medicine, University of New South Wales, Randwick, New South Wales, Australia
| | - Stephen Barnett
- GP Academic Unit, University of Wollongong, Wollongong, New South Wales, Australia
| | - Geraldine Hassett
- Ingham Institute, Liverpool, New South Wales, Australia
- Department of Rheumatology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Ayano Kelly
- Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Barbara Bazarnik
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Wafaa Ezz
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kate Luckie
- Musculoskeletal Clinical Group, University of New South Wales, Sydney, New South Wales, Australia
| | - Stephen Ross Carter
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
2
|
Lao-Domínguez FÁ, Robustillo-Cortés MDLA, Morillo-Verdugo R. Drug burden index in people living with HIV over 50 years of age in a real clinical practice cohort. ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA (ENGLISH ED.) 2023:S2529-993X(23)00189-2. [PMID: 37394403 DOI: 10.1016/j.eimce.2023.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 04/30/2023] [Indexed: 07/04/2023]
Abstract
OBJECTIVES To determine DBI and its relationship with polypharmacy and pharmacotherapeutic complexity (PC) in a cohort of PLWH over 50 years of age at follow-up of pharmacotherapy in a tertiary hospital. METHODS Observational and retrospective study that included PLWH in active antiretroviral treatment over 50 years of age who have been followed up in outpatient pharmacy services. Pharmacotherapeutic complexity was estimated through Medication Regimen Complexity Index (MRCI). Collected variables included comorbidities, current prescriptions and its classification according to anticholinergic and sedative activity and associated risk of falls. RESULTS Studied population included 251 patients (85.7% men; median age: 58 years, interquartile range: 54-61). There was a high prevalence of high DBI scores (49.2%). High DBI was significantly correlated with a high PC, polypharmacy, psychiatric comorbidity and substances abuse (p<0.05). Among sedative drugs, the most prescribed were anxiolytic drugs (N05B) (n=85), antidepressant drugs (N06A) (n=41) and antiepileptic drugs (N03A) (n=29). For anticholinergic drugs, alpha-adrenergic antagonist drugs (G04C) were the most prescribed (n=18). Most frequent drugs associated with risk of falls were anxiolytics (N05B) (n=85), angiotensin-converting enzyme inhibitors (C09A) (n=61) and antidepressants (N06A) (n=41). CONCLUSION The DBI score in older PLWH is high and it is related to PC, polypharmacy, mental diseases and substance abuse as is the prevalence of fall-related drugs. Control of these parameters as well as the reduction of the sedative and anticholinergic load should be included in the lines of work in the pharmaceutical care of people living with HIV+.
Collapse
|
3
|
Birt L, Wright DJ, Blacklock J, Bond CM, Hughes CM, Alldred DP, Holland R, Scott S. Enhancing deprescribing: A qualitative understanding of the complexities of pharmacist-led deprescribing in care homes. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e6521-e6531. [PMID: 36336895 PMCID: PMC10100492 DOI: 10.1111/hsc.14099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/15/2022] [Accepted: 10/16/2022] [Indexed: 06/16/2023]
Abstract
The English National Overprescribing Review identified that older people often take eight or more medicines a day. The report recommended pharmacists in primary care should take responsibility for addressing polypharmacy. Overprescribing is a safety concern in care homes as approximately half of older care home residents are prescribed at least one medicine that is unnecessary or now harmful. This predisposes them to adverse outcomes including hospitalisation and mortality. Deprescribing is the planned activity of stopping or reducing a medicine that may no longer be appropriate. Deprescribing, when performed by a pharmacist, is a multidisciplinary activity requiring close communication with general practitioners (GPs) and care home staff. A recently completed trial that integrated pharmacists with prescribing rights into older peoples' care homes found significant variation in proactive deprescribing activity. The aim of the current study was to specifically explore beliefs and practices of deprescribing in care homes. A qualitative approach was adopted to examine individual, social and contextual factors that acted as enablers and barriers to pharmacist deprescribing in care homes. Semi-structured interviews were conducted with participants of the previous study (16 pharmacists, 6 GPs and 7 care home staff from Northern Ireland, Scotland and England). Using thematic analysis, we identified two themes: (a) Structures and systems affecting deprescribing, that is the context in which deprescribing happened, including team involvement and routine practices in GP surgeries and care homes; (b) Balancing risks when deprescribing, that is the perception of individual risk and social barriers were mitigated by understanding the medical background of residents. This supported the clinical understanding that risks from overprescribing were greater than risks from deprescribing. While deprescribing can involve all health professionals in the primary care team, these results suggest the pharmacist is well placed to lead the process; by having both clinical competence and professional willingness to drive this activity forward.
Collapse
Affiliation(s)
- Linda Birt
- School Allied Health ProfessionalsUniversity of LeicesterLeicesterUK
| | - David J. Wright
- Allied Health ProfessionalsUniversity of LeicesterLeicesterUK
| | | | - Christine M. Bond
- Institute of Applied Health SciencesUniversity of AberdeenLeicesterUK
| | | | | | | | - Sion Scott
- Allied Health ProfessionalsUniversity of LeicesterLeicesterUK
| |
Collapse
|
4
|
Niznik J, Ferreri SP, Armistead L, Urick B, Vest MH, Zhao L, Hughes T, McBride JM, Busby-Whitehead J. A deprescribing medication program to evaluate falls in older adults: methods for a randomized pragmatic clinical trial. Trials 2022; 23:256. [PMID: 35379307 PMCID: PMC8981935 DOI: 10.1186/s13063-022-06164-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/09/2022] [Indexed: 11/18/2022] Open
Abstract
Background Opioids and benzodiazepines (BZDs) are some of the most commonly prescribed medications that contribute to falls in older adults. These medications are challenging to appropriately prescribe and monitor, with little guidance on safe prescribing of these medications for older patients. Only a handful of small studies have evaluated whether reducing opioid and BZD use through deprescribing has a positive impact on outcomes. Leveraging the strengths of a large health system, we evaluated the impact of a targeted consultant pharmacist intervention to deprescribe opioids and BZDs for older adults seen in primary care practices in North Carolina. Methods We developed a toolkit and process for deprescribing opioids and BZDs in older adults based on a literature review and guidance from an interprofessional team of pharmacists, geriatricians, and investigators. A total of fifteen primary care practices have been randomized to receive the targeted consultant pharmacist service (n = 8) or usual care (n = 7). The intervention consists of several components: (1) weekly automated reports to identify chronic users of opioids and BZDs, (2) clinical pharmacist medication review, and (3) recommendations for deprescribing and/or alternate therapies routed to prescribers through the electronic health record. We will collect data for all patients presenting one of the primary care clinics who meet the criteria for chronic use of opioids and/or BZDs, based on their prescription order history. We will use the year prior to evaluate baseline medication exposures using morphine milligram equivalents (MMEs) and diazepam milligram equivalents (DMEs). In the year following the intervention, we will evaluate changes in medication exposures and medication discontinuations between control and intervention clinics. Incident falls will be evaluated as a secondary outcome. To date, the study has enrolled 914 chronic opioid users and 1048 chronic BZD users. We anticipate that we will have 80% power to detect a 30% reduction in MMEs or DMEs. Discussion This clinic randomized pragmatic trial will contribute valuable evidence regarding the impact of pharmacist interventions to reduce falls in older adults through deprescribing of opioids and BZDs in primary care settings. Trial registration Clinicaltrials.govNCT04272671. Registered on February 17, 2020 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06164-5.
Collapse
|
5
|
Change in Medication-Associated Fall Risk Among Older Adults After Admission for Fall-Related Trauma. J Trauma Nurs 2021; 28:363-366. [PMID: 34766931 DOI: 10.1097/jtn.0000000000000615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND As the population ages, it is predicted that approximately 40% of all patients who experience fall-related trauma will be 65 years of age and older. Most injuries in older adults are caused by falls that are the result of multiple contributing factors including home hazards, comorbidities, frailty, and medications. A variety of medications have been associated with falls, specifically those with sedating and anticholinergic effects. The drug burden index can be used to quantify sedating and anticholinergic drug burden, with higher scores being associated with reduced psychomotor function. OBJECTIVE Assess the medication-associated fall risk on admission and discharge for older patients admitted to a trauma nurse practitioner service. METHODS Retrospective, observational study of patients managed by trauma nurse practitioners at a Level 1 trauma center between January 1, 2018, and December 31, 2019. Patients were included if they were at least 65 years of age, the primary diagnosis for the admission was fall-related trauma, and length of stay was at least 7 days. RESULTS A total of 172 patients were included in the study. The drug burden index was significantly higher at discharge than admission (M = 1.4, SD = 0.9 vs. M = 1.9, SD = 0.9) as was the total number of medications (M = 11.0, SD = 5.2 vs. M = 15.1, SD = 5.8). CONCLUSIONS Medication-related fall risk was increased during admission due to fall-related trauma. Patients were discharged with a higher sedating and anticholinergic burden than on admission, which increases risk for future falls.
Collapse
|
6
|
Shmuel S, Pate V, Pepin MJ, Bailey JC, Golightly YM, Hanson LC, Stürmer T, Naumann RB, Gnjidic D, Lund JL. Effects of anticholinergic and sedative medication use on fractures: A self-controlled design study. J Am Geriatr Soc 2021; 69:3212-3224. [PMID: 34291817 PMCID: PMC8595585 DOI: 10.1111/jgs.17377] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/20/2021] [Accepted: 06/15/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVES Unintentional falls are a leading cause of injury for older adults, and evidence is needed to understand modifiable risk factors. We evaluated 1-year fall-related fracture risk and whether dispensing of medications with anticholinergic/sedating properties is temporally associated with an increased odds of these fractures. DESIGN A retrospective cohort study with nested self-controlled analyses conducted between January 1, 2014, and December 31, 2016. SETTING Twenty percent nationwide, random sample of US Medicare beneficiaries. PARTICIPANTS New users of medications with anticholinergic/sedating properties who were 66+ years old and had Medicare Parts A, B, and D coverage but no claims for medications with anticholinergic/sedating properties in the year before initiation were eligible. MEASUREMENTS We followed new users of medications with anticholinergic/sedating properties until first non-vertebral, fall-related fracture (primary outcome), Medicare disenrollment, death, or end of study data. We estimated the 1-year risk with corresponding 95% confidence intervals (CIs) of first fracture after new use. We applied the self-controlled case-crossover and case-time-control designs to estimate odds ratios (ORs) and 95% CIs by comparing anticholinergic and/or sedating medication exposure (any vs. none) during a 14-day hazard period preceding the fracture to exposure to these medications during an earlier 14-day control period. RESULTS A total of 1,097,989 Medicare beneficiaries initiated medications with anticholinergic/sedating properties in the study period. The 1-year cumulative incidence of fall-related fracture, accounting for death as a competing risk, was 5.0% (95% CI: 5.0%-5.0%). Using the case-crossover design (n = 41,889), the adjusted OR for the association between anticholinergic/sedating medications and fractures was 1.03 (95% CI: 0.99, 1.08). Accounting for the noted temporal trend using the case-time-control design (n = 209,395), the adjusted OR was 1.60 (95% CI: 1.52, 1.69). CONCLUSION Use of anticholinergic/sedating medication was temporally associated with an increased odds of fall-related fractures. Patients and their healthcare providers should consider pharmacologic and non-pharmacologic treatments for the target condition that are safer.
Collapse
Affiliation(s)
- Shahar Shmuel
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | - Virginia Pate
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | - Marc J. Pepin
- Durham VA Geriatric Research Education and Clinical Center (GRECC), Durham, NC 27705 USA
| | - Janine C. Bailey
- Durham VA Geriatric Research Education and Clinical Center (GRECC), Durham, NC 27705 USA
| | - Yvonne M. Golightly
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, 3300 Thurston Building, CB #7820, Chapel Hill, NC 27599 USA
- Division of Physical Therapy, University of North Carolina at Chapel Hill, Bondurant Hall, CB #7135, Chapel Hill, NC 27599 USA
| | - Laura C. Hanson
- Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
- Division of Geriatric Medicine & Palliative Care Program, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | - Til Stürmer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | - Rebecca B. Naumann
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | - Danijela Gnjidic
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Jennifer L. Lund
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| |
Collapse
|