Individualized Medication Review in Older People with Multimorbidity: A Comparative Analysis between Patients Living at Home and in a Nursing Home

The Impact of Pharmacist Medication Reviews on Geriatric Patients: A Scoping Review

Medication review is an intervention with the potential to reduce drug-related problems (DRPs) in the elderly. This study aimed to determine the effect of pharmacists' medication reviews on geriatric patients. This study accessed two online databases, MEDLINE Complete and Scopus, and examined all studies published in English between 2019 and 2023, except for reviews. The studies included (1) participants over 65 years of age and (2) medication reviews conducted by pharmacists. The titles, abstracts, and full texts were reviewed for data extraction to determine whether the studies satisfied the inclusion and exclusion criteria. Forty-four of the initial 709 articles were included in this study. The articles included discussions on the incidence rates of DRPs and potentially inappropriate medications (PIMs) (n=21), hospitalization (n=14), medication adherence (n=9), quality of life (QoL) (n=8), and falls (n=7). Pharmacist medication reviews were associated with a reduced incidence of DRPs and PIMs, and improved adherence to medications. Patients' overall QoL is also increasing. However, pharmacist medication reviews were not strongly associated with decreased hospitalization or falls. A pharmacist's medication review may be a feasible intervention for reducing the incidence rates of DRPs and PIMs, regardless of whether it is performed as a sole intervention or supplemented with other interventions. The intervention was also effective in increasing medication adherence and QoL.

Trajectories network analysis of chronic diseases among middle-aged and older adults: evidence from the China Health and Retirement Longitudinal Study (CHARLS)

BACKGROUND

Given the increased risk of chronic diseases and comorbidity among middle-aged and older adults in China, it is pivotal to identify the disease trajectory of developing chronic multimorbidity and address the temporal correlation among chronic diseases.

METHOD

The data of 15895 participants from the China Health and Retirement Longitudinal Study (CHARLS 2011 - 2018) were analyzed in the current study. Binomial tests and the conditional logistic regression model were conducted to estimate the associations among 14 chronic diseases, and the disease trajectory network analysis was adopted to visualize the relationships.

RESULTS

The analysis showed that hypertension is the most prevalent disease among the 14 chronic conditions, with the highest cumulative incidence among all chronic diseases. In the disease trajectory network, arthritis was found to be the starting point, and digestive diseases, hypertension, heart diseases, and dyslipidemia were at the center, while memory-related disease (MRD), stroke, and diabetes were at the periphery of the network.

CONCLUSIONS

With the chronic disease trajectory network analysis, we found that arthritis was prone to the occurrence and development of various other diseases. In addition, patients of heart diseases/hypertension/digestive disease/dyslipidemia were under higher risk of developing other chronic conditions. For patients with multimorbidity, early prevention can preclude them from developing into poorer conditions, such as stroke, MRD, and diabetes. By identifying the trajectory network of chronic disease, the results provided critical insights for developing early prevention and individualized support services to reduce disease burden and improve patients' quality of life.

Opioid deprescribing in long-term care in Ontario: A comparison of resident and facility characteristics

Residents of long-term care (LTC) homes have potentially painful conditions and are prescribed opioids to manage their pain, despite the risks associated with the use of these high-risk medications. Therefore, the overall aim of this study was to describe the associations between resident and facility characteristics of residents prescribed long-term opioid therapy and those who remained on opioids or had opioids deprescribed. We conducted a retrospective cohort study utilizing health administrative databases housed within ICES. Our cohort included 26,592 of 121,564 LTC residents (21.9%) of Ontario LTC homes who were prescribed long-term opioid therapy at cohort inception. Of these residents, 4,299 (16.2%) residents had opioids deprescribed during the follow-up period. Opioid deprescribing was associated with younger age, high comorbidity, and co-prescription with benzodiazepines and gabapentinoids. Our findings suggest that there is variation in the characteristics of residents who continued long-term opioid therapy and those who subsequently had opioids deprescribed, and these characteristics need to be considered as part of individualized pain management plans of care.

[Polypharmacy in nursing homes: options to improve drug therapy safety]

Patients in need of care usually suffer from multiple chronic conditions and therefore receive a high number of drugs. Polypharmacy involves multiple risks, for example, drug-drug and drug-disease interactions, adverse effects and potentially inappropriate medication (PIM), more hospital admissions, and increased mortality.Residents in long-term care facilities are particularly sensitive to adverse drug reactions because of age-related changes, frailty, and the high prevalence of dementia. Numerous drugs have side effects that lead to sedation, particularly in old age, and increase the risk of falls. In addition, anticholinergic effects negatively modify cognition. These PIMs are frequently prescribed to nursing home residents.The medication process in long-term care facilities is complex and requires numerous coordinated processes. In addition to the correct administration, the nursing staff have other important tasks such as monitoring the effects and potential adverse drug reactions and communicating their observations to the prescribing physicians and home-supplying pharmacists. The nursing staff therefore play a crucial role in the prescription of psychotropic drugs and contribute to the medication quality for nursing home residents. National and international studies indicate that improvements of polypharmacy and drug therapy safety in nursing homes can only be achieved by interprofessional collaboration.

Medication Assessment in an Older Population during Acute Care Hospitalization and Its Effect on the Anticholinergic Burden: A Prospective Cohort Study

(1) Background: Anticholinergic and sedative drugs (ASDs) contribute to negative health outcomes, especially in the frail population. In this study, we aimed to assess whether frailty increases with anticholinergic burden and to evaluate the effects of medication reviews (MRs) on ASD regimens among patients attending an acute care for the elderly (ACE) unit. (2) Methods: A cohort study was conducted between June 2019 and October 2020 with 150 consecutive patients admitted to our ACE unit. Demographic, clinical, and pharmacological data were assessed. Frailty score was determined using the Frail-VIG index (FI-VIG), and ASD burden was quantified using the drug burden index (DBI). In addition, the MR was performed using the patient-centered prescription (PCP) model. We used a paired T-test to compare the DBI pre- and post-MR and univariate and multivariate regression to identify the factors associated with frailty. (3) Results: Overall, 85.6% (n = 128) of participants showed some degree of frailty (FI-VIG > 0.20) and 84% (n = 126) of patients received treatment with ASDs upon admission (pre-MR). As the degree of frailty increased, so did the DBI (p < 0.001). After the implementation of the MR through the application of the PCP model, a reduction in the DBI was noted (1.06 ± 0.8 versus 0.95 ± 0.7) (p < 0.001). After adjusting for covariates, the association between frailty and the DBI was apparent (OR: 11.42, 95% (CI: 2.77-47.15)). (4) Conclusions: A higher DBI was positively associated with frailty. The DBI decreased significantly in frail patients after a personalized MR. Thus, MRs focusing on ASDs are crucial for frail older patients.

Frailty modifies the effect of polypharmacy and multimorbidity on the risk of death among nursing home residents: Results from the SHELTER study

Background

Frailty, disability, and polypharmacy are prevalent in nursing home (NH) residents, often co-occurring with multimorbidity. There may be a complex interplay among them in terms of outcomes such as mortality. Aims of the study were to (i) assess whether nursing home residents with polypharmacy (5-9 medications) or hyperpolypharmacy (≥10 drugs), have an increased risk of death and (ii) whether any association is modified by the co-presence of frailty or disability.

Methods

Cohort study with longitudinal mortality data including 4,023 residents from 50 European and 7 Israeli NH facilities (mean age = 83.6 years, 73.2% female) in The Services and Health for Elderly in Long Term care (SHELTER) cohort study. Participants were evaluated with the interRAI-LongTerm Care assessment tool. Frailty was evaluated with the FRAIL-NH scale. Hazard ratio (HR) of death over 12 months was assessed with stratified Cox proportional hazards models adjusted for demographics, facilities, and cognitive status.

Results

1,042 (25.9%) participants were not on polypharmacy, 49.8% (n = 2,002) were on polypharmacy, and 24.3% (n = 979) on hyperpolypharmacy. Frailty and disability mostly increased risk of death in the study population (frailty: HR = 1.85, 95%CI 1.49-2.28; disability: HR = 2.10, 95%CI 1.86-2.47). Among non-frail participants, multimorbidity (HR = 1.34, 95%CI = 1.01-1.82) and hyperpolypharmacy (HR = 1.61, 95%CI = 1.09-2.40) were associated with higher risk of death. Among frail participants, no other factors were associated with mortality. Polypharmacy and multimorbidity were not associated with mortality after stratification for disability.

Conclusions

Frailty and disability are the strongest predictors of death in NH residents. Multimorbidity and hyperpolypharmacy increase mortality only in people without frailty. These findings may be relevant to identify patients who could benefit from tailored deprescription.

Frail Older People Ageing in Place in Italy: Use of Health Services and Relationship with General Practitioner

Functional limitations, chronic diseases and frailty often occur in later life. These aspects become very challenging when older people age alone in place, thus needing support in the activities of daily living, and in this context, it is important they can access and use health services. The present study aimed to explore these issues in Italy. In 2019, 120 qualitative interviews were carried out within the “Inclusive Ageing in Place” (IN-AGE) project, involving frail older people living at home in three Italian regions (Lombardy, Marche, and Calabria). A content analysis and some quantifications of main statements are presented. Results showed that the majority of seniors report poor self-rated health (SRH), suffer from many chronic diseases, and mainly use the General Practitioner (GP) and Medical Specialists (MSs), even though long waiting list in the public sector and high costs in the private one act as barriers to access health services. Complaints regarding GPs mainly refer to the almost exclusive provision of prescriptions and the lack of home visits. Some regional peculiarities highlighted a better overall context in the north than in the south, especially with regards to the public health sector. These results can provide useful insights for policy makers, in order to deliver health services assuring frail, older people the continuity of assistance needed at home.

Caring for Frail Older People Living Alone in Italy: Future Housing Solutions and Responsibilities of Family and Public Services, a Qualitative Study

When frail older people age alone in place, with increasing functional limitations, they require support in performing daily living activities. In this respect, it is important to assess their preferences in terms of future housing solutions, and their opinions/orientations on the care responsibilities of both family and public services. The present study aimed to explore these aspects in Italy. Qualitative interviews were carried out in 2019 within the “Inclusive ageing in place” (IN-AGE) research project, involving 120 frail older people who lived at home in three Italian regions (Lombardy, Marche, and Calabria). A content analysis was conducted, and some quantifications of interviewees’ statements were provided. The results revealed that the majority of seniors prefer ageing at home, at least with a personal care assistant (PCA), whereas moving to a nursing home is typically deemed as a last option. Moreover, they considered the family to be primarily responsible for taking care of them, even with the support of public services. In addition, some territorial differences emerged. Strengthening an integrated model of long-term care (LTC) for older people, where both formal and informal supports allow frail older people to age at home, seems thus a good overall policy solution to pursue, with interventions based also on the needs and preferences of both seniors and their respective families.

Improving individualized prescription in patients with multimorbidity through medication review

Background

Older patients tend to have multimorbidity, represented by multiple chronic diseases or geriatric conditions, which leads to a growing number of prescribed medications. As a result, pharmacological prescription has become a major concern because of the increased difficulties to ensure appropriate prescription in older adults. The study’s main objectives were to characterize a cohort of older adults with multimorbidity, carry out a medication review and compare the pharmacological data before and after the medication review globally and according to the frailty index.

Methods

This was a quasi-experimental (uncontrolled pre-post) study with a cohort of patients ≥ 65 years old with multimorbidity. Data were collected from June 2019 to October 2020. Variables assessed included demographic, clinical, and pharmacological data, degree of frailty (Frail-VIG index), medication regimen complexity index, anticholinergic and or sedative burden index, and monthly drug expenditure. Finally, a medication review was carried out by an interdisciplinary team (primary care team and a consultant team with a geriatrician and a clinical pharmacist) by applying the Patient-Centered Prescription model to align the treatment with care goals.

Results

Four hundred twenty-eight patients were recruited [66.6% women; mean age 85.5 (SD 7.67)]. The mean frail index was 0.39 (SD 0.13), corresponding with moderate frailty. Up to 90% of patients presented at least one inappropriate prescription, and the mean of inappropriate prescriptions per patient was 3.14 (SD 2.27). At the three-month follow-up [mortality of 17.7% (n = 76)], the mean chronic medications per patient decreased by 17.96%, varying from 8.13 (SD 3.87) to 6.67 (SD 3.72) (p < 0.001). The medication regimen complexity index decreased by 19.03%, from 31.0 (SD 16.2) to 25.1 (SD 15.1), and the drug burden index mean decreased by 8.40%, from 1.19 (SD 0.82) to 1.09 (SD 0.82) (p < 0.001). A decrease in polypharmacy, medication regimen complexity index, and drug burden index was more frequent among frail patients, especially those with severe frailty (p < 0.001).

Conclusions

An individualized medication review in frail older patients, applying the Patient-Centered Prescription model, decreases pharmacological parameters related to adverse drug effects, such as polypharmacy, therapeutical complexity, and anticholinergic and, or sedative burden. The benefits are for patients with frailty.