Beliefs about prescribed medication among older patients with polypharmacy: a mixed methods study in primary care

Experiences and Perceptions of Medication Management Communication During Transitions of Care for Residents in Aged Care Homes and Their Caregivers: A Qualitative Meta-Synthesis

AIM

To explore the experiences and perceptions of communication about managing medication across transitions of care for residents living in aged care homes and their family caregivers.

BACKGROUND

Effective medication communication across transitions of care involves exchanging information, resident, and family caregiver's participation in decision-making, and shared responsibility.

DESIGN

A qualitative meta-synthesis.

METHOD

This review was conducted in accordance with the PRISMA 2020 guidelines and the accompanying 27-item checklist. A systematic search of seven electronic databases (Embase, PsycINFO, Medline Ovid, Scopus, CINAHL, EmCare and Web of Science) was performed from inception to December 2023. Studies eligible for inclusion in this review were required to be published in peer-reviewed English journals and focus on medication communication among healthcare providers, residents and family caregivers during transitions of care for aged care residents. The JBI Critical Appraisal Checklist for Qualitative Research was employed for the critical appraisal of the studies, and the COREQ checklist was used to evaluate their quality.

RESULTS

Of the 2610 studies identified, 12 met the inclusion criteria. No study was excluded based on quality. Two main themes were generated: (1) Medication information exchange involving residents and families, and (2) resident and family factors influencing medication communication engagement. The findings revealed a lack of supportive structure for effective communication and collaboration among residents, family caregivers and healthcare providers during transitions of care, marked by one-way interactions and limited evidence of shared decision-making or family caregiver engagement in medication management communication, despite varying individual needs and preferences.

CONCLUSIONS

Communication about medication management during transitions of care focused on sharing details rather than active engagement. Residents and their family caregivers have individual needs and perspectives regarding communication about medication management, which are not well addressed by healthcare providers during transitions of care. Healthcare providers' communication remains limited, and family caregivers are underutilised.

Deprescribing in older adults in a French community: a questionnaire study on patients' beliefs and attitudes

BACKGROUND

General practitioners (GPs) have a central role to play on reduction of polypharmacy and deprescribing. This study aimed to assess beliefs and attitudes towards deprescribing in patients, aged 65 years or older in primary care, and to identify factors associated with deprescribing and their willingness to stop medication.

METHODS

A questionnaire study was performed between 23 May and 29 July 2022 on patients aged 65 years or older attending a GP's surgery in a French area. We used the French version of the revised Patients' Attitudes Towards Deprescribing self-report questionnaire (rPATD), which measures four subscales ("Burden", "Appropriateness", "Concerns about stopping" and, "Involvement"), patients' willingness to stop one of their regular medicines, and patients' satisfaction with their current medicines.

RESULTS

The study enrolled 200 patients. Median age was 76 years old (IQR 71-81), 55% were women, and 42.5% took 5 or more medications per day. Although most patients (92.5%) were satisfied with their current medicines, 35% were reluctant to stop medications they had been taking for a long time, and 89.5% were willing to stop medication if asked to by their GP. Patients aged less than 75 years old reported more concerns about stopping. Women and patients with higher educational attainment showed significantly higher involvement in medication management.

CONCLUSIONS

The majority of older adults were willing to stop one or more of their regular medicines if asked to do so by their GP. GPs should address deprescribing into their current practice.

Self-administration medication errors at home and its predictors among illiterate and low-literate community-dwelling older adults with polypharmacy: A negative binomial hierarchical regression

BACKGROUND

Older adults with polypharmacy are more prone to medication errors. People with low educational attainment have more difficulties in taking their medications.

OBJECTIVES

This study aimed to identify the extent of medication self-administration errors (MSEs) and the contributing factors among illiterate and low-literate community-dwelling older adults with polypharmacy.

METHOD

The present cross-sectional study was conducted among people aged 60 and above. The data were collected using the sociodemographic, clinical, and Belief about Medicines Questionnaires (BMQ). To determine the extent of MSE, a medication error checklist was used. The negative binomial hierarchical regression model in the five blocks was performed.

RESULTS

The final sample size was 276 people. The frequency of MSEs in the last 6 months was 69.2%. Sixteen percent of participants had made four or more mistakes. The most common MSEs were forgetting, improper taking of medications with food, improper timing, incorrect dosage (lower dose), and forgetting the doctor's instructions. Near 18% of participants reported adverse events following their mistakes. The significant predictors of MSEs were being completely illiterate (p = 0.021), the higher number of doctor visits per year (p = 0.014), irregularly seeing doctors (p < .001), the higher number of medications (p < .001), and having poor medication beliefs (p < .001).

CONCLUSION

Despite the high prevalence of MSEs among older patients, practical strategies to deal with them at their homes have not been established among health systems. MSE as a multifactorial event can be caused by a collection of internal and external factors. Further studies to identify the role of patients, clinicians, procedures, and systems in developing MSEs as interconnected components are needed.

Attitudes and barriers towards deprescribing in older patients experiencing polypharmacy: a narrative review

Polypharmacy, commonly defined as ≥5 medications, is a rising public health concern due to its many risks of harm. One commonly recommended strategy to address polypharmacy is medication reviews, with subsequent deprescription of inappropriate medications. In this review, we explore the intersection of older age, polypharmacy, and deprescribing in a contemporary context by appraising the published literature (2012-2022) to identify articles that included new primary data on deprescribing medications in patients aged ≥65 years currently taking ≥5 medications. We found 31 articles were found which describe the current perceptions of clinicians towards deprescribing, the identified barriers, key enabling factors, and future directions in approaching deprescribing. Currently, clinicians believe that deprescribing is a complex process, and despite the majority of clinicians reporting feeling comfortable in deprescribing, fewer engage with this process regularly. Common barriers cited include a lack of knowledge and training around the deprescribing process, a lack of time, a breakdown in communication, perceived 'abandonment of care', fear of adverse consequences, and resistance from patients and/or their carers. Common enabling factors of deprescribing include recognition of key opportunities to instigate this process, regular medication reviews, improving lines of communication, education of both patients and clinicians and a multidisciplinary approach towards patient care. Addressing polypharmacy requires a nuanced approach in a generally complex group of patients. Key strategies to reducing the risks of polypharmacy include education of patients and clinicians, in addition to improving communication between healthcare providers in a multidisciplinary approach.

Factors associated with medication adherence among older adults with multimorbidity: A culture perspective

Multimorbidity is a healthcare concern. To manage diseases, older adults with multimorbidity are expected to practice health behaviors, particularly medication adherence. Studies have examined adherence issues in older patients with multiple diseases, but it remains unclear which factors affect medication adherence. Therefore, this study aimed to identify the factors affecting medication adherence among older adults with multimorbidity. The participants were recruited from the outpatient departments of two hospitals in the Republic of Korea using convenience sampling. Data were collected using structured questionnaires and analyzed using multiple regression analysis. The results showed that those with a lower education level, no side effects, better health literacy, higher medication self-efficacy, and more social support exhibited better medication adherence. In addition, beliefs about medication were not related to medication adherence. These results suggest that providing individualized education, strengthening social support, and decreasing harmful side effects can improve medication adherence.

Contexts and mechanisms relevant to General Practitioner (GP) based interventions to reduce adverse drug events (ADE) in community dwelling older adults: a rapid realist review

Background

Older adults in Ireland are at increased risk of adverse drug events (ADE) due, in part, to increasing rates of polypharmacy. Interventions to reduce ADE in community dwelling older adults (CDOA) have had limited success, therefore, new approaches are required.A realist review uses a different lens to examine why and how interventions were supposed to work rather than if, they worked. A rapid realist review (RRR) is a more focused and accelerated version.The aim of this RRR is to identify and examine the contexts and mechanisms that play a role in the outcomes relevant to reducing ADE in CDOA in the GP setting that could inform the development of interventions in Ireland.

Methods

Six candidate theories (CT) were developed, based on knowledge of the field and recent literature, in relation to how interventions are expected to work. These formed the search strategy. Eighty full texts from 633 abstracts were reviewed, of which 27 were included. Snowballing added a further five articles, relevant policy documents increased the total number to 45. Data were extracted relevant to the theories under iteratively developed sub-themes using NVivo software.

Results

Of the six theories, three theories, relating to GP engagement in interventions, relevance of health policy documents for older adults, and shared decision-making, provided data to guide future interventions to reduce ADEs for CDOA in an Irish setting. There was insufficient data for two theories, a third was rejected as existing barriers in the Irish setting made it impractical to use.

Conclusions

To improve the success of Irish GP based interventions to reduce ADEs for CDOA, interventions must be relevant and easily applied in practice, supported by national policy and be adequately resourced. Future research is required to test our theories within a newly developed intervention.

Predictors of older patients' willingness to have medications deprescribed: A cross-sectional study

BACKGROUND

Deprescribing is a complex process requiring a patient-centred approach. One frequently expressed deprescribing barrier is patients' attitudes and beliefs towards deprescribing. This study aimed to identify the predictors of patients' willingness to have medications deprescribed.

METHODS

A cross-sectional study was conducted with community-dwelling patients aged ≥65 who are taking at least one regular medication. Data collection included patients' demographic and clinical characteristics and the Portuguese revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. Descriptive statistics were used to present the patients' characteristics. Multiple binary logistic regression analysis was performed to identify the predictors of the patients' willingness to have medications deprescribed.

RESULTS

One hundred ninety-two participants (median age 72 years; 65.6% female) were included. Most (83.33%) were willing to have medications deprescribed, and the predictors were age (adjusted odds ratio [aOR] = 1.136; 95% CI 1.026, 1.258), female sex (aOR = 3.036; 95% CI 1.059, 8.708) and the rPATD concerns about stopping factor (aOR = 0.391; 95% CI 0.203, 0.754).

CONCLUSIONS

Most patients were willing to have their medications deprescribed if it is recommended by their doctors. Older age and female sex increased the odds of willingness to deprescribe; higher concerns about stopping medications decreased the odds. These findings suggest that addressing patients' concerns about stopping their medicines may contribute to deprescribing success.

Older Adults' Experiences With Participation and eHealth in Care Coordination: Qualitative Interview Study in a Primary Care Setting

BACKGROUND

Owing to the demographic changes in the elderly population worldwide, delivering coordinated care at home to multimorbid older adults is of great importance. Older adults living with multiple chronic conditions need information to manage and coordinate their care. eHealth can be effective for gaining sufficient information, communicating, and self-managing chronic conditions. However, incorporating older adults' health preferences and ensuring active involvement remain challenging. More knowledge is needed to ensure successful participation and eHealth use in care coordination.

OBJECTIVE

This study aimed to explore multimorbid older adults' experiences with participation and eHealth in care coordination with general practitioners (GPs) and district nurses (DNs).

METHODS

The study had a qualitative explorative approach. Data collection included semistructured interviews with 20 older adults with multimorbidity receiving primary care services from their GPs and DNs. The participants were included by their GPs or nurses at a local intermunicipal acute inpatient care unit. The data analysis was guided by systematic text condensation.

RESULTS

We identified 2 categories: (1) older adults in charge of and using eHealth in care coordination, and (2) older adults with a loss of control in care coordination. The first category describes how communication with GPs and DNs can facilitate participation, the importance of managing own medication, and how eHealth can support older adults' information needs. The second category focuses on older adults who depend on guidance and help from their GPs and DNs to manage their health, describing how a lack of capacity and system support to be involved makes these adults lose control of their care coordination.

CONCLUSIONS

Being in charge of care coordination is important for older multimorbid adults. The results show that older adults are willing to use eHealth to be informed and to seek information, which ensures high levels of participation in care coordination. Future research should investigate how older adults can be involved in electronic information sharing with health care providers.

Barriers and facilitators to reducing paracetamol use in low back pain: A qualitative study

BACKGROUND

Paracetamol is widely used for low back pain (LBP), but research questions its efficacy and safety. Patient education booklets have been explored for promoting deprescribing, but barriers and facilitators specific to LBP deprescribing remain unexamined.

OBJECTIVE

To identify contextual factors facilitating and obstructing successful deprescribing of paracetamol for LBP after receiving an educational booklet.

STUDY DESIGN

This study is part of an uncontrolled cohort feasibility study (CEASE NOW) in the community, recruiting from Musculoskeletal Australia and painaustralia.

PATIENT SAMPLE

Twenty-four participants with acute, sub-acute, or chronic LBP, self-reporting paracetamol consumption, were included.

METHODS

Thematic content analysis was used to analyze qualitative data on barriers and facilitators. Data were categorized by deprescribing outcomes: i) successful deprescribing, ii) attempted but failed, or iii) no attempt. Semi-structured telephone interviews were conducted within one week after each participant completed the one-month follow-up.

RESULTS

Successful deprescribing was facilitated by supportive healthcare professionals, willingness, high self-efficacy, fear of future illness, and diverse strategies for deprescribing plans. Barriers included unsupportive healthcare professionals and fear of flare-ups. Participants not attempting deprescribing believed it unnecessary, perceived it as effortful, unquestioningly trusted healthcare professionals, and lacked risk awareness.

CONCLUSIONS

Support from healthcare professionals, patient willingness, perceived necessity, risk awareness, effort, and varied strategies influence deprescribing outcomes for LBP patients using paracetamol. Addressing these factors is crucial when designing interventions to promote safe and effective deprescribing in LBP management.

Exploring the Multidimensional Relationship Between Medication Beliefs and Adherence to Medications Among Older Adults Living With Multimorbidity Using Polynomial Regression: An Observational Cohort Study

BACKGROUND

People living with multimorbidity may hold complex beliefs about medicines, potentially influencing adherence. Polynomial regression offers a novel approach to examining the multidimensional relationship between medication beliefs and adherence, overcoming limitations associated with difference scores.

PURPOSE

To explore the multidimensional relationship between medication beliefs and adherence among people living with multimorbidity.

METHODS

Secondary analysis was conducted using observational data from a cohort of older adults living with ≥2 chronic conditions, recruited from 15 family practices in Ireland in 2010 (n = 812) and followed up in 2012 (n = 515). Medication beliefs were measured with the Beliefs about Medicines Questionnaire-Specific. Adherence was assessed with the medication possession ratio using prescription data from the national primary care reimbursement service. Polynomial regression was used to explore the best-fitting multidimensional models for the relationship between (i) beliefs and adherence at baseline, and (ii) beliefs at baseline and adherence at follow-up.

RESULTS

Confirmatory polynomial regression rejected the difference-score model, and exploratory polynomial regression indicated quadratic models for both analyses. Reciprocal effects were present in both analyses (slope [Analysis 1]: β = 0.08, p = .007; slope [Analysis 2]: β = 0.07, p = .044), indicating that adherence was higher when necessity beliefs were high and concern beliefs were low. Nonreciprocal effects were also present in both analyses (slope [Analysis 1]: β = 0.05, p = .006; slope [Analysis 2]: β = 0.04, p = .043), indicating that adherence was higher when both necessity and concern beliefs were high.

CONCLUSIONS

Among people living with multimorbidity, there is evidence that the relationship between medication beliefs and adherence is multidimensional. Attempts to support adherence should consider the combined role of necessity and concern beliefs.

Beliefs and attitudes of residents, family members and healthcare professionals regarding deprescribing in long-term care: a qualitative study

BACKGROUND

Polypharmacy is prevalent among long-term care (LTC) residents and can cause significant morbidity. In 2018, we concluded a deprescribing pilot study that reduced potentially inappropriate medication use among LTC residents.

AIM

We sought to understand the experience and views of physicians, nurses, pharmacists, LTC residents and family members who participated in the pilot study.

METHOD

Qualitative semi-structured interviews were conducted with residents and families, a physician, pharmacist and pharmacy student, and licensed-practical nurses. Interviews were audio recorded, transcribed, and analyzed using an inductive thematic analysis approach.

RESULTS

Interviews with 13 participants yielded themes in 3 categories: (1) views about medication use in LTC and willingness to engage in deprescribing, (2) perceived barriers and enablers for deprescribing, and (3) impact of participating in deprescribing study. Participants were willing to engage in deprescribing; residents were motivated by physician suggestions, and family members prioritized quality of life in decision-making and wanted to be part of the decision-making process. Solutions to overcome barriers included assigning responsibility to identify deprescribing opportunities to pharmacists, scheduling rounds to enable face-to-face team discussions, and consulting families to provide missing medical history to inform deprescribing decisions. Participating in a deprescribing intervention resulted in improved healthcare professional (HCP) confidence and interprofessional collaboration, and caused continued practice change after the study.

CONCLUSION

Residents, families, and HCPs are concerned about problems associated with polypharmacy in LTC and are willing to consider deprescribing. Barriers to deprescribing in LTC exist but are not insurmountable. Results provide valuable insight into strategies to optimize deprescribing interventions within LTC.

Treatment Adherence in Patients with Obstructive Pulmonary Diseases

COPD is the third most common cause of death globally. Adherence rates in patients with obstructive pulmonary diseases usually range between 10% and 40%. The aim of the study was to evaluate the level of treatment adherence to inhaled therapy in patients with obstructive pulmonary diseases. A total of 325 patients, of mean age 63.04 ± 11.29, with COPD or asthma, were included into the study between 2020 and 2021. The following questionnaires were used: Beliefs about Medicines Questionnaire, Test of Adherence to Inhalers and Adherence to Refills and Medications Scale. The respondents tended to be convinced of the necessity of their medication (3.87 points per question). The patients reported moderate levels of overall adherence (21.15 ± 6.23). A total of 74% of patients demonstrated sporadic non-compliance. We conclude that patients with obstructive pulmonary diseases are moderately adherent to their medication. Beliefs about medicines have a significant impact on adherence to medications. Being unemployed, being a non-smoker and belief in the necessity of medication are independent determinants of better medication adherence. The number of hospital admissions due to exacerbations of the disease over the last year and belief that medicines are harmful are independent determinants of poorer medication adherence.

Strategies and Tools for Supporting the Appropriateness of Drug Use in Older People

Through this structured review of the published literature, we aimed to provide an up-to-date description of strategies (human-related) and tools (mainly from the digital field) facilitating the appropriateness of drug use in older adults. The evidence of each strategy and tool's effectiveness and sustainability largely derives from local and heterogeneous experiences, with contrasting results. As a general framework, three main steps should be considered in implementing measures to improve appropriateness: prescription, acceptance by the patient, and continuous monitoring of adherence and risk-benefit profile. Each step needs efforts from specific actors (physicians, patients, caregivers, healthcare professionals) and dedicated supporting tools. Moreover, how to support the appropriateness also strictly depends on the particular setting of care (hospital, ambulatory or primary care, nursing home, long-term care) and available economic resources. Therefore, it is urgent assigning to each approach proposed in the literature the following characteristics: level of effectiveness, strength of evidence, setting of implementation, needed resources, and issues for its sustainability.

Contexts and mechanisms relevant to General Practitioner (GP) based interventions to reduce adverse drug events (ADE) in community dwelling older adults: a rapid realist review

Background: Older adults in Ireland are at increased risk of adverse drug events (ADE) due, in part, to increasing rates of polypharmacy. Interventions to reduce ADE in community dwelling older adults (CDOA) have had limited success, therefore, new approaches are required. A realist review uses a different lens to examine why and how interventions were supposed to work rather than if, they worked. A rapid realist review (RRR) is a more focused and accelerated version. The aim of this RRR is to identify and examine the contexts and mechanisms that play a role in the outcomes relevant to reducing ADE in CDOA in the GP setting that could inform the development of interventions in Ireland. Methods: Six candidate theories (CT) were developed, based on knowledge of the field and recent literature, in relation to how interventions are expected to work. These formed the search strategy. Eighty full texts from 633 abstracts were reviewed, of which 27 were included. Snowballing added a further five articles, relevant policy documents increased the total number to 45. Data were extracted relevant to the theories under iteratively developed sub-themes using NVivo software. Results: Of the six theories, three theories, relating to GP engagement in interventions, relevance of health policy documents for older adults, and shared decision-making, provided data to guide future interventions to reduce ADEs for CDOA in an Irish setting. There was insufficient data for two theories, a third was rejected as existing barriers in the Irish setting made it impractical to use. Conclusions: To improve the success of Irish GP based interventions to reduce ADEs for CDOA, interventions must be relevant and easily applied in practice, supported by national policy and be adequately resourced. Future research is required to test our theories within a newly developed intervention.

Attitudes of older adults and their carers towards de-prescribing: A systematic review

AIM

The aim of this systematic review is to explore the attitudes of older adults (≥65 years old) and their carers towards de-prescribing.

METHODS

We identified relevant studies from three databases; MEDLINE, CINAHL and Web of Science. Two reviewers (MS, SS) independently extracted data from each selected study using a standardised self-developed data extraction form. Main findings of the studies were summarised descriptively.

RESULTS

A total of 35 studies were included in the review. Of them, 19 were questionnaire studies, 11 semi-structured interviews, 4 focus groups and 1 study used the nominal group technique approach. Most older adults and their carers were willing to have medication de-prescribed if told to do so by a healthcare professional (HCP). Other factors that increased willingness to de-prescribing included; trust in the HCP, side effects and inconvenience from medications as well as the prospect of follow-up and monitoring during de-prescribing. In contrast, perceived effectiveness, unawareness of lack of benefit, negative expectations of ageing and fear were factors preventing de-prescribing.

CONCLUSION

De-prescribing is an important concept in older people given the harm associated with polypharmacy in this age group. Overall, older adults and their carers are willing to have medication de-prescribed if facilitated by their HCP. However, there remain a few barriers to de-prescribing which may need to be addressed in certain patients, through discussions between older adults/their carers and a HCP, to allow de-prescribing to be more effective.

Medication use problems among older adults at a primary care: A narrative of literature review

Appropriate medication use is one of the most significant challenges among the older population. Although medication use problems are well documented at the secondary and tertiary health care level, the evidence at the primary care level of OECD region is limited. A narrative review of existing literature was conducted through a nonsystematic search for original articles through electronic search databases, Ovid Medline, Google Scholar from 2001 to 2021, and a combination of citation references. Medication use problems are prevalent in older adults at the primary care level. The main issues of medication use identified were as follows; nonadherence, adverse drug events, accessibility, polypharmacy, inappropriate medications, belief about medications, lack of knowledge and awareness, and lack of deprescribing. In addition, the current review has identified the possibilities of the problems: many medications, forgetfulness, lack of deprescribing, lack of communication, poor understanding, and limited awareness of inappropriate medications. This review found that various medication use problems subclusters were identified to impact the health care need among older adults. Therefore, effective interventions targeting these issues need to be developed to reduce medication use problems among older adults at a primary care level.

Attitudes toward deprescribing among older adults with dementia in the United States

BACKGROUND

People with dementia (PWD) take medications that may be unnecessary or harmful. This problem can be addressed through deprescribing, but it is unclear if PWD would be willing to engage in deprescribing with their providers. Our goal was to investigate attitudes toward deprescribing among PWD.

METHODS

This was a cross-sectional study of 422 PWD aged ≥65 years who completed the medications attitudes module of the National Health and Aging Trends Study (NHATS) in 2016. Proxies provided responses when a participant was unable to respond due to health or cognitive problems. Attitudinal outcomes comprised responses to two statements from the patients' attitudes toward deprescribing questionnaire and its revised version (representing belief about the necessity of one's medications and willingness to deprescribe); another elicited the maximum number of pills that a respondent would be comfortable taking.

RESULTS

The weighted sample represented over 1.8 million PWD; 39% were 75 to 84 years old and 38% were 85 years or older, 60% were female, and 55% reported six or more regular medications. Proxies provided responses for 26% of PWD. Overall, 22% believed that they may be taking one or more medicines that they no longer needed, 87% were willing to stop one or more of their medications, and 50% were uncomfortable taking five or more medications. Attitudinal outcomes were similar across sociodemographic and clinical factors. PWD taking ≥6 medications were more likely to endorse a belief that at least one medication was no longer necessary compared to those taking <6 (adjusted probability 29% [95% confidence interval (CI), 22%-38%] vs. 13% [95% CI, 8%-20%]; p = 0.004); the same applied for willingness to deprescribe (92% [95% CI, 87%-95%] vs. 83% [95% CI, 76%-89%]; p = 0.04).

CONCLUSIONS

A majority of PWD are willing to deprescribe, representing an opportunity to improve quality of life for this vulnerable population.

Older Patient and Surrogate Attitudes Toward Deprescribing During the Transition From Acute to Post-Acute Care

Attitudes toward deprescribing among hospitalized older patients transitioning to post-acute care in the United States are less known. This study describes older patients' and their surrogate's attitudes using all items of the Patient Attitudes Toward Deprescribing (PATD) questionnaire and compares perceived pill burden to the actual count of total daily pills and potentially inappropriate medications (PIMs). Overall, 93% of participants were willing to deprescribe if their physician agreed. Compared to patients, surrogates had 64% reduced odds (95% CI: 0.18-0.74) of believing that all of the care recipient's medications were necessary and 61% reduced odds (95% CI: 0.17-0.88) of attributing cost as a factor in deprescribing. Perceptions of medication burden were associated with patients' total daily pills (median 16) and PIMS (median 7), yet 61% agreed that all their medicines were necessary. Patients and surrogates typically express a willingness to deprescribe but have differing perceptions of medication appropriateness.

Optimizing Older Adults' Medication Use

This article is the third in a series, Supporting Family Caregivers in the 4Ms of an Age-Friendly Health System, published in collaboration with the AARP Public Policy Institute as part of the ongoing Supporting Family Caregivers: No Longer Home Alone series. The 4Ms of an Age-Friendly Health System (What Matters, Medication, Mentation, and Mobility) is an evidence-based framework for assessing and acting on critical issues in the care of older adults across settings and transitions of care. Engaging the health care team, including older adults and their family caregivers, with the 4Ms framework can help to ensure that every older adult gets the best care possible, is not harmed by health care, and is satisfied with the care they receive. The articles in this series present considerations for implementing the 4Ms framework in the inpatient hospital setting and incorporating family caregivers in doing so. Resources for both nurses and family caregivers, including a series of accompanying videos developed by AARP and the Rush Center for Excellence in Aging and funded by The John A. Hartford Foundation, are also provided. Nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses.

Psychotropic medication deprescribing in residential aged care facilities: An exploratory study of the knowledge and attitudes of family members of residents with dementia

OBJECTIVES

General practitioners face many barriers to deprescribing psychotropic medications in people with dementia in nursing homes, including a lack of knowledge about their medication histories. This study explored the knowledge of family members about residents' medications and their willingness to support deprescribing.

METHODS

Sixty-six family members of residents from seven residential aged care facilities participated in this cross-sectional study. Participation involved nomination of recognised medications, rating their effectiveness and rating level of support for deprescribing.

RESULTS

Fifty-five per cent of medications were recognised by family members; significantly fewer psychotropics were recognised than non-psychotropic medications. Though rated as just as effective, support for deprescribing psychotropics was significantly higher. Most family members were agreeable to deprescribing with general practitioner support.

CONCLUSIONS

Although there is a gap in family members' knowledge about psychotropic medications, overall they are supportive of deprescribing. Findings emphasise the need for psychoeducation among family members. Providing family members with a list of prescribed medications, specifying the type of and reason for prescription and side effects of each, is recommended to facilitate their advocacy for deprescribing on behalf of nursing home residents.

Home care patients’ experiences from living with polypharmacy - a qualitative interview study

Background

Patients with home care (HC) are frail and multi-diseased older persons who are often treated with many medicines. Their perspectives on polypharmacy have previously been sparsely explored.

Aim

To investigate these patients’ experiences and perceptions regarding polypharmacy.

Design & setting

Semi-structured interviews with seventeen patients with HC in Stockholm, Sweden. The informants’ median age was 83,5 years (range 74–97 years) and the median number of prescribed medicines was 11 (range 5-30).

Method

The interview questions were open and aimed to encourage informants to speak freely about their personal experiences of living with polypharmacy. Data was analysed using an inductive thematic analysis.

Results

Two themes were identified: 1) Experiences from daily life with polypharmacy, and 2) Dependency on the relationship to healthcare professionals. The first theme contains the main finding which was the diversity in how older persons experienced polypharmacy and how they coped with polypharmacy in everyday life. While some were satisfied despite having multiple medicines, others experienced such psychological unease due to polypharmacy that it led to reduced quality of life. The second theme reflects the importance of the relationship between the older person and healthcare professionals for medicine-related ideas and attitudes.

Conclusions

The individual variation in experiences regarding polypharmacy points to the value of interprofessional teamwork with the patient as an active partner. Therefore, healthcare professionals need to adapt a more person-centred approach where the patient’s perspectives are respected and considered in medicine-related decision-making.

Relational dynamics involved in therapeutic discordance among prescribers and patients: A Grounded Theory study

OBJECTIVE

No studies have explored the negative process of concordance: discordance in prescribing-medication-taking. This study provides a deeper understanding of discordance as a co-constructed process among patients and prescribers.

METHODS

To explore the question "what psychological and relational processes are involved when therapeutic discordance among prescribers and receivers occurs?" a constructivist Grounded Theory study was carried out through semi-structured interviews with patients and their medical doctors.

RESULTS

The final sample of our study was composed of 29 participants: 16 receivers and 13 prescribers. "Neglecting the relationship", the core category, shapes the therapeutic discordance and connects three main conceptual phases: signing a non-negotiating contract, acting alone, and establishing a superficial relationship.

CONCLUSION

Our grounded theory conceptualization contributes to the concordance-related debate by evidencing the processes among prescribers and receivers in interwoven actions. It offers another dimension to how notions of compliance, adherence and concordance have been theorized to date.

PRACTICE IMPLICATIONS

More than one interaction with receivers is recommended. If there are hints that conflict potentially is compromising the relationship, prescribers should involve intermediaries. Setting aside for a moment, evidence-based justification for treatments and trying to understand prescribers' motivations may boost a positive change.

Beliefs about medication after hospital discharge in geriatric patients with polypharmacy

OBJECTIVES

To describe beliefs about medication in geriatric patients with polypharmacy post-discharge and to evaluate the impact of discharge management on patients' medication beliefs.

METHODS

A cross-sectional study was conducted between November 2019 and March 2020 in twelve general hospitals in Belgium. Four hundred geriatric patients with polypharmacy were surveyed at hospital discharge and two to five days post-discharge using the Beliefs about Medicines Questionnaire and self-developed questionnaires.

RESULTS

According to participants, the benefits of medication outweighed the disadvantages as the mean necessity score (19.4/25) outweighed the mean concern score (11.9/25). Patients receiving help with medication management post-discharge had stronger necessity-, concern- and overuse-related beliefs. No patient- or discharge management-related factors were significant predictors of medication beliefs.

CONCLUSIONS

Assessing patients' medication beliefs and identifying and addressing patients' concerns, can be an opportunity to improve medication use, to prevent non-adherence and to enhance safe medication practices at home.

Patients' and clinicians' perceptions of oral anticoagulants in atrial fibrillation: a systematic narrative review and meta-analysis

Background

Atrial fibrillation (AF) increases the risk of developing a stroke by 20%. AF related strokes are associated with greater morbidity. Historically, warfarin was the anticoagulant of choice for stroke prevention in patients with AF but lately patients are being switched or started on direct oral anticoagulants (DOACs). DOACs are promoted as safer alternatives to warfarin and it is expected that they will be associated with fewer challenges both for patients and healthcare professionals. This systematic narrative review aimed to explore perspectives of patients and professionals on medicines optimisation of oral anticoagulation with vitamin K antagonists and DOACs in atrial fibrillation.

Methods

Prospero registration CRD42018091591. Systematic searches undertaken of research studies (qualitative and quantitative), published February 2018 to November 2020 from several databases (Web of Science, Scopus, Medline Via Ovid, CINHAL via Ebsco, and PubMED via NCBI) following PRISMA methodology. Data were organised using Covidence software. Two reviewers independently assessed the quality of the included studies and synthesized the findings (thematic analysis approach).

Results

Thirty-four studies were included. Studies were critically appraised using established critical appraisal tools (Qualsyst) and a risk of bias was assigned. Clinicians considered old age and the associated complexities such as co-morbidities and the increased potential for bleeding as potential barriers to optimising anticoagulation. Whereas patients’ health and medication beliefs influenced adherence. Notably, structured patient support was important in enhancing safety and effective anticoagulation. For both patients and clinicians, confidence and experience of safe anticoagulation was influenced by the presence of co-morbidities,  poor knowledge and understanding of AF and the purpose of anticoagulation.

Conclusion

Age, complex multimorbidity and polypharmacy influence prescribing, with DOACs being perceived to be safer than warfarin. This systematic narrative review suggests that interventions are needed to support patient self-management. There are residual anxieties associated with long term anticoagulation in the context of complexities.

Trial registration

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01590-x.

Knowledge and Power Relations in Older Patients' Communication About Medications Across Transitions of Care

Communicating about medications across transitions of care is a challenging process for older patients. In this article, we examined communication processes between older patients, family members, and health professionals about managing medications across transitions of care, focusing on older patients' experiences. A focused ethnographic design was employed across two metropolitan hospitals. Data collection methods included interviews, observations, and focus groups. Following thematic analysis, data were analyzed using Fairclough's Critical Discourse Analysis and Medication Communication Model. Older patients' medication knowledge and family members' advocacy challenged unequal power relations between clinicians and patients and families. Doctors' use of authoritative discourse impeded older patients' participation in the medication communication. Older patients perceived that nurses' involvement in medication communication was limited due to their task-related routines. To reduce the unequal power relations, health professionals should be more proactive in sharing information about medications with older patients across transitions of care.

Self-Efficacy, Social Activity, and Spirituality in the Care of Elderly Patients with Polypharmacy in Germany-A Multicentric Cross-Sectional Study within the HoPES3 Trial

About one third of Europe’s elderly population takes ≥5 drugs. Polypharmacy increases their risk of adverse drug reactions. To ensure drug safety, innovative approaches are needed. The aim of this cross-sectional study was to explore the relationship between psychosocial factors and medication-related beliefs and behaviors. Medication lists of 297 patients were recorded according to the ATC classification. Correlations between the dependent variables, Medication Adherence (MARS) and Beliefs about Medicines (BMQ), and independent variables, General Self-Efficacy (GSE), self-efficacy for managing chronic diseases (SES6G), spiritual needs (SpNQ), patient activity (PAM), loneliness (DJG), and social networks (LSNS), were measured. Patients with higher self-efficacy (OR: 1.113; 95% CI [1.056–1.174]; p < 0.001) or self-confidence in managing their chronic condition (OR: 1.188; 95% CI [1.048–1.346]; p < 0.007) also showed higher adherence. Lonely patients (OR: 0.420; 95% CI [0.267–0.660]; p < 0.001) and those with a need for inner peace (OR: 0.613; 95% CI [0.444–0.846], p = 0.003) were more likely nonadherent. Stronger positive beliefs about medications’ usefulness weakly correlated with higher scores on the SES6G (ρ = 0.178, p = 0.003) and GSES scale (ρ = 0.121, p = 0.042), patient activity (ρ = 0.155, p = 0.010) and functioning social networks scale (ρ = 0.159, p = 0.008). A weak positive correlation was found between loneliness and the belief that drugs were harmful (ρ = 0.194, p = 0.001). Furthermore, interesting correlations were detected regarding the number of medications and overuse beliefs. Psychosocial factors, such as self-efficacy, loneliness, and spiritual needs and medication-related beliefs and behaviors seem to interrelate. Addressing these factors may improve medication management and drug safety.

Patient values and preferences on polypharmacy and deprescribing: a scoping review

Background Understanding how patient values and preferences towards polypharmacy and deprescribing have been studied is important to gain insight on current knowledge in this area and to identify knowledge gaps. Aim To describe methods and outcomes for studying patient values and preferences towards polypharmacy and deprescribing, and to identify gaps in the existing literature. Method A scoping review was conducted on English-language studies that examined patient preferences and values related to polypharmacy and/or deprescribing among community-dwelling adults. MEDLINE, Embase, PubMed, PsycINFO, EconLit, Social Science Citation Index, Science Citation Index Expanded, International Pharmaceutical Abstracts, and CINAHL/AgeLine were searched. Results Thirty articles were included. Surveys (n = 17, 56.7%), interviews/focus groups (n = 9, 30.0%), and mixed methods (n = 3, 10.0%), were commonly used methods. Patients Attitudes Towards Deprescribing (PATD) was the most common tool used (n = 9, 30.0%). Twelve themes related to attitudes, social pressure, and control of polypharmacy/deprescribing were identified. The most frequently-encountered themes included desire or willingness to reduce medication load and influence of healthcare provider on medication use. Conclusion PATD was commonly used to assess preferences and values towards polypharmacy and limited knowledge on patient-important outcomes were addressed. Future research should focus on shared decision-making and communicating risk versus benefit of medications.

General practitioners' compliance with benzodiazepine discontinuation guidelines in patients treated with long-term lorazepam: A case-vignette cross-sectional survey

AIM

To study determinants associated with GPs' compliance with benzodiazepine discontinuation guidelines through a case-vignette of a patient with multimorbidity treated with long-term lorazepam for insomnia.

METHODS

This cross-sectional survey was performed in a sample of French GPs. The questionnaire included items on their characteristics and questions related to the management of a case-vignette with long-term lorazepam use consulting for a prescription renewal. GPs who proposed a dedicated consultation to discuss discontinuation or progressive discontinuation were considered as "following guidelines", while they were considered as "out-of-guidelines" if they proposed immediate discontinuation or decided not to discontinue lorazepam. A backward selection process was used to select factors to be included in the final logistic regression model. The probabilities of out-of-guidelines practice and their 95% confidence interval (95% CI) were then plotted using a heatmap graph.

RESULTS

Of 1,177 GPs, the majority (92.2%) were aware of the necessity to discontinue lorazepam and reported practice consistent with good practice guidelines. Women GPs aged under 50 years had the lowest estimated probability of out-of-guidelines practice. Conversely, men aged over 58 years with high consideration of patient preferences and low concern about the benefit-risk ratio of lorazepam had the highest probability of out-of-guidelines practice (27.3% [18.7%; 34.7%]).

CONCLUSION

GPs largely reported practice compliant with benzodiazepine discontinuation guidelines, although some GPs, mainly older men who overemphasise patient preferences, were more likely to adopt out-of-guidelines practice.

Beliefs about Polypharmacy among Home-Dwelling Older Adults Living with Multiple Chronic Conditions, Informal Caregivers and Healthcare Professionals: A Qualitative Study

Although home-dwelling older adults are frequently assisted with polypharmacy management by their informal caregivers, they can still face medication-related problems. Identifying older adults’ and their informal caregivers’ beliefs about medication is a gateway to understanding and improving medication adherence. This study aimed to analyse beliefs about polypharmacy among home-dwelling older adults with multiple chronic conditions and their informal caregivers, focusing on their daily medication practices. Semi-structured interviews were conducted with 28 older adults, 17 informal caregivers, but also 13 healthcare professionals. Based on an inductive methodological approach, data were analysed using thematic content analysis. Interviews revealed the different attitudes adopted by older adults and their informal caregivers in relation to the treatment information provided by healthcare professionals. A variety of beliefs were identified and linked to medication adherence by examining daily medication practices. Polypharmacy was experienced as a habit but also an obligation, highlighting some of the strategies and negotiations underlying medication use at home. Collecting viewpoints from multiple stakeholders is an innovative way of accessing and analysing beliefs about polypharmacy. Daily medication practices provided information about medication beliefs and may contribute to developing targeted professional interventions that improve medication adherence.

Older Patients' Perceptions of Medicines and Willingness to Deprescribe

Introduction Major barriers in deprescribing are the ambivalence of patients, resistance to change, and poor acceptance of alternative treatments. Objective To investigate older patients' beliefs, understanding and knowledge, satisfaction with medicine use, health outcome priorities, their attitude toward deprescribing, and to identify associated patient factors. Methods This multi-center cross-sectional, semistructured survey study involved older outpatients (70 years of age and older) with polypharmacy. The survey comprised three validated questionnaires: Beliefs about Medicines Questionnaire, Patients' Attitudes Towards Deprescribing questionnaire, and the Health Outcome Prioritization tool, with additional questions about understanding and satisfaction. The association between questionnaire outcomes and patient characteristics was investigated. Results Fifty participants were included; they used an average of 9 (+/- SD 2.7) medicines. For most participants (82%), the necessity of using medicines outweighed their concerns. Participants could name 35% of their medicines and 43% of the indications. Overall, 76% were satisfied with the effect of their medicines, but 94% would be willing to stop their medication if advised by their doctor. Maintaining independence (46%) and reducing pain (31%) were the most important health outcome priorities reported by the patients; staying alive had the lowest priority (51%). Participants with higher levels of educational attainment had better knowledge and had more concerns about harmful effects. Conclusions Patients are open to deprescribing but would probably not initiate the conversation themselves because they are generally very satisfied with their medicines. Knowledge about their medicines and their indications is poor. If doctors initiate deprescribing, patients are probably willing to follow their advice. Patients' life priorities should be discussed in deprescribing conversations.

"I must, and I can live with that": a thematic analysis of patients' perspectives on polypharmacy and a digital decision support system for GPs

Background

To investigate patients’ perspectives on polypharmacy and the use of a digital decision support system to assist general practitioners (GPs) in performing medication reviews.

Methods

Qualitative interviews with patients or informal caregivers recruited from participants in a cluster-randomized controlled clinical trial (cRCT). The interviews were transcribed verbatim and analyzed using thematic analysis.

Results

We conducted 13 interviews and identified the following seven themes: the patients successfully integrated medication use in their everyday lives, used medication plans, had both good and bad personal experiences with their drugs, regarded their healthcare providers as the main source of medication-related information, discussed medication changes with their GPs, had trusting relationships with them, and viewed the use of digital decision support tools for medication reviews positively. No unwanted adverse effects were reported.

Conclusions

Despite drug-related problems, patients appeared to cope well with their medications. They also trusted their GPs, despite acknowledging polypharmacy to be a complex field for them. The use of a digital support system was appreciated and linked to the hope that reasons for selecting specific medication regimens would become more comprehensible. Further research with a more diverse sampling might add more patient perspectives.

Trial registration

ClinicalTrials.gov, NCT03430336. Registered on February 6, 2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01517-6.

Potentially inappropriate medications (PIMs): frequency and extent of GP-related variation in PIMs: a register-based cohort study

OBJECTIVES

Potentially inappropriate medications (PIMs) pose an increasing challenge in the ageing population. We aimed to assess the extent of PIMs and the prescriber-related variation in PIM prevalence.

DESIGN

Nationwide register-based cohort study.

SETTING

General practice.

PARTICIPANTS

The 4.2 million adults listed with general practitioner (GP) clinics in Denmark (n=1906) in 2016.

MAIN OUTCOME MEASURES

We estimated the patients' time with PIMs by using 29 register-operationalised STOPP criteria linking GP clinics and redeemed prescriptions. For each criterion and each GP clinic, we calculated ratios between the observed PIM time and that predicted by multivariate Poisson regressions on the patients. The observed variation was measured as the 90th/10th percentile ratios of these ratios. The extent of expectable random variation was assessed as the 90th/10th percentile ratios in randomly sampled GP populations (ie, the sampled variation). The GP-related excess variation was calculated as the ratio between the observed variation and sampled variation. The linear correlation between the observed/expected ratio for each of the criteria and the observed/expected ratio of total PIM time (for each clinic) was measured by Pearson's rho.

RESULTS

Overall, 294 542 individuals were exposed to 1 44 117 years of PIMs. The two most prevalent PIMs were long-term use (>3 months) of non-steroidal anti-inflammatory drugs (51 074 years of PIMs) or benzodiazepines (48 723 years of PIMs). These two criteria showed considerable excess variation of 2.33 and 3.05, respectively; for total PIMs, this figure was 1.65. For more than half of the criteria, we observed a positive correlation between the specific PIM and the sum of remaining PIMs.

CONCLUSIONS

This study documents considerable variations in the prescribing practice of GPs for certain PIMs. These findings highlight a need for exploring the causal explanations for such variations, which could be markers of suboptimal GP-prescribing strategies.

'I just take them because I know the people that give them to me': A theory-informed interview study of community-dwelling people with dementia and carers' perspectives of medicines management

OBJECTIVE

Identify facilitators and barriers to successful medicines management for people with dementia (PwD) in primary care from the perspectives of community-dwelling PwD and carers.

METHODS

Semi-structured interviews conducted with PwD and carers in Northern Ireland. The 14-domain Theoretical Domains Framework guided data collection and analysis. Interviews explored participants' experiences and perceptions of medicines management. PwD also completed the Beliefs about Medicines Questionnaire indicating their level of agreement with statements about medicines. Qualitative data were analysed using the framework method and content analysis. Quantitative data were analysed descriptively.

RESULTS

Eighteen PwD and 15 carers were interviewed. PwD believed they were competent with medicines management ('beliefs about capabilities'). Most PwD reported having strategies to prompt them to take their medicines ('memory, attention and decision processes'). Carers played an important role in supporting PwD with medicines management ('social influences') and monitoring adherence ('behavioural regulation') and anticipated having to take on a greater role as patients' cognitive impairment worsened ('beliefs about consequences'). Participants highlighted assistance provided by community pharmacies with medicines acquisition and delivery ('environmental context and resources') and placed great trust in primary healthcare professionals ('social influences'). PwD had positive attitudes towards medication and believed strongly in the necessity of their medicines.

CONCLUSIONS

This is the first study to use a theoretical approach to explore medicines management for community-dwelling PwD. The findings provide new insights into the critical role of carers in facilitating optimal medicines management and will inform future intervention development, in which carers' needs assessment and involvement will be key.

Impact of Beliefs about Medicines on the Level of Intentional Non-Adherence to the Recommendations of Elderly Patients with Hypertension

Background: Non-adherence to pharmaceutical treatment is one of the most common causes of uncontrolled hypertension. Non-adherence may be intentional or unintentional. In the case of intentional non-adherence, it is crucial to understand the reasons behind it. The literature increasingly addresses the issue of beliefs and concerns about medication, but studies on this subject performed in a Polish population of hypertensive patients are still lacking. The aim of the study was to assess the level of intentional non-adherence among patients with hypertension, and to determine the relationship between beliefs about medication and the level of intentional non-adherence to treatment in elderly patients with hypertension. Material and methods: The study included 300 patients (106 of whom were male, mean age (SD) 71.71 (8.12) years) with hypertension, treated at a hypertension clinic. The following instruments were used: the Intentional Non-Adherence Scale (INAS) for evaluating intentional non-adherence, and the Beliefs about Medicines Questionnaire (BMQ) for evaluating patients’ beliefs and opinions regarding medication. Socio-demographic and clinical data were obtained from patients’ medical records. Results: The mean (SD) INAS score in the study was 47.28 (19.12). Patients were most concerned about the harm caused by medication, and least concerned about the necessity to take medication (mean score per item 3.49 vs. 2.14). Correlation analysis demonstrated weak correlations between BMQ and INAS: higher scores for necessity were associated with more intentional non-adherence (r = 0.174, p = 0.003), while higher scores for overuse, harm, and concerns were associated with less intentional non-adherence (respectively: r = −0.253, p < 0.001 vs. r = −0.336, p < 0.001 vs. r = −0.351, p < 0.001). In multiple-factor analysis, factors increasing the level of intentional non-adherence were elderly age (β = −0.352, p = 0.009), multimorbidity (β = −2.374, p = 0.035), and a higher BMQ concerns score (β = −1.376, p < 0.001), while being single was an independent predictor decreasing intentional non-adherence (β = 5.646, p = 0.013). Conclusions: The overall level of intentional non-adherence among patients with hypertension is moderate, but approximately one third of patients with hypertension demonstrate a high level of non-adherence. Independent determinants of intentional non-adherence include concerns, elderly age, multimorbidity, and being single.

Sociodemographic factors and beliefs about medicines in the uptake of pharmacogenomic testing in older adults

Aim: To assess the impact of sociodemographic factors and beliefs about medicines on the uptake of pharmacogenomic testing in older adults in a public healthcare system. Materials & methods: Data are based on a sample of 347 primary care older adults. Results: Most respondents (90%) were willing to provide a saliva sample and 47% were willing to pay for it. Increased age (odds ratio: 0.91; p = 0.04) and negative beliefs about the harmfulness of medicines (odds ratio: 0.68; p = 0.02) were associated with a decreased willingness to provide a sample. Lower education (less than university, odds ratio: 0.54; p = 0.04) was associated with a decreased willingness to pay. Conclusion: Education and beliefs about medicines are important factors in the acceptability of pharmacogenomic testing in older adults.

The impact of health literacy on beliefs about medication in a Dutch medication-using population

PURPOSE

Medication beliefs are likely contingent on aspects of health literacy: knowledge, motivation, and competences to access, understand, appraise, and apply health information. An association between medication beliefs and health literacy is expected as they both influence self-management. The aim of this study was to examine the association between health literacy and the beliefs about overuse and harmful effects of medication and to examine modifying effects of age, gender, and number of medications on this association.

METHODS

The data were collected using the online "Medication panel" of the Dutch Institute for Rational Use of Medicine. A linear regression model was used to examine the association between health literacy and beliefs about medication and the modifying effects of age, gender, and number of medications on this association.

RESULTS

Respondents with a lower level of health literacy had more concerns about overuse (β adj.= -.174, p<.001) and harmful (β adj.= -.189, p<.001) effects of medication. This study found no modifying effects.

CONCLUSIONS

A lower health literacy level is associated with more concerns about the overuse and harmful effects of medication. The results of this study suggest that extra attention should be given to persons with low health literacy level by healthcare professionals, to decrease their concerns about overuse and harmful effects, and improve adherence to self-management behavior.

Patient and caregiver agreement on prognosis estimates for older adults with advanced cancer

BACKGROUND

Disagreements between patients and caregivers about treatment benefits, care decisions, and patients' health are associated with increased patient depression as well as increased caregiver anxiety, distress, depression, and burden. Understanding the factors associated with disagreement may inform interventions to improve the aforementioned outcomes.

METHODS

For this analysis, baseline data were obtained from a cluster-randomized geriatric assessment trial that recruited patients aged ≥70 years who had incurable cancer from community oncology practices (University of Rochester Cancer Center 13070; Supriya G. Mohile, principal investigator). Patient and caregiver dyads were asked to estimate the patient's prognosis. Response options were 0 to 6 months, 7 to 12 months, 1 to 2 years, 2 to 5 years, and >5 years. The dependent variable was categorized as exact agreement (reference), patient-reported longer estimate, or caregiver-reported longer estimate. The authors used generalized estimating equations with multinomial distribution to examine the factors associated with patient-caregiver prognostic estimates. Independent variables were selected using the purposeful selection method.

RESULTS

Among 354 dyads (89% of screened patients were enrolled), 26% and 22% of patients and caregivers, respectively, reported a longer estimate. Compared with dyads that were in agreement, patients were more likely to report a longer estimate when they screened positive for polypharmacy (β = 0.81; P = .001), and caregivers reported greater distress (β = 0.12; P = .03). Compared with dyads that were in agreement, caregivers were more likely to report a longer estimate when patients screened positive for polypharmacy (β = 0.82; P = .005) and had lower perceived self-efficacy in interacting with physicians (β = -0.10; P = .008).

CONCLUSIONS

Several patient and caregiver factors were associated with patient-caregiver disagreement about prognostic estimates. Future studies should examine the effects of prognostic disagreement on patient and caregiver outcomes.

Focus and features of prescribing indications spanning multiple chronic conditions in older adults: A narrative review

Background:

Inappropriate prescribing is frequent in older adults and associated with adverse outcomes. Prescribing indications aim to optimize prescribing, but little is known about the focus and features of prescribing indications for the most common chronic conditions in older adults. Understanding the conditions, medications, and issues addressed (e.g., patient perspective, drug-disease interaction, adverse drug event) in current prescribing indications may help to identify missing indications and develop standardized measures to improve prescribing quality.

Methods:

We searched Ovid/MEDLINE and EMBASE for articles published between 2015 and 2020 reporting prescribing indications for older adults. Prescribing indication included 1) prescribing “criteria,” or statements that guide prescribing action, and 2) prescribing “measures,” or prescribing actions observed in a population. We categorized their focus by conditions, medications and issues addressed, as well as level of evidence provided.

Results:

Among 16 sets of prescribing indications, we identified 748 criteria and 47 measures. The most common addressed medications were antihypertensives, analgesics/antirheumatics, and antiplatelets/anticoagulants. The most frequently addressed issues were drug-disease interaction, adverse drug event, administration, better therapeutic alternative, and (co-)prescription omission (20.8–36.1%). Age/functioning, drug-drug interaction, monitoring, and efficacy/safety ratio were found in only 9.9–16.5% of indications. Indications rarely focused on the patient perspective or issues with multiple providers.

Conclusion:

Most prescribing indications for chronic conditions in older patients are criteria rather than measures. Indications accounting for patient perspective and multiple providers are limited. The gaps identified in this review may help improve the development of prescribing measures for older adults and ultimately improve quality of care.

Mixed Methods Evaluation of Reasons Why Care Deviates From Clinical Guidelines Among Patients With Multimorbidity

Reasons why care does not conform to single-disease guideline recommendations for multimorbid patients have not been systematically measured in practice. Using a mixed methods approach, we identified and quantified types of reasons why care deviates from nine sets of disease guideline recommendations for multimorbid patients. Utilizing a focus group concept mapping technique, we built on a categorization of reasons explaining guideline deviation, and surveyed treating nurses about these reasons for patients' specific care processes. Directed content analysis was conducted to classify the responses into reasons categories. Of 4,386 guideline-recommended care processes evaluated, 920 were not guideline-concordant (944 reasons). Three broad categories of reasons and 18 specific reasons were identified: Biomedical-related occurred 35.2% of the time, patient personal-related (30.4%), context-related (18.4%), and unknown (16.0%). Patient- and context-related factors are prevalent drivers for guideline deviation in multimorbidity, demonstrating that patient-centered aspects are as much a part of care decisions as biomedical aspects.

Developing a model of the determinants of medication nonadherence in older community-dwelling patients

Medication nonadherence is associated with adverse health outcomes in older populations. The aim of this study was to develop a model that describes the relationship between the determinants of nonadherence, per the World Health Organization (WHO) model of nonadherence and the necessity-concerns framework (NCF) and nonadherence in a cohort of older community-dwelling patients. A retrospective cohort study of 855 community-dwelling patients aged ≥70 years from 15 practices. Medication nonadherence was assessed by (i) medication possession ratio (MPR < 80%) and (ii) the median MPR across all drugs dispensed. Patient questionnaires, interviews, and medical records measured the determinants of nonadherence per the WHO and NCF frameworks. Confirmatory factor analysis (CFA) was undertaken to generate the model of best fit. Two structural equation models (SEM) were developed to evaluate the relationship between the WHO factors, the NCF, and nonadherence (Model 1: MPR < 80%, Model 2: median MPR). The CFA produced a reasonable fit (χ2(113) = 203, p < .001; root mean square error of approximation = 0.03; comparative fit index = 0.98, and weighted root mean square residual = 0.97) and adequate internal consistency (r = .26-.40). SEM analysis (Model 1) showed a significant direct relationship between patient-related (β = 0.45, p < .01), socioeconomic (β = 0.20, p < .01), and therapy-related factors (β = -0.27, p < .01) and nonadherence (MPR < 80%). Similar results were found for Model 2 (median MPR). There was a significant direct relationship between medication concerns (β = -0.13, p < .01) and nonadherence. Therapy-related (β = -0.04, p < .05) and patient-related factors (β = -0.06, p < .05) also had a significant mediating effect on nonadherence through medication concerns. Health care professionals need to address medication concerns and management of adverse effects in older populations to improve adherence and clinical outcomes.

Provider anticipation and experience of patient reaction when deprescribing guideline discordant inhaled corticosteroids

Introduction

Despite evidence of possible patient harm and substantial costs, medication overuse is persistent. Patient reaction is one potential barrier to deprescribing, but little research has assessed this in specific instances of medication discontinuation. We sought to understand Veteran and provider experience when de-implementing guideline-discordant use of inhaled corticosteroids (ICS) in those with mild-to-moderate chronic obstructive pulmonary disease (COPD).

Methods

We conducted a mixed-methods analysis in a provider-randomized quality improvement project testing a proactive electronic-consultation from pulmonologists recommending ICS discontinuation when appropriate. PCPs at two Veterans Health Administration healthcare systems were included. We completed interviews with 16 unexposed providers and 6 intervention-exposed providers. We interviewed 9 patients within 3 months after their PCP proposed ICS discontinuation. We conducted inductive and deductive content analysis of qualitative data to explore an emergent theme of patient reaction. Forty-eight PCPs returned surveys (24 exposed and 24 unexposed, response rate: 35%).

Results

The unexposed providers anticipated their patients might resist ICS discontinuation because it seems counterintuitive to stop something that is working, patient’s fear of worsening symptoms, or if the prescription was initiated by another provider. Intervention-exposed providers reported similar experiences in post-intervention interviews. Unexposed providers anticipated that patients may accept ICS discontinuation, citing tactical use of patient-centered care strategies. This was echoed by intervention-exposed providers who had successfully discontinued an ICS. Veterans reported acceding to their providers out of trust or deference to their advanced training, even after describing an ICS as a ‘security blanket’. Our survey findings supported the subthemes from our interviews. Among providers who proposed discontinuation of an ICS, 76% reported that they were able to discontinue it or switch to another more appropriate medication.

Conclusions

While PCPs anticipated that patients would resist discontinuing an ICS, interviews with patient and intervention-exposed PCPs along with surveys suggest that patients were receptive to this change.

Diagnosis Between Chaos and Control: Affect and Hospital Clinicians' and Older Adult Patients' Narratives of Urinary Tract Infections

Research has observed that older adults are frequently overdiagnosed with urinary tract infection (UTI) and unnecessarily prescribed antibiotics in hospitals. In this article we explore the overlooked affective dimension of experiences of diagnosis and prescribing. Drawing on interviews with doctors, nurses and older adult patients (n = 41) on UTI diagnosis in two UK hospitals and Arthur Frank's work on illness narratives we identified two affective ways of experiencing diagnosis. Some clinicians and older adult patients articulated chaos narratives about being overwhelmed by contradictory evidence and events, doubting the repeated UTI diagnoses and courses of antibiotics but being unable to do anything about their concerns. Other clinicians and patients articulated control narratives about UTIs being frequently diagnosed and antibiotics prescribed to restore patients' health, echoing certainty and security, even if the processes described typically did not follow current guidance. We contend that analyzing the affective dimension offers conceptual insights that push forward sociological discussions on diagnosis as reflective or dogmatic in the context of the contradiction between acute care and chronic illnesses of old age. Our findings contribute practical ideas of why overdiagnosis and overprescribing happen in hospitals and complicate notions of patients pressuring for antibiotics. We also present methodological suggestions for analyzing how participants tell about their experiences in order to explore the typically not directly spoken affective dimension that influences thoughts and actions about diagnosis.

Barriers and facilitators to deprescribing in primary care: a systematic review

BACKGROUND

Managing polypharmacy is a challenge for healthcare systems globally. It is also a health inequality concern as it can expose some of the most vulnerable in society to unnecessary medications and adverse drug-related events. Care for most patients with multimorbidity and polypharmacy occurs in primary care. Safe deprescribing interventions can reduce exposure to inappropriate polypharmacy. However, these are not fully accepted or routinely implemented.

AIM

To identify barriers and facilitators to safe deprescribing interventions for adults with multimorbidity and polypharmacy in primary care.

DESIGN & SETTING

A systematic review of studies published from 2000, examining safe deprescribing interventions for adults with multimorbidity and polypharmacy.

METHOD

A search of electronic databases: MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature (CINHAL), Cochrane, and Health Management Information Consortium (HMIC) from inception to 26 Feb 2019, using an agreed search strategy. This was supplemented by handsearching of relevant journals, and screening of reference lists and citations of included studies.

RESULTS

In total, 40 studies from 14 countries were identified. Cultural and organisational barriers included: a culture of diagnosing and prescribing; evidence-based guidance focused on single diseases; a lack of evidence-based guidance for the care of older people with multimorbidities; and a lack of shared communication, decision-making systems, tools, and resources. Interpersonal and individual-level barriers included: professional etiquette; fragmented care; prescribers' and patients' uncertainties; and gaps in tailored support. Facilitators included: prudent prescribing; greater availability and acceptability of non-pharmacological alternatives; resources; improved communication, collaboration, knowledge, and understanding; patient-centred care; and shared decision-making.

CONCLUSION

A whole systems, patient-centred approach to safe deprescribing interventions is required, involving key decision-makers, healthcare professionals, patients, and carers.

Necessity and concerns about lipid-lowering medical treatments and risk factors for non-adherence: A cross-sectional study in Palestine

AIMS

Strong evidence indicates that drugs reduce blood lipids and improve cardiovascular end-points, leading to their wide usage. However, the success of these drugs can be affected by poor patient's adherence to prescribed medication. This study aimed to evaluate medication adherence in patients with dyslipidaemia in association with patient beliefs about medicines.

METHODS

The study was conducted from January 2019 to July 2019 at the middle governmental primary healthcare clinics in Ramallah and Bethlehem cities, and used a cross-sectional design. Adherence was determined using the 4-item Morisky medication adherence scale, while beliefs were determined using the Beliefs about Medicines Questionnaire.

RESULTS

Of 220 patients, 185 agreed to participate in the study, resulting in a response rate of 84.1%. Of the participants, 106 (57.3%) were men, and almost half (88, 46.5%) were ≥56 years. Medication non-adherence was high (47.6%), but a majority (65.5%) reported believing their treatment to be necessary for their continued good health. Accordingly, the mean necessity score (17.3, SD 3.7) significantly outweighed (P < .001) the mean concerns score (14.0, SD 3.5). Multivariate regression demonstrated four variables to be significantly correlated with non-adherence: illiterate (OR = 2.52; CI: 0.9-4.3; P = .03), polypharmacy (OR = 3.18; CI: 1.9-5.7; P = .007), having comorbidity (OR = 3.10; CI: 2.2-4.6; P = .005) and having concerns about side effects (OR = 2.89; CI: 1.1-4.6, P = .04).

CONCLUSION

Non-adherence among patients taking lipid-lowering agents was high despite most holding positive beliefs regarding medication necessity. This may be due to concern also being high. Physicians should identify and target high-risk patients and individualise their treatment plans in order to achieve adequate control of dyslipidaemia.

Beliefs about immunosuppressant medication and correlates in a German kidney transplant population

OBJECTIVE

A common reason for organ rejection after transplantation is the lack of adherence regarding immunosuppressive medication (ISM). A variety of different aspects can promote non-adherent behavior, including the relationship between perceived benefits and concerns regarding ISM ("necessity-concerns-framework"). Little is known about the variables associated with this framework.

METHODS

As part of this cross-sectional study, 570 patients after kidney transplantation who participated in a structured multimodal follow-up program (KTx360°) were examined in two transplant centers in Lower Saxony. We used the Beliefs about Medicines Questionnaire (BMQ) to evaluate the patients' believes and concerns regarding their ISM.

RESULTS

The mean age of the participants was 51.9 (SD 14.17) years, 58.4% were men, and 25.8% had ≥12 years of school attendance. The mean time since transplantation was 65.9 months. In patients undergoing kidney transplantation, the perceived benefit of ISM mostly exceeded the concerns. We found an association between lower perceived benefits and greater concerns and lower adherence. Also, a higher perceived necessity was significantly associated with higher age and lower levels of depression and anxiety. Greater concerns were significantly associated with more symptoms of depression and anxiety, lower perceived social support, and lower kidney functioning (eGFR).

CONCLUSION

Even though patients after kidney transplantation usually acknowledge the importance of their ISM, they still have considerable concerns that are associated with less adherence and various psychosocial risk factors. Further longitudinal studies are needed to assess the extent to which beliefs about medication are variable and can be individually addressed to improve adherence.