Treatment options for sundowning in patients with dementia

Potentially inappropriate medication prescribing based on 2019 Beers criteria and the impact of pharmacist intervention in elderly patients with kidney diseases: A report from Iran

Background and Aims

A potentially inappropriate medication (PIM) is a pharmaceutical agent that poses a greater risk of harm than potential benefit to elderly patients. This study aimed to detect PIMs and their risk factors in hospitalized elderly patients with kidney disease.

Methods

This cross-sectional study assessed medication orders of elderly patients (≥65 years old) with kidney diseases admitted to the hospital. In the first 6 months, we retrospectively evaluated all medications to identify PIMs according to the 2019 Beers criteria. In the second phase, a clinical pharmacist prospectively evaluated all medications and suggested modifications as needed. Data were analyzed to determine risk factors for prescribing PIMs.

Results

Based on our evaluation of 258 patients, we observed that the utilization of PIMs was prevalent among the study population. Of the total patients evaluated, 273 instances of PIM use were identified, with only 23.3% of patients not having any PIMs. Notably, proton pump inhibitors and benzodiazepines were the most frequently prescribed PIMs. The risk of experiencing a PIM was significantly amplified by a higher degree of polypharmacy, with odds approximately 2.68 times higher (p < 0.01). Several factors were found to be associated with an increased likelihood of having a PIM, including being male, undergoing hemodialysis, having chronic kidney disease or other comorbidities, and having an extended hospital stay. The second phase of study, in terms of addressing these issues, physicians adhered to 67.5% of the 120 recommendations made by pharmacists regarding the discontinuation of PIM usage.

Conclusion

High prevalence of PIMs was detected in our study population. Preventing medication-associated harms in the elderly can reduce the financial burden imposed on healthcare systems. Therefore, routine evaluation of medications with clinical pharmacists and/or implementation of computerized medication decision support systems is recommended to prevent PIMs use.

Chronic Administration of Melatonin: Physiological and Clinical Considerations

Background: Exogenous melatonin is commonly used to treat insomnia, other sleep problems, and numerous medical illnesses, including Alzheimer’s disease, autism spectrum disorder, and mild cognitive impairment in adults and children. There is evolving information regarding issues with the use of chronic melatonin. Methods: The present investigation was a narrative review. Results: Melatonin usage has risen dramatically in recent years. Many countries only allow melatonin prescriptions. In the United States (U.S.), it is classified as a dietary supplement accessible over the counter and can be derived from animals, microorganisms, or, most commonly, made synthetically. No regulatory agency oversees its manufacturing or sale in the U.S. melatonin concentration of marketed preparations varies widely between product labels and manufacturers. Melatonin’s ability to induce sleep is detectable. However, it is modest for most people. Sleep length appears to be less important in sustained-release preparations. The optimal dosage is unknown, and routinely used amounts vary substantially. Melatonin’s short-term negative effects are minimal, resolve at medicine cessation, and do not usually prevent usage overall. Much research on long-term melatonin administration has found no difference between exogenous melatonin and placebo in terms of long-term negative effects. Conclusion: Melatonin at low to moderate dosages (approximately 5–6 mg daily or less) appears safe. Long-term usage appears to benefit certain patient populations, such as those with autism spectrum disorder. Studies investigating potential benefits in reducing cognitive decline and increased longevity are ongoing. However, it is widely agreed that the long-term effects of taking exogenous melatonin have been insufficiently studied and warrant additional investigation.

Dementia-Friendly "Design": Impact on COVID-19 Death Rates in Long-Term Care Facilities Around the World

Persons with dementia (PWD) make up a large portion of the long-term care (LTC) population the world over. Before a global pandemic swept the world, governments and healthcare providers struggled with how to best care for this unique population. One of the greatest challenges is a PWD's tendency to "walk with purpose" and exhibit unsafe wayfinding and elopement, which places them at risk of falls and injury. Past solutions included increased use of restraints and pharmacological interventions, but these have fallen out of favor over the years and are not optimal. These challenges put enormous strain on staff and caregivers, who are often poorly trained in dementia care, underpaid, overworked, and overstressed. PWD are impacted by these stresses, and unmet needs in LTC places an even greater stress on them and increases their risks of morbidity and mortality. The physical design of their environments contributes to the problem. Old, institutionalized buildings have poor lighting, poor ventilation, long dead-end hallways, poor visual cues, lack of home-like décor, shared bedrooms and bathrooms, and are often dense and overcrowded. These design elements contribute to the four 'A's' of dementia: apathy, anxiety, agitation, and aggression, and they also contributed to the rapid spread of COVID-19 in these facilities the world over. In this review, we present current "dementia friendly" design models in the home, community, and LTC, and argue how they could have saved lives during the pandemic and reduced the stresses on both the dementia resident and the caregiver/staff.