Comparison of polypharmacy and potentially inappropriate medication use in older adults with and without dementia receiving residential medication management reviews

OBJECTIVES

Among residents who had a residential medication management review (RMMR), there is a lack of studies assessing exposure to polypharmacy and potentially inappropriate medications (PIMs) in people with dementia. This study compared the exposure to polypharmacy and PIMs in residents with dementia and without dementia receiving RMMR.

METHODS

A retrospective analysis was performed using data of 16,261 residents living in 343 Australian residential aged care facilities who had an RMMR in 2019. Medication use was assessed as polypharmacy (defined as ≥9 medications) and use of ≥1 PIMs using the 2019 updated Beers criteria. Dementia diagnosis was determined with ICD-10 coding from medical records. Descriptive analyses reported resident demographics and patterns of medication use. Pearson's χ2 tests and logistic regression analysis were conducted to compare medication exposure between residents with and without dementia.

RESULTS

Among 16,261 residents, 6781 (42%) had dementia. Residents with dementia were significantly more likely to be exposed to polypharmacy and PIMs, compared to those without dementia (74% vs. 70% and 83% vs. 73%, p < .001 respectively). Residents with dementia had 1.31 times the odds of exposure to polypharmacy (adjusted OR: 1.31, 95% CI: 1.22-1.41, p < .001) and 1.88 times the odds of being prescribed ≥1 PIMs than people without dementia (adjusted OR: 1.88, 95% CI: 1.73-2.04, p < .001).

CONCLUSIONS

In a study of residents receiving RMMR, polypharmacy and PIMs were highly common, and those with dementia were more likely to be exposed to inappropriate polypharmacy. There is a need for targeted deprescribing strategies to immediately address inappropriate prescribing in residents, particularly those living with dementia.

Strategies for Identifying Patients for Deprescribing of Blood Pressure Medications in Routine Practice: An Evidence Review

PURPOSE OF REVIEW

To summarise the evidence regarding which patients might benefit from deprescribing antihypertensive medications.

RECENT FINDINGS

Older patients with frailty, multi-morbidity and subsequent polypharmacy are at higher risk of adverse events from antihypertensive treatment, and therefore may benefit from antihypertensive deprescribing. It is possible to examine an individual's risk of these adverse events, and use this to identify those people where the benefits of treatment may be outweighed by the harms. While such patients might be considered for deprescribing, the long-term effects of this treatment strategy remain unclear. Evidence now exists to support identification of those who are at risk of adverse events from antihypertensive treatment. These patients could be targeted for deprescribing interventions, although the long-term benefits and harms of this approach are unclear.

PERSPECTIVES

Randomised controlled trials are still needed to examine the long-term effects of deprescribing in high-risk patients with frailty and multi-morbidity.

Understanding general practitioners' prescribing choices to patients with chronic low back pain: a discrete choice experiment

BACKGROUND

Although NSAIDs are recommended as a first line analgesic treatment, opioids are very commonly prescribed to patients with low back pain (LBP) despite risks of harms.

AIM

This study aimed to determine factors contributing to general practitioners' (GPs') prescribing choices to patients with chronic LBP in a primary care setting.

METHOD

This discrete choice experiment (DCE) presented 210 GPs with hypothetical scenarios of a patient with chronic LBP. Participants chose their preferred treatment for each choice set, either the opioid, NSAID or neither. The scenarios varied by two patient attributes; non-specific LBP or LBP with referred leg pain (sciatica) and number of comorbidities. The three treatment attributes also varied, being: the type of opioid or NSAID, degree of pain reduction and number of adverse events. The significance of each attribute in influencing clinical decisions was the primary outcome and the degree to which GPs preferred the alternative based on the number of adverse events or the amount of pain reduction was the secondary outcome.

RESULTS

Overall, GPs preferred NSAIDs (45.2%, 95% CI 38.7-51.7%) over opioids (28.8%, 95% CI 23.0-34.7%), however there was no difference between the type of NSAID or opioid preferred. Additionally, the attributes of pain reduction and adverse events did not influence a GP's choice between NSAIDs or opioids for patients with chronic LBP.

CONCLUSION

GPs prefer prescribing NSAIDs over opioids for a patient with chronic low back pain regardless of patient factors of comorbidities or the presence of leg pain (i.e. sciatica).

Association of the Drug Burden Index (DBI) exposure with outcomes: A systematic review

BACKGROUND

The Drug Burden Index (DBI) measures an individual's total exposure to anticholinergic and sedative medications. This systematic review aimed to investigate the association of the DBI with clinical and prescribing outcomes in observational pharmaco-epidemiological studies, and the effect of DBI exposure on functional outcomes in pre-clinical models.

METHODS

A systematic search of nine electronic databases, citation indexes and gray literature was performed (April 1, 2007-December 31, 2022). Studies that reported primary data on the association of the DBI with clinical or prescribing outcomes conducted in any setting in humans aged ≥18 years or animals were included. Quality assessment was performed using the Joanna Briggs Institute critical appraisal tools and the Systematic Review Centre for Laboratory animal Experimentation risk of bias tool.

RESULTS

Of 2382 studies screened, 70 met the inclusion criteria (65 in humans, five in animals). In humans, outcomes reported included function (n = 56), cognition (n = 20), falls (n = 14), frailty (n = 7), mortality (n = 9), quality of life (n = 8), hospitalization (n = 7), length of stay (n = 5), readmission (n = 1), other clinical outcomes (n = 15) and prescribing outcomes (n = 2). A higher DBI was significantly associated with increased falls (11/14, 71%), poorer function (31/56, 55%), and cognition (11/20, 55%) related outcomes. Narrative synthesis was used due to significant heterogeneity in the study population, setting, study type, definition of DBI, and outcome measures. Results could not be pooled due to heterogeneity. In animals, outcomes reported included function (n = 18), frailty (n = 2), and mortality (n = 1). In pre-clinical studies, a higher DBI caused poorer function and frailty.

CONCLUSIONS

A higher DBI may be associated with an increased risk of falls and decreased function and cognition. Higher DBI was inconsistently associated with increased mortality, length of stay, frailty, hospitalization or reduced quality of life. Human observational findings with respect to functional outcomes are supported by preclinical interventional studies. The DBI may be used as a tool to identify older adults at higher risk of harm.

The Carer Assessment of MedicaTion Management GuidanCe for People With Dementia at Hospital Discharge (CATCH) Tool: Exploratory Factor Analysis

PURPOSE

The Carer Assessment of medicaTion management guidanCe for people with dementia at Hospital discharge (CATCH) tool was developed to examine the carer's experiences of medication management guidance delivery at discharge. This study explored its factor structure, characterized carers' experiences at discharge, and identified predictors of carer preparedness to manage medications at discharge.

METHODS

A cross-sectional survey of carers across Australia was distributed. Survey responses were analyzed descriptively, and exploratory factor and regression analyses were performed.

RESULTS

A total of 185 survey responses were completed. Exploratory factor analysis revealed 2 factors in the CATCH tool: (1) shared and supported decision-making in medication management (16 items loading 0.47 to 0.93); 2) provision of medication management guidance that is easy to understand (4 items loading (0.48 to 0.82). Internal consistency was acceptable (Cronbach alpha >0.8). Almost 18% of participants stated that they were not included in decisions about medications for people with dementia. The carer reported that the measure of how guidance is provided was positively related to their confidence in the management of medications postdischarge and satisfaction ( P < 0.05 for both).

CONCLUSIONS

The CATCH tool can give the patient and carer an opportunity to provide feedback on key elements of medication management guidance delivered at discharge.

Survey content validation evaluating the dissemination and implementation of deprescribing guidelines

BACKGROUND

Policies, protocols and processes within organisations can facilitate or hinder guideline adoption. There is limited knowledge on the strategies used by organisations to disseminate and implement evidence-based deprescribing guidelines or their impact.

METHODS

We aimed to develop an online survey targeting key organisations involved in deprescribing guideline endorsement, dissemination, modification or translation internationally. Survey questions were drafted, mirroring the six components of the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) framework. Content validation was undertaken and established by a panel of clinicians, researchers and implementation experts.

RESULTS

A 52-item survey underwent two rounds of content validation. The minimum threshold (I-CVI > 0.78) for relevance and importance was met for 39 items (75%) in the first round and 44 of 48 items (92%) in the second round. The expert panel concluded that the adoption, implementation and effectiveness survey sections were largely relevant and important to this topic, whereas the reach and maintenance sections were harder to understand and may be less pertinent to the research question.

CONCLUSIONS

A 44-item survey investigating dissemination and implementation strategies for deprescribing guidelines has been developed and its content validated. Widespread survey distribution may identify effective strategies and inform dissemination and implementation planning for newly developed guidelines.

Context matters: using an Evidence to Decision (EtD) framework to develop and encourage uptake of opioid deprescribing guideline recommendations at the point-of-care

OBJECTIVES

To describe the development and use of an Evidence to Decision (EtD) framework when formulating recommendations for the Evidence-Based Clinical Practice Guideline for Deprescribing Opioid Analgesics.

STUDY DESIGN AND SETTING

Evidence was derived from an overview of systematic reviews and qualitative studies conducted with healthcare professionals and people who take opioids for pain. A multidisciplinary guideline development group conducted extensive EtD framework review and iterative refinement to ensure that guideline recommendations captured contextual factors relevant to the guideline target setting and audience.

RESULTS

The guideline development group considered and accounted for the complexities of opioid deprescribing at the individual and health system level, shaping recommendations and practice points to facilitate point-of-care use. Stakeholders exhibited diverse preferences, beliefs, and values. This variability, low certainty of evidence, and system-level policies and funding models impacted the strength of the generated recommendations, resulting in the formulation of four 'conditional' recommendations.

CONCLUSION

The context within which evidence-based recommendations are considered, as well as the political and health system environment, can contribute to the success of recommendation implementation. Use of an EtD framework allowed for the development of implementable recommendations relevant at the point-of-care through consideration of limitations of the evidence and relevant contextual factors.

Patient-targeted interventions for opioid deprescribing: An overview of systematic reviews

BACKGROUND

Deprescribing (reduction or cessation) of prescribed opioids can be challenging for both patients and healthcare professionals.

OBJECTIVE

To synthesize and evaluate evidence from systematic reviews examining the effectiveness and outcomes of patient-targeted opioid deprescribing interventions for all types of pain.

METHODS

Systematic searches were conducted in five databases with results screened against predetermined inclusion/exclusion criteria. Primary outcomes were (i) reduction in opioid dose, reported as change in oral Morphine Equivalent Daily Dose (oMEDD) and (ii) success of opioid deprescribing, reported as the proportion of the sample for which opioid use declined. Secondary outcomes included pain severity, physical function, quality of life and adverse events. The certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

FINDINGS

Twelve reviews were eligible for inclusion. Interventions were heterogeneous in nature and included pharmacological (n = 4), physical (n = 3), procedural (n = 3), psychological or behavioural (n = 3) and mixed (n = 5) interventions. Multidisciplinary care programmes appeared to be the most effective intervention for opioid deprescribing; however, the certainty of evidence was low, with significant variability in opioid reduction across interventions.

CONCLUSIONS

Evidence is too uncertain to draw firm conclusions about specific populations who may derive the greatest benefit from opioid deprescribing, warranting further investigation.

Transforming blood pressure control in primary care through a novel remote decision support strategy based on wearable blood pressure monitoring: The NEXTGEN-BP randomized trial protocol

BACKGROUND

Despite high blood pressure being the leading preventable risk factor for death, only 1 in 3 patients achieve target blood pressure control. Key contributors to this problem are clinical inertia and uncertainties in relying on clinic blood pressure measurements to make treatment decisions.

METHODS

The NEXTGEN-BP open-label, multicenter, randomized controlled trial will investigate the efficacy, safety, acceptability and cost-effectiveness of a wearable blood pressure monitor-based care strategy for the treatment of hypertension, compared to usual care, in lowering clinic blood pressure over 12 months. NEXTGEN-BP will enroll 600 adults with high blood pressure, treated with 0 to 2 antihypertensive medications. Participants attending primary care practices in Australia will be randomized 1:1 to the intervention of a wearable-based remote care strategy or to usual care. Participants in the intervention arm will undergo continuous blood pressure monitoring using a wrist-wearable cuffless device (Aktiia, Switzerland) and participate in 2 telehealth consultations with their primary care practitioner (general practitioner [GP]) at months 1 and 2. Antihypertensive medication will be up-titrated by the primary care practitioner at the time of telehealth consults should the percentage of daytime blood pressure at target over the past week be <90%, if clinically tolerated. Participants in the usual care arm will have primary care consultations according to usual practice. The primary outcome is the difference between intervention and control in change in clinic systolic blood pressure from baseline to 12 months. Secondary outcomes will be assessed at month 3 and month 12, and include acceptability to patients and practitioners, cost-effectiveness, safety, medication adherence and patient engagement.

CONCLUSIONS

NEXTGEN-BP will provide evidence for the effectiveness and safety of a new paradigm of wearable cuffless monitoring in the management of high blood pressure in primary care.

TRIAL REGISTRATION

ACTRN12622001583730.

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.

Comparison of a multidomain frailty index from routine health data with the hospital frailty risk score in older patients in an Australian hospital

BACKGROUND

Frailty is an important determinant of health-care needs and outcomes for people in hospital.

OBJECTIVES

To compare characteristics and predictive ability of a multidomain frailty index derived from routine health data (electronic frailty index-acute hospital; eFI-AH) with the hospital frailty risk score (HFRS).

METHODS

This retrospective study included 6771 patients aged ≥75 years admitted to an Australian metropolitan tertiary referral hospital between October 2019 and September 2020. The eFI-AH and the HFRS were calculated for each patient and compared with respect to characteristics, agreement, association with age and ability to predict outcomes.

RESULTS

Median eFI-AH was 0.17 (range 0-0.66) whilst median HFRS was 3.2 (range 0-42.9). Moderate agreement was shown between the tools (Pearson's r 0.61). After adjusting for age and gender, both models had associations with long hospital stay, in-hospital mortality, unplanned all-cause readmission and fall-related readmission. Specifically, the eFI-AH had the strongest association with in-hospital mortality (adjusted odds ratio (aOR) 2.81, 95% confidence intervals (CI) 2.49-3.17), whilst the HFRS was most strongly associated with long hospital stay (aOR 1.20, 95% CI 1.18-1.21). Both tools predicted hospital stay >10 days with good discrimination and calibration.

CONCLUSIONS

Although the eFI-AH and the HFRS did not consistently identify the same inpatients as frail, both were associated with adverse outcomes and they had comparable predictive ability for prolonged hospitalisation. These two constructs of frailty may have different implications for clinical practice and health service provision and planning.

Deprescribing interventions for gabapentinoids in adults: A scoping review

The emerging issue of rising gabapentinoid misuse is being recognized alongside the lack of current evidence supporting the safe and effective deprescribing of gabapentinoids. This scoping review aimed to assess the extent and nature of gabapentinoid deprescribing interventions in adults, either in reducing dosages, or prescribing of, gabapentinoids. Electronic databases were searched on 23 February 2022 without restrictions. Eligible studies included randomized, non-randomized and observational studies that assessed an intervention aimed at reducing/ceasing the prescription/use of a gabapentinoid in adults for any indication in a clinical setting. The research outcomes investigated the type of intervention, prescribing rates, cessations, patient outcomes and adverse events. Extracted outcome data were categorized as either short (≤3 months), intermediate (>3 but <12 months) or long (≥12 months) term. A narrative synthesis was conducted. The four included studies were conducted in primary and acute care settings. Interventions were of dose-reducing protocols, education and/or pharmacological-based approaches. In the randomized trials, gabapentinoid use could be ceased in at least one third of participants. In the two observational trials, gabapentinoid prescribing rates decreased by 9%. Serious adverse events and adverse events specifically related to gabapentinoids were reported in one trial. No study included patient-focused psychological interventions in the deprescribing process, nor provided any long-term follow-up. This review highlights the lack of existing evidence in this area. Due to limited available data, our review was unable to make any firm judgements on the most effective gabapentinoid deprescribing interventions in adults, highlighting the need for more research in this area.

Frailty knowledge, training and barriers to frailty management: A national cross-sectional survey of health professionals in Australia

OBJECTIVE(S)

To understand Australian health professionals' perceptions of their knowledge and previous training about frailty, as well as barriers to frailty assessment and management in their practice.

METHODS

A cross-sectional online survey was developed and distributed to health professionals (medical, nursing and allied health) engaged in clinical practice in Australia through convenience and snowball sampling techniques from March to May 2022. The survey consisted of five sections: frailty training and knowledge; confidence in recognising and managing adults with frailty; the importance and relevance of frailty; barriers to assessing and managing frailty in practice; and interest in further frailty training. Responses were analysed using descriptive statistics.

RESULTS

The survey was taken by 736 health professionals. Less than half of respondents (44%, 321/733) reported receiving any training on frailty, with 14% (105/733) receiving training specifically focussed on frailty. Most respondents (78%, 556/712) reported 'good' or 'fair' understanding of frailty. The majority (64%, 448/694) reported being 'fairly' or 'somewhat' confident with identifying frailty. Almost all respondents (>90%) recognised frailty as having an important impact on outcomes and believed that there are beneficial interventions for frailty. Commonly reported barriers to frailty assessment in practice included 'lack of defined protocol for managing frailty' and 'lack of consensus about which frailty assessment tool to use'. Most respondents (88%, 521/595) were interested in receiving further education on frailty, with a high preference for online training.

CONCLUSIONS

The findings suggest frailty is important to health professionals in Australia, and there is a need for and interest in further frailty education.

Preferences for deprescribing antihypertensive medications amongst clinicians, carers and people living with dementia: a discrete choice experiment

BACKGROUND

Optimal management of hypertension in people with dementia may involve deprescribing antihypertensives. Understanding differing treatment priorities is important to enable patient-centred care. This study explored preferences for antihypertensive deprescribing amongst people living with dementia, carers and clinicians.

METHODS

Discrete choice experiments (DCEs) are a stated preference survey method, underpinned by economic theory. A DCE was conducted, and respondents completed 12 labelled choice-questions, each presenting a status quo (continuing antihypertensives) and antihypertensive deprescribing option. The questions included six attributes, including pill burden, and event risks for stroke, myocardial infarction, increased blood pressure, cognitive decline, falls.

RESULTS

Overall, 112 respondents (33 carers, 19 people living with dementia, and 60 clinicians) completed the survey. For people with dementia, lower pill burden increased preferences for deprescribing (odds ratio (OR) 1.95, 95% confidence interval (95% CI) 1.08-3.52). Increased stroke risk (for each additional person out of 100 having a stroke) decreased the likelihood of deprescribing for geriatricians (OR 0.71, 95% CI 0.55-0.92) and non-geriatrician clinicians (OR 0.62, 95% CI 0.45-0.86), and carers (OR 0.71, 95% CI 0.58-0.88). Increased myocardial infarction risk decreased preferences for deprescribing for non-geriatricians (OR 0.81, 95% CI 0.69-0.95) and carers (OR 0.84, 95% CI 0.73-0.98). Avoiding cognitive decline increased preferences for deprescribing for geriatricians (OR 1.17, 95% CI 1.03-1.33) and carers (OR 1.27, 95% CI 1.09-1.48). Avoiding falls increased preferences for deprescribing for clinicians (geriatricians (OR 1.20, 95% CI 1.11-1.29); non-geriatricians (OR 1.16, 95% CI 1.07-1.25)). Other attributes did not significantly influence respondent preferences.

CONCLUSIONS

Antihypertensive deprescribing preferences differ amongst people with dementia, carers and clinicians. The study emphasises the importance of shared decision-making within the deprescribing process.

Towards Optimizing Hospitalized Older adults' MEdications (TO HOME): Multi-centre study of medication use and outcomes in routine care

AIMS

Comprehensively investigate prescribing in usual care of hospitalized older people with respect to polypharmacy; potentially inappropriate medications (PIMs) according to Beers criteria; and cumulative anticholinergic and sedative medication exposure calculated with Drug Burden Index (DBI). Specifically, to quantify exposure to these measures on admission, changes between admission and discharge, associations with adverse outcomes and medication costs.

METHODS

Established new retrospective inpatient cohort of 2000 adults aged ≥75 years, consecutively admitted to 6 hospitals in Sydney, Australia, with detailed information on medications, clinical characteristics and outcomes. Conducted cross-sectional analyses of index admission data from cohort.

RESULTS

Cohort had mean (standard deviation) age 86.0 (5.8) years, 59% female, 21% from residential aged care. On admission, prevalence of polypharmacy was 77%, PIMs 34% and DBI > 0 in 53%. From admission to discharge, mean difference (95% confidence interval) in total number of medications increased 1.05 (0.92, 1.18); while prevalence of exposure to PIMs (-3.8% [-5.4, -2.1]) and mean DBI score (-0.02 [-0.04, -0.01]) decreased. PIMs and DBI score were associated with increased risks (adjusted odds ratio [95% confidence interval]) of falls (PIMs 1.63 [1.28, 2.08]; DBI score 1.21[1.00, 1.46]) and delirium (PIMs 1.76 [1.38, 1.46]; DBI score 1.42 [1.19, 1.71]). Each measure was associated with increased risk of adverse drug reactions (polypharmacy 1.42 [1.19, 1.71]; PIMs 1.87 [1.40, 2.49]; DBI score 1.90 [1.55, 2.15]). Cost (AU$/patient/hospital day) of medications contributing to PIMs and DBI was low ($0.29 and $0.88).

CONCLUSION

In this large cohort of older inpatients, usual hospital care results in an increase in number of medications and small reductions in PIMs and DBI, with variable associations with adverse outcomes.

Clinical practice guideline for deprescribing opioid analgesics: summary of recommendations

INTRODUCTION

Long term opioids are commonly prescribed to manage pain. Dose reduction or discontinuation (deprescribing) can be challenging, even when the potential harms of continuation outweigh the perceived benefits. The Evidence-based clinical practice guideline for deprescribing opioid analgesics was developed using robust guideline development processes and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, and contains deprescribing recommendations for adults prescribed opioids for pain.

MAIN RECOMMENDATIONS

Eleven recommendations provide advice about when, how and for whom opioid deprescribing should be considered, while noting the need to consider each person's goals, values and preferences. The recommendations aim to achieve: implementation of a deprescribing plan at the point of opioid initiation; initiation of opioid deprescribing for persons with chronic non-cancer or chronic cancer-survivor pain if there is a lack of overall and clinically meaningful improvement in function, quality of life or pain, a lack of progress towards meeting agreed therapeutic goals, or the person is experiencing serious or intolerable opioid-related adverse effects; gradual and individualised deprescribing, with regular monitoring and review; consideration of opioid deprescribing for individuals at high risk of opioid-related harms; avoidance of opioid deprescribing for persons nearing the end of life unless clinically indicated; avoidance of opioid deprescribing for persons with a severe opioid use disorder, with the initiation of evidence-based care, such as medication-assisted treatment of opioid use disorder; and use of evidence-based co-interventions to facilitate deprescribing, including interdisciplinary, multidisciplinary or multimodal care.

CHANGES IN MANAGEMENT AS A RESULT OF THESE GUIDELINES

To our knowledge, these are the first evidence-based guidelines for opioid deprescribing. The recommendations intend to facilitate safe and effective deprescribing to improve the quality of care for persons taking opioids for pain.

Impact of a Comprehensive Intervention Bundle Including the Drug Burden Index on Deprescribing Anticholinergic and Sedative Drugs in Older Acute Inpatients: A Non-randomised Controlled Before-and-After Pilot Study

INTRODUCTION

Implementation of the Drug Burden Index (DBI) as a risk assessment tool in clinical practice may facilitate deprescribing.

OBJECTIVE

The purpose of this study is to evaluate how a comprehensive intervention bundle using the DBI impacts (i) the proportion of older inpatients with at least one DBI-contributing medication stopped or dose reduced on discharge, compared with admission; and (ii) the changes in deprescribing of different DBI-contributing medication classes during hospitalisation.

METHODS

This before-and-after study was conducted in an Australian metropolitan tertiary referral hospital. Patients aged ≥ 75 years admitted to the acute aged care service for ≥ 48 h from December 2020 to October 2021 and prescribed DBI-contributing medication were included. During the control period, usual care was provided. During the intervention, access to the intervention bundle was added, including a clinician interface displaying DBI score in the electronic medical record. In a subsequent 'stewardship' period, a stewardship pharmacist used the bundle to provide clinicians with patient-specific recommendations on deprescribing of DBI-contributing medications.

RESULTS

Overall, 457 hospitalisations were included. The proportion of patients with at least one DBI-contributing medication stopped/reduced on discharge increased from 29.9% (control period) to 37.5% [intervention; adjusted risk difference (aRD) 6.5%, 95% confidence intervals (CI) -3.2 to 17.5%] and 43.1% (stewardship; aRD 12.1%, 95% CI 1.0-24.0%). The proportion of opioid prescriptions stopped/reduced rose from 17.9% during control to 45.7% during stewardship (p = 0.04).

CONCLUSION

Integrating a comprehensive intervention bundle and accompanying stewardship program is a promising strategy to facilitate deprescribing of sedative and anticholinergic medications in older inpatients.

Availability and evaluation of medication management resources for carers of people with dementia: a scoping review with an environmental scan

INTRODUCTION

There is a need for resources to guide informal carers in medication management for people with dementia. Availability of resources on medication management guidance has yet to be explored.

AREAS COVERED

A systematic search of MEDLINE, Embase, CINAHL and PsycINFO was performed in May 2022 to identify and evaluate resources for carers of people with dementia that provide guidance in medication management. Google and known repositories were also searched. Readability of text-based resources was examined using the Flesch-Kincaid reading level, the Flesch reading ease and the Gunning-Fog index. Resources were further evaluated using the Patient Education Material Assessment Tool (PEMAT or PEMAT-A/V).

EXPERT OPINION

Fifteen resources were identified, which largely focused on medication administration with limited discussion of shared decision-making. Current resources do not appear to have included people living with dementia or their carers in their development and did not address high-risk care settings. Codesign of resources with carers and people with dementia would ensure that resources are comprehensive and target their needs. Future research should therefore focus on development of readily available and understandable resources that provide medication management guidance for carers across different health settings, to comprehensively address the multi-faceted nature of dementia.

Opioid deprescribing in patients with chronic noncancer pain: a systematic review of international guidelines

ABSTRACT

In response to the overuse of prescription opioid analgesics, clinical practice guidelines encourage opioid deprescribing (ie, dose reduction or cessation) in patients with chronic noncancer pain. Therefore, this study evaluated and compared international clinical guideline recommendations on opioid deprescribing in patients with chronic noncancer pain. We searched PubMed, EMBASE, PEDro, National Institute for Health and Care Excellence (United Kingdom), and MAGICapp databases from inception to June 4, 2021, with no language or publication restrictions. In addition, we searched the National Guideline Clearinghouse and International Guideline Network databases from inception to December 2018. Two independent reviewers conducted the initial title and abstract screening. After discrepancies were resolved through discussion, 2 independent reviewers conducted the full-text screening of each potentially eligible reference. Four independent reviewers completed the prepiloted, standardized data extraction forms of each included guideline. Extracted information included bibliographical details; strength of recommendations; and the outcomes, such as when and how to deprescribe, managing withdrawal symptoms, additional support, outcome monitoring, and deprescribing with coprescription of sedatives. A narrative synthesis was used to present the results. This study found that clinical practice guidelines agree on when and how to deprescribe opioid analgesics but lack advice on managing a patient's withdrawal symptoms, outcome monitoring, and deprescribing with coprescription of sedatives. Quality assessment of the guidelines suggests that greater discussion on implementation and dissemination is needed.

Potential factors that can affect the performance of undergraduate pharmacy research students: a descriptive study

OBJECTIVE

This descriptive study aimed to examine whether student past coursework performance, student or research supervisor characteristics, and the type of research project are related to the overall academic performance of a pharmacy student completing an honours research program.

METHODS

Data on undergraduate honours students who completed a Bachelor of Pharmacy degree at The University of Sydney, Sydney, Australia, between Jan 2015 and Dec 2020 was collected. This included socio-demographic characteristics, type of project undertaken, and academic outputs. Data was also collected on each supervisor's academic role, level of experience, research area, and where they completed their PhD. Descriptive statistics were used to describe the study cohort and correlation analysis and unpaired t-tail analyses were conducted using SPSS software.

RESULTS

This five year study included 130 students of which 67% were female and 60% were domestic students. Each student was supervised by one of 48 individual academics who were a mix of early- (31%), mid-career (29%), and experienced researchers (40%) for pharmaceutical science (50%), clinical (45%), and education (5%) projects. Just less than half (49%) of students published one peer-reviewed journal article. Female students outperformed male students (p = 0.031) with female students also twice as likely (15%) to receive a university medal eligible mark compared with male students (7.0%). Similarly, domestic students were twice as likely (15%) to receive a university medal eligible mark when compared with international students (7.7%). Students who undertook a pharmaceutical science-based project outperformed education-based project students (p = 0.0235). Students who had published at least one peer-reviewed journal article outperformed those who had not published (p = 0.0014).

CONCLUSION

Factors that affected honours performance were student gender, residential status, type of project undertaken, and whether a student had published a peer-reviewed journal article.

(C)onsumer focused (E)ducation on p(A)racetamol (S)ide (E)ffects, i(N)adequate (O)utcomes and (W)eaning (CEASE NOW) for individuals with low back pain: results of a feasibility study

OBJECTIVES

To determine the feasibility of a patient-education booklet to support patients with low back pain (LBP) to reduce paracetamol intake.

DESIGN

Single group, repeated measures feasibility study.

SETTING

Community.

PARTICIPANTS

Adults experiencing LBP of any kind and self-reporting consumption of paracetamol for LBP weekly for at least 1 month were invited to participate.

INTERVENTION

Participants received a patient-education booklet 1 week after the baseline measures were collected. The intervention was designed to change beliefs, increase knowledge and self-efficacy to deprescribe paracetamol for their LBP and create discussion with a health professional through the mechanisms of motivation, capacity and opportunity.

PRIMARY OUTCOME MEASURES

Feasibility of recruitment procedures, data collection and acceptability of the intervention.

SECONDARY OUTCOME MEASURES

Changes in motivation, self-efficacy, opportunity to deprescribe paracetamol for their LBP, paracetamol usage and LBP clinical outcomes at baseline, 1-week and 1-month follow-up.

RESULTS

A total of 24 participants were recruited into the study within the timeframe of 3 months from study advertisement and all completed the study follow-up. There were no missing data for any outcome measure across all follow-up points, 22 (91.6%) participants were willing to participate in a future randomised control trial (RCT) and over 60% of participants responded positively to questions regarding acceptability of the patient-educational booklet. Overall, at the 1-month follow-up, approximately two thirds (15/24) of participants had an increase in motivation and self-efficacy scores and had discussed or intended to discuss their paracetamol use for LBP with a health professional.

CONCLUSIONS

The results of this study demonstrate that the patient-education booklet is feasible to implement, and both the intervention and study design were well-received by participants. This study supports the undertaking an RCT to assess the effects of the patient-education booklet on deprescribing paracetamol in people with LBP.

The anticholinergic burden: from research to practice

Drugs with anticholinergic effects are known to cause adverse effects such as dry mouth, constipation and urinary retention. In older people drugs with anticholinergic effects may contribute to cognitive decline and a loss of functional capacity.

Many drugs that are not in the anticholinergic drug class also have anticholinergic effects. They include antidepressants, antipsychotics and antihistamines.

Taking multiple drugs with anticholinergic effects creates an anticholinergic burden. It is important that clinicians identify which patients are at risk. There are several tools to assess the anticholinergic burden.

Clinicians can use these tools to make a pharmacological risk assessment when reviewing a patient’s medicines. This can assist decisions about continuing or stopping drugs with anticholinergic effects.

Deprescribing drugs with anticholinergic effects has several potential benefits in older people. In addition to reversing adverse effects, deprescribing may prevent problems such as falls.

The Prevalence of Adverse Drug Reactions and Adverse Drug Events from Heart Failure Medications in Frail Older Adults: A Systematic Review

Introduction

Frailty is highly prevalent in heart failure populations and a major risk factor for adverse drug reactions (ADRs) and adverse drug events (ADEs). This review aimed to describe the prevalence, causality and severity of ADRs or ADEs from heart failure medications among frail compared with non-frail older adults.

Methods

A systematic search of CENTRAL, MEDLINE, Embase, Ageline, CINAHL, International Pharmaceutical Abstracts, PsychInfo, Scopus, registries and citations prior to 18 May 2021 was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist. Risk of bias and quality of evidence were assessed. Eligible studies included randomised controlled trials (RCTs) and observational studies of people diagnosed with heart failure, aged ≥ 65 years, with frailty defined by an objective measurement, and reported ADRs/ADEs from/with heart failure medications.

Results

Two reviewers screened 2419 articles; interrater reliability kappa = 0.88. Three observational studies (n = 2596), a secondary analysis of two RCTs (n = 2098) and two cohort studies (n = 498) were included in a narrative synthesis. Frail patients in randomised trials of sacubitril/valsartan, aliskiren, or enalapril had twice the risk of mortality (hazard ratio [HR] 2.09, 1.62–2.71) and hospitalisations (HR 1.82, 1.37–2.41) compared with robust patients, which may reflect responsiveness to medications and/or factors unrelated to medication use. Hospitalisations from falls, tiredness and nausea were probably attributable to digoxin and possibly preventable according to the Naranjo and Hallas scales, respectively.

Conclusion

The potential harms from heart failure medications in frail older people are poorly studied and understood. Clinical trials and pharmacovigilance studies should include frailty as a covariate to inform medication optimisation for this vulnerable and growing population.

Registration

Prospero registration number: CRD 42021253762.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s40266-022-00957-8.

Development of a tool to evaluate medication management guidance provided to carers of people living with dementia at hospital discharge: a mixed methods study

OBJECTIVE

Medication management guidance for carers of people with dementia at hospital discharge is important to prevent medication-related harm during transitions of care. This study aimed to develop a tool to evaluate medication management guidance provided to carers of people with dementia at hospital discharge.

DESIGN

The tool was developed using mixed methods involving two stages. Stage 1 involved item generation and content validation. Items were based on a previous qualitative study and systematic review. Content validation involved experts and consumers with knowledge or experience of medication management guidance in the acute care setting, and rating each item on importance and relevance. Stage 2 involved conducting cognitive interviews with carers of people with dementia to pretest the tool.

SETTING

For stage 1, experts and consumers from Australia, USA and New Zealand were included. For stage 2, carers of people with dementia were recruited across Australia.

PARTICIPANTS

18 experts and consumers participated in round 1 of content validation, and 13 experts and consumers completed round 2. Five carers of people with dementia participated in cognitive interviews.

RESULTS

The final tool contained 30 items capturing information across five domains: (1) provision of medication management guidance at hospital discharge; (2) carer understanding of medication management guidance provided at discharge; (3) carer engagement in discussing the safe use of medications at discharge; (4) carer preparedness to conduct medication management activities after discharge; and (5) co-ordination of medication management guidance after discharge.

CONCLUSIONS

We developed the first tool to assess medication management guidance provided for carers of people with dementia at hospital discharge. The tool may be useful to inform future research strategies to improve the delivery of medication management guidance at discharge.

Hydroxyzine Initiation Following Drug Safety Advisories on Cardiac Arrhythmias in the UK and Canada: A Longitudinal Cohort Study

Introduction

Regulatory advisories on hydroxyzine and risk of QT prolongation and Torsade de pointes (TdP) were issued in the UK in April 2015 and Canada in June 2016. We hypothesized patients with risk factors for QT prolongation and TdP, compared with those without risk factors, would be less likely to initiate hydroxyzine in the UK and in British Columbia (BC), Canada, following advisories.

Methods

We conducted a longitudinal study with repeated measures, and evaluated hydroxyzine initiation in a UK cohort and a concurrent BC control cohort (April 2013–March 2016) as well as in a BC advisory cohort (June 2014–May 2017).

Results

This study included 247,665 patients in the UK cohort, 297,147 patients in the BC control cohort, and 303,653 patients in the BC advisory cohort. Over a 12-month post-advisory period, hydroxyzine initiation decreased by 21% in the UK (rate ratio 0.79, 95% confidence interval 0.66–0.96) relative to the expected level of initiation based on the pre-advisory trend. Hydroxyzine initiation did not change in the BC control cohort or following the Canadian advisory in the BC advisory cohort. The decrease in hydroxyzine initiation in the UK in the 12 months after the advisories was not significantly different for patients with risk factors compared with those without risk factors.

Conclusion

Hydroxyzine initiation decreased in the UK, but not in BC, in the 12 months following safety advisories. The decrease in hydroxyzine initiation in the UK was not significantly different for patients with versus without risk factors for QT prolongation and TdP.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40264-022-01175-2.

Barriers, facilitators, and resources to opioid deprescribing in primary care: experiences of general practitioners in Australia

ABSTRACT

Deprescribing is the systematic process of discontinuing drugs when harms outweigh the benefits. We conducted semistructured telephone interviews with 22 general practitioners (GPs) who had prescribed or deprescribed opioids in patients with chronic noncancer pain within the past 6 months to investigate the barriers and facilitators to deprescribing opioid analgesics in patients with chronic noncancer pain. We also explored GPs' perspectives on the available resources to assist them with opioid deprescribing. Interviews were audio-recorded, transcribed verbatim, and then coded using an iterative process until data saturation reached. The thematic analysis process identified themes, first as concepts, and then refined to overarching themes after the merging of similar subthemes. Themes exploring barriers to deprescribing highlighted the difficulties GPs face while considering patient factors and varying prescribing practices within the confines of the health system. Patient motivation and doctor-patient rapport were central factors to facilitate deprescribing and GPs considered the most important deprescribing resource to be a multidisciplinary network of clinicians to support themselves and their patients. Therefore, although GPs emphasised the importance of deprescribing opioid analgesics, they also expressed many barriers relating to managing complex pain conditions, patient factors, and varying prescribing practices between clinicians. Some of these barriers could be mitigated by GPs having time and resources to educate and build rapport with their patients. This suggests the need for further development of multimodal resources and improved support through the public health system to enable GPs to prioritise patient-centred care.

Comparing Effects of Polypharmacy on Inflammatory Profiles in Older Adults and Mice: Implications for Translational Ageing Research

Aging and multimorbidity are associated with inflammation. Polypharmacy is common in older people with multimorbidity. Given the potential for interactions between polypharmacy and inflammation, the relationship between inflammation and polypharmacy were studied in older adults with multimorbidity and in healthy aging mice. A cross-sectional analysis of data from the 5-year wave of the Concord Health and Ageing in Men Project, a population-based study of community-dwelling men aged ≥70 years. Serum concentrations of 27 cytokines were measured using a multiplex immunoassay. Associations between polypharmacy (≥5 medications) and cytokines were evaluated using multivariable linear regression adjusting for age, frailty, comorbidities, and individual drug classes. Interaction between polypharmacy and Drug Burden Index (DBI―drugs with anticholinergic and sedative effects) was analyzed. Effects of polypharmacy and DBI on serum levels of 23 cytokines were determined in aging male mice treated with chronic polypharmacy or control. Compared to the nonpolypharmacy group (n = 495), CHAMP participants with polypharmacy (n = 409) had significantly higher concentrations of IL-8, IL-6, CCL3, Eotaxin, IL-1ra, IL-1β, IP-10, and lower concentrations of anti-inflammatory cytokine IL-4. In fully-adjusted multivariable models, polypharmacy was positively associated with concentrations of IL-8 and CCL3. There were no significant differences in inflammatory profiles between control and polypharmacy-treated mice. The relationship was not influenced by DBI in men or in mice. Inflammatory markers associated with polypharmacy in older adults were not seen in healthy aged mice administered polypharmacy, and may be related to underlying diseases. The polypharmacy mouse model provides opportunities for mechanistic investigations in translational research.

Opioid-related adverse drug events in surgical patients: risk factors and association with clinical outcomes

BACKGROUND

Opioid analgesics are commonly used to treat acute post-operative pain. The primary objective of this study was to identify the risk factors for opioid related adverse drug events (ORADEs) in surgical patients and the association between ORADEs and clinical outcomes.

RESEARCH DESIGN AND METHODS

: A retrospective cohort study was conducted using data from July 2016 to April 2020. ORADEs were defined using International Classification of Diseases 10^th Revision Australian Modification codes. Multivariate logistic regression was performed to identify risk factors for ORADEs. To investigate the association between ORADEs and clinical outcomes, propensity score matching was performed.

RESULTS

Among 17,886 surgical patients who received opioid analgesics during hospital stay, 1,814 patients (10.2%) experienced ORADEs. Risk factors for general ORADEs included advanced age, comorbidities, concurrent use of benzodiazepines or gabapentionoids and a higher opioid daily dose. Patients who experienced ORADEs were associated with longer length of stay (LOS, Rate Ratio 3.00, 95% CI 2.97-3.04) but similar 28-day readmission rate (Odds Ratio 0.89, 95% CI 0.71-1.11).

CONCLUSIONS

Risk factors for general ORADEs were advanced age, specific comorbidities, use of benzodiazepines or gabapentionoids and higher opioid dose. Routine use of opioids with gabapentionoids should be avoided and only used after careful consideration.

Association Between Potentially Inappropriate Medications and 30-Day Post-Hospital Discharge Outcomes in US Veterans

BACKGROUND

Potentially inappropriate medication (PIMs) use is common in older inpatients and it may lead to increased risk of adverse drug events.

OBJECTIVES

To examine prevalence of PIMs at hospital discharge and its contribution to health care utilization and mortality within 30-days of hospital discharge.

METHODS

This was a prospective cohort of 117 570 veterans aged ≥65 years and hospitalized in 2013. PIMs at discharge were categorized into central nervous system acting (CNS) and non-CNS. Outcomes within 30-days of hospital discharge were: (1) time to first acute care hospital readmission, and all-cause mortality, (2) an emergency room visit, and (3) ≥3 primary care clinic visits.

RESULTS

The cohort's mean age was 74.3 years (SD 8.1), with 51.3% exposed to CNS and 62.8% to non-CNS PIMs. Use of CNS and non-CNS PIMs, respectively, was associated with a reduced risk of readmission, with an adjusted hazard ratio (aHR) of 0.93 (95% CI = 0.89-0.96) for ≥2 (vs 0) CNS PIMs and an aHR of 0.85 (95% CI = 0.82-0.88) for ≥2 (vs 0) non-CNS PIMs. Use of CNS PIMs (≥2 vs 0) was associated with increased risk of mortality (aHR = 1.37 [95% CI = 1.25-1.51]), whereas non-CNS PIMs use was associated with a reduced risk of mortality (aHR = 0.75 [95% CI = 0.69-0.82]).

CONCLUSION AND RELEVANCE

PIMs were highly common in this veteran cohort, and the association with outcomes differed by PIMs. Thus, it is important to consider whether PIMs are CNS acting to optimize short-term posthospitalization outcomes.

Influence of drug safety advisories on drug utilisation: an international interrupted time series and meta-analysis

Objective

To evaluate the association between regulatory drug safety advisories and changes in drug utilisation.

Design

We conducted controlled, interrupted times series analyses with administrative prescription claims data to estimate changes in drug utilisation following advisories. We used random-effects meta-analysis with inverse-variance weighting to estimate the average postadvisory change in drug utilisation across advisories.

Study population

We included advisories issued in Canada, Denmark, the UK and the USA during 2009–2015, mainly concerning drugs in common use in primary care. We excluded advisories related to over-the-counter drugs, drug-drug interactions, vaccines, drugs used primarily in hospital and advisories with co-interventions within ±6 months.

Main outcome measures

Change in drug utilisation, defined as actual versus predicted percentage change in the number of prescriptions (for advisories without dose-related advice), or in the number of defined daily doses (for dose-related advisories), per 100 000 population.

Results

Among advisories without dose-related advice (n=20), the average change in drug utilisation was −5.83% (95% CI −10.93 to –0.73; p=0.03). Advisories with dose-related advice (n=4) were not associated with a statistically significant change in drug utilisation (−1.93%; 95% CI −17.10 to 13.23; p=0.80). In a post hoc subgroup analysis of advisories without dose-related advice, we observed no statistically significant difference between the change in drug utilisation following advisories with explicit prescribing advice, such as a recommendation to consider the risk of a drug when prescribing, and the change in drug utilisation following advisories without such advice.

Conclusions

Among safety advisories issued on a wide range of drugs during 2009–2015 in 4 countries (Canada, Denmark, the UK and the USA), the association of advisories with changes in drug utilisation was variable, and the average association was modest.

Preclinical frailty assessments: Phenotype and frailty index identify frailty in different mice and are variably affected by chronic medications

Use of different objective frailty assessment tools may improve understanding of the biology of frailty and allow evaluation of effects of interventions on frailty. Polypharmacy is associated with increased risk of frailty in epidemiologic studies, regardless of frailty definition, but the pathophysiology of the association is not well understood. This study aims to (1) assess and compare the prevalence of frailty from middle to old age following control, chronic polypharmacy or monotherapy treatment, when measured using the clinical frailty index assessment and the mouse frailty phenotype tools; and (2) to evaluate and compare the effects of chronic polypharmacy regimens with zero, low and high Drug Burden Index (DBI) and monotherapies from middle to old age on the rate of deficit accumulation on the frailty index, mean number of phenotype criteria, odds of being frail assessed by the frailty index or phenotype, and the time to onset of frailty assessed by the frailty index or phenotype. In a longitudinal study, middle-aged (12 months) male C57BL/6J(B6) mice were administered non medicated control feed and water, or therapeutic doses of different polypharmacy combinations or monotherapies in feed and/or water. Frailty assessments were performed at 12, 15, 18, 21 and 24 months. There was limited overlap between animals identified as frail using different frailty assessments. Polypharmacy has measurable and different effects on each frailty assessment. Long-term chronic administration of some polypharmacy and monotherapy therapeutic drug regimens increased the number of frailty deficits (clinical frailty index: low DBI polypharmacy (15 and 21 months), high DBI polypharmacy (15-21 months), oxycodone (15-18 months), oxybutynin (15-18 months), citalopram (15-21 months) and metoprolol monotherapy (15 months) and modified frailty phenotype assessment (over the whole duration of treatment, low DBI polypharmacy (adjusted Risk Ratio(aRR) = 1.97, 95% confidence interval (CI) 1.43-2.72), high DBI polypharmacy (aRR = 1.88; 95% CI 1.36-2.60), oxybutynin (aRR = 1.48; 95% CI 1.01-2.16) and citalopram monotherapy (aRR = 1.96; 95% CI 1.41-2.74), p < 0.05) . The odds of developing frailty measured with the clinical frailty index increased with high DBI polypharmacy (adjusted odds ratio (aOR) = 3.13; 95% CI 1.01-9.66) and when measured with the frailty phenotype assessment increased with low DBI polypharmacy (aOR = 4.38, 95% CI 1.40-13.74), high DBI polypharmacy (aOR = 3.43; 95% CI 1.12-10.50) and citalopram monotherapy (aOR = 4.63; 95% CI 1.39-15.54)). No treatment affected time to frailty using either frailty assessment. Analysis of the number of deficits on the frailty index or number of positive criteria on the frailty phenotype allows analysis of rate of change and provides greater sensitivity, while the odds of being frail analysis provided a clinically relevant indicator of whether mice had greater chance of reaching a cut-off for becoming frail with medication exposure than without. Our results are consistent with clinical studies, demonstrating that certain polypharmacy regimens induce frailty, with different relationships observed when using different frailty assessments and analyses.

Caregivers' experiences of medication management advice for people living with dementia at discharge

RATIONALE, AIMS, AND OBJECTIVES

Caregivers of people living with dementia play an essential role in managing medications across transitions of care. Adequate caregiver medication management guidance at hospital discharge is important to ensure optimal outcomes from medication use. This qualitative study explores the experiences and perspectives of caregivers about the medication management guidance provided at hospital discharge.

METHODS

A qualitative approach using semi-structured, telephone interviews was conducted with 31 caregivers of people with dementia across Australia. Purposive sampling was used to ensure maximum variation of diverse experiences and perspectives.

RESULTS

Caregivers' experiences of medication guidance for people with dementia at discharge were described in three themes including: (a) inadequate information about medication management at discharge; (b) limited caregiver engagement in medication management decisions; and (c) difficulties ensuring medication supply post discharge. Most participants indicated they would like to be included in discussions at discharge. However, participation was influenced by caregivers being overwhelmed by discharge processes; proactively seeking information on medication-related harm; and belief in advocacy as part of their caregiver role. Caregivers reported they would like to receive a tailored medication list for people with dementia which included information on medications that may impact on the patient's cognition, and for hospital staff to communicate with both the community pharmacist and primary care physician, to improve co-ordination post transition.

DISCUSSION

In our study of caregivers of people with dementia, we identified key recommendations to facilitate regular participation of people living with dementia and their caregiver around medication guidance at discharge.

Deprescribing paracetamol in pain conditions: A scoping review

OBJECTIVE

To examine evidence on deprescribing paracetamol in pain conditions and inform future strategies for paracetamol deprescription.

DESIGN

Scoping review.

PARTICIPANTS

Adults with pain conditions, taking paracetamol.

RESULTS

After two independent teams of reviewers screening for titles, abstracts, and then full texts, 16 original articles were included. Deprescribing strategies were grouped into 5 categories: (1) Pharmacological, (2) Psychological, (3) Physiological, (4) Policy, and (5) Combination. We found strategies were predominately consumer-focused, conducted in community settings and involved individuals experiencing musculoskeletal pain (such as low back pain and osteoarthritis). A total of twelve studies investigated interventions targeting dose reduction and four studies examined interventions focusing on discontinuation of paracetamol. The most common strategies used to deprescribe paracetamol in pain conditions were physiological strategies, followed by psychological strategies. All included studies demonstrated some level of effectiveness to deprescribe paracetamol in a pain conditions through dose reduction or discontinuation, although the effectiveness of deprescribing strategies were highly variable, ranging from the majority of participants discontinuing their paracetamol use, to less than 10% reducing their paracetamol use upon the latest follow-up.

CONCLUSIONS

There are clear opportunities for prospective trials to be designed more purposely and primarily focused to influence reduction and cessation of paracetamol for specific pain conditions where deprescription is appropriate.

"The lesser of two evils": a framework analysis of consumers' perspectives on opioid deprescribing and the development of opioid deprescribing guidelines

ABSTRACT

Deprescribing opioids has been identified as an intervention to mitigate opioid harm; however, it is often challenging to implement interventions and communicate deprescribing decisions to consumers. The development of opioid deprescribing guidelines may provide guidance and support on when and how to reduce or cease opioids in routine care. This study aimed to explore the perspectives of opioid consumers on opioid deprescribing and determine factors to be considered in the development of opioid deprescribing guidelines. A purposive sample of 20 consumers using opioids for pain was recruited. Semistructured interviews were conducted, audio recorded, and transcribed verbatim. Inductive thematic analysis was undertaken, followed by a framework analysis informed by Bandura's Social Cognitive Theory. Behavioral, cognitive, and environmental factors influence consumers' attitudes and actions regarding opioid deprescribing. Significant barriers to opioid deprescribing were identified, including fears of pain and withdrawal effects, opioid-related stigma, and perceived inadequacies of the healthcare system. Improved communication between healthcare professionals and consumers regarding expectations of deprescribing and goals of care, as well as the provision of greater opportunities for consumer engagement in decision making were identified as avenues to improve the success of opioid deprescribing. For opioid deprescribing guidelines to be effective and achieve the intended goal of optimizing opioid use, consumers need to feel empowered to engage in opioid reduction or cessation. The findings of this study may facilitate a patient-centred approach for practitioners and guideline developers in creating recommendations and interventions to enable opioid deprescribing through targeting behavioral change.

Effects of anticholinergic and sedative medication use on fractures: A self-controlled design study

BACKGROUND/OBJECTIVES

Unintentional falls are a leading cause of injury for older adults, and evidence is needed to understand modifiable risk factors. We evaluated 1-year fall-related fracture risk and whether dispensing of medications with anticholinergic/sedating properties is temporally associated with an increased odds of these fractures.

DESIGN

A retrospective cohort study with nested self-controlled analyses conducted between January 1, 2014, and December 31, 2016.

SETTING

Twenty percent nationwide, random sample of US Medicare beneficiaries.

PARTICIPANTS

New users of medications with anticholinergic/sedating properties who were 66+ years old and had Medicare Parts A, B, and D coverage but no claims for medications with anticholinergic/sedating properties in the year before initiation were eligible.

MEASUREMENTS

We followed new users of medications with anticholinergic/sedating properties until first non-vertebral, fall-related fracture (primary outcome), Medicare disenrollment, death, or end of study data. We estimated the 1-year risk with corresponding 95% confidence intervals (CIs) of first fracture after new use. We applied the self-controlled case-crossover and case-time-control designs to estimate odds ratios (ORs) and 95% CIs by comparing anticholinergic and/or sedating medication exposure (any vs. none) during a 14-day hazard period preceding the fracture to exposure to these medications during an earlier 14-day control period.

RESULTS

A total of 1,097,989 Medicare beneficiaries initiated medications with anticholinergic/sedating properties in the study period. The 1-year cumulative incidence of fall-related fracture, accounting for death as a competing risk, was 5.0% (95% CI: 5.0%-5.0%). Using the case-crossover design (n = 41,889), the adjusted OR for the association between anticholinergic/sedating medications and fractures was 1.03 (95% CI: 0.99, 1.08). Accounting for the noted temporal trend using the case-time-control design (n = 209,395), the adjusted OR was 1.60 (95% CI: 1.52, 1.69).

CONCLUSION

Use of anticholinergic/sedating medication was temporally associated with an increased odds of fall-related fractures. Patients and their healthcare providers should consider pharmacologic and non-pharmacologic treatments for the target condition that are safer.

Tools to evaluate medication management for caregivers of people living with dementia: A systematic review

BACKGROUND

Caregivers often undertake medication management for people living with dementia without formal training. There is a need to evaluate caregiver medication management practices for people living with dementia to identify and address the key issues that contribute to caregiver burden.

OBJECTIVES

This study aimed to identify and summarize approaches that evaluate medication management for caregivers of people living with dementia and appraise caregiver's involvement in aspects of medication management.

SEARCH STRATEGY

A systematic search was undertaken in five databases: Medline, Embase, PsycINFO, Scopus and International Pharmaceutical Abstracts. Studies written in English that contained tools and surveys that evaluated aspects of medication management for caregivers of PWD were included.

RESULTS

A total of 10 studies were included. Medication selection was assessed in six studies, supply and monitoring/review was captured in seven studies, with administration assessed in nine studies. Caregivers were commonly involved in decision-making for medication changes (77.1%-86.8%) and in the ordering (55.9%-86.0%) and collection (87.0%-92.4%) of medications. Reported caregiver involvement in medication administration showed a wide range (44%-94.7%) between the studies. Challenges in administration were commonly related to polypharmacy and dosage regimen complexity.

CONCLUSIONS

Current tools capture specific aspects of medication management, with medication administration the most evaluated aspect of medication management. Future research is needed to develop a tool to holistically evaluate the complexities of medication management for caregivers of people living with dementia to minimize adverse events at transitions of care.

PUBLIC CONTRIBUTION

From the authors' previous research, caregivers highlighted the need to address key issues in medication management for people living with dementia.

The value of deprescribing in older adults with dementia: a narrative review

Introduction:Mitigating the burden of unnecessary polypharmacy or multiple medication use in people living with dementia has been recognized as a key priority internationally. One approach to reducing inappropriate polypharmacy is through medication withdrawal or deprescribing.Area covered:Non-systematic searches of key databases including PubMed, Embase, and Google Scholar were conducted from inception to 28 February 2021 for articles that assessed the safety and/or efficacy of deprescribing in older adults living with dementia. Personal reference libraries were also utilized. Information on current clinical trials was found in clinicaltrial.gov.Expert Opinion: There is limited direct evidence to inform deprescribing in older adults with dementia specifically. This review identified nineteen studies that have assessed the impact of deprescribing interventions to reduce inappropriate polypharmacy or direct deprescribing of specific medications. However, the current evidence is limited in scope as most studies focused on medication-related outcomes (e.g. discontinuation of high-risk medications) rather than patient-centered outcomes in individuals living with dementia. Furthermore, most studies focused on addressing inappropriate polypharmacy in older adults with dementia living in long-term care facilities, and interventions did not involve the person and their carer. Further evidence on the impact of deprescribing in this population across clinical settings is needed.

The Effectiveness of Stewardship Interventions to Reduce the Prescribing of Extended-Release Opioids for Acute Pain: A Systematic Review

OBJECTIVE

To evaluate the effectiveness of stewardship interventions in reducing the prescribing of extended-release opioids for acute pain.

DESIGN

Systematic review of randomized controlled trials, pre-post intervention studies, cohort studies and case-control studies.

METHODS

A search was conducted using Medline, Scopus, Cochrane Central Register of Controlled Trials, International Pharmaceutical Abstracts, and PsycINFO from inception to March 24, 2019. Search terms included opioids, interventions, extended-release, and acute pain. Included articles were original research articles outlining the impact of stewardship interventions on reducing the prescribing of extended-release opioids for acute pain.

RESULTS

The search resulted in 1,264 articles after the removal of duplicates. Of these, 141 full texts were assessed, with three eligible for inclusion. One additional article was obtained via a manual search. Three studies explored forcing function interventions; two included prior authorization policies, which saw decreases in extended-release/long-acting scripts by 18-36%, while another evaluated order restrictions producing increased adherence to guidelines by 36%. One study explored the impact of education targeting prescribers and patients through a risk mitigation and evaluation strategy, which decreased extended-release/long-acting quarterly script volumes by 4.3%. All studies were performed at system levels. Forcing function interventions decreased extended-release/long-acting prescriptions and increased adherence to guidelines to a greater extent than less restrictive interventions such as education.

CONCLUSIONS

Forcing function interventions implemented at system levels show promise in decreasing the prescribing of extended-release opioids for acute pain. The current lack of literature warrants future research to increase understanding of the effectiveness of such interventions.

Impact of an Australian/New Zealand organisational position statement on extended-release opioid prescribing among surgical inpatients: a dual centre before-and-after study

Extended-release opioids are often prescribed to manage postoperative pain despite being difficult to titrate to analgesic requirements and their association with long-term opioid use. An Australian/New Zealand organisational position statement released in March 2018 recommended avoiding extended-release opioid prescribing for acute pain. This study aimed to evaluate the impact of this organisational position statement on extended-release opioid prescribing among surgical inpatients. Secondary objectives included predictors and clinical outcomes of prescribing extended-release opioids among surgical inpatients. We conducted a retrospective, dual centre, 11-month before-and-after study and time-series analysis by utilising electronic medical records from two teaching hospitals in Sydney, Australia. The primary outcome was the proportion of patients prescribed an extended-release opioid. For surgical patients prescribed any opioid (n = 16,284), extended-release opioid prescribing decreased after the release of the position statement (38.4% before vs. 26.6% after, p < 0.001), primarily driven by a reduction in extended-release oxycodone (31.1% before vs. 14.1% after, p < 0.001). There was a 23% immediate decline in extended-release opioid prescribing after the position statement release (p < 0.001), followed by an additional 0.2% decline per month in the following months. Multivariable regression showed that the release of the position statement was associated with a decrease in extended-release opioid prescribing (OR 0.54, 95%CI 0.50-0.58). Extended-release opioid prescribing was also associated with increased incidence of opioid-related adverse events (OR 1.52, 95%CI 1.35-1.71); length of stay (RR 1.44, 95%CI 1.39-1.51); and 28-day re-admission (OR 1.26, 95%CI 1.12-1.41). Overall, a reduction in extended-release opioid prescribing was observed in surgical inpatients following position statement release.

Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review

BACKGROUND

Hospital discharge has a significant impact on the continuity of care for people living with dementia. Clear guidance on medication management should be provided to caregivers of people living with dementia to ensure appropriate use of medications post-discharge.

AIM

Identify and appraise the impact of interventions at hospital discharge to guide caregivers in the medication management for people living with dementia.

METHOD

A systematic search of original studies was performed in Medline, Embase, PsycINFO, and CINAHL. Articles published in English that reported on interventions to guide caregivers in medication management for people living with dementia were included. Two authors independently reviewed titles and abstract. Full-text articles were assessed for eligibility and quality assessment was conducted by two authors.

RESULTS

A total of five studies were included with a range of interventions that were typically delivered post-discharge by a multidisciplinary team and most targeted administration of medications by caregivers. Overall, three types of discharge interventions were identified including a pre-discharge caregiver educational intervention, a post-discharge multidisciplinary team intervention, and discharge summary documentation intervention at transitions of care. Of these, a pre-discharge caregiver education led to shorter hospital stay (25 days vs. 31 days, p = 0.005). A post-discharge intervention that included follow-up visits resulted in lower use of high-risk medications (19% vs. 40%), and reduction in 30-day re-hospitalization rates (11% vs. 20%). In contrast, in another post-discharge intervention study, no difference in one-month re-hospitalization rates (8.4% vs. 8.0%, p = 0.82) was demonstrated. In another study, a post-discharge hospital educational program provided to caregivers  led to significantly reduced caregiver burden (31.7 ± 17.6 (SD) pre-intervention to 27.7 ± 16.9 (SD) post-intervention (p = 0.037)).

DISCUSSION

Current findings suggest there is a need for well-designed interventions to guide caregivers in all aspects of medication management for people living with dementia, and should include support for caregivers in care coordination.

Polypharmacy Results in Functional Impairment in Mice: Novel Insights into Age and Sex Interactions

Males and females may respond differently to medications, yet knowledge about sexual dimorphisms in the effects of polypharmacy remains limited, particularly in aging. This study aimed to assess the effect of high Drug Burden Index (DBI) polypharmacy treatment compared to control on physical function and behavior in young and old, male and female mice. We studied whether age and sex play a role in physical function and behavior following polypharmacy treatment, and whether they are parallelled by differences in serum drug levels. Young (2.5 months) and old (21.5 months), C57BL/6 mice were randomized to control or high DBI polypharmacy treatment (simvastatin, metoprolol, oxybutynin, oxycodone, citalopram) (n=6-8/group) for 4-6 weeks. Compared to control, polypharmacy reduced physical function (grip strength, rotarod latency, gait speed, total distance), middle zone distance (increased anxiety) and nesting score (reduced activities of daily living) in mice of both ages and sexes (p<0.001). Old animals had a greater decline in nesting score (p<0.05) and midzone distance (p<0.001) than young animals. Grip strength declined more in males than females (p<0.05). Drug levels at steady state were not significantly different between polypharmacy-treated animals of both ages and sexes. We observed polypharmacy-induced functional impairment in both age and sex groups, with age and sex interactions in the degree of impairment, which were not explained by serum drug levels. Studies of pathogenesis of the functional impairment from polypharmacy may improve management strategies in both sexes.

Pain, Complex Chronic Conditions and Potential Inappropriate Medication in People with Dementia. Lessons Learnt for Pain Treatment Plans Utilizing Data from the Veteran Health Administration

Alzheimer's disease and related dementias (ADRD), pain and chronic complex conditions (CCC) often co-occur leading to polypharmacy and with potential inappropriate medications (PIMs) use, are important risk factors for adverse drug reactions and hospitalizations in older adults. Many US veterans are at high risk for persistent pain due to age, injury or medical illness. Concerns about inadequate treatment of pain-accompanied by evidence about the analgesic efficacy of opioids-has led to an increase in the use of opioid medications to treat chronic pain in the Veterans Health Administration (VHA) and other healthcare systems. This study aims to investigate the relationship between receipt of pain medications and centrally (CNS) acting PIMs among veterans diagnosed with dementia, pain intensity, and CCC 90-days prior to hospitalization. The final analytic sample included 96,224 (81.7%) eligible older veterans from outpatient visits between October 2012-30 September 2013. We hypothesized that veterans with ADRD, and severe pain intensity may receive inappropriate pain management and CNS-acting PIMs. Seventy percent of the veterans, and especially people with ADRD, reported severe pain intensity. One in three veterans with ADRD and severe pain intensity have an increased likelihood for CNS-acting PIMs, and/or opioids. Regular assessment and re-assessment of pain among older persons with CCC, patient-centered tapering or discontinuation of opioids, alternatives to CNS-acting PIMs, and use of non-pharmacological approaches should be considered.

Development and validation of a frailty index based on data routinely collected across multiple domains in NSW hospitals

OBJECTIVE(S)

To develop and validate a frailty index (FI) that covers multiple domains, using routine hospital data. To investigate the FI's validity, after excluding medication-related items (FI-ExMeds), for studies of frailty and polypharmacy.

METHODS

A FI was derived from routine NSW hospital data following standard published guidance. In a development cohort (151 inpatients ≥ 70 years), the FI was correlated with the Reported Edmonton Frail Scale (REFS) using Pearson's R. Validity and distribution of FI and FI-ExMeds, and correlation with each other, were evaluated in a validation cohort (999 inpatients ≥ 75 years).

RESULTS

The mean FI for the development cohort was 0.27 (SD 0.09). The FI showed moderate linear correlation with the REFS (n = 148, R = 0.52, P < .001). In the validation cohort, mean FI (n = 993) and FI-ExMeds (n = 990) were both 0.28 (SD 0.11). FI-ExMeds showed high linear correlation with the FI (n = 990, R = 0.99, P < .001).

CONCLUSION

This multi-domain FI is comparable to REFS, with adequate redundancy to exclude deficits for specific analyses.