Physicians' and nurses' perceptions of the factors influencing the implementation of paediatric clinical pharmacy services in Hong Kong: a qualitative study

OBJECTIVES

To identify barriers and facilitators that influence the implementation of paediatric clinical pharmacy services in Hong Kong public hospitals from physicians' and nurses' perspectives.

METHODS

A qualitative study was conducted based on semistructured interviews of physicians and nurses who worked in the field of paediatrics in four public hospitals in Hong Kong. Interviews were held via telephone conversations using spoken Cantonese which were audio recorded, then translated and transcribed directly into English by the research team. Thematic analysis was used for data analysis and reflexivity was engaged through member checking, making field notes and reporting using the Consolidated Criteria for Reporting Qualitative Studies checklist.

RESULTS

A total of six barriers and five facilitators were identified from interviewing 17 participants, which included 7 physicians and 10 nurses. The barriers identified were the public's lack of understanding and recognition of clinical pharmacists, a culture of medical dominance, lack of resources and heavy workload, the need for a more transparent and defined role of clinical pharmacist at the institutional level, lack of proactive approach and involvement in direct patient care activities. The facilitators identified were the belief in the improvement of patient outcomes and the overall pharmaceutical service efficiency, trust and confidence in clinical pharmacy services, filling the clinical gap as a medicine information provider, and direct and coherent communication as a multidisciplinary team member.

CONCLUSIONS

Physicians and nurses reported that the implementation of paediatric clinical pharmacy services was adequate, but several key barriers were identified at both the external and internal levels.

Clinical pharmacists' perceptions of the barriers and facilitators to the implementation of paediatric clinical pharmacy services in Hong Kong

OBJECTIVES

To identify barriers and facilitators that influenced the implementation of paediatric clinical pharmacy service (CPS) in Hong Kong's public hospitals from clinical pharmacists' perspective.

METHODS

A qualitative study based on semi-structured interviews of clinical pharmacists who practiced in paediatrics in public hospitals in Hong Kong. Interview schedule was designed based on determined themes identified in previous research and pilot testing was performed. The coding process was performed by two researchers with the resulting topics organised by thematic analysis. Consensus was reached amongst the researchers for the identification of themes that emerged during the interviews. The Consolidated Criteria for Reporting Qualitative Research guideline was followed to ensure the complete and transparent reporting of this research. Ethical approval for this study was obtained from the research ethics committee of the relevant institutions.

KEY FINDINGS

Of the 32 clinical pharmacists from across the study sites, 12 were interviewed. Five barriers and three facilitators were identified as main themes. The barriers that were identified which hindered service implementation include the service penetration into the healthcare system, practice environment constraints, lack of affirmation from the administrative stakeholders, governance of the profession and partnership with universities. The facilitators that were identified which enabled service implementation include other healthcare professionals' trust and confidence in the service, the support from the pharmacy management team and clinical pharmacists' self-efficacy.

CONCLUSIONS

Clinical pharmacists interviewed reported that the successful implementation of CPS in paediatrics in public hospitals in Hong Kong is an area of continued development with several key barriers identified.

REalist Synthesis Of non-pharmacologicaL interVEntions for antipsychotic-induced weight gain (RESOLVE) in people living with severe mental illness (SMI)

BACKGROUND

People with severe mental illnesses (SMI) such as schizophrenia die on average 15 to 20 years earlier than everyone else. Two thirds of these deaths are from preventable physical illnesses such as hypertension, cardiovascular disease, and diabetes, which are worsened by weight gain. Antipsychotics are associated with significant weight gain. In REalist Synthesis Of non-pharmacologicaL interVEntions (RESOLVE), a realist synthesis, combining primary and secondary data, will be used to understand and explain how, why, for whom, and in what contexts non-pharmacological interventions can help service users to manage antipsychotic-induced weight gain.

METHODS

A five-step approach will be used to develop guidance: 1. Developing the initial programme theory An initial (candidate) programme theory, which sets out how and why outcomes occur within an intervention, will be developed. 2. Developing the search The initial programme theory will be refined using academic and grey literature. The proposed initial sampling frame are as follows: Context: people living with SMI, taking antipsychotics, different types of SMI.

INTERVENTION

non-pharmacological interventions.

MECHANISMS

triggered by the intervention. Outcomes e.g. weight, metabolic adverse events, quality of life, adherence, burden, economic. Searching for relevant documents will continue until sufficient data is found to conclude that the refined programme theory is coherent and plausible. Lived experience (service users) and stakeholder (practitioners) groups will provide feedback. 3. Selection, appraisal and data extraction Documents will be screened against inclusion and exclusion criteria. The text extracted from these documents will be coded as contexts, mechanisms and their relationships to outcomes. 4. Primary data collection Realist interviews with up to 30 service users and informal carers, and 20 practitioners will gather data to support, refute or refine the programme theory. 5. Data analysis A realist logic of analysis will be used to develop and refine the programme theory from secondary and primary data. The analysis will aim to identify practical intervention strategies to change contexts so that key mechanisms are triggered to produce desired outcomes. Guidance will be produced based on these strategies.

DISCUSSION

This realist synthesis aims to develop guidance for service users and practitioners on the most appropriate interventional strategies to manage and limit antipsychotic weight gain.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42021268697.

Factors influencing the implementation of clinical pharmacy services on paediatric patient care in hospital settings

OBJECTIVES

This systematic review (SR) was undertaken to identify and summarise any factors which influence the implementation of paediatric clinical pharmacy service (CPS) from service users' perspectives in hospital settings.

METHODS

Literature search from EMBASE, MEDLINE, Web of Science (Core Collection), Cochrane Library, Scopus and CINAHL databases were performed in order to identify any relevant peer-reviewed quantitative and qualitative studies from inception until October 2019 by following the inclusion criteria. Boolean search operators were used which consisted of service, patient subgroup and attribute domains. Studies were screened independently and included studies were quality assessed using Mixed Methods Appraisal Tool. The study was reported against the 'Enhancing Transparency in Reporting the Synthesis of Qualitative Research' statement.

RESULTS

4199 citations were screened by title and abstract and 6 of 32 full publications screened were included. There were two studies that were graded as 'high' in quality, with four graded as 'moderate'. The analysis has led to the identification of seven factors categorised in five predetermined overarching themes. These were: other healthcare professionals' attitudes and acceptance; availability of clinical pharmacist on ward or outpatient settings; using drug-related knowledge to perform clinical activities; resources for service provision and coverage; involvement in a multidisciplinary team; training in the highly specialised areas and development of communication skills.

CONCLUSION

Evidence for paediatric CPS was sparse in comparison to a similar SR conducted in the adult population. An extensive knowledge gap within this area of practice has therefore been identified. Nevertheless, majority of the factors identified were viewed as facilitators which enabled a successful implementation of CPS in paediatrics. Further research is needed to identify more factors and exploration of these would be necessary in order to provide a strong foundation for strategic planning for paediatric CPS implementation and development.

Anticholinergic drugs and incident dementia, mild cognitive impairment and cognitive decline: a meta-analysis

Background

the long-term effect of the use of drugs with anticholinergic activity on cognitive function remains unclear.

Methods

we conducted a systematic review and meta-analysis of the relationship between anticholinergic drugs and risk of dementia, mild cognitive impairment (MCI) and cognitive decline in the older population. We identified studies published between January 2002 and April 2018 with ≥12 weeks follow-up between strongly anticholinergic drug exposure and the study outcome measurement. We pooled adjusted odds ratios (OR) for studies reporting any, and at least short-term (90+ days) or long-term (365+ days) anticholinergic use for dementia and MCI outcomes, and standardised mean differences (SMD) in global cognition test scores for cognitive decline outcomes. Statistical heterogeneity was measured using the I² statistic and risk of bias using ROBINS-I.

Results

twenty-six studies (including 621,548 participants) met our inclusion criteria. ‘Any’ anticholinergic use was associated with incident dementia (OR 1.20, 95% confidence interval [CI] 1.09–1.32, I² = 86%). Short-term and long-term use were also associated with incident dementia (OR 1.23, 95% CI 1.17–1.29, I² = 2%; and OR 1.50, 95% CI 1.22–1.85, I² = 90%). ‘Any’ anticholinergic use was associated with cognitive decline (SMD 0.15; 95% CI 0.09–0.21, I² = 3%) but showed no statistically significant difference for MCI (OR 1.24, 95% CI 0.97–1.59, I² = 0%).

Conclusions

anticholinergic drug use is associated with increased dementia incidence and cognitive decline in observational studies. However, a causal link cannot yet be inferred, as studies were observational with considerable risk of bias. Stronger evidence from high-quality studies is needed to guide the management of long-term use.

Increasing prevalence of anticholinergic medication use in older people in England over 20 years: cognitive function and ageing study I and II

BACKGROUND

Anticholinergic medication use is linked with increased cognitive decline, dementia, falls and mortality, and their use should be limited in older people. Here we estimate the prevalence of anticholinergic use in England's older population in 1991 and 2011, and describe changes in use by participant's age, sex, cognition and disability.

METHODS

We compared data from participants aged 65+ years from the Cognitive Function and Ageing Studies (CFAS I and II), collected during 1990-1993 (N = 7635) and 2008-2011 (N = 7762). We estimated the prevalence of potent anticholinergic use (Anticholinergic Cognitive Burden [ACB] score = 3) and average anticholinergic burden (sum of ACB scores), using inverse probability weights standardised to the 2011 UK population. These were stratified by age, sex, Mini-Mental State Examination score, and activities of daily living (ADL) or instrumental ADL (IADL) disability.

RESULTS

Prevalence of potent anticholinergic use increased from 5.7% (95% Confidence Interval [CI] 5.2-6.3%) of the older population in 1990-93 to 9.9% (9.3-10.7%) in 2008-11, adjusted odds ratio of 1.90 (95% CI 1.67-2.16). People with clinically significant cognitive impairment (MMSE [Mini Mental State Examination] 21 or less) were the heaviest users of potent anticholinergics in CFAS II (16.5% [95% CI 12.0-22.3%]). Large increases in the prevalence of the use medication with 'any' anticholinergic activity were seen in older people with clinically significant cognitive impairment (53.3% in CFAS I to 71.5% in CFAS II).

CONCLUSIONS

Use of potent anticholinergic medications nearly doubled in England's older population over 20 years with some of the greatest increases amongst those particularly vulnerable to anticholinergic side-effects.

Preparing care home staff to manage challenging behaviours among residents living with dementia: A mixed-methods evaluation

We evaluated an intervention designed to manage challenging behaviours of people with dementia. Framework analysis of interviews (n = 21) showed the intervention modified practice and perceptions. The intervention (n = 58; power calculation proposed n = 160 for medium effect) had no significant effect on attitudes to dementia for time (p = .42) or care home (p = .15). The Maslach burnout scores did not change significantly for person-centredness for time (p = .83) or care home (p = .29). Hope scores showed a significant effect post-intervention (p = .004), but this was not maintained. No significant main effect was found for care home (p = .36). Experiential learning enabled staff to experience benefits of person-centred care firsthand.

Medication management in older people: the MEMORABLE realist synthesis

Background

The number and proportion of older people in the UK are increasing, as are multimorbidity (potentially reducing quality of life) and polypharmacy (increasing the risk of adverse drug events). Together, these complex factors are challenging for older people, informal carers, and health and care practitioners.

Objectives

MEMORABLE (MEdication Management in Older people: Realist Approaches Based on Literature and Evaluation) aimed to understand how medication management works and propose improvements.

Design

A realist approach informed three work packages, combining a realist review of secondary data with a realist evaluation of primary interview data, in a theory-driven, causal analysis.

Setting

The setting was in the community.

Participants

Older people, informal carers, and health and care practitioners.

Interventions

Studies relating to medication management and to reviewing and reconciling medications; and realist-informed interviews.

Main outcome measures

Not applicable.

Data sources

MEDLINE, CINAHL (Cumulative Index of Nursing and Allied Health Literature) and EMBASE were searched (all searched from January 2009 to July 2017; searched on 1 August 2017). Supplementary articles were identified by the Research Team. Data were also obtained through interviews.

Review methods

Searches of electronic databases were supplemented by citation-tracking for explanatory contributions, as well as accessing topic-relevant grey literature. Following RAMESES (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) guidelines, articles were screened and iteratively analysed with interview data, to generate theory-informed (normalisation process theory) explanations.

Results

Developing a framework to explain medication management as a complex intervention across five stages: identifying problem (Stage 1), starting, changing or stopping medications (Stage 3) and continuing to take medications (Stage 4), where older people, sometimes with informal carers, make individual decisions and follow routines that fit medication management into their day-to-day lives, engendering a sense of control. In getting diagnosis and/or medications (Stage 2) and reviewing/reconciling medications (Stage 5), older people and practitioners share decision-making in time-limited contacts: involving four steps – sense-making, relationships, action and reflection/monitoring (normalisation process theory); and conceptualising burden – through a detailed analysis of Stage 5, generating a theoretical framework and identifying five burden types amendable to mitigation: ambiguity, concealment, unfamiliarity, fragmentation and exclusion. Proposing interventions: risk identification – a simple way of identifying older people and informal carers who are not coping, at risk and who need appropriate help and support; and individualised information – a short, personalised record and reference point, co-produced and shared by older people, informal carers and practitioners that addresses the experience of living with multimorbidities and polypharmacy.

Limitations

Few studies directly address the complexity of medication management as a process and how it works. Limitations included, having identified the overall complexity, the need to focus the analysis on reviewing/reconciling medications (Stage 5), the exclusion of non-English-language literature, the focus on non-institutionalised populations and the broad definition of older people.

Conclusions

MEMORABLE explored the complexity of medication management. It highlighted the way interpersonal stages in the medication management process, notably reviewing/reconciling medications, contribute to the mitigation of burdens that are often hidden.

Future work

Co-produced studies to scope and trial the two proposed interventions; studies to extend the detailed understanding of medication management, linked to burden mitigation; and a study to clarify the medication management outcomes wanted by older people, informal carers and practitioners.

Study registration

This study is registered as PROSPERO CRD42016043506.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 26. See the NIHR Journals Library website for further project information.

Does the Formulation of Oral Solid Dosage Forms Affect Acceptance and Adherence in Older Patients? A Mixed Methods Systematic Review

OBJECTIVES

Age-related changes mean that the older population can encounter barriers toward taking medication orally. Further work is needed to identify the characteristics of oral solid dosage forms that will improve patient acceptance and adherence. The aim of this systematic review was to identify if and how formulation aspects of oral solid dosage forms affect acceptance and adherence in older people.

DESIGN

Mixed methods systematic review using a data-based convergent synthesis design.

SETTING AND PARTICIPANTS

Articles were selected if they included participants aged 60 years and older, or included health care professionals, social care professionals, and informal carers of patients aged 60 years and older.

METHODS

A systematic search of the following databases was undertaken: Web of Science, MEDLINE, Scopus, and The Cochrane Databases. The search of databases was supplemented by a search of gray literature, and reference lists of included papers were manually searched.

RESULTS

A total of 16 studies were included in the final synthesis. Three themes were generated from the thematic analysis: (1) dimensions, (2) palatability, and (3) appearance. The dimensions and palatability are often modified to improve swallowability by breaking tablets in half or taste masking with food. Polypharmacy can lead to patients using the appearance to identify tablets; however, this can lead to confusion when products appear similar. No study was identified that explored formulation characteristics across all 3 categories directly in the older population.

CONCLUSION AND IMPLICATIONS

Manufacturers should take into account practical problems older people may encounter when considering the dimensions, palatability, and appearance of the final drug product. These characteristics should be optimized to aid visual identification and swallowability. Medical providers and pharmacists have an important role in ensuring that these patient-centric drug products are prescribed and dispensed appropriately so that patients receive the most suitable formulation.

MEDREV (pharmacy-health psychology intervention in people living with dementia with behaviour that challenges): the feasibility of measuring clinical outcomes and costs of the intervention

Background

People living with dementia in care homes frequently exhibit “behaviour that challenges”. Anti-psychotics are used to treat such behaviour, but are associated with significant morbidity. This study researched the feasibility of conducting a trial of a full clinical medication review for care home residents with behaviour that challenges, combined with staff training. This paper focusses on the feasibility of measuring clinical outcomes and intervention costs.

Methods

People living with moderate to severe dementia, receiving psychotropics for behaviour that challenges, in care homes were recruited for a medication review by a specialist pharmacist. Care home and primary care staff received training on the management of challenging behaviour.

Data were collected at 8 weeks, and 3 and 6 months. Measures were Neuropsychiatric Inventory-Nursing Home version (NPI-NH), cognition (sMMSE), quality of life (EQ-5D-5 L/DEMQoL) and costs (Client Services Receipt Inventory).

Response rates, for clinical, quality of life and health economic measures, including the levels of resource-use associated with the medication review and other non-intervention costs were calculated.

Results

Twenty-nine of 34 participants recruited received a medication review. It was feasible to measure the effects of the complex intervention on the management of behaviour that challenges with the NPI-NH. There was valid NPI-NH data at each time point (response rate = 100%). The sMMSE response rate was 18.2%. Levels of resource-use associated with the medication review were estimated for all 29 participants who received a medication review. Good response levels were achieved for other non-intervention costs (100% completion rate), and the EQ-5D-5 L and DEMQoL (≥88% at each of the time points where data was collected).

Conclusions

It is feasible to measure the clinical and cost effectiveness of a complex intervention for behaviour that challenges using the NPI-NH and quality of life measures.

Trial registration

ISRCTN58330068. Retrospectively registered, 15 October 2017.

Medication review plus person-centred care: a feasibility study of a pharmacy-health psychology dual intervention to improve care for people living with dementia

BACKGROUND

"Behaviour that Challenges" is common in people living with dementia, resident in care homes and historically has been treated with anti-psychotics. However, such usage is associated with 1800 potentially avoidable deaths annually in the UK. This study investigated the feasibility of a full clinical trial of a specialist dementia care pharmacist medication review combined with a health psychology intervention for care staff to limit the use of psychotropics. This paper focuses on feasibility; including recruitment and retention, implementation of medication change recommendations and the experiences and expectations of care staff.

METHODS

West Midlands care homes and individuals meeting the inclusion criteria (dementia diagnosis; medication for behaviour that challenges), or their personal consultee, were approached for consent. A specialist pharmacist reviewed medication. Care home staff received an educational behaviour change intervention in a three-hour session promoting person-centred care. Primary healthcare staff received a modified version of the training. The primary outcome measure was the Neuropsychiatric Inventory-Nursing Home version at 3 months. Other outcomes included quality of life, cognition, health economics and prescribed medication. A qualitative evaluation explored expectations and experiences of care staff.

RESULTS

Five care homes and 34 of 108 eligible residents (31.5%) were recruited, against an original target of 45 residents across 6 care homes. Medication reviews were conducted for 29 study participants (85.3%) and the pharmacist recommended stopping or reviewing medication in 21 cases (72.4%). Of the recommendations made, 57.1% (12 of 21) were implemented, and implementation (discontinuation) took a mean of 98.4 days. In total, 164 care staff received training and 21 were interviewed. Care staff reported a positive experience of the intervention and post intervention adopting a more holistic patient-centred approach.

CONCLUSIONS

The intervention contained two elements; staff training and medication review. It was feasible to implement the staff training, and the training appeared to increase the ability and confidence of care staff to manage behaviour that challenges without the need for medication. The medication review would require significant modification for full trial partly related to the relatively limited uptake of the recommendations made, and delay in implementation.

TRIAL REGISTRATION

ISRCTN58330068 . Registered 15 October 2017. Retrospectively registered.

A medication error reporting scheme: analysis of the first 12 months

Aims and Method

A new medication error reporting scheme (‘Safemed’) was introduced within the East Kent NHS and Social Care Partnership Trust. All medication incidents reported using this system in the first year were analysed by the Chief Pharmacist.

Results

Over a 12-month period a total of 66 incidents were reported through Safemed, compared with 55 incidents under the previous system. The low level of reporting made detailed statistical analysis and drawing meaningful conclusions problematic. There was a large variability in reporting between similar sites.

Clinical Implications

The low level of reporting was associated with cultural factors, in particular the failure to fully implement a ‘no blame’ culture. Until such a culture is established, reporting will remain variable and a systems approach to preventing medication errors will not be adopted, leading to significant clinical risk.

A qualitative study exploring medication management in people with dementia living in the community and the potential role of the community pharmacist

Background

The prevalence of dementia is increasing rapidly. People with dementia may be prescribed complex medication regimens, which may be challenging for them and any carers involved to safely manage.

Objective

To describe and understand the key challenges, in relation to medication issues, experienced by people with dementia and their informal carers dwelling in the community and the potential role of community pharmacists.

Design

Qualitative semi‐structured interviews.

Participants

People with dementia, informal carers and health and social care professionals (HSCPs).

Results

Thirty‐one participants (eleven informal carers, four people with dementia and sixteen HSCPs) were interviewed. Three key themes were identified: the key challenges, improving medication management and the role of pharmacists. The caring role commonly included responsibility for medication management which created both practical problems and an emotional burden. This burden was worsened by any difficulty in obtaining support and if the person with dementia was on a complex regimen. Participants believed that the process could be improved by coordinated and on‐going support from HSCPs, which should focus on the informal carer. Medication reviews, particularly when conducted in the home environment, could be helpful.

Conclusion

Medication management for people with dementia living in the community is a complex process, and informal carers have a key role, which they frequently find challenging. Community pharmacists could have an enhanced role in this area, but would need to work within a more multidisciplinary environment outside the pharmacy.

Association of anticholinergic burden with adverse effects in older people with intellectual disabilities: an observational cross-sectional study

BACKGROUND

No studies to date have investigated cumulative anticholinergic exposure and its effects in adults with intellectual disabilities.

AIMS

To determine the cumulative exposure to anticholinergics and the factors associated with high exposure.

METHOD

A modified Anticholinergic Cognitive Burden (ACB) scale score was calculated for a representative cohort of 736 people over 40 years old with intellectual disabilities, and associations with demographic and clinical factors assessed.

RESULTS

Age over 65 years was associated with higher exposure (ACB 1-4 odds ratio (OR) = 3.28, 95% CI 1.49-7.28, ACB 5+ OR = 3.08, 95% CI 1.20-7.63), as was a mental health condition (ACB 1-4 OR = 9.79, 95% CI 5.63-17.02, ACB 5+ OR = 23.74, 95% CI 12.29-45.83). Daytime drowsiness was associated with higher ACB (P<0.001) and chronic constipation reported more frequently (26.6% ACB 5+ v. 7.5% ACB 0, P<0.001).

CONCLUSIONS

Older people with intellectual disabilities and with mental health conditions were exposed to high anticholinergic burden. This was associated with daytime dozing and constipation.

Zaleplon for Insomnia

Objective:

To assess the effectiveness data of zaleplon.

Data Sources:

Primary and review articles were identified by MEDLINE (1985 to August 2000) and via secondary sources.

Study Selection and Data Extraction:

All of the articles identified from the data sources were evaluated, and all information deemed relevant was included in this review.

Data Synthesis:

Eight studies were identified. Two trials in a nonelderly population investigated the effectiveness of zaleplon and the incidence of withdrawal symptoms. Zaleplon's only significant effect on insomnia was to reduce sleep latency by six to 16 minutes. The tools used in the trials showed that stopping zaleplon after 14–28 days of therapy did not cause significant rebound events. Two recent studies that investigated the use of zaleplon in the elderly produced similar results, although one study showed that stopping zaleplon causes significant rebound events. Three studies determined whether zaleplon caused any hangover effects and concluded that there is a low potential for these effects in a nonelderly population. In healthy nonelderly volunteers, standard doses of zaleplon had no residual effects when taken as little as two hours before the subjects arose. One small-scale study indicated that the abuse potential of zaleplon is similar to that of benzodiazepines.

Conclusions:

Although zaleplon significantly reduces sleep latency, the effect does not appear to be highly clinically significant. Zaleplon's short half-life does appear to reduce the risk of hangover effects. Until further data become available, zaleplon should be considered to have the same abuse potential as benzodiazepines.

Improving the management of behaviour that challenges associated with dementia in care homes: protocol for pharmacy-health psychology intervention feasibility study

INTRODUCTION

The inappropriate use of antipsychotics in people with dementia for behaviour that challenges is associated with an estimated 1800 deaths annually. However, solely focusing on antipsychotics may transfer prescribing to other equally dangerous psychotropics. Little is known about the role of pharmacists in the management of psychotropics used to treat behaviours that challenge. This research aims to determine whether it is feasible to implement and measure the effectiveness of a combined pharmacy-health psychology intervention incorporating a medication review and staff training package to limit the prescription of psychotropics to manage behaviour that challenges in care home residents with dementia.

METHODS/ANALYSIS

6 care homes within the West Midlands will be recruited. People with dementia receiving medication for behaviour that challenges, or their personal consultee, will be approached regarding participation. Medication used to treat behaviour that challenges will be reviewed by the pharmacist, in collaboration with the general practitioner (GP), person with dementia and carer. The behavioural intervention consists of a training package for care home staff and GPs promoting person-centred care and treating behaviours that challenge as an expression of unmet need. The primary outcome measure is the Neuropsychiatric Inventory-Nursing Home version (NPI-NH). Other outcomes include quality of life (EQ-5D and DEMQoL), cognition (sMMSE), health economic (CSRI) and prescribed medication including whether recommendations were implemented. Outcome data will be collected at 6 weeks, and 3 and 6 months. Pretraining and post-training interviews will explore stakeholders' expectations and experiences of the intervention. Data will be used to estimate the sample size for a definitive study.

ETHICS/DISSEMINATION

The project has received a favourable opinion from the East Midlands REC (15/EM/3014). If potential participants lack capacity, a personal consultee will be consulted regarding participation in line with the Mental Capacity Act. Results will be published in peer-reviewed journals and presented at conferences.

Role of community pharmacists in the use of antipsychotics for behavioural and psychological symptoms of dementia (BPSD): a qualitative study

OBJECTIVE

This study aimed to use qualitative methodology to understand the current role of community pharmacists in limiting the use of antipsychotics prescribed inappropriately for behavioural and psychological symptoms of dementia.

DESIGN

A qualitative study employing focus groups was conducted. Data were analysed using thematic analysis.

SETTING

3 different geographical locations in the England.

PARTICIPANTS

Community pharmacists (n=22).

RESULTS

The focus groups identified an array of factors and constraints, which affect the ability of community pharmacists to contribute to initiatives to limit the use of antipsychotics. 3 key themes were revealed: (1) politics and the medical hierarchy, which created communication barriers; (2) how resources and remit impact the effectiveness of community pharmacy; and (3) understanding the nature of the treatment of dementia.

CONCLUSIONS

Our findings suggest that an improvement in communication between community pharmacists and healthcare professionals, especially general practitioners (GPs) must occur in order for community pharmacists to assist in limiting the use of antipsychotics in people with dementia. Additionally, extra training in working with people with dementia is required. Thus, an intervention which involves appropriately trained pharmacists working in collaboration with GPs and other caregivers is required. Overall, within the current environment, community pharmacists question the extent to which they can contribute in helping to reduce the prescription of antipsychotics.

A predictive in vitro model of the impact of drugs with anticholinergic properties on human neuronal and astrocytic systems

The link between off-target anticholinergic effects of medications and acute cognitive impairment in older adults requires urgent investigation. We aimed to determine whether a relevant in vitro model may aid the identification of anticholinergic responses to drugs and the prediction of anticholinergic risk during polypharmacy. In this preliminary study we employed a co-culture of human-derived neurons and astrocytes (NT2.N/A) derived from the NT2 cell line. NT2.N/A cells possess much of the functionality of mature neurons and astrocytes, key cholinergic phenotypic markers and muscarinic acetylcholine receptors (mAChRs). The cholinergic response of NT2 astrocytes to the mAChR agonist oxotremorine was examined using the fluorescent dye fluo-4 to quantitate increases in intracellular calcium [Ca2+]i. Inhibition of this response by drugs classified as severe (dicycloverine, amitriptyline), moderate (cyclobenzaprine) and possible (cimetidine) on the Anticholinergic Cognitive Burden (ACB) scale, was examined after exposure to individual and pairs of compounds. Individually, dicycloverine had the most significant effect regarding inhibition of the astrocytic cholinergic response to oxotremorine, followed by amitriptyline then cyclobenzaprine and cimetidine, in agreement with the ACB scale. In combination, dicycloverine with cyclobenzaprine had the most significant effect, followed by dicycloverine with amitriptyline. The order of potency of the drugs in combination frequently disagreed with predicted ACB scores derived from summation of the individual drug scores, suggesting current scales may underestimate the effect of polypharmacy. Overall, this NT2.N/A model may be appropriate for further investigation of adverse anticholinergic effects of multiple medications, in order to inform clinical choices of suitable drug use in the elderly.

Perspectives of carers on medication management in dementia: lessons from collaboratively developing a research proposal

BACKGROUND

The need for carers to manage medication-related problems for people with dementia living in the community raises dilemmas, which can be identified by carers and people with dementia as key issues for developing carer-relevant research projects. A research planning Public Patient Involvement (PPI) workshop using adapted focus group methodology was held at the Alzheimer's Society's national office, involving carers of people with dementia who were current members of the Alzheimer's Society Research Network (ASRN) in dialogue with health professionals aimed to identify key issues in relation to medication management in dementia from the carer viewpoint. The group was facilitated by a specialist mental health pharmacist, using a topic guide developed systematically with carers, health professionals and researchers. Audio-recordings and field notes were made at the time and were transcribed and analysed thematically. The participants included nine carers in addition to academics, clinicians, and staff from DeNDRoN (Dementias and Neurodegenerative Diseases Research Network) and the Alzheimer's Society.

FINDINGS

Significant themes, for carers, which emerged from the workshop were related to: (1) medication usage and administration practicalities, (2) communication barriers and facilitators, (3) bearing and sharing responsibility and (4) weighing up medication risks and benefits. These can form the basis for more in-depth qualitative research involving a broader, more diverse sample.

DISCUSSION

The supported discussion enabled carer voices and perspectives to be expressed and to be linked to the process of identifying problems in medications management as directly experienced by carers. This was used to inform an agenda for research proposals which would be meaningful for carers and people with dementia.

The impact of anticholinergic burden in Alzheimer's dementia-the LASER-AD study

OBJECTIVE

to examine the effect of medications with anticholinergic effects on cognitive impairment and deterioration in Alzheimer's dementia (AD).

METHODS

cognitive function was measured at baseline and at 6- and 18-month follow-up using the Mini-Mental State Exam (MMSE), the Severe Impairment Battery (SIB) and the Alzheimer's Disease Assessment Battery, Cognitive subsection (ADAS-COG) in a cohort study of 224 participants with AD. Baseline anticholinergic Burden score (ABS) was measured using the Anticholinergic Burden scale and included all prescribed and over the counter medication.

RESULTS

the sample was 224 patients with Alzheimer's dementia and 71.4% were women. Their mean age was 81.0 years [SD 7.4 (range 55-98)]. The mean number of medications taken was 3.6 (SD 2.4) and the mean anticholinergic load was 1.1 (SD 1.4, range 0-7). The total number of drugs taken and anticholinergic load correlated (rho = 0.44; P < 0.01). There were no differences in MMSE and other cognitive functioning at either 6 or 18 months after adjusting for baseline cognitive function, age, gender and use of cholinesterase inhibitors between those with, and those without high anticholinergenic load.

CONCLUSIONS

medications with anticholinergic effect in patients with AD were not found to effect deterioration in cognition over the subsequent 18 months. Our study did not support a continuing effect of these medications on people with AD who are established on them.

Anticholinergic medication use and cognitive impairment in the older population: the medical research council cognitive function and ageing study

OBJECTIVES

To determine whether the use of medications with possible and definite anticholinergic activity increases the risk of cognitive impairment and mortality in older people and whether risk is cumulative.

DESIGN

A 2-year longitudinal study of participants enrolled in the Medical Research Council Cognitive Function and Ageing Study between 1991 and 1993.

SETTING

Community-dwelling and institutionalized participants.

PARTICIPANTS

Thirteen thousand four participants aged 65 and older.

MEASUREMENTS

Baseline use of possible or definite anticholinergics determined according to the Anticholinergic Cognitive Burden Scale and cognition determined using the Mini-Mental State Examination (MMSE). The main outcome measure was decline in the MMSE score at 2 years.

RESULTS

At baseline, 47% of the population used a medication with possible anticholinergic properties, and 4% used a drug with definite anticholinergic properties. After adjusting for age, sex, educational level, social class, number of nonanticholinergic medications, number of comorbid health conditions, and cognitive performance at baseline, use of medication with definite anticholinergic effects was associated with a 0.33-point greater decline in MMSE score (95% confidence interval (CI)=0.03-0.64, P=.03) than not taking anticholinergics, whereas the use of possible anticholinergics at baseline was not associated with further decline (0.02, 95% CI=-0.14-0.11, P=.79). Two-year mortality was greater for those taking definite (OR=1.68; 95% CI=1.30-2.16; P<.001) and possible (OR=1.56; 95% CI=1.36-1.79; P<.001) anticholinergics.

CONCLUSION

The use of medications with anticholinergic activity increases the cumulative risk of cognitive impairment and mortality.

An exploratory study of the role of trust in medication management within mental health services

OBJECTIVE

To develop understandings of the nature and influence of trust in the safe management of medication within mental health services.

SETTING

Mental health services in the UK.

METHOD

Qualitative methods were applied through focus groups across three different categories of service user--older adult, adults living in the community and forensic services. An inductive thematic analysis was carried out, using the method of constant comparison derived from grounded theory.

MAIN OUTCOME MEASURE

Participants' views on the key factors influencing trust and the role of trust in safe medication management.

RESULTS

The salient factors impacting trust were: the therapeutic relationship; uncertainty and vulnerability; and social control. Users of mental health services may be particularly vulnerable to adverse events and these can damage trust.

CONCLUSION

Safe management of medication is facilitated by trust. However, this trust may be difficult to develop and maintain, exposing service users to adverse events and worsening adherence. Practice and policy should be oriented towards developing trust.

Medication error in mental health: implications for primary care

Medication errors are associated with significant morbidity and people with mental health problems may be particularly susceptible to medication errors due to various factors. Primary care has a key role in improving medication safety in this vulnerable population. The complexity of services, involving primary and secondary care and social services, and potential training issues may increase error rates, with physical medicines representing a particular risk. Service users may be cognitively impaired and fail to identify an error placing additional responsibilities on clinicians. The potential role of carers in error prevention and medication safety requires further elaboration. A potential lack of trust between service users and clinicians may impair honest communication about medication issues leading to errors. There is a need for detailed research within this field.

Medication errors in older people with mental health problems: a review

OBJECTIVE

To review and summarise published data on medication errors in older people with mental health problems.

METHODS

A systematic review was conducted to identify studies that investigated medication errors in older people with mental health problems. MEDLINE, EMBASE, PHARMLINE, COCHRANE COLLABORATION and PsycINFO were searched electronically. Any studies identified were scrutinized for further references. The title, abstract or full text was systematically reviewed for relevance.

RESULTS

Data were extracted from eight studies. In total, information about 728 errors (459 administration, 248 prescribing, 7 dispensing, 12 transcribing, 2 unclassified) was available. The dataset related almost exclusively to inpatients, frequently involved non-psychotropics, and the majority of the errors were not serious.

CONCLUSIONS

Due to methodology issues it was impossible to calculate overall error rates. Future research should concentrate on serious errors within community settings, and clarify potential risk factors.

Efficacy of memantine on behavioral and psychological symptoms related to dementia: a systematic meta-analysis

BACKGROUND

The behavioral and psychological symptoms related to dementia (BPSD) are difficult to manage and are associated with adverse patient outcomes.

OBJECTIVE

To systematically analyze the data on memantine in the treatment of BPSD.

METHODS

We searched MEDLINE, EMBASE, Pharm-line, the Cochrane Centre Collaboration, www.clinicaltrials.gov, www.controlled-trials.com, and PsycINFO (1966-July 2007). We contacted manufacturers and scrutinized the reference sections of articles identified in our search for further references, including conference proceedings. Two researchers (IM and CF) independently reviewed all studies identified by the search strategy. We included 6 randomized, parallel-group, double-blind studies that rated BPSD with the Neuropsychiatric Inventory (NPI) in our meta-analysis. Patients had probable Alzheimer's disease and received treatment with memantine for at least one month. Overall efficacy of memantine on the NPI was established with a t-test for the average difference between means across studies, using a random effects model.

RESULTS

Five of the 6 studies identified had NPI outcome data. In these 5 studies, 868 patients were treated with memantine and 882 patients were treated with placebo. Patients on memantine improved by 1.99 on the NPI scale (95% Cl -0.08 to -3.91; p = 0.041) compared with the placebo group.

CONCLUSIONS

Initial data appear to indicate that memantine decreases NPI scores and may have a role in managing BPSD. However, there are a number of limitations with the current data; the effect size was relatively small, and whether memantine produces significant clinical benefit is not clear.

Medication errors in mental healthcare: a systematic review

BACKGROUND

It has been estimated that medication error harms 1-2% of patients admitted to general hospitals. There has been no previous systematic review of the incidence, cause or type of medication error in mental healthcare services.

METHODS

A systematic literature search for studies that examined the incidence or cause of medication error in one or more stage(s) of the medication-management process in the setting of a community or hospital-based mental healthcare service was undertaken. The results in the context of the design of the study and the denominator used were examined.

RESULTS

All studies examined medication management processes, as opposed to outcomes. The reported rate of error was highest in studies that retrospectively examined drug charts, intermediate in those that relied on reporting by pharmacists to identify error and lowest in those that relied on organisational incident reporting systems. Only a few of the errors identified by the studies caused actual harm, mostly because they were detected and remedial action was taken before the patient received the drug. The focus of the research was on inpatients and prescriptions dispensed by mental health pharmacists.

CONCLUSION

Research about medication error in mental healthcare is limited. In particular, very little is known about the incidence of error in non-hospital settings or about the harm caused by it. Evidence is available from other sources that a substantial number of adverse drug events are caused by psychotropic drugs. Some of these are preventable and might probably, therefore, be due to medication error. On the basis of this and features of the organisation of mental healthcare that might predispose to medication error, priorities for future research are suggested.

Memantine combined with an acetyl cholinesterase inhibitor - hope for the future?

BACKGROUND

Memantine and cholinesterase inhibitors (ChEI) have distinct pharmacological actions, and interest in the use of combination therapy for Alzheimer's disease (AD) is increasing.

OBJECTIVE

To assess the available data on the use of memantine-ChEI combination and to develop evidence-based recommendations.

METHOD

A systematic literature review with detailed discussion of the current evidence base.

RESULTS

AVAILABLE DATA ARE LIMITED: five studies of which two were randomized, double-blind, placebo-controlled trials. One study indicated that memantine-ChEI combination is not significantly more effective than placebo-ChEI in mild to moderate AD, but data were published in abstract and poster form only. A second study indicated that the memantine-ChEI combination is significantly more effective than placebo-ChEI in moderate to severe AD. The calculated effect sizes of 0.36 on cognition and 0.12 on function, which were the primary outcomes, were small, indicating a clinically minimal effect on cognition and no effect on function. No data are available on whether combination treatment is more effective than memantine monotherapy.

CONCLUSION

The available data do not justify the use of combination therapy. Future studies should include three arms (memantine-placebo, placebo-ChEI, and memantine-ChEI), be of an adequate size and duration, and use pragmatic measures. Clinicians should have full access to data from any future trials.

A review of studies describing the use of acetyl cholinesterase inhibitors in Parkinson's disease dementia

OBJECTIVE

To review the literature relating to the use of acetyl cholinesterase inhibitors in Parkinson's disease dementia (PDD).

METHOD

MEDLINE (1966--December 2004), PsychINFO (1972--December 2004), EMBASE (1980--December 2004), CINHAL (1982--December 2004), and the Cochrane Collaboration were searched in December 2004.

RESULTS

Three controlled trials and seven open studies were identified. Efficacy was assessed in three key domains: cognitive, neuropsychiatric and parkinsonian symptoms.

CONCLUSION

Cholinesterase inhibitors have a moderate effect against cognitive symptoms. There is no clear evidence of a noticeable clinical effect against neuropsychiatric symptoms. Tolerability including exacerbation of motor symptoms--in particular tremor--may limit the utility of cholinesterase inhibitors.

Efficacy of Stimulants in Adult ADHD

OBJECTIVE

To review the literature regarding the efficacy of stimulants to treat attention-deficit-hyperactivity disorder (ADHD) in adults.

DATA SOURCES

The relevant pharmaceutical manufacturers were contacted, and searches of MEDLINE (1966-December 2002) and the reference sections of each article obtained were performed using the key search terms: adult ADHD, stimulants, methylphenidate, amphetamines, and pemoline.

STUDY SELECTION AND DATA EXTRACTION

All English-language original studies identified from the data sources were evaluated and all information deemed relevant was included in the review.

DATA SYNTHESIS

Studies involving methylphenidate, amphetamines, and pemoline were identified. There was evidence for the efficacy of amphetamines from 5 studies (4 controlled, 1 open). Methylphenidate data from 6 controlled trials were conflicting. Three studies indicated efficacy; 2 studies failed to show efficacy, possibly due to methodologic reasons; and the results from 1 study were conflicting. The limited data from 1 controlled and 1 open study indicated that pemoline may be less effective than methylphenidate and amphetamines.

CONCLUSIONS

While the current limited data indicate that stimulants may be effective in adult ADHD, more data are required to confirm long-term efficacy.

The use of antidepressants to treat attention deficit hyperactivity disorder in adults

There is increasing evidence that children continue to experience attention deficit hyperactivity disorder (ADHD) symptoms into adult life. The two main treatments for ADHD are antidepressants and stimulants. Here, the effectiveness data relating to the use of antidepressants in adults with ADHD are reviewed. Four controlled and six open studies were identified. Although, there is only limited data currently available, antidepressants may offer an effective therapy for adult ADHD. Controlled trials have studied desipramine, atomoxetine and bupropion, with most evidence supporting the efficacy of desipramine. The initial data indicate that atomoxetine is less effective than desipramine. The efficacy of bupropion is unclear. Initial published open data suggest a response rate of 50-78% with venlafaxine. Controlled studies are required to confirm this efficacy. Most of the present data are short-term, therefore long-term effectiveness data are required.

The use of topiramate in mood stabilization

OBJECTIVE

To review data on the effectiveness of topiramate as a mood stabilizer.

DATA SOURCES

Clinical literature accessed through MEDLINE (1985-September 2001) and the manufacturer. Key search terms included topiramate, mania, mood stabilizer, and bipolar disorder.

DATA SYNTHESIS

The traditional standard therapy for bipolar disorder has been lithium. Other mood stabilizers are increasingly being used to manage this complex disorder. Studies that used topiramate in bipolar disorders were evaluated.

CONCLUSIONS

The present data from open trials suggest that topiramate may possibly possess antimanic properties. Controlled, double-blind studies are required to confirm this efficacy.

Gabapentin treatment for bipolar disorders

OBJECTIVE

[corrected] To review the effectiveness data on the use of gabapentin in bipolar disorders.

DATA SOURCES

Clinical literature was accessed through MEDLINE (January 1985-November 2000). Key search terms included gabapentin, mood stabilizer, and bipolar disorder.

DATA SYNTHESIS

Bipolar disorder is a complex condition that can be difficult to treat effectively. Mood stabilizers are increasingly being used to manage bipolar disorder. Studies that used gabapentin in bipolar disorders are evaluated.

CONCLUSIONS

From the data presented, gabapentin cannot be recommended for treatment of bipolar disorder. Further studies are required to determine whether gabapentin has any role in the management of bipolar disorder.

Are fish oils an effective therapy in mental illness--an analysis of the data

OBJECTIVE

To review the literature regarding the use of fish oils in the treatment of psychiatric illness.

METHOD

A Medline search was conducted in September 1999.

RESULTS

Five papers have investigated omega-3 fatty acids levels in depression. One study used omega-3 fatty acids as an adjunctive therapy in bipolar disorder. Four studies used fatty acids as an adjunctive therapy in schizophrenia.

CONCLUSION

There is a great deal of current research in this field. While omega-3 fatty acids levels may be lowered in depression, there are no data suggesting that omega-3 fatty acids are effective. One paper indicates that omega-3 fatty acids are effective in bipolar disorders. The data on schizophrenia are conflicting. Omega-3 and omega-6 fatty acids have proved effective. Most of the evidence suggests that the main effect is an improvement in negative symptoms. One recent study showed that omega-3 fatty acids had no effect on negative symptoms.

Lamotrigine--an effective mood stabilizer?

OBJECTIVE

To review the literature regarding the use of lamotrigine as a mood stabilizer, and to discuss its efficacy in treating this condition.

DATA SOURCES

Data were obtained from MEDLINE, Micromedex, and Cochrane collaboration searches from January 1985 to July 1998.

DATA SUMMARY

There are insufficient data to confirm that lamotrigine is an effective mood stabilizer. There are no controlled studies, and the current evidence is from case studies and open trials. Furthermore, only one study shows any evidence of effectiveness in the manic phase, although this may be because the data tend to relate to a treatment-refractory population.

CONCLUSIONS

From the current evidence, lamotrigine cannot be recommended as a mood stabilizer except when conventional therapies have failed.

Amiodarone-Associated Depression

Objective:

To report a case of depression secondary to or aggravated by amiodarone-induced hypothyroidism.

Case Summary:

An 84-year-old white man was admitted to a psychiatric unit with severe depression approximately seven months after amiodarone had been initiated to treat paroxysmal supraventricular tachycardia. On admission, the thyroid-stimulating hormone (TSH) concentration was 11.50 μU/mL (normal 0.17–4.00) and the total thyroxine concentration was 3.9 μg/dL (4.0–11.0). About 21 months before initiation of amiodarone therapy, the TSH concentration was 2.4 μU/mL; this was the only previous TSH result available. Seven days after admission, thyroxine (levothyroxine) 25 μg/d was started. Twenty-eight days after admission, the patient's mood had improved, and the TSH concentration (2.67 μU/mL) was within normal range. The patient was discharged four days later.

Discussion:

Amiodarone contains 37.2% iodine. This is a greatly increased iodine load compared with normal intake. Amiodarone may therefore have three possible effects on thyroid function: (1) the serum concentration of thyroid hormones in clinically euthyroid patients may change, complicating assessment; (2) hyperthyroidism may occur (1–5% of patients); and (3) hypothyroidism may occur (6–10% of patients). Thus, thyroid function should be checked at least every six months. The elevated TSH concentration could indicate mild hypothyroidism or possibly be a symptom of the depressive illness. Furthermore, our patient's mood appeared to improve after he had received six to seven weeks of treatment with fluoxetine; he had also experienced depressive episodes throughout his life. Thus, particularly because the TSH concentration was only moderately raised, it is possible that amiodarone-induced hypothyroidism worsened rather than caused the depressive episode. The usual treatment for amiodarone-induced hypothyroidism is continuation of amiodarone and initiation of thyroxine at a dosage of 25–50 μg/d.

Conclusions:

This case illustrates the need to be vigilant for amiodarone-induced hypothyroidism, which may cause depression or exacerbate an underlying depressive illness. Supplemental treatment with levothyroxine may effect a rapid mood response.