Pharmacists' Impact on Older Adults Transitioning To and From Patient Care Centers: A Scoping Review

Objective: Expand upon previous reviews conducted on transitions of care (TOC) services with a focus on pharmacist interventions for older adults specifically transitioning to and from long-term care, acute rehabilitation, residential care facilities, care homes, skilled nursing, or assisted living facilities, collectively termed patient care centers (PCC). Data Sources: A PubMed and Ovid MEDLINE search was conducted including citations between 1974 and July 14, 2022. Bibliographies were also reviewed for additional citations. Methods: Articles included described pharmacist interventions during TOC for patients transitioning to and from PCC, were written in English, and reported outcomes pertaining to TOC services. Of 873 citations reviewed, 22 articles met the inclusion criteria. Results: Most studies were prospective in design with small sample sizes, of limited duration, and with varying interventions and reported outcomes. Most explored the transition from hospital to PCC and included a pharmacist intervention involving the identification of medication errors and discrepancies during the TOC. Few studies reported cost savings or 30- and 60-day reductions in readmission rates or mortality. Conclusions: This scoping review revealed a lack of robust clinical trials to assess the effectiveness of specific interventions performed by pharmacists for patients transitioning to and from PCC. Of the available data, pharmacist involvement within an interprofessional team can be an effective intervention to resolve medication discrepancies, reduce readmissions, and medication-related adverse events. An opportunity exists for future studies to explore ways to improve outcomes during TOC within PCC.

Pharmacist Involvement in an Acute Care of the Elderly Team: Impact on Appropriate Medication Use

Background Currently, our institution does not have a full-time pharmacist rounding with the inpatient acute care of the elderly (ACE) team daily. We sought to evaluate the involvement of a clinical pharmacy service within the ACE team and its impact on appropriate medication use. Objective The primary outcome was the number of drug-related problems (DRPs) and potentially inappropriate medications (PIMs) detected by the pharmacist compared with no pharmacist on the ACE team. Secondary outcomes included length of stay, 30-day re-hospitalization, and accepted DRPs and PIMs recommendations made by the pharmacist. Methods This was a retrospective, single-center, cohort study. The control cohort consisted of patients seen over 3 months when no pharmacist was present. The intervention cohort comprised patients seen over 3 months when a pharmacist was present on the ACE team. Patients were excluded if there was not a documented chart note from a geriatric provider or pharmacist. Results A total of 125 patients were included in the intervention group and 106 patients in the control group. Regarding the primary outcome, the control cohort had significantly fewer identified PIMs and DRPs in comparison with the intervention cohort (P < 0.001; P < 0.01, respectively). There was no significant difference in length of stay (P = 0.317). There was a statistical difference between groups regarding 30-day readmission rates (P = 0.007). Conclusion Our study shows that the inclusion of a pharmacist on the ACE team was associated with more DRPs, and PIMs identified, creating a positive impact on patient care and 30-day readmission.

Longitudinal Evaluation of a Deprescribing Protocol in Skilled Nursing Facilities

Objective: To determine whether a deprescribing effort reduced several key classes of medications, and the overall number of medication classes per patient, among long-term residents of skilled nursing facilities (SNFs). Design: Retrospective, longitudinal pre/post evaluation. Data from before and during the implementation of the deprescribing effort (2017 through 2019) were compared with data from the post-intervention year (2020). Setting and Patients: Long-term resident data reported through annual comprehensive reviews conducted at two SNFs located in central New York State between 2017 and 2020 (N = 12,144). Interventions: Multifaceted, interdisciplinary deprescribing effort to reduce medications in SNF residence including clinician education, guideline development, and individual chart reviews began in 2019. Results: The mean number of medications prescribed per resident was lower at both facilities after the intervention (mean = 1.74 at both facilities) versus preintervention (1.90 at Facility 1, 1.86 at Facility 2). Significant decreases were observed in the usage rates for diuretics (-4.2%; P = 0.001), opioids (-3.8%; P = 0.001), and antipsychotics (-2.4%; P = 0.010). The raw antidepressant usage rate increased by 1.5% after the intervention but the change was not significant. Effects were robust to covariate adjustment. Conclusion: A combined, comprehensive approach to deprescribing was associated with a reduction in the overall number of medication classes per resident and in several key classes of medications. Additional research with more data and covariate control is in progress for verification of these findings.

Efficacy and Safety of Megestrol in the Hospitalized Older Person

Objectives To evaluate the efficacy and safety of megestrol for off-label use in older patients with weight loss. Design Retrospective, nonblinded cohort study. Setting Upstate University Hospital is a 420-bed facility and academic medical center with a level 1 trauma center. Upstate Community Hospital is a 314-bed acute care/hospital/ambulatory care center and long-term care hospital that also provides teaching services. Participants Patients 65 years of age and older without malignancy or acquired immunodeficiency syndrome who were initiated and continued megestrol therapy at the Upstate University hospitals for at least two weeks were included. Of the 1,290 patients initially screened, 16 patients on megestrol were evaluated. An age- and gender-matched control group of 16 patients was utilized for comparison of changes in weight and other variables. Interventions Patients in the megestrol group have received daily doses of megestrol between 160 mg to 800 mg for an average duration of 19 days. Patients in the control group had no history or current use of megestrol utilization. Main Outcome Measurements The primary outcome was an increase in weight. Secondary outcome measures included albumin and thromboembolic events. Changes in weight and albumin were also compared with the control group. Results At a mean duration of 19 days, there was no significant difference in weight gain (0.95 kg, OR = 1.33 [95% CI -1.615-3.527]). Albumin decreased by (0.4 g/dL OR = 0.916 [95% CI 0.12-0.78]) and none of the patients developed a thromboembolic event. Conclusion In older hospitalized patients, megestrol did not increase weight, and did not improve albumin. No thromboembolic events were observed, but this may be because of a limited duration of observation of therapy and the routine use of anticoagulation prophylaxis in the inpatient setting.

Verifying Medication Orders in the Older Population: Are We Using Enough Caution?

OBJECTIVE: To test the common hypothesis that pharmacists may use more caution and resources when processing pediatric versus geriatric medication orders in the hospital setting.<br/> DESIGN: A 26-item electronic survey was distributed to a sample of participating academic medical-center pharmacy directors with the request to disseminate it to staff pharmacists. The survey was resent at two-week intervals on two occasions.<br/> MAIN OUTCOME MEASURE(S): To identify if pharmacists take more caution when processing geriatric or pediatric medication orders, to characterize the frequency pharmacists use drug information resources when processing these orders, and to assess the level of importance pharmacists place on guidelines for medication error prevention when processing medication orders.<br/> RESULTS: A total of 173 out of 271 pharmacists completed the survey, resulting in a high final completion rate of 63.8%. Most were clinical, residencytrained pharmacists. A majority of respondents stated that they take more caution when verifying pediatric medication orders than they do for orders for older people (125 out of 172, or 72.7%). Pharmacists report they were 4.2 times more likely to refer to a drug information resource for ≥ 50% of pediatric orders versus geriatric orders (pediatric: 118 out of 171, or 69.0% vs. geriatric: 59 out of 172, or 34.3%; P < 0.001, or 95% confidence interval [CI] 4.156 [2.647-6.524]). Finally, pharmacists familiar with the guidelines for medication error prevention were 2.3 times more likely to state the pediatric guidelines were very important (pediatric: 51/171, or 29.8% vs. geriatric: 27/172, or 15.7%; P = 0.002, or 95% CI 2.28 [1.35-3.86]).<br/> CONCLUSION: This survey reveals evidence for attitudinal differences in work practices for pharmacists working with medication orders relating to different age groups. Given the challenges involved in drug treatment for the older patient population, a similar level of caution, preparedness to refer to drug information, and to use guidelines should apply for both pediatric medication orders and those for older people, in order to provide safe and comprehensive care.

Targeted Medication Deprescribing in the Elderly: Results of a Pharmacist-Driven Procedure in a Transitional Care Unit

OBJECTIVE: Assess the impact of a pharmacist-driven deprescribing procedure on reduction of target medications at discharge among geriatric patients receiving care in a hospital-based transitional care unit.<br/> DESIGN: Retrospective, single-center chart review.<br/> SETTING: Transitional care unit located within a hospital.<br/> PARTICIPANTS: Patients 65 years of age and older were included if they were admitted to the transitional care unit between June 1, 2017, and December 15, 2017, on one or more of the following target medication classes: antihistamines, benzodiazepines, hypnotic sleep aids, proton-pump inhibitors, and skeletal muscle relaxants.<br/> INTERVENTIONS: Pharmacists performed a structured review of patient's medications upon admission and utilized the deprescribing procedure developed by our institution to identify and deprescribe target medications in an attempt to optimize the patient's medication regimen prior to discharge.<br/> RESULTS: Overall, 129 patients on 198 target medications were included in the study. Patients were on an average of 1.5 ± 0.78 target medications at admission, which was reduced to 0.78 ± 0.73 at discharge (P < 0.001). Overall, a 50% reduction of target medications was achieved.<br/> CONCLUSION: A pharmacist-driven deprescribing procedure significantly reduced the quantity of target medications that older patients were discharged on.

Targeted Medication Deprescribing in the Elderly: Results of a Pharmacist-Driven Procedure in a Transitional Care Unit

OBJECTIVE: Assess the impact of a pharmacist-driven deprescribing procedure on reduction of target medications at discharge among geriatric patients receiving care in a hospital-based transitional care unit.<br/> DESIGN: Retrospective, single-center chart review.<br/> SETTING: Transitional care unit located within a hospital.<br/> PARTICIPANTS: Patients 65 years of age and older were included if they were admitted to the transitional care unit between June 1, 2017, and December 15, 2017, on one or more of the following target medication classes: antihistamines, benzodiazepines, hypnotic sleep aids, proton-pump inhibitors, and skeletal muscle relaxants.<br/> INTERVENTIONS: Pharmacists performed a structured review of patient's medications upon admission and utilized the deprescribing procedure developed by our institution to identify and deprescribe target medications in an attempt to optimize the patient's medication regimen prior to discharge.<br/> RESULTS: Overall, 129 patients on 198 target medications were included in the study. Patients were on an average of 1.5 ± 0.78 target medications at admission, which was reduced to 0.78 ± 0.73 at discharge (P < 0.001). Overall, a 50% reduction of target medications was achieved.<br/> CONCLUSION: A pharmacist-driven deprescribing procedure significantly reduced the quantity of target medications that older patients were discharged on.