Inappropriate Medication In Patients Research Articles

Deprescribing in an outpatient medical clinic at a tertiary care hospital in Sri Lanka

Introduction: Use of multiple concomitant medications or ‘polypharmacy’ is linked to decreased medication adherence, adverse drug reactions and increased financial burden on patients and the economy. Deprescribing by experienced healthcare personnel can ensure safe and effective use of medications. Many medications, prescribed during hospital stay or at clinic level are continued for unnecessarily long periods, highlighting the necessity for deprescribing. The objectives of this audit were to identify and deprescribe inappropriate medications in patients, identify their comorbidities and explore reasons for the inappropriate medication use.Methods: This deprescribing audit was conducted by systematic sampling in selected adult patients >18 years, attending a medical clinic at National Hospital, Kandy over one month. The audit standard was the American Academy of Family Physicians (AAFP) ‘5-step process in deprescribing’. Our study was based only on the first 3 steps of the AAFP deprescribing process.Results: Out of a total of 402 patients, deprescribing was carried out in 135 (33.58%). In this deprescribed group, 59.3% of patients were female and the mean age was 62.3 (±10.9) years. Furthermore, of the deprescribed patients, 52.6% had hypertension, 44.4% had ischaemic heart disease, and 34.1% had diabetes mellitus. The most deprescribed medication was antiplatelets (37.8%), followed by analgesics (24.4%) and diuretics (20%). A clear indication for using the drug was lacking in 68.9%, while 31.1% of patients continued taking the medication for longer than recommended. Conclusions: In this audit, over one third of patients underwent deprescribing. It provides just a glimpse of the broader issue of inappropriate polypharmacy and the necessity of deprescribing. Future research involving multiple centres is recommended to enhance understanding of medication patterns necessitating deprescribing.

Polypharmacy and Potentially Inappropriate Medications in Patients With Advanced Cancer: Prevalence and Associated Factors at the End of Life.

Background: Polypharmacy and potentially inappropriate medications (PIMs) impose a burden on patients with advanced cancer near the end of their lives. However, only a few studies have addressed factors associated with PIMs in such patients. Objective: To examine polypharmacy and factors associated with PIMs in end-of-life patients with advanced cancer. Design: Retrospective chart review. Setting/Subjects: We analyzed 265 patients with advanced cancer who died in a palliative care unit (PCU) or at home in a home medical care (HMC) from April 2018 to December 2022 in Japan. Measurements: Sociodemographic, clinical, and prescription data at the time of PCU admission or HMC initiation were collected from electronic medical records. PIMs were assessed using OncPal Deprescribing Guidelines. Results: Patients with advanced cancer with an average age of 76.3 years and median survival days of 20 were included in the analyses. The average number of medications was 6.4 (standard deviation = 3.4), and PIMs were prescribed to 50.2%. Frequent PIMs included antihypertensive medications, peptic ulcer prophylaxis, and dyslipidemia medications. A multivariate logistic regression analysis revealed that age ≥75 years (adjusted odds ratio [aOR] = 2.30, 95% confidence interval [CI] = 1.30-4.05), referral from an outpatient setting compared with inpatient setting (aOR = 2.06, 95% CI = 1.12-3.80), more than two comorbidities (aOR = 1.88, 95% CI = 1.08-3.29), and more than five medications (aOR = 1.84, 95% CI = 1.03-3.28) were associated with PIMs. Conclusions: Medication reconciliation is recommended at the time of transition to a PCU or HMC, especially for older patients with advanced cancer who were referred from an outpatient setting and present more comorbidities and prescriptions.

Irrational polypharmacy and potentially inappropriate medications in patients with dementia: Treatment strategies

AbstractMost patients with dementia are treated with irrational polypharmacy, which leads to higher mortality and other negative consequences (higher costs). Nearly 50% of elderly patients take one or more medications that are not medically necessary, which represents another important aspect of medication optimization. Research has established a strong relationship between irrational polypharmacy and its negative clinical consequences, including a negative impact on dementia, especially in patients with excessive polypharmacy (10 or more medications). These patients are underrepresented in the treatment guidelines and randomized controlled trials, although they represent a substantial patient population. The burden of irrational polypharmacy has also been associated with a greater risk of adverse drug events, drug-drug interactions, medication non-adherence and a higher risk of potentially inappropriate medication (PIM) use. Different treatment strategies have been available to reduce irrational polypharmacy in this population. The best intervention for irrational polypharmacy reduction in this population involves an inter-professional approach (collaborative care approach) that often includes special tools, a basic pharmacological approach and collaboration with a clinical pharmacist.Disclosure of InterestNone Declared

Implementation of targeted deprescribing of potentially inappropriate medications in patients on hemodialysis.

Patients on hemodialysis have a high risk of medication-related problems. Studies using deprescribing algorithms to reduce the number of inappropriate medications in this population have been published, but none have used a patient-partnership approach. Our study evaluated the impact of a similar intervention with a patient-partnership approach. The objective was to describe the implementation of a pharmacist-led intervention with a patient-partnership approach using deprescribing algorithms and its impact on the reduction of inappropriate medications in patients on hemodialysis. Eight algorithms were developed by pharmacists and nephrologists to assess the appropriateness of medications. Pharmacists identified patients taking targeted medications. Following patient enrollment, pharmacists assessed medications with patients and applied the algorithms. With patient consent, deprescription was suggested to nephrologists if applicable. Specific data on each targeted medication were collected at 4 and 16 weeks. Descriptive statistics were used to examine the effects of the deprescribing intervention. Of 270 patients, 256 were taking at least one targeted medication. Of the 122 patients taking at least one targeted medication who were approached to participate, 66 were included in the study. At enrollment, these patients were taking 252 targeted medications, of which 59 (23.4%) were determined to be inappropriate. Deprescription was initiated for 35 of these 59 medications (59.3%). At 4 weeks, 33 of the 59 medications (55.9%) were still deprescribed, while, at 16 weeks, 27 of the 59 medications (45.8%) were still deprescribed. Proton pump inhibitors and benzodiazepines or Z-drugs were the most common inappropriate medications, and allopurinol was the most deprescribed medication. A pharmacist-led intervention with a patient-partnership approach and using deprescribing algorithms reduced the number of inappropriate medications in patients on hemodialysis.

Prevalence and Predictors of Potentially Inappropriate Medications Among Patients Aged ≥65 Years on Hospital Admissions in Kuwait.

BackgroundPotentially inappropriate medications are major health concerns for patients aged ≥65 years. To investigate the prevalence of potentially inappropriate medications, Beer’s criteria can be used. We estimated the prevalence of potentially inappropriate medications prescription among patients aged ≥65 years admitted to Kuwait’s largest hospital and identified the predictors of prescribing a potentially inappropriate medication.MethodsA cross-sectional study was conducted retrospectively using inpatient records from the medical department at the Hospital in Kuwait from 1 January 2019 to 31 December 2019. The latest version of Beer’s criteria was used to identify potentially inappropriate medications in patients’ medical records. Data were analyzed descriptively to estimate the prevalence of potentially inappropriate medications and to describe participant characteristics. The predictors of potentially inappropriate medications prescribing were determined using binary logistic regression.ResultsA total of 423 medical records of patients were collected. The mean age of the patients admitted was 76 ± 7 years, and 222 of them (52.5%) were women. Upon hospital admission, potentially inappropriate medication was prevalent in 58.4% of patients. The most prevalent potentially inappropriate medications identified were proton pump inhibitors (27.3%), diuretics (21.5%), antipsychotic agents (9%), selective serotonin reuptake inhibitors (5%), and methyldopa (4%). Polypharmacy, Alzheimer’s disease, depression, irritable bowel syndrome, hypothyroidism, chronic kidney disease were predictors of potentially inappropriate medications prescription.ConclusionA high prevalence of potentially inappropriate medication prescription was observed among patients aged ≥65 years admitted to a hospital in Kuwait. The most likely predictor of potentially inappropriate medication prescription was polypharmacy.

Potentially inappropriate medication in patients with chronic kidney disease and elderly patients.

Most patients with chronic kidney disease (CKD) are old, comorbid, and subjected to polypharmacy. This study describes prevalence and predictors of potentially inappropriate medication (PIM) in CKD patients. Medication plans of CKD patients of the "Greifswald Approach to Individualized Medicine" cross-sectional study (GANI_MED) were checked for PIM based on kidney function (PIM-K) and PIM for elderly patients (PIM-E). PIM-K were defined by prescription instructions of product labeling. PIM-E were defined by BEERS, -PRISCUS, and FORTA criteria. Predictors for PIM were identified through multiple stepwise regression. 375 patients were included (age: 67.9±13.5 years; estimated glomerular filtration rate (eGFR): 23.3±18.6 mL/min/1.73m2; prescriptions: 11.1±4.7). 44.5% of all CKD patients had PIM-K, and 43.2 to 79.0% of all elderly patients had PIM-E. Polypharmacy and reduced eGFR were predictors for PIM. The risk for PIM-K was increased by 3.8 (95% confidence interval (CI): 1.5-9.6) with 10 or more prescriptions and by 8.7 (95% CI: 1.3-58.5) with an eGFR below 30mL/min/1.73m2. On average, elderly patients with 10 or more prescriptions had 3.0±1.7 PIM-E. Polypharmacy, PIM-K, and PIM-E affect many CKD patients and can lead to adverse events. Deprescribing and targeted prescribing may improve the outcome of CKD patients and elderly patients.

Pharmacist-led intervention on the reduction of inappropriate medication use in patients with heart failure: A systematic review of randomized trials and non-randomized intervention studies.

Polipharmacy has been identified as a contributing factor to the high hospital readmission rates of heart failure (HF) patients. Nevertheless, there limited evidence on pharmacist-led intervention on the reduction of inappropriate medication use in patients. To summarize the available evidence resulting from interventions, led by pharmacists (alone or as part of a professional team), aimed at reducing inappropriate medications in patients with heart failure. A systematic review was conducted using MEDLINE through PubMed, Embase, the Cochrane Library and Scopus until June 2020. We reviewed both randomized controlled trials and non-randomized intervention studies.The quality of evidence was assessed in accordance with the modified Cochrane Collaboration tool to assess risk of bias for randomized controlled trials. The search and extraction process followed PRISMA guidelines. Of the 4367 records screening, 9 studies were included in the analysis. In 4 (44.4%) studies, the intervention was carried out by a pharmacist working together with a physician; in 4 (44.4%) the intervention was carried out by a pharmacist alone, and in 1 study, the pharmacist collaborated with a nurse. Only 5 (55.5%) studies described the utilization of guidelines or recommendations to carry out the deprescription, and 3 of these showed improved clinical outcomes in the interventional group compared to the control group. The other studies (4, 44.4%) did not follow a specific guideline or recommendation to evaluate the appropriateness of medication, and none of them showed statistically significant differences in clinical outcomes between interventional and control groups. Only those studies where pharmacists evaluated the appropriateness of treatment to specific HF guidelines showed significant differences in patients' clinical outcomes. The development and validation of a specific tool to evaluate medication appropriateness in patients with HF, could contribute to the improvement of patient health.

Benefits Of An Interdisciplinary Nurse Practitioner And Clinical Pharmacy Specialist Heart Failure Access Clinic

Background : To help reduce heart failure (HF) readmissions and improve patient outcomes, the Madison VA established a Nurse Practitioner (NP) led Heart Failure Access Clinic (HFAC) to provide patient follow-up within 4-7 days of discharge. Studies have demonstrated medication discrepancies and delayed implementation of guideline-directed medical therapy as potential contributors to 30-day hospital readmission. Thus, a clinical pharmacy specialist (CPS) was incorporated into the Madison VA HFAC model to focus on optimizing medication regimens. The purpose of this project is to evaluate the impact of an interdisciplinary NP-CPS HFAC versus a NP HFAC on 30-day patient outcomes. Methodology A retrospective chart review was completed for all patients hospitalized with a primary discharge diagnosis of acute on chronic systolic heart failure (ADHF) at the Madison VA and seen in a HFAC after discharge between November 2019 and November 2020. Patients with LVEF greater than 50% and those discharged to hospice were excluded. During the early period of the COVID-19 pandemic (mid-March through July 2020), patients were seen by the NP only. Outcomes and interventions for patients who attended an interdisciplinary NP-CPS HFAC were compared to those who attended the NP HFAC. Primary outcomes included rehospitalization, emergency department (ED) visit, and all-cause mortality at 30 days. Secondary outcomes included HF medication adjustments, identification of inappropriate medications in patients with HF, medication discrepancies, alerts to another provider for follow up, referral to another service, or referral to HF CPS for continued optimization of GDMT. Results A total of 90 veterans met the inclusion criteria; 43 were seen in the NP HFAC and 47 were seen in the interdisciplinary NP-CPS HFAC. The incidence of adverse 30-day outcomes in this patient cohort was very low (readmission 5.6%, ED visit 1.1%, death 1.1%) and there were no significant between group differences. Statistically significant secondary outcomes favoring the interdisciplinary HF clinic included identification of medication discrepancies (P=<0.0001), alert to another providers for follow up (P=0.004), as well as referral to the HF CPS for continued medication titration (P=0.02). Conclusion Patients seen in the interdisciplinary NP-CPS HFAC and HP HFAC had similarly low 30-day hospital readmission rates, ED visits and mortality. Involvement of a CPS in the HFAC led to more frequent identification of medication discrepancies, notification to providers regarding medication issues, and referral to a HF CPS for timely GDMT optimization. Further analysis is warranted to assess the impact of these early CPS interventions on long-term patient outcomes. : To help reduce heart failure (HF) readmissions and improve patient outcomes, the Madison VA established a Nurse Practitioner (NP) led Heart Failure Access Clinic (HFAC) to provide patient follow-up within 4-7 days of discharge. Studies have demonstrated medication discrepancies and delayed implementation of guideline-directed medical therapy as potential contributors to 30-day hospital readmission. Thus, a clinical pharmacy specialist (CPS) was incorporated into the Madison VA HFAC model to focus on optimizing medication regimens. The purpose of this project is to evaluate the impact of an interdisciplinary NP-CPS HFAC versus a NP HFAC on 30-day patient outcomes. A retrospective chart review was completed for all patients hospitalized with a primary discharge diagnosis of acute on chronic systolic heart failure (ADHF) at the Madison VA and seen in a HFAC after discharge between November 2019 and November 2020. Patients with LVEF greater than 50% and those discharged to hospice were excluded. During the early period of the COVID-19 pandemic (mid-March through July 2020), patients were seen by the NP only. Outcomes and interventions for patients who attended an interdisciplinary NP-CPS HFAC were compared to those who attended the NP HFAC. Primary outcomes included rehospitalization, emergency department (ED) visit, and all-cause mortality at 30 days. Secondary outcomes included HF medication adjustments, identification of inappropriate medications in patients with HF, medication discrepancies, alerts to another provider for follow up, referral to another service, or referral to HF CPS for continued optimization of GDMT. A total of 90 veterans met the inclusion criteria; 43 were seen in the NP HFAC and 47 were seen in the interdisciplinary NP-CPS HFAC. The incidence of adverse 30-day outcomes in this patient cohort was very low (readmission 5.6%, ED visit 1.1%, death 1.1%) and there were no significant between group differences. Statistically significant secondary outcomes favoring the interdisciplinary HF clinic included identification of medication discrepancies (P=<0.0001), alert to another providers for follow up (P=0.004), as well as referral to the HF CPS for continued medication titration (P=0.02). Patients seen in the interdisciplinary NP-CPS HFAC and HP HFAC had similarly low 30-day hospital readmission rates, ED visits and mortality. Involvement of a CPS in the HFAC led to more frequent identification of medication discrepancies, notification to providers regarding medication issues, and referral to a HF CPS for timely GDMT optimization. Further analysis is warranted to assess the impact of these early CPS interventions on long-term patient outcomes.

Implementation of Pharmacist Reviews to Screen for Potentially Inappropriate Medications in Patients With Cognitive Impairment.

Objective: To describe two pharmacist-led initiatives aimed to reduce potentially inappropriate medication (PIM) use in community-dwelling patients with dementia or cognitive impairment. Design: Retrospective, descriptive analysis of two clinical initiatives. Setting: Academic geriatric primary care clinics. Participants: Patients were included if they received a Memory Clinic pharmacist review May 1, 2017, to December 31, 2019, or a Living with Dementia (LWD) program pharmacist review November 15, 2018 to December 31, 2019 with provider follow-up within 6 months. Interventions: Both initiatives involved medication review by a clinical pharmacist to identify and make recommendations regarding medications that may contribute to cognitive impairment. The Memory Clinic served patients with concerns of cognitive impairment; whereas, the LWD program enrolled patients with an established diagnosis of dementia. Main Outcome Measure: Number of PIMs that could negatively impact cognition within each cohort. Additionally, 6-month implementation rates were analyzed for actionable pharmacist recommendations. RESULTS: Memory Clinic patients (n = 110) were taking an average of 2.4 PIMs; whereas, LWD patients (n = 40) were taking an average of 1.5 PIMs. Six-month implementation rates for all actionable pharmacist recommendations were 61.0% for the Memory Clinic and 42.4% for the LWD program. Specifically evaluating deprescribing recommendations, the 6-month PIM discontinuation rate was 63.6% for the Memory Clinic group and 60.0% for the LWD group. Conclusion: Pharmacists routinely identified PIMs during medication reviews, which led to successful recommendation implementation throughout multiple stages of cognitive decline. Both programs will continue to be adapted to ensure maximal impact.

Prevalence of polypharmacy and associated adverse health outcomes in adult patients with chronic kidney disease: protocol for a systematic review and meta-analysis

BackgroundPolypharmacy, often defined as the concomitant use of ≥ 5 medications, has been identified as a significant global public health threat. Aging and multimorbidity are key drivers of polypharmacy and have been linked to a broad range of adverse health outcomes and mortality. Patients with chronic kidney disease (CKD) are particularly at high risk of polypharmacy and use of potentially inappropriate medications given the numerous risk factors and complications associated with CKD. The aim of this systematic review will be to assess the prevalence of polypharmacy among adult patients with CKD, and the potential association between polypharmacy and adverse health outcomes within this population.Methods/designWe will search empirical databases such as MEDLINE, Embase, Cochrane Library, CINAHL, Web of Science, and PsycINFO and grey literature from inception onwards (with no language restrictions) for observational studies (e.g., cross-sectional or cohort studies) reporting the prevalence of polypharmacy in adult patients with CKD (all stages including dialysis). Two reviewers will independently screen all citations, full-text articles, and extract data. Potential conflicts will be resolved through discussion. The study methodological quality will be appraised using an appropriate tool. The primary outcome will be the prevalence of polypharmacy. Secondary outcomes will include any adverse health outcomes (e.g., worsening kidney function) in association with polypharmacy. If appropriate, we will conduct random effects meta-analysis of observational data to summarize the pooled prevalence of polypharmacy and the associations between polypharmacy and adverse outcomes. Statistical heterogeneity will be estimated using Cochran’s Q and I2 index. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., sex, kidney replacement therapy, multimorbidity).DiscussionGiven that polypharmacy is a major and a growing public health issue, our findings will highlight the prevalence of polypharmacy, hazards associated with it, and medication thresholds associated with adverse outcomes in patients with CKD. Our study will also draw attention to the prognostic importance of improving medication practices as a key priority area to help minimize the use of inappropriate medications in patients with CKD.Systematic review registrationPROSPERO registration number: [CRD42020206514].

Polypharmacy and Potentially Inappropriate Medications in Patients With Dementia

INTRODUCTION: The use of polypharmacy and potentially inappropriate medication (PIM) is a critical issue in geriatrics. Furthermore, the number of patients with dementia is dramatically increasing worldwide. In this study, we investigated: (1) if the states of polypharmacy and PIM differed in patients with and without dementia; (2) the types of medicine that were commonly prescribed; (3) the types of dementia that resulted in the prescription of multiple medicines; (4) if there was a correlation between the number of medicines and the number of medical institutions (hospitals and clinics) that the patients attended. METHODS: In total, 216 patients who were 65 years of age and older were analyzed. The number of medicines prescribed and the medical institutions they attended were counted through the electronic medical charts of Tohoku Medical and Pharmaceutical University Hospital. We employed the Beers 2019 criteria for the definition of PIM. RESULTS: (1) The number of prescribed medicines was not significantly different between patients with dementia and those without dementia. (2) Anti-hypertensives and gastro-intestinal medicines were the most commonly prescribed medicines in patients with and without dementia. (3) Patients with “dementia with Lewy bodies” and “mixed dementia” were prescribed the highest number of medicines. (4) The number of medicines and PIM use were significantly and positively correlated with the number of medical institutions. CONCLUSIONS: The number of medical institutions strongly affected the number of medicines prescribed and PIM use. Efforts should be made to organize and reduce the number of medical institutions that a patient attends.

97 Potentially Inappropriate Medications in Patients with Alzheimer’s Disease: Data from NILVAD

Abstract Background Prescription of Potentially Inappropriate Medications (PIMs) is common in older adults and is associated with adverse drug events, hospitalisation and mortality. Less well described are the patterns and predictors of PIM usage in patients with Alzheimer’s Disease (AD), a patient group who may be particularly vulnerable to polypharmacy and medication associated adverse events. Methods Secondary analysis of the NILVAD trial, an international phase three trial of Nilvadipine in mild/moderate AD. The v2 STOPP/START criteria were individually applied by a physician to each participant’s medication list and cross-reference with their medical history to identify PIM usage. Predictors of PIM usage were modelled using binary logistic regression. Results Five-hundred and ten patients with AD were included (mean age 72.8 +/-8.3 years; 62% female). The median number of prescribed medications was 5 (IQR 3-7). Over half (55.5%) were prescribed at least one PIM, whilst a minority of patients (14.8%) were prescribed three or more PIMs. The most frequent PIMs were benzodiazepines &gt;4 weeks without indication (n = 55), long-term Proton-Pump Inhibitor (PPI) use without appropriate indication (n = 49), use of non-steroidal analgesics without use of PPI (n=19) and antimuscarinic use in dementia (n= 18). On multivariate analysis, significant predictors of PIM use were higher total number of medications (p=0.001; OR 1.52; 1.36-1.59) in addition to greater AD severity, as rated using the Clinical Dementia Rating Scale Sum-of-Boxes (CDR-sb) (p=0.024; OR 1.18; 1.02-1.35). Conclusion The majority of older patients with AD were prescribed at least one PIM. Usage of PIMs was associated with greater number of medications and increased dementia severity. Particularly concerning is the potentially inappropriate use of benzodiazepines and anti-muscarinic agents in this population, given recent evidence for the adverse cognitive profile associated with these medications. De-prescribing and medication review interventions aimed particularly at patients with AD are warranted.

Use of nonsteroidal anti-inflammatory drugs and renal failure in nursing home residents-results of the study "Inappropriate Medication in Patients with Renal Insufficiency in Nursing Homes".

Use of potentially inappropriate medications may result in increased morbidity, mortality and resource utilisation. Due to polypharmacy and age-related decline in renal function the elderly population is at particular risk. Therefore, the Beers Criteria include use of nonsteroidal anti-inflammatory drugs in chronic renal failure stage 4 and 5 as these drugs may worsen renal function. According to the summary of product characteristics, the nonsteroidal anti-inflammatory drugs ibuprofen and diclofenac are contraindicated in these patients. Objective was to assess the extent of nonsteroidal anti-inflammatory drug use in nursing homes with a focus on residents with severe renal failure. Multi-centre cross-sectional study in 21 German nursing homes. The study population comprised residents for whom at least one serum creatinine value and information about sex were available, so that creatinine clearance rate could be estimated. In all, 685 of 852 residents were included as they fulfilled the abovementioned criteria. Renal failure was severe (estimated creatinine clearance rate < 30ml/min) in 106 residents (15.5 %). Approximately one-fifth was treated with at least one nonsteroidal anti-inflammatory drug in both the total study population (20.3 %) and that with severe renal failure (20.8 %). With one exception, all residents prescribed nonsteroidal anti-inflammatory drugs with severe renal failure were treated with at least one nonsteroidal anti-inflammatory drug that was contraindicated due to the underlying renal function. Notwithstanding their classification as potentially inappropriate medications and underlying contraindications, use of nonsteroidal anti-inflammatory drugs is common among nursing home residents with severe renal failure.

Pain medication in German nursing homes: a whole lot of metamizole.

Prescribing of metamizole (dipyrone), an analgesic that has been withdrawn from the market or never approved in many countries owing to safety concerns, is high in elder persons in Germany. This study assessed the use of pain medications in German nursing homes with a special focus on prescribing patterns of metamizole. Using data of the 'Inappropriate Medication in Patients with Renal Insufficiency in Nursing Homes' (IMREN) study conducted between October 2014 and April 2015 in nursing homes in Bremen and Lower Saxony, we studied prescribing of analgesics including both scheduled and as-needed medications. For residents with scheduled medication, dosage and duration of use were analysed. A total of 852 residents from 21 nursing homes were included. They were on average 83.5 years old, and 76.5% were women; 73.8% received at least one analgesic with 70.3% obtaining World Health Organization step I drugs. The most frequently prescribed substances were metamizole (for 40.6%) and paracetamol (acetaminophen; 35.6%), with paracetamol given mostly as-needed. The proportion of residents receiving metamizole increased with age (up to 47.4% in persons aged 90 years and over). Of 143 residents with scheduled metamizole (16.8%), the mean daily dosage was 1843 mg (interquartile range [IQR]: 1500-2250); 66.9% received metamizole for at least 90 days and 23.2% for at least 365 days (mean duration 276 days; IQR: 59-314). There is a discrepancy between prescribing of metamizole for older persons, on the one hand, and evidence on comparative effectiveness and safety as well as approval and recommendations, on the other hand. Copyright © 2016 John Wiley & Sons, Ltd.

Untersuchungen zu Polypharmazie: Eine Frage der Definition und der verwendeten Daten

Older persons are often subjected to polypharmacy. There is a large degree of variability in the definitions used, the underlying data sources and the medications included. Our aim was to analyse the influence of different definitions on the prevalence of polypharmacy.We used data of the study "Inappropriate Medication in patients with REnal insufficiency in Nursing homes" (IMREN) conducted in nursing homes in Bremen and the surrounding area. Anonymised data were collected by nursing staff. Prescription drugs and over-the-counter drugs as well as scheduled and as-needed medications were assessed.852 residents from 21 nursing homes were recruited (mean age: 83.5 years; 76.5% female). Each resident received an average of 8.8 scheduled and as-needed medications, the prevalence of polypharmacy (≥5 medications) was 83.5%. When including scheduled medications only, residents received an average of 6.3 medications (polypharmacy 69.7%). When restricting the analysis to prescription-only medicines, the results were comparable (6.3 medications per resident; polypharmacy 69.1%). However, the two analyses included different drugs. A total of 74.3% received at least one over-the-counter drug as scheduled medication (59.7% on an as-needed basis).In studies investigating polypharmacy, the methods used should be reported in a transparent manner. This is particularly important when addressing the question of which drugs were included in the study.

Polypharmacy and Renal Failure in Nursing Home Residents: Results of the Inappropriate Medication in Patients with Renal Insufficiency in Nursing Homes (IMREN) Study

Polypharmacy has become an emerging public health issue in recent years, since use of multiple medications or polypharmacy is beneficial for many conditions, but may also have negative effects like adverse drug reactions. The risk further increases in patients with chronic renal failure, a comorbidity very frequent in nursing home residents. Since more than 50% of all drugs were renally excreted, dose adjustments in patients with renal failure are required. To assess polypharmacy in German nursing homes, in particular in residents with renal failure. Multi-center cross-sectional study in 21 nursing homes in Bremen and Lower Saxony/Germany. Baseline data were analysed using descriptive statistics. Multivariable logistic regression model and 95% confidence intervals were used to study the association of renal failure and polypharmacy. Of all 852 residents, the analysis comprised those 685 with at least one serum creatinine value so that the estimated creatinine clearance could be calculated. Of those, 436 (63.6%) had a severe or moderate renal failure, defined as estimated creatinine clearance <60 mL/min. Polypharmacy (5-9 drugs) was found in 365 (53.3%) and excessive polypharmacy (≥10 drugs) in 112 (16.4%) residents. Diuretics and psycholeptics were the most commonly used drug classes. Severe renal failure (estimated creatinine clearance <30 mL/min) was associated with polypharmacy (OR: 2.8, 95% CI 1.4-5.7). Both, polypharmacy and renal failure are common in German nursing home residents and an association of both could be found. Further studies are needed to assess the appropriateness of polypharmacy in these patients.

P-414: Comparative analysis of the potentially inappropriate medication in patients during their 1st geriatric appointment, by Beers 2012 and STOPP/START criteria

P-414: Comparative analysis of the potentially inappropriate medication in patients during their 1st geriatric appointment, by Beers 2012 and STOPP/START criteria

Multiple medication use in older patients in post-acute transitional care: a prospective cohort study.

BackgroundOlder adults with a range of comorbidities are often prescribed multiple medications, which may impact on their function and cognition and increase the potential for drug interactions and adverse events.AimsThis study investigated the extent of polypharmacy and potentially inappropriate medications in patients receiving post-discharge transitional home care and explored the associations of polypharmacy with patient characteristics, functional outcomes, and frailty.MethodsA prospective observational study was conducted of 351 patients discharged home from hospital with support from six Transition Care Program (TCP) sites in two states of Australia. A comprehensive geriatric assessment was conducted at TCP admission and discharge using the interRAI Home Care assessment tool, with frailty measured using an index of 57 accumulated deficits. Medications from hospital discharge summaries were coded using the World Health Organization Anatomical Therapeutic Chemical Classification System.ResultsPolypharmacy (5–9 drugs) was observed in 46.7% and hyperpolypharmacy (≥10 drugs) in 39.2% of patients. Increasing numbers of medications were associated with greater number of comorbid conditions, a higher prevalence of diabetes mellitus, coronary heart disease, chronic obstructive pulmonary disease, dizziness, and dyspnea and increased frailty. At discharge from the program, the non-polypharmacy group (<5 drugs) had improved outcomes in Activities of Daily Living, Instrumental Activities of Daily Living and fewer falls, which was mediated because of lower levels of frailty. The commonest drugs were analgesics (56.8%) and antiulcer drugs (52.7%). The commonest potentially inappropriate medications were tertiary tricyclic antidepressants.ConclusionPolypharmacy is common in older patients discharged from hospital. It is associated with frailty, falls, and poor functional outcomes. Efforts should be made to encourage regular medication reviews and rationalization of medications as part of discharge planning. Whether careful deprescribing improves outcomes in frail patients should be the focus of randomized trials.

Drug cessation in complex older adults: time for action

general opinion is growing that drug cessation in complex older patients is warranted in certain situations. From a clinical viewpoint, drug cessation seems most warranted in four situations, i.e., falls, delirium, cognitive impairment and end-of-life situations. To date, little information about the effects of drug cessation in these four situations is available. to identify the effects and effectiveness of drug cessation on falls, delirium and cognitive impairment. For end-of-life situations, we reviewed cessation of inappropriate drug use. electronic databases were searched using MeSH terms and relevant keywords. Studies published in English were included if they evaluated the effects of drug cessation in older persons, aged ≥65 years, with falls, delirium or cognitive impairment; or cessation of inappropriate drug use in end-of-life situations. we selected seven articles for falls, none for delirium, two for cognition and two for end-of-life situations. Withdrawal of psychotropics reduced fall rate; a prescribing modification programme for primary care physicians reduced fall risk. Withdrawal of psychotropics and a systematic reduction of polypharmacy resulted in an improvement of cognition. Very little rigorous research has been conducted on reducing inappropriate medications in patients approaching end of life. little research has focussed on drug cessation. Available studies showed a beneficial impact of cessation of psychotropic drugs on falls and cognitive status. More research in this field is needed. The issue of systematic drug withdrawal in end-of-life cases is controversial, but is increasingly relevant in the face of rising numbers of older people of this clinical status.

Patients with advanced lung cancer: is there scope to discontinue inappropriate medication?

Polypharmacy-taking five or medications per day-is common in lung cancer patients. This patient group is prescribed medication to control acute symptoms associated with cancer and also to prevent or treat other long-term conditions. These medications increase the pill burden for the patient and also the probability of developing a drug-related toxicity. To assess the prevalence of inappropriate medication in patients taking erlotinib for the treatment of advanced non-small cell lung cancer. This was a multicentre study across three sites in the North of England. Medication histories for patients receiving erlotinib were retrospectively extracted from medical notes and assessed by the clinical team (a consultant pharmacist, nurse specialist and clinical oncologist) to determine if the medication was appropriate or inappropriate. The clinical team considered the following factors when deciding if the medication was appropriate or inappropriate: remaining life expectancy of the patient, time until benefit of the treatment, goals of care and treatment targets. Among the 20 patients assessed, 19 (95 %) according to the clinical team were taking medications that were inappropriate. The mean number of medications the patients were taking was 8 (range 1-16) and the most common class of medication used were drugs affecting the Central Nervous System. In addition, there were 11 patients (55 %) who were taking erlotinib in combination with a proton pump inhibitor (PPI)-a clinically significant drug interaction that impairs the absorption of erlotinib. Patients taking erlotinib for the treatment of advanced non-small cell lung cancer take many inappropriate medications for the treatment or prevention of long-term conditions. These patients should have their medications reviewed in the context of their original therapeutic goals.