Medication Management In Older Adults Research Articles

De-Med—a tool to identify and classify potentially inappropriate medication according to Beers criteria, STOPP, and FORTA: a cross-sectional study

Abstract Objective A significant number of older adults are affected by the use of potentially inappropriate medications (PIMs), leading to various adverse outcomes, such as increased physical and cognitive impairment, frailty, hospitalization, and mortality. The objective of this study was to develop and test the reliability and feasibility of the De-Med tool. Methods This tool was developed using ReactJS for data extraction and manipulation. Users can upload drug lists for analysis, and the software delineates PIMs adhering to the Beers 2019 version, Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP) Version 2, and Fit fOR The Aged (FORTA) 2021 criteria. Reliability was assessed by juxtaposing software-generated outputs with manual assessments conducted by independent research pharmacists using retrospective medication records. The System Usability Scale (SUS) and AttrakDiff Mini questionnaires were used to assess feasibility and usability, respectively. Key findings Manual and software-generated PIM identifications agreed completely, demonstrating high reliability (100% concordance). A total of 1496 PIMs were identified from 231 records, with an average of 0.63 encounters per patient. The overall usability score was 83.75, indicating “Excellent.” According to the AttrakDiff ratings, users attributed the software to both pragmatic (mean PQ:1.84) and hedonic (mean HQ:1.50) qualities, with moderate overall attractiveness (mean ATT:2.13). Conclusions This web-based tool successfully identified PIMs with perfect reliability, high usability, and a moderate level of attractiveness. This tool has the potential to improve medication management in older adults by reducing PIMs.

Medication Adherence and Self-Efficacy of Medication Management in Older Adults Immediately Following Hematopoietic Cell Transplant (HCT)

Medication Adherence and Self-Efficacy of Medication Management in Older Adults Immediately Following Hematopoietic Cell Transplant (HCT)

Enhancing medication management of older adults in Qatar: healthcare professionals' perspectives on challenges, barriers and enabling solutions.

Polypharmacy and potentially inappropriate medications are significant challenges in older adults' medication management. The Consolidated Framework for Implementation Research (CFIR) is a comprehensive approach used to explore barriers and enablers to the healthcare system in guiding the effective implementation of evidence-based practices. This study examines the barriers and enablers to promote safe medication management among older adults in Qatar from healthcare professionals' perspectives. This includes identifying critical factors within the healthcare system influencing medication management and suggesting practical solutions to improve it. The study employs a qualitative design. Focus Groups (FGs) were conducted with healthcare professionals from the geriatric, mental health and medicine departments of Hamad Medical Corporation (HMC), the leading governmental sector in Qatar serving the older adult population. Utilising the CFIR, this study analysed feedback from healthcare professionals through FGs at HMC. A combined inductive and deductive thematic analysis was applied to transcripts from five FGs, focusing on identifying barriers and enablers to safe medication management among older adults. Two researchers transcribed the audio-recorded FG discussions verbatim, and two researchers analysed the data using a mixed inductive and deductive thematic analysis approach utilising CFIR constructs. We engaged 53 healthcare professionals (31 physicians, 10 nurses and 12 clinical pharmacists) in FGs. The analysis identified current barriers and enabler themes under different CFIR constructs, including inner settings, outer settings, individual characteristics and intervention characteristics. We identified 44 themes, with 25 classifieds as barriers and 19 as enablers. The findings revealed that barriers and enablers within the inner settings were primarily related to structural characteristics, resources, policies, communication and culture. On the other hand, barriers and enablers from the outer settings included patients and caregivers, care coordination, policies and laws, and resources. This study identified several barriers and enablers to promote medication management for older adults using the CFIR constructs from the perspective of healthcare professionals. The multifaceted findings emphasise involving stakeholders like clinical leaders, policymakers and decision-makers to address medication safety factors. A robust action plan, continuously monitored under Qatar's national strategy, is vital. Further research is needed to implement recommended interventions.

POLYPHARMACY AND THE SYMPTOM EXPERIENCE OF OLDER ADULTS WITH AND WITHOUT ALZHEIMER’S DISEASE AND RELATED DEMENTIAS

Abstract Older adults, including those living with Alzheimer’s disease and related dementias (ADRD), experience polypharmacy (PPY) (>5 medications daily) due to multiple chronic conditions. High symptom burden in older adults with ADRD and multimorbidity is well known. However, there is a gap in knowledge regarding symptoms experienced by older adults with and without ADRD who experience PPY. To address this gap, we conducted a longitudinal case-control observational study utilizing Rounds 6 to 9 (2016 to 2019) of the National Health and Aging Trends Study (NHATS) datasets. PPY was categorized by the number of medications from Round 6. We categorized individuals into four groups based on presence of ADRD and/or PPY (PPY and ADRD, PPY only, ADRD only, no PPY/ADRD) (N=2052). We identified symptoms associated with PPY (hopelessness, anxiety, general pain, stomach pain, breathing problems, weight loss, balance problems, fatigue, insomnia) in each group over each time point. Among those with ADRD (11.8%), over half experienced PPY (52.3%). Older adults with PPY and ADRD experienced a mean of 4.85 symptoms over all time points compared to 3.52 (ADRD only), 2.79 (no PPY/ADRD) and 3.93 (PPY only) (p=<0.001). Symptom frequencies in the PPY and ADRD group remained higher than all other groups across all four time points. Understanding the impact of medications on older adult’s quality life is a goal of the 4Ms framework. Future research will examine the symptoms associated with PPY and ADRD, physical function and health outcomes to inform medication management for older adults with dementia.

Abstract B017: Adverse events following immune checkpoint inhibitors by pre-existing comorbidities and polypharmacy among patients with lung cancer: A population-based study

Abstract Introduction: Pre-existing comorbidities and polypharmacy (PP) are significant issues among older lung cancer patients leading to complex treatment decisions. Immune check inhibitors (ICIs) have significantly improved lung cancer outcomes; however, most patients with comorbidities are excluded from ICI trials. Moreover, medication management in older adults with cancer is complex due to the volume of medications used and existing comorbidities requiring a high degree of coordination among multiple specialists. This study aims to understand the impact of pre-existing comorbidities and PP among older lung cancer patients using ICI. Methods: We used Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked data to identify patients aged ≥66 diagnosed with lung cancer (1999-2017) having continuous Medicare coverage for up to 2 years or until death. Immune-related adverse events (irAEs) grade 3/4 were defined as immune-suppressive medication claims during inpatient hospitalization 2 years after ICI, excluding the 14 days before the hospitalization. Comorbidities were calculated using a modified Charlson comorbidity index (CCI) and stratified into 3 groups: 0, 1, and more than 2 conditions. PP was stratified into 3 groups: No PP (<5 medications), PP (5-9 medications), and excessive PP (>10 medications). Incidence rates (IRs) and adjusted IR ratios (IRRs) were determined using negative binomial regression. The IRR model was adjusted for age, race, marital status, SEER region, state buy-in, education, and income. Results: We identified 2,461 lung cancer patients treated with ICIs. The IR for grade 3/4 irAEs was 27.59 per 100 person-years (PY) for CCI³2, 20.25 per 100 PY among 1 CCI, and 14.99 per 100 PY among no CCI. Overall IR of grade 3/4 irAEs was 29.29 per 100 PY among patients with excessive PP vs. 19.25 per 100 PY among PP and 13.99 per 100 PY among no PP. Patients with CCI more than 2 are 1.53 times more likely to develop a grade 3/4 irAE than those without CCI (IRR: 1.53; 95% CI: 1.09-2.14). Patients with excessive PP were 1.92 times more likely to develop a grade 3/4 irAE than those using <5 medications (IRR: 1.92; 95% CI: 1.31-2.83). Conclusion: Older adults with lung cancer usually have pre-existing comorbidities and, on average, use at least 11 concurrent medications. Multi-morbidity and polypharmacy are associated with a higher rate of irAEs among these patients; therefore, it’s critical to pay close attention to this population while on ICIs. Further studies are warranted to confirm these findings. Citation Format: Nikita Nikita, Swapnil Sharma, Amy Shaver, Krupa Gandhi, Scott Keith, Christopher Yang, Sarah Gordon, Grace Lu-Yao. Adverse events following immune checkpoint inhibitors by pre-existing comorbidities and polypharmacy among patients with lung cancer: A population-based study [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr B017.

1067-P: The Association between Appointment Modality and Medication Management Discussions in High-Risk Older Adults with Type 2 Diabetes

In older adults with type 2 diabetes (T2D), treatment with sulfonylureas (SUs) or insulin is associated with increased risk for severe hypoglycemia leading to falls, cognitive decline, lower quality of life, and death. Safe medication management in older adults requires effective and ongoing doctor-patient communication about self-management, glucose control, and other factors associated with hypoglycemia. In recent years, health care systems have increasingly relied on virtual appointments for chronic disease management. However, research has suggested that at-risk older populations may be less comfortable navigating these virtual spaces. We tested the hypothesis that older adults with T2D on SUs or insulin would be less likely to have conversations with their doctor about changes to diabetes medications during virtual visits (e.g., by video or telephone). Using data from an ongoing clinical trial (NCT04585191), we examined the association of visit modality with patient-reported medication discussions during the visit. We studied 180 Kaiser Permanente Northern California members (age = 81.1±3.8 years, Hba1c = 7.0±0.6%, 56% women, 73% on SUs). Visit modalities included in-person (n = 110, 61%), video (43, 24%), or telephone (27, 15%) appointments with their primary physician. We found that self-reported diabetes medication discussion did not differ by visit modality (48% vs. 44% vs 41%, p = 0.79). These results were unchanged after adjusting for demographic and clinical variables in a logistic regression model (p = 0.82). Qualitative analysis of open-ended surveys found that most adults (59/85, 69%) who engaged in these conversations considered them to be positive experiences that increased confidence in their treatment plan and satisfaction with their physician. Our results suggest that the ongoing expansion of virtual visit options does not deter older adults from discussing diabetes care with their doctor. Disclosure S.Degrace: None. I.Peterson: None. C.Board: None. R.W.Grant: None. Funding Patient-Centered Outcomes Research Institute (CDR-2019C1-16126)

Disturbed medication management in older adults with good cognitive health and mild cognitive impairment associated with semantic memory impairment: The Wakuya Project

For older adults with mild cognitive impairment or mild dementia, maintaining daily lives at home is also ideal for quality of life. However, they have serious problems with medication management. Although the Dementia Assessment Sheet in community-based integrated care system-21 items and the regimen comprehension scale are assessment scales for medication, there have been no reports evaluating both semantic memory and actual performance. A total of 180 older adults aged ≥75 years were entered in the Wakuya Project. They underwent the Clinical Dementia Rating, with two original tests: (i) the original semantic memory task for taking medication including the Dementia Assessment Sheet in community-based integrated care system-21 items; and (ii) the actual performance task related to medication including regimen comprehension scale. Non-demented participants were classified into two groups based on reports from their families; that is, a good management group (n=66) and a poor management group (n=42), and the two original tests were analyzed as explanatory variables. There were no differences between the two groups for the actual performance task related to medication including regimen comprehension scale. The success rates for the actual performance task related to medication including regimen comprehension scale (good management group/poor management group) were: regimen comprehension scale 40.9/23.8, One-Day Calendar 93.9/90.5, Medicine Chest 36.4/23.8 and Sequential Behavior Task 66.7/66.7, respectively. In the original semantic memory task for taking medication including the Dementia Assessment Sheet in community-based integrated care system-21 items, logistic regression analysis showed that only the mechanism of action remained (B -2.38, SE 1.10, Wald 4.69, P-value=0.03, OR 0.09, 95%CI 0.01-0.80). Our results suggest that disruption of medicine management might also be associated with drug semantic memory impairment between the two groups, with no difference in general cognitive and executive functions. Geriatr Gerontol Int 2023; 23: 319-325.

Team-based primary care reforms and older adults: a descriptive assessment of sociodemographic trends and prescribing endpoints in two Canadian provinces

BackgroundTeam-based primary care reforms aim to improve care coordination by involving multiple interdisciplinary health professionals in patient care. Team-based primary care may support improved medication management for older adults with polypharmacy and multiple points of contact with the healthcare system. However, little is known about this association. This study compares sociodemographic and prescribing trends among older adults in team-based vs. traditional primary care models in Ontario and Quebec.MethodsWe constructed two provincial cohorts using population-level health administrative data from 2006–2018. Our primary exposure was enrollment in a team-based model of care. Key endpoints included adverse drug events (ADEs), potentially inappropriate prescriptions (PIPs), and polypharmacy. We plotted prescribing trends across the observation period (stratified by model of care) in each province. We used standardized mean differences to compare characteristics of older adults and providers, as well as prescribing endpoints.ResultsFormal patient/physician enrollment increased in both provinces since the time of policy implementation; team-based enrollment among older adults was higher in Quebec (47%) than Ontario (33%) by the end of our observation period. The distribution of sociodemographic characteristics was reasonably comparable between team-based and non-team-based patients in both provinces, aside from a persistently higher share of rural patients in team-based care. Most PIPs assessed either declined or remained relatively steady over time, regardless of model of care and province. Several PIPs were more common among team-based patients than non-team-based patients, particularly in Quebec. We did not detect notable trends in ADEs or polypharmacy in either province.ConclusionsOur findings offer encouraging evidence that many PIPs are declining over time in this population, regardless of patients’ enrollment in team-based care. Rates of decline appear similar across models of care, suggesting these models may not meaningfully influence prescribing endpoints. Additional efforts are needed to understand the impact of team-based care among older adults and improve primary care prescribing practices.

Optimizing treatment for older adults with depression.

This review presents a comprehensive guide for optimizing medication management in older adults with depression within an outpatient setting. Medication optimization involves tailoring the antidepressant strategy to the individual, ensuring the administration of appropriate medications at optimal dosages. In the case of older adults, this process necessitates not only adjusting or changing antidepressants but also addressing the concurrent use of inappropriate medications, many of which have cognitive side effects. This review outlines various strategies for medication optimization in late-life depression: (1) Utilizing the full dose range of a medication to maximize therapeutic benefits and strive for remission. (2) Transitioning to alternative classes (such as a serotonin and norepinephrine reuptake inhibitor [SNRI], bupropion, or mirtazapine) when first-line treatment with selective serotonin reuptake inhibitors [SSRIs] proves inadequate. (3) Exploring augmentation strategies like aripiprazole for treatment-resistant depression. (4) Implementing measurement-based care to help adjust treatment. (5) Sustaining an effective antidepressant strategy for at least 1 year following depression remission, with longer durations for recurrent episodes or severe presentations. (6) Safely discontinuing anticholinergic medications and benzodiazepines by employing a tapering method when necessary, coupled with counseling about the benefits of stopping them. Additionally, this article explores favorable medications for depression, as well as alternatives for managing anxiety, insomnia, allergy, overactive bladder, psychosis, and muscle spasm in order to avoid potent anticholinergics and benzodiazepines.

Collaborative medication management for older adults after hospital discharge: a qualitative descriptive study

BackgroundSafe medication management for older adults after hospital discharge requires a well-coordinated, interprofessional, patient-centered approach. This study aimed to describe the perceived needs for collaborative medication management for older adults taking several different medications at home after hospital discharge.MethodsA qualitative descriptive study was conducted using semi-structured interviews with older adults (n = 28), informal (n = 17), and professional caregivers (n = 13).ResultsFindings revealed four main needs: older adults and informal caregivers’ perceived needs for greater involvement in discharge planning; older adults’ perceived needs to be informed, listened to, and to be actively involved in decision-making; informal caregivers’ perceived needs for help in supporting and coordinating medication management; and older adults’ and informal and professional caregivers’ perceived needs for better communication and coordination between professional caregivers.ConclusionThis study revealed two underutilized pathways towards improving collaborative medication management: medication follow-up involving a community healthcare professional taking an overarching responsibility and empowering older adults and their informal caregivers in medication management after hospital discharge.

Assisted Living Facilities: Benefits, Challenges, and the Importance of Culture

Assisted Living Facilities: Benefits, Challenges, and the Importance of Culture

The current state of geriatric pharmacy education in the United States – A cross-sectional survey

IntroductionConcerns exist that the current health care workforce is underprepared to meet the needs of the aging American population. This study evaluated the current emphasis on geriatrics in doctor of pharmacy curricula. MethodsA 61-item web-based survey was distributed to associate deans with oversight of pharmacy curricula at all United States (US) schools and colleges of pharmacy (S/COP). Information collected included school demographics, employment of geriatrics faculty, geriatric education (required, elective, and experiential courses), co-curricular geriatric experiences, postgraduate residency training in geriatrics, student interest in geriatrics, and perception of preparedness of the profession to care for older adults. ResultsOf responding S/COP, 35% required a course in geriatrics while 63% offered a geriatrics elective. An advanced pharmacy practice experience (APPE) in geriatrics was required by 14%, and 79% offered an elective APPE. Insufficient curricular emphasis on geriatrics was noted by 44% of responding schools, and 33% lacked confidence that the profession of pharmacy is adequately prepared to care for the aging population. ConclusionsAccording to the survey respondents, most pharmacy schools do not have a required didactic course or APPE in geriatrics. Additional emphasis on foundational principles of medication management for older adults in pharmacy curricula is warranted to meet the health care needs of the rapidly aging US population.

Development of a clinician guide for electronic medication adherence products in older adults.

Background/objectives:The ability to manage medications independently may be affected in older adults due to physical and cognitive limitations. Numerous electronic medication adherence products (eMAPs) are available to aid medication management. Unfortunately, there are no available guidelines to support clinicians in recommending eMAPs. The objective of this study was to create and validate a clinician tool to guide use of eMAPs.Methods:Pharmacists who previously tested the usability of the eMAPs participated in a focus group to provide feedback on 5 metrics of the clinician guide: unassisted task completion, efficiency, usability, workload and an overall eMAP score. Participants were asked semistructured questions on how they would use the tool to inform recommendations of medication aids to patients. The discussions were audio-recorded and transcribed verbatim and qualitatively analyzed. The clinician guide was modified to reflect feedback.Results:Five pharmacists (80% female, mean years of practice: 15.8) participated in the focus group. The clinician guide was modified by removing 2 metrics and adding an additional 8 metrics: maximum number of alarms, number of days the product can accommodate for based on a daily dosing regimen, price, monthly subscription, portability, locking feature, average time to set the device and number of steps required to set the device. The definition and calculation for unassisted task completion were modified. Additional instructions and specific patient case examples were also included in the final clinician guide.Conclusion:Since significant variability exists between eMAPs, it is imperative to have a tool for frontline clinicians to use when appropriately recommending the use of these products for medication management in older adults.

Understanding social workers’ hidden roles in medication safety for older adults: A qualitative study

ABSTRACT Older adults are vulnerable to risks associated with medications. This study explores the roles of Social Workers in facilitating medication safety for older adults. Eight social workers from federally qualified health centers participated in a case-based and interactive medication safety curriculum. They participated in an in-depth, semi-structured interview to explore their roles and strategies in assisting older adults and caregivers with medication management. Findings were transcribed and analyzed. Six themes characterizing social workers’ roles in medication management were identified: a) Referral: matching patients and medication-related resources within the health-care system and community; b) Communication: connecting providers, patients, caregivers, and support system; c) Access to medicine: addressing unique needs of each patient to foster their ability to obtain their medicines; d) Social Determinants of Health: investigating the social challenges of each patient and facilitating specific medication management approaches to meet identified needs; e) Engagement: engaging patients in co-developing a treatment plan; f) Caregiver Support: preparing caregivers to assist in medication management. Social workers are trained and well positioned to provide a multi-faceted approach to improve medication management for older adults. Their unique perspectives and skills are important in addressing the complex challenges of medication management.

Acute Care and Medication Management in Older Adults

The number of healthy and frail older adults is increasing worldwide, especially in industrialized countries, as a result of the increase in life expectancy [...].

Nurse Practitioners’ Experiences of Polypharmacy in Community-Dwelling Older Adults

Numerous studies exist that define polypharmacy and its impact on health. Additionally, the literature is rich in studies documenting the benefits of care provided by nurse practitioners. A gap in research exists at the intersection of the value of nurse practitioners in caring for older adults and their management of polypharmacy. Coinciding with a growth of America’s older adult population and the need for adequate care, the purpose of this study was to explore the experiences of nurse practitioners caring for older adults experiencing polypharmacy. A qualitative descriptive study was conducted using a purposive sampling of nurse practitioners who care for older adults. Interviews were conducted and data was analyzed for themes. Four themes emerged: defining polypharmacy, communicating and collaborating, clinical judgement of nurse practitioners in relation to polypharmacy, and medication issues of older adults. Major themes emerged that depict the complexity of medication management in older adults as well as the important role of NPs in providing care to older adults. The significance of the study findings to future practice includes improving communication and collaboration of prescribing health care providers, better identification and management of polypharmacy, and improving the health care delivered to older adults. Safe and effective prescribing for older adults requires NPs consider the unique needs of each older adult while utilizing technology to support collaboration and decision making.

Stakeholder Feedback of Electronic Medication Adherence Products: Qualitative Analysis.

BackgroundMedication management among older adults continues to be a challenge, and innovative electronic medication adherence products have been developed to address this need.ObjectiveThe aim of this study is to examine user experience with electronic medication adherence products, with particular emphasis on features, usefulness, and preferences.MethodsOlder adults, caregivers, and health care providers tested the usability of 22 electronic medication adherence products. After testing 5 products, participants were invited to participate in a one-on-one interview to investigate their perceptions and experiences with the features, usefulness, and preference for electronic medication adherence products tested. The interviews were audio recorded, transcribed, and analyzed using exploratory inductive coding to generate themes. The first 13 interviews were independently coded by 2 researchers. The percentage agreement and Cohen kappa after analyzing those interviews were 79% and 0.79, respectively. A single researcher analyzed the remaining interviews.ResultsOf the 37 participants, 21 (57%) were older adults, 5 (14%) were caregivers, and 11 (30%) were health care providers. The themes and subthemes generated from the qualitative analysis included product factors (subthemes: simplicity and product features, including availability and usability of alarms, portability, restricted access to medications, and storage capacity) and user factors (subthemes: sentiment, affordability, physical and cognitive capability, and technology literacy and learnability).ConclusionsElectronic medication adherence products have the potential to enable independent medication management in older adults. The choice of a particular product should be made after considering individual preferences for product features, affordability, and the sentiment of the users. Older adults, caregivers, and health care providers prefer electronic medication adherence products that are simple to set up and use, are portable, have easy-to-access medication compartments, are secure, and have adequate storage capacity.

The Translational Approaches to Personalized Health Collaborative: Pharmacogenomics for African American Older Adults.

Older adults (i.e., 60 years and older), are the leading consumers of medications, and consequently are suffering the most from medication‐related adverse events. Not only are older adults the largest consumers of medications, they are more likely to experience an adverse drug event contributing to increased hospitalization, utilization of emergency medical services, and mortality. Translational Approaches to Personalized Health (TAPH) is a transdisciplinary team of researchers conducting community‐engaged participatory research focused on the discovery and translation of pharmacogenomic (PGx) data to improve health outcomes. Underserved and ethnically diverse older adults living in urban settings are significantly under‐represented in PGx studies. To address the issue of under‐representation, our study enrolls older African American adults into a community‐based PGx study. Therefore, we will characterize the frequency of actionable PGx genotypes and identify novel PGx response genes in our cohort of older community dwelling African Americans. The translational component of our work is to use the PGx findings to improve therapeutic outcomes for medication management in older adults. Such findings will serve as a foundation for translational PGx studies aimed at improving medication efficacy and safety for older adults. In this article, we describe the process for launching the TAPH collaborative group, which includes the transdisciplinary team, community‐engaged participatory research model, study measures, and the evaluation of PGx genes.

Nurse practitioners' experiences of polypharmacy in community-dwelling older adults.

Numerous studies have defined polypharmacy and its impact on health. The literature is also rich in studies documenting the benefits of care provided by nurse practitioners (NPs). A gap in research exists at the intersection of the value of NPs in caring for older adults and their management of polypharmacy. Coinciding with growth in America's older adult population and the need for adequate care, the purpose of this study was to explore the experiences of NPs caring for community-dwelling older adults experiencing polypharmacy. A qualitative descriptive study was conducted. Interviews were conducted, and data were analyzed for themes. This study was conducted using a purposive sampling of NPs who care for older adults (n = 15). Four themes emerged: defining polypharmacy, communicating and collaborating, clinical judgement of NPs in relation to polypharmacy, and medication issues of older adults. The themes depict the complexity of medication management in older adults and the important role of NPs in providing care to older adults. The significance of the study findings to future practice includes improving communication and collaboration between prescribing health care providers, better identification and management of polypharmacy, and improving the health care delivered to older adults. Safe and effective prescribing for older adults requires that NPs consider the unique needs of each older adult while using technology to support collaboration and decision making.

The OPTIMIZE patient- and family-centered, primary care-based deprescribing intervention for older adults with dementia or mild cognitive impairment and multiple chronic conditions: study protocol for a pragmatic cluster randomized controlled trial

BackgroundMost individuals with dementia or mild cognitive impairment (MCI) have multiple chronic conditions (MCC). The combination leads to multiple medications and complex medication regimens and is associated with increased risk for significant treatment burden, adverse drug events, cognitive changes, hospitalization, and mortality. Optimizing medications through deprescribing (the process of reducing or stopping the use of inappropriate medications or medications unlikely to be beneficial) may improve outcomes for MCC patients with dementia or MCI.MethodsWith input from patients, family members, and clinicians, we developed and piloted a patient-centered, pragmatic intervention (OPTIMIZE) to educate and activate patients, family members, and primary care clinicians about deprescribing as part of optimal medication management for older adults with dementia or MCI and MCC. The clinic-based intervention targets patients on 5 or more medications, their family members, and their primary care clinicians using a pragmatic, cluster-randomized design at Kaiser Permanente Colorado. The intervention has two components: a patient/ family component focused on education and activation about the potential value of deprescribing, and a clinician component focused on increasing clinician awareness about options and processes for deprescribing. Primary outcomes are total number of chronic medications and total number of potentially inappropriate medications (PIMs). We estimate that approximately 2400 patients across 9 clinics will receive the intervention. A comparable number of patients from 9 other clinics will serve as wait-list controls. We have > 80% power to detect an average decrease of − 0.70 (< 1 medication). Secondary outcomes include the number of PIM starts, dose reductions for selected PIMs (benzodiazepines, opiates, and antipsychotics), rates of adverse drug events (falls, hemorrhagic events, and hypoglycemic events), ability to perform activities of daily living, and skilled nursing facility, hospital, and emergency department admissions.DiscussionThe OPTIMIZE trial will examine whether a primary care-based, patient- and family-centered intervention educating patients, family members, and clinicians about deprescribing reduces numbers of chronic medications and PIMs for older adults with dementia or MCI and MCC.Trial registrationNCT03984396. Registered on 13 June 2019