Medication-related Harm Research Articles

The importance and added value of patient involvement in person-centred medication reviews.

Background: The iSIMPATHY (implementing Stimulating Innovation in the Management of Polypharmacy and Adherence Through the Years) team is conducting person-centred medication reviews using a 7-step review tool focusing on ‘what matters to you’1.
 iSIMPATHY is an EU-funded partnership between Scotland, Ireland and Northern Ireland. One of the main drivers for change is the WHO 3rd global patient safety challenge, Medication Without Harm which aims to reduce severe avoidable medication-related harm by 50% globally in the next 5 years, with one of the key action areas being polypharmacy2. To date over 1400 person-centred medication reviews have been conducted with patients in Northern Ireland. These reviews aim to reduce inappropriate polypharmacy, promote adherence and health literacy and provide patient education.
 Personal and Public Involvement (PPI) feedback was sought prior to the project starting and patient engagement has continued throughout.
 Method: Structured, person-centred medication reviews were conducted in acute medical wards in a secondary care setting in Northern Ireland. Priority was given to those on 10 or more medicines or a high risk medicine, over 50 and resident in a care home or approaching end of life. Data were collected for a cohort of 66 patients who consented to an iSIMPATHY review. Data were analysed to determine the interventions made due to patient involvement in the review as compared with interventions which could be made by completing a kardex (medicine list) review only.
 Results: An average of 9.3 interventions were made per patient, significance was graded using the Eadon system, with 4.4% graded 3 (significant but does not lead to an improvement in patient care), 88.9% graded 4 (significant and results in an improvement in standard of care) and 6.7% graded 5 (very significant and prevents major organ failure or an adverse reaction of similar importance). Interventions included checking and requesting laboratory tests, omitted medicines started, adjustments made for allergy, frailty, renal or liver impairment and identification of adverse drug reactions. Importantly, 88% (n=58) of patients had an intervention made because the medication review was discussed with them. This resulted in 38% additional interventions and included 22% of grade 5 interventions.
 The themes of additional interventions were: adherence and inhaler education (19%), identification of unmet/unknown health need and symptom control (15%), community support services (15%), lifestyle (12%), reduction and stopping unnecessary/inappropriate medicines (10%), identification of important additional information (10%), sick day rules (8%), self-care (7%) and referral to other services (5%).
 Conclusion: Patient involvement in their medication review leads to the identification of new and unmet needs, allows for the provision of counselling on medicines, adherence and lifestyle and prompts discussion and action on the deprescribing of inappropriate and unnecessary medicines. These additional interventions are clinically significant for the patient.
 Next steps: Medication reviews and data collection continues with the aim of scale and spread. For results and learning opportunities search https://www.isimpathy.eu/.
 
 https://www.isimpathy.eu/
 Medication Safety in Polypharmacy Technical Report, World Health Organisation 2019.
 
 https://www.who.int/initiatives/medication-without-harm
 
 Eadon, H. Assessing the quality of ward pharmacists’ interventions. Int. J. Pharm. Pract 1992, 1, 145–147
 

A CONSULTANT PHARMACIST INTERVENTION TO DEPRESCRIBE OPIOIDS AND BENZODIAZEPINES FOR OLDER ADULTS IN PRIMARY CARE

Abstract Long-term use of opioids and benzodiazepines (BZDs) by older adults may cause harm. We evaluated the impact of a targeted consultant pharmacist opioid and BZD deprescribing intervention for older adults. We conducted a pragmatic study in which fifteen primary care clinics were randomized to receive standard care (n=7) or a consultant pharmacist service (n=8) to provide targeted medication review and recommendations for deprescribing opioids and BZDs. The primary outcome was opioid and BZD prescribing in the following year, using average daily morphine milligram equivalents (MMEs) and diazepam milligram equivalents (DMEs). We used generalized linear models to evaluate the association of the intervention with average daily MMEs and DMEs, adjusted for medication exposures in the prior year and demographics. Incident falls were examined as a secondary outcome. We included 961 opioid and 1107 BZD users, with 15.6% and 13.6% being prescribed both medications, respectively. Average daily MMEs and DMEs prescribed at baseline were 23.6 and 7.67. Deprescribing recommendations were made for 71% of opioid and BZD users seen in intervention clinics. We observed non-statistically significant reductions in average daily MMEs (Intervention: -2.42 MMEs, Control: -1.02 MMEs, p=0.71) and DMEs (Intervention: -1.0 DMEs, Control: -0.1 DMEs, p=0.06). There was no significant reduction in incident falls. A consultant pharmacist-driven intervention is a feasible approach to deliver targeted deprescribing recommendations, but did not significantly impact medication use or falls. Future studies should explore whether multimodal interventions would be more effective in achieving deprescribing and reducing medication-related harms.

Effect of educational intervention on medication reconciliation practice of hospital pharmacists in a developing country – A non-randomised controlled trial

BackgroundMedication reconciliation is an evidence-based practice that reduces medication-related harm to patients. This study evaluated the effect of educational intervention on medication reconciliation practice of pharmacists among ambulatory diabetes and hypertensive patients.MethodsA non-randomized clinical trial on medication reconciliation practice was carried out among 85 and 61 pharmacists at the intervention site and control site, respectively. Medication reconciliation was carried out among 334 (intervention-183; control-151) diabetes and/or hypertensive patients by the principal investigator to indirectly evaluate pharmacists’ baseline medication reconciliation practice at both sites. A general educational intervention was carried out among intervention pharmacists. Medication reconciliation was carried out by the principal investigator among another cohort of 96 (intervention-46; control-50) and 90 (intervention-44; control-46) patients at three and six months postintervention, respectively, to indirectly assess pharmacists’ postintervention medication reconciliation practice. Thereafter, a focused educational intervention was carried out among 15 of the intervention pharmacists. Three experts in clinical pharmacy analysed the medication reconciliation form filled by the 15 pharmacists after carrying out medication reconciliation on another cohort of 140 patients, after the focused intervention. Data was summarized with descriptive (frequency, percentage, mean ± standard deviation) and inferential (Pearson product-moment correlations analysis, independent-samples t-test and one-way ANOVA) statistics with level of significance set at p<0.05.Key findingsBaseline medication reconciliation practice was poor at both sites. Post-general educational intervention, medication discrepancy was significantly reduced by 42.8% at the intervention site (p<0.001). At the intervention site, a significant increase of 54.3% was observed in patients bringing their medication packs for clinic appointments making medication reconciliation easier (p=0.003), at 6-months postintervention. Thirty-five, 66 and 48 drug therapy problems were detected by 31 (43.1%), 33 (66.0%) and 32 (71.1%) intervention pharmacists at 1-, 3- and 6-month post-general educational intervention, respectively. Post-focused educational intervention, out of a total of 695 medications prescribed, 75 (10.8%) medication discrepancies were detected and resolved among 42 (30%) patients by the 15 pharmacists.ConclusionsThe educational interventions improved pharmacists’ medication reconciliation practice at the intervention site. It is expected that this research would help create awareness on medication reconciliation among pharmacists in developing countries, with a view to reducing medication-related patient harm.

Healthcare providers beliefs about the meanings and impacts of prescription drug monitoring program alerts

Background Addiction and overdose death associated with high-risk prescription medications such as benzodiazepines and opioids, are significant global issues. Prescription Drug Monitoring Programs (PDMP), which allow healthcare providers to track and monitor patients’ high-risk medication history have been implemented widely throughout North America and recently in Victoria, Australia. Australia’s PDMP uses a red alert notification to notify healthcare providers to patients at ‘high risk’ of medication related harm. Very little is known about healthcare providers beliefs about the meaning of these notifications and what impact these meanings have on the clinical encounter and patient outcome. Methods Twenty-nine interviews with Victorian healthcare providers (15 prescribers and 14 pharmacists) were thematically analyzed. Results Red alerts were understood as being both synonymous with addiction, as well as a single data point with further investigation required to draw conclusion from. The red alert both disrupted and exposed underlying addiction stigma. Healthcare providers assumptions about patient’s readiness to change influenced their decision to discuss the red alert with patients. Conclusions How healthcare providers make sense of and response to PMDP generated red alerts can impact upon the clinical encounter, including clinical decision-making and the care that patients receive. By identifying and understanding the social factors and forces driving beliefs, attitudes and behaviors toward people who use addictive prescription medications, healthcare providers may be able to pause, assess and reflect on how these factors shape their decision making in unhelpful or unethical ways.

Management pattern and medication-related harms and its predictors in colorectal cancer patients: an institutional-based retrospective study.

Data on colorectal cancer (CRC) patients' thorough management practices and medication-related harms (MRH) are scarce. This study's aim was to investigate the MRHs in patients receiving CRC chemotherapy at the comprehensive specialized hospital of the University of Gondar (UoGCSH). A registry-based retrospective cohort study was conducted on CRC patients at the UoGCSH during 2017-2021. From February to May 2022, medical records were reviewed using a pretested data collection tool to collect socio-demographic and disease-related characteristics, MRHs, and medication regimens. MRHs occurrence and adverse drug reactions (ADRs) severity were assessed using standard guidelines and protocols. Version 16/MP of STATA for Windows was used for the analysis. Independent predictors of MRHs were investigated using logistic regression analysis. A p-value ≤0.05 was used to determine an independent variable's statistical significance. One hundred forty three CRC patients were included, with a mean age of 49.9 ± 14.5 years. About 32.9% and 33.6% had stage II and III cancer, respectively. Significant patients had co-morbidities (15.4%) and complications (13.3%). Fluorouracil (5-FU)-based regimens were given to more than half (56%) of the patients. MRHs were found in 53.1% of the patients, with a mean of 2.45 ± 1.37 MRHs. The most common MRHs were the need for additional drug therapy, sub-therapeutic dose, DDIs, and ADRs. Being on stage IV (AOR = 27.7, 95% CI = 3.85-199.38, p = 0.001), having co-morbidity (AOR = 7.42, 95% CI = 1.80-30.59, p = 0.018) and having complication (AOR = 11.04, 95% CI = 1.72-70.95, p = 0.011) and treated with five or more drugs (AOR = 2.54, 95% CI = 1.07-6.07, p = 0.035) were independent predictors of MRHs. A fluorouracil-based treatment regimen was most frequently used. MRHs were found in nearly half of CRC patients. Furthermore, MRHs were significantly associated with cancer stage, comorbidity and complication status, and the number of medications used. Because MRHs are common, improving clinical pharmacy services is critical for optimizing drug therapy in CRC patients.

Exploring medication safety through a social determinants of health and health literacy lens

Abstract Background The study addressed an evidence gap in Northern Ireland (NI) on social determinants of health &amp; medication safety. Almost 50% more prescription items are prescribed in the most deprived areas and they suffer a heavier burden of illness &amp; higher mortality rates. Low health literacy is associated with medication adherence &amp; more negative beliefs about medication. The research aimed to discover the social circumstances behind unsafe medication practices and avoidable medication-related harm to inform the implementation of the Transforming Medication Safety in NI plan. Methods This exploratory study used a community-based participatory research (CBPR) approach that engaged community members to share their unique perspectives &amp; local knowledge. A community survey &amp; interviews with key stakeholders informed the sample &amp; topic guides for focus groups with people in the community (63 participants) &amp; health &amp; social care staff (25 participants). Data underwent thematic analysis &amp; findings were discussed &amp; interpreted at a Knowledge Exchange Workshop. Results Many social factors influence medication safety, such as busy lives, prioritising others, social support, work, physical &amp; psychological capabilities, mental health, addiction, income, transport, access to healthcare &amp; social stigma. Health literacy was a key theme; people have varying abilities accessing, understanding, appraising, remembering, &amp; using information about their medication. Health &amp; social care staff can assume people to know &amp; understand how to take their medication correctly. Health literacy was influenced by many sources including friends’ &amp; family's experiences, individual research, health &amp; social care staff, social media, &amp; stories in the media. Conclusions The research gathered people's lived experiences on medication use at home. It is evident that the social determinants of health, health literacy and social practices and norms need to be considered in medication safety.

Evaluation of the Effect of a Safe Medication Strategy on Potentially Inappropriate Medications, Polypharmacy and Anticholinergic Burden for People with Dementia: An Intervention Study.

People with dementia (PWD) are at risk for medication-related harm due to their impaired cognition and frequently being prescribed many medications. This study evaluated a medication safety intervention (including pharmacist medication reconciliation and review) for PWD during an unplanned admission to hospital. This article reports the effect of the intervention on polypharmacy, potentially inappropriate medications (PIMs), and anticholinergic burden scores for PWD. A pre-post design using an intervention site and a control site was conducted in 2017-2019, in a regional area in New South Wales, Australia. Polypharmacy, PIMs, and anticholinergic burden were measured at admission, discharge, and three months after discharge. There were 628 participants including 289 at the control site and 339 at the intervention site. Polypharmacy was 95% at admission and 90% at discharge. PIMs at admission were 95-98% across timepoints and decreased significantly at discharge. The mean anticholinergic score decreased significantly between admission (2.40-3.15) and discharge (2.01-2.57). Reduced PIMs at discharge were correlated with reduced anticholinergic burden (rho = 0.48-0.55, p < 0.001). No significant differences were identified between the study and control sites for Polypharmacy, PIMs, and anticholinergic burden rates and scores. High rates of polypharmacy and PIMs in this study indicate a study population with multiple comorbidities. This intervention was feasible to implement but was limited due to difficulty recruiting participants and deaths during the study. Future multisite studies should be designed to recruit larger study samples to evaluate interventions for improving medication safety for PWD and improve outcomes for these vulnerable people.

Carer involvement in medication adherence: carer views and experiences of facilitating medication adherence using pharmacy-filled multi-compartment medication compliance aids and other methods of adherence support-a questionnaire survey.

Unpaid carers are an increasing proportion of the UK population. One of the many ways in which they help those they care for is assisting with medication adherence. Many older adults have medicines dispensed in pharmacy-filled multi-compartment medication compliance aids (pMCAs). However, evidence suggests that pMCAs may increase medication-related harm, and little is known about the interaction between the user, medication adherence systems and the carer. To explore the views of carers supporting older adults to manage their medications with and without a pMCA. A researcher-administered questionnaire survey of carers supporting older adults to manage their medicines with or without a pMCA. Participants were recruited from inpatient wards, outpatient clinics and community services in central London. Responses were analysed by two independent researchers to identify overarching themes. Eighty-eight unpaid carers were interviewed and responses were categorised according to the medication adherence method used; 47 supported a user with a pMCA and 41 supported without a pMCA. The main themes were: Time, Responsibility and Mistakes, Waste and Sustainability, and Polypharmacy, with sub-themes of design of multi-compartment medication compliance aids, organisation and reassurance. Supporting medication adherence puts considerable burden on carers regardless of whether a self- or pharmacy-filled medication compliance aid is used or not. Prescribers could alleviate this burden through regular medication review by considering the prescribing frequency and duration and medication rationalisation. Redesign of both pMCAs and systems surrounding their use could also help reduce carer's burden and environmental burden.

Exploration of an On-Site Pharmacist Intervention within Australian Residential Aged Care Facilities Using Normalisation Process Theory: A Mixed-Methods Study

Residents living in residential aged care facilities (RACFs) continue to experience medication-related harm. There is ongoing interest in expanding the role of pharmacists, including on-site pharmacists (OSPs), to help improve medication management in RACFs. The objectives of this mixed-methods study were to explore the extent and ways in which on-site pharmacists (OSPs) were normalised within RACFs as part of a complex intervention seeking to improve medication management. This study consisted of semistructured interviews informed by normalisation process theory (NPT) and a quantitative survey adapted from the normalisation measure development questionnaire (NoMAD) instrument which is underpinned by NPT. Semistructured interviews with prescribers, RACF managers, RACF nursing staff, OSPs, residents, and family members (n = 47) indicated that most participants supported OSPs within RACFs that having OSPs in RACFs made sense and was perceived as beneficial and that participants were invested in working with OSPs who often became part of routine practice, i.e., “normalised.” Prescribers, RACF managers, and nursing staff (health care team members) completed the adapted survey, and their responses (n = 16) strongly complemented the positive qualitative findings. Overall, OSPs were positively appraised by health care team members as well as residents and family members and were generally considered to be normalised within their respective RACFs. This study explored the normalisation of OSPs within RACFs. From the perspective of residents, family members, health care team members, and OSPs, OSPs could become part of routine practice within Australian RACFs. The findings of this study also highlighted the value of using theory to guide the evaluation of a pharmacist intervention in RACFs and the utility of applying NPT in a new setting, Australian RACFs. Importantly, the findings of this study could help inform the future role of OSPs working and the rollout of OSPs within Australian RACFs.

237 Drug–drug interactions and the risk of adverse drug reaction hospital admissions in the older population: a prospective cohort study

Abstract Background Drg–Drg Interactions (DDIs) can lead to medication-related harm; the older population is at greatest risk. We estimate DDI prevalence and the average causal effect of DDI exposure on adverse drug reaction (ADR)-related hospital admission in an older (≥65 years) population admitted acutely to hospital in Ireland. We also examine the effect of DDI exposure on health-related quality of life (HRQoL) and Length of Stay (LoS) in hospital. Methods Prospectively collected (2016–17) data from the Adverse Drg Reactions in an Ageing PopulaTion cohort were used (N = 798). Medication (current/recently-discontinued/over-the-counter) and objective clinical data (e.g. renal function) were available. DDIs (which may result in a life-threatening event/permanent detrimental effect) were identified using the BNF and Stockley’s. Causal inference models were developed using directed acyclic graphs. HRQoL was measured using the EQ-5D-5L. Multivariable logistic regression was performed using SAS (v9.4). Results N = 782 patients using ≥2drugs were included, mean age = 80.9(±7.5); 52.2% female; 92.2% polypharmacy (≥5drugs); 45.1% had an ADR-related hospital admission. N = 316 (40.4% [95% Confidence Interval (CI):37.0–43.9]) patients with at least one DDI at hospital admission. After controlling for confounding, the average causal effect of DDI exposure on ADR-related hospital admission was Odds Ratio (OR) = 1.2 [95% CI: 0.9–1.6]. This risk was significantly increased for patients exposed to DDIs which increase bleeding risk (OR: 2.0 [1.3–3.1]); for aspirin-warfarin (OR: 2.8 [1.4–5.7]) and esomeprazole-escitalopram (OR: 3.2 [1.1–10.3] DDIs. Patients with a DDI had a lower HRQoL (mean EQ-5D: 0.49 [±0.39]) compared to those with none (mean EQ-5D: 0.58 [±0.41], p = 0.08). Patients with an ADR-related hospitalisation and DDI had a significantly greater LoS in hospital (8 [Interquartile Range:5–17] days) compared to those with no DDI (6[Interquartile Range: 3–13] days, p = 0.02). Conclusion DDIs are prevalent among older adults on acute admission to hospital, and increase the risk of ADR-related hospitalisation, significantly for patients with DDIs that increase bleeding risk. Patients with a DDI had lower HRQoL, and prolonged LOS in hospital.

Cutaneous Adverse Drug Reactions to Antibiotics: How Much is the Extent of the Problem?

Medication-related harm or adverse drug reaction is a great global health concern today. They are frequent and, most often, devastating. With the rising incidences of drug-related adverse outcomes, it is imperative that clinicians have the knowledge and understanding of these occurrences to prevent, diagnose, and manage them properly. Skin is a very commonly affected organ system, and incidences of cutaneous adverse drug reactions are between 1-5% depending on the geographic location. Up to 60% or more of all adverse drug reactions may represent cutaneous reactions. These may fall into either of the dose-dependent or dose-independent categories. Being the most prescribed and utilized drug group, antibiotics have been implicated as one of the major drug groups causing cutaneous drug reactions. There is ample evidence that antibiotics cause severe and non-severe cutaneous adverse drug reactions. A review of the present literature was done using MEDLINE/PubMed, Google Scholar, and other search engines to gather evidence to find how extensive the problem is and how much the burden is. Which will enlighten clinicians from all backgrounds and medical students and help them deal with cutaneous adverse drug reactions more prudently

A precision medicine approach to personalized prescribing using genetic and nongenetic factors for clinical decision-making

Screening potential drug–drug interactions, drug–gene interactions, contraindications, and other factors is crucial in clinical practice. However, implementing these screening concepts in real-world settings poses challenges. This work proposes an approach towards precision medicine that combines genetic and nongenetic factors to facilitate clinical decision-making. The approach focuses on raising the performance of four potential interaction screenings in the prescribing process, including drug–drug interactions, drug–gene interactions, drug–herb interactions, drug–social lifestyle interactions, and two potential considerations for patients with liver or renal impairment. The work describes the design of a curated knowledge-based model called the knowledge model for potential interaction and consideration screening, the screening logic for both the detection module and inference module, and the personalized prescribing report. Three case studies have demonstrated the proof-of-concept and effectiveness of this approach. The proposed approach aims to reduce decision-making processes for healthcare professionals, reduce medication-related harm, and enhance treatment effectiveness. Additionally, the recommendation with a semantic network is suggested to assist in risk–benefit analysis when health professionals plan therapeutic interventions with new medicines that have insufficient evidence to establish explicit recommendations. This approach offers a promising solution to implementing precision medicine in clinical practice.

Translation, cultural adaptation and validation of the revised patients’ attitudes towards deprescribing (rPATD) questionnaire in Romanian older adults

BackgroundDeprescribing is part of ensuring appropriate medication use and may reduce medication-related harm. Capturing the beliefs and attitudes of patients towards deprescribing by using a validated tool may support optimizing medication use in practice. ObjectivesTo translate, culturally adapt and validate the revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire in Romanian and to investigate the attitudes and beliefs of older adults towards deprescribing. MethodsThe rPATD questionnaire was translated using forward-backward translation into Romanian and culturally adapted. The psychometric properties were evaluated in older adults ≥65 years of age. Structural validity was assessed by item load on factors using an exploratory factor analysis (EFA) which was compared to the original English version and the internal consistency by Cronbach's alpha. Construct validity was evaluated by calculating the Spearman's rank correlation coefficients between the factor scores obtained using the revised version of the Romanian rPATD and scores on the Beliefs about Medicines Questionnaire (BMQ) Specific Concerns Romanian version. Floor and ceiling effect were also examined. ResultsWe translated the questionnaire and administered it to 224 participants (median age 72 years [interquartile range: 68.0; 77.0]). In the EFA individual items loaded onto 4 factors, grouped similarly to the English version (Involvement, Burden, Appropriateness, Concerns about Stopping factors). Two items from each of the Involvement and Appropriateness factors were removed to improve factor loading and avoid cross-loading. The Cronbach's alpha values for the 4 factors ranged between 0.522 and 0.773. The scores for Burden and Concerns about Stopping factors were found to be positively correlated with BMQ Specific Concerns score. We identified a ceiling effect for one of the four factors (Involvement) and no floor effects. ConclusionsThe Romanian rPATD was validated in 4 factor structure similar to the original English questionnaire. The Romanian version of the questionnaire may support the health care professionals in Romania to initiate and support patient-centered deprescribing.

Treatment Harms in Paediatric Primary Care.

The aim of this study was to describe the epidemiology in children of harms detectable from general practice records, and to identify risk factors. The SHARP study examined 9076 patient records from 44 general practices in New Zealand, with an enrolled population of 210,559 patients. "Harm" was defined as disease, injury, disability, suffering, and death, arising from the health system. The age group studied was ≤20 years of age. There were 193 harms to 141 children and adolescents during the 3-year study period. Harms were reported in one (3.5%) patient aged <2 years, 80 (6.6%) aged 2 to <12 years, 36 (4.9%) aged 12 to <18 years, and 24 (7.5%) aged 18 to ≤20 years. The annualised rates of harm were 36/1000 child and adolescent population for all harms, 20/1000 for medication-related harm (MRH), 2/1000 for severe MRH, and 0.4/1000 for hospitalisation. For MRH, the drug groups most frequently involved were anti-infectives (51.9%), genitourinary (15.4%), dermatologicals (12.5%), and the nervous system (9.6%). Treatment-related harm in children was less common than in a corresponding adult population. MRH was the most common type of harm and was related to the most common treatments used. The risk of harm increased with the number of consultations.

Associations between potentially inappropriate prescribing and increased number of medications with postdischarge health outcomes among geriatric rehabilitation inpatients: RESORT study.

Older adults are vulnerable to medication-related harm mainly due to high use of medications and inappropriate prescribing. This study aimed to investigate the associations between inappropriate prescribing and number of medications identified at discharge from geriatric rehabilitation with subsequent postdischarge health outcomes. RESORT (REStORing health of acutely unwell adulTs) is an observational, longitudinal cohort study of geriatric rehabilitation inpatients. Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) were measured at acute admission, and at admission and discharge from geriatric rehabilitation, using Version 2 of the STOPP/START criteria. In total, 1890 (mean age 82.6 ±8.1years, 56.3% female) were included. The use of at least 1 PIM or PPO at geriatric rehabilitation discharge was not associated with 30-day and 90-day readmission and 3-month and 12-month mortality. Central nervous system/psychotropics and fall risk PIMs were significantly associated with 30-day hospital readmission (adjusted odds ratio [AOR] 1.53; 95% confidence interval [CI] 1.09-2.15), and cardiovascular PPOs with 12-month mortality (AOR 1.34; 95% CI 1.00-1.78). Increased number of discharge medications was significantly associated with 30-day (AOR 1.03; 95% CI 1.00-1.07) and 90-day (AOR 1.06; 95% CI 1.03-1.09) hospital readmissions. The use and number of PPOs (including vaccine omissions) were associated with reduced independence in instrumental activities of daily living scores at 90-days after geriatric rehabilitation discharge. The number of discharge medications, central nervous system/psychotropics and fall risk PIMs were significantly associated with readmission, and cardiovascular PPOs with mortality. Interventions are needed to improve appropriate prescribing in geriatric rehabilitation patients to prevent hospital readmission and mortality.

Complexity: Tending to the Medication-Related Needs of Older People.

The solutions to reduce the prevalence of medication-related harm in aged care are just as multifaceted as those that can be used in other industries where processes are complicated and complex. Designing safe systems is a key element of these efforts, with factors such as automation, electronic medication management systems, and the emergence of artificial intelligence all supplementing other aspects of safe health delivery such as appropriate environmental design and safe staffing levels. Nevertheless, as any experienced health practitioner will readily confirm, there is both art and science involved in the processes of safely delivering care for patients, particularly people of advanced age.

Sex-based differences in the association between loneliness and polypharmacy among older adults in Ontario, Canada.

Emerging evidence shows loneliness is associated with polypharmacy and high-risk medications in older adults. Despite notable sex-based differences in the prevalence in each of loneliness and polypharmacy, the role of sex in the relationship between loneliness and polypharmacy is unclear. We explored the relationship between loneliness and polypharmacy in older female and male respondents and described sex-related variations in prescribed medication subclasses. We performed a cross-sectional analysis of representative data from the Canadian Community Health Survey-Healthy Aging cycle (2008/2009) linked to health administrative databases in Ontario respondents aged 66 years and older. Loneliness was measured using the Three-Item Loneliness Scale, with respondents classified as not lonely, moderately lonely, or severely lonely. Polypharmacy was defined as five or more concurrently-prescribed medications. Sex-stratified multivariable logistic regression models with survey weights were used to assess the relationship between loneliness and polypharmacy. Among those with polypharmacy, we examined the distribution of prescribed medication subclasses and potentially inappropriate medications. Of the 2348 individuals included in this study, 54.6% were female respondents. The prevalence of polypharmacy was highest in those with severe loneliness both in female (no loneliness, 32.4%; moderate loneliness, 36.5%; severe loneliness, 44.1%) and male respondents (32.5%, 32.2%, and 42.5%). Severe loneliness was significantly associated with greater adjusted odds of polypharmacy in female respondents (OR = 1.59; 95% CI: 1.01-2.50) but this association was attenuated after adjustment in male respondents (OR = 1.00; 95% CI: 0.56-1.80). Among those with polypharmacy, antidepressants were more commonly prescribed in female respondents with severe loneliness (38.7% [95% CI: 27.3-50.0]) compared to those who were moderately lonely (17.7% [95% CI: 9.3-26.2]). Severe loneliness was independently associated with polypharmacy in older female but not male respondents. Clinicians should consider loneliness as an important risk factor in medication reviews and deprescribing efforts to minimize medication-related harms, particularly in older women.

#4594 INPATIENT POLYPHARMACY AND THE AGING KIDNEY

Abstract Background and Aims Individuals aged ≥80 years have been found to have some of the highest rates of polypharmacy. Nearly 50% of these people are likely to have significant renal impairment, either from chronic kidney disease or age-related decline. Since many drugs are renally excreted, reduced renal function will cause pharmacokinetic and pharmacodynamic changes. As a result, some medications are inappropriate and there is an increased risk of adverse effects which are dose-related or related to drug interactions. We aim to examine the prevalence of highly renally excreted and nephrotoxic medications taken by our oldest old medical inpatients. Method Data was obtained as part of an ongoing prospective cross-sectional observational study examining polypharmacy in elderly inpatients at Ballina Hospital, Australia. Data as of 03/01/2019 for participants aged ≥80 years were retrieved as part of this nested study involving acute medical inpatients with sufficient capacity to provide informed consent. Exclusion criteria comprised of people with insufficient working knowledge of English, cognitive impairment (including delirium) and those under the age of 80 years. Information with regards to inpatient medication use, co-morbidities and renal function (creatinine clearance, CrCl) were retrieved from inpatient medical records as part of routine clinical care. Renally excreted medications and potential nephrotoxic medications were identified via the Australian Medicines Handbook and Renal Drug Database. Cognition was assessed by the Montreal Cognitive Assessment, multimorbidity via the Charlson Co-morbidity Index and frailty using the Clinical Frailty Score. A polypharmacy questionnaire was used to further probe participant insight and aptitude towards medication use. Results One hundred and five inpatients, with mean age of 86.7 years (range 80.2 to 102.7) met the inclusion criteria and participated in the study. The patients were prescribed an average of 12 medications (range 3–26). They had multiple co-morbidities (mean CCI 6), 64% were assessed to have mild cognitive impairment and 62% were classified as frail. Also, 28% did not know the indication for their medication and 30% reported missing medications. The calculated CrCl ranged from 19–99ml/min, with the majority of patients falling between the range of 30–60ml/min (mean 49ml/min). On average, each patient was taking 1 medication that is ≥50% renally excreted unchanged (or their active metabolites), 1 medication that requires dose reduction when CrCl is 30–60ml/min, 2 medications that require dose reduction when CrCl is 10–30ml/min and 1 medication infrequently or commonly classed as nephrotoxic. The average total number of medications did not change significantly with decrease in CrCl, however, there was a non-significant increase in potentially nephrotoxic medication use. Patients experienced a similar anticholinergic or sedative load (as measured by the drug burden index) regardless of CrCl. Conclusion A substantal burden of medications was found in individuals of advanced age (&amp;gt;80years) with renal impairment. The risk of medication-related harm may be further compounded by age-related barriers and challenges to managing multi-drug regimens. Regular medication reviews are essential for this vulnerable patient group.

COPD Is an Illness Society Will Live With for Some Time

As life expectancy increases, it is reasonable to expect that toward the latter years of their lives, people can expect to be living with complex multimorbidity, in many cases necessitating concurrent management of several significant medical conditions. This multimorbidity renders enormous challenges for those who have responsibility for serving the health needs of older people: Pharmacists in this domain are very much aware that with multimorbidity comes an increased tendency to polypharmacy and an accompanying burden of medication-related harm. In this edition of the journal, we publish the first of a multi-part series addressing the complexities of chronic obstructive pulmonary disease.

Lidocaine for Neuropathic Cancer Pain (LiCPain): study protocol for a mixed-methods pilot study

IntroductionMany patients experience unrelieved neuropathic cancer-related pain. Most current analgesic therapies have psychoactive side effects, lack efficacy data for this indication and have potential medication-related harms. The local anaesthetic lidocaine...