Medications In Older People Research Articles

Adverse drug reactions in older people following hospitalisation: a qualitative exploration of general practitioners' perspectives.

Older people have greater comorbidity and medication burden. Adverse drug reactions occur in up to 30% of older people within one month of hospital discharge. General practitioners are key stakeholders in transitions of care from hospital to the community. The study aimed to explore general practitioner perspectives of adverse drug reactions in older people after hospitalisation, investigating the medication-related issues encountered and possible approaches to reduce the risk. An invitation to participate in the study was sent to general practitioners in Southern Tasmania, Australia. A semi-structured interview occurred in person at their practice or online. The questions covered experiences with managing medication in older people after hospital discharge, challenges and risks involving adverse drug reactions and suggestions to prevent adverse drug reactions. The interviews were transcribed and analysed through thematic analysis. Twelve general practitioners were interviewed, revealing four themes describing challenges, including (i) complex patients and acceptance of risk, (ii) patient confusion and decline in hospital, (iii) time taken to manage older patients and (iv) communication challenges. Three themes describing recommendations were identified, including (i) clear communication on discharge, (ii) patient involvement and (iii) roles for pharmacists. Prevention of adverse drug reactions after hospital discharge may require clear and timely communication to general practitioners, patients and families to be educated and empowered to help manage their own health and risk, and pharmacists to support both patients and general practitioners in managing the risks.

A deprescribing programme aimed to optimise blood glucose-lowering medication in older people with type 2 diabetes mellitus, the OMED2-study: the study protocol for a randomised controlled trial

BackgroundOlder patients with type 2 diabetes mellitus (T2D) have an increased risk of hypoglycaemic episodes when using sulphonylureas or insulin. In the Netherlands, guidelines exist for reducing glucose-lowering medication in older patients. However, evidence is lacking that a medication reduction in older patients can be safely pursued. Here, we will examine if promoting the deprescribing of insulin/sulphonylureas with a deprescribing programme (DPP) in general practice affects T2D-complications in older overtreated patients.MethodsWe will perform a 1:1 cluster randomised controlled trial in 86 general practices in the Netherlands. The DPP will consist of education sessions with general practitioners and practice nurses about reducing glucose-lowering medication in older patients (≥ 70 years). Topics of the sessions include the necessity of deprescribing, tools to initiate deprescribing and strategies to discuss deprescribing with patients (shared decision making). The DPP further includes a support programme with practice visits. The study will employ a selection tool to identify possibly overtreated older patients from the electronic medical records of the general practitioner. Eligibility for enrolment in the study will be based on HbA1c targets indicated by the Dutch guidelines, which depend on age, diabetes duration, presence of frailty, and life expectancy. The control group will provide usual care. We aim to include 406 patients. The follow-up period will be 2 years. For the primary outcome, the effect of the DPP on T2D-complications will be assessed by counting the cumulative incidence of events related to under- and overtreatment in T2D as registered in the electronic medical records. We shall perform an intention-to-treat analysis and an analysis including only patients for whom deprescribing was initiated. The implementation of the DPP in general practice will be evaluated quantitatively and qualitatively using the Extended Normalisation Process Theory (ENPT) and the Reach, Efficacy – Adoption, Implementation and Maintenance (RE-AIM) model. Other secondary outcomes include quality of life, cognitive functioning, events related to overtreatment or undertreatment, biomarkers of health, amount of blood glucose-lowering medication prescriptions, and cost-effectiveness.DiscussionThis study will provide insight into the safety and feasibility of a programme aimed at deprescribing sulphonylureas/insulin in older people with T2D who are treated in general practice.Trial registrationISRCTN Registry, ISRCTN50008265, registered 09 March, 2023.

Validation of MyFORTA: An Automated Tool to Improve Medications in Older People Based on the FORTA List.

Listing tools have been developed to improve medications in older patients, including the Fit fOR The Aged (FORTA) list, a clinically validated, positive-negative list of medication appropriateness. Here, we aim to validate MyFORTA, an automated tool for individualized application of the FORTA list. 331 participants of a multi-center cohort study (AgeCoDe) for whom the FORTA score (sum of overtreatment and undertreatment errors) had been determined manually (gold standard [GS]) were reassessed using the automated MyFORTA (MF) tool. This tool determines the score from ATC and ICD codes combined with clinical parameters. The FORTA scores were 9.01±2.91 (mean±SD, MF) versus 6.02±2.52 (GS) (p<0.00001). Removing undertreatment errors for calcium/vitamin D (controversial guidelines) and influenza/pneumococcal vaccinations (no robust information in the database), the difference decreased: 7.5±2.7 (MF) versus 5.98±2.55 (GS) (p<0.00001). The remaining difference was driven by, for example, missing nitro spray in coronary heart disease/acute coronary syndrome as the related information was rarely found in the database, but notoriously detected by MF. Three hundred and forty errors from those 100 patients with the largest score deviation accounted for 68% of excess errors by MF. MF was more sensitive to detect medication errors than GS, all frequent errors only detected by MF were plausible, and almost no adaptations of the MF algorithm seem indicated. This automated tool to check medication appropriateness according to the FORTA list is now validated and represents the first clinically directed algorithm in this context. It should ease the application of FORTA and help to implement the proven beneficial effects of FORTA on clinical endpoints.

Geriatric Pharmacology: A new journal to disseminate current and future knowledge enhancing the use of medications in older people

Geriatric Pharmacology: A new journal to disseminate current and future knowledge enhancing the use of medications in older people

Factors associated with non-adherence to taking medication in elderly people with hypertension

Nonadherence to taking medication in older people with hypertension is a serious problem in the management of this health condition. This study aims to identify factors associated with nonadherence to taking medication in older people with hypertension. The study used descriptive quantitative methods with a cross-sectional approach. Purposive sampling technique with Chi-Square statistical test. The results found the relationship between adherence to hypertension medication with education level, a p-value of 0.297, ease of access to health services, a p-value of 0.297, motivation to seek treatment, a p-value of 0.014, family support, p-value of 0.201, support of health workers p-value of 0.595. It can be concluded that there is no significant relationship between education level, family support, and health worker support, and there is a significant relationship between access to health services and motivation with adherence to taking medication in older people with hypertension. However, of course, analysis is needed related to these factors. Effective treatment must consider each patient's social, economic, psychological, and cultural conditions. Health education, social support, and cooperation between patients, doctors, and health workers can help improve adherence rates in treating hypertension in the elderly. This effort is important to prevent serious complications that can arise due to non-compliance in taking medication.

The impact of partnered pharmacist medication charting in the emergency department on the use of potentially inappropriate medications in older people.

Introduction: A process redesign, partnered pharmacist medication charting (PPMC), was recently piloted in the emergency department (ED) of a tertiary hospital. The PPMC model was intended to improve medication safety and interdisciplinary collaboration by having pharmacists work closely with medical officers to review and chart medications for patients. This study, therefore, aimed to evaluate the impact of PPMC on potentially inappropriate medication (PIM) use. Methods: A pragmatic concurrent controlled study compared a PPMC group to both early best-possible medication history (BPMH) and usual care groups. In the PPMC group, pharmacists initially documented the BPMH and collaborated with medical officers to co-develop treatment plans and chart medications in ED. The early BPMH group included early BPMH documentation by pharmacists, followed by traditional medication charting by medical officers in ED. The usual care group followed the traditional charting approach by medical officers, without a pharmacist-collected BPMH or collaborative discussion in ED. Included were older people (≥65 years) presenting to the ED with at least one regular medication with subsequent admission to an acute medical unit. PIM outcomes (use of at least one PIM, PIMs per patient and PIMs per medication prescribed) were assessed at ED presentation, ED departure and hospital discharge using Beers criteria. Results: Use of at least one PIM on ED departure was significantly lower for the PPMC group than for the comparison groups (χ2, p = 0.040). However, PIM outcomes at hospital discharge were not statistically different between groups. PIM outcomes on ED departure or hospital discharge did not differ from baseline within the comparison groups. Discussion: In conclusion, PIM use on leaving ED, but not at hospital discharge, was reduced with PPMC. Close interprofessional collaboration, as in ED, needs to continue on the wards.

Impact of a deprescribing tool on the use of sedative hypnotics among older patients: study protocol for a cluster randomised controlled trial in Swiss primary care (the HYPE trial)

IntroductionBenzodiazepines and other sedative hypnotics (BSH) are potentially inappropriate and harmful medications in older people due to their higher susceptibility for adverse drug events. BSH prescription rates are constantly high...

The effectiveness of computerised clinical decision support systems on deprescribing inappropriate medications in older people: A systematic review protocol

The effectiveness of computerised clinical decision support systems on deprescribing inappropriate medications in older people: A systematic review protocol

Rational Prescribing and Deprescribing of Antihypertensive Medications in Older People, a Three-Part Narrative Review, Part 3.

What happens when you stop? This is the third of a three-part series on antihypertensive medication use in older people. In the first, we reviewed the importance of better blood pressure (BP) control, even in older people with hypertension. In the second, we discussed the limitations of the evidence favoring intensive therapy for some older people. For older people with advanced frailty or those with a limited life expectancy, medications taken for BP can actually be a source of morbidity. Guidelines encourage clinical judgment and rational prescribing. Sometimes the best action is to stop prescribing. De-prescribing of medical therapy is now considered good practice for a range of medications for suitable patients; should this include antihypertensives? In part three of this three-part series, we will review some of the evidence available thus far, demonstrating de-intensification of antihypertensive medications is not a new idea. We will offer a guide to identifying the most suitable patients for de-prescribing: cognitive impairment, frailty, when circumstances change, or when BP is (too) well-controlled. This is an area of equipoise and needs more research. There is a path forward that we hope to illuminate.

Rational Prescribing and Deprescribing of Antihypertensive Medications in Older People, Part 2.

The evidence is strong in favor of blood pressure (BP) control in robust older people as a way to reduce morbidity and mortality in the same way that treatment improves the lives of middle-aged people. Expert editorials have been written over the last five decades persuasively arguing for or against more intensive treatment of older people with hypertension, supported by the specificity of (then) contemporaneous randomized controlled trials (RCTs) or the generalizability of observational studies. But there are limitations.First, there has always been such a thing as too low. Early epidemiological studies showed an upward inflection in mortality curves that resemble a slanted letter J. Second, certain complex older people encountered routinely in a clinic, pharmacy, or nursing facility were often excluded from the RCTs showing benefit from intensive BP control. Cohort studies of these complex people showed a different truth, that the point of "too low" might move up and that BP targets for adults might be too low for select older people. Not all older people are the same. Some are burdened by frailty superimposed on cardiovascular disease and a limited life-expectancy. It is one thing not to start BP-lowering medications for this patient; it is an entirely different matter to stop.

Application of a person-centered prescription model improves pharmacotherapeutic indicators and reduces costs associated with pharmacological treatment in hospitalized older patients at the end of life.

ObjectiveThis study sought to investigate whether applying an adapted person-centered prescription (PCP) model reduces the total regular medications in older people admitted in a subacute hospital at the end of life (EOL), improving pharmacotherapeutic indicators and reducing the expense associated with pharmacological treatment.DesignRandomized controlled trial. The trial was registered with ClinicalTrials.gov (NCT05454644).SettingA subacute hospital in Basque Country, Spain.SubjectsAdults ≥65 years (n = 114) who were admitted to a geriatric convalescence unit and required palliative care.InterventionThe adapted PCP model consisted of a systematic four-step process conducted by geriatricians and clinical pharmacists. Relative to the original model, this adapted model entails a protocol for the tools and assessments to be conducted on people identified as being at the EOL.MeasurementsAfter applying the adapted PCP model, the mean change in the number of regular drugs, STOPPFrail (Screening Tool of Older Persons' Prescriptions in Frail adults with limited life expectancy) criteria, drug burden index (DBI), drug–drug interactions, medication regimen complexity index (MRCI) and 28-days medication cost of chronic prescriptions between admission and discharge was analyzed. All patients were followed for 3 months after hospital discharge to measure the intervention's effectiveness over time on pharmacotherapeutic variables and the cost of chronic medical prescriptions.ResultsThe number of regular prescribed medications at baseline was 9.0 ± 3.2 in the intervention group and 8.2 ± 3.5 in the control group. The mean change in the number of regular prescriptions at discharge was −1.74 in the intervention group and −0.07 in the control group (mean difference = 1.67 ± 0.57; p = 0.007). Applying a PCP model reduced all measured criteria compared with pre-admission (p < 0.05). At discharge, the mean change in 28-days medication cost was significantly lower in the intervention group compared with the control group (−34.91€ vs. −0.36€; p < 0.004).ConclusionApplying a PCP model improves pharmacotherapeutic indicators and reduces the costs associated with pharmacological treatment in hospitalized geriatric patients at the EOL, continuing for 3 months after hospital discharge. Future studies must investigate continuity in the transition between hospital care and primary care so that these new care models are offered transversally and not in isolation.

Part Six: Antidiabetic Medication Benefits Beyond Glucose Lowering in Older People.

Older people with type 2 diabetes are at an increased risk for macrovascular (damage to arteries that can lead to myocardial infarction or stroke) and microvascular (damage to small blood vessels including retinopathy and nephropathy) disease. Since 2008, newly approved antidiabetic medications have been required to show cardiovascular safety as part of the US Food and Drug Administration approval process. Since this time, new data have emerged regarding the differences between agents in terms of reducing diabetes-related complications. Older people often are at risk for or currently have one or more diabetes-related complication. When managing antidiabetic medication in older people, it is imperative to consider the risk versus benefit of each medication and to use agents that have proven benefits.

Weighted Blankets' Effect on the Health of Older People Living in Nursing Homes.

Background: An increasingly aging population is a global phenomenon. While considered a positive step forward, vulnerability to age-related health problems increases along with the ageing population. The aim of the study was to investigate weighted blankets’ effect on health regarding quality of life (QoL), sleep, nutrition, cognition, activities of daily living ADL and medication in older people living in nursing homes. Methods: In total, 110 older people were involved in an intervention with weighted blankets, and 68 older people completed the intervention. Measures before and after were performed regarding quality of life; QoL-AD, EQ-VAS, sleep; MISS, nutrition; MNA, cognition; S -MMSE (ADL) and medication. Comparative statistical analyses were applied. Results: After intervention with weighted blankets, health in general, such as QoL, improved. Sleep also improved significantly, especially with respect to waking up during the night. Nutrition was enhanced, health as a cognitive ability improved, and medication in the psychoanaleptic group decreased. The effect size varied between small and large. Conclusions: A weighted blanket seems to be an effective and safe intervention for older people in nursing homes, as several improvements were made regarding the health of older people.

Medical Treatment of Heart Failure with Reduced Ejection Fraction in the Elderly.

The aging population, higher burden of predisposing conditions and comorbidities along with improvements in therapy all contribute to the growing prevalence of heart failure (HF). Although the majority of trials have not demonstrated age-dependent heterogeneity in the efficacy or safety of medical treatment for HF, the latest trials demonstrate that older participants are less likely to receive established drug therapies for HF with reduced ejection fraction. There remains reluctance in real-world clinical practice to prescribe and up-titrate these medications in older people, possibly because of (mis)understanding about lower tolerance and greater propensity for developing adverse drug reactions. This is compounded by difficulties in the management of multiple medications, patient preferences and other non-medical considerations. Future research should provide a more granular analysis on how to approach medical and device therapies in elderly patients, with consideration of biological differences, difficulties in care delivery and issues relevant to patients’ values and perspectives. A variety of approaches are needed, with the central principle being to ‘add years to life – and life to years’. These include broader representation of elderly HF patients in clinical trials, improved education of healthcare professionals, wider provision of specialised centres for multidisciplinary HF management and stronger implementation of HF medical treatment in vulnerable patient groups.

Assessment of the appropriateness of cardiovascular preventive medication in older people: using the RAND/UCLA Appropriateness Method.

BackgroundIn clinical practice and science, there is debate for which older adults the benefits of cardiovascular preventive medications (CPM) still outweigh the risks in older age. Therefore, we aimed to assess how various clinical characteristics influence the judgement of appropriateness of CPM in older adults.MethodWe assessed the appropriateness of CPM for adults ≥75 years with regard to clinical characteristics (cardiovascular variables, complexity of health problems, age, side effects and life expectancy) using the RAND/ University of California at Los Angeles Appropriateness Method. A multidisciplinary panel, including 11 medical professionals and 3 older representatives of the target population, received an up-to-date overview of the literature. Using 9-point Likert scales (1 = extremely inappropriate; 9 = extremely appropriate), they assessed the appropriateness of starting and stopping cholesterol lowering medication, antihypertensives and platelet aggregation inhibitors, for various theoretical clinical scenarios. There were two rating rounds, with one face-to-face discussion in between. The overall appropriateness judgments were based on the median panel ratings of the second round and level of disagreement.ResultsThe panelists emphasized the importance of the individual context of the patient for appropriateness of CPM. They judged that in general, a history of atherosclerotic cardiovascular disease strongly adds to the appropriateness of CPM, while increasing complexity of health problems, presence of hindering or severe side effects, and life expectancy < 1 year all contribute to the inappropriateness of CPM. Age had only minor influence on the appropriateness judgments. The appropriateness judgments were different for the three types of CPM. The literature, time-to-benefit, remaining life expectancy, number needed to treat, and quality of life, were major themes in the panel discussions. The considerations to stop CPM were different from the considerations not to start CPM.ConclusionNext to the patients’ individual context, which was considered decisive in the final decision to start or stop CPM, there were general trends of how clinical characteristics influenced the appropriateness, according to the multidisciplinary panel. The decision to stop, and not start CPM, appeared to be two distinct concepts. Results of this study may be used in efforts to support clinical decision making about CPM in older adults.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12877-022-03082-8.

Development of a board game to assist pharmacists learning the potentially inappropriate medications in older people

Background and purposePharmacists have been reported to have inadequate awareness about potentially inappropriate medications (PIMs) in older people. This warrants more efforts to enhance their familiarity and knowledge in this topic. A board game was developed based on the 2019 American Geriatrics Society (AGS) Beers Criteria to assist pharmacists learning the topic. Educational activity and settingThe board game is played using dice and pawns and involved players encounter questions on various aspects of PIMs in older people. Questions used in the board game were reviewed by a panel of experts. The board game exposed pharmacists to drug-drug and drug-disease/syndrome interactions. The board game was pilot tested among 16 pharmacists and played by a group of 34 pharmacists. Close- and open-ended feedback regarding the board game were sought in both sessions using a self-developed questionnaire. FindingsAll pharmacists in the pilot test (PT) and actual game (AG) sessions agreed that the board game is an innovative, useful, and interesting way to learn about PIMs in older people. All pharmacists in the PT session and a high majority of those in the AG session agreed that the board game increased their knowledge about PIMs in older people. The open-ended responses showed generally positive feedback. SummaryThe board game can be useful as an educational tool to supplement traditional teaching methods to assist pharmacists learning the PIMs in older people. Periodic review and relevant modifications of the board game content can be done to ensure its efficiency and relevance.

Common Ground When Choosing Wisely® for Patients.

Since 2012, the American Board of Internal Medicine Foundation, in collaboration with the National Physicians Alliance and Consumer Reports, have compiled a list of evidence-based statements from approximately 80 organizations to advise clinicians, patients, and their caregivers about optimization of care and avoiding unnecessary medical testing and therapies through the Choosing Wisely® (CW) campaign. Although started in the Unites States, similar initiatives were created across the globe demonstrating and recognizing CW's importance in improving global patient care. Pharmacists are specifically in tune to the use of medications in older people, but they also consider the complexity and holistic view of the patient. In many ways, the goals of the CW initiative mirror those of senior care pharmacy, but in reading through the nearly 740 statements currently published through www.ChoosingWisely.org, the number of overlapping recommendations produced between organizations is striking. Outside of regulations and mandates from federal and state governments, could CW assist interprofessional teams to find additional "common ground" while caring for older people?

705 CHARACTERISING OLDER ADULTS’ RISK OF HARM FROM BLOOD-PRESSURE LOWERING MEDICATIONS: A SUB-ANALYSIS FROM THE PRIME STUDY

Abstract Introduction Hypertension is a major risk factor for cardiovascular disease and death. Randomised trials in older adults with relatively few co-morbidities recommend treatment of their hypertension [1]. However, blood-pressure lowering medications increase the risk of medication-related harm (MRH) from adverse drug reactions (ADRs), non-adherence, medication errors and drug–drug interactions. We aimed to identify characteristics associated with MRH in older people on blood-pressure lowering medications. Method The PRIME (prospective study to develop a model to stratify the risk of MRH in hospitalized elderly patients in the UK) study investigating the incidence and cost of MRH in 1280 older people in Southern England [2]. Adults ≥65 years were recruited from five teaching hospitals at hospital discharge and followed up for 8-weeks. Telephone interviews with study participants, review of primary care records and hospital readmissions were undertaken to identify MRH. PRIME study participants taking blood-pressure lowering medications, as defined by National Institute for Health and Care Excellence hypertension guidelines [3], were included in this analysis. Results Sixty-six percent of the PRIME cohort (n = 841) were taking blood-pressure lowering medications. Patients on four blood-pressure lowering medications were five times more likely to experience MRH compared to those taking just one medication (OR 4.96; 95%CI 1.63-15.13;p = 0.01). Most harm events were serious (80%,n = 123), requiring dose change or treatment cessation. Most MRH cases were potentially preventable (49%,n = 75). Conclusion MRH from blood-pressure lowering medication in older people is common, serious, and potentially preventable. Decisions around maximising cardiovascular risk reduction must be carefully considered in the context of MRH from blood-pressure lowering medications.

Stakeholders' views on the use of psychotropic medication in older people: a systematic review.

Backgroundpsychotropic medication use has been shown to increase with age and has been associated with increased risk of falls, strokes and mortality. Various guidelines, regulations and tools have been developed to reduce inappropriate prescribing, but this remains high. In order to understand the reasons for this, we aimed to systematically review healthcare professionals’, patients’ and family caregivers’ attitudes towards the use of psychotropic medication in older people.Methodsa systematic literature search was carried out from inception to September 2020 using PUBMED, EMBASE, PsycINFO and CINAHL and hand-searching of reference lists. Included studies investigated stakeholder views on psychotropic in adults over the age of 65. Findings were thematically synthesised.Resultsoverall, there was an acceptance of long-term psychotropic medication for older people both living in the community and in residential care. While healthcare professionals were aware of guidelines for the use of benzodiazepines and psychotropic medicines, they identified barriers to following them on individual, team and organisational levels. Alternative non-pharmacological approaches were not always available or accepted by patients.Conclusionpsychotropic medicine use in older adults remains a complex issue, which needs to be addressed on a broad level. Attitudes of older people and healthcare professionals encourage long-term use. Meanwhile, various internal and external factors act as barriers to the use of non-drug alternatives in this population. In order to reduce overprescribing of psychotropics, there is a need to increase the acceptability and accessibility of alternative interventions in both care homes and the community.

Older peoples' views on cardiovascular disease medication: a qualitative study.

There is increasing evidence for the potential benefits and harms of cardiovascular disease (CVD) medications in older people (>75 years) prompting updating of clinical guidelines. We explored the views of older people about CVD medication to inform guideline development. Qualitative study using semistructured interviews and focus groups. An ethnically diverse group of community dwelling older people were purposefully recruited from northern New Zealand using flyers in primary care clinics, local libraries, social groups, and places of worship, and by word of mouth. Interviews and focus groups were digitally recorded, transcribed verbatim, and analysed using an iterative and inductive approach to thematic analysis. Thirty-nine participants from 4 ethnic groups were recruited (mean 74 years; range 61-91 years; Māori (7), South Asian (8), European (9), and Pasifika (15)). Most participants were taking CVD medication/s. Four main themes emerged: (i) emphasizing the benefits of CVD medication and downplaying the harms; (ii) feeling compelled to take medication; (iii) trusting "my" doctor; and (iv) expecting medication to be continued. Findings raise questions about older people's agency in decision-making regarding CVD medication. CVD risk management guidelines for older people could include strategies to support effective communication of the potential benefits and harms of CVD medication in older people, balancing life expectancy, and the expected duration of therapy.