Residential Medication Management Reviews Research Articles

Development of a protocol for telehealth Residential Medication Management Reviews to enable collaboration of pharmacists and geriatricians

Development of a protocol for telehealth Residential Medication Management Reviews to enable collaboration of pharmacists and geriatricians

The Utilization of Antithrombotic Therapy in Older Patients in Aged Care Facilities With Atrial Fibrillation

Oral anticoagulants are essential drugs for the prevention of thromboembolic events in patients with atrial fibrillation (AF). Anticoagulants are, however, commonly withheld in older people due to the risk and fear of hemorrhage. Although the underutilization of anticoagulants in patients with AF has been demonstrated internationally, few studies have been conducted among aged care residents. The aim of this study was to determine the utilization of anticoagulants among people with AF residing in aged care facilities. We performed a non-experimental, retrospective analysis designed to evaluate antithrombotic usage in patients with AF in Australia residing in aged care facilities, using data collected by pharmacists while performing Residential Medication Management Reviews (RMMRs). The utilization of antithrombotic therapy and the appropriateness of therapy were determined based on the CHADS2, CHA2DS2-VASc, and HAS-BLED risk stratification schemes in consideration of documented contraindications to treatment. Predictors of anticoagulant use were determined using multivariate logistic regression. A total of 1952 RMMR patients with AF were identified. Only 35.6% of eligible patients (CHADS2 score ≥2 and no contraindications to anticoagulants) received an anticoagulant. As age increased, the likelihood of receiving an anticoagulant decreased and the likelihood of receiving an antiplatelet or no therapy increased. In patients at high risk of stroke (CHADS score ≥2), utilization of anticoagulants dropped by 19.7% when the HAS-BLED score increased from 2 to 3, suggesting that physicians placed a heavier weighting on bleeding risk rather than stroke risk. Prescribing of anticoagulants was influenced to a greater extent by bleeding risk than it was by the risk of stroke. Further research investigating whether the growing availability of direct oral anticoagulants influences practice in this patient population is needed.

Residential medication management reviews of antithrombotic therapy in aged care residents with atrial fibrillation: assessment of stroke and bleeding risk.

Antithrombotics reduce the risk of stroke in individuals with atrial fibrillation (AF). However, optimal prescribing of antithrombotics in older people remains a challenge. The objective of this study was to assess the risk of stroke for aged care home residents with AF and to examine the pharmacist-led medication reviews on the utilization of antithrombotic therapy. This retrospective study included a random sample of de-identified residential medication management reviews (RMMRs) conducted by accredited pharmacists in aged care homes in Sydney, Australia, between August 2011 and December 2012. The study participants were 146 residents aged 65 years and older with AF living in low- and high-care residential aged care facilities. Antithrombotic therapy was examined among the residents, before and after medication review. CHADS2 , CHA2 DS2 -VASc, and HEMORR2 HAGES scoring tools were used to assess the risk of stroke and bleeding and indicate the appropriateness of antithrombotic therapy. The mean age (±SD) of individuals was 88·4 (7·5) years, and 63·7% (n = 93) were female. The majority of residents (n = 99, 67·8%) were aged between 85 and 99 years. The mean (±SD) CHADS2 score was 3·1 (1·1), CHA2 DS2 -VASc was 4·6 (1·5), and HEMORR2 HAGES was 2·3 (1·0). All residents were classified as being at high risk of developing stroke. A total of 115 of 146 (78·8%) residents with AF were prescribed antithrombotics. There was a relatively low usage of anticoagulation (28·1%), and few recommendations from the medication review pharmacists to alter the thromboprophylactic therapy in AF. Application of the CHA2 DS2 -VASc risk tool indicated that 146 residents were eligible for antithrombotic treatments; of these, 74 (50·7%) were prescribed antiplatelets and 41 (28·1%) were prescribed anticoagulants. Of the 31 (21·2%) residents with AF were not prescribed antithrombotics, 21 (67·7%) had relative contraindications for anticoagulant treatments. Although there was a high overall use of antithrombotic agents, the study found a reluctance to prescribe or recommend anticoagulants in eligible older people with AF, potentially due to associated contraindications and multimorbidity. The use of guideline-recommended stroke risk tools could assist medication review pharmacists in optimizing antithrombotic therapy in older adults with AF.

Pharmacist-Led Home Medicines Review and Residential Medication Management Review: The Australian Model.

Older people are often prescribed multiple medicines and have a high prevalence of polypharmacy. Polypharmacy is associated with an increased risk of inappropriate use of medicines and drug-related problems. As experts in pharmacotherapy, pharmacists are well placed to review complex medication regimens and identify causes of drug-related problems and recommend solutions to prevent or resolve them. Involvement in medication review services represents a major philosophical shift and paradigm change in the way pharmacists practice, in that the focus is shifted away from the dispensing of prescription medicines to the provision of a professional service for a patient, in collaboration with their general practitioner (GP). In Australia, there are two established medication review programs: Home Medicines Review (HMR) and Residential Medication Management Review (RMMR). The objectives of this article were to describe the process of government-funded medication review services in Australia and to evaluate the contribution of pharmacists to HMR and RMMR, using evidence-based measures, such as the Drug Burden Index (DBI) and the Medication Appropriateness Index (MAI). This review found that there is good evidence to support the role of pharmacists in delivering medication review services across different settings. Although the positive impact of such services has been demonstrated using a variety of validated measures (DBI, MAI), there remains a need to also evaluate actual clinical outcomes and/or patient-reported outcomes.

Impact of residential medication management reviews on anticholinergic burden in aged care residents

Objectives:The primary objective of this study was to investigate the impact of Residential Medication Management Reviews (RMMRs) on anticholinergic burden quantified by seven anticholinergic risk scales.Design:Retrospective analysis.Setting:Accredited pharmacists conducted RMMRs in aged-care facilities (ACFs) in Sydney, Australia.Participants:RMMRs pertained to 814 residents aged 65 years or older.Measurements:Anticholinergic burden was quantified using seven scales at baseline, after pharmacists’ recommendations and after the actual GP uptake of pharmacists’ recommendations. Change in the anticholinergic burden was measured using the Wilcoxon sign rank test.Results:At baseline, depending on the scale used to estimate the anticholinergic burden, between 36% and 67% of patients were prescribed at least one regular anticholinergic medication (ACM). Anticholinergic burden scores were significantly (p < 0.001) lower after pharmacists’ recommendations as determined by each of the seven scales. The reduction in anticholinergic burden was also significant (p < 0.001) after GPs’ acceptance of the pharmacists’ recommendations according to all scales with the exception of one scale which reached borderline significance (p = 0.052).Conclusion:Despite the limitations of the retrospective design and differences in the estimation of anticholinergic burden, this is the first study to demonstrate that RMMRs are effective in reducing ACM prescribing in ACF residents, using a range of measures of anticholinergic burden. Future studies should focus on whether a decrease in anticholinergic burden will translate into improvement in clinical outcomes.

Potentially inappropriate prescribing of renally cleared drugs in elderly patients in community and aged care settings.

Limited data are available on the prevalence of inappropriate prescribing of renally cleared drugs in elderly patients in Australia. To quantify and compare the extent of inappropriate prescribing (defined as at least one drug prescribed in an excessive dose or when contraindicated with respect to renal function) of renally cleared drugs in elderly patients across the community and aged care settings, and to determine factors associated with patients being prescribed one or more potentially inappropriate renally cleared drugs. This retrospective study examined de-identified Home Medicines Review (HMR) and Residential Medication Management Review (RMMR) cases pertaining to 30,898 patients aged 65 years and over. Only 25 % (n = 7625) of these patients had documented information on their renal function. Among them, 4035 patients were prescribed at least one of the 31 renally cleared drugs examined in this study. For these patients, details including demographics, medications, medical conditions and pathology test results were extracted. Creatinine clearance was estimated using the Cockcroft-Gault formula, and the prevalence of inappropriate prescribing of the 31 drugs was examined on the basis of conformity with the recommendations in the Australian Medicines Handbook. Multivariate logistic regression was performed to determine the factors associated with patients being prescribed one or more potentially inappropriate renally cleared drugs. The mean (± standard deviation) ages of the HMR patients (n = 3315; 59 % female) and RMMR patients (n = 720; 68 % female) were 78.3 ± 7.2 and 86 ± 7.3 years, respectively. Over one quarter of the patients (n = 1135 out of 4035; 28.1 %) prescribed the renally cleared drugs examined in this study had evidence of inappropriate prescribing of at least one of the drugs, with respect to their renal function. The drugs/drug classes most commonly prescribed inappropriately were perindopril, fenofibrate, glibenclamide, gliptins, metformin, olmesartan, bisphosphonates and strontium. The factors independently associated with patients being prescribed one or more potentially inappropriate renally cleared drugs were advancing age [odds ratio (OR) 1.06 per year increase, 95 % confidence interval (CI) 1.05-1.07; P < 0.001], the total number of renally cleared drugs prescribed (OR 1.44 per unit increase, 95 % CI 1.29-1.61; P < 0.001), presence of diabetes (OR 1.51, 95 % CI 1.30-1.76; P < 0.001), presence of heart failure (OR 1.38, 95 % CI 1.13-1.69; P < 0.005) and living in aged care facilities (OR 1.28, 95 % CI 1.06-1.5; P < 0.05). Inappropriate prescribing of renally cleared drugs is common in older Australians. Intervention studies to improve prescribing of renally cleared drugs in the elderly appear to be warranted.

Metformin utilisation in Australian community and aged care settings

ObjectiveThe objective of this study was to: (i) evaluate the potentially inappropriate prescribing (PIP; defined as the use of metformin in the presence of contraindications and/or use in excessive dosage based on the renal function) of metformin in people receiving medication reviews in Australia and (ii) identify the predictors for PIP of metformin. MethodRetrospective study of patients taking metformin through a large medication review database, containing records between January 2010 and June 2012. Data, including demographics, medical conditions, medications and relevant pathology results, were extracted for analysis. Multivariate logistic regression analysis was used to detect risk factors for PIP of metformin. ResultsMedication reviews pertaining to 6386 patients who received Home Medicines Reviews (HMRs, n=5327) or Residential Medication Management Reviews (RMMRs, n=1059) were included in this study. Overall, there were 12.9% (n=685) of patients in the HMR group and 17.4% (n=184) of patients in the RMMR group who had PIP of metformin. Multivariate logistic regression showed age, gender and type of medication review service as the significant (p<0.05) independent risk factors for PIP of metformin. ConclusionMetformin was often used in patients with contraindications, or in higher than recommended dosages in patients with renal impairment. Given the recent debate in the literature about the role of metformin in the presence of contraindications, a detailed prospective study in patients with contraindications and its association with lactic acidosis is warranted to establish the way in which metformin is to be used in these patients.

Impact of Residential Medication Management Reviews on Drug Burden Index in Aged-Care Homes

The Drug Burden Index (DBI) is an evidence-based tool that associates medication exposure with functional outcomes in older people. Accredited clinical pharmacists performing medication reviews could consider including the DBI in their medication reviews to optimize prescribing in older people. To examine the impact of residential medication management reviews (RMMRs) performed by accredited clinical pharmacists on DBI in older people living in aged-care homes. A retrospective analysis was performed of a random sample of 500 de-identified RMMR reports from residents aged (mean +/- SD) 84 +/- 9.0 years who had medication reviews conducted by ten accredited clinical pharmacists from 1 January 2008 through 30 June 2008. The data on medication use were collected over 8 months across 62 aged-care homes. DBI scores were calculated at baseline, after the recommendations had been made by the pharmacist and after uptake of pharmacist recommendations by the general practitioner (GP). A statistically significant decrease (p < 0.001) in median DBI score was observed as a result of uptake of pharmacist recommendations by the GP. GPs were more likely to take up recommendations made by pharmacists that resulted in a decrease in DBI score than recommendations that resulted in an increase in DBI score (60.7% vs 34.6%, respectively). The mean decrease in DBI as a result of pharmacist recommendations was 0.12 (95% CI 0.09, 0.14) representing a 20% decrease in mean baseline DBI for residents. When GPs implemented pharmacists' recommendations, DBI decreased by a mean of 12% from baseline (mean decrease 0.07; 95% CI 0.05, 0.08). Most of the recommendations proposed by the pharmacists involved withdrawing benzodiazepines or reducing antipsychotic drug dosage. This is the first study in which DBI has been used as a tool to evaluate the impact of RMMRs conducted by accredited clinical pharmacists. The study demonstrates that pharmacist-conducted medication reviews can reduce prescribing of sedative and anticholinergic drugs in older people, resulting in a significant decrease in the DBI score.

Determinants of antidepressant medication prescribing in elderly residents of aged care homes in Australia: A retrospective study

Background: Depression is underrecognized and poorly treated among older people living in aged care homes worldwide. Depression has been associated with higher rates of recurrence, disability, and death in older people. Objectives: The primary objective of this study was to assess the determinants of antidepressant medication prescribing among older people living in aged care homes in Australia. A further objective was to investigate the anti-depressant medications in common use, doses of antidepressants, and concurrent pharmacotherapy among people receiving antidepressants. Methods: A random sample of 500 deidentified medication review reports was extracted from a database containing >165,000 Residential Medication Management Review reports. Residents' demographic and clinical characteristics, medical diagnoses, and prescribed medications were systematically extracted from these reports. Logistic regression models were used to determine factors associated with the prescribing of any antidepressant, including tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and “other” antidepressants (eg, mianserin, mirtazapine, venlafaxine). Results: The mean (SD) age of the residents was 84.0 (9.0) years. Seventy-five percent were female. The prevalence of antidepressant prescribing among these aged care home residents was 33.0%. SSRIs were more commonly prescribed than TCAs, monoamine oxidase inhibitors, and other antidepressants. Antidepressants were more likely to be prescribed in people treated for dementia with mood disorder (odds ratio [OR] = 9.70; 95% CI, 5.26–17.88), depression (OR = 13.28; 95% CI, 6.44–27.36), and Parkinson's disease (OR = 3.56; 95% CI, 1.37–9.23). SSRI prescribing was associated with dementia with mood disorder (OR = 5.85; 95% CI, 3.19–10.72) and depression (OR = 6.44; 95% CI, 3.38–12.26). TCA prescribing was associated with depression (OR = 2.95; 95% CI, 1.18–7.35) and concurrent benzodiazepine use (OR = 2.43; 95% CI, 1.03–5.72). Other antidepressant prescribing was associated with dementia with mood disorder (OR = 6.53; 95% CI, 3.15–13.50) and depression (OR = 5.00; 95% CI, 2.23–11.19). Conclusions: There was preferential prescribing of SSRI antidepressants among these older aged care home residents with depression. Cognitive impairment alone was not significantly associated with antidepressant prescribing; however, these aged care home residents with dementia and mood disorders had an increased likelihood of being treated with antidepressants. The prescribing of TCAs was significantly associated with concurrent benzodiazepine use.

Vitamin D Deficiency in Aged‐Care Facilities: Prescribing Support through Residential Medication Management Reviews

ABSTRACTBackgroundVitamin D deficiency is common in residents in aged‐care facilities, contributing to muscle and bone weakness, falls and fractures. Although supplementation is recommended by guidelines for the treatment and prevention of vitamin D deficiency, implementation remains a challenge.AimTo improve vitamin D supplementation in an aged‐care facility in a rural Australian town.MethodAn audit of vitamin D supplementation and serum 25‐hydroxyvitamin D (25‐OHD) levels was conducted by the pharmacist providing residential medication management review services and the results were reported to attending general practitioners (GPs).Results21% of residents were prescribed vitamin D. Serum 25‐OHD levels were available for 8 residents and indicated deficiency/insufficiency for 7. This information was reported to attending GPs with an offer to identify other residents who would benefit from vitamin D supplementation. 41 residents were identified solely on clinical criteria such as falls risk, malabsorption, malnutrition, osteoporosis and fracture risk, inadequate exposure to sunlight and medication use. These residents were referred to the GPs for assessment without an expressed recommendation to measure 25‐OHD levels. Within 40 days of the dissemination of the audit results, 33 residents were started on vitamin D supplements, increasing the level of supplementation at the facility from 21% to 65%. This level of supplementation was maintained without further pharmacist intervention for 9 months.ConclusionAn audit of vitamin D prescribing and subsequent GP‐pharmacist collaboration is an effective way of increasing vitamin D supplementation in aged‐care facilities.