Quality use of antipsychotic medicines inresidential aged care facilities in New Zealand

INTRODUCTION Antipsychotic medicines are used regularly or when required in residential aged care facilities to treat symptoms of dementia, but have been associated with several adverse effects. AIM The aim of this study was to examine 'quality use' of antipsychotic medicines in residential aged care facilities in New Zealand, by surveying nurse managers. METHODS A cross-sectional survey was mailed to 318 nurse managers working in a nationally representative sample of aged care facilities. A purpose-developed, pre-tested, 22-item structured questionnaire was used to explore practice related to the quality use of antipsychotic medicines. RESULTS Overall, 31.4% of nurse managers responded to the survey. They mostly (88%) had ≥ 1 year's relevant work experience and 83% of facilities provided care for those within the range of 21 to 100 residents. Respondents reported that staff education on dementia management occurred early in employment. Two-thirds of participants reported non-pharmacological interventions were commonly used for managing challenging behaviours, while less than half (45%) cited administering antipsychotic medicine. Respondents reported 'managing behavioural symptoms' (81%) as one of the main indications for antipsychotic use. Frequently identified adverse effects of antipsychotic medicines were drowsiness or sedation (64%) and falls (61%). Over 90% reported general practitioners reviewed antipsychotic use with respect to residents' target behaviour 3-monthly, and two-thirds used an assessment tool to appraise residents' behaviour. DISCUSSION Staff education on dementia management soon after employment and resident 3-monthly antipsychotic medicine reviews were positive findings. However, a wider use of behavioural assessment tools might improve the care of residents with dementia and the quality use of antipsychotic medicines.

Temporal trends in the use of antidiabetic medicines: a nationwide 9-year study in older people living in New Zealand

BACKGROUND

The global burden of diabetes is increasing worldwide. The aim of the study was to investigate the trends in use of antidiabetic medicines among older New Zealanders between 2005 and 2013, and to perform a separate analysis by age, sex, ethnicity, district health board domicile and socioeconomic deprivation index.

METHODS

The study population included individuals' aged 65 years and older living in New Zealand (NZ) captured in the pharmaceutical collections. Repeated cross-sectional analysis of population-level dispensing data was conducted from 1 January 2005 to 31 December 2013. Linear regression model using a gamma link function was used to estimate prevalence ratios and trends between 2005 and 2013. The main outcome measure was the prevalence of antidiabetic medicines in older New Zealanders.

RESULTS

The prevalence of antidiabetic medicines in older New Zealanders increased by 17.6% between 2005 and 2013. Individuals in the 70-74 age group had the highest utilization of each of the classes of antidiabetic medicines and those aged ⩾85 had the lowest utilization. Among the antidiabetic class of medicines, utilization of sulfonylureas was highest and alpha-glucosidase inhibitors the least. The utilization of thiazolidinediones increased over the study period. In 2013, insulin isophane and insulin glargine were the most common insulin analogues used. Insulin use was high in those aged ⩾85 years across the entire study period. The utilization of metformin increased gradually throughout the study period (by 43.9% in 2013 compared with 2005).

CONCLUSION

This population-level study showed an increase in utilization of antidiabetic medicines in older people in NZ from 2005 to 2013; however, the increase does not seem to parallel the proportional increase in prevalence of diabetes for the study period. Improving access to newer antidiabetic medicines in line with emerging evidence should be a consideration for decision makers.

An overview of pharmacodynamic modelling, ligand-binding approach and its application in clinical practice

The study of the magnitude and variation of drug response is defined as pharmacodynamics (PDs). PD models examine plasma concentration and effect relationship. It can predict the archetypal effect ([Formula: see text]) of a drug as a function of the drug concentration ([Formula: see text]) and estimate an unknown PD parameter ([Formula: see text]). The PD models have been described as fixed, linear, log-linear, [Formula: see text], sigmoid [Formula: see text], and indirect PD response. Ligand binding model is an example of a PD model that works on the underpinning PD principle of a drug, eliciting its pharmacological effect at the receptor site. The pharmacological effect is produced by the drug binding to the receptor to either activate or antagonise the receptor. Ligand binding models describe a system of interacting components, i.e. the interaction of one or more ligands with one or more binding sites. The [Formula: see text] model is the central method that provides an empirical justification for the concentration/dose-effect relationship. However, for ligand binding models justification is provided by theory of receptor occupancy. In essence, for ligand binding models, the term [Formula: see text] is best used to describe the fraction of receptors occupied at a particular ligand concentration. It is stated that the [Formula: see text], which means the effect of a drug should depend on the fraction of receptors that are occupied. In the future, network-based systems pharmacology models using ligand binding principles could be an effective way of understanding drug-related adverse effects. This will facilitate and strengthen the development of rational drug therapy in clinical practice.

Temporal Trends in Polypharmacy and Hyperpolypharmacy in Older New Zealanders over a 9-Year Period: 2005–2013

BACKGROUND

Polypharmacy and hyperpolypharmacy are proxy indicators for inappropriate medicine use. Inappropriate medicine use in older people leads to adverse clinical outcomes.

OBJECTIVE

The objectives of this study were to investigate the prevalence and trends of polypharmacy and hyperpolypharmacy in older people in New Zealand from 2005 to 2013, analyzing the pharmaceutical collections maintained by the Ministry of Health.

METHODS

A repeated cross-sectional analysis of population-level dispensing data was conducted from January 1, 2005 to December 31, 2013. Polypharmacy and hyperpolypharmacy in individuals were defined as the use of 5-9 medicines and ≥10 medicines, respectively, dispensed concurrently for a period of ≥90 days. Differences in polypharmacy and hyperpolypharmacy between 2005 and 2013 were examined. A multinomial regression model was used to predict sociodemographic characteristics associated with polypharmacy and hyperpolypharmacy.

RESULTS

Polypharmacy and hyperpolypharmacy were found to be higher in 2013 compared to 2005 (polypharmacy: 29.5 vs. 23.4%, p<0.001; hyperpolypharmacy: 2.1 vs. 1.3%, p<0.001). The risk of polypharmacy and hyperpolypharmacy was higher in females, in those aged 80-84 years, in the Māori population (for polypharmacy) and the Middle Eastern, Latin American, or African population (for hyperpolypharmacy), in people living in the Southern-district health board, and in individuals with increasing deprivation.

CONCLUSION

The population of New Zealand is aging and the number of older people with multiple chronic conditions is increasing. The proportion of older people exposed to polypharmacy and hyperpolypharmacy has increased in 2013 compared to 2005. Our study provides important information to alert health policy makers, researchers, and clinicians about the dire need to reduce the medication burden in older New Zealanders.

Proton pump inhibitors utilisation in older people in New Zealand from 2005 to 2013

BACKGROUND

The prescriptions for proton pump inhibitors (PPI) to treat acid-related disorders continue to rise internationally and in New Zealand. Concerns have been raised regarding its widespread use, costs and potential adverse effects in older people.

AIMS

This study aimed to characterise the utilisation of PPI by older people (aged 65 years and older) in New Zealand from 2005 to 2013.

METHODS

Repeated cross-sectional analysis of population-level dispensing data was conducted from 1 January 2005 to 31 December 2013. Dispensing data for all PPI prescriptions from 2005 to 2013 were obtained from the Ministry of Health, New Zealand. Utilisation was measured in defined daily doses (DDD) per 1000 older people per day using the World Health Organization Collaborating Centre for Drug Statistics Methodology anatomic, therapeutic and chemical classification system. Utilisation was standardised by sex, age, ethnicity and district health board.

RESULTS

Overall PPI utilisation showed a 26.7% increase from 2005 to 2013, from 273.41 to 346.53 DDD/1000/day. The greatest utilisation was observed in individuals aged between 80 and 84 years. Middle Eastern/Latin American/African utilised more PPI compared with other ethnic groups.

CONCLUSIONS

Utilisation of PPI among older people in New Zealand increased by a fifth from 2005 to 2013. Given the concerns surrounding the long-term PPI use in older people, the appropriateness of the increased utilisation needs to be continuously re-evaluated by prescribers and health policy makers.

Serum Anticholinergic Activity and Cognitive and Functional Adverse Outcomes in Older People: A Systematic Review and Meta-Analysis of the Literature

INTRODUCTION

Studies have reported associations between serum anticholinergic activity (SAA) and decline in cognitive performance, delirium, and functional impairment. The aim of this meta-analysis was to explore and quantify associations between SAA and adverse cognitive and functional outcomes in older people.

MATERIALS AND METHODS

A literature search in Ovid MEDLINE, EMBASE, PsycINFO and IPA from 1946-2014 was completed. The primary outcomes of interest were cognitive and functional adverse outcomes associated with SAA in older people aged 55 years and above. The Cochrane Risk-Bias assessment tool was used to assess bias in randomised controlled trials (RCTs). The Newcastle-Ottawa Scale was used to assess the quality of non-RCTs. Meta-analyses were conducted for RCTs and cohort studies separately. Heterogeneity was assessed using I2 tests.

RESULTS

The primary electronic literature search identified a total of 1559 records in the 4 different databases. On the basis of full-text analysis, 33 studies that met the inclusion criteria. The review included 4 RCTs, 5 prospective cohort studies, 3 longitudinal cohort studies, 17 cross-sectional studies, and 4 case-control studies. Twenty-four of the retrieved studies examined an association between SAA and cognitive outcomes, 2 studies examined an association with SAA and functional outcomes and 8 studies examined associations between SAA and both cognitive, and functional outcomes. The meta-analysis on 4 RCTs showed no association with higher SAA and cognitive performance (I2 = 89.38%, H2 = 25.53 and p-value = <0.05) however, the pooled data from 4 observational studies showed elevated SAA was associated with reduced cognitive performance (I2 = 0.00%, H2 = 3.37 and p-value = 0.34).

CONCLUSION

This systematic review summarises the limitations of the SAA on predicting cognitive and functional outcomes in older people. SAA measured by receptor bioassay is flawed and its use in older people with multimorbidity and polypharmacy is questionable.

General practitioners' insight into deprescribing for the multimorbid older individual: a qualitative study

INTRODUCTION

The majority of older people with chronic diseases are prescribed multiple medicines resulting in polypharmacy. The extrapolation of the 'single disease model' represented by disease-specific guidelines is a major driver for polypharmacy. Polypharmacy is associated with negative health outcomes. Safely reducing or discontinuing harmful medicines, commonly referred to as deprescribing, has been shown to reduce adverse health outcomes, healthcare costs and mortality. However, there are barriers to deprescribing such as time constraints, limited appropriate clinical resources and the influence of multiple prescribers.

AIM

To explore general practitioners' (GPs') opinions and awareness of deprescribing in an older multimorbid patient.

METHODS

A qualitative study design using face-to-face semi-structured interviews was implemented. GP practices were randomly selected from two cities in New Zealand. Face-to-face in depth interviews were carried out with participants. A hypothetical profile of a multimorbid patient was included to elicit discussions about whether medicines should be continued or discontinued. Interviews were transcribed verbatim for thematic analysis. Transcripts were read and re-read. Themes were identified with iterative building of a coding list until all data were accounted for. Interviews continued until saturation of ideas occurred.

RESULTS

Forty GPs were contacted and 10 consented to participate. Responses to each medicine in the hypothetical patient profile varied. Opinions on deprescribing preventive and symptomatic medicines varied a great deal. Conflicting opinions existed particularly around the prescription of statins, dipyridamole and bisphosphonates. Dilemmas around the appropriate clinical management of reflux disease and insomnia in older people also came to light.

CONCLUSION

Gaining an insight into GPs' current prescribing patterns is important in designing any interventions aimed at reducing inappropriate prescribing. This study highlights the lack of clarity around deprescribing in multimorbidity. The participants' individual responses varied considerably. Deprescribing guidelines may help to clarify evidence based medicine relating to controversial areas and could hence decrease this variation.

Credentials for a PharmD graduate: The voyage never ends

Doctor of Pharmacy (PharmD) is a professional pharmacy degree qualification offered by universities world-wide. While the graduates from the West are familiar with scope and job opportunities that present on completion of a PharmD degree, graduates from Asia and the Middle-East are coming to grips with the future of PharmD program and the role that it could play in career advancement. Through this review, we would like to highlight that numerous credential programs are available which can be added to the armory of PharmD graduates for advancement of their professional careers. The credentials detailed in this review are designed for PharmD graduates to optimize pharmaceutical care in specialized clinical settings such as geriatrics and ambulatory medicine. We have assembled an extensive list of post-PharmD educational opportunities to enhance professional practice for pharmacy graduates.

The Influence of Patient Characteristics on Anticholinergic Events in Older People

Aims

To examine patient characteristics that predict adverse anticholinergic-type events in older people.

Methods

This retrospective population-level study included 2,248 hospitalised patients. Individual data on medicines that are commonly associated with anticholinergic events (delirium, constipation and urinary retention) were identified. Patient characteristics examined were medicines with anticholinergic effects (ACh burden), age, sex, non-anticholinergic medicines (non-ACM), Charlson comorbidity index scores and ethnicity. The Akaike information criterion was used for model selection. The data were analysed using logistic regression models for anticholinergic events using the software NONMEM.

Results

ACh burden was found to be a significant independent predictor for developing an anticholinergic event [adjusted odds ratio (aOR): 3.21, 95% CI: 1.23-5.81] for those taking an average of 5 anticholinergic medicines compared to those taking 1. Both non-ACM and age were also independent risk factors (aOR: 1.41, 95% CI: 1.31-1.51 and aOR: 1.08, 95% CI: 1.05-1.10, respectively).

Conclusion

To our knowledge, this is the first study that has examined population-level data in a nonlinear model framework to predict anticholinergic-type adverse events. This study evaluated the relationship between important patient characteristics and the occurrence of anticholinergic-type events. These findings reinforce the clinical significance of reviewing anticholinergic medicines in older people.

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.

Donepezil Adherence, Persistence and Time to First Discontinuation in a Three-Year Follow-Up of Older People

Background

Donepezil is indicated for the management of mild to moderate dementia, particularly in Alzheimer's disease. Several studies have described low adherence rates with donepezil.

Aim

To examine and measure donepezil adherence, persistence and time to first discontinuation in older New Zealanders.

Methods

An inception cohort of 1,999 new users of donepezil, aged 65 years or older, were identified from the Pharmaceutical Collections and National Minimum Dataset from 1 November 2010 to 31 December 2013. Kaplan-Meier curves and Cox regression analysis were used to estimate the cumulative probability and risk of time to first discontinuation of donepezil therapy.

Results

The mean age of the cohort was 79.5 ± 6.4 years and included 42.7% females. Adherence was high (89.0%), while the proportion of donepezil dispensings (81.0-32.5%) declined between 6 and 36 months. Persistence between the 1st and 6th dispensing visit decreased by 19.0%, and 11.0% of the total cohort had a gap of 31 days or more. The adjusted risk of time to first discontinuation in the non-adherent group was 2.2 times (95% CI 1.9-2.6) that of the adherent group.

Conclusions

The non-adherent new donepezil users, on average, discontinued faster than the adherent group. Time to first discontinuation in this study was higher compared to discontinuation rates observed in clinical trials.

Prevalence of potentially inappropriate medicine use in older New Zealanders: a population-level study using the updated 2012 Beers criteria

RATIONAL, AIMS AND OBJECTIVES

To examine the prevalence of potentially inappropriate medicines (PIMs) in older New Zealanders at a population level.

METHODS

De-identified prescription data for all individuals ≥65 years were obtained from the Pharmaceutical Claims Data Mart for 2011. International Classification of Diseases-10-AM (version 6) codes were used to extract diagnostic information from the National Minimum Datasets and PIMs were identified using the updated Beers 2012 criteria.

RESULTS

40.9% of older people were prescribed PIMs with approximately half dispensed ≥2 PIMs in 2011. Exposure was highest in individuals aged 65-74 years (68.9 ± 2.9). The most prevalent PIMs dispensed were diclofenac (6.0%), amitriptyline (4.9%), ibuprofen (4.6%), zopiclone (3.2%) and naproxen (3.0%). 66.3% of individuals were dispensed ≥1 and 80.8% were dispensed ≥2 medicines with a potential for drug-disease/syndrome interaction.

CONCLUSIONS

The updated Beers 2012 criteria identified that the use of PIMs at a population level is common in older New Zealanders.

Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systematic review

Background

The cumulative effect of taking multiple medicines with anticholinergic properties termed as anticholinergic burden can adversely impact cognition, physical function and increase the risk of mortality. Expert opinion derived risk scales are routinely used in research and clinical practice to quantify anticholinergic burden. These scales rank the anticholinergic activity of medicines into four categories, ranging from no anticholinergic activity (= 0) to definite/high anticholinergic activity (= 3). The aim of this systematic review was to compare anticholinergic burden quantified by the anticholinergic risk scales and evaluate associations with adverse outcomes in older people.

Methods

We conducted a literature search in Ovid MEDLINE, EMBASE and PsycINFO from 1984-2014 to identify expert opinion derived anticholinergic risk scales. In addition to this, a citation analysis was performed in Web of Science and Google Scholar to track prospective citing of references of selected articles for assessment of individual scales for adverse anticholinergic outcomes. The primary outcomes of interest were functional and cognitive outcomes associated with anticholinergic burden in older people. The critical appraisals of the included studies were performed by two independent reviewers and the data were extracted onto standardised forms.

Results

The primary electronic literature search identified a total of 1250 records in the 3 different databases. On the basis of full-text analysis, we identified 7 expert-based anticholinergic rating scales that met the inclusion criteria. The rating of anticholinergic activity for medicines among these rating scales was inconsistent. For example, quetiapine was rated as having high anticholinergic activity in one scale (n = 1), moderate in another scale (n = 1) and low in two other scales (n = 2). Citation analysis of the individual scales showed that the Anticholinergic Cognitive Burden (ACB) scale was the most frequently validated expert based anticholinergic scale for adverse outcomes (N = 13).

Conclusions

In conclusion, there is not one standardised tool for measuring anticholinergic burden. Cohort studies have shown that higher anticholinergic burden is associated with negative brain effects, poorer cognitive and functional outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-015-0029-9) contains supplementary material, which is available to authorized users.

A retrospective study of drug-related problems in Australian aged care homes: medication reviews involving pharmacists and general practitioners

BACKGROUND

Drug-related problems (DRPs) in Australian aged care homes have been studied previously. However, little is known about the acceptance and implementation of pharmacists' recommendations by general practitioners (GPs) to resolve DRPs.

OBJECTIVES

The primary objective of this study was to investigate the number and nature of DRPs identified by accredited clinical pharmacists. The secondary objective was to study the GP acceptance and implementation of pharmacist recommendations to resolve DRPs.

METHODS

This was a retrospective study of 500 randomly selected, de-identified medication reviews performed by 10 accredited clinical pharmacists over 6 months across 62 aged care homes. The DRPs identified by pharmacists were subsequently classified by the drugs involved, types of problem (indication, effectiveness and safety) and medical diagnoses of the patient. GP written feedback on the medication review reports determined implementation of pharmacists' recommendations to resolve the DRPs.

RESULTS

A total of 1433 DRPs were identified in 480 of the 500 residents. Potential DRPs were frequently classified as risk of adverse drug reactions, need for additional monitoring and inappropriate choice of a drug. Alimentary, cardiovascular, central nervous system and respiratory drugs were most frequently implicated, accounting for more than 75% of the DRPs. GPs' acceptance and implementation of pharmacists recommendations were 72.5% (95% CI; 70.2, 74.8) and 58.1% (95% CI; 55.5, 60.6), respectively.

CONCLUSIONS

Over 96% of the residents had potential DRPs identified by pharmacists. GP acceptance of pharmacists' recommendations was independent of the drug category, but not independent of the disease category.

Determinants of antipsychotic medication use among older people living in aged care homes in Australia

OBJECTIVE

To investigate determinants of antipsychotic medication use among older people living in aged care homes in Australia.

DESIGN

Retrospective study of a random sample of de-identified medication reports using cross-sectional data gathered between 1 January 2008 and 30 June 2008 in Australia.

SUBJECTS

The mean (SD) age of the residents was 84.0 (9.0) years. Seventy-five per cent were females.

MEASURES

Resident demographics, clinical characteristics, medical diagnoses and prescribed medication were systematically recorded. Logistic regression (LR) models were used to determine predictors for any antipsychotic, atypical and conventional antipsychotic use.

RESULTS

Twenty-three per cent of the residents were prescribed one or more antipsychotics. In the LR model, factors for predicting the odds ratio and 95% confidence interval (CI) for any antipsychotic medication use were agitation (7.11, 95% CI 3.15-16.03), challenging behaviours (7.47, 95% CI 2.53-22.10), dementia (2.35, 95% CI 1.36-4.06), dementia with mood disorder (0.39, 95% CI 0.16-0.92), paranoia (6.70, 95% CI 1.08-41.55), psychosis (14.79, 95% CI 3.64-60.00) and any psychiatric diagnosis (3.30, 95% CI 1.82-6.00). Use of atypical antipsychotic medication was significant for agitation (4.58, 95% CI 2.05-10.23), aggression (2.25, 95% CI 1.05-4.78), challenging behaviours (8.01, 95% CI 2.76-23.24), dementia (3.64, 95% CI 1.99-6.67), dementia with mood disorder (0.16, 95% CI 0.06-0.43), psychosis (16.51, 95% CI 4.28-63.66) and any psychiatric diagnosis (4.44, 95% CI 2.33-8.46).

CONCLUSIONS

Psychiatric diagnosis, psychosis and dementia were associated with significantly greater odds for the use of antipsychotic medications. Older people suffering from dementia and comorbid mood disorders treated with antidepressants were less likely to be prescribed atypical antipsychotics.

Anticholinergic activity of commonly prescribed medications and neuropsychiatric adverse events in older people

This study sought to determine whether the presence of in vitro anticholinergic activity (AA) among different drugs is associated with reporting of neuropsychiatric adverse events (NPAEs) and whether age affects this relationship. Retrospective case/noncase analyses using Australia's spontaneous Adverse Drug Reaction System (ADRS) database containing 150 475 reports determined crude and adjusted reporting odds ratios (RORs) for NPAEs for 23 drugs with various reported in vitro AA. Covariates were age (treated as a dichotomous variable [> or =65 years]), gender, and concomitant use of antipsychotics, benzodiazepines, tricyclic antidepressants, and drugs with recognized inherent anticholinergic properties (anticholinergic drugs). The interaction effect between these covariates and each drug exposure category was examined. Age (> or =65 years) has a significant association with greater odds relative to younger age for reporting NPAEs. Drugs with reported significant AA in vitro were not always associated with RORs greater than 1 for reporting NPAEs, highlighting a dissonance between the in vitro AA index and ADRS observations. Significant interactions were observed between age (> or =65 years) and exposure to cimetidine, anticholinergic drugs, antipsychotics, and tricyclic antidepressants in modifying odds for reporting NPAEs, reinforcing the need for cautious use and monitoring of drugs with AA in older people.