Therapeutic optimization through goal-oriented prescription in nursing homes

[Pharmacological intervention in the medication review of institutionalised elderly patients under polypharmacy]

OBJECTIVE

To describe the Drug-Related Problems (DRP) and their resolution after pharmacological review in institutionalised elderly patients under polypharmacy.

DESIGN

Descriptive, retrospective cohort study from January to October of 2022.

LOCATION

Twelve nursing homes at the Community of Madrid.

PARTICIPANTS

295 patients aged 65 or older taking at least 5 chronic medications prescribed prior to the treatment review.

INTERVENTIONS

Medication reviews carried out by the pharmacist and agreed upon in face-to-face meetings between the primary care doctor, the nursing home doctor and the pharmacist.

MAIN MEASUREMENTS

Detected DRP, types and resolution. A age, sex, and number of medications before and after the intervention. Pharmacological subgroups according to anatomical therapeutic chemical classification system (ATC) and active pharmaceutical ingredients involved in the detected DRPs.

RESULTS

1425 DRP were detected, with a mean of 4.85 (SD 3.33) DRPs/patient. The most frequent DRP was reconciliation error (32.52%), followed by pharmaceutical regimen and dosaje. Among the 1425 improvement proposals, 86.73% of them were accepted.Significant statistically differences were observed between the number of medications per patient prior to the pharmacotherapy review (12.29) and after it (10.20), obtaining an average difference of 2.09 (95%CI: 1.98-2.21; P<.001).

CONCLUSIONS

It is found that the intervention of multidisciplinary team in which the pharmacist performs a revision of the medication decreased the number of prescribed medications. Therefore, it reduces polymedication and its associated risks.

Patterns of inappropriate prescribing and clinical characteristics in patients at admission to an acute care of the elderly unit

PURPOSE

Inappropriate prescribing (IP) is common among the elderly and is associated with adverse health outcomes. The role of different patterns of IP in clinical practice remains unclear. The aim of this study is to analyse the characteristics of different patterns of IP in hospitalized older adults.

METHODS

This is a prospective observational study conducted in the acute care of elderly (ACE) unit of an acute hospital in Barcelona between June and August 2021. Epidemiological and demographic data were collected, and a comprehensive geriatric assessment (CGA) was performed on admitted patients. Four patterns of inappropriate prescribing were identified: extreme polypharmacy (10 or more drugs), potentially inappropriate medications (PIMs), potential prescribing omissions (PPOs) and anticholinergic burden.

RESULTS

Among 93 admitted patients (51.6% male, mean age of 82.83), the main diagnosis was heart failure (36.6%). Overprescribing patterns (extreme polypharmacy, PIMs, PPOs and anticholinergic burden) were associated with higher comorbidity, increased dependence on instrumental activities of daily living (IADL) and greater prevalence of dementia. Underprescribing (omissions) was associated with important comorbidity, residence in nursing homes, an increased risk of malnutrition, higher social risk and greater frailty. Comparing different patterns of IP, patients with high anticholinergic burden exhibited more extreme polypharmacy and PIMs. In the case of omissions, no association was identified with other IP patterns.

CONCLUSIONS

We found statistically significant association between patterns of inappropriate prescribing and clinical and CGA variables such as comorbidity, dependency, dementia or frailty. There is a statistically significant association between patterns of overprescribing among patients admitted to the ACE unit.

The RESPECT-tool as a facilitator for person-centered medication reviews for nursing home residents: tool development and pilot study

BACKGROUND

Although support is needed, no method exists to elicit and integrate personal goals into medication optimization interventions for nursing home residents.

AIM

To develop and evaluate a tool to (1) elicit and evaluate residents' personal goals during medication optimization, and (2) elicit involvement preferences regarding medication decision-making.

METHOD

A draft was composed by the research team, on which feedback was collected through four focus groups with healthcare professionals (n = 23) and pilot interviews with residents (n = 6). The tool was then pilot tested in 11 nursing homes as means to facilitate person-centered medication reviews, focusing on feasibility, appropriateness, and meaningfulness. Evaluation was performed through interviews and focus groups with residents and healthcare professionals, and reports for executed medication reviews. Interview summaries and reports were analyzed inductively.

RESULTS

The RESident's Participation in the Evaluation and Customization of Therapy tool (RESPECT-tool) was drafted as a modular approach of five modules. Pilot study results showed that the tool supported the formulation of personal goals. Goals resulted in changes in all aspects of the nursing home stay, indicating the tool's potential to promote person-centered care. The RESPECT-tool showed value in the context of medication optimization as it allowed to determine potential links between residents' personal goals and medication plans, and its use regularly led to medication changes.

CONCLUSION

A person-centered medication review facilitated by the RESPECT-tool holds a promising approach to medication optimization in nursing homes. Further research should assess impact on relevant outcomes like goal attainment, appropriateness of prescribing and quality of life.

Medication optimization according to the Fit fOR The Aged (FORTA) rules improves functional status in patients hospitalized for geriatric rehabilitation

INTRODUCTION

Functional status is one of the most important issues of geriatric care. Polypharmacy seems to be a modifiable factor associated with functional decline in older adults. However, the impact of pharmacotherapy optimization on the activities of daily living in patients undergoing geriatric rehabilitation has not been investigated prospectively so far.

METHODS

This post hoc analysis of a subsample of the VALFORTA study included individuals only undergoing geriatric rehabilitation with a length of in-hospital stay of at least 14 days. Medication was modified according to the FORTA rules in the intervention group while in the control group standard drug treatment was applied. Both groups received comprehensive geriatric treatment.

RESULTS

The intervention and control groups consisted of 96 and 93 individuals respectively. They did not differ according to basic data except for age and Charlson Comorbidity Index (CCI) on admission. On discharge, activities of daily living (Barthel index, BI) were improved in both groups. An increase of at least 20 points of the BI was observed in 40% of patients in the intervention group and in 12% of patients in the control group (p< 0.001). Logistic regression analysis with an increase of at least 20 BI-points was significantly and independently associated with patient group (2.358, p< 0.02), BI on admission (0.957, p< 0.001), and the CCI (0.793, p< 0.041).

CONCLUSION

This post hoc analysis of a subsample of older individuals hospitalized for geriatric rehabilitation demonstrates a significant additional improvement in activities of daily living by modification of medication according to FORTA.

REGISTRATION

DRKS-ID: DRKS00000531.

Improving individualized prescription in patients with multimorbidity through medication review

Background

Older patients tend to have multimorbidity, represented by multiple chronic diseases or geriatric conditions, which leads to a growing number of prescribed medications. As a result, pharmacological prescription has become a major concern because of the increased difficulties to ensure appropriate prescription in older adults. The study’s main objectives were to characterize a cohort of older adults with multimorbidity, carry out a medication review and compare the pharmacological data before and after the medication review globally and according to the frailty index.

Methods

This was a quasi-experimental (uncontrolled pre-post) study with a cohort of patients ≥ 65 years old with multimorbidity. Data were collected from June 2019 to October 2020. Variables assessed included demographic, clinical, and pharmacological data, degree of frailty (Frail-VIG index), medication regimen complexity index, anticholinergic and or sedative burden index, and monthly drug expenditure. Finally, a medication review was carried out by an interdisciplinary team (primary care team and a consultant team with a geriatrician and a clinical pharmacist) by applying the Patient-Centered Prescription model to align the treatment with care goals.

Results

Four hundred twenty-eight patients were recruited [66.6% women; mean age 85.5 (SD 7.67)]. The mean frail index was 0.39 (SD 0.13), corresponding with moderate frailty. Up to 90% of patients presented at least one inappropriate prescription, and the mean of inappropriate prescriptions per patient was 3.14 (SD 2.27). At the three-month follow-up [mortality of 17.7% (n = 76)], the mean chronic medications per patient decreased by 17.96%, varying from 8.13 (SD 3.87) to 6.67 (SD 3.72) (p < 0.001). The medication regimen complexity index decreased by 19.03%, from 31.0 (SD 16.2) to 25.1 (SD 15.1), and the drug burden index mean decreased by 8.40%, from 1.19 (SD 0.82) to 1.09 (SD 0.82) (p < 0.001). A decrease in polypharmacy, medication regimen complexity index, and drug burden index was more frequent among frail patients, especially those with severe frailty (p < 0.001).

Conclusions

An individualized medication review in frail older patients, applying the Patient-Centered Prescription model, decreases pharmacological parameters related to adverse drug effects, such as polypharmacy, therapeutical complexity, and anticholinergic and, or sedative burden. The benefits are for patients with frailty.

Individualized Medication Review in Older People with Multimorbidity: A Comparative Analysis between Patients Living at Home and in a Nursing Home

(1) Background: aging is associated with complex and dynamic changes leading to multimorbidity and, therefore, polypharmacy. A periodic medication review (MR) in frail older people leads to optimizing medication use. The aims of the study were to perform a comparative analysis of the impact of place of residence (own home versus nursing home) in a cohort of older patients on the characteristics of the baseline therapeutic plan and characteristics of the therapeutic plan after an MR; (2) Methods: Study with paired pre- and post-MR data based on person-centred prescription, with a follow-up assessment at three months. Patients who lived either in their own home or in a nursing home were recruited. We selected patients of 65 years or more with multimorbidity whose General Practitioner identified difficulties with the prescription management and the need for an MR. Each patient’s treatment was analysed by applying the Patient-Centred Prescription (PCP) model; (3) Results: 428 patients. 90% presented at least one inappropriate prescription (IP) in both settings. In nursing homes, a higher number of implemented optimization proposals was detected (81.6% versus 65.7% (p < 0.001)). After the MR, nursing-home patients had a greater decrease in their mean number of medications, polypharmacy prevalence, therapeutic complexity, and monthly drug expenditure (p < 0.001); (4) Conclusions: PCP model detected a high number of IP in both settings. However, after an individualized MR, nursing-home patients presented a greater decrease in some pharmacological parameters related to adverse events, such as polypharmacy and therapeutic complexity, compared to those living at home. Nursing homes may be regarded as a highly suitable scenario to carry out a periodic MR, due to its high prevalence of frail people and its feasibility to apply the recommendations of an MR. Prospective studies with a robust design should be performed to demonstrate this quasi-experimental study along with a longitudinal follow-up on clinical outcomes.

Methodological Challenges for Epidemiologic Studies of Deprescribing at the End of Life

Purpose of Review

To describe approaches to measuring deprescribing and associated outcomes in studies of patients approaching end of life (EOL).

Recent Findings

We reviewed studies published through 2020 that evaluated deprescribing in patients with limited life expectancy and approaching EOL. Deprescribing includes reducing the number of medications, decreasing medication dose(s), and eliminating potentially inappropriate medications. Tools such as STOPPFrail, OncPal, and the Unnecessary Drug Use Measure can facilitate deprescribing. Outcome measures vary and selection of measures should align with the operationalized deprescribing definition used by study investigators.

Summary

EOL deprescribing considerations include medication appropriateness in the context of patient goals for care, expected benefit from medication given life expectancy, and heightened potential for medication-related harm as death nears. Additional data are needed on how EOL deprescribing impacts patient quality of life, caregiver burden, and out-of-pocket medication-related costs to patients and caregivers. Investigators should design deprescribing studies with this information in mind.

Factors Associated with Medication Non-Adherence among Patients with Multimorbidity and Polypharmacy Admitted to an Intermediate Care Center

Identifying determinants of medication non-adherence in patients with multimorbidity would provide a step forward in developing patient-centered strategies to optimize their care. Medication appropriateness has been proposed to play a major role in medication non-adherence, reinforcing the importance of interdisciplinary medication review. This study examines factors associated with medication non-adherence among older patients with multimorbidity and polypharmacy. A cross-sectional study of non-institutionalized patients aged ≥65 years with ≥2 chronic conditions and ≥5 long-term medications admitted to an intermediate care center was performed. Ninety-three patients were included (mean age 83.0 ± 6.1 years). The prevalence of non-adherence based on patients' multiple discretized proportion of days covered was 79.6% (n = 74). According to multivariable analyses, individuals with a suboptimal self-report adherence (by using the Spanish-version Adherence to Refills and Medications Scale) were more likely to be non-adherent to medications (OR = 8.99, 95% CI 2.80-28.84, p < 0.001). Having ≥3 potentially inappropriate prescribing (OR = 3.90, 95% CI 0.95-15.99, p = 0.059) was barely below the level of significance. These two factors seem to capture most of the non-adherence determinants identified in bivariate analyses, including medication burden, medication appropriateness and patients' experiences related to medication management. Thus, the relationship between patients' self-reported adherence and medication appropriateness provides a basis to implement targeted strategies to improve effective prescribing in patients with multimorbidity.

Improving medication adherence and effective prescribing through a patient-centered prescription model in patients with multimorbidity

PURPOSE

This study aimed to assess the impact of the patient-centered prescription (PCP) model in medication adherence and effective prescribing in patients with multimorbidity.

METHODS

Uncontrolled before-after study in an intermediate care facility in a mixed urban-rural district. Inpatients aged ≥ 65 years with multimorbidity exposed to polypharmacy before hospital admission were consecutively enrolled. Every patient's treatment plan was analyzed through the PCP model, which includes interventions aimed at improving medication adherence. The primary endpoint was the change in the proportion of adherent patients between pre-admission and after discharge for all regularly scheduled long-term medications, using the proportion of days covered (PDC). Secondary endpoints included the change on mean PDC for all long-term medications, number of long-term medications, proportion of patients with hyperpolypharmacy, medication regimen complexity index (MRCI) score, drug burden index (DBI) score, number of potential inappropriate prescribing (PIP), and proportion of patients with ≥ 2 PIPs.

RESULTS

Ninety-three non-institutionalized patients were included (mean age 83.0 ± SD 6.1 years). The proportion of adherent patients increased from 22.1 to 51.9% (P < 0.001). Intervention also improved mean PDC [mean difference (95% CI) 10.6 (7.7, 13.5)] and effective prescribing through a reduction on the number of long-term medications [- 1.3 (- 1.7, - 0.9)], proportion of patients exposed to hyperpolypharmacy (- 16.1%, P < 0.001), MRCI score [- 2.2 (- 3.4, - 1.0)], DBI score [- 0.16 (- 1.8, - 1.3)], number of PIPs [- 1.6 (- 1.8, - 1.3)], and proportion of patients with ≥ 2 PIPs (- 53.7%, P < 0.001).

CONCLUSION

Studied intervention provides significant effective prescribing and medication adherence enhancements in non-institutionalized older patients with multimorbidity and polypharmacy.