Use of a structured medication history to establish medication use at admission to an old age psychiatric clinic: a prospective observational study

Prevalence and solving strategies of drug-related problems in adult psychiatric inpatients - a systematic review

Introduction

Most psychiatric inpatients receive psychopharmacological treatment indicated for their mental diseases. The aim of this systematic review is to give clinical pharmacists and physicians a comprehensive summary of common drug-related problems (DRPs) in adult psychiatric inpatients and of potential interventions to solve them in clinical practice.

Methods

Six databases and registers were searched for English, German and French articles published between 1999 and 2023 with content regarding the prevalence and/or type or interventions to solve DRPs in adult psychiatric inpatients. Studies were categorized based on types of DRPs and clinical interventions. The prevalence rates of DRPs and subtypes were compared quantitatively and the tested interventions were summarized qualitatively.

Results

A total of 88 articles with an overall sample of over 95.425 adult psychiatric inpatients were included in this review. DRPs were reported with a prevalence range of 0.32 to 9.48 per patient. The most frequently reported DRPs were caused by prescribing errors (1.91 per patient), the most frequent subtype was drug interaction (0.77 per patient). Clinical pharmacists were involved in interventions in 7 of 13 included articles. Interventions consisted of clinical pharmacy services on the ward, educational classes, medication reviews, and the implementation of digital tools such as dispensing cabinets and prescribing tools.

Discussion

The included studies were heterogeneous. The most frequent DRPs in psychiatry are related to prescribing errors and drug interactions. Clinical pharmacists may support the drug therapy by identifying and effectively solving DRPs in psychiatric inpatients using interdisciplinary approaches.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022354958.

Medication Reconciliation of Patients by Pharmacist at the Time of Admission and Discharge from Adult Nephrology Wards

PURPOSE

The aim of the present study was to investigate the impact of medication reconciliation by pharmacists at both admission and discharge in hospitalized patients with different kidney diseases.

METHODS

A prospective study was performed in adult nephrology wards of a teaching referral hospital in Iran from September 2020 to March 2021. All patients hospitalized in the nephrology ward for at least 1 day who received the minimum of one medication during their ward stay within the study period were considered eligible. Medication reconciliation was performed by taking a best-possible medication history from eligible patients during the first 24 h of ward admission. Medications were evaluated for possible intentional as well as unintentional discrepancies.

RESULTS

Here, 178 patients at admission and 134 patients at discharge were included. The mean numbers of unintentional drug discrepancies for each patient at admission and discharge were 6.13 ± 4.13 and 1.63 ± 1.94, respectively. The mean ± SD numbers of prescribed medications for patients before ward admission detected by the nurse/physician and pharmacist were 6.06 ± 3.53 and 9.22 ± 4.71, respectively (p = 0.0001). The number of unintentional discrepancies at admission and discharge had a significant correlation with the number of drugs used and underlying diseases. The number of unintentional discrepancies at admission was also correlated with patients' age. The number of comorbidities was significantly associated with the number of unintentional medication discrepancies at both admission and discharge. At the time of ward discharge, all patients were given medication consultations.

CONCLUSIONS

The rate of reconciliation errors was high in the adult nephrology ward. The active contribution of pharmacists in the process of medication reconciliation can be significantly effective in identifying these errors.

Approaches to medication history taking in different hospital settings: A scoping review

PURPOSE

A comprehensive medication history can contribute to safe therapy. Many approaches aiming to improve medication history taking require significant human resources. To design an efficient process that delivers high-quality medication histories, the individual requirements and resources of a given setting need to be considered. We aimed to provide an overview of existing approaches to medication history taking and their performance in different settings to potentially support the selection of an appropriate procedure.

METHODS

We searched 3 literature databases (PubMed/MEDLINE, CINAHL, PsycINFO) for publications on approaches to medication history taking and analyzed them with regard to their key components as well as the setting, patient population, assessed outcomes, and efficacy.

RESULTS

In total, 65 publications were included and analyzed. The majority of the reported approaches relied on involvement of dedicated staff (n = 43), followed by process-oriented interventions (eg, checklists; n = 15) and information technology (IT)-guided interventions (n = 11). A mean (SD) of 6 (2.9) outcomes were described in each study. Medication discrepancies were reported in 89% of all studies, yet about 75 different descriptions of this outcome were used, making it difficult to compare study results. Only 11 studies applied a sample size calculation and statistical tests. Of those, 10 reported a positive effect of their respective intervention on the quality of medication histories.

CONCLUSION

Most approaches focused on pharmacy staff, which are associated with considerable cost and resources. Therefore, IT-based approaches and patient engagement should be investigated as cost-effective alternatives and tested for superiority in the same setting. Reporting guidelines and standardized methodology are needed to improve the comparability of such studies.

Frequency and Acceptance of Clinical Decision Support System-Generated STOPP/START Signals for Hospitalised Older Patients with Polypharmacy and Multimorbidity

BACKGROUND

The Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) instrument is used to evaluate the appropriateness of medication in older people. STOPP/START criteria have been converted into software algorithms and implemented in a clinical decision support system (CDSS) to facilitate their use in clinical practice.

OBJECTIVE

Our objective was to determine the frequency of CDSS-generated STOPP/START signals and their subsequent acceptance by a pharmacotherapy team in a hospital setting.

DESIGN AND METHODS

Hospitalised older patients with polypharmacy and multimorbidity allocated to the intervention arm of the OPERAM (OPtimising thERapy to prevent Avoidable hospital admissions in the Multimorbid elderly) trial underwent a CDSS-assisted structured medication review in four European hospitals. We evaluated the frequency of CDSS-generated STOPP/START signals and the subsequent acceptance of these signals by a trained pharmacotherapy team consisting of a physician and pharmacist after evaluation of clinical applicability to the individual patient, prior to discussing pharmacotherapy optimisation recommendations with the patient and attending physicians. Multivariate linear regression analysis was used to investigate potential patient-related (e.g. age, number of co-morbidities and medications) and setting-related (e.g. ward type, country of inclusion) determinants for acceptance of STOPP and START signals.

RESULTS

In 819/826 (99%) of the patients, at least one STOPP/START signal was generated using a set of 110 algorithms based on STOPP/START v2 criteria. Overall, 39% of the 5080 signals were accepted by the pharmacotherapy team. There was a high variability in the frequency and the subsequent acceptance of the individual STOPP/START criteria. The acceptance ranged from 2.5 to 75.8% for the top ten most frequently generated STOPP and START signals. The signal to stop a drug without a clinical indication was most frequently generated (28%), with more than half of the signals accepted (54%). No difference in mean acceptance of STOPP versus START signals was found. In multivariate analysis, most patient-related determinants did not predict acceptance, although the acceptance of START signals increased in patients with one or more hospital admissions (+ 7.9; 95% confidence interval [CI] 1.6-14.1) or one or more falls in the previous year (+ 7.1; 95% CI 0.7-13.4). A higher number of co-morbidities was associated with lower acceptance of STOPP (- 11.8%; 95% CI - 19.2 to - 4.5) and START (- 11.0%; 95% CI - 19.4 to - 2.6) signals for patients with more than nine and between seven and nine co-morbidities, respectively. For setting-related determinants, the acceptance differed significantly between the participating trial sites. Compared with Switzerland, the acceptance was higher in Ireland (STOPP: + 26.8%; 95% CI 16.8-36.7; START: + 31.1%; 95% CI 18.2-44.0) and in the Netherlands (STOPP: + 14.7%; 95% CI 7.8-21.7). Admission to a surgical ward was positively associated with acceptance of STOPP signals (+ 10.3%; 95% CI 3.8-16.8).

CONCLUSION

The involvement of an expert team in translating population-based CDSS signals to individual patients is essential, as more than half of the signals for potential overuse, underuse, and misuse were not deemed clinically appropriate in a hospital setting. Patient-related potential determinants were poor predictors of acceptance. Future research investigating factors that affect patients' and physicians' agreement with medication changes recommended by expert teams may provide further insight for implementation in clinical practice.

REGISTRATION

ClinicalTrials.gov Identifier: NCT02986425.

Cross-cultural adaptation to the Spanish version of the "Structured HIstory of Medication Use" questionnaire for medication reconciliation at admission

BACKGROUND AND OBJECTIVE

The "Structured HIstory of Medication use" (SHIM) questionnaire is a tool developed to obtain an accurate pre-admission overview of medications, involving a structured interview with patients, and has demonstrated its potential to prevent reconciliation errors. The objective of this study was to cross-culturally adapt the SHIM questionnaire to Spanish.

PATIENTS AND METHODS

Forward and blind-back translations followed by a synthesis and adaptation, with the participation of an expert panel, to guarantee the equivalence between the original questionnaire and the Spanish version. Subsequently, pilot testing of the Spanish version was carried out through cognitive interviews in a sample of polymedicated patients under follow-up by the Department of Internal Medicine.

RESULTS

The Spanish version of the SHIM questionnaire (SHIM-e) was obtained. Scores for difficulty assigned by translators involved in forward and back translations were low. During the synthesis and adaptation phase, three discrepancies were resolved, and the expert panel decided to include some terms commonly used for clinical interviews in the Spanish version of the questionnaire. The pilot testing, which was performed in a sample of 10 polymedicated patients admitted to the Department of General and Digestive Surgery, showed 100% comprehensibility for all items, except for number 13, which was 90%.

CONCLUSIONS

This work presents the first cross-cultural adaptation to Spanish of the SHIM questionnaire. The forward and blind-back translations presented low difficulty and the results of the pilot testing showed a high level of comprehensibility for the Spanish version of this tool.

Intervention protocol: OPtimising thERapy to prevent avoidable hospital Admission in the Multi-morbid elderly (OPERAM): a structured medication review with support of a computerised decision support system

BACKGROUND

Several approaches to medication optimisation by identifying drug-related problems in older people have been described. Although some interventions have shown reductions in drug-related problems (DRPs), evidence supporting the effectiveness of medication reviews on clinical and economic outcomes is lacking. Application of the STOPP/START (version 2) explicit screening tool for inappropriate prescribing has decreased inappropriate prescribing and significantly reduced adverse drug reactions (ADRs) and associated healthcare costs in older patients with multi-morbidity and polypharmacy. Therefore, application of STOPP/START criteria during a medication review is likely to be beneficial. Incorporation of explicit screening tools into clinical decision support systems (CDSS) has gained traction as a means to improve both quality and efficiency in the rather time-consuming medication review process. Although CDSS can generate more potential inappropriate medication recommendations, some of these have been shown to be less clinically relevant, resulting in alert fatigue. Moreover, explicit tools such as STOPP/START do not cover all relevant DRPs on an individual patient level. The OPERAM study aims to assess the impact of a structured drug review on the quality of pharmacotherapy in older people with multi-morbidity and polypharmacy. The aim of this paper is to describe the structured, multi-component intervention of the OPERAM trial and compare it with the approach in the comparator arm.

METHOD

This paper describes a multi-component intervention, integrating interventions that have demonstrated effectiveness in defining DRPs. The intervention involves a structured history-taking of medication (SHiM), a medication review according to the systemic tool to reduce inappropriate prescribing (STRIP) method, assisted by a clinical decision support system (STRIP Assistant, STRIPA) with integrated STOPP/START criteria (version 2), followed by shared decision-making with both patient and attending physician. The developed method integrates patient input, patient data, involvement from other healthcare professionals and CDSS-assistance into one structured intervention.

DISCUSSION

The clinical and economical effectiveness of this experimental intervention will be evaluated in a cohort of hospitalised, older patients with multi-morbidity and polypharmacy in the multicentre, randomized controlled OPERAM trial (OPtimising thERapy to prevent Avoidable hospital admissions in the Multi-morbid elderly), which will be completed in the last quarter of 2019.

TRIAL REGISTRATION

Universal Trial Number: U1111-1181-9400 Clinicaltrials.gov: NCT02986425, Registered 08 December 2016. FOPH (Swiss national portal): SNCTP000002183. Netherlands Trial Register: NTR6012 (07-10-2016).

Patient safety in inpatient mental health settings: a systematic review

OBJECTIVES

Patients in inpatient mental health settings face similar risks (eg, medication errors) to those in other areas of healthcare. In addition, some unsafe behaviours associated with serious mental health problems (eg, self-harm), and the measures taken to address these (eg, restraint), may result in further risks to patient safety. The objective of this review is to identify and synthesise the literature on patient safety within inpatient mental health settings using robust systematic methodology.

DESIGN

Systematic review and meta-synthesis. Embase, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium, MEDLINE, PsycINFO and Web of Science were systematically searched from 1999 to 2019. Search terms were related to 'mental health', 'patient safety', 'inpatient setting' and 'research'. Study quality was assessed using the Hawker checklist. Data were extracted and grouped based on study focus and outcome. Safety incidents were meta-analysed where possible using a random-effects model.

RESULTS

Of the 57 637 article titles and abstracts, 364 met inclusion criteria. Included publications came from 31 countries and included data from over 150 000 participants. Study quality varied and statistical heterogeneity was high. Ten research categories were identified: interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorised leave, clinical decision making, falls and infection prevention and control.

CONCLUSIONS

Patient safety in inpatient mental health settings is under-researched in comparison to other non-mental health inpatient settings. Findings demonstrate that inpatient mental health settings pose unique challenges for patient safety, which require investment in research, policy development, and translation into clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42016034057.

How complete is the information on preadmission psychotropic medications in inpatients with dementia? A comparison of hospital medical records with dispensing data

OBJECTIVES

Reliable information on preadmission medications is essential for inpatients with dementia, but its quality has hardly been evaluated. We assessed the completeness of information and factors associated with incomplete recording.

METHODS

We compared preadmission medications recorded in hospital electronic medical records (EMRs) with community-pharmacy dispensations in hospitalizations with discharge code for dementia at the University Hospital of Udine, Italy, 2012-2014. We calculated: (a) prevalence of omissions (dispensed medication not recorded in EMRs), additions (medication recorded in EMRs not dispensed), and discrepancies (any omission or addition); (b) multivariable logistic regression odds ratio, with 95% confidence interval (95% CI), of ≥1 omission.

RESULTS

Among 2,777 hospitalizations, 86.1% had ≥1 discrepancy for any medication (Kappa 0.10) and 33.4% for psychotropics. When psychotropics were recorded in EMR, antipsychotics were added in 71.9% (antidepressants: 29.2%, antidementia agents: 48.2%); when dispensed, antipsychotics were omitted in 54.4% (antidepressants: 52.7%, antidementia agents: 41.5%). Omissions were 92% and twice more likely in patients taking 5 to 9 and ≥10 medications (vs. 0 to 4), 17% in patients with psychiatric disturbances (vs. none), and 41% with emergency admission (vs. planned).

CONCLUSION

Psychotropics, commonly used in dementia, were often incompletely recorded. To enhance information completeness, both EMRs and dispensations should be used.

The Systematic Tool to Reduce Inappropriate Prescribing (STRIP): Combining implicit and explicit prescribing tools to improve appropriate prescribing

Inappropriate prescribing is a major health care issue, especially regarding older patients on polypharmacy. Multiple implicit and explicit prescribing tools have been developed to improve prescribing, but these have hardly ever been used in combination. The Systematic Tool to Reduce Inappropriate Prescribing (STRIP) combines implicit prescribing tools with the explicit Screening Tool to Alert physicians to the Right Treatment and Screening Tool of Older People's potentially inappropriate Prescriptions criteria and has shared decision-making with the patient as a critical step. This article describes the STRIP and its ability to identify potentially inappropriate prescribing. The STRIP improved general practitioners' and final-year medical students' medication review skills. The Web-application STRIP Assistant was developed to enable health care providers to use the STRIP in daily practice and will be incorporated in clinical decision support systems. It is currently being used in the European Optimizing thERapy to prevent Avoidable hospital admissions in the Multimorbid elderly (OPERAM) project, a multicentre randomized controlled trial involving patients aged 75 years and older using multiple medications for multiple medical conditions. In conclusion, the STRIP helps health care providers to systematically identify potentially inappropriate prescriptions and medication-related problems and to change the patient's medication regimen in accordance with the patient's needs and wishes. This article describes the STRIP and the available evidence so far. The OPERAM study is investigating the effect of STRIP use on clinical and economic outcomes.

Medication discrepancies in late-stage chronic kidney disease

Background

Late-stage chronic kidney disease (LS-CKD) can be defined by glomerular filtration rate (GFR) 0–30 mL/min. It is a period of risk for medication discrepancies because of frequent hospitalizations, fragmented medical care, inadequate communication and polypharmacy. In this study, we sought to characterize medication discrepancies in LS-CKD.

Methods

We analyzed all patients enrolled in Northwell Health’s Healthy Transitions in LS-CKD program. All patients had estimated GFR 0–30 mL/min, not on dialysis. Medications were reviewed by a nurse at a home visit. Patients’ medication usage and practice were compared with nephrologists’ medication lists, and discrepancies were characterized. Patients were categorized as having either no discrepancies or one or more. Associations between patient characteristics and number of medication discrepancies were evaluated by chi-square or Fisher’s exact test for categorical variables, and two-sample t-test or Wilcoxon text for continuous variables.

Results

Seven hundred and thirteen patients with a median age of 70 (interquartile range 58–79) years were studied. There were 392 patients (55.0% of the study population) with at least one medication discrepancy. The therapeutic classes of medications with most frequently occurring medication discrepancies were cardiovascular, vitamins, bone and mineral disease agents, diuretics, analgesics and diabetes medications. In multivariable analysis, factors associated with higher risk of discrepancies were congestive heart failure [odds ratio (OR) 2.13; 95% confidence interval (CI) 1.44–3.16; P = 0.0002] and number of medications (OR 1.29; 95% CI 1.21–1.37; P < 0.0001).

Conclusions

Medication discrepancies are common in LS-CKD, affect the majority of patients and include high-risk medication classes. Congestive heart failure and total number of medications are independently associated with greater risk for multiple drug discrepancies. The frequency of medication discrepancies indicates a need for great care in medication management of these patients.

Discrepancies Identified Through a Telephone-Based, Student-Led Initiative for Medication Reconciliation in Ambulatory Psychiatry

PURPOSE

To identify the number of medication discrepancies following establishment of a telephone-based, introductory pharmacy practice experience student-driven, medication reconciliation service for new patients in an ambulatory psychiatry clinic. Secondarily, to identify factors impacting medication discrepancies to better target medication profiles to reconcile and to evaluate whether the implementation of a call schedule effected clinic no-show rates.

METHODS

This was a retrospective analysis of a telephone-based medication reconciliation service from June 2014 to January 2016.

RESULTS

At least 1 medication discrepancy was identified among 84.7% of medication profiles (N = 438), with a total of 1416 medication discrepancies reconciled (3.2 discrepancies per patient). Of the 1416 discrepancies, 38.6% were deletions, 38.9% were additions, and 22.5% were changes in dosage strength or frequency. Discrepancies pertaining to prescription medications totaled 57.8%. Student pharmacists were critical team members in the service. Patient's age, number of medications on the patient's list, and number of days since the last medication reconciliation were not clinically significant determinants for targeting medication profiles. There was a statistically significant reduction in the clinic no-show rates following implementation of a call schedule compared with no-show rates prior to call schedule implementation.

CONCLUSION

This student pharmacist-led telephone medication reconciliation service demonstrated the importance of medication reconciliation in ambulatory psychiatry by identifying numerous discrepancies within this population. Further, we demonstrated pharmacy students across various levels of education can assist in this process under the supervision of a pharmacist.

The development of a subjective assessment framework for individuals presenting for clinical exercise services: A Delphi study

OBJECTIVES

The American College of Sports Medicine and Exercise and Sports Science Australia recognise the importance of gathering a client history (subjective assessment) to inform clinical decisions for clients with chronic disease and/or disability. Despite the importance of the subjective assessment in problem-oriented exercise management, there is currently no primary evidence to indicate the important domains that should be addressed during the subjective assessment to guide safe and effective clinical decisions.

DESIGN

Modified e-Delphi METHODS: A panel of 32 experts was recruited with a median of 12 years of experience (Q₃=15.5 years; Q₁=10 years). The panel was asked to rate the importance of each domain in guiding clinical decisions on a 9-point Likert scale with consensus for inclusion or exclusion pre-defined at 80%.

RESULTS

The panel of experts elected that best practice for conducting the subjective assessment was a semi-structured approach using a combination of prompts and follow-up questions. The Delphi process resulted in an initial list of 36 domains that was identified by the panel of which 23 domains reached consensus for agreement after Round 3.

CONCLUSIONS

The subjective assessment is important for Clinical Exercise Physiologists to provide safe and effective services. Best practice for conducting the assessment is the semi-structured approach to prompt the clinician on the domains to include. Twenty three domains have been considered as important for a Clinical Exercise Physiologist to address in a subjective assessment to implement the delivery of safe and effective exercise assessment and/or prescription.

Predicting risk of adverse drug reactions in older adults

Adverse drug reactions (ADRs) are common in older adults, with falls, orthostatic hypotension, delirium, renal failure, gastrointestinal and intracranial bleeding being amongst the most common clinical manifestations. ADR risk increases with age-related changes in pharmacokinetics and pharmacodynamics, increasing burden of comorbidity, polypharmacy, inappropriate prescribing and suboptimal monitoring of drugs. ADRs are a preventable cause of harm to patients and an unnecessary waste of healthcare resources. Several ADR risk tools exist but none has sufficient predictive value for clinical practice. Good clinical practice for detecting and predicting ADRs in vulnerable patients includes detailed documentation and regular review of prescribed and over-the-counter medications through standardized medication reconciliation. New medications should be prescribed cautiously with clear therapeutic goals and recognition of the impact a drug can have on multiple organ systems. Prescribers should regularly review medication efficacy and be vigilant for ADRs and their contributory risk factors. Deprescribing should occur at an individual level when drugs are no longer efficacious or beneficial or when safer alternatives exist. Inappropriate prescribing and unnecessary polypharmacy should be minimized. Comprehensive geriatric assessment and the use of explicit prescribing criteria can be useful in this regard.

Application of the structured history taking of medication use tool to optimise prescribing for older patients and reduce adverse events

BACKGROUND

Older patients, due to polypharmacy, co-morbidities and often multiple prescribing doctors are particularly susceptible to medication history errors, leading to adverse drug events, patient harm and increased costs. Medication reconciliation at the point of admission to hospital can reduce medication discrepancies and adverse events. The Structured HIstory taking of Medication use (SHiM) tool was developed to provide a structure to the medication reconciliation process. There has been very little research with regards to SHiM, it's application to older patients and it's potential to reduce adverse events.

OBJECTIVE

To determine whether application of SHiM could optimise older patients' prescriptions on admission to hospital, and in-turn reduce adverse events, compared to standard care.

SETTING

A sub-study of a large clinical trial involving hospital inpatients over the age of 65 in five hospitals across Europe.

METHOD

A modified version of SHiM was used to obtain accurate drug histories for patients after the attending physician had obtained a medication list via standard methods. Discrepancies between the two lists were recorded and classified, and the clinical relevance of the discrepancies was determined. Whether discrepancies in patients' medication histories, as revealed by SHiM, resulted in actual clinical consequences was then investigated. As this study was carried out during the observation phase of the clinical trial, results were not communicated to the medical teams.

MAIN OUTCOME MEASURE

Discrepancies between medication lists and whether these resulted in clinical consequences.

RESULTS

SHiM was applied to 123 patients. The mean age of the participants was 78 (±6). 200 discrepancies were identified. 90 patients (73 %) had at least one discrepancy with a median of 1.0 discrepancies per patient (IQR 0.00-2.25). 53 (26.5 %) were classified as 'unlikely to cause patient discomfort or clinical deterioration', 145 (72.5 %) as 'having potential to cause moderate discomfort or clinical deterioration', and 2 (1 %) as 'having potential to cause severe discomfort or clinical deterioration'. Of the 200 discrepancies identified, 2(1 %) resulted in adverse events.

CONCLUSION

The results suggest SHiM is an effective medications reconciliation tool and does identify discrepancies with potential for patient harm. However, it's the capacity to prevent actual adverse events is less convincing.

Medication Discontinuation in Patients After Discharge From a Psychiatric Hospital

BACKGROUND

Patients discharged from psychiatric hospitals may be at risk for intentional or unintentional discontinuation of their medication.

OBJECTIVE

To describe and assess the discontinuation of, and changes to, psychiatric and/or somatic medication in patients after discharge from psychiatric hospitals.

METHODS

A retrospective follow-up study was conducted in patients discharged from 4 psychiatric hospitals in The Netherlands between 2006 and 2009. Patients' medication use during the last 2 days of hospitalization was compared with medication dispensed during the 3 months following discharge. Changes in psychiatric and somatic medication were investigated and defined as medication discontinuation, start, or switch. Patients were classified as continuing users, when there were no changes to the medication after discharge. Relative risks with 95% confidence intervals to measure differences in discontinuation were estimated using Cox regression analysis.

RESULTS

This study included 1324 patients, 69.8% of whom discontinued medication, and 9.7% switched one or more medications. Nearly half (47.4%) of all patients started a medication other than that dispensed during the last 2 days of hospitalization, and 13.7% of all patients experienced no changes to their medication regimen. Approximately 40% of the patients discontinued one or more medications for chronic conditions. From these, 68% discontinued psychiatric medications and 49.4% discontinued somatic medications. A quarter (25.2%) of the 644 patients discontinued using antipsychotics. More than a quarter (28.4%) of the 292 patients using medications for cardiovascular problems discontinued. Patients using as-needed medication prior to discharge were more likely to discontinue their medication (relative risk = 1.85; 95% confidence interval = 1.55-2.20).

CONCLUSIONS

Discharge from a psychiatric hospital led to medication discontinuation in approximately 70% of all patients. Approximately 40% of the patients discontinued medications for chronic conditions. Discontinuation of somatic medication was more frequent than discontinuation of psychiatric medication, and risk of discontinuation was lower for patients with depressive and anxiety disorders. Although medication discontinuation can be deliberate it is alarming that a quarter of our patients using antipsychotics and cardiovascular medications discontinued their use, both of which are meant for chronic conditions.

Appropriate prescribing in the elderly: Current perspectives

Advances in medical therapeutics have undoubtedly contributed to health gains and increases in life expectancy over the last century. However, there is growing evidence to suggest that therapeutic decisions in older patients are frequently suboptimal or potentially inappropriate and often result in negative outcomes such as adverse drug events, hospitalisation and increased healthcare resource utilisation. Several factors influence the appropriateness of medication selection in older patients including age-related changes in pharmacokinetics and pharmacodynamics, high numbers of concurrent medications, functional status and burden of co-morbid illness. With ever-increasing therapeutic options, escalating proportions of older patients worldwide, and varying degrees of prescriber education in geriatric pharmacotherapy, strategies to assist physicians in choosing appropriate pharmacotherapy for older patients may be helpful. In this paper, we describe important age-related pharmacological changes as well as the principal domains of prescribing appropriateness in older people. We highlight common examples of drug-drug and drug-disease interactions in older people. We present a clinical case in which the appropriateness of prescription medications is reviewed and corrective strategies suggested. We also discuss various approaches to optimising prescribing appropriateness in this population including the use of explicit and implicit prescribing appropriateness criteria, comprehensive geriatric assessment, clinical pharmacist review, prescriber education and computerized decision support tools.

Discontinuation of somatic medication during psychiatric hospitalization

BACKGROUND

Psychiatric hospitalization can increase the risk of discontinuation of pharmacotherapy, which may negatively influence patients' health.

OBJECTIVE

To investigate the association between psychiatric hospitalization and discontinuation of somatic medication.

METHODS

A retrospective crossover study was performed in patients admitted to a psychiatric hospital (index date), who had got somatic medication dispensed during the 3 months prior to hospitalization. Discontinuation of somatic medication was investigated at the following time points: index date and 3, 6, and 9 months before the index date. Relative risks (RR) with 95% confidence intervals (95% CIs) of discontinuing somatic medication at the index date versus the time points before the index date were estimated using Cox regression.

RESULTS

In all, 471 hospitalized patients were included in the study; 38.9% of the patients were discontinuers on the index date. RR for discontinuation of ≥1 somatic medication was 1.88 (95% CI=1.55-2.27) at the index date compared with the other time points and highest for patients<45 years (RR=2.83; 95% CI=1.92-4.18).

CONCLUSIONS

Psychiatric hospitalization was associated with an almost doubled risk of discontinuation of somatic medication. Future studies should address the influence of discontinuation of care on patients' health.