The impact of family caregivers on potentially inappropriate medication use in noninstitutionalized older adults with dementia

Initiation and Persistence of Antipsychotic Medications at Hospital Discharge Among Community-Dwelling Veterans With Dementia

OBJECTIVES

Adults with dementia are frequently prescribed antipsychotic medications despite concerns that risks outweigh benefits. Understanding conditions where antipsychotics are initially prescribed, such as hospitalization, may offer insights into reducing inappropriate use.

DESIGN, SETTING, PARTICIPANTS

Retrospective cohort study of community-dwelling veterans with dementia aged ≥68 with VA hospitalizations in 2014, using Veterans Health Administration (VA) and Medicare data.

MEASUREMENTS

The primary outcome was new outpatient antipsychotic prescription at hospital discharge. We used generalized estimating equations to study associations between antipsychotic initiation and patient, hospitalization, and facility characteristics. Among veterans with antipsychotic initiation, we used a cumulative incidence function to evaluate discontinuation in the year following hospitalization, accounting for competing risks.

RESULTS

4,719 community-dwelling veterans with dementia had VA hospitalizations in 2014; 264 (5.6%) filled new antipsychotic prescriptions at discharge. Antipsychotic initiation was associated with discharge unit (surgical vs medical, OR 0.41, 95% CI 0.19-0.87; psychiatric vs medical, OR 6.58, 95% CI 4.48-9.67), length of stay (OR 1.03/day, 95% CI 1.02-1.05), and delirium diagnosis (OR 2.61, 95% CI 1.78-3.83), but not demographic or facility characteristics. Among veterans with antipsychotic initiation, the 1-year cumulative incidence of discontinuation was 18.2% (n = 47); 15.9% (n = 42) of those who were alive and not censored remained on antipsychotics at 1 year.

CONCLUSIONS

Antipsychotic initiation at hospital discharge was uncommon among community-dwelling veterans with dementia; however, once initiated, antipsychotic persistence at 1 year was common among those who remained community-dwelling. Hospitalization is a contributor to potentially-inappropriate medications in the community, suggesting an opportunity for medication review after hospitalization.

Aligning Medications With What Matters Most: Conversations Between Pharmacists, People With Dementia, and Care Partners

INTRODUCTION

Successful deprescribing for people with dementia (PWD) depends on communication about medication-related priorities between PWD, care partners and clinicians. The objective of this study was to gain in-depth knowledge of how elicitation of PWD and care partner medication-related priorities during a deprescribing intervention shaped discussions with pharmacists about medications.

METHODS

Qualitative analysis of audio-recorded interactions between pharmacists and patient-care partner dyads in a pilot study of a pharmacist-led deprescribing intervention for PWD in primary care. Patients ≥ 65 years taking ≥ 7 medications and care partners were recruited from an integrated delivery system in Colorado and a community-based medical practice in Maryland. Qualitative content analysis was used to analyze 82 transcripts from encounters with 55 patient-care partner dyads.

RESULTS

The mean (SD) age of PWD was 81 (8.1) years; 45% were women, 33% Black, and 15% Hispanic. PWD took an average of 13 (±5.3) medications at baseline. Care partners were on average 66 (13) years of age and most were spouses/partners of the PWD. Content analysis identified five themes: (1) Reducing medication-related treatment burden; (2) Alleviating burdensome symptoms; (3) Maintaining cognition and function; (4) Discussion of tradeoffs; (5) Challenges to deprescribing. After eliciting patient and care partner priorities, pharmacists recommended both deprescribing and prescribing.

CONCLUSION

Findings from this secondary analysis of a pilot deprescribing intervention suggest eliciting medication-related priorities of PWD and care partners can support goal-concordant care. These results can inform development of interventions to optimize medications for this population.

Resigned but Resilient: Caregiver Perceptions of Role Ambiguity and Quality of Care During Hospital-to-Home Transitions of Older Latinos Living With Dementia

ObjectivesHospital-to-home transitions are high-risk periods, especially for Latinos living with dementia. Cultural differences may exacerbate role ambiguity-unclear patient/caregiver/provider roles. The objective was to elicit views on role ambiguity and care quality during hospital-to-home transitions of older Latinos with dementia and categorize factors shaping healthcare-related task distribution.MethodsQualitative study using semi-structured interviews with caregivers of older Latinos with dementia.ResultsInterviews with 21 caregivers indicated 1) concern about over-medication, 2) resignation over limited medication effectiveness, 3) scarcity of culturally specific resources, 4) wariness to trust medical institutions, and 5) aversion to institutional care. Factors shaping healthcare-related tasks were geographic proximity, gender roles, relationship to patient, English fluency, and work schedules.DiscussionCaregivers felt disillusioned and unsupported during care transitions. Findings suggest healthcare professionals and advocacy organizations should carefully consider efforts to connect caregivers to sources of culturally tailored, home-based support, and they could engage in concerted efforts to earn trust.

Receipt of Medicare Part D comprehensive medication reviews in older adults with dementia

BACKGROUND

Older adults with Alzheimer disease and related dementias (ADRDs) are at high risk for medication-related problems. Comprehensive medication reviews (CMRs), required in Medicare Part D medication therapy management (MTM) programs, aim to optimize medication use and reduce adverse events. Individual factors related to MTM eligibility and CMR receipt among beneficiaries with ADRD are unknown.

OBJECTIVE

To examine MTM eligibility and CMR receipt among older adults with ADRD compared with those without.

METHODS

This retrospective, cross-sectional study included 2014 Health and Retirement Study participants aged at least 65 years, with continuous Medicare fee-for-service and Part D coverage. Outcomes were MTM eligibility and CMR receipt in 2014 or 2015. Our primary independent variable was presence of diagnosed ADRD. Covariates included sociodemographic characteristics, health conditions, and functional limitations. Weighted descriptive and bivariate statistics and multivariable logistic regression were used.

RESULTS

We included 14,778,506 older adults and 10.1% had ADRD. Those with ADRD were older (mean age [SE] = 83 [0.6] vs 75 [0.2] years; P < 0.001), had a higher proportion of Black (11.6% vs 6.3%) and Hispanic (5.7% vs 4.7%) race and ethnicity (P = 0.008), and had higher MTM eligibility (25.3% vs 14.8%; P < 0.001) compared with those without ADRD. Older adults with ADRD were more likely to be eligible for MTM (odds ratio [OR] = 1.95, 95% CI = 1.41-2.70) but not after adjusting for covariates (adjusted OR = 1.41, 95% CI = 0.88-2.27). Overall, 16.9% received a CMR. CMR receipt was lower in those with ADRD compared with those without (10.4% vs 18.2%), but not significantly different (P  = 0.12). ADRD status was not associated with CMR receipt (OR = 0.52, 95% CI = 0.23-1.21, adjusted OR = 0.75, 95% CI = 0.25-2.29).

CONCLUSIONS

Older adults with ADRD were not more likely to be MTM eligible or receive a CMR compared with those without ADRD. Strategies to improve MTM program design are needed to increase CMR receipt among older adults with ADRD.

Improving How Caregivers of People Living With Dementia Are Identified in the Electronic Health Record: Qualitative Study and Exploratory Chart Review

Background

Family and unpaid caregivers play a crucial role in supporting people living with dementia; yet, they are not systematically identified and documented by health systems.

Objective

The aims of the study are to determine the extent to which caregivers are currently identified and documented in the electronic health record (EHR) and to elicit the perspectives of caregivers and clinical staff on how to best identify, engage, and support caregivers of people living with dementia through the EHR.

Methods

People with dementia were identified based on International Classification of Diseases, Tenth Revision (ICD-10) codes or dementia medications in the EHR. A chart review of people with dementia characterized how caregiver information was documented and whether caregivers had shared access to the patient portal. Caregivers of eligible people with dementia were then recruited through mailed letters and follow-up calls to the homes of people with dementia. We conducted semistructured interviews with caregivers, clinicians, and staff involved in the care of people with dementia within 2 health systems in Maryland and Colorado. Transcripts were analyzed using a mixed inductive and deductive approach.

Results

Caregivers of people with dementia (N=22) were usually identified in the "contact information" or "patient contacts" tab (n=20, 91%) by their name and relation to the people with dementia; this tab did not specify the caregiver's role. Caregivers were also mentioned, and their roles were described to a varying degree in clinical notes (n=21, 96%). Of the 22 caregivers interviewed, the majority (n=17, 77%) reported that the people with dementia had additional caregivers. The presence of multiple caregivers could be gleaned from most charts (n=16, 73%); however, this information was not captured systematically, and caregivers' individual contributions were not explicitly recorded. Interviews with 22 caregivers and 16 clinical staff revealed two major themes: (1) caregiving arrangements are complex and not systematically captured or easy to locate in the EHR and (2) health systems should develop standardized processes to obtain and document caregiver information in the EHR.

Conclusions

This exploratory chart review and qualitative interview study found that people with dementia frequently have multiple caregivers, whose roles and needs are captured inconsistently in the EHR. To address this concern, caregivers and clinical staff suggested that health systems should develop and test workflows to identify caregivers, assess their needs at multiple touchpoints, and record their information in extractable EHR fields.

Use of the Patient Portal to Discuss Medications Among People with Dementia and Their Care Partners

BACKGROUND

People with dementia (PWD) often use potentially inappropriate medications (PIM), exposing them to harm. Patient portals are a promising platform for delivering deprescribing educational interventions to reduce PIM use, yet little is known about how PWD and their care partners use patient portals to communicate with clinicians about medications.

OBJECTIVE

To characterize the content of patient portal messages relating to medications among PWD, care partners, and clinicians, to inform development of a portal-based intervention to reduce use of PIM among PWD.

DESIGN

Descriptive analysis of data from the electronic health record and qualitative analysis of patient portal messages.

PARTICIPANTS

Adults 65 and older, categorized as having dementia based on EHR algorithm, who received care in an academic health system from 2017 to 2022.

APPROACH

Electronic health record data were analyzed using descriptive statistics. Qualitative coding identified topics raised in portal messages.

KEY RESULTS

A total of 399 message threads from 159 unique patients were analyzed. Patients were on average 78.4 years old (SD 8.0). Most (65%) were female, White (76%), and non-Hispanic/Latinx (96%); 15% had a registered proxy portal user. The most common topics raised in portal messages were logistics (42%), concerns about adverse effects/treatment burden (25%), asking for new medications (23%), and openness to stopping medications (21%). Qualitative analysis revealed three main themes related to deprescribing: (1) Opportunities to deprescribe, (2) challenges to deprescribing, and (3) medication-related counseling in the portal.

CONCLUSIONS

PWD and their care partners frequently raise medication concerns in the portal, suggesting it is a promising platform for delivering deprescribing interventions for this population. Future research should identify characteristics of portal-based interventions that would best support deprescribing for PWD and develop pragmatic workflows.

Mapping racial and ethnic healthcare disparities for persons living with dementia: A scoping review

INTRODUCTION

We set out to map evidence of disparities in Alzheimer's disease and Alzheimer's disease related dementias healthcare, including issues of access, quality, and outcomes for racial/ethnic minoritized persons living with dementia (PLWD) and family caregivers.

METHODS

We conducted a scoping review of the literature published from 2000 to 2022 in PubMed, PsycINFO, and CINAHL. The inclusion criteria were: (1) focused on PLWD and/or family caregivers, (2) examined disparities or differences in healthcare, (3) were conducted in the United States, (4) compared two or more racial/ethnic groups, and (5) reported quantitative or qualitative findings.

RESULTS

Key findings include accumulating evidence that minoritized populations are less likely to receive an accurate and timely diagnosis, be prescribed anti-dementia medications, and use hospice care, and more likely to have a higher risk of hospitalization and receive more aggressive life-sustaining treatment at the end-of-life.

DISCUSSION

Future studies need to examine underlying processes and develop interventions to reduce disparities while also being more broadly inclusive of diverse populations.

Medication exposure of the dyad patient-caregiver in Alzheimer's disease and related dementias: a cross-sectional study

BACKGROUND

Patients with Alzheimer's disease and related dementias and their caregivers can be defined as people with higher risk of developing medication-related problems due to aging and polypharmacy.

AIM

To assess the medication exposure of patient with Alzheimer's disease and related dementias and their caregivers.

METHOD

Ancillary cross-sectional study based on baseline medication data of the PHARMAID RCT. The PHARMAID study was a multi-center RCT assessing an integrated pharmaceutical care at a psychosocial program. Older outpatients with Alzheimer's disease and related dementias and their older caregivers were eligible for inclusion. Baseline medication data were used to assess the medication exposure, illustrated by the number of medications, the prevalence of potentially inappropriate medications (PIMs) using the EU(7)-PIM list and the Medication Regimen Complexity Index (MRCI).

RESULTS

Seventy-three dyads were included in this ancillary study. The mean numbers (SD) of medications used by patients was 6.8 (2.6) and by caregivers was 4.7 (3.7). Overall, 60.3% of patients used at least one PIM and 47.9% of caregivers. Regarding the medication regimen complexity, the mean MRCI was 16.3(8.1) for patients and 11.3(10.5) for caregivers.

CONCLUSION

The results of this study confirm the relevance of carrying out medication review with patients, but also with their caregivers who can be considered as hidden patients.

Factors Associated with Psychotropic Medication Use in People Living with Dementia in the Community: A Systematic Review and Meta-Analysis

BACKGROUND

There has been considerable focus on the use of psychotropic agents in people living with dementia in long-term care. However, psychotropic use often commences well before transitioning to long-term care.

OBJECTIVES

To synthesize the available literature to identify factors associated with psychotropic medication use in people living with dementia in the community.

METHODS

This PROSPERO-registered review reports findings from a comprehensive search of Embase, PsycINFO, and PubMed (including MEDLINE) databases according to predefined inclusion and exclusion criteria (2010-2022). Inclusion criteria were original prospective or retrospective design research papers enrolling people diagnosed with dementia utilizing a psychotropic medication and living at home. Quality and risk of bias was assessed Newcastle-Ottawa Quality Assessment Scale. The last search was conducted in November 2022. Thematic analysis was used to synthesize the emergent factors identified, and a meta-analysis was undertaken on suitable data.

RESULTS

The search identified 619 articles. After review and exclusions, 39 articles were included for synthesis, including 1,338,737 people. The majority of papers (67%) were rated as low risk of bias and corresponding good quality. Thematic analysis suggested associations between psychotropic prescribing and patient and environmental factors, with little data concerning carer and prescriber factors. Such factors included age (< 75 years, > 90 years), sex, more advanced functional decline, and living alone. Meta-analysis identified significant associations between psychotropic use and respite (temporary full-time care or hospitalization) and comorbid psychiatric illness.

CONCLUSIONS

While it is clear from this review that there remains a significant lack of clarity as to the reasons why these medications are being utilized in this population, this review provides greater insight and understanding into the context of psychotropic use. The study has highlighted an opportunity for further targeted research to be conducted and provides a much-needed context for this to occur.

PROSPERO REGISTRATION NUMBER

CRD42021286322.

Global prevalence of polypharmacy and potentially inappropriate medication in older patients with dementia: a systematic review and meta-analysis

Background: Older patients with dementia always need multiple drugs due to comorbidities and cognitive impairment, further complicating drug treatment and increasing the risk of potentially inappropriate medication. The objective of our study is to estimate the global prevalence of polypharmacy and potentially inappropriate medication (PIM) and explore the factors of PIM for older patients with dementia. Methods: We searched PubMed, Embase (Ovid), and Web of Science databases to identify eligible studies from inception to 16 June 2023. We conducted a meta-analysis for observational studies reporting the prevalence of potentially inappropriate medication and polypharmacy in older patients with dementia using a random-effect model. The factors associated with PIM were meta-analyzed. Results: Overall, 62 eligible studies were included, of which 53 studies reported the prevalence of PIM and 28 studies reported the prevalence of polypharmacy. The pooled estimate of PIM and polypharmacy was 43% (95% CI 38-48) and 62% (95% CI 52-71), respectively. Sixteen studies referred to factors associated with PIM use, and 15 factors were further pooled. Polypharmacy (2.83, 95% CI 1.80-4.44), diabetes (1.31, 95% CI 1.04-1.65), heart failure (1.17, 95% CI 1.00-1.37), depression (1.45, 95% CI 1.14-1.88), history of cancer (1.20, 95% CI 1.09-1.32), hypertension (1.46, 95% CI 1.05-2.03), ischemic heart disease (1.55, 95% CI 0.77-3.12), any cardiovascular disease (1.11, 95% CI 1.06-1.17), vascular dementia (1.09, 95% CI 1.03-1.16), chronic obstructive pulmonary disease (1.39, 95% CI 1.13-1.72), and psychosis (1.91, 95% CI 1.04-3.53) are positively associated with PIM use. Conclusion: PIM and polypharmacy were highly prevalent in older patients with dementia. Among different regions, the pooled estimate of PIM use and polypharmacy varied widely. Increasing PIM in older patients with dementia was closely associated with polypharmacy. For other comorbidities such as heart failure and diabetes, prescribing should be cautioned.

Deprescribing research in nursing home residents using routinely collected healthcare data: a conceptual framework

BACKGROUND

Efforts are needed to strengthen evidence and guidance for appropriate deprescribing for older nursing home (NH) residents, who are disproportionately affected by polypharmacy and inappropriate prescribing. Given the challenges of conducting randomized drug withdrawal studies in this population, data from observational studies of routinely collected healthcare data can be used to identify patients who are apparent candidates for deprescribing and evaluate subsequent health outcomes. To improve the design and interpretation of observational studies examining determinants, risks, and benefits of deprescribing specific medications in older NH residents, we sought to propose a conceptual framework of the determinants of deprescribing in older NH residents.

METHODS

We conducted a scoping review of observational studies examining patterns and potential determinants of discontinuing or de-intensifying (i.e., reducing) medications for NH residents. We searched PubMed through September 2021 and included studies meeting the following criteria: conducted among adults aged 65 + in the NH setting; (2) observational study designs; (3) discontinuation or de-intensification as the primary outcome with key determinants as independent variables. We conceptualized deprescribing as a behavior through a social-ecological lens, potentially influenced by factors at the intrapersonal, interpersonal, organizational, community, and policy levels.

RESULTS

Our search in PubMed identified 250 potentially relevant studies published through September 2021. A total of 14 studies were identified for inclusion and were subsequently synthesized to identify and group determinants of deprescribing into domains spanning the five core social-ecological levels. Our resulting framework acknowledges that deprescribing is strongly influenced by intrapersonal, patient-level clinical factors that modify the expected benefits and risks of deprescribing, including index condition attributes (e.g., disease severity), attributes of the medication being considered for deprescribing, co-prescribed medications, and prognostic factors. It also incorporates the hierarchical influences of interpersonal differences relating to healthcare providers and family caregivers, NH facility and health system organizational structures, community trends and norms, and finally healthcare policies.

CONCLUSIONS

Our proposed framework will serve as a useful tool for future studies seeking to use routinely collected healthcare data sources and observational study designs to evaluate determinants, risks, and benefits of deprescribing for older NH residents.

Impact of pharmaceutical care integrated at a psychosocial intervention to reduce caregiver's burden in Alzheimer's disease or related dementias: Negative results at 18 months and difficulties to conduct PHARMAID RCT

Background

Psychosocial interventions for caregivers of patients with Alzheimer disease and relative dementias (ADRD) reported a caregiver burden improvement. Multicomponent intervention integrating pharmaceutical care has not yet been evaluated while ADRD patients and their caregivers are exposed to high risk of drug-related problems. The PHARMAID study aimed to assess the impact of personalized pharmaceutical care integrated to a psychosocial program on the burden of ADRD caregivers at 18 months.

Methods

The PHARMAID RCT was conducted between September 2016 and June 2020 [ClinicalTrials.gov: NCT02802371]. PHARMAID study planned to enroll 240 dyads, i.e. ADRD patients and caregivers, whose inclusion criteria were: outpatient with mild or major neurocognitive disorders due to ADRD, living at home, receiving support from a family caregiver. Three parallel groups compared a control group with two interventional groups: psychosocial intervention and integrated pharmaceutical care at a psychosocial intervention. The main outcome was the caregiver burden assessed by the Zarit Burden Index (ZBI, score range 0-88) at 18 months.

Results

Overall, 77 dyads were included (32% of the expected sample size). At 18 months, the mean ZBI scores were 36.7 ± 16.8 in the control group, 30.3 ± 16.3 for the group with psychosocial intervention, and 28.8 ± 14.1 in group with integrated pharmaceutical care at psychosocial intervention. No significant difference was demonstrated between the three groups (p = 0.326).

Conclusions

The findings suggest that PHARMAID program had no significant impact on caregiver burden at 18 months. Several limitations have been highlighted and discussed by the authors in order to formulate recommendations for further research.

Helping the Helpers - A research protocol for user-centered technology to aid caregiver management of medications for people with Alzheimer's disease and related dementias

BACKGROUND AND OBJECTIVE

Systematically supporting caregiver-assisted medication management through IT interventions is a critical area of need toward improving outcomes for people living with ADRD and their caregivers, but a significant gap exists in the evidence base from which IT interventions to support caregivers' medication tasks can be built. User-centered design can address the user needs evidence gap and provide a scientific mechanism for developing IT interventions that meet caregivers' needs. The present study employs the three phases of user-centered design to address the first two stages of the NIH Stage Model for Behavioral Intervention Development.

METHODS

We will conduct a three-phase study employing user-centered design techniques across three aims: Aim 1) assess the needs of ADRD caregivers who manage medications for people with ADRD (Stage 0); Aim 2) co-design a prototype IT intervention to support caregiver-assisted medication management collaboratively with ADRD caregivers (Stage IA); and Aim 3) feasibility test the prototype IT intervention with ADRD caregivers (Stage IB).

DISCUSSION

Our user-centered design protocol provides a template for integrating the three phases of user-centered design to address the first two stages of the NIH Stage Model that can be used broadly by researchers who are developing IT interventions for ADRD caregivers.

Prevalence of potentially inappropriate medications among old people with major neurocognitive disorder in 2012 and 2017

Background

The increased risk of adverse drug reactions due to age-related altered pharmacokinetics and pharmacodynamics is a challenge when prescribing medications to older people, and especially among older people with major neurocognitive disorder who are particularly sensitive to drug effects. The aim of this study was to investigate the use of potential inappropriate medications (PIMs) in 2012 and 2017 among old people with major neurocognitive disorder. A secondary aim was to investigate factors associated with PIM use.

Methods

This register-study was based on the Swedish registry for cognitive/dementia disorders and the Swedish prescribed drug register. Criteria from the National Board of Health and Welfare were used to identify PIMs between 1 July–31 December 2012 and 1 July-–31 December 2017 among people ≥ 65 years. Drug use was defined as one or more filled prescriptions during each timeframe.

Results

The total use of PIMs declined significantly between 2012 (28.7%) and 2017 (21.7%). All PIMs and PIM groups declined between these years, except for antipsychotic drugs, which increased from 11.6% to 12.3%. The results from the multiple regression model found that PIM use was associated with younger age (OR: 0.97 CI: 0.96–0.97), a lower Mini Mental State Examination score (OR: 0.99 CI: 0.99–1.00), the use of multi-dispensed drugs (OR: 2.05 CI: 1.93–2.18), and compared to Alzheimer’s disease, with the subtypes dementia with Lewy bodies and Parkinson’s disease dementia (OR: 1.57 CI: 1.40–1.75), frontotemporal dementia (OR: 1.29 CI: 1.08–1.54) and vascular dementia (OR: 1.10 CI: 1.03–1.16).

Conclusions

Overall, the use of PIMs decreased between the years 2012 and 2017. The increase of antipsychotic drugs and the association between PIM use and multi-dispensed drugs warrant concern.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03240-y.

Potentially Inappropriate Medications Pre- and Post-Diagnosis of Major Neurocognitive Disorders Among Older People in Sweden: A Register-Based, 6-Year Longitudinal Study

Objective

The aim of the present study was to investigate how potentially inappropriate medication usage and anti-dementia drug use change from 3 years prior to, up until 3 years post-diagnosis of major neurocognitive disorders among older people living in Sweden.

Methods

People registered in the Swedish registry for cognitive/dementia disorders from 1 July, 2008 to 31 December, 2017, and aged 68 years or older at diagnosis, were included (n = 67,226). Data were combined with the Swedish Prescribed Drug Registry to obtain information about drugs collected in 6-month periods at Swedish pharmacies from 3 years pre-diagnosis until 3 years post-diagnosis. Potentially inappropriate medications were identified according to Swedish national guidelines. A generalised estimating equation regression model and estimated marginal means were used.

Results

Of the 67,226 people included in the study population, 59.2% were women and the mean age ± standard deviation was 81.5 ± 6.4 years, 47.0% lived together with a spouse or partner, and 88.9% were living at home at the time of diagnosis. The proportions of people using potentially inappropriate medications continuously decreased pre- and post-diagnosis, except for antipsychotic drug use, which continuously increased both pre- and post-diagnosis. Moreover, anticholinergic drug use increased pre-diagnosis and declined post-diagnosis. When comparing the periods pre- and post-diagnosis date, the adjusted proportion of people using potentially inappropriate medications was significantly lower post-diagnosis compared with pre-diagnosis, except for the adjusted proportion using antipsychotics, which was significantly higher post-diagnosis, 10.6%, compared with the period before, 3.1% (adjusted odds ratio 3.71; 95% confidence interval 3.59–3.83). The adjusted proportion of people using anticholinergic drugs was significantly lower post-diagnosis, 7.2%, compared with the pre-diagnosis period, 8.9% (adjusted odds ratio 0.80; 95% confidence interval 0.78–0.82). Anti-dementia drug use was significantly higher post-diagnosis, 52.6%, when compared with the pre-diagnosis period, 3.5% (adjusted odds ratio 30.13; 95% confidence interval 29.19–31.10).

Conclusions

Overall, the prevalence of people using potentially inappropriate medications decreased and was significantly lower post-diagnosis of major neurocognitive disorders, except for antipsychotics. This indicates that potentially inappropriate medication use should be noticed and reviewed among all older people. The small decrease in the prevalence of anticholinergic drug users and the increasing proportions of people using antipsychotic drugs post-diagnosis are of special concern because of the adverse drug reactions associated with these types of potentially inappropriate medications. Consequently, it is important to identify and regularly question anticholinergic and antipsychotic drug treatment to prevent unnecessary and serious adverse drug reactions among a vulnerable group of people.

Development of a tool to evaluate medication management guidance provided to carers of people living with dementia at hospital discharge: a mixed methods study

OBJECTIVE

Medication management guidance for carers of people with dementia at hospital discharge is important to prevent medication-related harm during transitions of care. This study aimed to develop a tool to evaluate medication management guidance provided to carers of people with dementia at hospital discharge.

DESIGN

The tool was developed using mixed methods involving two stages. Stage 1 involved item generation and content validation. Items were based on a previous qualitative study and systematic review. Content validation involved experts and consumers with knowledge or experience of medication management guidance in the acute care setting, and rating each item on importance and relevance. Stage 2 involved conducting cognitive interviews with carers of people with dementia to pretest the tool.

SETTING

For stage 1, experts and consumers from Australia, USA and New Zealand were included. For stage 2, carers of people with dementia were recruited across Australia.

PARTICIPANTS

18 experts and consumers participated in round 1 of content validation, and 13 experts and consumers completed round 2. Five carers of people with dementia participated in cognitive interviews.

RESULTS

The final tool contained 30 items capturing information across five domains: (1) provision of medication management guidance at hospital discharge; (2) carer understanding of medication management guidance provided at discharge; (3) carer engagement in discussing the safe use of medications at discharge; (4) carer preparedness to conduct medication management activities after discharge; and (5) co-ordination of medication management guidance after discharge.

CONCLUSIONS

We developed the first tool to assess medication management guidance provided for carers of people with dementia at hospital discharge. The tool may be useful to inform future research strategies to improve the delivery of medication management guidance at discharge.

The value of deprescribing in older adults with dementia: a narrative review

Introduction:Mitigating the burden of unnecessary polypharmacy or multiple medication use in people living with dementia has been recognized as a key priority internationally. One approach to reducing inappropriate polypharmacy is through medication withdrawal or deprescribing.Area covered:Non-systematic searches of key databases including PubMed, Embase, and Google Scholar were conducted from inception to 28 February 2021 for articles that assessed the safety and/or efficacy of deprescribing in older adults living with dementia. Personal reference libraries were also utilized. Information on current clinical trials was found in clinicaltrial.gov.Expert Opinion: There is limited direct evidence to inform deprescribing in older adults with dementia specifically. This review identified nineteen studies that have assessed the impact of deprescribing interventions to reduce inappropriate polypharmacy or direct deprescribing of specific medications. However, the current evidence is limited in scope as most studies focused on medication-related outcomes (e.g. discontinuation of high-risk medications) rather than patient-centered outcomes in individuals living with dementia. Furthermore, most studies focused on addressing inappropriate polypharmacy in older adults with dementia living in long-term care facilities, and interventions did not involve the person and their carer. Further evidence on the impact of deprescribing in this population across clinical settings is needed.

Polypharmacy among older adults with dementia compared with those without dementia in the United States

BACKGROUND/OBJECTIVES

In older persons with dementia (PWD), extensive medication use is often unnecessary, discordant with goals of care, and possibly harmful. The objective of this study was to determine the prevalence and medication constituents of polypharmacy among older PWD attending outpatient visits in the United States.

DESIGN

Cross-sectional analysis.

SETTING AND PARTICIPANTS

PWD and persons without dementia (PWOD) aged ≥65 years attending outpatient visits recorded in the nationally representative National Ambulatory Medical Care Survey (NAMCS), 2014-2016.

MEASUREMENTS

PWD were identified as those with a diagnosis of dementia on the NAMCS encounter form and/or those receiving an anti-dementia medication. Visits with PWD and PWOD were compared in terms of sociodemographic, practice/physician factors, comorbidities, and prescribing outcomes. Regression analyses examined the effect of dementia diagnosis on contributions by clinically relevant medication categories to polypharmacy (defined as being prescribed ≥5 prescription and/or nonprescription medications).

RESULTS

The unweighted sample involved 918 visits for PWD and 26,543 visits for PWOD, representing 29.0 and 780 million outpatient visits. PWD had a median age of 81 and on average had 2.8 comorbidities other than dementia; 63% were female. The median number of medications in PWD was eight compared with three in PWOD (p < 0.001). After adjustment, PWD had significantly higher odds of being prescribed ≥5 medications (AOR 3.0; 95% CI: 2.1-4.3) or ≥10 medications (AOR 2.8; 95% CI: 2.0-4.2) compared with PWOD. The largest sources of medications among PWD were cardiovascular and central nervous system medications; usage from other categories was generally elevated in PWD compared with PWOD. PWD had higher odds of receiving at least one highly sedating or anticholinergic medication (AOR 2.5; 95% CI: 1.6-3.9).

CONCLUSION

In a representative sample of outpatient visits, polypharmacy was extremely common among PWD, driven by a wide array of medication categories. Addressing polypharmacy in PWD will require cross-cutting and multidisciplinary approaches.

Healthcare Utilization in Different Stages among Patients with Dementia: A Nationwide Population-Based Study

To evaluate the trend of healthcare utilization among patients with dementia (PwD) in different post-diagnosis periods, Taiwan's nationwide population database was used in this study. PwD were identified on the basis of dementia diagnoses during 2002-2011. We further subdivided the cases into 10 groups from the index year to the 10th year after diagnosis. The frequency of emergency department visits and hospitalizations, the length of stay, outpatient and department visits, and the number of medications used were retrieved. The Joinpoint regression approach was used to estimate the annual percent change (APC) of healthcare utilization. The overall trend of healthcare utilization increased with the progression of dementia, with a significant APC during the first to second year after diagnosis (p < 0.01), except that the frequency of outpatient visits showed a decreasing trend with a significant APC from the first to fifth year. All sex- and age-stratified analyses revealed that male gender and old age contributed to greater use of healthcare services but did not change the overall trend. This study provides a better understanding of medical resource utilization across the full spectrum of dementia, which can allow policymakers, physicians, and caregivers to devise better care plans for PwD.

Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review

BACKGROUND

Hospital discharge has a significant impact on the continuity of care for people living with dementia. Clear guidance on medication management should be provided to caregivers of people living with dementia to ensure appropriate use of medications post-discharge.

AIM

Identify and appraise the impact of interventions at hospital discharge to guide caregivers in the medication management for people living with dementia.

METHOD

A systematic search of original studies was performed in Medline, Embase, PsycINFO, and CINAHL. Articles published in English that reported on interventions to guide caregivers in medication management for people living with dementia were included. Two authors independently reviewed titles and abstract. Full-text articles were assessed for eligibility and quality assessment was conducted by two authors.

RESULTS

A total of five studies were included with a range of interventions that were typically delivered post-discharge by a multidisciplinary team and most targeted administration of medications by caregivers. Overall, three types of discharge interventions were identified including a pre-discharge caregiver educational intervention, a post-discharge multidisciplinary team intervention, and discharge summary documentation intervention at transitions of care. Of these, a pre-discharge caregiver education led to shorter hospital stay (25 days vs. 31 days, p = 0.005). A post-discharge intervention that included follow-up visits resulted in lower use of high-risk medications (19% vs. 40%), and reduction in 30-day re-hospitalization rates (11% vs. 20%). In contrast, in another post-discharge intervention study, no difference in one-month re-hospitalization rates (8.4% vs. 8.0%, p = 0.82) was demonstrated. In another study, a post-discharge hospital educational program provided to caregivers  led to significantly reduced caregiver burden (31.7 ± 17.6 (SD) pre-intervention to 27.7 ± 16.9 (SD) post-intervention (p = 0.037)).

DISCUSSION

Current findings suggest there is a need for well-designed interventions to guide caregivers in all aspects of medication management for people living with dementia, and should include support for caregivers in care coordination.

The Critical Need to Recognize That Families Matter for Adult Health: A Systematic Review of the Literature

A systemic approach to researching families and health should capture the complex network within which family members are embedded, including multiple family relationships and larger systems of health care. However, much of the families and health research focused on adult family members has focused solely on intimate partnerships, usually the marital relationship. This neglects the remainder of the powerfully influencing family relationships adults retain, and may increasingly focus on as they age. We conducted a systematic review of the families and adult health literature, retaining 72 articles which were subsequently thematically coded to highlight main foci of this area of research. Results highlight six themes, which include family relationship quality, family composition, behavioral factors in health and health care, psychophysiological mediators, caregiving, and aging health. Findings support an underrepresentation of family members, other than the intimate partner, in research on adult health.

Potentially inappropriate medication and associated factors such as depression and dementia: An analysis of middle-aged and elderly people

AIMS: To establish the frequency potentially inappropriate medications use and the associated factors, such as signs and symptoms of depression and cognitive deficit among middle-aged and elderly people.METHODS: A cross-sectional population study was performed with 2,350 people, aged between 55-103 years, registered in the primary health care. Potentially inappropriate medications were defined by updated 2019 Beers criteria. Studied variables were sociodemographic, lifestyle and health, and signs and symptoms of depression and cognitive deficit. Multinomial regression analysis was executed.RESULTS: The frequency of potentially inappropriate medications use was 65.4%. Former and current smokers, regular self-perception of health, polypharmacy, and individuals with signs and symptoms of depression and cognitive deficit were significantly associated with potentially inappropriate medications use. Antiarrhythmics, antihistamines and antiadrenergic agents were the highest potentially inappropriate medications classes used for individuals with signs and symptoms of depression and cognitive deficit.CONCLUSIONS: The frequency of use of potentially inappropriate medications is high among middle-aged people, a population that was previously under-researched, as well as among elderly people. Cognitive impairment alone or together with depression symptoms were associated factor for a potentially inappropriate medications use. Knowledge of the pharmacoepidemiology of potentially inappropriate medications is an important for the promotion of the rational use of drugs in public health.

Effect of Andrographis paniculata leaves extract on neurobehavioral and biochemical indices in scopolamine-induced amnesic rats

Andrographis paniculata is a medicinal herb that is used to treat various disease conditions due to its pharmacological properties. Thus, this study sought to assess the effect of A. paniculata extract on neurobehavioral and some biochemical parameters in scopolamine-induced amnesic rats. Thirty-five male rats were divided into seven groups and treated with aqueous extract of A. paniculata (50 and 500 mg/kg) and donepezil (5 mg/kg) for 14 days before administration of scopolamine. Behavioral studies (Morris water maze and Y-maze) were carried out to evaluate cognitive dysfunction in scopolamine-induced rats. Biochemical assays such as cholinesterases (AChE and BChE), monoamine oxidase (MAO), and purinergic activities were determined. Results revealed the presence of orientin, quercetin, caffeic acid, apigenin, and gallic acid in A. paniculata. Also, findings from this study showed that aqueous extract of A. paniculata had a modulatory effect on scopolamine-induced cognitive impairment and could be used in the management of memory loss. PRACTICAL APPLICATIONS: Aqueous extract of A. paniculata characterized revealed the presence of polyphenols which are antioxidants. The inhibitory activity possessed by A. paniculata on some enzymes linked to neurodegeneration could be due to the antioxidant activity. Given this, we recommend that results gotten from this study could be used to develop treatment therapy for neurodegeneration. However, in-depth studies should be carried out on the toxic effect of A. paniculata to ascertain a safe dose for treatment.

Interdisciplinary palliative care for people with advanced Parkinson's disease: a view from the home

BACKGROUND

Advanced Parkinson's disease (PD) is a multidimensional neurodegenerative condition with motor and non-motor symptoms contributing to increasing disability and decreasing quality of life. As the disease progresses, patients may become homebound and estranged from neurological care, with dire consequences. We describe the increasing epidemiologic burden of and individual risks faced by patients with palliative-stage PD and their caregivers.

METHODS

With the aim of mitigating these risks, we designed and iterated two models of interdisciplinary home visits to maintain continuity of care and illuminate the unmet needs and barriers to care faced by this population. We describe both models in detail, with data on feasibility and patient-centered outcomes achieved in the initial model, and baseline characteristics of participants in the ongoing expanded model. Finally, we illustrate the scope and common themes of such palliative care-informed home visits with two cases.

RESULTS

The pilot model involved over 380 visits with 109 individual patients. Among those patients, PD severity worsened by nearly 12 points annually on the Unified Parkinson's Disease Rating Scale (UPDRS), without a corresponding decline in quality of life. In an ongoing study of the second iteration of the model, 52 patient-caregiver dyads have completed their initial visit, with 44% bearing a diagnosis of dementia and the majority requiring an assistive device or being bedbound. Two cases highlight the critical importance of thorough medication reconciliation and home safety assessment in the comprehensive evaluation and management of such patients.

CONCLUSIONS

As our population ages, therapies increase, and the number of individuals living with advanced PD and related disorders grows, so too does the imperative to recognize and address the palliative care needs of such patients and families. For many, home may be a viable, and perhaps optimal, site for this care.

Creatinine versus cystatin C for renal function-based mortality prediction in an elderly cohort: The Northern Manhattan Study

Background

Estimated glomerular filtration rate (eGFR) is routinely utilized as a measure of renal function. While creatinine-based eGFR (eGFRcr) is widely used in clinical practice, the use of cystatin-C to estimate GFR (eGFRcys) has demonstrated superior risk prediction in various populations. Prior studies that derived eGFR formulas have infrequently included high proportions of elderly, African-Americans, and Hispanics.

Objective

Our objective as to compare mortality risk prediction using eGFRcr and eGFRcys in an elderly, race/ethnically diverse population.

Design

The Northern Manhattan Study (NOMAS) is a multiethnic prospective cohort of elderly stroke-free individuals consisting of a total of 3,298 participants recruited between 1993 and 2001, with a median follow-up of 18 years.

Participants

We included all Northern Manhattan Study (NOMAS) participants with concurrent measured creatinine and cystatin-C.

Main measures

The eGFRcr was calculated using the CKD-EPI 2009 equation. eGFRcys was calculated using the CKD-EPI 2012 equations. The performance of each eGFR formula in predicting mortality risk was tested using receiver-operating characteristics, calibration and reclassification. Net reclassification improvement (NRI) was calculated based on the Reynolds 10 year risk score from adjusted Cox models with mortality as an outcome. The primary hypothesis was that eGFRcys would better predict mortality than eGFRcr.

Results

Participants (n = 2988) had a mean age of 69±10.2 years and were predominantly Hispanic (53%), overweight (69%), and current or former smokers (53% combined). The mean eGFRcr (74.68±18.8 ml/min/1.73m²) was higher than eGFRcys (51.72±17.2 ml/min/1.73m²). During a mean of 13.0±5.6 years of follow-up, 53% of the cohort had died. The AUC of eGFRcys (0.73) was greater than for eGFRcr (0.67, p for difference<0.0001). The proportions of correct reclassification (NRI) based on 10 year mortality for the model with eGFRcys compared to the model with eGFRcr were 4.2% (p = 0.002).

Conclusions

In an elderly, race/ethnically diverse cohort low eGFR is associated with risk of all-cause mortality. Estimated GFR based on serum cystatin-C, in comparison to serum creatinine, was a better predictor of all-cause mortality.

Usability and feasibility of consumer-facing technology to reduce unsafe medication use by older adults

BACKGROUND

Mobile health technology can improve medication safety for older adults, for instance, by educating patients about the risks associated with anticholinergic medication use.

OBJECTIVE

This study's objective was to test the usability and feasibility of Brain Buddy, a consumer-facing mobile health technology designed to inform and empower older adults to consider the risks and benefits of anticholinergics.

METHODS

Twenty-three primary care patients aged ≥60 years and using anticholinergic medications participated in summative, task-based usability testing of Brain Buddy. Self-report usability was assessed by the System Usability Scale and performance-based usability data were collected for each task through observation. A subset of 17 participants contributed data on feasibility, assessed by self-reported attitudes (feeling informed) and behaviors (speaking to a physician), with confirmation following a physician visit.

RESULTS

Overall usability was acceptable or better, with 100% of participants completing each Brain Buddy task and a mean System Usability Scale score of 78.8, corresponding to "Good" to "Excellent" usability. Observed usability issues included higher rates of errors, hesitations, and need for assistance on three tasks, particularly those requiring data entry. Among participants contributing to feasibility data, 100% felt better informed after using Brain Buddy and 94% planned to speak to their physician about their anticholinergic related risk. On follow-up, 82% reported having spoken to their physician, a rate independently confirmed by physicians.

CONCLUSION

Consumer-facing technology can be a low-cost, scalable intervention to improve older adults' medication safety, by informing and empowering patients. User-centered design and evaluation with demographically heterogeneous clinical samples uncovers correctable usability issues and confirms the value of interventions targeting consumers as agents in shared decision making and behavior change.

An Interdisciplinary Academic Detailing Approach to Decrease Inappropriate Medication Prescribing by Physician Residents for Older Veterans Treated in the Emergency Department

OBJECTIVE

To evaluate the impact of an academic detailing intervention delivered as part of a quality improvement project by a physician-pharmacist pair on (1) self-reported confidence in prescribing for older adults and (2) rates of potentially inappropriate medications (PIMs) prescribed to older adults by physician residents in a Veteran Affairs emergency department (ED).

METHODS

This quality improvement project at a single site utilized a questionnaire that assessed knowledge of Beers Criteria, self-perceived barriers to appropriate prescribing in older adults, and self-rated confidence in ability to prescribe in older adults which was administered to physician residents before and after academic detailing delivered during their emergency medicine rotation. PIM rates in the resident cohort who received the academic detailing were compared to residents who did not receive the intervention.

RESULTS

Sixty-three residents received the intervention between February 2013 and December 2014. At baseline, approximately 50% of the residents surveyed reported never hearing about nor using the Beers Criteria. A significantly greater proportion of residents agreed or strongly agreed in their abilities to identify drug-disease interactions and to prescribe the appropriate medication for the older adult after receiving the intervention. The resident cohort who received the educational intervention was less likely to prescribe a PIM when compared to the untrained resident cohort with a rate ratio of 0.73 ( P < .0001).

CONCLUSION

Academic detailing led by a physician-pharmacist pair resulted in improved confidence in physician residents' ability to prescribe safely in an older adult ED population and was associated with a statistically significant decrease in PIM rates.

Identifying potentially inappropriate prescribing in older people with dementia: a systematic review

PURPOSE

Older people with dementia are at risk of adverse events associated with potentially inappropriate prescribing.

AIM

to describe (1) how international tools designed to identify potentially inappropriate prescribing have been used in studies of older people with dementia, (2) the prevalence of potentially inappropriate prescribing in this cohort and (3) advantages/disadvantages of tools METHODS: Systematic literature review, designed and reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). MEDLINE, EMBASE, PsychInfo, CINAHL, the Cochrane Library, the Social Science Citation Index, OpenGrey, Base, GreyLit, Mednar and the National Database of Ageing Research were searched in April 2016 for studies describing the use of a tool or criteria to identify potentially inappropriate prescribing in older people with dementia.

RESULTS

Three thousand three hundred twenty-six unique papers were identified; 26 were included in the review. Eight studies used more than one tool to identify potentially inappropriate prescribing. There were variations in how the tools were applied. The Beers criteria were the most commonly used tool. Thirteen of the 15 studies using the Beers criteria did not use the full tool. The prevalence of potentially inappropriate prescribing ranged from 14 to 74% in older people with dementia. Benzodiazepines, hypnotics and anticholinergics were the most common potentially inappropriately prescribed medications.

CONCLUSIONS

Variations in tool application may at least in part explain variations in potentially inappropriate prescribing across studies. Recommendations include a more standardised tool usage and ensuring the tools are comprehensive enough to identify all potentially inappropriate medications and are kept up to date.

Neurocognitive disorders: what are the prioritized caregiver needs? A consensus obtained by the Delphi method

Background

The symptoms related to neurocognitive disorders (NCD) may lead to caregiver burden increase. Involving caregivers in research may be an effective way of improving the practicalities and relevance of interventions. The aim of this study was to gather opinion and gain consensus on the caregivers ‘priorities, using a Delphi method and including aspects of needs in pharmaceutical dimension.

Methods

Observational study using a modified Delphi method. This study was conducted in the Clinical and Research Memory Center of the University Hospital of Lyon (France), between September 2015 and January 2016. The expert panel was composed of 68 informal caregivers of people with subjective cognitive decline or NCD living at home.

Results

Caregivers assigned a very high importance to the dimension “information needs about their relative’s disease”, i.e. information on the disease, the treatment and the research; and to “coping skills”, i.e. skills related to emotional support, communication, relationship evolution with the relative and skills to cope with behavioural crisis, behavioural and cognitive disorders. The aspect “coping with behavioural disorders” received a high selection rate (83%).

Conclusions

The main needs selected can be used to design relevant interventions and give guidance to policy to support caregivers. To meet caregiver’s needs, interventions should focus on information about disease and treatment and psychoeducational interventions.

Characteristics of dual drug benefit use among veterans with dementia enrolled in the Veterans Health Administration and Medicare Part D

BACKGROUND

Obtaining prescription medications from multiple health systems may complicate coordination of care. Older Veterans who obtain medications concurrently through Veterans Affairs (VA) benefits and Medicare Part D benefits (dual users) are at higher risk of unintended negative outcomes.

OBJECTIVE

To explore characteristics predicting dual drug benefit use from both VA and Medicare Part D in a national sample of older Veterans with dementia.

METHODS

Administrative data were obtained from the VA and Medicare for a national sample of 110,828 Veterans with dementia ages 68 and older in 2010. Veterans were classified into three drug benefit user groups based on the source of all prescription medications they obtained in 2010: VA-only, Part D-only, and Dual Use. Multinomial logistic regression was used to examine predictors of drug benefit user group. The source of prescriptions was described for each of the ten most frequently used drug classes and opioids.

RESULTS

Fifty-six percent of Veterans received all of their prescription medications from VA-only, 28% from Part D-only, and 16% from both VA and Part D. Veterans who were eligible for Medicaid or who had a priority group score conferring less generous drug benefits within the VA were more likely to be Part D-only or dual users. Nearly one fourth of Veterans taking opioids concurrently received opioid prescriptions from dual sources (24.7%).

CONCLUSIONS

Medicaid eligibility and Veteran priority group status, which largely decrease copayments for drugs obtained outside versus within the VA, respectively, were the main factors predicting drug user benefit group. Policies to encourage single-system prescribing and enhance communication across health systems are crucial to preventing negative health outcomes related to care fragmentation.

Perspective of elderly patients on chronic use of potentially inappropriate medication - Results of the qualitative CIM-TRIAD study

Although potentially inappropriate medication (PIM) is associated with risk of harm due to adverse effects, it is frequently prescribed for elderly patients. The aim of this qualitative multi-center study was to gain insight into contextual factors that might lead to chronic PIM use. We conducted semi-structured interviews with elderly patients with or without chronic PIM use (patient interviews: n = 52). Patients were between 86 and 96 years old. The participants were recruited from the AgeCoDe study. Interviews were audiotaped and transcribed verbatim. The transcripts of the interviews were analysed using qualitative content analysis. Deductive and inductive categories were determined. We found contextual factors related to the patient and related to patient-general practitioner (GP) communication that might lead to chronic PIM use (i.e., positive features of PIM, maintaining characteristics of medication intake, barriers to deprescribe PIM, external actors supporting PIM intake, system-related factors). Besides certain health-related behaviours (e.g., own obligation to report to GP) and medication-related attitudes and knowledge (e.g., awareness of side effects and interaction of medicines), patient-GP-interactions that were characterised by mutual agreements on drugs (e.g., concerning dosage or discontinuation of a drug) might be advantageous to reduce the probability of chronic PIM use. The results might assist in the development of guidelines and educational programs aiming to reduce PIM use in the elderly.

Patient-Family Agenda Setting for Primary Care Patients with Cognitive Impairment: the SAME Page Trial

BACKGROUND

Establishing priorities for discussion during time-limited primary care visits is challenging in the care of patients with cognitive impairment. These patients commonly attend primary care visits with a family companion.

OBJECTIVE

To examine whether a patient-family agenda setting intervention improves primary care visit communication for patients with cognitive impairment DESIGN: Two-group pilot randomized controlled study PARTICIPANTS: Patients aged 65 + with cognitive impairment and family companions (n = 93 dyads) and clinicians (n = 14) from two general and one geriatrics primary care clinic INTERVENTION: A self-administered paper-pencil checklist to clarify the role of the companion and establish a shared visit agenda MEASUREMENTS: Patient-centered communication (primary); verbal activity, information disclosure including discussion of memory, and visit duration (secondary), from audio recordings of visit discussion RESULTS: Dyads were randomized to usual care (n = 44) or intervention (n = 49). Intervention participants endorsed an active communication role for companions to help patients understand what the clinician says or means (90% of dyads), remind patients to ask questions or ask clinicians questions directly (84% of dyads), or listen and take notes (82% of dyads). Intervention dyads identified 4.4 health issues for the agenda on average: patients more often identified memory (59.2 versus 38.8%; p = 0.012) and mood (42.9 versus 24.5%; p = 0.013) whereas companions more often identified safety (36.7 versus 18.4%; p = 0.039) and personality/behavior change (32.7 versus 16.3%; p = 0.011). Communication was significantly more patient-centered in intervention than in control visits at general clinics (p < 0.001) and in pooled analyses (ratio of 0.86 versus 0.68; p = 0.046). At general clinics, intervention (versus control) dyads contributed more lifestyle and psychosocial talk (p < 0.001) and less biomedical talk (p < 0.001) and companions were more verbally active (p < 0.005). No intervention effects were found at the geriatrics clinic. No effect on memory discussions or visit duration was observed.

CONCLUSION

Patient-family agenda setting may improve primary care visit communication for patients with cognitive impairment.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT02986958.

The risk of fall accidents for home dwellers with dementia-A register- and population-based case-control study

Introduction

Institutionalized people with dementia have an increased risk of fall accidents, but little is known about whether this increased risk holds for home dwellers.

Methods

This register- and population-based study comprised 115,584 cases and 394,679 controls. Cases were individuals with any fall between 2009 and 2014, and matched with up to six controls on age, sex, and geographic location. Individuals were excluded if they (1) had any fall in 2008, or (2) lived in a nursing home on the date of the fall. Dementia, other chronic diseases, and sedative medicines were assessed from Danish national registers.

Results

After adjusting for potential confounders, older people with dementia living at home had a 1.89-fold higher risk of fall (odds ratio = 1.89, 95% confidence interval [1.84–1.94], P < .001).

Discussion

Dementia almost doubles the risk of fall for older Danish people living at home. This highlights the need for effective fall preventions that target people with dementia.

Informal caregivers' perspectives on health of and (potentially inappropriate) medication for (relatively) independent oldest-old people - a qualitative interview study

BACKGROUND

Oldest-old persons frequently receive potentially inappropriate medication. Medication use takes place under the patients' informal caregivers' influence. We explored informal caregivers' perspectives on medication of (relatively) independent oldest-old persons to identify starting points for safer medication prescription/handling.

METHODS

In this exploratory qualitative interview study we interviewed 45 informal caregivers of 45 oldest-old persons (23 with potentially inappropriate medication/22 without potentially inappropriate medication). Interviews were recorded, transcribed and content analyzed (deductive/inductive coding).

RESULTS

Interviewees had little knowledge about/influence on oldest-old persons' medication, but declared to monitor oldest-old persons' needs for assistance. They were unaware of the concept of potentially inappropriate medication but sometimes sensitive to substance dependency. Most informal caregivers were satisfied with the oldest-old persons' medication and viewed medication as increasing the patients' quality of life. Inadequate communication was found between informal caregivers and general practitioners.

CONCLUSIONS

Influence of informal caregivers on (relatively) independent oldest-old persons' medication seems low. Stakeholders need to be aware that there is a transitional period where independency of oldest-old persons decreases and support needs increase which may be missed by (in-)formal caregivers or concealed by oldest-old persons. Monitoring patients' medication competencies; measures supporting communication between informal caregivers and health care professionals; provision of educational and support resources for informal caregivers and the acceptance of oldest-old persons' increasing assistance needs may increase medication safety.

Dementia and road traffic accidents among non-institutionalized older people in Denmark: A Danish register-based nested case-control study

AIM

We used register-based data to estimate the effect of all-type dementia on road traffic accidents (RTAs) risk, combined with comorbidities or sedative medicines, among non-institutionalized older people in Denmark.

METHODS

The source population was all residents in Denmark aged 65 years and older, alive as of January 1, 2008 ( n = 853,228). Cases were those who had any type of RTA in 2009-2014. Each case was matched for age, sex and geographic location to 4-6 controls. All-type dementia was ascertained using the International Classification of Diseases version 10 (ICD-10) diagnosis supplemented with prescribed medicine records. Eight chronic diseases were selected to assess comorbidities. Four types of medicines were categorized as sedative medicines for analysis. Conditional logistic regression with adjustment for education and marital status as well as either the number of comorbidities or sedative medications use was performed using STATA software.

RESULTS

Older people with dementia had lower RTAs risk compared to their controls (odds ratio = 0.43, 95% confidence interval (0.32-0.60), p < 0.001). Significant interaction was observed between dementia and the number of comorbidities for RTAs estimation.

CONCLUSIONS

The significantly lower RTAs risk for older individuals with dementia observed in our study may be due to people with dementia living at home having a lower frequency of outdoor activities; that is, less exposure to traffic. However, this, together with the interaction between dementia and comorbidities as well as sedative medications, should be investigated further.

Health literacy and its correlates in informal caregivers of adults with memory loss

This secondary analysis examined health literacy among informal caregivers of community-dwelling older adults with memory loss and assessed correlates of caregiver health literacy using the Abilities, Skills and Knowledge Model. Caregiver health literacy (n = 91) was assessed by the Newest Vital Sign. Limited health literacy presented in 38.5% caregivers, with significantly low document literacy. Health literacy was associated bivariately with age, education, global cognitive function, executive function, and working memory (all ps < 0.001), as well as medication knowledge (p = 0.015). Hierarchical regression analyses revealed that older age (p = 0.017), and lower global cognitive function (p < 0.001), working memory (p = 0.001), and academic skills (years of education) (p = 0.004), independently predicted lower health literacy (R² = 0.54). Medication knowledge, however, was not found to be an independent predictor in the model. Findings suggest limited health literacy is a potential issue among informal caregivers of adults with memory loss. Appropriate assessment and personalized support are needed for informal caregivers who are at high risk for poor health literacy.

(In-)formal caregivers' and general practitioners' views on hospitalizations of people with dementia - an exploratory qualitative interview study

Background

Dementia is an irreversible chronic disease with wide-ranging effects on patients’, caregivers’ and families’ lives. Hospitalizations are significant events for people with dementia. They tend to have poorer outcomes compared to those without dementia. Most of the previous studies focused on diagnoses leading to hospitalizations using claims data. Further factors (e.g. context factors) for hospitalizations are not reproduced in this data. Therefore, we investigated the factors leading to hospitalization with an explorative, qualitative study design.

Methods

We interviewed informal caregivers (N = 12), general practitioners (GPs, N = 12) and formal caregivers (N = 5) of 12 persons with dementia using a semi-structured interview guideline. The persons with dementia were sampled using criteria regarding their living situation (home care vs. nursing home care) and gender. The transcripts were analyzed using the method of structuring content analysis.

Results

Almost none of the hospitalizations, discussed with the (in-)formal caregivers and GPs, seemed to have been preventable or seemed unjustifiable from the interviewees’ points of view. We identified several dementia-specific factors promoting hospitalizations (e.g. the neglect of constricted mobility, the declining ability to communicate about symptoms/accidents and the shift of responsibility from person with dementia to informal or formal caregivers) and context-specific factors promoting hospitalizations (e.g. qualification of nursing home personal, the non-availability of the GP and hospitalizations for examinations/treatments also available in ambulatory settings). Hospitalizations were always the result of the interrelation of two factors: illnesses/accidents and context factors. The impact of both seems to be stronger in presence of dementia.

Conclusions

Points for action in terms of reducing hospitalization rates were: better qualified nurses, a 24-h-GP-emergency service and better compensation for ambulatory monitoring/treatments and house calls. Many hospitalizations of people with dementia cannot be prevented. Therefore, hospital staffs need to be better prepared to handle patients with dementia in order to reduce the negative effects of hospitalizations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2484-9) contains supplementary material, which is available to authorized users.

Use of potentially inappropriate medications among ambulatory home-dwelling elderly patients with dementia: A review of the literature

BACKGROUND

Older adults with dementia are at high risk for drug-related adverse outcomes. While much is known about potentially inappropriate medication use in older adults, its prevalence and characteristics among those with dementia are not as well elucidated. We conducted a literature review to examine the prevalence of potentially inappropriate medication use among home-dwelling older adults with dementia. Our secondary aim was to determine the most frequently implicated medications and factors associated with potentially inappropriate medication use.

METHODS

MEDLINE, EMBASE, CINAHL, and International Pharmaceutical Abstracts were searched between 1946 and 2014 for articles that referenced potentially inappropriate medication use and types of dementia. One reviewer screened all titles and abstracts from the initial search and full-text articles after the initial screen for eligibility, then 2 reviewers independently abstracted data from included studies.

RESULTS

Searches yielded 81 articles, of which 7 met inclusion criteria. Prevalence of potentially inappropriate medication use varied from 15% to 46.8%. No single drug or drug class was reported consistently across all studies as the most frequent potentially inappropriate medication, but anticholinergics and benzodiazepines, drugs that affect cognition, were among the most common medications or pharmacological classes listed.

DISCUSSION

Older adults with dementia may be particularly vulnerable to potentially inappropriate medications because of cognitive impairment from their condition and the greater likelihood of experiencing adverse events from medications. Given this population's greater susceptibility to adverse events, more intense medication and patient monitoring may be warranted, especially among those taking anticholinergics and benzodiazepines, as these drugs can contribute to cognitive impairment.

Dual Health Care System Use and High-Risk Prescribing in Patients With Dementia: A National Cohort Study

BACKGROUND

Recent federal policy changes attempt to expand veterans' access to providers outside the Department of Veterans Affairs (VA). Receipt of prescription medications across unconnected systems of care may increase the risk for unsafe prescribing, particularly in persons with dementia.

OBJECTIVE

To investigate the association between dual health care system use and potentially unsafe medication (PUM) prescribing.

DESIGN

Retrospective cohort study.

SETTING

National VA outpatient care facilities in 2010.

PARTICIPANTS

75 829 veterans with dementia who were continuously enrolled in Medicare from 2007 to 2010; 80% were VA-only users, and 20% were VA-Medicare Part D (dual) users.

MEASUREMENTS

Augmented inverse propensity weighting was used to estimate the effect of dual-system versus VA-only prescribing on 4 indicators of PUM prescribing in 2010: any exposure to Healthcare Effectiveness Data and Information Set (HEDIS) high-risk medication in older adults (PUM-HEDIS), any daily exposure to prescriptions with a cumulative Anticholinergic Cognitive Burden (ACB) score of 3 or higher (PUM-ACB), any antipsychotic prescription (PUM-antipsychotic), and any PUM exposure (any-PUM). The annual number of days of each PUM exposure was also examined.

RESULTS

Compared with VA-only users, dual users had more than double the odds of exposure to any-PUM (odds ratio [OR], 2.2 [95% CI, 2.2 to 2.3]), PUM-HEDIS (OR, 2.4 [CI, 2.2 to 2.8]), and PUM-ACB (OR, 2.1 [CI, 2.0 to 2.2]). The odds of PUM-antipsychotic exposure were also greater in dual users (OR, 1.5 [CI, 1.4 to 1.6]). Dual users had an adjusted average of 44.1 additional days of any-PUM exposure (CI, 37.2 to 45.0 days).

LIMITATION

Observational study design of veteran outpatients only.

CONCLUSION

Among veterans with dementia, rates of PUM prescribing are significantly higher among dual-system users than with VA-only users.

PRIMARY FUNDING SOURCE

U.S. Department of Veterans Affairs.

A qualitative study exploring medication management in people with dementia living in the community and the potential role of the community pharmacist

Background

The prevalence of dementia is increasing rapidly. People with dementia may be prescribed complex medication regimens, which may be challenging for them and any carers involved to safely manage.

Objective

To describe and understand the key challenges, in relation to medication issues, experienced by people with dementia and their informal carers dwelling in the community and the potential role of community pharmacists.

Design

Qualitative semi‐structured interviews.

Participants

People with dementia, informal carers and health and social care professionals (HSCPs).

Results

Thirty‐one participants (eleven informal carers, four people with dementia and sixteen HSCPs) were interviewed. Three key themes were identified: the key challenges, improving medication management and the role of pharmacists. The caring role commonly included responsibility for medication management which created both practical problems and an emotional burden. This burden was worsened by any difficulty in obtaining support and if the person with dementia was on a complex regimen. Participants believed that the process could be improved by coordinated and on‐going support from HSCPs, which should focus on the informal carer. Medication reviews, particularly when conducted in the home environment, could be helpful.

Conclusion

Medication management for people with dementia living in the community is a complex process, and informal carers have a key role, which they frequently find challenging. Community pharmacists could have an enhanced role in this area, but would need to work within a more multidisciplinary environment outside the pharmacy.

Exploring the prevalence of and factors associated with pain: a cross-sectional study of community-dwelling people with dementia

Few pain studies have made community-dwelling people with dementia (PWD) their focus. The aim of this study was to determine the prevalence of pain among this patient population and to explore medication use. Moreover, we sought to investigate patient and caregiver variables associated with the presence of pain. Community-dwelling PWD and their caregivers were recruited between May 2009 and July 2012 from outpatient memory clinics in Northern Ireland to take part in a face-to-face structured interview with a researcher. Patients' cognitive status and presence of depression were established. A full medication history was taken. Both patients and caregivers were asked to rate patients' pain, at the time of the interview and on an average day, using a 7-point verbal descriptor scale. From the 206 patients who were eligible to take part, 75 patient-caregiver dyads participated in the study (participation rate = 36.4%). The majority of patients (92.0%) had dementia classed as mild or moderate. Pain was commonly reported among the sample, with 57.3% of patients and 70.7% of caregivers reporting patient pain on an average day. Significant differences were found between patients' and caregivers' reports of pain. Two-fifths of patients (40.0%) were prescribed analgesia. Antipsychotic, hypnotic and anxiolytic drug use was low, whereas antidepressant drugs were prescribed more commonly. Presence of pain was unaffected by dementia severity; however, the use of prescribed analgesic medication was a significant predictor of the presence of pain in these patients, whether reported by the patient or their caregiver 'right now' or 'on an average day' (P < 0.001). Patient and caregiver recruitment was challenging, and remains a barrier to research in this area in the future.

Impact of Clinical Pharmacy Specialists on the Design and Implementation of a Quality Improvement Initiative to Decrease Inappropriate Medications in a Veterans Affairs Emergency Department

BACKGROUND

As the proportion of older adult patients who interface with the health care system grows, clinical pharmacy specialists (CPS) have a pivotal role in reducing potentially inappropriate medication (PIM) use in this population.

OBJECTIVES

To (a) describe CPS involvement in the design and implementation of a quality improvement (QI) initiative to decrease PIM prescribing in a Veterans Affairs (VA) emergency department (ED) and (b) report on changes in PIM prescribing before and after the initiative.

METHODS

Enhancing Quality of Prescribing Practices for Veterans Discharged from the Emergency Department (EQUiPPED) is an ongoing multisite QI project that aims to decrease ED PIM prescribing. We used a mixed-method approach that applied qualitative and quantitative measures in describing the CPS role and evaluating PIM rates. PIMs were defined using the 2012 Beers Criteria. We reported monthly PIM rates in patients aged 65 years and older who were discharged from the ED from January 2012 to November 2014. A piecewise, nonlinear regression model evaluated the pattern in PIM prescriptions over time.

RESULTS

At the Durham, North Carolina, VA Medical Center, a total of 4 CPS were involved with tailoring the design and implementation of the EQUiPPED intervention for local use. CPS input led to 3 key innovations: academic detailing performed by a physician-CPS pair, medication alert messages identifying medications as PIMs in the computerized patient record system, and automated reports describing the frequency and type of PIMs prescribed by each ED provider. Between February 2013 and November 2014, 73 ED providers received the academic detailing. The ED facility experienced a relative reduction of 47.5% in the rate of PIM prescribing over the observation period.

CONCLUSIONS

This QI project resulted in a meaningful decrease in PIM prescribing in older ED adults. CPS contributions to QI can extend beyond pharmacotherapy and provider education to also include information technology tools using formulary management expertise.

Immigrant patients with dementia and memory impairment in primary health care in Norway: a national registry study

BACKGROUND

Immigrants comprise a growing proportion of the elderly population. However, knowledge about the diagnosis and management of dementia and memory impairment among immigrants is scarce in Norway and elsewhere.

AIMS

To compare proportions of Norwegians and immigrants aged ≥50 years with a diagnosis of dementia or memory impairment in primary health care and to study the demographic characteristics, utilization of primary health care services and pharmacological treatment of Norwegians and immigrants with either of the two diagnoses in 2008.

METHOD

This is a registry-based study using linked data at the individual level from 4 national Norwegian registers.

RESULTS

A significantly lower proportion of immigrants, especially those from other than high-income countries, had a diagnosis of dementia or memory impairment. Among patients with such diagnoses, anti-dementia medication was purchased 20-50% more often by Norwegians than by immigrants, although the differences remained significant only for immigrants from other than high-income countries after adjustment for several variables.

CONCLUSION

The lower proportions of immigrants with a dementia diagnosis and lower proportions of patients receiving treatment might indicate a lower prevalence or milder forms of dementia among immigrants. However, the cultural validity of the assessment tools, linguistic barriers and challenges for general practitioners should be further investigated.

Informal Caregiver Disability and Access to Preventive Care in Care Recipients

INTRODUCTION

Many informal caregivers of dependent midlife and older adults suffer from their own functional limitations. The impact of caregiver functional limitations on care recipient receipt of preventive services is unknown. The purpose of this study is to examine the association between caregiver functional limitations and decreased access to recommended preventive services in dependent care recipients.

METHODS

Dependent adults (those receiving assistance with activities of daily living or instrumental activities of daily living) and their primary informal caregiver were identified from pooled alternate years (2000-2008) of the nationally representative Medical Expenditure Panel Survey (data analyzed February-October 2014). The impact of caregiver limitations (cognitive, mobility, sensory, emotional health) on care recipient's receipt of up to seven different preventive services was assessed via survey-weighted linear and logistic regression.

RESULTS

Of the 5-year weighted estimate of 14.2 million caregiver-care recipient dyads, 38.0% of caregivers reported at least one functional limitation. The percentage of recommended preventive services received by care recipients was significantly lower if the caregiver had cognitive, mobility, or emotional health limitations. Each type of caregiver functional limitation was negatively associated with at least four different preventive services.

CONCLUSIONS

Informal caregivers burdened by their own functional impairments may face challenges in facilitating access to preventive care in dependent midlife and older adults. Policies and interventions designed to prevent or mitigate the impact of caregiver functional impairments are critical to the success of community-based models of care for dependent adults.

The influence of personal communities on the self-management of medication taking: A wider exploration of medicine work

OBJECTIVES

There is a lack of focus on the broader social context, networks and influences on medicine-taking as part of illness work. This work adopts a social network approach and seeks to explicate the nature of medicine-taking work that people with multiple long-term conditions (LTCs) and their social network members (SNMs) do in attempting to take their medications on a daily basis, the division of labour amongst these members and when and why SNMs become involved in that work.

METHODS

Semi-structured interviews were conducted with 20 people who had multiple LTCs. Medication networks were constructed and the division of labour in relation to medication-work was explored.

RESULTS

Four types of medication-work emerged: medication articulation, surveillance, emotional and informational. Involvement of SNMs in medication-work was selective, performed primarily by family members, within the home. Involvement reflected network composition and/or an individual's conceptualisation/presentation of self.

DISCUSSION

Our findings support and extend the conceptualisation of routine medicine-taking as a type of work. Furthermore, we illustrate the involvement of SNMs in aspects of medicine-work. Health professionals should explore and support the role of SNMs in medicine-taking where possible. Future research should explore the implications of network types and compositions on medicine-taking and associated work.

Elder and caregiver solutions to improve medication adherence

Medication mismanagement is a growing public health concern, especially among elders. Annually, it is a major contributor to emergency hospitalization and nursing home placement. Elders and their caregivers, as healthcare consumers and stakeholders in this issue, are uniquely qualified to inform strategies to improve medication adherence. We conducted a qualitative study to ascertain caregiver and elder perceptions of barriers to medication management and to identify community-derived solutions to improve medication management. Nine focus groups (N = 65, mean age = 71) were conducted with caregivers or elders from five communities. Participants were recruited by key informants utilizing snowball sampling methodology. The following themes were identified in the participant-recommended proposed solutions improving medication adherence: (i) use of personal systems to overcome barriers to medication adherence, (ii) various solutions to address cost concerns, (iii) the need for regular review of medications by doctors or pharmacists to eliminate unnecessary medications, (iv) desire for community-driven support systems, and (v) using medical advocates. Elders and caregivers recognized medication non-adherence as a community-wide issue and were eager to offer solutions they thought would work in their communities. These solutions can lend credibility to strategies currently being developed/utilized and offer innovative recommendations for future interventions.