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Japelj N, Horvat N, Knez L, Kos M. Deprescribing: An umbrella review. ACTA PHARMACEUTICA (ZAGREB, CROATIA) 2024; 74:249-267. [PMID: 38815201 DOI: 10.2478/acph-2024-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 06/01/2024]
Abstract
This umbrella review examined systematic reviews of deprescribing studies by characteristics of intervention, population, medicine, and setting. Clinical and humanistic outcomes, barriers and facilitators, and tools for deprescribing are presented. The Medline database was used. The search was limited to systematic reviews and meta-analyses published in English up to April 2022. Reviews reporting deprescribing were included, while those where depre-scribing was not planned and supervised by a healthcare professional were excluded. A total of 94 systematic reviews (23 meta--analyses) were included. Most explored clinical or humanistic outcomes (70/94, 74 %); less explored attitudes, facilitators, or barriers to deprescribing (17/94, 18 %); few focused on tools (8/94, 8.5 %). Reviews assessing clinical or humanistic outcomes were divided into two groups: reviews with deprescribing intervention trials (39/70, 56 %; 16 reviewing specific deprescribing interventions and 23 broad medication optimisation interventions), and reviews with medication cessation trials (31/70, 44 %). Deprescribing was feasible and resulted in a reduction of inappropriate medications in reviews with deprescribing intervention trials. Complex broad medication optimisation interventions were shown to reduce hospitalisation, falls, and mortality rates. In reviews of medication cessation trials, a higher frequency of adverse drug withdrawal events underscores the importance of prioritizing patient safety and exercising caution when stopping medicines, particularly in patients with clear and appropriate indications.
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Affiliation(s)
- Nuša Japelj
- 1University of Ljubljana Faculty of Pharmacy, Department of Social Pharmacy 1000 Ljubljana, Slovenia
| | - Nejc Horvat
- 1University of Ljubljana Faculty of Pharmacy, Department of Social Pharmacy 1000 Ljubljana, Slovenia
| | - Lea Knez
- 1University of Ljubljana Faculty of Pharmacy, Department of Social Pharmacy 1000 Ljubljana, Slovenia
- 2University Clinic Golnik 4204 Golnik, Slovenia
| | - Mitja Kos
- 1University of Ljubljana Faculty of Pharmacy, Department of Social Pharmacy 1000 Ljubljana, Slovenia
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Rataj A, Alcusky M, Baek J, Ott B, Lapane KL. Geographic Variation of Antidementia and Antipsychotic Medication Use Among US Nursing Home Residents With Dementia. Med Care 2024:00005650-990000000-00236. [PMID: 38833712 DOI: 10.1097/mlr.0000000000002016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
BACKGROUND Several antidementia medications have been approved for symptomatic treatment of cognitive and functional impairment due to Alzheimer disease. Antipsychotics are often prescribed off-label for behavioral symptoms. OBJECTIVE The aim of this study was to describe the basis for regional variation in antidementia and antipsychotic medication use. SETTING US nursing homes (n=9735), hospital referral regions (HRR; n=289). SUBJECTS Long-stay residents with dementia (n=273,004). METHODS Using 2018 Minimum Data Set 3.0 linked to Medicare data, facility information, and Dartmouth Atlas files, we calculated prevalence of use and separate multilevel logistic models [outcomes: memantine, cholinesterase inhibitor (ChEI), antipsychotic use] estimated adjusted odds ratios (aOR) and 95% CIs for resident, facility, and HRR characteristics. We then fit a series of cross-classified multilevel logistic models to estimate the proportional change in cluster variance (PCV). RESULTS Overall, 20.9% used antipsychotics, 16.1% used memantine, and 23.3% used ChEIs. For antipsychotics, facility factors [eg, use of physical restraints (aOR: 1.08; 95% CI: 1.05-1.11) or poor staffing ratings (aOR: 1.10; 95% CI: 1.06-1.14)] were associated with more antipsychotic use. Nursing homes in HRRs with the highest health care utilization had greater antidementia drug use (aOR memantine: 1.68; 95% CI: 1.44-1.96). Resident/facility factors accounted for much regional variation in antipsychotics (PCVSTATE: 27.80%; PCVHRR: 39.54%). For antidementia medications, HRR-level factors accounted for most regional variation (memantine PCVSTATE: 37.44%; ChEI PCVSTATE: 39.02%). CONCLUSION Regional variations exist in antipsychotic and antidementia medication use among nursing home residents with dementia suggesting the need for evidence-based protocols to guide the use of these medications.
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Affiliation(s)
- Alison Rataj
- Department of Population and Quantitative Health Sciences, Division of Epidemiology, University of Massachusetts Chan Medical School, Worcester, MA
| | - Matthew Alcusky
- Department of Population and Quantitative Health Sciences, Division of Epidemiology, University of Massachusetts Chan Medical School, Worcester, MA
| | - Jonggyu Baek
- Department of Population and Quantitative Health Sciences, Division of Biostatistics and Health Services Research, University of Massachusetts Chan Medical School, Worcester, MA
| | - Brian Ott
- Department of Neurology, Alpert Medical School of Brown University, Providence, RI
| | - Kate L Lapane
- Department of Population and Quantitative Health Sciences, Division of Epidemiology, University of Massachusetts Chan Medical School, Worcester, MA
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Ott BR, Hollins C, Tjia J, Baek J, Chen Q, Lapane KL, Alcusky M. Antidementia Medication Use in Nursing Home Residents. J Geriatr Psychiatry Neurol 2024; 37:194-205. [PMID: 37715795 PMCID: PMC10947315 DOI: 10.1177/08919887231202948] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
BACKGROUND Antidementia medication can provide symptomatic improvements in patients with Alzheimer's disease, but there is a lack of consensus guidance on when to start and stop treatment in the nursing home setting. METHODS We describe utilization patterns of cholinesterase inhibitors (ChEI) and memantine for 3,50,197 newly admitted NH residents with dementia between 2011 and 2018. RESULTS Overall, pre-admission use of antidementia medications declined from 2011 to 2018 (ChEIs: 44.5% to 36.9%; memantine: 27.4% to 23.2%). Older age, use of a feeding tube, and greater functional dependency were associated with lower odds of ChEI initiation. Coronary artery disease, parenteral nutrition, severe aggressive behaviors, severe cognitive impairment, and high functional dependency were associated with discontinuation of ChEIs. Comparison of clinical factors related to anti-dementia drug treatment changes from pre to post NH admission in 2011 and 2018 revealed a change toward lower likelihood of initiation of treatment among residents with more functional dependency and those with indicators of more complex illness as well as a change toward higher likelihood of discontinuation in residents having 2 or more hospital stays. CONCLUSIONS These prescribing trends highlight the need for additional research on the effects of initiating and discontinuing antidementia medications in the NH to provide clear guidance for clinicians when making treatment decisions for individual residents.
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Affiliation(s)
- Brian R. Ott
- Department of Neurology, Brown University Warren Alpert Medical School, Providence, RI
| | - Carl Hollins
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Jennifer Tjia
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Jonggyu Baek
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Qiaoxi Chen
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Kate L. Lapane
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Matthew Alcusky
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
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Yang T, Wei F, Guo Y, Zhu M, Hou H, Guo Z, Liu X. The increased effective connectivity from left middle occipital gyrus to right medial septum/diagonal bands in AD patients after donepezil intervention. Front Aging Neurosci 2024; 16:1362790. [PMID: 38659702 PMCID: PMC11039922 DOI: 10.3389/fnagi.2024.1362790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 03/27/2024] [Indexed: 04/26/2024] Open
Abstract
Introduction Donepezil enhances the function of cholinergic nerves by increasing the concentration of acetylcholine, thereby improving clinical symptoms in patients with Alzheimer's disease (AD). However, the neural mechanisms of how donepezil modulates the effective connectivity (EC) network of cholinergic system in AD patients remain unknown. We speculated that the effective network of the cholinergic system changes in AD patients after donepezil intervention. Methods We employed resting-state functional magnetic resonance imaging and Granger causality analysis approach to explore changes in the effective connectivity network of the basal forebrain in AD patients before and after donepezil intervention. This study included 32 participants, including 16 healthy controls (HCs) and 16 AD patients. In a 3T MRI scanner, the 16 AD patients were scanned before and after the donepezil intervention. To compare EC differences between the three groups of participants, ANOVA and post-hoc t-tests analysis were employed. Results Compared to baseline status, AD patients after donepezil intervention had an increased EC from left middle occipital gyrus to right medial septum/diagonal bands. Compared to HCs, AD patients after donepezil intervention had an increased EC from right inferior frontal gyrus/orbit part to right medial septum/diagonal bands, AD patients before donepezil intervention had a reduced EC from right precuneus to right medial septum/diagonal bands. A significant positive correlation was found between EC values in right precuneus and Mini-Mental State Examination in pre-intervention AD patients (r = 0.7338, p = 0.0012). Discussion Our study showed that effective connectivity of brain regions associated with the default mode network in the cholinergic pathway was enhanced after donepezil intervention. The results of this study will help us to better understand the neural mechanisms of donepezil intervention in AD and to find clinical targets for intervention.
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Affiliation(s)
- Ting Yang
- The Second Affiliated Hospital and Yuying Children’s Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Fuquan Wei
- Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Yufei Guo
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Mengxiao Zhu
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Hongtao Hou
- Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Zhongwei Guo
- Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Xiaozheng Liu
- The Second Affiliated Hospital and Yuying Children’s Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
- Wenzhou Key Laboratory of Structural and Functional Imaging, Wenzhou, Zhejiang, China
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Lapane KL, Ott BR, Hargraves JL, Cosenza C, Liang S, Alcusky M. Changes in Antidementia Medications upon Admission to the Nursing Home: Who Decides and Why? Results From a National Survey of Nursing Home Administrators. J Am Med Dir Assoc 2024; 25:41-46.e5. [PMID: 38173265 PMCID: PMC10783796 DOI: 10.1016/j.jamda.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVE Little is known about who is involved and what factors influence changes in antidementia medications for older adults living in nursing homes. The study sought to describe factors associated with initiation and discontinuation of antidementia medications in nursing home residents with dementia. DESIGN National survey of nursing homes with ≥30 beds; homes with dementia units were oversampled. SETTINGS AND PARTICIPANTS Nursing home administrators [eg, Directors of Nursing (DoNs)]. METHODS In 2022, 1293 homes were surveyed (response rate: 26.6%, n = 340). Weighted analyses provided nationally representative results corrected for nonresponse (n = 14,455). RESULTS DoNs reported that people always/almost always involved in antidementia medication decisions included nursing home prescriber (84.4%), nursing staff (33.2%), family (23.4%), resident (13.8%), community primary care provider (12.1%), and dementia specialist (5.8%). DoNs reported that antidementia medications were much more likely to be initiated if residents (55.8%) and family members (53.2%) wanted antidementia medications, a dementia specialist was involved (51.9%), resident had aggressive behaviors (44.8%), resisted care (31.6%), or had severe physical/cognitive impairment (22.3%). DoNs reported that antidementia medications were much more likely to be discontinued with dementia specialist involvement (46.5%), progression to severe impairment (39.2%), hospice involvement (31.5%), <6 months' prognosis (28.5%), emergence of aggressive behaviors (25.2%), or resisting care (19.0%) and much less likely to be discontinued if residents (30.2%) and family (27.3%) were reluctant to discontinue. One in 6 homes reported that residents had no immediate family/caregivers usually or almost always/always. CONCLUSIONS AND IMPLICATIONS DoNs report that family/caregivers and dementia specialists have significant influence on antidementia medication decisions in nursing homes, but many residents lack their involvement. Real-world evidence on the risks and benefits of antidementia medications in nursing homes is needed to inform clinical guidance about appropriate use of antidementia medications in nursing homes.
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Affiliation(s)
- Kate L Lapane
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA.
| | - Brian R Ott
- Department of Neurology, Alpert Medical School of Brown University, Providence, RI, USA
| | - J Lee Hargraves
- Center for Survey Research, University of Massachusetts Boston, Boston, MA, USA
| | - Carol Cosenza
- Center for Survey Research, University of Massachusetts Boston, Boston, MA, USA
| | - Shiwei Liang
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Matthew Alcusky
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
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Anlay DZ, Paque K, Van Leeuwen E, Cohen J, Dilles T. Tools and guidelines to assess the appropriateness of medication and aid deprescribing: An umbrella review. Br J Clin Pharmacol 2024; 90:12-106. [PMID: 37697479 DOI: 10.1111/bcp.15906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/24/2023] [Accepted: 08/29/2023] [Indexed: 09/13/2023] Open
Abstract
AIMS The aim of this umbrella review was to identify tools and guidelines to aid the deprescribing process of potentially inappropriate medications (PIMs), evaluate development and validation methods, and describe evidence levels for medication inclusion. METHODS Searches were conducted on MEDLINE (Ovid), Embase.com, Cochrane CDSR, CINAHL (EBSCO), Web of Science Core Collection and guideline databases from the date of inception to 7 July 2022. Following the initial search, an additional search was conducted to identify an updated versions of tools on 17 July 2023. We analysed the contents of tools and guidelines. RESULTS From 23 systematic reviews and guidelines, we identified 95 tools (72 explicit, 12 mixed and 11 implicit) and nine guidelines. Most tools (83.2%) were developed to use for older persons, including 14 for those with limited life expectancy. Seven tools were for children <18 years (7.37%). Most explicit/mixed tools (78.57%) and all guidelines were validated. We found 484 PIMs and 202 medications with different appropriateness independent of disease for older persons with normal and limited life expectancy, respectively. Only two tools and eight guidelines reported the evidence level, and a quarter of medications had high-quality evidence. CONCLUSIONS Tools are available for a diversity of populations. There were discrepancies, with the same medication being classified as inappropriate in some tools and appropriate in others, possibly due to low-quality evidence. In particular, tools for patients with limited life expectancy were developed based on very limited evidence, and research to generate this evidence is urgently needed. Our medication lists, along with the level of evidence, could facilitate efforts to strengthen the evidence.
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Affiliation(s)
- Degefaye Zelalem Anlay
- End-of-life Care Research Group, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
- Centre for Research and Innovation in Care, Nurse and Pharmaceutical Care, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Kristel Paque
- Centre for Research and Innovation in Care, Nurse and Pharmaceutical Care, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- HAST, Hasselt, Belgium
| | - Ellen Van Leeuwen
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences & Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Joachim Cohen
- End-of-life Care Research Group, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Tinne Dilles
- Centre for Research and Innovation in Care, Nurse and Pharmaceutical Care, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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Ahuja M, Siddhpuria S, Karimi A, Lewis K, Wong E, Lee J, Reppas-Rindlisbacher C, Sood E, Gabor C, Patterson C. Cholinesterase inhibitors and falls, syncope and injuries in patients with cognitive impairment: a systematic review and meta-analysis. Age Ageing 2023; 52:afad205. [PMID: 37993407 DOI: 10.1093/ageing/afad205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Cholinesterase inhibitors are commonly used to treat patients with neurocognitive disorders, who often have an elevated risk of falling. Effective use of these medications requires a thoughtful assessment of risks and benefits. OBJECTIVE To provide an update on previous reviews and determine the association between cholinesterase inhibitors and falls, syncope, fracture and accidental injuries in patients with neurocognitive disorders. METHODS Embase, MEDLINE, Cochrane Central Register of Controlled Trials, Cumulative Index of Nursing and Allied Health Literature and AgeLine were systematically searched through March 2023 to identify all randomised controlled trials of cholinesterase inhibitors (donepezil, galantamine, rivastigmine) in patients with cognitive impairment. Corresponding authors were contacted for additional data necessary for meta-analysis. Inclusion criteria consisted of adults ≥19 years, with a diagnosis of dementia, Parkinson's disease, mild cognitive impairment or traumatic brain injury. Data were extracted in duplicate for the aforementioned primary outcomes and all outcomes were analysed using random-effects meta-analysis. RESULTS Fifty three studies (30 donepezil, 14 galantamine, 9 rivastigmine) were included providing data on 25, 399 patients. Cholinesterase inhibitors, compared to placebo, were associated with reduced risk of falls (risk ratio [RR] 0.84 [95% confidence interval [CI] = 0.73-0.96, P = 0.009]) and increased risk of syncope (RR 1.50 [95% CI = 1.02-2.21, P = 0.04]). There was no association with accidental injuries or fractures. CONCLUSION In patients with neurocognitive disorders, cholinesterase inhibitors were associated with decreased risk of falls, increased risk of syncope and no association with accidental trauma or fractures. These findings will help clinicians better evaluate risks and benefits of cholinesterase inhibitors.
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Affiliation(s)
- Manan Ahuja
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Shailee Siddhpuria
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Arian Karimi
- Department of Medicine, University of Illinois College of Medicine, Chicago, IL, USA
| | - Kaitlin Lewis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Eric Wong
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Canada
| | - Justin Lee
- Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, Canada
| | | | - Emma Sood
- Faculty of Science, Department of Psychology, Neuroscience & Behaviour, McMaster University, Hamilton, Ontario, Canada
| | | | - Christopher Patterson
- Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, Canada
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Portlock GE, Smith MD, van Poelgeest EP, Welsh TJ. Therapeutic dilemmas: cognitive enhancers and risk of falling in older adults-a clinical review. Eur Geriatr Med 2023; 14:721-732. [PMID: 37418063 PMCID: PMC10447592 DOI: 10.1007/s41999-023-00821-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/14/2023] [Indexed: 07/08/2023]
Abstract
PURPOSE Cognitive enhancers are the primary pharmacological therapy prescribed to those with dementia, comprising of memantine and the acetylcholinesterase inhibitors (AChEIs). The long-term cognitive and behavioural benefits of these medications, as well as their potential contribution to falls is currently debated, with recent Delphi studies being unable to reach consensus on whether these medications should be deprescribed. In this narrative clinical review, as part of a series on deprescribing in people at risk of falls, we explore the potential falls-related side effects experienced in people taking cognitive enhancers, alongside situations where deprescribing may be appropriate. METHODS We undertook a literature search of PubMed and Google Scholar, using terms capturing falls and cognitive enhancers, as well as consulting the British National Formulary and published Summary of Medicinal Product Characteristics. These searches informed the subsequent clinical review. RESULTS Cognitive enhancers should be subject to regular review, including confirmation of appropriate treatment indication, and occurrence of side effects in the context of falls. AChEIs, in particular, are associated with a broad range of side effects that can contribute to increased falls risk. These include bradycardia, syncope and neuromuscular effects. Where these have been identified, deprescribing should be considered, as well as alternative treatment options. Deprescribing studies have shown mixed results, likely due to considerable methodological heterogeneity. Several suggested guidelines exist to aid deprescribing decisions, many of which are highlighted in this review. CONCLUSIONS The use of cognitive enhancers should be regularly reviewed and decisions to deprescribe made on a case-by-case basis, considering both the risks and benefits of stopping these medications.
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Affiliation(s)
| | - Matthew D Smith
- Bristol Medical School, University of Bristol, Bristol, UK
- The Research Institute for the Care of Older People (RICE), The RICE Centre Royal United Hospital, Combe Park, Bath, BA1 3NG, UK
| | | | - Tomas James Welsh
- Bristol Medical School, University of Bristol, Bristol, UK.
- The Research Institute for the Care of Older People (RICE), The RICE Centre Royal United Hospital, Combe Park, Bath, BA1 3NG, UK.
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK.
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Gerlach LB, Maust DT, Kales HC, Chang M, Kim HM, Wiechers IR, Zivin K. Evaluation of Antipsychotic Reduction Efforts in Patients With Dementia in Veterans Health Administration Nursing Homes. Am J Psychiatry 2022; 179:544-552. [PMID: 35615813 PMCID: PMC9349465 DOI: 10.1176/appi.ajp.21060591] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The Veterans Health Administration (VHA) and the Centers for Medicare and Medicaid Services (CMS) each created initiatives to reduce off-label use of antipsychotics in patients with dementia in nursing homes. Although CMS has reported antipsychotic reductions, the impact on prescribing of antipsychotic and other CNS-active medications in the VHA remains unclear. The authors evaluated national trends in antipsychotic and other CNS-active medication prescribing for nursing home patients with dementia in the VHA. METHODS The study sample was all veterans with dementia residing in VHA nursing homes for more than 30 days (N=35,742). Using an interrupted time-series design, the quarterly prevalences of antipsychotic, antidepressant, antiepileptic, anxiolytic, opioid, and memory medication prescribing were evaluated from FY2009 through FY2018. RESULTS Antipsychotic prescribing in VHA nursing homes declined from FY2009 to FY2018 (from 33.7% to 27.5%), with similar declines in anxiolytic prescribing (from 33.5% to 27.1%). During this period, prescribing of antiepileptics, antidepressants, and opioids increased significantly (antiepileptics: from 26.8% to 43.3%; antidepressants: from 56.8% to 63.4%; opioids: from 32.6% to 41.2%). Gabapentin served as the main driver of antiepileptic increases (from 11.1% to 23.5%). Increases in antidepressant prescribing included sertraline, mirtazapine, and trazodone. From FY2009 to FY2018, the overall prescribing of non-antipsychotic psychotropic medications grew from 75.0% to 81.1%. CONCLUSIONS Antipsychotic and anxiolytic prescribing for VHA nursing home residents with dementia declined, although overall prescribing of other psychotropic and opioid medications increased. Policies focused primarily on reducing antipsychotic use without considering use in the context of other medications may contribute to growth in alternative medication classes with even less evidence of benefit and similar risks.
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Affiliation(s)
- Lauren B. Gerlach
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Donovan T. Maust
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Helen C. Kales
- Department of Psychiatry, University of California Davis, Sacramento, California
| | - Myron Chang
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - H. Myra Kim
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan,Center for Statistical Consulting and Research, University of Michigan, Ann Arbor, Michigan
| | - Ilse R. Wiechers
- Office of Mental Health and Suicide Prevention, U.S. Dept. of Veterans Affairs,Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA,Department of Psychiatry, Yale University School of Medicine, New Haven, CT
| | - Kara Zivin
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
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[Deprescription in old people: It's time to take action]. Aten Primaria 2022; 54:102367. [PMID: 35653980 PMCID: PMC9160471 DOI: 10.1016/j.aprim.2022.102367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 12/02/2022] Open
Abstract
El uso de fármacos conlleva innegables beneficios en las personas mayores, pero no está exento de efectos indeseables. La deprescripción es el proceso de revisión sistemática de la medicación con el objetivo de lograr la mejor relación riesgo-beneficio en base a la mejor evidencia disponible. Este proceso es especialmente importante en mayores polimedicados, sobretratados, frágiles, con enfermedades terminales y en el final de la vida. La deprescripción debe hacerse de forma escalonada, estableciendo un seguimiento estrecho por si aparecen problemas tras la retirada. En la toma de decisiones es muy importante contar con la opinión del paciente y de los cuidadores, valorando los objetivos del tratamiento según la situación clínica, funcional y social del enfermo. Existen múltiples herramientas para facilitar a los clínicos la tarea de seleccionar qué fármacos deprescribir (criterios Beers, STOPP-START…). Los grupos farmacológicos más susceptibles de intervención son: antihipertensivos, antidiabéticos, estatinas, benzodiacepinas, antidepresivos, anticolinérgicos, anticolinesterásicos y neurolépticos.
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Mardani A, Paal P, Weck C, Jamshed S, Vaismoradi M. Practical Considerations of PRN Medicines Management: An Integrative Systematic Review. Front Pharmacol 2022; 13:759998. [PMID: 35496317 PMCID: PMC9039188 DOI: 10.3389/fphar.2022.759998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 03/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background and objectives: Highly widespread use of pro re nata (PRN) medicines in various healthcare settings is a potential area for improper medication prescription and administration leading to patient harm. This study aimed to summarize and integrate the findings of all relevant individual studies regarding the practical considerations of PRN medicines management including strategies and interventions by healthcare professionals for safe prescription, dispensing, administration, monitoring, and deprescription of PRN medicines in healthcare settings. Methods: An integrative systematic review on international databases were performed. Electronic databases including Web of Knowledge, Scopus, PubMed (including MEDLINE), and Cinahl were searched to retrieve articles published until end of May 2021. Original qualitative, quantitative, and mixed methods studies written in English were included with a focus on PRN medicines management in healthcare settings. Research synthesis using the narrative method was performed to summarise the results of included studies. Results: Thirty-one studies on PRN medicines in healthcare settings by different healthcare providers were included after the screening of the databases based on eligibility criteria. They were published from 1987 to 2021. The majority of studies were from Australia, the United States, Canada, and the United Kingdom and were conducted in psychiatric settings. Given variations in their purposes, methods, and outcomes, the research synthesis was conducted narratively based on diversities and similarities in findings. Eight categories were developed by the authors as follows: "PRN indications and precautionary measures," "requirements of PRN prescription," "interventions for PRN administration," "monitoring and follow up interventions," "deprescription strategies," "healthcare professionals' role," "participation of patients and families," and "multidisciplinary collaboration." Each category consists of several items and describes what factors should be considered by healthcare professionals for PRN medicines management. Conclusion: The review findings provide insights on the practical considerations of PRN medicines management in clinical practice. The suggested list of considerations in our review can be used by healthcare professionals for optimal PRN medicines management and safeguarding patient care.
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Affiliation(s)
- Abbas Mardani
- Nursing Care Research Center, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
| | - Piret Paal
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
| | - Christiane Weck
- Palliative Care, Paracelsus Medical University, Salzburg, Austria.,Department of Neurology, Klinikum Agatharied, Hausham, Germany
| | - Shazia Jamshed
- Clinical Pharmacy and Practice, Faculty of Pharmacy, University Sultan Zainal Abidin, Terengganu, Malaysia
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12
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Hedna K, Fastbom J, Jonson M, Wilhelmson K, Waern M. Psychoactive medication use and risk of suicide in long-term care facility residents. Int J Geriatr Psychiatry 2022; 37:10.1002/gps.5684. [PMID: 35142388 PMCID: PMC9306521 DOI: 10.1002/gps.5684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 01/26/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To investigate psychoactive medication use and risk of suicide in long-term care facility (LTCF) residents aged 75 and above. A second aim was to investigate the role of psychiatric and medical conditions in the occurrence of suicide in LTCF residents. METHODS A Swedish national register-based cohort study of LTFC residents aged ≥75 years between 1 January 2008 and 31 December 2015, and followed until 31 December 2016 (N = 288,305). Fine and Gray regression models were used to analyse associations with suicide. RESULTS The study identified 110 suicides (15.8 per 100,000 person-years). Half of these occurred during the first year of residence. Overall, 54% of those who died by suicide were on hypnotics and 45% were on antidepressants. Adjusted sub-hazard ratio (aSHR) for suicide was decreased in those who were on antidepressants (aSHR 0.64, 95% confidence interval 0.42-0.97), even after the exclusion of residents who had healthcare contacts for dementia or were on anti-dementia drugs. The aSHR for suicide was more than two-fold higher in those who were on hypnotics (2.20, 1.46-3.31). Suicide risk was particularly elevated in those with an episode of self-harm prior to LTCF admittance (15.78, 10.01-24.87). Specialized care for depression was associated with increased risk, while medical morbidity was not. CONCLUSIONS A lower risk of suicide in LTCF residents was found in users of antidepressants, while elevated risk was observed in those on hypnotics. Our findings suggest that more can be done to prevent suicide in this setting.
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Affiliation(s)
- Khedidja Hedna
- AgeCap Center, Department of Psychiatry and NeurochemistryGothenburg UniversityGothenburgSweden,Statistikkonsulterna ABGothenburgSweden
| | - Johan Fastbom
- Aging Research CenterKarolinska Institute and Stockholm UniversityStockholmSweden
| | - Mattias Jonson
- AgeCap Center, Department of Psychiatry and NeurochemistryGothenburg UniversityGothenburgSweden,Neuropsychiatric Epidemiology Unit, Department of Psychiatry and NeurochemistrySahlgrenska Academy, University of GothenburgGothenburgSweden,Affective ClinicRegion Västra Götaland, Sahlgrenska University HospitalGothenburgSweden
| | - Katarina Wilhelmson
- AgeCap Center, Department of Psychiatry and NeurochemistryGothenburg UniversityGothenburgSweden,Department of Health and RehabilitationInstitute of Neuroscience and Physiology, Sahlgrenska Academy, University of GothenburgGothenburgSweden,Department of Acute Medicine and GeriatricsRegion Västra Götaland, Sahlgrenska University HospitalGothenburgSweden
| | - Margda Waern
- AgeCap Center, Department of Psychiatry and NeurochemistryGothenburg UniversityGothenburgSweden,Psychosis ClinicRegion Västra Götaland, Sahlgrenska University HospitalGothenburgSweden
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13
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Cammisuli DM, Cignoni F, Ceravolo R, Bonuccelli U, Castelnuovo G. Transcranial Direct Current Stimulation (tDCS) as a Useful Rehabilitation Strategy to Improve Cognition in Patients With Alzheimer's Disease and Parkinson's Disease: An Updated Systematic Review of Randomized Controlled Trials. Front Neurol 2022; 12:798191. [PMID: 35185754 PMCID: PMC8847129 DOI: 10.3389/fneur.2021.798191] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/30/2021] [Indexed: 11/29/2022] Open
Abstract
Alzheimer's disease (AD) and Parkinson's disease (PD) are neurodegenerative disorders characterized by cognitive impairment and functional decline increasing with disease progression. Within non-pharmacological interventions, transcranial direct current stimulation (tDCS) might represent a cost-effective rehabilitation strategy to implement cognitive abilities with positive implications for functional autonomy and quality-of-life of patients. Our systematic review aimed at evaluating the effects of tDCS upon cognition in people suffering from AD and PD. We searched for randomized controlled trials (RCTs) into PubMed, Web of Science, and Cochrane Library. Three review authors extracted data of interest, with neuropsychological tests or experimental cognitive tasks scores as outcome measures. A total of 17 RCTs (10 trials for AD and 7 trials for PD) were included. Compared with sham stimulation, tDCS may improve global cognition and recognition memory in patients with AD and also some executive functions (i.e., divided attention, verbal fluency, and reduction of sensitivity to interference) in patients with PD. Criticism remains about benefits for the other investigated cognitive domains. Despite preliminary emerging evidences, larger RCTs with common neuropsychological measures and long-term follow-ups establishing longevity of the observed effects are necessary for future research in applied psychology field, alongside improved clinical guidelines on the neurodegenerative disorders pertaining electrodes montage, sessions number, duration and intensity of the stimulation, and cognitive battery to be used.
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Affiliation(s)
| | - Fabio Cignoni
- Neurological Clinic, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Roberto Ceravolo
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Azienda Unità Sanitaria Locale (USL) Toscana Nord Ovest, Pisa, Italy
| | - Ubaldo Bonuccelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Azienda Unità Sanitaria Locale (USL) Toscana Nord Ovest, Pisa, Italy
| | - Gianluca Castelnuovo
- Department of Psychology, Catholic University of the Sacred Heart, Milan, Italy
- Psychology Research Laboratory, Istituto Auxologico Italiano IRCCS, Milan, Italy
- *Correspondence: Gianluca Castelnuovo ;
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Herrmann N, Ismail Z, Collins R, Desmarais P, Goodarzi Z, Henri‐Bhargava A, Iaboni A, Kirkham J, Massoud F, Moser A, Silvius J, Watt J, Seitz D. CCCDTD5 recommendations on the deprescribing of cognitive enhancers in dementia. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2022; 8:e12099. [PMID: 35128025 PMCID: PMC8802736 DOI: 10.1002/trc2.12099] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 09/21/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Cognitive enhancers (ie, cholinesterase inhibitors and memantine) can provide symptomatic benefit for some individuals with dementia; however, there are circumstances in which the risks of continuing treatment may potentially outweigh benefits. The decision to deprescribe cognitive enhancers must consider each patient's preferences, treatment indications, current clinical status and symptoms, prognosis, and dementia type. METHODS The 5th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD5) established a subcommittee of experts to review current evidence on the deprescribing of cognitive enhancers. The questions answered by this group included: When should cognitive enhancers be deprescribed in persons with dementia and mild cognitive impairment? How should cognitive enhancers be deprescribed? And, what clinical factors should be considered when deprescribing cognitive enhancers? RESULTS Patient and care-partner preferences should be incorporated into all decisions to deprescribe cognitive enhancers. Cognitive enhancers should be discontinued in individuals without ongoing evidence of benefit or when the indication for cognitive enhancer use was inappropriate (eg, mild cognitive impairment). Deprescribing should occur gradually and cognitive enhancers should be reinitiated if patients' cognition or function deteriorates. Cognitive enhancers should be continued in individuals whose neuropsychiatric symptoms improve in response to treatment. Clinicians should not deprescribe cognitive enhancers in individuals with significant neuropsychiatric symptoms until symptoms have stabilized. CONCLUSION CCCDTD5 deprescribing recommendations provide evidence-informed recommendations related to cognitive enhancer deprescribing that will facilitate shared decision making among patients, care partners, and clinicians.
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Affiliation(s)
- Nathan Herrmann
- Department of PsychiatrySunnybrook Health Sciences CentreUniversity of TorontoTorontoOntarioCanada
| | - Zahinoor Ismail
- Departments of Psychiatry, Clinical Neurosciences, and Community Health Sciences, Cumming School of Medicine; Hotchkiss Brain Institute and O'Brien Institute of Public HealthUniversity of Calgary, Calgary, Alberta, Canada
| | - Rhonda Collins
- Department of Family MedicineMcMaster UniversityChief Medical Officer, Revera IncHamiltonOntarioCanada
| | - Philippe Desmarais
- Department of MedicineDivision of Geriatrics and Department of NeurosciencesCentre de Recherche du Centre Hospitalier de l'Université de MontréalMontréalQuébecCanada
| | - Zahra Goodarzi
- Division of Geriatrics, Department of Medicine, Cumming School of Medicine; Hotchkiss Brain Institute; O'Brien Institute of Public HealthUniversity of CalgaryCalgaryCanada
| | - Alexandre Henri‐Bhargava
- Division of Neurology, Faculty of MedicineUniversity of British Columbia; Division of Medical Sciences, University of Victoria, Victoria, British Columbia, Canada
| | - Andrea Iaboni
- Department of PsychiatryUniversity of TorontoTorontoOntarioCanada
- Kite Research Institute, Toronto Rehabilitation InstituteUniversity Health NetworkTorontoOntarioCanada
| | - Julia Kirkham
- Department of PsychiatryCumming School of Medicine, University of Calgary
| | - Fadi Massoud
- Department of MedicineUniversity of SherbrookeSherbrookeQuebecCanada
| | - Andrea Moser
- Department of Family and Community MedicineUniversity of Toronto, Associate Medical Director, Jewish Home for the Aged, BaycrestTorontoOntarioCanada
| | - James Silvius
- Division of Geriatric Medicine, Department of Medicine, Cumming School of MedicineUniversity of Calgary, Calgary, Alberta, Canada
| | - Jennifer Watt
- Division of Geriatric MedicineDepartment of Medicine, University of TorontoTorontoOntarioCanada
| | - Dallas Seitz
- Departments of Psychiatry, Clinical Neurosciences, and Community Health Sciences, Cumming School of Medicine; Hotchkiss Brain Institute and O'Brien Institute of Public HealthUniversity of Calgary, Calgary, Alberta, Canada
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15
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James T, Mukadam N, Sommerlad A, Pour HR, Knowles M, Azocar I, Livingston G. Protection against discrimination in national dementia guideline recommendations: A systematic review. PLoS Med 2022; 19:e1003860. [PMID: 35015760 PMCID: PMC8752020 DOI: 10.1371/journal.pmed.1003860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 11/03/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND National dementia guidelines provide recommendations about the most effective approaches to diagnosis and interventions. Guidelines can improve care, but some groups such as people with minority characteristics may be disadvantaged if recommended approaches are the same for everyone. It is not known if dementia guidelines address specific needs related to patient characteristics. The objectives of this review are to identify which countries have national guidelines for dementia and synthesise recommendations relating to protected characteristics, as defined in the UK Equality Act 2010: age, disability, gender identity, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation. METHODS AND FINDINGS We searched CINAHL, PsycINFO, and Medline databases and the Guideline International Network library from inception to March 4, 2020, for dementia guidelines in any language. We also searched, between April and September 2020, Google and the national health websites of all 196 countries in English and in each country's official languages. To be included, guidelines had to provide recommendations about dementia, which were expected to be followed by healthcare workers and be approved at a national policy level. We rated quality according to the iCAHE guideline quality checklist. We provide a narrative synthesis of recommendations identified for each protected characteristic, prioritising those from higher-quality guidelines. Forty-six guidelines from 44 countries met our criteria, of which 18 were rated as higher quality. Most guidelines (39/46; 85%) made at least one reference to protected characteristics, and we identified recommendations relating to age, disability, race (or culture, ethnicity, or language), religion, sex, and sexual orientation. Age was the most frequently referenced characteristic (31/46; 67%) followed by race (or culture, ethnicity, or language; 25/46; 54%). Recommendations included specialist investigation and support for younger people affected by dementia and consideration of culture when assessing whether someone had dementia and providing person-centred care. Guidelines recommended considering religion when providing person-centred and end-of-life care. For disability, it was recommended that healthcare workers consider intellectual disability and sensory impairment when assessing for dementia. Most recommendations related to sex recommended not using sex hormones to treat cognitive impairment in men and women. One guideline made one recommendation related to sexual orientation. The main limitation of this study is that we only included national guidelines applicable to a whole country meaning guidelines from countries with differing healthcare systems within the country may have been excluded. CONCLUSIONS National guidelines for dementia vary in their consideration of protected characteristics. We found that around a fifth of the world's countries have guidelines for dementia. We have identified areas of good practice that can be considered for future guidelines and suggest that all guidelines provide specific evidence-based recommendations for minority groups with examples of how to implement them. This will promote equity in the care of people affected by dementia and help to ensure that people with protected characteristics also have high-quality clinical services.
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Affiliation(s)
- Tiffeny James
- Division of Psychiatry, University College London, London, United Kingdom
| | - Naaheed Mukadam
- Division of Psychiatry, University College London, London, United Kingdom
| | - Andrew Sommerlad
- Division of Psychiatry, University College London, London, United Kingdom
| | | | - Melanie Knowles
- Camden and Islington NHS Foundation Trust, London, United Kingdom
| | - Ignacia Azocar
- Division of Psychiatry, University College London, London, United Kingdom
| | - Gill Livingston
- Division of Psychiatry, University College London, London, United Kingdom
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16
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Ruangritchankul S, Chantharit P, Srisuma S, Gray LC. Adverse Drug Reactions of Acetylcholinesterase Inhibitors in Older People Living with Dementia: A Comprehensive Literature Review. Ther Clin Risk Manag 2021; 17:927-949. [PMID: 34511919 PMCID: PMC8427072 DOI: 10.2147/tcrm.s323387] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 08/16/2021] [Indexed: 12/30/2022] Open
Abstract
The rising of global geriatric population has contributed to increased prevalence of dementia. Dementia is a neurodegenerative disease, which is characterized by progressive deterioration of cognitive functions, such as judgment, language, memory, attention and visuospatial ability. Dementia not only has profoundly devastating physical and psychological health outcomes, but it also poses a considerable healthcare expenditure and burdens. Acetylcholinesterase inhibitors (AChEIs), or so-called anti-dementia medications, have been developed to delay the progression of neurocognitive disorders and to decrease healthcare needs. AChEIs have been widely prescribed in clinical practice for the treatment of Alzheimer's disease, which account for 70% of dementia. The rising use of AChEIs results in increased adverse drug reactions (ADRs) such as cardiovascular and gastrointestinal adverse effects, resulting from overstimulation of peripheral cholinergic activity and muscarinic receptor activation. Changes in pharmacokinetics (PK), pharmacodynamics (PD) and pharmacogenetics (PGx), and occurrence of drug interactions are said to be major risk factors of ADRs of AChEIs in this population. To date, comprehensive reviews in ADRs of AChEIs have so far been scarcely studied. Therefore, we aimed to recapitulate and update the diverse aspects of AChEIs, including the mechanisms of action, characteristics and risk factors of ADRs, and preventive strategies of their ADRs. The collation of this knowledge is essential to facilitate efforts to reduce ADRs of AChEIs.
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Affiliation(s)
- Sirasa Ruangritchankul
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Prawat Chantharit
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sahaphume Srisuma
- Ramathibodi Poison Center and Division of Clinical Pharmacology and Toxicology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Leonard C Gray
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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17
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Vaismoradi M, Jamshed S, Lorenzl S, Paal P. PRN Medicines Management for Older People with Long-Term Mental Health Disorders in Home Care. Risk Manag Healthc Policy 2021; 14:2841-2849. [PMID: 34262371 PMCID: PMC8274703 DOI: 10.2147/rmhp.s316744] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/02/2021] [Indexed: 12/21/2022] Open
Abstract
Older people with long-term mental health conditions who receive care in their own home are vulnerable to the inappropriate use of medications and polypharmacy given their underlying health conditions and comorbidities. Inappropriate use of pro re nata (PRN) medications in these older people can enhance their suffering and have negative consequences for their quality of life and well-being, leading to readmission to healthcare settings and the increased cost of health care. This narrative review on published international literature aims at improving our understanding of medicines management in home care and how to improve PRN medication use among older people with long-term health conditions in their own home. Accordingly, the improvement of PRN medicines management for these older people requires the development of an individualised care plan considering ‘reduction of older people’s dependence on PRN medications’, ‘empowerment of family caregivers’, and ‘support by healthcare professionals.’ PRN medication use should be reduced through deprescription and discontinuation strategies. Also, older people and their family caregivers should be encouraged to prioritize the use of non-pharmacologic methods to relieve physical and psychological problems. Besides the empowerment of family caregivers through role development, education and training about PRN medications, and involvement in decision-making, they need support by the multidisciplinary network in terms of supervision, monitoring, and home visits.
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Affiliation(s)
- Mojtaba Vaismoradi
- Faculty of Nursing and Health Sciences, Nord University, Bodø, 8049, Norway
| | - Shazia Jamshed
- Clinical Pharmacy and Practice, Faculty of Pharmacy, University Sultan Zainal Abidin, Terengganu, 22200, Malaysia
| | - Stefan Lorenzl
- Professorship for Palliative Care, Institute of Nursing Science and -Practice, Paracelsus Medical University, Salzburg, 5020, Austria.,Department of Neurology, Klinikum Agatharied, Hausham, 83734, Germany
| | - Piret Paal
- WHO Collaborating Centre at the Institute for Nursing Science and Practice, Paracelsus Medical University, Salzburg, A-5020, Austria
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18
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Moo LR, Martinez E, Padala K, Dunay MA, Scali RR, Chen S, Thielke SM. Unexpected Findings During Double-blind Discontinuation of Acetylcholinesterase Inhibitor Medications. Clin Ther 2021; 43:942-952. [PMID: 34127273 DOI: 10.1016/j.clinthera.2021.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The long-term effects of acetylcholinesterase inhibitors (AChEIs) used in the treatment of patients with various types of dementia remain unclear, largely due to challenges in the study of their discontinuation. We present several unexpected results from a discontinuation trial that might merit further investigation. METHODS This double-blind, placebo-controlled study of the discontinuation of AChEI medications was conducted in 62 US veterans. Participants were randomized to receive continued treatment with their medication (sham-taper group) or to treatment discontinuation via tapering (real-taper group), over a period of 6 weeks. The primary end point was the patient's/family caregiver's decision to discontinue the study medication. FINDINGS The study was underpowered to detect a significant between-group difference in the primary end point, but examination of the discontinuation process generated several unexpected results: (1) recruitment proved extremely challenging for a variety of reasons, with <5% of potentially eligible participants enrolled; (2) all 3 patients with Parkinson disease-associated dementia showed a worsening of symptoms when they discontinued their AChEI medication, but they showed improvement after they restarted it; (3) changes in symptom-scale scores varied quite broadly across participants, regardless of treatment arm; (4) unusual effects were noted in the sham-taper arm; and (5) the only significant predictor of the decision to discontinue the study medication was a worsening in the caregiver's mood. IMPLICATIONS These findings argue for the use of caution in discontinuing AChEIs in patients with Parkinson disease-associated dementia, although there may be potential benefits of a "drug holiday." The findings also urge the consideration of distress on the part of the caregiver while making medication treatment decisions in dementia. Future research must address challenges with recruitment and symptom fluctuations. (Clin Ther. 2021;43:XXX-XXX) © 2021 Elsevier Inc.
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Affiliation(s)
- Lauren R Moo
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Bedford Healthcare System, Bedford, Massachusetts; Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Erica Martinez
- Puget Sound Veterans Affairs Medical Center, Seattle, Washington.
| | - Kalpana Padala
- Geriatric Research, Education, and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas; University of Arkansas for Medical Sciences, Little Rock, Arkansas.
| | - Megan A Dunay
- Boise Veterans Affairs Medical Center, Boise, Idaho.
| | - Rachael R Scali
- The Department of Biomedical Sciences, Tufts University School of Medicine, Medford, Massachusetts.
| | - Sunny Chen
- Puget Sound Veterans Affairs Medical Center, Seattle, Washington.
| | - Stephen M Thielke
- Puget Sound Veterans Affairs Medical Center, Seattle, Washington; The Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington.
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19
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Hung WW. Older Adults with Alzheimer's Disease: The Need to Improve Systems of Care. Clin Ther 2021; 43:920-921. [PMID: 34103178 DOI: 10.1016/j.clinthera.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 11/22/2022]
Affiliation(s)
- William W Hung
- Geriatric Research Education and Clinical Center, James J Peters VA Medical Center, Bronx NY USA; Icahn School of Medicine at Mount Sinai, New York, NY USA
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20
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Renom-Guiteras A. Potentially inappropriate medication among people with dementia: towards individualized decision-making. Eur Geriatr Med 2021; 12:569-575. [PMID: 34003481 DOI: 10.1007/s41999-021-00502-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 04/15/2021] [Indexed: 12/18/2022]
Abstract
AIM The aims of this manuscript are to report on several aspects that may deserve special consideration when individualizing decisions on the prescription appropriateness among people with dementia, and to discuss current research needs in relation to these aspects. METHODS Review article based on selective literature. RESULTS The aspects that may deserve special consideration are: the prescription of pychotropic medications, for being commonly inappropriately prescribed; the presence of advanced stage of dementia, comorbidities or multi-morbidity and/or frailty, as they can determine the prognosis and goals of care; the values and wishes of the person with dementia, as they may prioritize different goals of care; and medication adherence, as it may be poorer compared with persons without dementia. Further research on these aspects including representative participants is necessary as evidence base to guide clinical practice. CONCLUSION Individualised decisions on prescription appropriateness among people with dementia may require a comprehensive evaluation of the person in order to establish a shared care plan. Further research will probably support this process.
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Affiliation(s)
- Anna Renom-Guiteras
- Department of Geriatric Medicine. Parc de Salut Mar, Barcelona, Spain. .,Health Services Research on Chronic Patients Network (REDISSEC), Madrid, Spain.
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21
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Pohanka M. Inhibitors of Cholinesterases in Pharmacology: the Current Trends. Mini Rev Med Chem 2021; 20:1532-1542. [PMID: 31656151 DOI: 10.2174/1389557519666191018170908] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 03/30/2018] [Accepted: 05/27/2018] [Indexed: 12/20/2022]
Abstract
Inhibitors of cholinesterases are a wide group of low molecular weight compounds with a significant role in the current pharmacology. Besides the pharmacological importance, they are also known as toxic compounds like military nerve agents. In the pharmacology, drugs for Alzheimer disease, myasthenia gravis and prophylaxis of poisoning by nerve agents can be mentioned as the relevant applications. Besides this, anti-inflammation and antiphrastic drugs are other pharmacological applications of these inhibitors. This review is focused on a survey of cholinesterase inhibitors with known or expected pharmacological impact and indications of their use. Recent literature with comments is provided here as well.
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Affiliation(s)
- Miroslav Pohanka
- Faculty of Military Health Sciences, University of Defense, Trebesska 1575, Hradec Kralove, Czech Republic
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22
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Parsons C, Lim WY, Loy C, McGuinness B, Passmore P, Ward SA, Hughes C. Withdrawal or continuation of cholinesterase inhibitors or memantine or both, in people with dementia. Cochrane Database Syst Rev 2021; 2:CD009081. [PMID: 35608903 PMCID: PMC8094886 DOI: 10.1002/14651858.cd009081.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Dementia is a progressive syndrome characterised by deterioration in memory, thinking and behaviour, and by impaired ability to perform daily activities. Two classes of drug - cholinesterase inhibitors (donepezil, galantamine and rivastigmine) and memantine - are widely licensed for dementia due to Alzheimer's disease, and rivastigmine is also licensed for Parkinson's disease dementia. These drugs are prescribed to alleviate symptoms and delay disease progression in these and sometimes in other forms of dementia. There are uncertainties about the benefits and adverse effects of these drugs in the long term and in severe dementia, about effects of withdrawal, and about the most appropriate time to discontinue treatment. OBJECTIVES To evaluate the effects of withdrawal or continuation of cholinesterase inhibitors or memantine, or both, in people with dementia on: cognitive, neuropsychiatric and functional outcomes, rates of institutionalisation, adverse events, dropout from trials, mortality, quality of life and carer-related outcomes. SEARCH METHODS We searched the Cochrane Dementia and Cognitive Improvement Group's Specialised Register up to 17 October 2020 using terms appropriate for the retrieval of studies of cholinesterase inhibitors or memantine. The Specialised Register contains records of clinical trials identified from monthly searches of a number of major healthcare databases, numerous trial registries and grey literature sources. SELECTION CRITERIA We included all randomised, controlled clinical trials (RCTs) which compared withdrawal of cholinesterase inhibitors or memantine, or both, with continuation of the same drug or drugs. DATA COLLECTION AND ANALYSIS Two review authors independently assessed citations and full-text articles for inclusion, extracted data from included trials and assessed risk of bias using the Cochrane risk of bias tool. Where trials were sufficiently similar, we pooled data for outcomes in the short term (up to 2 months after randomisation), medium term (3-11 months) and long term (12 months or more). We assessed the overall certainty of the evidence for each outcome using GRADE methods. MAIN RESULTS We included six trials investigating cholinesterase inhibitor withdrawal, and one trial investigating withdrawal of either donepezil or memantine. No trials assessed withdrawal of memantine only. Drugs were withdrawn abruptly in five trials and stepwise in two trials. All participants had dementia due to Alzheimer's disease, with severities ranging from mild to very severe, and were taking cholinesterase inhibitors without known adverse effects at baseline. The included trials randomised 759 participants to treatment groups relevant to this review. Study duration ranged from 6 weeks to 12 months. There were too few included studies to allow planned subgroup analyses. We considered some studies to be at unclear or high risk of selection, performance, detection, attrition or reporting bias. Compared to continuing cholinesterase inhibitors, discontinuing treatment may be associated with worse cognitive function in the short term (standardised mean difference (SMD) -0.42, 95% confidence interval (CI) -0.64 to -0.21; 4 studies; low certainty), but the effect in the medium term is very uncertain (SMD -0.40, 95% CI -0.87 to 0.07; 3 studies; very low certainty). In a sensitivity analysis omitting data from a study which only included participants who had shown a relatively poor prior response to donepezil, inconsistency was reduced and we found that cognitive function may be worse in the discontinuation group in the medium term (SMD -0.62; 95% CI -0.94 to -0.31). Data from one longer-term study suggest that discontinuing a cholinesterase inhibitor is probably associated with worse cognitive function at 12 months (mean difference (MD) -2.09 Standardised Mini-Mental State Examination (SMMSE) points, 95% CI -3.43 to -0.75; moderate certainty). Discontinuation may make little or no difference to functional status in the short term (SMD -0.25, 95% CI -0.54 to 0.04; 2 studies; low certainty), and its effect in the medium term is uncertain (SMD -0.38, 95% CI -0.74 to -0.01; 2 studies; very low certainty). After 12 months, discontinuing a cholinesterase inhibitor probably results in greater functional impairment than continuing treatment (MD -3.38 Bristol Activities of Daily Living Scale (BADLS) points, 95% CI -6.67 to -0.10; one study; moderate certainty). Discontinuation may be associated with a worsening of neuropsychiatric symptoms over the short term and medium term, although we cannot exclude a minimal effect (SMD - 0.48, 95% CI -0.82 to -0.13; 2 studies; low certainty; and SMD -0.27, 95% CI -0.47 to -0.08; 3 studies; low certainty, respectively). Data from one study suggest that discontinuing a cholinesterase inhibitor may result in little to no change in neuropsychiatric status at 12 months (MD -0.87 Neuropsychiatric Inventory (NPI) points; 95% CI -8.42 to 6.68; moderate certainty). We found no clear evidence of an effect of discontinuation on dropout due to lack of medication efficacy or deterioration in overall medical condition (odds ratio (OR) 1.53, 95% CI 0.84 to 2.76; 4 studies; low certainty), on number of adverse events (OR 0.85, 95% CI 0.57 to 1.27; 4 studies; low certainty) or serious adverse events (OR 0.80, 95% CI 0.46 to 1.39; 4 studies; low certainty), and on mortality (OR 0.75, 95% CI 0.36 to 1.55; 5 studies; low certainty). Institutionalisation was reported in one trial, but it was not possible to extract data for the groups relevant to this review. AUTHORS' CONCLUSIONS This review suggests that discontinuing cholinesterase inhibitors may result in worse cognitive, neuropsychiatric and functional status than continuing treatment, although this is supported by limited evidence, almost all of low or very low certainty. As all participants had dementia due to Alzheimer's disease, our findings are not transferable to other dementia types. We were unable to determine whether the effects of discontinuing cholinesterase inhibitors differed with baseline dementia severity. There is currently no evidence to guide decisions about discontinuing memantine. There is a need for further well-designed RCTs, across a range of dementia severities and settings. We are aware of two ongoing registered trials. In making decisions about discontinuing these drugs, clinicians should exercise caution, considering the evidence from existing trials along with other factors important to patients and their carers.
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Affiliation(s)
- Carole Parsons
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - Wei Yin Lim
- Centre for Clinical Epidemiology, Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Malaysia
| | - Clement Loy
- Brain and Mind Centre and Sydney School of Public Health, Faculty of Medicine, University of Sydney, Sydney, Australia
| | | | - Peter Passmore
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Stephanie A Ward
- Monash Aging Research Center, The Kingston Centre, Cheltenham, Australia
| | - Carmel Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, UK
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Etxeberria A, Iribar J, Vrotsou K, Rotaeche R, Barral I, Barral I, Belzunegui J, Bustinduy A, Caso J, Del Bosque C, Etxeberria A, Frias O, Iribar J, Lekuona A, Lombera L, López B, Núñez J, Olasagasti B, Rotaeche R, Royo I, Vrotsou K, Zapata E, Zubeldia X. [Evaluation of the collaboration between Primary and Hospital Care in order to improve inappropriate prescription]. J Healthc Qual Res 2021; 36:91-97. [PMID: 33495114 DOI: 10.1016/j.jhqr.2020.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/12/2020] [Accepted: 09/20/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND OBJECTIVES To evaluate the implementation of a collaborative experience between Primary (PC) and Hospital Care (HC) aimed at reducing potentially inappropriate prescribing (PIP) in patients with polypharmacy. MATERIALS AND METHODS Collaborative experience including a controlled before-after intervention study, carried out in the Donostialdea Integrated Health Organization (IHO), with Bilbao Basurto IHO as control group, Osakidetza, Basque Health Service. Participant were 227 PC physicians and physicians from 7 hospital services, and patients with 5 or more drugs meeting at least one PIP criteria. The intervention consisted of communication and knowledge between professionals, PC-HC consensus, training, identification of patients at risk, medication review, evaluation and feed-back. The collaboration process (agreements, consensus documents, training activities) and the change in the prevalence of PIP in polymedicated patients (using computerised health records) were evaluated. RESULTS A total of 21 PIP criteria and 6 recommendation documents were agreed. An analysis was performed on 15,570 PIP from OSI Donostialdea and 24,866 from the control group. The prevalence of PIP in polymedicated patients was reduced by -4.53% (95% CI: -4.71 to -4.36, P< .0001) in comparison with the control group. The before-after differences were statistically significant across the 7 services. CONCLUSIONS PC-HC collaboration is feasible and, along with other intervention components, reduces inappropriate polypharmacy in the context of a recently integrated healthcare organisation. The collaboration process is complex and requires continuous monitoring, policy involvement, leadership that encourages health professional participation, and intensive use of information systems.
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Affiliation(s)
- A Etxeberria
- Osakidetza, OSI Donostialdea, Farmacia Atención Primaria, Hernani, España; Instituto de Investigación Sanitaria Biodonostia, Grupo de Atención Primaria, Donostia-San Sebastián, España
| | - J Iribar
- Osakidetza, OSI Donostialdea, Farmacia Atención Primaria, Hernani, España.
| | - K Vrotsou
- Instituto de Investigación Sanitaria Biodonostia, Grupo de Atención Primaria, Donostia-San Sebastián, España; Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), España; Instituto de Investigación en Servicios de Salud Kronikgune, Torre del BEC, Barakaldo, España
| | - R Rotaeche
- Instituto de Investigación Sanitaria Biodonostia, Grupo de Atención Primaria, Donostia-San Sebastián, España; Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), España; Osakidetza, OSI Donostialdea, Centro de Salud de Alza, Donostia-San Sebastián, España
| | - I Barral
- Osakidetza, Hospital Universitario Donostia, Donostia-San Sebastián, España
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Schlögl M, Riese F, Little MO, Blum D, Jox RJ, O'Neill L, Pautex S, Piers R, Way D, Jones CA. Top Ten Tips Palliative Care Clinicians Should Know About Cognitive Impairment and Institutional Care. J Palliat Med 2020; 23:1525-1531. [PMID: 32955961 DOI: 10.1089/jpm.2020.0552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Most long-term care (LTC) residents are of age >65 years and have multiple chronic health conditions affecting their cognitive and physical functioning. Although some individuals in nursing homes return home after receiving therapy services, most will remain in a LTC facility until their deaths. This article seeks to provide guidance on how to assess and effectively select treatment for delirium, behavioral and psychological symptoms for patients with dementia, and address other common challenges such as advanced care planning, decision-making capacity, and artificial hydration at the end of life. To do so, we draw upon a team of physicians with training in various backgrounds such as geriatrics, palliative medicine, neurology, and psychiatry to shed light on those important topics in the following "Top 10" tips.
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Affiliation(s)
- Mathias Schlögl
- Centre on Aging and Mobility, University Hospital Zurich and City Hospital Waid Zurich, Zurich, Switzerland.,University Clinic for Acute Geriatric Care, City Hospital Waid Zurich, Zurich, Switzerland
| | - Florian Riese
- Psychiatric University Hospital Zurich, Zurich, Switzerland.,University Research Priority Program: Dynamics of Healthy Aging, University of Zurich, Zurich, Switzerland
| | - Milta O Little
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - David Blum
- Department of Radiation Oncology, Competence Center Palliative Care, University Hospital Zurich, Zurich, Switzerland
| | - Ralf J Jox
- Palliative and Supportive Care Service, Chair of Geriatric Palliative Care, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Lynn O'Neill
- Division of Palliative Medicine, Department of Family & Preventive Medicine, Atlanta Veterans Health Care System and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sophie Pautex
- Palliative Medicine Division, Department of Rehabilitation and Geriatrics, Geneva University Hospitals, Geneva, Switzerland.,University of Geneva, Geneva, Switzerland
| | - Ruth Piers
- Department of Geriatrics, Ghent University Hospital, Ghent, Belgium
| | - Deborah Way
- Department of Palliative Care, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.,Division of Geriatric Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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25
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Cacabelos R. Pharmacogenetic considerations when prescribing cholinesterase inhibitors for the treatment of Alzheimer's disease. Expert Opin Drug Metab Toxicol 2020; 16:673-701. [PMID: 32520597 DOI: 10.1080/17425255.2020.1779700] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Cholinergic dysfunction, demonstrated in the late 1970s and early 1980s, led to the introduction of acetylcholinesterase inhibitors (AChEIs) in 1993 (Tacrine) to enhance cholinergic neurotransmission as the first line of treatment against Alzheimer's disease (AD). The new generation of AChEIs, represented by Donepezil (1996), Galantamine (2001) and Rivastigmine (2002), is the only treatment for AD to date, together with Memantine (2003). AChEIs are not devoid of side-effects and their cost-effectiveness is limited. An option to optimize the correct use of AChEIs is the implementation of pharmacogenetics (PGx) in the clinical practice. AREAS COVERED (i) The cholinergic system in AD, (ii) principles of AD PGx, (iii) PGx of Donepezil, Galantamine, Rivastigmine, Huperzine and other treatments, and (iv) practical recommendations. EXPERT OPINION The most relevant genes influencing AChEI efficacy and safety are APOE and CYPs. APOE-4 carriers are the worst responders to AChEIs. With the exception of Rivastigmine (UGT2B7, BCHE-K), the other AChEIs are primarily metabolized via CYP2D6, CYP3A4, and UGT enzymes, with involvement of ABC transporters and cholinergic genes (CHAT, ACHE, BCHE, SLC5A7, SLC18A3, CHRNA7) in most ethnic groups. Defective variants may affect the clinical response to AChEIs. PGx geno-phenotyping is highly recommended prior to treatment.
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Affiliation(s)
- Ramón Cacabelos
- Department of Genomic Medicine, EuroEspes Biomedical Research Center, International Center of Neuroscience and Genomic Medicine , Bergondo, Corunna, Spain
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26
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Rausch C, Hoffmann F. Prescribing medications of questionable benefit prior to death: a retrospective study on older nursing home residents with and without dementia in Germany. Eur J Clin Pharmacol 2020; 76:877-885. [PMID: 32219538 PMCID: PMC7239800 DOI: 10.1007/s00228-020-02859-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 03/11/2020] [Indexed: 12/04/2022]
Abstract
Purpose We studied the prevalence of medications of questionable benefit in the last 6 months of life among older nursing home residents with and without dementia in Germany. Methods A retrospective cohort study was conducted on claims data from 67,328 deceased nursing home residents aged 65+ years who were admitted between 2010 and 2014. We analyzed prescription regimens of medications of questionable benefit in the 180–91-day period and the 90-day period prior to death for residents with dementia (n = 29,052) and without dementia (n = 38,276). Factors associated with new prescriptions of medications of questionable benefit prior to death were analyzed using logistic regression models among all nursing home residents and stratified by dementia. Results A higher proportion of nursing home residents with dementia were prescribed at least one medication of questionable benefit in the 180–91-day (29.6%) and 90-day (26.8%) periods prior to death, compared with residents without dementia (180–91 days, 22.8%; 90 days, 20.1%). Lipid-lowering agents were the most commonly prescribed medications. New prescriptions of medications of questionable benefit were more common among residents with dementia (9.8% vs. 8.7%). When excluding anti-dementia medication, new prescriptions of these medications were more common among residents without dementia (6.4% vs. 8.0%). The presence of dementia (odds ratio [OR] 1.40, 95% confidence interval [95%CI] 1.32–1.48) and excessive polypharmacy were associated with new prescriptions of medications of questionable benefit prior to death (OR 4.74, 95%CI 4.15–5.42). Conclusion Even when accounting for anti-dementia prescriptions, the prevalence of nursing home residents with dementia receiving medications of questionable benefit is considerable and may require further attention. Electronic supplementary material The online version of this article (10.1007/s00228-020-02859-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christian Rausch
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Ammerländer Heerstraße 140, 26129, Oldenburg, Germany.
- Department of Health Sciences, Community and Occupational Medicine, University of Groningen, University Medical Center Groningen, Antonius Deusinglaan 1, FA10, 9713 AV, Groningen, The Netherlands.
- Department of Global Public Health, Karolinska Institutet, Widerströmska huset, Tomtebodavägen 18A, SE, 17177, Stockholm, Sweden.
| | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Ammerländer Heerstraße 140, 26129, Oldenburg, Germany
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27
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Niznik JD, Zhao X, He M, Aspinall SL, Hanlon JT, Nace D, Thorpe JM, Thorpe CT. Impact of deprescribing AChEIs on aggressive behaviors and antipsychotic prescribing. Alzheimers Dement 2020; 16:630-640. [PMID: 32052930 DOI: 10.1002/alz.12054] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/04/2019] [Accepted: 12/04/2019] [Indexed: 01/09/2023]
Abstract
INTRODUCTION We evaluated the impact of deprescribing acetylcholinesterase inhibitors (AChEIs) on aggressive behaviors and incident antipsychotic use in nursing home (NH) residents with severe dementia. METHODS We conducted a retrospective study of Medicare claims, Part D, Minimum Data Set for NH residents aged 65+ with severe dementia receiving AChEIs in 2016. Aggressive behaviors were measured using the aggressive behavior scale (ABS; n = 30,788). Incident antipsychotic prescriptions were evaluated among antipsychotic non-users (n = 25,188). Marginal structural models and inverse probability of treatment weights were used to evaluate associations of AChEI deprescribing and outcomes. RESULTS The severity of aggressive behaviors was low at baseline (mean ABS = 0.5) and was not associated with deprescribing AChEIs (0.002 increase in ABS, P = .90). Incident antipsychotic prescribing occurred in 5.1% of residents and was less likely with AChEI deprescribing (adjusted odds ratio = 0.52 [0.40-0.68], P <.001]). DISCUSSION Deprescribing AChEIs was not associated with a worsening of aggressive behaviors or incident antipsychotic prescriptions.
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Affiliation(s)
- Joshua D Niznik
- Department of Medicine, Division of Geriatric Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Pittsburgh, Pennsylvania, USA
| | - Xinhua Zhao
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Pittsburgh, Pennsylvania, USA.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Meiqi He
- University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Sherrie L Aspinall
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Pittsburgh, Pennsylvania, USA.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA.,VA Center for Medication Safety, Hines, Illinois, USA
| | - Joseph T Hanlon
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Pittsburgh, Pennsylvania, USA.,Geriatric Division, Kaufmann Medical Building, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - David Nace
- Geriatric Division, Kaufmann Medical Building, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Joshua M Thorpe
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Pittsburgh, Pennsylvania, USA.,University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Carolyn T Thorpe
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Pittsburgh, Pennsylvania, USA.,University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
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Avram S, Mernea M, Limban C, Borcan F, Chifiriuc C. Potential Therapeutic Approaches to Alzheimer's Disease By Bioinformatics, Cheminformatics And Predicted Adme-Tox Tools. Curr Neuropharmacol 2020; 18:696-719. [PMID: 31885353 PMCID: PMC7536829 DOI: 10.2174/1570159x18666191230120053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/24/2019] [Accepted: 12/28/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Alzheimer's disease (AD) is considered a severe, irreversible and progressive neurodegenerative disorder. Currently, the pharmacological management of AD is based on a few clinically approved acethylcholinesterase (AChE) and N-methyl-D-aspartate (NMDA) receptor ligands, with unclear molecular mechanisms and severe side effects. METHODS Here, we reviewed the most recent bioinformatics, cheminformatics (SAR, drug design, molecular docking, friendly databases, ADME-Tox) and experimental data on relevant structurebiological activity relationships and molecular mechanisms of some natural and synthetic compounds with possible anti-AD effects (inhibitors of AChE, NMDA receptors, beta-secretase, amyloid beta (Aβ), redox metals) or acting on multiple AD targets at once. We considered: (i) in silico supported by experimental studies regarding the pharmacological potential of natural compounds as resveratrol, natural alkaloids, flavonoids isolated from various plants and donepezil, galantamine, rivastagmine and memantine derivatives, (ii) the most important pharmacokinetic descriptors of natural compounds in comparison with donepezil, memantine and galantamine. RESULTS In silico and experimental methods applied to synthetic compounds led to the identification of new AChE inhibitors, NMDA antagonists, multipotent hybrids targeting different AD processes and metal-organic compounds acting as Aβ inhibitors. Natural compounds appear as multipotent agents, acting on several AD pathways: cholinesterases, NMDA receptors, secretases or Aβ, but their efficiency in vivo and their correct dosage should be determined. CONCLUSION Bioinformatics, cheminformatics and ADME-Tox methods can be very helpful in the quest for an effective anti-AD treatment, allowing the identification of novel drugs, enhancing the druggability of molecular targets and providing a deeper understanding of AD pathological mechanisms.
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Affiliation(s)
| | - Maria Mernea
- Address correspondence to this author at the Department of Anatomy, Animal Physiology and Biophysics, Faculty of Biology, University of Bucharest, 91-95th Spl. Independentei, Bucharest, Romania; Tel/Fax: ++4-021-318-1573; E-mail:
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Greiman TL, Dear BN, Wilkening GL. Adverse outcomes of abrupt switch and discontinuation of acetylcholinesterase inhibitors in dementia with Lewy bodies: Case report and literature review. Ment Health Clin 2019; 9:309-314. [PMID: 31534872 PMCID: PMC6728118 DOI: 10.9740/mhc.2019.09.309] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Due to the well-defined risks of abrupt discontinuation of certain psychiatric medications, such as withdrawal and worsening symptoms, guideline recommendations describe evidence-based strategies for tapering some psychiatric medications, such as antidepressants. Despite widespread use of acetylcholinesterase inhibitor (ACHEI) therapy in the management of dementia, guideline recommendations for discontinuation of these therapies are very inconsistent. Specifically, studies and evidence-based recommendations for discontinuing ACHEIs in patients with dementia with Lewy bodies (DLB) are severely lacking. This deficit is problematic in that emerging reports suggest several adverse outcomes, such as worsening cognition and behavioral symptoms, are associated with abrupt switching and discontinuation of ACHEI therapy in this population. A case of rapid cognitive and functional decline following both abrupt switch and discontinuation of donepezil in a patient diagnosed with DLB is presented. A literature review of outcomes following changes in ACHEI therapy in DLB is also presented.
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Niznik JD, Zhao X, He M, Aspinall SL, Hanlon JT, Nace D, Thorpe JM, Thorpe CT. Factors Associated With Deprescribing Acetylcholinesterase Inhibitors in Older Nursing Home Residents With Severe Dementia. J Am Geriatr Soc 2019; 67:1871-1879. [PMID: 31162642 DOI: 10.1111/jgs.15985] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/18/2019] [Accepted: 04/23/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND/OBJECTIVE Uncertainty regarding benefits and risks associated with acetylcholinesterase inhibitors (AChEIs) in severe dementia means providers do not know if and when to deprescribe. We sought to identify which patient-, provider-, and system-level characteristics are associated with AChEI discontinuation. DESIGN Analysis of 2015 to 2016 data from Medicare claims, Part D prescriptions, Minimum Data Set (MDS), version 3.0, Area Health Resource File, and Nursing Home Compare. Cox-proportional hazards models with time-varying covariates were used to identify patient-, provider-, and system-level factors associated with AChEI discontinuation (30-day or more gap in supply). SETTING US Medicare-certified nursing homes (NHs). PARTICIPANTS Nonskilled NH residents, aged 65 years and older, with severe dementia receiving AChEIs within the first 14 days of an MDS assessment in 2016 (n = 37 106). RESULTS The sample was primarily white (78.7%), female (75.5%), and aged 80 years or older (77.4%). The most commonly prescribed AChEIs were donepezil (77.8%), followed by transdermal rivastigmine (14.6%). The cumulative incidence of AChEI discontinuation was 29.7% at the end of follow-up (330 days), with mean follow-up times of 194 days for continuous users of AChEIs and 105 days for those who discontinued. Factors associated with increased likelihood of discontinuation were new admission, older age, difficulty being understood, aggressive behavior, poor appetite, weight loss, mechanically altered diet, limited prognosis designation, hospitalization in 90 days prior, and northeastern region. Factors associated with decreased likelihood of discontinuation included memantine use, use of strong anticholinergics, polypharmacy, rurality, and primary care prescriber vs geriatric specialist. CONCLUSION Among NH residents with severe dementia being treated with AChEIs, the cumulative incidence of AChEI discontinuation was just under 30% at 1 year of follow-up. Our findings provide insight into potential drivers of deprescribing AChEIs, identify system-level barriers to deprescribing, and help to inform covariates that are needed to address potential confounding in studies evaluating the potential risks and benefits associated with deprescribing. J Am Geriatr Soc 67:1871-1879, 2019.
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Affiliation(s)
- Joshua D Niznik
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania.,Geriatric Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Veterans Affairs Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania.,Department of Veterans Affairs Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Meiqi He
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Sherrie L Aspinall
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania.,Department of Veterans Affairs Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Veterans Affairs Center for Medication Safety, Hines, Illinois
| | - Joseph T Hanlon
- Geriatric Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Veterans Affairs Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - David Nace
- Geriatric Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Joshua M Thorpe
- Department of Veterans Affairs Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Carolyn T Thorpe
- Department of Veterans Affairs Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
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31
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Clough AJ, Hilmer SN, Kouladjian‐O'Donnell L, Naismith SL, Gnjidic D. Health professionals' and researchers' opinions on conducting clinical deprescribing trials. Pharmacol Res Perspect 2019; 7:e00476. [PMID: 31049205 PMCID: PMC6482940 DOI: 10.1002/prp2.476] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 03/11/2019] [Indexed: 12/16/2022] Open
Abstract
While clinical deprescribing trials are increasingly being performed, there is no guidance on the optimum conduction of such studies. The aim of this survey was to explore the perspectives, attitudes, interests, barriers, and enablers of conducting clinical deprescribing trials among health professionals and researchers. An anonymous survey was developed, reviewed, and piloted by all investigators and informed by consultation with experts, as well as current deprescribing guidelines. The questions were formulated around current clinical trial frameworks and incorporated identified enablers and barriers of performing deprescribing studies. The survey was sent to members of Australian and international deprescribing, pharmacological, and pharmacy organizations, and other researchers published in deprescribing. A total of 96 respondents completed the survey (92.3% completion rate). Respondents indicated the main deprescribing trial rationale is to generate evidence to optimize patient-centered outcomes (79.2%). Common barriers identified included the time and effort required (18.2%), and apprehension of health professionals involved in trials (17.1%). Studies are enabled by positive attitudes toward deprescribing of treating prescribers (24.4%) and patients (20.9%). Classical randomized controlled trials (RCTs) were deemed the most appropriate methodology (93.2%). Sixty percent of participants indicated a good clinical practice framework is required to guide the conduct of deprescribing trials. There were no significant differences in responses based on previous experience in conducting clinical deprescribing trials. In conclusion, clinical deprescribing trials should be conducted to investigate whether deprescribing medications improves patient care. A future deprescribing trial framework should use classical RCTs as a model, ensure participant safety, and target patient-centered outcomes.
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Affiliation(s)
- Alexander J. Clough
- School of PharmacyUniversity of SydneyCamperdownNSWAustralia
- Kolling Institute of Medical ResearchUniversity of Sydney and Royal North Shore HospitalSt LeonardsNSWAustralia
| | - Sarah N. Hilmer
- Kolling Institute of Medical ResearchUniversity of Sydney and Royal North Shore HospitalSt LeonardsNSWAustralia
| | - Lisa Kouladjian‐O'Donnell
- Kolling Institute of Medical ResearchUniversity of Sydney and Royal North Shore HospitalSt LeonardsNSWAustralia
| | - Sharon L. Naismith
- Brain & Mind CentreUniversity of SydneyCamperdownNSWAustralia
- Charles Perkins CentreUniversity of SydneyCamperdownNSWAustralia
| | - Danijela Gnjidic
- School of PharmacyUniversity of SydneyCamperdownNSWAustralia
- Charles Perkins CentreUniversity of SydneyCamperdownNSWAustralia
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Molochkina EM, Treshchenkova YA. The Effect of Alpha-Tocopherol on the Activity of Acetylcholinesterases from Different Sources. NEUROCHEM J+ 2019. [DOI: 10.1134/s1819712419010161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Soler A, Amer G, Leiva A, Ripoll J, Llorente MA, Leiva A, Taltavull JM, Molina R, Llobera J. Continuation versus discontinuation of treatment for severe dementia: randomized, pragmatic, open-label, clinical trial to evaluate the efficacy of continuing drug treatment in patients with severe dementia (STOP-DEM). BMC Geriatr 2019; 19:101. [PMID: 30971215 PMCID: PMC6458648 DOI: 10.1186/s12877-019-1122-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 03/27/2019] [Indexed: 01/26/2023] Open
Abstract
Background Previous observational studies and clinical trials have shown that cholinesterase inhibitors (with or without memantine) provide benefit for patients with mild-to-moderate Alzheimer’s disease. However, the impact of treatment continuation after progression to severe disease is unknown. The main aim of this study is to evaluate the effect and safety of continuing treatment with ChEIs (with or without memantine) for patients with severe dementia. Methods This randomized, pragmatic, open-label clinical trial with blinded evaluators will evaluate the efficacy of continuing drug treatment in patients with advanced dementia. A total of 302 community-dwelling patients with severe dementia, Alzheimer’s disease, with or without a coexisting diagnosis of vascular dementia, and a score of 10 or less on the Mini-Mental State Examination who received previous treatment with a cholinesterase inhibitor (with or without memantine) for at least 3 months, will be randomized to continue or discontinue drug treatment. Follow-up will be 12 months or until the primary endpoint is achieved. The primary endpoint is entry into institutional care and progression of disability, defined as a loss of 2 of 4 basic functions, or 6 of 11 instrumental functions, according to the Bristol Activities of Daily Living Scale at 12 months. The secondary outcomes are patient changes in functional and cognitive state, quality of life, and caregiver burden. Discussion We expect that the results of our study will allow to identify if there is clinical relevant impact for patients and caregivers between maintaining or halting pharmacological treatment. Trial registration The study was prospectively registered in the REec (2017–000042-22) on May 11 2017 and ID ISRCTN12134230 on February 25 2019.
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Affiliation(s)
- Aina Soler
- Primary Care Research Unit of Mallorca, Baleares Health Services-IbSalut, Palma, Spain. .,Instituto de Investigación Sanitaria de Palma, Palma, Spain.
| | - Guillem Amer
- Son Espases Hospital, Baleares Health Services-IbSalut, Palma, Spain
| | - Alicia Leiva
- Primary Care Research Unit of Mallorca, Baleares Health Services-IbSalut, Palma, Spain.,Instituto de Investigación Sanitaria de Palma, Palma, Spain
| | - Joana Ripoll
- Primary Care Research Unit of Mallorca, Baleares Health Services-IbSalut, Palma, Spain.,Instituto de Investigación Sanitaria de Palma, Palma, Spain
| | | | - Alfonso Leiva
- Primary Care Research Unit of Mallorca, Baleares Health Services-IbSalut, Palma, Spain.,Instituto de Investigación Sanitaria de Palma, Palma, Spain
| | - Joana Maria Taltavull
- Primary Care Research Unit of Mallorca, Baleares Health Services-IbSalut, Palma, Spain.,Instituto de Investigación Sanitaria de Palma, Palma, Spain
| | - Rosa Molina
- Manacor Hospital, Baleares Health Services-IbSalut, Mallorca, Spain
| | - Joan Llobera
- Primary Care Research Unit of Mallorca, Baleares Health Services-IbSalut, Palma, Spain.,Instituto de Investigación Sanitaria de Palma, Palma, Spain
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Abstract
Neurodegenerative disorders are progressive, debilitating impairments of neurologic function. Dementia affects cognition and function. Persons with cognitive deficits should undergo a full workup and may be treated with cholinesterase inhibitors and/or memantine. Behavioral and psychological symptoms of dementia may be assessed and treated individually. Parkinson disease is a disorder of movement. Levodopa is the standard treatment of dopamine-related movement symptoms. Associated symptoms should be assessed and treated. Other neurodegenerative syndromes are less common but highly debilitating. Currently, there are no curative or disease-modifying therapies for neurodegenerative disorders. Novel therapies or research are in the pipeline.
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Affiliation(s)
- Abby Luck Parish
- Vanderbilt University School of Nursing, 461 21st Avenue South, Nashville, TN 37240, USA.
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White S, Griffiths R, Baxter M, Beanland T, Cross J, Dhesi J, Docherty AB, Foo I, Jolly G, Jones J, Moppett IK, Plunkett E, Sachdev K. Guidelines for the peri-operative care of people with dementia. Anaesthesia 2019; 74:357-372. [DOI: 10.1111/anae.14530] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2018] [Indexed: 12/24/2022]
Affiliation(s)
- S. White
- Royal Sussex County Hospital; Co-Chair, Association of Anaesthetists Working Party; Brighton UK
| | - R. Griffiths
- Peterborough and Stamford Hospitals Foundation NHS Trust; Co-Chair, Association of Anaesthetists Working Party; Peterborough UK
| | - M. Baxter
- University Hospital Southampton; British Geriatrics Society; UK
| | | | - J. Cross
- Guy's and St. Thomas’ Hospitals NHS Trust; Royal College of Nursing; London UK
| | - J. Dhesi
- Guy's and St. Thomas’ Hospitals NHS Trust; British Geriatrics Society; London UK
| | - A. B. Docherty
- Department of Anaesthesia and Critical Care; University of Edinburgh; UK
| | - I. Foo
- Western General Hospital; Age Anaesthesia Association; Edinburgh UK
| | | | | | - I. K. Moppett
- Anaesthesia and Peri-operative Medicine; University of Nottingham; Royal College of Anaesthetists; UK
| | - E. Plunkett
- University Hospitals Birmingham; Association of Anaesthetists Trainees; UK
| | - K. Sachdev
- Homerton University Hospital NHS Foundation Trust; London UK
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Margenfeld F, Klocke C, Joos S. Manual massage for persons living with dementia: A systematic review and meta-analysis. Int J Nurs Stud 2019; 96:132-142. [PMID: 30679034 DOI: 10.1016/j.ijnurstu.2018.12.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 10/21/2018] [Accepted: 12/04/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND The number of persons living with dementia will increase. So far, pharmacological management is limited because of small effect sizes and side effects of the drugs. Therefore, it is important to assess non-pharmacological treatment options such as massage, which have nearly no side effects and are easy for caregivers to apply. OBJECTIVES To conduct a systematic review with meta-analysis, aiming to pool the evidence for the efficacy of manual massage for persons living with dementia. DESIGN A systematic review and meta-analysis. DATA SOURCES EMBASE, Medline, PubMed, PSYinfo, BIOSIS, EBM, PSYCINDEX, Osteopathic Research Web, and OSTMED.DR were searched, regardless of publication year, through August 2017. REVIEW METHODS Randomized controlled trials (RCTs) evaluating manual massage in patients with dementia with or without using (aromatic) oil were included. The intervention of the control group had to guarantee no physical contact between caregiver and patient. Only studies assessing behavioural and psychological symptoms of dementia, cognitive abilities or depressive symptoms with validated instruments were included. Two reviewers independently extracted data and assessed risk of bias using The Cochrane Collaboration's 'Risk of bias' tool. Continuous outcomes are given as standardized mean difference (SMD), with 95% confidence intervals (CI) if different scaling of outcome measurement was used, and as mean difference (MD), with 95% confidence intervals (CI) for identical scaling. Data were pooled using the random-effects model. Sensitivity analysis considered type of massage, oil and outcome. Funnel plots were performed. RESULTS Eleven RCTs, with a total of 825 persons living with dementia, were eligible for qualitative synthesis and nine for quantitative synthesis. Two studies, with a total of 95 participants, had a high risk of bias. A pooled analysis of the mean change showed a benefit of manual massage compared to the control group using the Cohen Mansfield Agitation Inventory (SMD = -0.56, 95% CI [-0.95, -0.17], P = 0.005), which included six studies with 395 participants, and using the Cornell Scale of Depression in Dementia (MD = -6.14 [-8.66, -3.61], P < 0.00001), which included three studies with 193 participants. No significant effect could be demonstrated using the Neuropsychiatric Inventory and Mini Mental State Examination. Subgroup analysis of 'acupressure' did not show significant group differences. CONCLUSIONS Manual massage may serve as a non-pharmacological strategy to improve behavioural and psychological symptoms in persons living with dementia. Thus, healthcare professionals and family caregivers should be encouraged to apply massage to their patients and relatives. More research is needed, however, to provide clearer recommendations with respect to frequency and types of massage.
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Affiliation(s)
- Felix Margenfeld
- Institute for General Practice and Interprofessional Healthcare, Eberhardt-Karls-University Tübingen, Osianderstraße 5, 72076, Tübingen, Germany; National Graduate College 'Optimisation strategies in Dementia - OptiDem', Karl and Veronica Carstens-Foundation, Essen, Germany.
| | - Carina Klocke
- Institute for General Practice and Interprofessional Healthcare, Eberhardt-Karls-University Tübingen, Osianderstraße 5, 72076, Tübingen, Germany; National Graduate College 'Optimisation strategies in Dementia - OptiDem', Karl and Veronica Carstens-Foundation, Essen, Germany
| | - Stefanie Joos
- Institute for General Practice and Interprofessional Healthcare, Eberhardt-Karls-University Tübingen, Osianderstraße 5, 72076, Tübingen, Germany; National Graduate College 'Optimisation strategies in Dementia - OptiDem', Karl and Veronica Carstens-Foundation, Essen, Germany
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Maclagan LC, Bronskill SE, Guan J, Campitelli MA, Herrmann N, Lapane KL, Hogan DB, Amuah JE, Seitz DP, Gill SS, Maxwell CJ. Predictors of Cholinesterase Discontinuation during the First Year after Nursing Home Admission. J Am Med Dir Assoc 2018; 19:959-966.e4. [PMID: 30262440 DOI: 10.1016/j.jamda.2018.07.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 07/24/2018] [Accepted: 07/28/2018] [Indexed: 12/28/2022]
Abstract
OBJECTIVES For persons with dementia, the appropriate duration of cholinesterase inhibitor (ChEI) use remains unclear. We examined patterns of ChEI use during nursing home (NH) transition and the factors associated with discontinuation following admission. DESIGN Population-based retrospective cohort study using linked health administrative and Resident Assessment Instrument Minimum Dataset, version 2.0 databases. SETTING AND PARTICIPANTS A total of 47,851 older adults (mean age = 84.8 years, standard deviation = 6.8) with dementia newly admitted to a NH in Ontario, Canada between 2011 and 2015. MEASUREMENTS ChEI use at admission and during the following year was identified from prescription claims. Resident sociodemographic and health characteristics at admission, including a 72-item frailty index, were derived from the Resident Assessment Instrument Minimum Dataset 2.0. Additional resident and prescriber characteristics were derived from administrative data. Discontinuation was defined as a 30+-day gap in ChEI supply. Multivariable subdistribution hazard models were used to estimate the independent effect of resident frailty and other factors on ChEI discontinuation. RESULTS Approximately one-third (17,560) of residents with dementia were on a ChEI at admission. Among this group, 17.7% (3110) discontinued use over follow-up. Incidence of discontinuation was significantly higher among residents with syncope [subdistribution hazard ratio, sHR = 2.21, 95% confidence interval, CI (1.52, 3.22)], more severe behavioral symptoms [sHR = 1.79, 95% CI (1.57, 2.05)], cognitive impairment [sHR = 1.26, 95% CI (1.07, 1.48)], higher frailty, [sHR = 1.19, 95% CI (1.04, 1.36)], and a primary prescriber active in the NH [sHR = 1.28, 95% CI (1.14, 1.45)]. A significantly lower incidence was observed for older and unmarried residents and those with a longer duration of use. CONCLUSIONS/IMPLICATIONS Less than one-fifth of residents on a ChEI at admission discontinued use during the following year. Although some of the predictors of discontinuation align with past research and current clinical recommendations, others were unexpected and point to novel drivers of ChEI use. Future investigations should explore the varied reasons underlying these associations and resident outcomes associated with ChEI discontinuation.
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Affiliation(s)
- Laura C Maclagan
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Susan E Bronskill
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Jun Guan
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | | | - Nathan Herrmann
- Evaluative Clinical Sciences, Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Kate L Lapane
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - David B Hogan
- Division of Geriatric Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Joseph E Amuah
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Dallas P Seitz
- Institute for Clinical Evaluative Sciences, Queen's University, Kingston, Ontario, Canada; Division of Geriatric Psychiatry, Queen's University, Kingston, Ontario, Canada
| | - Sudeep S Gill
- Institute for Clinical Evaluative Sciences, Queen's University, Kingston, Ontario, Canada; Division of Geriatric Medicine, Queen's University, Kingston, Ontario, Canada; Providence Care Hospital, Kingston, Ontario, Canada
| | - Colleen J Maxwell
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada.
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Herrmann N. Cholinesterase Inhibitor Discontinuation: The Buck Stops Here. Am J Geriatr Psychiatry 2018; 26:148-149. [PMID: 29174877 DOI: 10.1016/j.jagp.2017.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 10/25/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Nathan Herrmann
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
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