Interventions for self-management of medicines for community-dwelling people with dementia and mild cognitive impairment and their family carers: a systematic review

Community pharmacists' knowledge of, and role in, managing anticholinergic burden among patients with dementia in primary care: a cross-sectional survey study

BACKGROUND

Anticholinergic medications and associated anticholinergic burden can impair cognitive function and increase mortality rates in patients with dementia.

AIM

To explore community pharmacists' knowledge of anticholinergic burden and perceptions of their role in anticholinergic burden management amongst patients with dementia.

METHOD

A self-administered, postal questionnaire was distributed to all registered community pharmacies in Northern Ireland (n = 526) on two occasions (October and November 2022). The questionnaire comprised four sections: (1) demographics associated with pharmacists and pharmacies, (2) contact between community pharmacists and patients with dementia/their carers, and types of medication-related queries received by pharmacists, (3) understanding and knowledge about anticholinergic burden, and (4) community pharmacist role in management of anticholinergic burden in patients with dementia. Data were analysed descriptively using Stata v17.

RESULTS

A response rate of 15.2% (80/526) was achieved. Most contact was with patients with dementia/carers in their own homes. Community pharmacists lacked knowledge about anticholinergic burden in dementia, did not use any anticholinergic burden scales in their practice (n = 77, 96.3%), and rarely discussed anticholinergic burden with patients, carers (n = 60, 75.0%), or other healthcare professionals (n = 42, 52.5%). However, they were positive about their role in future interventions and saw value in managing anticholinergic burden in patients with dementia as part of a multidisciplinary primary healthcare team (n = 67; 83.3%).

CONCLUSION

Despite the low response rate, the study findings have highlighted community pharmacists' willingness to contribute to the management of anticholinergic burden in patients with dementia. Further research is required to understand how this can be achieved.

Deprescribing in cognitively vulnerable older people: development and validation of STOPPCog criteria

OBJECTIVE

To validate STOPPCog, a list of explicit criteria for potentially inappropriate medication use in cognitively vulnerable older adults.

DESIGN

A Delphi consensus survey of an expert panel comprising academic geriatricians, old age psychiatrists, general practitioners, and clinical pharmacists.

SETTING

Ireland.

SUBJECTS

Nine panellists.

METHODS

STOPPCog criteria were initially created by the authors based on clinical experience and literature appraisal. Criteria were organised according to drug/drug class. Using Delphi consensus methodology, panellists ranked their agreement with each criterion on a 5-point Likert scale and provided written feedback. Criteria with a median value of 1 or 2 (strongly agree/agree) and a 25th centile value of ≤2 were included in the final list.

RESULTS

All panellists completed two Delphi consensus validation rounds. Twenty-five criteria were proposed initially, twenty were accepted. One criterion was rejected (multi-vitamin supplements), and four criteria were rephrased (two of these were combined to one criterion for greater clarity). The final list comprised 23 criteria that are arranged in six subgroups i.e. (i) drugs with anticholinergic properties taken daily; (ii) drugs with sedative properties taken daily; (iii) drugs that may exacerbate psychotic symptoms in patients with alpha-synuclein pathology; (iv) drugs used for chronic pain; (v) drugs without proven efficacy for dementia taken daily; (vi) drugs that are of no proven benefit in advanced stage dementia i.e. clinical dementia rating of 3.0 where palliation may be appropriate.

CONCLUSION

STOPPCog comprises 23 criteria relating to medications that are potentially inappropriate in cognitively vulnerable older adults. STOPPCog may assist physicians in deprescribing medications in this patient population.

Interventions to improve medication adherence in persons with mental disorders

PURPOSE OF REVIEW

Nonadherence to medication is prevalent in patients with mental illness. Various factors responsible for it. As a result, there are more hospitalizations, increased risk of suicide and increased cost of care. Thus, there is a need for effective interventions to improve adherence in mentally ill patients.

RECENT FINDINGS

Adherence to medication includes participation of patient in decision making. Interventions in the recent years help patients through techniques like psychoeducation, motivational interviewing and cognitive behaviour therapy. Interventions involve both patients and caregivers. There is a growing body of research about use of technology -based interventions using smart phones, various applications, digital platforms and artificial intelligence. Recent findings of research indicate that a combination of methods of intervention may be more useful in improving adherence. Some conventional interventions yield good results. Robust research is needed in the field of technology- based interventions.

SUMMARY

Non adherence to medication leads to poorer health outcomes and hampers integration of the patient in the society. A collaborative effort of the team of healthcare providers, the patient and caregivers is the way ahead for better adherence and good quality of life.

Navigating complexity of the medication management system within the home setting-a functional resonance analysis method (FRAM) analysis of people with dementia and their carers' experiences

BACKGROUND

There is a strong imperative to support people with dementia to live independently in their homes for as long as possible. A starting point is to understand how they manage medications on a daily basis.

AIM

To understand how people with dementia and their informal carers manage medications within the home setting to inform the identification of opportunities to improve medication management.

METHODS

A qualitative study using the Functional Resonance Analysis Method (FRAM). Interview data with people with dementia and informal carers were analysed to (i) Identify and describe key functions, (ii) identify and describe variability in performing key functions, and its potential consequences and (iii) map performance variability to Resilient Healthcare capacities.

RESULTS AND DISCUSSION

A FRAM model was developed and consisted of 14 interdependent key functions. The interdependent nature of functions, and the different nature and sources of variability in how each key function was performed highlighted the level of complexity of the medication management system within the home setting. The medication system was managed almost entirely by the person with dementia and/or their informal carers. This shows the lack of system-level controls to support the safe functioning of the medication management system in the home setting.

CONCLUSION

Future work will develop a comprehensive FRAM model that includes the perspectives of health and social care professionals and those from the third sectors to underpin the development of a range of system recommendations to strengthen resilience in the medication management system within the home setting.

Influence of Potentially Inappropriate Medication Use on Older Australians' Admission to Emergency Department Short Stay

Older people in the emergency department (ED) often pose complex medical challenges, with a significant prevalence of polypharmacy and potentially inappropriate medicines (PIMs) in Australia. A retrospective analysis of 200 consecutive patients aged over 65 years admitted to the emergency short stay unit (ESSU) aimed to identify polypharmacy (five or more regular medications), assess PIM prevalence, and explore the link between pre-admission PIMs and ESSU admissions. STOPP/START version 2 criteria were used for the PIM assessment, with an expert panel categorizing associated risks. Polypharmacy was observed in 161 patients (80.5%), who were older (mean age 82 versus 76 years) and took more regular medications (median 9 versus 3). One hundred and eighty-five (92.5%) patients had at least one PIM, 81 patients (40.5%) had STOPP PIMs, and 177 patients (88.5%) had START omissions. Polypharmacy significantly correlated with STOPP PIM (OR 4.8; 95%CI: 1.90-12.1), and for each additional medication the adjusted odds of having a STOPP PIM increased by 1.20 (95%CI: 1.11-1.28). Nineteen admissions (9.5%) were attributed to one or more PIMs (total 21 PIMs). Of these PIMs, the expert panel rated eight (38%) as high risk, five (24%) as moderate risk, and eight (38%) as low risk for causing hospital admission. The most common PIMs were benzodiazepines, accounting for 14 cases (73.6%). Older ESSU-admitted patients commonly presented with polypharmacy and PIMs, potentially contributing to their admission.

A rapid review of interventions to improve medicine self-management for older people living at home

BACKGROUND

As people age, they are more likely to develop multiple long-term conditions that require complicated medicine regimens. Safely self-managing multiple medicines at home is challenging and how older people can be better supported to do so has not been fully explored.

AIM

This study aimed to identify interventions to improve medicine self-management for older people living at home and the aspects of medicine self-management that they address.

DESIGN

A rapid review was undertaken of publications up to April 2022. Eight databases were searched. Inclusion criteria were as follows: interventions aimed at people 65 years of age or older and their informal carers, living at home. Interventions needed to include at least one component of medicine self-management. Study protocols, conference papers, literature reviews and articles not in the English language were not included. The results from the review were reported through narrative synthesis, underpinned by the Resilient Healthcare theory.

RESULTS

Database searches returned 14,353 results. One hundred and sixty-seven articles were individually appraised (full-text screening) and 33 were included in the review. The majority of interventions identified were educational. In most cases, they aimed to improve older people's adherence and increase their knowledge of medicines. Only very few interventions addressed potential issues with medicine supply. Only a minority of interventions specifically targeted older people with either polypharmacy, multimorbidities or frailty.

CONCLUSION

To date, the emphasis in supporting older people to manage their medicines has been on the ability to adhere to medicine regimens. Most interventions identify and target deficiencies within the patient, rather than preparing patients for problems inherent in the medicine management system. Medicine self-management requires a much wider range of skills than taking medicines as prescribed. Interventions supporting older people to anticipate and respond to problems with their medicines may reduce the risk of harm associated with polypharmacy and may contribute to increased resilience in the system.

PATIENT OR PUBLIC CONTRIBUTION

A patient with lived experience of medicine self-management in older age contributed towards shaping the research question as well as the inclusion and exclusion criteria for this review. She is also the coauthor of this article. A patient advisory group oversaw the study.