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Carollo M, Crisafulli S, Vitturi G, Besco M, Hinek D, Sartorio A, Tanara V, Spadacini G, Selleri M, Zanconato V, Fava C, Minuz P, Zamboni M, Trifirò G. Clinical impact of medication review and deprescribing in older inpatients: A systematic review and meta-analysis. J Am Geriatr Soc 2024. [PMID: 38822740 DOI: 10.1111/jgs.19035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 04/25/2024] [Accepted: 05/13/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Polypharmacy is a primary risk factor for the prescription of potentially inappropriate medications (PIMs), drug-drug interactions (DDIs), and ultimately, adverse drug reactions (ADRs). Medication review and deprescribing represent effective strategies to simplify therapeutic regimens, minimize risks, and reduce PIM prescriptions. This systematic review and meta-analysis of experimental and observational studies aimed to evaluate the impact of different medication review and deprescribing interventions in hospitalized older patients. METHODS Experimental and observational prospective cohort studies evaluating the clinical effects of medication review and deprescribing strategies in older hospitalized patients were searched in the bibliographic databases, PubMed, Embase, and Scopus, from inception until January 8, 2024. A narrative synthesis of the results was provided, along with a meta-analysis of dichotomous data (i.e., re-hospitalizations and mortality). RESULTS Overall, 21 randomized controlled trials, 7 non-randomized interventional studies, and 2 prospective cohort studies were included in the systematic review. Of these, 14 (46.7%) assessed medication appropriateness as the primary outcome, while the remaining evaluated clinical outcomes (e.g., length of hospital stay, hospital readmissions, emergency department visits, and incidence of ADRs) and/or quality of life. The meta-analysis revealed a slight but statistically significant 8% reduction in hospital readmissions (HR: 0.92; 95% CI: 0.85-0.99) following medication review and deprescribing, but no significant impact on mortality (HR: 0.98; 95% CI: 0.96-1.00). Of the 30 included studies, 21 were considered at high risk of bias, mostly due to potential deviations from intended interventions and randomization processes. The remaining nine studies had "some concerns" (eight studies) or were considered at "low" risk of bias (one study). CONCLUSION Medication review and deprescribing are associated with potential benefits in reducing hospital readmission rates among hospitalized older patients, particularly through the reduction of PIM prescriptions. The integration of thorough medication review and deprescribing protocols in hospital settings may improve post-discharge outcomes and reduce overall healthcare costs.
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Affiliation(s)
- Massimo Carollo
- Department of Diagnostics and Public Health, Clinical Pharmacology Unit, University of Verona, Verona, Italy
| | | | - Giacomo Vitturi
- Department of Diagnostics and Public Health, Clinical Pharmacology Unit, University of Verona, Verona, Italy
| | - Matilde Besco
- Department of Medicine, Geriatrics Division, University of Verona, Verona, Italy
| | - Damiano Hinek
- Department of Pharmacy, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Andrea Sartorio
- Department of Medicine, Section of Internal Medicine C, University of Verona, Verona, Italy
| | - Valentina Tanara
- Department of Pharmacy, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Giulia Spadacini
- Department of Medicine, Geriatrics Division, University of Verona, Verona, Italy
| | - Margherita Selleri
- Department of Diagnostics and Public Health, Clinical Pharmacology Unit, University of Verona, Verona, Italy
| | - Valentina Zanconato
- Department of Medicine, Section of Internal Medicine C, University of Verona, Verona, Italy
| | - Cristiano Fava
- Department of Medicine, Section of Internal Medicine C, University of Verona, Verona, Italy
| | - Pietro Minuz
- Department of Medicine, Section of Internal Medicine C, University of Verona, Verona, Italy
| | - Mauro Zamboni
- Department of Surgery, Dentistry, Pediatric and Gynecology, Section of Geriatric Medicine, University of Verona, Verona, Italy
| | - Gianluca Trifirò
- Department of Diagnostics and Public Health, Clinical Pharmacology Unit, University of Verona, Verona, Italy
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Garfinkel D, Levy Y. Optimizing clinical outcomes in polypharmacy through poly-de-prescribing: a longitudinal study. Front Med (Lausanne) 2024; 11:1365751. [PMID: 38745740 PMCID: PMC11091405 DOI: 10.3389/fmed.2024.1365751] [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: 01/04/2024] [Accepted: 02/26/2024] [Indexed: 05/16/2024] Open
Abstract
Objectives To evaluate polypharmacy in older people to determine whether the number of medications de-prescribed correlates with the extent of improvement in quality of life (QoL) and clinical outcomes. Design A prospective longitudinal cohort study of polypharmacy in people living in a community in Israel. Setting Participants aged 65 years or older who took at least six prescription drugs followed up for at least 3 years (range 3-10 years) after poly-de-prescription (PDP) recommendations. Interventions PDP recommended at first home visit using the Garfinkel algorithm. Annual follow-up and end-of-study questionnaires used to assess clinical outcomes, QoL, and satisfaction from de-prescribing. All medications taken, complications, hospitalizations, and mortality recorded. In total, 307 participants met the inclusion criteria; 25 incomplete end-of-study questionnaires meant 282 participants for subjective analysis. Participants divided into two subgroups: (i) those who discontinued more than 50% of the drugs (PDP group) or (ii) those who discontinued less than 50% of the drugs (non-responders, NR). Main outcome measures Objective: 3-year survival rate and hospitalizations. Subjective: general satisfaction from de-prescribing; change in functional, mental, and cognitive status; improved sleep quality, appetite, and continence; and decreased pain. Results Mean age: 83 years (range 65-99 years). Mean number of drugs at baseline visit: 9.8 (range 6-20); 6.7 ± 2.0 de-prescribed in the PDP group (n = 146) and 2.2 ± 2.1 in the NR group (n = 161) (p < 0.001).No statistical difference between the groups in the 3-year survival rate and hospitalizations, but a significant improvement in functional and cognitive status and, in general, satisfaction from the intervention in the PDP group compared to the NR group. Improvement usually evident within the first 3 months and persists for several years. Conclusion Poly-de-prescribing in the older population has beneficial effects on several clinical outcomes with no detrimental effect on the rate of hospitalization and survival. The extent of improvement correlates with the extent of de-prescribing. Applying the Garfinkel algorithm globally may improve QoL in millions of patients, a clinical and economic win-win situation.
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Affiliation(s)
- Doron Garfinkel
- Center for Appropriate Medication Use, Sheba Medical Center, Ramat Gan, Israel
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Clemens S, Iglseder B, Alzner R, Kogler M, Rose O, Kutschar P, Krutter S, Kanduth K, Dückelmann C, Flamm M, Pachmayr J. Effects of medication management in geriatric patients who have fallen: results of the EMMA mixed-methods study. Age Ageing 2024; 53:afae070. [PMID: 38619121 DOI: 10.1093/ageing/afae070] [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: 10/13/2023] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND comprehensive medication management (CMM) can reduce medication-related risks of falling. However, knowledge about inter-individual treatment effects and patient-related barriers remains scarce. OBJECTIVE to gain in-depth insights into how geriatric patients who have fallen view their medication-related risks of falling and to identify effects and barriers of a CMM in preventing falls. DESIGN complementary mixed-methods pre-post study, based on an embedded quasi-experimental model. SETTING geriatric fracture centre. METHODS qualitative, semi-structured interviews framed the CMM intervention, including a follow-up period of 12 weeks. Interviews explored themes of falling, medication-related risks, post-discharge acceptability and sustainability of interventions using qualitative content analysis. Optimisation of pharmacotherapy was assessed via changes in the weighted and summated Medication Appropriateness Index (MAI) score, number of fall-risk-increasing drugs (FRID) and potentially inappropriate medications (PIM) according to the Fit fOR The Aged and PRISCUS lists using parametric testing. RESULTS thirty community-dwelling patients aged ≥65 years, taking ≥5 drugs and admitted after an injurious fall were recruited. The MAI was significantly reduced, but number of FRID and PIM remained largely unchanged. Many patients were open to medication reduction/discontinuation, but expressed fear when it came to their personal medication. Psychosocial issues and pain increased the number of indications. Safe alternatives for FRID were frequently not available. Psychosocial burden of living alone, fear, lack of supportive care and insomnia increased after discharge. CONCLUSION as patients' individual attitudes towards trauma and medication were not predictable, an individual and longitudinal CMM is required. A standardised approach is not helpful in this population.
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Affiliation(s)
- Stephanie Clemens
- Institute of Pharmacy, Pharmaceutical Biology and Clinical Pharmacy, Paracelsus Medical University, Salzburg, Austria
- Center of Public Health and Health Services Research, Paracelsus Medical University, Salzburg, Austria
| | - Bernhard Iglseder
- Department of Geriatric Medicine, Christian Doppler Klinik, Paracelsus Medical University, Ignaz-Harrer-Straße 79, A-5020, Salzburg, Austria
| | - Reinhard Alzner
- Department of Geriatric Medicine, Christian Doppler Klinik, Paracelsus Medical University, Ignaz-Harrer-Straße 79, A-5020, Salzburg, Austria
| | | | - Olaf Rose
- Institute of Pharmacy, Pharmaceutical Biology and Clinical Pharmacy, Paracelsus Medical University, Salzburg, Austria
| | - Patrick Kutschar
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
| | - Simon Krutter
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
| | - Karin Kanduth
- Institute of Pharmacy, Pharmaceutical Biology and Clinical Pharmacy, Paracelsus Medical University, Salzburg, Austria
| | - Christina Dückelmann
- Institute of Pharmacy, Pharmaceutical Biology and Clinical Pharmacy, Paracelsus Medical University, Salzburg, Austria
- Landesapotheke Salzburg, Salzburg, Austria
| | - Maria Flamm
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Johanna Pachmayr
- Institute of Pharmacy, Pharmaceutical Biology and Clinical Pharmacy, Paracelsus Medical University, Salzburg, Austria
- Center of Public Health and Health Services Research, Paracelsus Medical University, Salzburg, Austria
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Azab M, Novella A, Ianes A, Pasina L. Potentially Inappropriate Psychotropic Drugs in Nursing Homes: An Italian Observational Study. Drugs Aging 2024; 41:187-197. [PMID: 38036916 DOI: 10.1007/s40266-023-01083-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Physicians often face difficulties in selecting appropriate medications for older adults with multiple comorbidities. As people age, they are more likely to be living with a number of chronic conditions (multimorbidity) and be prescribed a high number of medications (polypharmacy). Multimorbidity is frequent in nursing home (NH) residents and the use of potentially inappropriate medications, especially psychotropic drugs, is widespread. This retrospective cross-sectional cohort study examined the frequency of potentially inappropriate psychotropic drugs using the Beers, Screening Tool of Older Persons' Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) and Fit fOR The Aged (FORTA) criteria, and their association with mortality. METHODS This retrospective cross-sectional cohort study was conducted on a sample of long-term care NHs across Italy. Of the 34 NHs with an electronic medical records system, 27 met the inclusion criteria, with complete web-based case report forms (CRFs). Residents under the age of 65 years were excluded. We calculated the prevalence of potentially inappropriate psychotropics drugs (antipsychotics, antidepressants and anxiolytics/hypnotics) according to three criteria for prescriptive appropriateness. Univariate and multivariate correlations were examined, taking into account age, sex, comorbidities, and the number of psychotropic drugs, to analyse the relationship between inappropriate psychotropic use and mortality rates. The rate of inappropriate psychotropic prescriptions was calculated with the prevalence of residents receiving potentially inappropriate psychotropic drugs according to the three criteria. We used a logistic model to check for a possible predictive relationship between inappropriate use of psychotropics and mortality. The study evaluated differences in prescriptive appropriateness among NHs by analysing the proportions of potentially inappropriately treated residents at the last visit. Differences were compared with the overall sample mean using confidence intervals (CIs) calculated using Wald's method. RESULTS This study involved 2555 residents, of whom 1908 (74.7% of the total) were treated with psychotropic drugs; 186 (7.3% of the total) were exposed to at least one psychotropic drug considered potentially inappropriate according to the FORTA criteria. Analysis using the Beers criteria showed that 1616 residents (63.2% of the total) received at least one psychotropic drug considered potentially inappropriate. In line with the Beers recommendation, patients receiving at least three psychotropic drugs were also included and 440 were identified (17.2% of the total sample). According to the STOPP criteria, 1451 residents (56.8% of the total sample) were prescribed potentially inappropriate psychotropic drugs. No correlation was found between potentially inappropriate use of psychotropic drugs and mortality, in either univariate analysis or in a multivariate model adjusted for age, sex and comorbidity index. CONCLUSIONS Different criteria for appropriate drug prescription identify very different percentages of patients in NHs exposed to psychotropics considered potentially inappropriate. The Beers and STOPP/START criteria identified a larger percentage of patients exposed in NHs than FORTA.
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Affiliation(s)
- Marina Azab
- Laboratory of Clinical Pharmacology and Appropriateness of Drug Prescription, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156, Milan, Italy.
| | - Alessio Novella
- Laboratory of Clinical Pharmacology and Appropriateness of Drug Prescription, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156, Milan, Italy
| | | | - Luca Pasina
- Laboratory of Clinical Pharmacology and Appropriateness of Drug Prescription, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156, Milan, Italy
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Hoffmann U. [Management of polypharmacy in older people with multimorbidity]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:9-16. [PMID: 38059997 DOI: 10.1007/s00108-023-01630-x] [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: 11/03/2023] [Indexed: 12/08/2023]
Abstract
If the individual diagnoses of older people with multimorbidity are treated according to guidelines and by different specialists, confusing medication plans are sometimes the consequence. Therefore, a regular and structured drug evaluation is essential. As the life goals of patients can be very different, especially in older age, certain preliminary considerations should be made when starting, prescribing or discontinuing medication, taking into account the individual situation, including geriatric aspects. Updated so-called positive and negative lists provide assistance as to which medications are suitable or unsuitable for older people. Discontinuing certain medications when the life expectancy is reduced certainly makes sense but undertreatment of symptoms that cause distress to people, such as pain, should definitely be avoided.
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Affiliation(s)
- Ute Hoffmann
- Klinik für Allgemeine Innere Medizin und Geriatrie, Krankenhaus Barmherzige Brüder, Prüfeninger Str. 86, 93049, Regensburg, Deutschland.
- Klinik für Alterstraumatologie, Krankenhaus Barmherzige Brüder, Regensburg, Deutschland.
- Zentrum für Ernährungsmedizin, Krankenhaus Barmherzige Brüder, Regensburg, Deutschland.
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Hsu YH, Chou MY, Chang WC, Chen MT, Wang YC, Liao MC, Liang CK, Chen LK, Lin YT. Association between changes in potentially inappropriate medication use and adverse outcomes during hospitalization in older adults: A retrospective study. Arch Gerontol Geriatr 2024; 116:105139. [PMID: 37567097 DOI: 10.1016/j.archger.2023.105139] [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: 05/24/2023] [Revised: 07/12/2023] [Accepted: 07/28/2023] [Indexed: 08/13/2023]
Abstract
PURPOSE To evaluate the association between the change in the number of PIMs in older adults during hospitalization and adverse outcomes. METHODS This retrospective cohort study was conducted in the internal medicine wards of a tertiary teaching hospital between May and December 2017. 3,460 patients (77.5±8.4 years, 60.4% male) were enrolled, and 206 patients died during hospitalization. PIMs were defined using the Beers Criteria as suggested by the American Geriatrics Society. Adverse outcomes studied were functional decline (a loss in 1 or more activities of daily living from admission to discharge), prolonged length of stay (LOS) (≥14 days), and mortality. RESULTS 2258 patients (65.3%) had increasing PIMs during hospitalization. They tended to be younger (77.0±8.3 versus 78.5±8.5 years, p<0.001) and had lower numbers of PIMs at admission (0.4±0.8 versus 0.8±1.1, p<0.001). Increasing PIM use was strongly associated with greater functional decline (aOR 1.36, 95%CI 1.01-1.67, p=0.005), prolonged LOS (aOR 3.47, 95%CI 2.71-4.44, p<0.001) and higher mortality rate (aOR 2.68, 95%CI 1.75-4.12, p<0.001), even after adjusting for all covariates. We observed a strong association between adverse outcomes and increasing PIMs in older adults during hospitalization (p for trend <0.001). CONCLUSIONS Older adults with increasing PIMs during hospitalization were at greater risk for functional decline, prolonged LOS, and mortality, especially in those with three or more PIMs. Further studies are needed to better understand the complex interactions and to evaluate the effectiveness of intervention programs to lower PIM number and improve discharge outcomes for patients who had increasing PIM use during hospitalization.
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Affiliation(s)
- Ying-Hsin Hsu
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan; Division of Neurology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
| | - Ming-Yueh Chou
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan; Center for Healthy Longevity and Aging Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Geriatric Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Wei-Cheng Chang
- Checheng Township Public Health Center, Pingtung County, Taiwan
| | - Miao-Ting Chen
- Department of Pharmacy, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
| | - Yu-Chun Wang
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
| | - Mei-Chen Liao
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
| | - Chih-Kuang Liang
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan; Division of Neurology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan; Center for Healthy Longevity and Aging Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Geriatric Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan.
| | - Liang-Kung Chen
- Taipei Municipal Gan-Dau Hospital, Taipei City, Taiwan; Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Yu-Te Lin
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan; Division of Neurology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
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Pazan F, Wehling M. [The FORTA (Fit fOR The Aged) List]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:3-8. [PMID: 38063911 DOI: 10.1007/s00108-023-01629-4] [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: 11/03/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Multimorbidity and the resulting polypharmacy are widespread in the very old and the evidence on the efficacy and safety of drugs in older people is sparse. Driven by guidelines, this often leads to inappropriate prescribing and drug-related problems. MATERIAL AND METHODS To improve this, numerous listing approaches were developed as tools to optimize medication. These approaches can be divided into drug-oriented listing approaches (DOLA), such as the Beers Criteria®, a list of potentially inappropriate medications for older people or patient-in-focus listing approaches (PILA), such as the Fit fOR The Aged (FORTA) list. RESULTS The most recent version of the FORTA list was published in 2022 and contains 299 drugs or drug groups targeting 30 age-related indications. In addition, several country-specific or region-specific FORTA lists, such as the EURO-FORTA list have been developed. Very few randomized controlled trials have demonstrated the utility of existing listing approaches for improving clinical outcomes, such as adverse drug events, falls or hospitalizations. In the VALFORTA study, the use of FORTA led to a significant improvement in medication treatment. In addition, important clinical endpoints, such as the occurrence of adverse drug events (number needed to treat = 5), activities of daily living (ADL) and the incidence of falls were significantly improved by the FORTA intervention in a clinically relevant manner. CONCLUSION Based on these promising results, the use of the FORTA list for medication optimization in older patients is recommended; the prerequisite for application is the needs analysis for drugs according to diagnoses, severity, life expectancy, functional status, and patient wishes.
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Affiliation(s)
- Farhad Pazan
- Ehemals Institut für Klinische Pharmakologie, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Martin Wehling
- Ehemals Institut für Klinische Pharmakologie, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
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van Poelgeest E, Seppala L, Bahat G, Ilhan B, Mair A, van Marum R, Onder G, Ryg J, Fernandes MA, Cherubini A, Denkinger M, Eidam A, Egberts A, Gudmundsson A, Koçak FÖK, Soulis G, Tournoy J, Masud T, Wehling M, van der Velde N. Optimizing pharmacotherapy and deprescribing strategies in older adults living with multimorbidity and polypharmacy: EuGMS SIG on pharmacology position paper. Eur Geriatr Med 2023; 14:1195-1209. [PMID: 37812379 PMCID: PMC10754739 DOI: 10.1007/s41999-023-00872-0] [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: 07/16/2023] [Accepted: 09/19/2023] [Indexed: 10/10/2023]
Abstract
Inappropriate polypharmacy is highly prevalent among older adults and presents a significant healthcare concern. Conducting medication reviews and implementing deprescribing strategies in multimorbid older adults with polypharmacy are an inherently complex and challenging task. Recognizing this, the Special Interest Group on Pharmacology of the European Geriatric Medicine Society has compiled evidence on medication review and deprescribing in older adults and has formulated recommendations to enhance appropriate prescribing practices. The current evidence supports the need for a comprehensive and widespread transformation in education, guidelines, research, advocacy, and policy to improve the management of polypharmacy in older individuals. Furthermore, incorporating deprescribing as a routine aspect of care for the ageing population is crucial. We emphasize the importance of involving geriatricians and experts in geriatric pharmacology in driving, and actively participating in this transformative process. By doing so, we can work towards achieving optimal medication use and enhancing the well-being of older adults in the generations to come.
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Affiliation(s)
- Eveline van Poelgeest
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Lotta Seppala
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Gülistan Bahat
- Division of Geriatrics, Department of Internal Medicine, Istanbul Medical School, Istanbul University, Capa, Istanbul, Turkey
| | - Birkan Ilhan
- Division of Geriatrics, Department of Internal Medicine, Liv Hospital Vadistanbul, Istanbul, Turkey
| | - Alpana Mair
- Effective Prescribing and Therapeutics, Health and Social Care Directorate, Scottish Government, Edinburgh, Scotland, UK
- Edinburgh Napier University, Edinburgh, UK
| | - Rob van Marum
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Department of Elderly Care Medicine, Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Graziano Onder
- Fondazione Policlinico Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Marília Andreia Fernandes
- Department of Internal Medicine, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Antonio Cherubini
- Geriatria Accettazione geriatrica e Centro di Ricerca per l'invecchiamento IRCCS INRCA, Ancona, Italy
| | - Michael Denkinger
- Agaplesion Bethesda Clinic Ulm, Institute for Geriatric Research, Ulm University, Geriatric Center Ulm, Ulm, Germany
| | - Annette Eidam
- Center for Geriatric Medicine, Heidelberg University Hospital, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Angelique Egberts
- Department of Hospital Pharmacy, Franciscus Gasthuis & Vlietland, Rotterdam, Schiedam, The Netherlands
| | - Aðalsteinn Gudmundsson
- Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Fatma Özge Kayhan Koçak
- Division of Geriatrics, Department of Internal Medicine, Faculty of Medicine, Ege University, Izmir, Turkey
| | - George Soulis
- Outpatient Geriatric Assessment Unit, Henry Dunant Hospital Center, Athens, Greece
- Hellenic Open University, Patras, Greece
| | - Jos Tournoy
- Department of Geriatric Medicine, KU Leuven University Hospitals Leuven Gasthuisberg Campus, Leuven, Belgium
- Department of Public Health and Primary Care, KU Leuven Biomedical Sciences Group, Leuven, Belgium
| | - Tahir Masud
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Martin Wehling
- Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nathalie van der Velde
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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Gray SL, Perera S, Soverns T, Hanlon JT. Systematic Review and Meta-analysis of Interventions to Reduce Adverse Drug Reactions in Older Adults: An Update. Drugs Aging 2023; 40:965-979. [PMID: 37702981 PMCID: PMC10600043 DOI: 10.1007/s40266-023-01064-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND We previously reported that interventions to optimize medication use reduced adverse drug reactions (ADRs) by 21% and serious ADRs by 36% in older adults. With new evidence, we sought to update the systematic review and meta-analysis. METHOD We searched OVID, Cochrane Library, ClinicalTrials.gov and Google Scholar from 30 April 2017-30 April 2023. Included studies had to be randomized controlled trials of older adults (mean age ≥65 years) taking medications that examined the outcome of ADRs. Two authors independently reviewed all citations, extracted relevant data, and assessed studies for potential bias. The outcomes were any and serious ADRs. We performed subgroup analyses by intervention type and setting. Random-effects models were used to combine the results from multiple studies and create summary estimates. RESULTS Six studies are new to the update, resulting in 19 total studies (15,675 participants). Interventions were pharmacist-led (10 studies), other healthcare professional-led (5 studies), technology based (3 studies), and educational (1 study). The interventions were implemented in various clinical settings, including hospitals, outpatient clinics, long-term care facilities/rehabilitation wards, and community pharmacies. In the pooled analysis, the intervention group participants were 19% less likely to experience an ADR (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.68-0.96) and 32% less likely to experience a serious ADR (OR 0.68, 95% CI 0.48-0.96). We also found that pharmacist-led interventions reduced the risk of any ADR by 35%, compared with 8% for other types of interventions. CONCLUSION Interventions significantly and substantially reduced the risk of ADRs and serious ADRs in older adults. Future research should examine whether effectiveness of interventions vary across health care settings to identify those most likely to benefit. Implementation of successful interventions in health care systems may improve medication safety in older patients.
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Affiliation(s)
- Shelly L Gray
- Department of Pharmacy, School of Pharmacy, University of Washington, Health Sciences Building, H-361D, Box 357630, Seattle, WA, 98195-7630, USA.
| | - Subashan Perera
- Department of Medicine (Geriatrics), School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tim Soverns
- Department of Pharmacy, School of Pharmacy, University of Washington, Health Sciences Building, H-361D, Box 357630, Seattle, WA, 98195-7630, USA
| | - Joseph T Hanlon
- Department of Medicine (Geriatrics), School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
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Wang SY, Larrain N, Groene O. Can peer effects explain prescribing appropriateness? a social network analysis. BMC Med Res Methodol 2023; 23:252. [PMID: 37898770 PMCID: PMC10613382 DOI: 10.1186/s12874-023-02048-7] [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: 05/17/2022] [Accepted: 09/25/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND Optimizing prescribing practices is important due to the substantial clinical and financial costs of polypharmacy and an increasingly aging population. Prior research shows the importance of social relationships in driving prescribing behaviour. Using social network analysis, we examine the relationship between a physician practices' connectedness to peers and their prescribing performance in two German regions. METHODS We first mapped physician practice networks using links established between two practices that share 8 or more patients; we calculated network-level (density, average path length) and node-level measures (degree, betweenness, eigenvector). We defined prescribing performance as the total number of inappropriate medications prescribed or appropriate medications not prescribed (PIMs) to senior patients (over the age of 65) during the calendar year 2016. We used FORTA (Fit fOR The Aged) algorithm to classify medication appropriateness. Negative binomial regression models estimate the association between node-level measures and prescribing performance of physician practices controlling for patient comorbidity, provider specialization, percentage of seniors in practice, and region. We conducted two sensitivity analyses to test the robustness of our findings - i) limiting the network mapping to patients younger than 65; ii) limiting the network ties to practices that share more than 25 patients. RESULTS We mapped two patient-sharing networks including 436 and 270 physician practices involving 28,508 and 20,935 patients and consisting of 217,126 and 154,274 claims in the two regions respectively. Regression analyses showed a practice's network connectedness as represented by degree, betweenness, and eigenvector centrality, is significantly negatively associated with prescribing performance (degree-bottom vs. top quartile aRR = 0.04, 95%CI: 0.035,0.045; betweenness-bottom vs. top quartile aRR = 0.063 95%CI: 0.052,0.077; eigenvector-bottom vs. top quartile aRR = 0.039, 95%CI: 0.034,0.044). CONCLUSIONS Our study provides evidence that physician practice prescribing performance is associated with their peer connections and position within their network. We conclude that practices occupying strategic positions at the edge of networks with advantageous access to novel information are associated with better prescribing outcomes, whereas highly connected practices embedded in insulated information environments are associated with poor prescribing performance.
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Affiliation(s)
- Sophie Y Wang
- Hamburg Center for Health Economics, Esplanade 36, 20354, Hamburg, Germany.
- OptiMedis AG, Buchardstraße 17, 20095, Hamburg, Germany.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
| | - Nicolas Larrain
- Hamburg Center for Health Economics, Esplanade 36, 20354, Hamburg, Germany
- Employment, Labour and Social Affairs, Health Division, OECD, 2 Rue André Pascal, Cedex 16, 75775, Paris, France
| | - Oliver Groene
- OptiMedis AG, Buchardstraße 17, 20095, Hamburg, Germany
- Faculty of Management, Economics and Society, University of Witten, Alfred-Herrhausen-Straße 50, 58455, HerdeckeWitten, Germany
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Chang CT, Chan HK, Cheah WK, Tan MP, Ch'ng ASH, Thiam CN, Abu Bakar NA, Yau WK, Abu Hassan MR, Rajan P, Tan KC, Ambigapathy S, Vengadasalam P, Zaman Huri S, Arvinder-Singh HS, Thum CC, Chung WM, Ooi JH, Sabki NH, Lee HP, Mohd Shariff SM, Azman MA, Teoh SL, Lee SWH. Development of a Malaysian potentially inappropriate prescribing screening tool in older adults (MALPIP): a Delphi study. J Pharm Policy Pract 2023; 16:122. [PMID: 37858273 PMCID: PMC10588247 DOI: 10.1186/s40545-023-00630-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/03/2023] [Indexed: 10/21/2023] Open
Abstract
INTRODUCTION Polypharmacy and potentially inappropriate medications (PIM) are common among older adults. To guide appropriate prescribing, healthcare professionals often rely on explicit criteria to identify and deprescribe inappropriate medications, or to start medications due to prescribing omission. However, most explicit PIM criteria were developed with inadequate guidance from quality metrics or integrating real-world data, which are rich and valuable data source. AIM To develop a list of medications to facilitate appropriate prescribing among older adults. METHODS A preliminary list of PIM and potential prescribing omission (PPO) were generated from systematic review, supplemented with local pharmacovigilance data of adverse reaction incidents among older people. Twenty-one experts from nine specialties participated in two Delphi to determine the list of PIM and PPO in February and March 2023. Items that did not reach consensus after the second Delphi round were adjudicated by six geriatricians. RESULTS The preliminary list included 406 potential candidates, categorised into three sections: PIM independent of diseases, disease dependent PIM and omitted drugs that could be restarted. At the end of Delphi, 92 items were decided as PIM, including medication classes, such as antacids, laxatives, antithrombotics, antihypertensives, hormones, analgesics, antipsychotics, antidepressants, and antihistamines. Forty-two disease-specific PIM criteria were included, covering circulatory system, nervous system, gastrointestinal system, genitourinary system, and respiratory system. Consensus to start potentially omitted treatment was achieved in 35 statements across nine domains. CONCLUSIONS The newly developed PIM criteria can serve as a useful tool to guide clinicians and pharmacists in identifying PIMs and PPOs during medication review and facilitating informed decision-making for appropriate prescribing.
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Affiliation(s)
- Chee Tao Chang
- School of Pharmacy, Monash University Malaysia, Subang Jaya, Malaysia.
- Clinical Research Centre, Hospital Raja Permaisuri Bainun, Ministry of Health Malaysia, Ipoh, Malaysia.
| | - Huan Keat Chan
- Clinical Research Centre, Hospital Sultanah Bahiyah, Ministry of Health Malaysia, Alor Setar, Malaysia
- Clinical Research Centre, Hospital Taiping, Ministry of Health Malaysia, Taiping, Malaysia
| | - Wee Kooi Cheah
- Department of Medicine, Hospital Taiping, Ministry of Health Malaysia, Taiping, Malaysia
| | - Maw Pin Tan
- Ageing and Age-Associated Disorders Research Group, Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- Department of Medical Sciences, School of Healthcare and Medical Sciences, Sunway University, Petaling Jaya, Malaysia
| | - Alan Swee Hock Ch'ng
- Clinical Research Centre, Hospital Seberang Jaya, Ministry of Health Malaysia, Seberang Jaya, Malaysia
| | - Chiann Ni Thiam
- Department of Medicine, Hospital Sultanah Bahiyah, Ministry of Health Malaysia, Alor Setar, Malaysia
| | - Nor Azlina Abu Bakar
- Medical Department, Hospital Raja Permaisuri Bainun, Ministry of Health Malaysia, Ipoh, Malaysia
| | - Weng Keong Yau
- Medical Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Muhammad Radzi Abu Hassan
- Clinical Research Centre, Hospital Sultanah Bahiyah, Ministry of Health Malaysia, Alor Setar, Malaysia
| | - Philip Rajan
- Clinical Research Centre, Hospital Raja Permaisuri Bainun, Ministry of Health Malaysia, Ipoh, Malaysia
| | - Kar Choon Tan
- Hepatological Department, Hospital Selayang, Ministry of Health Malaysia, Selayang, Malaysia
| | | | | | - Surina Zaman Huri
- Psychiatry Department, Hospital Sultan Ismail, Ministry of Health Malaysia, Johor Bahru, Malaysia
| | - H S Arvinder-Singh
- Clinical Research Centre, Hospital Raja Permaisuri Bainun, Ministry of Health Malaysia, Ipoh, Malaysia
- Department of Community Medicine, Hospital University Kebangsaan Malaysia, Bangi, Malaysia
| | - Chern Choong Thum
- Department of Psychiatry, Hospital Sultan Abdul Aziz Shah, Universiti Putra Malaysia, Serdang, Malaysia
| | - Wai Mun Chung
- Emergency and Trauma Department, Hospital Taiping, Taiping, Malaysia
| | - Jun How Ooi
- Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Noor Hamizah Sabki
- Pharmacy Department, Hospital Taiping, Ministry of Health Malaysia, Taiping, Malaysia
| | - Hooi Peng Lee
- Pharmacy Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | | | - Muhammad Azuan Azman
- Pharmacy Department, Hospital Raja Permaisuri Bainun, Ministry of Health Malaysia, Ipoh, Malaysia
| | - Siew Li Teoh
- School of Pharmacy, Monash University Malaysia, Subang Jaya, Malaysia
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Cole JA, Gonçalves-Bradley DC, Alqahtani M, Barry HE, Cadogan C, Rankin A, Patterson SM, Kerse N, Cardwell CR, Ryan C, Hughes C. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev 2023; 10:CD008165. [PMID: 37818791 PMCID: PMC10565901 DOI: 10.1002/14651858.cd008165.pub5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, so that many medicines may be used to achieve better clinical outcomes for patients. This is the third update of this Cochrane Review. OBJECTIVES To assess the effects of interventions, alone or in combination, in improving the appropriate use of polypharmacy and reducing medication-related problems in older people. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 13 January 2021, together with handsearching of reference lists to identify additional studies. We ran updated searches in February 2023 and have added potentially eligible studies to 'Characteristics of studies awaiting classification'. SELECTION CRITERIA For this update, we included randomised trials only. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy (four or more medicines) in people aged 65 years and older, which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people). DATA COLLECTION AND ANALYSIS Four review authors independently reviewed abstracts of eligible studies, and two authors extracted data and assessed the risk of bias of the included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach. MAIN RESULTS We identified 38 studies, which includes an additional 10 in this update. The included studies consisted of 24 randomised trials and 14 cluster-randomised trials. Thirty-six studies examined complex, multi-faceted interventions of pharmaceutical care (i.e. the responsible provision of medicines to improve patients' outcomes), in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists, nurses and geriatricians, and most were conducted in high-income countries. Assessments using the Cochrane risk of bias tool found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low. It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool) (mean difference (MD) -5.66, 95% confidence interval (CI) -9.26 to -2.06; I2 = 97%; 8 studies, 947 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs) (standardised mean difference (SMD) -0.19, 95% CI -0.34 to -0.05; I2 = 67%; 9 studies, 2404 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIM (risk ratio (RR) 0.81, 95% CI 0.68 to 0.98; I2 = 84%; 13 studies, 4534 participants; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.48, 95% CI -1.05 to 0.09; I2 = 92%; 3 studies, 691 participants; low-certainty evidence), however it must be noted that this effect estimate is based on only three studies, which had serious limitations in terms of risk of bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPO (RR 0.50, 95% CI 0.27 to 0.91; I2 = 95%; 7 studies, 2765 participants; very low-certainty evidence). Pharmaceutical care may make little or no difference to hospital admissions (data not pooled; 14 studies, 4797 participants; low-certainty evidence). Pharmaceutical care may make little or no difference to quality of life (data not pooled; 16 studies, 7458 participants; low-certainty evidence). Medication-related problems were reported in 10 studies (6740 participants) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies. This also applied to studies examining adherence to medication (nine studies, 3848 participants). AUTHORS' CONCLUSIONS It is unclear whether interventions to improve appropriate polypharmacy resulted in clinically significant improvement. Since the last update of this review in 2018, there appears to have been an increase in the number of studies seeking to address potential prescribing omissions and more interventions being delivered by multidisciplinary teams.
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Affiliation(s)
- Judith A Cole
- Clinical Trial Service Unit, University of Oxford, Oxford, UK
| | | | | | | | - Cathal Cadogan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Audrey Rankin
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | | | - Ngaire Kerse
- Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand
| | - Chris R Cardwell
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Cristin Ryan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Carmel Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, UK
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13
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Chang CT, Teoh SL, Cheah WK, Lee PJ, Azman MA, Ling SH, Chuah ASC, Sabki NH, George D, Oh HL, Goh JY, Lee SH, Foong WK, Lee JCY, Chan HK, Teoh LR, Lim XJ, Rajan P, Lee SWH. Impact of deprescribing intervention on potentially inappropriate medications and clinical outcomes among hospitalized older adults in Malaysia: a randomized controlled trial (REVMED RCT) protocol. J Pharm Policy Pract 2023; 16:113. [PMID: 37789376 PMCID: PMC10546756 DOI: 10.1186/s40545-023-00621-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/20/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Polypharmacy and the use of potentially inappropriate medications (PIMs) are prevalent among older patients admitted to hospitals, posing a heightened risk of adverse drug events. This trial aims to evaluate the effectiveness of a pharmacist-led deprescribing intervention in reducing medications, PIM and improving clinical outcomes, using the locally developed Malaysian Potentially Inappropriate Prescribing Screening tool in Older Adults (MALPIP). METHODS This is an 18-month cluster-randomized, open-label, parallel-arm controlled trial conducted at 14 public hospitals in the Perak state of Malaysia. Patients aged 60 and above, who have at least one medication and one comorbidity are eligible. A stratified-cluster randomization design is employed, with 7 hospitals assigned to the control arm and 7 hospitals assigned to the intervention arm. The MALPIP screening tool will be used in the intervention group to review the medications. If PIM is detected, the pharmacists will discuss with doctors and decide whether to stop or reduce the dose. The primary outcomes of this trial are the total number of medications and number of PIM. The secondary outcomes include fall, emergency department visits, readmissions, quality of life and mortality. Outcomes will be measured during enrolment, discharge, 6, 12, and 18 months. DISCUSSION This REVMED trial aims to test the hypothesis that a pharmacist-led deprescribing intervention initiated in the hospital will reduce the total number of medications and PIM 18 months after hospital discharge, reducing fall, emergency department visits, readmissions, mortality and lead to improvement in quality of life. Trial findings will quantify the clinical outcomes associated with reducing medications and PIM for hospitalized older adults with polypharmacy. TRIAL REGISTRATION NUMBER This trial was prospectively registered at clinicaltrials.gov (NCT05875623) on the 25th of May 2023. NCT05875623 Clinicaltrials.gov URL: NCT05875623 registered on 25th July 2023.
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Affiliation(s)
- Chee Tao Chang
- Clinical Research Centre, Hospital Raja Permaisuri Bainun, Ministry of Health Malaysia, Ipoh, Perak, Malaysia.
- School of Pharmacy, Monash University Malaysia, Subang Jaya, Malaysia.
| | - Siew Li Teoh
- School of Pharmacy, Monash University Malaysia, Subang Jaya, Malaysia
| | - Wee Kooi Cheah
- Clinical Research Centre, Hospital Taiping, Ministry of Health Malaysia, Taiping, Malaysia
- Department of Medicine, Hospital Taiping, Ministry of Health Malaysia, Taiping, Malaysia
| | - Pei Jia Lee
- Pharmacy Department, Hospital Raja Permaisuri Bainun, Ministry of Health Malaysia, Ipoh, Malaysia
| | - Muhammad Azuan Azman
- Pharmacy Department, Hospital Raja Permaisuri Bainun, Ministry of Health Malaysia, Ipoh, Malaysia
| | - Shiau Hui Ling
- Pharmacy Department, Hospital Seri Manjung, Ministry of Health Malaysia, Seri Manjung, Malaysia
| | - Angie Su Ching Chuah
- Pharmacy Department, Hospital Seri Manjung, Ministry of Health Malaysia, Seri Manjung, Malaysia
| | - Noor Hamizah Sabki
- Pharmacy Department, Hospital Taiping, Ministry of Health Malaysia, Taiping, Malaysia
| | - Doris George
- Pharmacy Department, Hospital Taiping, Ministry of Health Malaysia, Taiping, Malaysia
| | - Hoey Lin Oh
- Pharmacy Department, Hospital Slim River, Ministry of Health Malaysia, Slim River, Malaysia
| | - Jing Yi Goh
- Pharmacy Department, Hospital Slim River, Ministry of Health Malaysia, Slim River, Malaysia
| | - Siew Huang Lee
- Pharmacy Department, Hospital Kuala Kangsar, Ministry of Health Malaysia, Kuala Kangsar, Malaysia
| | - Wai Keng Foong
- Pharmacy Department, Hospital Batu Gajah, Ministry of Health Malaysia, Batu Gajah, Malaysia
| | - Jason Choong Yin Lee
- Perak Pharmaceutical Services Division, Ministry of Health Malaysia, Tanjung Rambutan, Malaysia
| | - Huan Keat Chan
- Clinical Research Centre, Hospital Sultanah Bahiyah, Ministry of Health Malaysia, Alor Setar, Malaysia
| | - Lee Rhui Teoh
- Pharmacy Department, Hospital Sungai Siput, Ministry of Health Malaysia, Sungai Siput, Malaysia
| | - Xin Jie Lim
- Clinical Research Centre, Hospital Raja Permaisuri Bainun, Ministry of Health Malaysia, Ipoh, Perak, Malaysia
| | - Philip Rajan
- Clinical Research Centre, Hospital Raja Permaisuri Bainun, Ministry of Health Malaysia, Ipoh, Perak, Malaysia
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Strassl I, Windhager A, Machherndl-Spandl S, Buxhofer-Ausch V, Stiefel O, Weltermann A. TOP-PIC: a new tool to optimize pharmacotherapy and reduce polypharmacy in patients with incurable cancer. J Cancer Res Clin Oncol 2023; 149:7113-7123. [PMID: 36877279 PMCID: PMC10374723 DOI: 10.1007/s00432-023-04671-9] [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: 02/14/2023] [Accepted: 02/26/2023] [Indexed: 03/07/2023]
Abstract
PURPOSE Polypharmacy is a significant problem in patients with incurable cancer and a method to optimize pharmacotherapy in this patient group is lacking. Therefore, a drug optimization tool was developed and tested in a pilot test. METHODS A multidisciplinary team of health professionals developed a "Tool to Optimize Pharmacotherapy in Patients with Incurable Cancer" (TOP-PIC) for patients with a limited life expectancy. The tool consists of five sequential steps to optimize medications, including medication history, screening for medication appropriateness and drug interactions, a benefit-risk assessment using the TOP-PIC Disease-based list, and shared decision-making with the patient. For pilot testing of the tool, 8 patient cases with polypharmacy were analyzed by 11 oncologists before and after training with the TOP-PIC tool. RESULTS TOP-PIC was considered helpful by all oncologists during the pilot test. The median additional time required to administer the tool was 2 min per patient (P < 0.001). For 17.4% of all medications, different decisions were made by using TOP-PIC. Among possible treatment decisions (discontinuation, reduction, increase, replacement, or addition of a drug), discontinuation of medications was the most common. Without TOP-PIC, physicians were uncertain in 9.3% of medication changes, compared with only 4.8% after using TOP-PIC (P = 0.001). The TOP-PIC Disease-based list was considered helpful by 94.5% of oncologists. CONCLUSIONS TOP-PIC provides a detailed, disease-based benefit-risk assessment with recommendations specific for cancer patients with limited life expectancy. Based on the results of the pilot study, the tool seems practicable for day-to-day clinical decision-making and provides evidence-based facts to optimize pharmacotherapy.
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Affiliation(s)
- Irene Strassl
- Division of Hematology With Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz and Seilerstätte 4, 4010, Linz, Austria.
- Doctoral Programme MedUni Vienna, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria.
| | - Armin Windhager
- Department of Cardiology and Intensive Care Medicine, Kepler University Hospital Linz, Krankenhausstrasse 9, 4021, Linz, Austria
| | - Sigrid Machherndl-Spandl
- Division of Hematology With Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz and Seilerstätte 4, 4010, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Veronika Buxhofer-Ausch
- Division of Hematology With Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz and Seilerstätte 4, 4010, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Olga Stiefel
- Division of Hematology With Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz and Seilerstätte 4, 4010, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Ansgar Weltermann
- Division of Hematology With Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz and Seilerstätte 4, 4010, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
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Pazan F, Weiss C, Wehling M. The EURO-FORTA (Fit fOR The Aged) List Version 2: Consensus Validation of a Clinical Tool for Improved Pharmacotherapy in Older Adults. Drugs Aging 2023; 40:417-426. [PMID: 37129833 PMCID: PMC10152014 DOI: 10.1007/s40266-023-01024-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND The aging of our societies leads to a higher prevalence of multimorbidity and therefore polypharmacy, which often results in inappropriate drug treatment. To address this issue, numerous listing approaches, such as the Fit fOR The Aged (FORTA) list have been developed. FORTA's positive impact on the quality of medications and relevant clinical outcomes has been shown. Based on new emerging evidence and experiences with the existing FORTA lists, we aimed to update the FORTA lists in several European countries/regions. METHODS Two-step Delphi consensus procedures were conducted in Poland, UK/Ireland, Italy, Spain, the Nordic countries, The Netherlands and France. The existing European FORTA lists served as survey proposals. RESULTS Thirty-two experts agreed to take part in this study (return rate: 96.9%). The country/region-specific overall consensus for all items and participants after the first round was > 90%. FORTA lists from six participating countries, plus the FORTA list for the German-speaking countries, were collated into the new EURO-FORTA List, which now contains 267 items aligned to 27 indications. Three items were added to the EURO-FORTA List, and no drugs were deleted. Eight FORTA items were relabeled, and 96.9% of the labels remained unchanged. CONCLUSION In this study, seven new country/region specific FORTA lists, as well as a new overarching EURO-FORTA List, were developed. An overall increase in the mean consensus coefficient and increases for all disease-specific mean consensus coefficients show a wider consensus among participants. The new lists have the potential to improve drug therapy in older people internationally.
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Affiliation(s)
- Farhad Pazan
- Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Christel Weiss
- Department of Medical Statistics, Biomathematics and Information Processing, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Martin Wehling
- Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Pazan F, Wehling M, Weiss C, Frohnhofen H. Medication optimization according to the Fit fOR The Aged (FORTA) rules improves functional status in patients hospitalized for geriatric rehabilitation. Eur Geriatr Med 2023:10.1007/s41999-023-00779-w. [PMID: 37074562 DOI: 10.1007/s41999-023-00779-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/03/2023] [Indexed: 04/20/2023]
Abstract
INTRODUCTION Functional status is one of the most important issues of geriatric care. Polypharmacy seems to be a modifiable factor associated with functional decline in older adults. However, the impact of pharmacotherapy optimization on the activities of daily living in patients undergoing geriatric rehabilitation has not been investigated prospectively so far. METHODS This post hoc analysis of a subsample of the VALFORTA study included individuals only undergoing geriatric rehabilitation with a length of in-hospital stay of at least 14 days. Medication was modified according to the FORTA rules in the intervention group while in the control group standard drug treatment was applied. Both groups received comprehensive geriatric treatment. RESULTS The intervention and control groups consisted of 96 and 93 individuals respectively. They did not differ according to basic data except for age and Charlson Comorbidity Index (CCI) on admission. On discharge, activities of daily living (Barthel index, BI) were improved in both groups. An increase of at least 20 points of the BI was observed in 40% of patients in the intervention group and in 12% of patients in the control group (p< 0.001). Logistic regression analysis with an increase of at least 20 BI-points was significantly and independently associated with patient group (2.358, p< 0.02), BI on admission (0.957, p< 0.001), and the CCI (0.793, p< 0.041). CONCLUSION This post hoc analysis of a subsample of older individuals hospitalized for geriatric rehabilitation demonstrates a significant additional improvement in activities of daily living by modification of medication according to FORTA. REGISTRATION DRKS-ID: DRKS00000531.
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Affiliation(s)
- Farhad Pazan
- Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Martin Wehling
- Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Christel Weiss
- Department of Medical Statistics, Biomathematics and Information Processing, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Helmut Frohnhofen
- Faculty of Health, Department Medicine, University Witten-Herdecke, Alfred-Herrhausen-Str. 50, 58455, Witten, Germany
- Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine-University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
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Schöttker B, Chen LJ, Caspari R, Brenner H. Protocol of the optimal study: Optimization of polypharmacy in geriatric oncology - A randomized controlled trial. BMC Cancer 2023; 23:357. [PMID: 37072729 PMCID: PMC10111774 DOI: 10.1186/s12885-023-10812-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/05/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Polypharmacy is very common in older cancer patients and these patients are particularly vulnerable to drug-drug interactions and adverse drug reactions because they often receive chemotherapy and symptom-relieving agents. METHODS The primary aim of the randomized, controlled Optimization of Polypharmacy in Geriatric Oncology (OPTIMAL) trial is to test whether an advisory letter with the results of a comprehensive medication review conducted with the Fit fOR The Aged (FORTA) list to the caring physician in rehabilitation clinics improves the quality of life (QoL) of older cancer patients exposed to polypharmacy more than usual care. The FORTA list detects medication overuse, underuse, and potentially inappropriate drug use among older adults. In the oncology departments of approximately 10 German rehabilitation clinics, we aim to recruit 514 cancer patients (22 common cancers; diagnosis or recurrence requiring treatment in the last 5 years; all stages) who are ≥ 65 years old, regularly take ≥ 5 drugs, and have ≥ 1 medication-related problem. All necessary information about the patients will be provided to a pharmacist at the coordinating center (German Cancer Research Center, Heidelberg), who will perform randomization (1:1) and conduct the medication review with the FORTA list. For the intervention group only, the results are sent by letter to the treating physician in the rehabilitation clinics, who shall discuss medication changes with the patient at the discharge visit, as well as implement them afterwards and disclose them in the discharge letter to the general practitioner. The control group gets the usual care provided in German rehabilitation clinics, which usually does not include a comprehensive medication review but can include medication changes. Patients will be blinded, as they cannot know whether proposed medication changes were part of the study or part of usual care. Study physicians cannot be blinded. The primary endpoint will be the EORTC-QLQ-C30 global health status/QoL score, assessed via self-administered questionnaires 8 months after baseline. DISCUSSION If the planned study shows that a medication review with the FORTA list improves the QoL of older cancer patients in oncological rehabilitation more than usual care, it would provide the necessary evidence to translate the trial's findings into routine care. TRIAL REGISTRATION German Clinical Trials Register (DRKS): DRKS00031024.
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Affiliation(s)
- Ben Schöttker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 581, 69120, Heidelberg, Germany.
| | - Li-Ju Chen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 581, 69120, Heidelberg, Germany
| | - Reiner Caspari
- Rehabilitation Clinic Niederrhein, Hochstraße 13-19, 53474, Bad Neuenahr-Ahrweiler, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 581, 69120, Heidelberg, Germany
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
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18
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Clarkson L, Hart L, Lam AK, Khoo TK. Reducing inappropriate polypharmacy for older patients at specialist outpatient clinics: a systematic review. Curr Med Res Opin 2023; 39:545-554. [PMID: 36847597 DOI: 10.1080/03007995.2023.2185390] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
OBJECTIVE Polypharmacy is associated with negative clinical consequences. The efficacy of deprescribing interventions within medical specialist outpatient clinics remains unclear. Here, we reviewed the research on the effectiveness of deprescribing interventions implemented within specialist outpatient clinics for patients ≥ 60 years. METHODS Systematic searches of key databases were undertaken for studies published between January 1990 and October 2021. The diverse nature of the study designs made it unsuitable for pooling for meta-analysis, thus, a narrative review was conducted and presented in both text and tabular formats. The primary outcome for review was that intervention resulted in a change in medication load (either total number of medications or appropriateness of medication). Secondary outcomes were the maintenance of deprescription and clinical benefits. Methodological quality of the publications was assessed using the revised Cochrane risk-of-bias tools. RESULTS Nineteen studies with a total of 10,914 participants were included for review. These included geriatric outpatient clinics, oncology/hematology clinics, hemodialysis clinics, and designated polypharmacy/multimorbidity clinics. Four randomized controlled trials (RCTs) reported statistically significant reductions in medication load with intervention; however, all studies had a high risk of bias. The inclusion of a pharmacist in outpatient clinics aims to increase deprescribing, however, the current evidence is mainly restricted to prospective and pilot studies. The data on secondary outcomes were very limited and highly variable. CONCLUSIONS Specialist outpatient clinics may provide valuable settings for implementing deprescribing interventions. The addition of a multidisciplinary team including a pharmacist and the use of validated medication assessment tools appear to be enablers. Further research is warranted.
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Affiliation(s)
- Louise Clarkson
- School of Medicine & Dentistry, Menzies Health Institute Queensland, Griffith University, Queensland, Australia
- Northern New South Wales Local Health District, NSW Health, Australia
| | - Laura Hart
- Lancet Neurology, London, London, United Kingdom
| | - Alfred K Lam
- School of Medicine & Dentistry, Menzies Health Institute Queensland, Griffith University, Queensland, Australia
| | - Tien K Khoo
- School of Medicine & Dentistry, Menzies Health Institute Queensland, Griffith University, Queensland, Australia
- Northern New South Wales Local Health District, NSW Health, Australia
- Graduate School of Medicine, University of Wollongong, New South Wales, Australia
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19
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Frohnhofen H, Kühn KU. [Sleep and sleep disorders in the elderly]. MMW Fortschr Med 2023; 165:52-58. [PMID: 36826669 DOI: 10.1007/s15006-022-2244-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Affiliation(s)
- Helmut Frohnhofen
- Klinik für Orthopädie und Unfallchirurgie/Altersmedizin, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland.
| | - Kai-Uwe Kühn
- Abteilung Gerontopsychiatrie und Psychotherapie, LVR-Klinik Bonn, Bonn, Deutschland
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20
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Bülow C, Clausen SS, Lundh A, Christensen M. Medication review in hospitalised patients to reduce morbidity and mortality. Cochrane Database Syst Rev 2023; 1:CD008986. [PMID: 36688482 PMCID: PMC9869657 DOI: 10.1002/14651858.cd008986.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND A medication review can be defined as a structured evaluation of a patient's medication conducted by healthcare professionals with the aim of optimising medication use and improving health outcomes. Optimising medication therapy though medication reviews may benefit hospitalised patients. OBJECTIVES We examined the effects of medication review interventions in hospitalised adult patients compared to standard care or to other types of medication reviews on all-cause mortality, hospital readmissions, emergency department contacts and health-related quality of life. SEARCH METHODS In this Cochrane Review update, we searched for new published and unpublished trials using the following electronic databases from 1 January 2014 to 17 January 2022 without language restrictions: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP). To identify additional trials, we searched the reference lists of included trials and other publications by lead trial authors, and contacted experts. SELECTION CRITERIA We included randomised trials of medication reviews delivered by healthcare professionals for hospitalised adult patients. We excluded trials including outpatients and paediatric patients. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, extracted data and assessed risk of bias. We contacted trial authors for data clarification and relevant unpublished data. We calculated risk ratios (RRs) for dichotomous data and mean differences (MDs) or standardised mean differences (SMDs) for continuous data (with 95% confidence intervals (CIs)). We used the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach to assess the overall certainty of the evidence. MAIN RESULTS In this updated review, we included a total of 25 trials (15,076 participants), of which 15 were new trials (11,501 participants). Follow-up ranged from 1 to 20 months. We found that medication reviews in hospitalised adults may have little to no effect on mortality (RR 0.96, 95% CI 0.87 to 1.05; 18 trials, 10,108 participants; low-certainty evidence); likely reduce hospital readmissions (RR 0.93, 95% CI 0.89 to 0.98; 17 trials, 9561 participants; moderate-certainty evidence); may reduce emergency department contacts (RR 0.84, 95% CI 0.68 to 1.03; 8 trials, 3527 participants; low-certainty evidence) and have very uncertain effects on health-related quality of life (SMD 0.10, 95% CI -0.10 to 0.30; 4 trials, 392 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS Medication reviews in hospitalised adult patients likely reduce hospital readmissions and may reduce emergency department contacts. The evidence suggests that mediation reviews may have little to no effect on mortality, while the effect on health-related quality of life is very uncertain. Almost all trials included elderly polypharmacy patients, which limits the generalisability of the results beyond this population.
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Affiliation(s)
- Cille Bülow
- Department of Clinical Pharmacology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Stine Søndersted Clausen
- The Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Lundh
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, University of Southern Denmark, Odense, Denmark
- Department of Respiratory Medicine and Infectious Diseases, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Mikkel Christensen
- Department of Clinical Pharmacology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Copenhagen Center for Translational Research (CCTR), Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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21
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Dreischulte T, Shahid F, Muth C, Schmiedl S, Emil Haefeli W. Prescribing Cascades: How to Detect Them, Prevent Them, and Use Them Appropriately. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:745-752. [PMID: 36045504 PMCID: PMC9853235 DOI: 10.3238/arztebl.m2022.0306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/02/2022] [Accepted: 08/11/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND A prescribing cascade is the treatment of an adverse drug reaction (ADR) with another drug. In this review, we discuss (a) the different types of prescribing cascade and (b) the measures that can be taken so that they will be recognized and dealt with appropriately, both in the hospital and in the outpatient setting. METHODS This review is based on pertinent publications retrieved by a selective literature search. RESULTS The literature distinguishes intentional from unintentional prescribing cascades, and appropriate from inappropriate ones. We further distinguish prophylactic from therapeutic prescribing cascades and draw a line between those that are necessary and those that are merely appropriate. The following main questions are essential for dealing with prescribing cascades appropriately: (1) Did the precipitating drug cause a clinically relevant ADR or risk of an ADR? (2) Is the precipitating drug still indicated? (3) Can an ADR be avoided by altering the treatment with the precipitating drug, or by (4) switching to another drug instead? (5) Can the drug used to treat the ADR actually affect it beneficially? (6) Do the benefits of the prescribing cascade outweigh its risks? CONCLUSION Prescribing cascades are not problematic in themselves; on the contrary, they are sometimes a necessary part of good prescribing practice. There is still a lack of practically implementable instruments to help physicians detect prescribing cascades reliably, assess them properly, and put them to appropriate use.
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Affiliation(s)
- Tobias Dreischulte
- *These authors share first authorship.,Institute of General Practice and Family Medicine, University Hospital of Ludwig-Maximilians-University Munich,*Institut für Allgemeinmedizin Klinikum der Ludwig-Maximilians-Universität München Campus Innenstadt Pettenkoferstraße 10 80336 München
| | - Faiza Shahid
- *These authors share first authorship.,Institute of General Practice and Family Medicine, University Hospital of Ludwig-Maximilians-University Munich
| | - Christiane Muth
- Department of General Practice and Family Medicine, Medical Faculty OWL, University of Bielefeld
| | - Sven Schmiedl
- Philipp Klee-of Clinical Pharmacology, Helios Clinic Wuppertal; Clinical Pharmacology, Witten/Herdecke University, Witten/Herdecke
| | - Walter Emil Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelbergg
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22
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Farhat A, Al-Hajje A, Lang PO, Csajka C. Impact of Pharmaceutical Interventions with STOPP/START and PIM-Check in Older Hospitalized Patients: A Randomized Controlled Trial. Drugs Aging 2022; 39:899-910. [PMID: 36175740 PMCID: PMC9626411 DOI: 10.1007/s40266-022-00974-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 11/29/2022]
Abstract
Introduction Pharmaceutical interventions can reduce negative outcomes related to potentially inappropriate prescriptions (PIPs). Objective The objective of this study was to compare the impact of interventions on the reduction of PIPs and on different clinical outcomes using two electronic explicit tools. Methods A randomized controlled trial was conducted in patients hospitalized between 2018 and 2019 at the Acute Care for Elders unit at Lausanne University Hospital in Switzerland. A medication review was conducted using PIM-Check in the first arm and STOPP/START in the second arm. Proposed interventions were communicated to the physicians. Clinical outcomes evaluated were incidence of falls, delirium, activities of daily living (ADL), length of stay, number of drugs at discharge and hospital readmission. Results The 123 included patients (60 in the first arm and 63 in the second arm) were 86.3 ± 6.6 years old, had 3.5 ± 1.7 diseases and were treated by 6.2 ± 2.7 drugs at admission. There was a significant decrease in PIPs in each arm, but no significant difference between arms. The deprescription of nervous system drugs was significantly higher with STOPP/START than with PIM-Check (Chi-square p = 0.025). ADL scores between home and discharge were significantly higher in the STOPP/START arm than in the PIM-Check arm (4.42 vs 3.77; p = 0.040). The predictors of ADL score improvement were the deprescription of nervous system drugs (β = 0.423; 95% CI 0.034–0.812; p = 0.033), the use of STOPP/START (β = 0.798, 95% CI 0.305–1.290; p = 0.002) and a shorter length of hospital stay (β = −0.033, 95% CI − 0.056 to − 0.010; p = 0.005). Conclusions Although PIM-Check was non-inferior to STOPP/START in reducing the number of PIPs, STOPP/START had a significantly higher impact on ADL. The use of STOPP/START or the deprescription of two nervous system drugs would allow the patient to acquire almost one more basic function of living. On the other hand, a loss of one point on the ADL score was observed per month of hospitalization. Clinical Trials Registration Number NCT04028583.
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Affiliation(s)
- Akram Farhat
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland. .,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Switzerland. .,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.
| | - Amal Al-Hajje
- Clinical and Epidemiological Research Laboratory, Faculty of Pharmacy, Lebanese University, Hadat, Lebanon
| | | | - Chantal Csajka
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
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23
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Higher FORTA (Fit fOR The Aged) scores are associated with poor functional outcomes, dementia, and mortality in older people. Eur J Clin Pharmacol 2022; 78:1851-1859. [PMID: 36167853 PMCID: PMC9546968 DOI: 10.1007/s00228-022-03389-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 09/07/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Higher Fit fOR The Aged (FORTA) scores have been shown to be negatively associated with adverse clinical outcomes in older hospitalized patients. This has not been evaluated in other health care settings. The aim of this study was to examine the association of the FORTA score with relevant outcomes in the prospective AgeCoDe-AgeQualiDe cohort of community-dwelling older people. In particular, the longitudinal relation between the FORTA score and mortality and the incidence of dementia was evaluated. METHODS Univariate and multivariate correlations between the FORTA score and activities of daily living (ADL) or instrumental activities of daily living (IADL) as well as comparisons between high vs. low FORTA scores were conducted. RESULTS The FORTA score was significantly correlated with ADL/IADL at baseline and at all follow-up visits (p < 0.0001). ADL/IADL results of participants with a low FORTA score were significantly better than in those with high FORTA scores (p < 0.0001). The FORTA score was also significantly (p < 0.0001) correlated with ADL/IADL in the multivariate analysis. Moreover, the mean FORTA scores of participants with dementia were significantly higher (p < 0.0001) than in those without dementia at follow-up visits 6 through 9. The mean FORTA scores of participants who died were significantly higher than those of survivors at follow-up visits 7 (p < 0.05), 8 (p < 0.001), and 9 (p < 0.001). CONCLUSION In this study, an association between higher FORTA scores and ADL as well as IADL was demonstrated in community-dwelling older adults. Besides, higher FORTA scores appear to be linked to a higher incidence of dementia and even mortality.
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24
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Seppala LJ, Kamkar N, van Poelgeest EP, Thomsen K, Daams JG, Ryg J, Masud T, Montero-Odasso M, Hartikainen S, Petrovic M, van der Velde N. Medication reviews and deprescribing as a single intervention in falls prevention: a systematic review and meta-analysis. Age Ageing 2022; 51:afac191. [PMID: 36153749 PMCID: PMC9509688 DOI: 10.1093/ageing/afac191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND our aim was to assess the effectiveness of medication review and deprescribing interventions as a single intervention in falls prevention. METHODS DESIGN systematic review and meta-analysis. DATA SOURCES Medline, Embase, Cochrane CENTRAL, PsycINFO until 28 March 2022. ELIGIBILITY CRITERIA randomised controlled trials of older participants comparing any medication review or deprescribing intervention with usual care and reporting falls as an outcome. STUDY RECORDS title/abstract and full-text screening by two reviewers. RISK OF BIAS Cochrane Collaboration revised tool. DATA SYNTHESIS results reported separately for different settings and sufficiently comparable studies meta-analysed. RESULTS forty-nine heterogeneous studies were included. COMMUNITY meta-analyses of medication reviews resulted in a risk ratio (RR) of 1.05 (95% confidence interval, 0.85-1.29, I2 = 0%, 3 studies(s)) for number of fallers, in an RR = 0.95 (0.70-1.27, I2 = 37%, 3 s) for number of injurious fallers and in a rate ratio (RaR) of 0.89 (0.69-1.14, I2 = 0%, 2 s) for injurious falls. HOSPITAL meta-analyses assessing medication reviews resulted in an RR = 0.97 (0.74-1.28, I2 = 15%, 2 s) and in an RR = 0.50 (0.07-3.50, I2 = 72% %, 2 s) for number of fallers after and during admission, respectively. LONG-TERM CARE meta-analyses investigating medication reviews or deprescribing plans resulted in an RR = 0.86 (0.72-1.02, I2 = 0%, 5 s) for number of fallers and in an RaR = 0.93 (0.64-1.35, I2 = 92%, 7 s) for number of falls. CONCLUSIONS the heterogeneity of the interventions precluded us to estimate the exact effect of medication review and deprescribing as a single intervention. For future studies, more comparability is warranted. These interventions should not be implemented as a stand-alone strategy in falls prevention but included in multimodal strategies due to the multifactorial nature of falls.PROSPERO registration number: CRD42020218231.
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Affiliation(s)
- Lotta J Seppala
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Nellie Kamkar
- Gait and Brain Laboratory, Lawson Research Health Institute, Parkwood Hospital, London Ontario, Canada
- Department of Epidemiology and Biostatistics, University of Western Ontario, London Ontario, Canada
| | - Eveline P van Poelgeest
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Katja Thomsen
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Joost G Daams
- Research Support, Medical Library, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- ODIN (Odense Deprescribing INitiative), Denmark
| | - Tahir Masud
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Manuel Montero-Odasso
- Gait and Brain Laboratory, Lawson Research Health Institute, Parkwood Hospital, London Ontario, Canada
- Schulich School of Medicine and Dentistry, London Ontario, Canada
- Departments of Medicine (Geriatrics) and of Epidemiology and Biostatistics, University of Western Ontario, London Ontario, Canada
| | | | - Mirko Petrovic
- Department of Internal Medicine and Paediatrics (Section of Geriatrics), Ghent University, Ghent, Belgium
| | - Nathalie van der Velde
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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25
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Klopotowska JE, Kuks PFM, Wierenga PC, Stuijt CCM, Arisz L, Dijkgraaf MGW, de Keizer N, Smorenburg SM, de Rooij SE. The effect of structured medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients - a multicenter interrupted time series study. BMC Geriatr 2022; 22:505. [PMID: 35715742 PMCID: PMC9206349 DOI: 10.1186/s12877-022-03118-z] [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: 12/22/2021] [Accepted: 04/27/2022] [Indexed: 11/10/2022] Open
Abstract
Background The effectiveness of interventions to improve medication safety in older inpatients is unclear, given a paucity of properly designed intervention studies applying clinically relevant endpoints such as hospital-acquired preventable Adverse Drug Events (pADEs) and unrecognized Adverse Drug Events (uADEs). Therefore, we conducted a quality improvement study and used hospital-acquired pADEs and uADEs as main outcomes to assess the effect of an intervention aimed to improve medication safety in older inpatients. Method The study followed an interrupted time series design and consisted of three equally spaced sampling points during baseline and during intervention measurements. Each sampling point included between 80 to 90 patients. A total of 500 inpatients ≥65 years and admitted to internal medicine wards of three Dutch hospitals were included. An expert team retrospectively identified and assessed ADEs via a structured patient chart review. The findings from baseline measurement and meetings with the internal medicine and hospital pharmacy staff were used to design the intervention. The intervention consisted of a structured medication review by hospital pharmacists, followed by face-to-face feedback to prescribers, on average 3 days per week. Results The rate of hospital-acquired pADEs per 100 hospitalizations was reduced by 50.6% (difference 16.8, 95% confidence interval (CI): 9.0 to 24.6, P < 0.001), serious hospital-acquired pADEs by 62.7% (difference 12.8, 95% CI: 6.4 to 19.2, P < 0.001), and uADEs by 51.8% (difference 11.2, 95% CI: 4.4 to 18.0, P < 0.001). Additional analyses confirmed the robustness of the intervention effect, but residual bias cannot be excluded. Conclusions The intervention significantly decreased the overall and serious hospital-acquired pADE occurrence in older inpatients, and significantly improved overall ADE recognition by prescribers. Trial registration International Standard Randomized Controlled Trial Number Register, trial registration number: ISRCTN64974377, registration date (date assigned): 07/02/2011. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03118-z.
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Affiliation(s)
- Joanna E Klopotowska
- Amsterdam University Medical Centers location University of Amsterdam, Medical Informatics, Amsterdam, The Netherlands. .,Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands.
| | - Paul F M Kuks
- Amsterdam University Medical Centers location University of Amsterdam, Pharmacy and Clinical Pharmacology, Amsterdam, The Netherlands
| | - Peter C Wierenga
- Gelderse Vallei Hospital, Hospital Pharmacy, Ede, The Netherlands
| | - Clementine C M Stuijt
- Center of Excellence on Parkinson's disease (Punt voor Parkinson), Groningen, The Netherlands
| | - Lambertus Arisz
- Amsterdam University Medical Centers location University of Amsterdam, Internal Medicine, Amsterdam, The Netherlands
| | - Marcel G W Dijkgraaf
- Amsterdam University Medical Centers location University of Amsterdam, Epidemiology and Data Science, Amsterdam, The Netherlands.,Amsterdam Public Health, Methodology, Amsterdam, the Netherlands
| | - Nicolette de Keizer
- Amsterdam University Medical Centers location University of Amsterdam, Medical Informatics, Amsterdam, The Netherlands.,Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands
| | - Susanne M Smorenburg
- Amsterdam University Medical Centers location University of Amsterdam, Internal Medicine, Amsterdam, The Netherlands
| | - Sophia E de Rooij
- Amstelland Hospital, Board of Directors, Amstelveen, The Netherlands
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26
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Affiliation(s)
- Martin Wehling
- Clinical Pharmacology Mannheim, Centre for Gerontopharmacology, University of Heidelberg, Heidelberg, Germany.
| | - Mirko Petrovic
- Section of Geriatrics, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
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27
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Maiworm A, Langner R, Wilm S, Hermann DM, Frohnhofen H, Gronewold J. Developing a novel tool to assess the ability to self-administer medication in non-demented in-hospital patients: ABLYMED study protocol. BMC Geriatr 2022; 22:466. [PMID: 35641903 PMCID: PMC9158197 DOI: 10.1186/s12877-022-03147-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Older people often suffer from multimorbidity resulting in polypharmacy. The correct administration of medication is a crucial factor influencing treatment efficacy. However, tools for evaluating the ability to self-administer different dosage forms of medications are lacking. The objectives of the ABLYMED study are to 1) assess the ability to self-administer different dosage forms of medication in older non-demented in-hospital patients who report autonomous management of medication, 2) identify factors influencing the ability to self-administer medication, and 3) develop a standardized tool to validly assess the ability to self-administer different dosage forms of medications based on the final study results. METHODS One hundred in-patients from the department of orthopedics and trauma surgery of the University Hospital Düsseldorf ≥ 70 years of age and regularly taking ≥ 5 different drugs autonomously will be prospectively recruited into the observational cross-sectional single-center ABLYMED study. Patients undergo an interview addressing demographic and clinical information, medication history (which medications are taken since when, in which dose and dosage form, and subjective proficiency of taking these medications), medication adherence, and factors possibly influencing adherence including personality traits and perceived quality of the medication regimen. Quality of the medication regimen is also rated by clinicians according to validated lists. Further, patients receive a comprehensive geriatric assessment including measures of cognition, mobility, and functional status. The ability to self-administer medication is assessed by having patients perform different tasks related to medication self-administration, which are video recorded and rated by different experts. The patients' self-reported ability will be correlated with the observed performance in the self-administration tasks. Further, factors correlating with the reported and observed ability to self-administer medication will be evaluated using correlation and regression models. Based on the final study results, a novel tool to assess the ability of older patients to self-administer medication will be developed. DISCUSSION In addition to guideline-based pharmacotherapy, correct intake of prescribed medication is crucial for optimal therapy of multimorbidity in older people. Tools to validly assess the ability of older patients to self-administer different dosage forms of medications are lacking, but should be included in comprehensive geriatric assessments to secure functional health. TRIAL REGISTRATION Development of an assessment instrument to evaluate the ability to manage various dosage forms, DRKS-ID: DRKS00025788 , (date of registration: 07/09/2021).
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Affiliation(s)
- Anneke Maiworm
- Hospital Pharmacy, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Robert Langner
- Institute of Systems Neuroscience, University Hospital Düsseldorf, Düsseldorf, Germany.,Institute of Neuroscience and Medicine (INM-7: Brain and Behaviour), Research Centre Jülich, Jülich, Germany
| | - Stefan Wilm
- Institute of General Practice, Centre for Health and Society (Chs), University Hospital Düsseldorf, Düsseldorf, Germany
| | - Dirk M Hermann
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45122, Essen, Germany
| | - Helmut Frohnhofen
- Department of Orthopedics and Trauma Surgery, University Hospital Düsseldorf, Düsseldorf, Germany.,Faculty of Health, Department of Medicine, Geriatrics, University Witten-Herdecke, Witten, Germany
| | - Janine Gronewold
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45122, Essen, Germany.
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Chen LJ, Nguyen TNM, Chang-Claude J, Hoffmeister M, Brenner H, Schöttker B. Incorporation of functional status, frailty, comorbidities, and co-medication in prediction models for colorectal cancer survival. Int J Cancer 2022; 151:539-552. [PMID: 35435251 DOI: 10.1002/ijc.34036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/31/2022] [Accepted: 04/04/2022] [Indexed: 11/08/2022]
Abstract
Limitations in functional status, frailty, multiple comorbidities, and co-medications are common among older colorectal cancer (CRC) patients. We investigated whether adding these factors could improve the predictive value of a reference model containing age, sex, tumor stage and location for prediction of 5-year overall survival (OS), disease-free survival (DFS), disease-specific survival (DSS), recurrence-free survival (RFS), and non-disease-specific survival (nDSS) for all CRC patients as well as for younger (<65 years) and older patients (≥65 years). Overall, 3,410 CRC patients from the DACHS study were analyzed and area under receiver operating characteristic curves (AUC) and net reclassification improvements (NRI) were assessed. In prediction of OS, the reference model plus functional status was identified as the best model among all CRC patients (AUC: 0.762) and younger CRC patients (AUC: 0.820). In older CRC patients, comorbidity should additionally be added (AUC: 0.747). For nDSS, the reference model plus comorbidity and frailty had the best predictive performance in all CRC patients (AUC: 0.776). For the outcomes DFS (AUC: 0. 727), DSS (AUC: 0. 838), and RFS (AUC: 0. 784), the reference model was already the best model in all CRC patients because no significant NRIs were observed. The pattern "The less CRC-specific the survival outcome and the older the CRC patients, the more relevant the inclusion of functional status, comorbidity, and frailty in CRC prognostic scores is" was observed. Thus, different nomograms for younger and older CRC patients for 1-, 3-, and 5-year OS prognosis estimation are being suggested.
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Affiliation(s)
- Li-Ju Chen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Network Aging Research, University of Heidelberg, Heidelberg, Germany
| | - Thi Ngoc Mai Nguyen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Network Aging Research, University of Heidelberg, Heidelberg, Germany
| | - Jenny Chang-Claude
- Unit of Genetic Epidemiology, Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Cancer Epidemiology Group, University Cancer Center Hamburg (UCCH), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Michael Hoffmeister
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Network Aging Research, University of Heidelberg, Heidelberg, Germany.,Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany.,German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Ben Schöttker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Network Aging Research, University of Heidelberg, Heidelberg, Germany
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Hias J, Van der Linden L, Walgraeve K, Lemper JC, Hellemans L, Spriet I, Tournoy J. Optimizing pharmacotherapy on geriatric hospital units in Belgium - a national survey. Acta Clin Belg 2022; 77:321-328. [PMID: 33345741 DOI: 10.1080/17843286.2020.1864162] [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: 10/22/2022]
Abstract
OBJECTIVE Inappropriate prescribing remains highly prevalent on geriatric units. The aim of this investigation, initiated by the Belgian College for Geriatrics, was to evaluate the implementation of strategies to optimize pharmacotherapy on geriatric units in Belgium. METHODS A literature search was performed to identify strategies to support the appropriate use of medications in very old inpatients. These strategies were subsequently validated based on Delphi consensus rounds and a national survey was developed. Experts were selected by the research team in collaboration with the Belgian College for Geriatrics. The survey was sent to the heads of the geriatric departments of all Belgian hospitals (n = 100). RESULTS After 3 months a response rate of 55% was achieved. Strategies that were implemented more frequently were the use of electronic prescribing (85%), performing a structured medication review (69%) and providing patient education (76%). In a minority (24%) of hospitals, a clinical pharmacist was directly involved in the multidisciplinary geriatric team. Implementation of clinical decisions support systems (CDSS) was reported by 36% of the hospitals. Educational strategies for healthcare professionals and strategies to optimize transitional care were variable. CONCLUSION Taking into account the current body of evidence, strategies that include transitional care components, CDSS or ward-based clinical pharmacy services should be further promoted on Belgian geriatric units.
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Affiliation(s)
- Julie Hias
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Lorenz Van der Linden
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | | | - Jean-Claude Lemper
- Department of Geriatric Medicine, University Hospitals Brussels, Brussels, Belgium
| | - Laura Hellemans
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Jos Tournoy
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
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Schmitt AK, Weiss C, Burkhardt H, Frohnhofen H, Wehling M, Pazan F. The Sex-Specific Impact of the FORTA (Fit-fOR-The-Aged) List on Medication Quality and Clinical Endpoints in Older Hospitalized Patients: Secondary Analysis of a Randomized Controlled Trial. Drugs Real World Outcomes 2022; 9:287-297. [PMID: 35297495 PMCID: PMC9114217 DOI: 10.1007/s40801-022-00292-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2022] [Indexed: 11/27/2022] Open
Abstract
Background Little is known about the sex-specific impact of drug optimization tools such as the Fit fOR The Aged (FORTA) list on drug use and relevant clinical endpoints in older people. Objective We aimed to detect gender differences of interventional effects on medication quality and related clinical effects in the VALFORTA trial. Patients and methods A sex-specific analysis of data from 409 patients (147 men and 262 women, mean age 79.4 and 82.7 years, respectively) in acute geriatric care comparing the control and FORTA intervention groups was performed. Changes of the FORTA score (sum of over- and undertreatment errors per patient), the incidence of adverse drug events (ADEs) during hospitalization, and several clinically relevant endpoints [e.g., the Barthel index (BI)] were tested for equivalence at a 20% margin. “Success” or “failure” for the development of these clinical endpoints was defined and their frequencies compared by a risk reduction analysis. Results Sex differences were insignificant for the reduction of the FORTA score, the improvement of BI, or over- and undertreatment errors (p > 0.05). In women only, the FORTA intervention significantly increased the number of patients without an ADE (p = 0.010). Statistical sex equivalence was found for the improvement of the FORTA scores, BI, and the number of prevented events (e.g., falls, confusion, or renal failure) (p < 0.05), but not for the improvement of specific mistreatments or over- and undertreatment scores under altered inclusion criteria (p > 0.05). Conclusions Both sexes benefit equally from the FORTA intervention regarding the amelioration of the quality of drug treatment as well as several clinically relevant outcomes. In addition, the positive impact of the FORTA intervention on the number of adverse drug events appears to be greater in women. Trial Registration Number DRKS00000531. Supplementary Information The online version contains supplementary material available at 10.1007/s40801-022-00292-9.
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Affiliation(s)
- Ann-Kathrin Schmitt
- Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Christel Weiss
- Department of Medical Statistics, Biomathematics and Information Processing, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Heinrich Burkhardt
- IV. Medical Department, Medical Faculty Mannheim, University Medical Center, Heidelberg University, Mannheim, Germany
| | - Helmut Frohnhofen
- Fakultät für Gesundheit, Universität Witten Herdecke, Alfred-Herrhausen-Str. 50, 58455, Witten, Germany.,Heinrich Heine Universität Düsseldorf, UKD, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Martin Wehling
- Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Farhad Pazan
- Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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31
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Frohnhofen H, Popp R. [Sleep and sleep disorders in old age]. Dtsch Med Wochenschr 2022; 147:258-268. [PMID: 35226925 DOI: 10.1055/a-1495-3348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The increasing interruptions of night sleep with normal ageing must be distinguished from sleep disorders. Somatic and psychiatric morbidity as well as medication have a huge impact on sleep. Furthermore, the relationship between sleep and morbidity is mutual. Disturbed sleep modifies the clinical appearance of diseases and morbidity affects the ability to sleep. Especially in geriatric medicine, geriatric syndromes such as falls, depression or dementia are modified by sleep disorders. Therefore, treatment for sleep disorders offers the chance to improve geriatric syndromes.When treating, it is important to identify the individual sleep disorders. Coincidences of different sleep disorders are common in the elderly. The history of a patient in connection with a sleeping diary is the basic diagnostic procedure. Sleep medicine provides further technical methods for further examination. Older people should also be examined in a sleep laboratory if the results have consequences that will be accepted by the patient. However, this should be clarified in advance.
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The FORTA (Fit fOR The Aged) List 2021: Fourth Version of a Validated Clinical Aid for Improved Pharmacotherapy in Older Adults. Drugs Aging 2022; 39:245-247. [PMID: 35194722 PMCID: PMC8934757 DOI: 10.1007/s40266-022-00922-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2022] [Indexed: 11/16/2022]
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Damoiseaux-Volman BA, Raven K, Sent D, Medlock S, Romijn JA, Abu-Hanna A, van der Velde N. Potentially inappropriate medications and their effect on falls during hospital admission. Age Ageing 2022; 51:6399892. [PMID: 34673915 PMCID: PMC8753037 DOI: 10.1093/ageing/afab205] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/17/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE to investigate the effect of potentially inappropriate medications (PIMs) on inpatient falls and to identify whether PIMs as defined by STOPPFall or the designated section K for falls of STOPP v2 have a stronger association with inpatient falls when compared to the general tool STOPP v2. METHODS a retrospective observational matching study using an electronic health records dataset of patients (≥70 years) admitted to an academic hospital (2015-19), including free text to identify inpatient falls. PIMs were identified using the STOPP v2, section K of STOPP v2 and STOPPFall. We first matched admissions with PIMs to those without PIMs on confounding factors. We then applied multinomial logistic regression analysis and Cox proportional hazards analysis on the matched datasets to identify effects of PIMs on inpatient falls. RESULTS the dataset included 16,678 hospital admissions, with a mean age of 77.2 years. Inpatient falls occurred during 446 (2.7%) admissions. Adjusted odds ratio (OR) (95% confidence interval (CI)) for the association between PIM exposure and falls were 7.9 (6.1-10.3) for STOPP section K, 2.2 (2.0-2.5) for STOPP and 1.4 (1.3-1.5) for STOPPFall. Adjusted hazard ratio (HR) (95% CI) for the effect on time to first fall were 2.8 (2.3-3.5) for STOPP section K, 1.5 (1.3-1.6) for STOPP and 1.3 (1.2-1.5) for STOPPFall. CONCLUSIONS we identified an independent association of PIMs on inpatient falls for all applied (de)prescribing tools. The strongest effect was identified for STOPP section K, which is restricted to high-risk medication for falls. Our results suggest that decreasing PIM exposure during hospital stay might benefit fall prevention, but intervention studies are warranted.
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Affiliation(s)
- Birgit A Damoiseaux-Volman
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kimmy Raven
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Danielle Sent
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Stephanie Medlock
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Johannes A Romijn
- Department of Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ameen Abu-Hanna
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nathalie van der Velde
- Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Kurczewska-Michalak M, Lewek P, Jankowska-Polańska B, Giardini A, Granata N, Maffoni M, Costa E, Midão L, Kardas P. Polypharmacy Management in the Older Adults: A Scoping Review of Available Interventions. Front Pharmacol 2021; 12:734045. [PMID: 34899294 PMCID: PMC8661120 DOI: 10.3389/fphar.2021.734045] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/26/2021] [Indexed: 12/24/2022] Open
Abstract
Background: Polypharmacy paves the way for non-adherence, adverse drug reactions, negative health outcomes, increased use of healthcare services and rising costs. Since it is most prevalent in the older adults, there is an urgent need for introducing effective strategies to prevent and manage the problem in this age group. Purpose: To perform a scoping review critically analysing the available literature referring to the issue of polypharmacy management in the older adults and provide narrative summary. Data sources: Articles published between January 2010–March 2018 indexed in CINHAL, EMBASE and PubMed addressing polypharmacy management in the older adults. Results: Our search identified 49 papers. Among the identified interventions, the most often recommended ones involved various types of drug reviews based on either implicit or explicit criteria. Implicit criteria-based approaches are used infrequently due to their subjectivity, and limited implementability. Most of the publications advocate the use of explicit criteria, such as e.g. STOPP/START, Beers and Medication Appropriateness Index (MAI). However, their applicability is also limited due to long lists of potentially inappropriate medications covered. To overcome this obstacle, such instruments are often embedded in computerised clinical decision support systems. Conclusion: Multiple approaches towards polypharmacy management are advised in current literature. They vary in terms of their complexity, applicability and usability, and no “gold standard” is identifiable. For practical reasons, explicit criteria-based drug reviews seem to be advisable. Having in mind that in general, polypharmacy management in the older adults is underused, both individual stakeholders, as well as policymakers should strengthen their efforts to promote these activities more strongly.
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Affiliation(s)
| | - P Lewek
- Department of Family Medicine, Medical University of Lodz, Lodz, Poland
| | - B Jankowska-Polańska
- Department of Clinical Nursing, Faculty of Health Science, Wroclaw Medical University, Wroclaw, Poland
| | - A Giardini
- IT Department, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - N Granata
- Psychology Unit, Istituti Clinici Scientifici Maugeri IRCCS, Montescano Institute, Pavia, Italy
| | - M Maffoni
- Psychology Unit, Istituti Clinici Scientifici Maugeri IRCCS, Montescano Institute, Pavia, Italy
| | - E Costa
- UCIBIO/REQUIMTE, Faculty of Pharmacy and Porto4Ageing, University of Porto, Porto, Portugal
| | - L Midão
- UCIBIO/REQUIMTE, Faculty of Pharmacy and Porto4Ageing, University of Porto, Porto, Portugal
| | - P Kardas
- Department of Family Medicine, Medical University of Lodz, Lodz, Poland
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Lun P, Law F, Ho E, Tan KT, Ang W, Munro Y, Ding YY. Optimising prescribing practices in older adults with multimorbidity: a scoping review of guidelines. BMJ Open 2021; 11:e049072. [PMID: 34907045 PMCID: PMC8671917 DOI: 10.1136/bmjopen-2021-049072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Inappropriate polypharmacy occurs when multiple medications are prescribed without clear indications or where harms outweigh their benefits. The aims of this scoping review are to (1) identify prescribing guidelines that are available for older adults with multimorbidity and (2) to identify cross-cutting themes used in these guidelines. DESIGN Scoping review. DATA SOURCES PubMed, Embase, Web of Science, the Cochrane Library databases, Cumulative Index to Nursing and Allied Health Literature, grey literature sources, six key geriatrics journals, and reference lists of identified review papers. The search was conducted in November 2018 and updated in September 2019. STUDY SELECTION General prescribing guidelines tailored to or for adults including older adults with multimorbidity. DATA EXTRACTION Data for publication description, guideline characteristics, information for users and criteria were extracted. The synthesis contains summarised qualitative descriptions of the studies and guideline characteristics as well as identified cross-cutting themes. RESULTS Our search strategy yielded 10 427 unique citations, of which 70 fulfilled the inclusion criteria for synthesis. Among these, there were 61 unique guidelines and tools which used implicit, explicit, mixed or other approaches in the prescriber decision-making process. There are 11 cross-cutting themes identified in the guidelines. Prescriber-related themes are: conduct a comprehensive assessment before prescribing, identify patients' needs, goals and priorities, adopt shared decision-making, consider evidence-based recommendations, use clinical prescribing tools, incorporate multidisciplinary inputs and embrace technology-enabled prescribing. Wider organisation-related and system-related themes related to education, training and the work environment are also identified. CONCLUSIONS From guidelines and tools identified, eleven cross-cutting themes provide a usable knowledge base when seeking to optimise prescribing among older adults with multimorbidity. Incorporating these themes in an approach that uses mixed criteria and implementation information could facilitate greater uptake of published prescribing recommendations.
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Affiliation(s)
- Penny Lun
- Geriatric Education and Research Institute, Singapore
| | - Felicia Law
- Geriatric Medicine, National Healthcare Group Woodlands Health Campus, Singapore
| | - Esther Ho
- Geriatric Medicine, Tan Tock Seng Hospital, Singapore
| | | | - Wendy Ang
- Pharmacy, Changi General Hospital, Singapore
| | - Yasmin Munro
- Medical Library, Lee Kong Chian School of Medicine, Singapore
| | - Yew Yoong Ding
- Geriatric Education and Research Institute, Singapore
- Geriatric Medicine, Tan Tock Seng Hospital, Singapore
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Onder G. Appropriate prescribing. JOURNAL OF GERONTOLOGY AND GERIATRICS 2021. [DOI: 10.36150/2499-6564-n462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Tarlovskaya EI, Omarova YV. Analysis of the compliance of the prescribed therapy with the EURO FORTA system in polymorbidic patients of elderly and old age with CHF. KARDIOLOGIIA 2021; 61:57-64. [PMID: 34882079 DOI: 10.18087/cardio.2021.11.n1619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/12/2021] [Indexed: 06/13/2023]
Abstract
Aim To study the consistency of the prescribed therapy with the EURO FORTA (2018) system in polymorbid patients with chronic heart failure (CHF) according to data of the local registry.Material and methods The study included 313 patients with CHF aged 75±8.2 years. The Charlson Comorbidity Index (CCI) and the number of diseases (1-2, 3-5, >5) were calculated for all patients. Inpatient and outpatient treatment was assessed according to the EURO FORTA (2018) system based on polymorbidity degree, age, gender, and CHF type and severity.Results For the retrospective analysis of outpatient treatment, 5 groups of patients were isolated based on the drug class in the EURO FORTA system: group 1, patients treated only with class A drugs (3.51 %); group 2, class A and B drugs (22.36 %); group 3, class A, B, and C drugs (17.25 %); group 4, class A, B, C, and D drugs 10.86 % (А, В, С, D) and 16.31 % (А, В, D); and group 5, patients without an outpatient drug therapy (29.71 %). For the analysis of inpatient treatment, 4 groups of patients were isolated based on the drug class in the EURO FORTA system: group 1, patients treated only with class A drugs (0.32 %); group 2, class A and B drugs (15.97 %); group 3, class A, B, and C drugs (57.19 %); and group 4, separately analyzed patients treated with class C and D drugs or only D in combination with class A and B drugs. Thus, 28.11 % of patients at the outpatient stage and 82.75 % of patients at the inpatient stage received drugs with questionable efficacy/safety profiles (class C); 27.17 % of patients at the outpatient stage and 26.52 % at the inpatient stage received potentially inappropriate drugs (class D). At the outpatient stage in groups 2-4, most of patients (51.43-70.59 %) had >5 diseases (pmg=0.020). At the inpatient stage, there were no significant differences between groups in the number of diseases (pmg=0.349). The groups were comparable in the left ventricular ejection fraction depending on the CHF type (pmg=0.027 and pmg=0.778) at both stages of treatment. For instance, the same patient with preserved left ventricular ejection fraction could be included into EURO FORTA group 2 for the analysis of outpatient treatment while after prescription of the inpatient treatment, he/she could be included into group 3; pmg (intergroup, detecting differences for comparison of 3 groups) exceeded 0.017; therefore, the groups were comparable in the number of CHF patients with reduced, mid-range, and preserved left ventricular ejection fraction.Conclusion Every second patient of the study had more than 5 diseases. Every third patient did not take any drugs at the outpatient stage. 28.11 % of patients received EURO FORTA class C drugs and 27.17% of patients received class D drugs at the outpatient stage. The drugs to be avoided in CHF, included primarily nonsteroid anti-inflammatory drugs (NSAIDs) and class I and III anti-arrhythmic medications (except for amiodarone). At the inpatient stage, 82.75 % of patients received EURO FORTA class C drugs and 26.52 % of patients received class D drugs. NSAIDs and ciprofloxacin prevailed among the drugs to be avoided in CHF.
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Affiliation(s)
| | - Yu V Omarova
- Privolzhsky Research Medical University, Nizhny Novgorod
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Lazaridis LD, Rizos E, Bounou L, Theodorou-Kanakari A, Kalousios S, Mavroeidi EA, Roma M, Chatzidakis A, Vlachonicolou G, Miltiadou K, Gkolfakis P, Tziatzios G, Triantafyllou K. An educational intervention to optimize use of proton pump inhibitors in a Greek university hospital. Ann Gastroenterol 2021; 34:781-787. [PMID: 34815643 PMCID: PMC8596207 DOI: 10.20524/aog.2021.0654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/20/2021] [Indexed: 11/11/2022] Open
Abstract
Background Misuse of proton pump inhibitors (PPIs) is an alarming issue for patients and healthcare systems. Methods We conducted a 3-phase interventional, prospective study in a Greek university hospital. During Phase I, we collected data from patients' records to evaluate the appropriate use of PPIs. During Phase II, educational seminars about the proper use of PPIs were offered to the medical staff. In Phase III we collected data from the records of patients admitted to the hospital department with the highest rate of inappropriate PPI administration during Phase I, to evaluate the efficacy of the intervention. Inappropriate use was defined as either PPI administration without indication, or lack of use despite adequate indication. Appropriateness of PPI use was measured at admission, during hospitalization and at discharge. Results The rate of inappropriate PPI use was higher (51.7% and 48.6%) during hospitalization than at admission (34.9% and 21.9%), but at discharge was similar to pre-hospitalization levels (26.9% and 23.6%), in Phases I and III, respectively. At discharge during Phase I, the inappropriate use of PPIs was significantly higher (odds ratio 3.79, 95% confidence interval 1.98-7.19) for internal medicine patients than for surgical patients. The educational intervention failed to reduce the inappropriate use of PPIs during hospitalization (51.7% vs. 48.6%, P=0.478) or at discharge (26.9% vs. 23.6%, P=0.391) in the internal medicine patients. Conclusions The rate of inappropriate PPI use is almost double during hospitalization compared to the rates at admission and at discharge. Implementation of an educational intervention failed to reduce the inappropriate use of PPIs in internal medicine patients.
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Affiliation(s)
- Lazaros-Dimitrios Lazaridis
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Evripidis Rizos
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Lamprini Bounou
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Anna Theodorou-Kanakari
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Sotirios Kalousios
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Electra-Antonia Mavroeidi
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Maria Roma
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Alexandros Chatzidakis
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Georgia Vlachonicolou
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Konstantinos Miltiadou
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Paraskevas Gkolfakis
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Georgios Tziatzios
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Propaedeutic Medicine-, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
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Alshammari H, Al-Saeed E, Ahmed Z, Aslanpour Z. Reviewing Potentially Inappropriate Medication in Hospitalized Patients Over 65 Using Explicit Criteria: A Systematic Literature Review. Drug Healthc Patient Saf 2021; 13:183-210. [PMID: 34764701 PMCID: PMC8572741 DOI: 10.2147/dhps.s303101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 07/16/2021] [Indexed: 12/29/2022] Open
Abstract
Potentially inappropriate medication (PIM) is a primary health concern affecting the quality of life of patients over 65. PIM is associated with adverse drug reactions including falls, increased healthcare costs, health services utilization and hospital admissions. Various strategies, clinical guidelines and tools (explicit and implicit) have been developed to tackle this health concern. Despite these efforts, evidence still indicates a high prevalence of PIM in the older adult population. This systematic review explored the practice of using explicit tools to review PIM in hospitalized patients and examined the outcomes of PIM reduction. A literature search was conducted in several databases from their inception to 2019. Original studies that had an interventional element using explicit criteria detecting PIM in hospitalized patients over 65 were included. Descriptive narrative synthesis was used to analyze the included studies. The literature search yielded 6116 articles; 25 quantitative studies were included in this systematic literature review. Twenty were prospective studies and five were retrospective. Approximately, 15,500 patients were included in the review. Various healthcare professionals were involved in reviewing PIM including physicians and hospital pharmacists. Several tools were used to review PIM for hospitalized patients over 65, most frequently Beer’s criteria and the STOPP/START tool. The reduction of PIM ranged from 3.5% up to 87%. The most common PIM were benzodiazepines and antipsychotics. This systematic review showed promising outcomes in terms of improving patient outcomes. However, the reduction of PIM varied in the studies, raising the question of the variance between hospitals in the explicit tools used for review. Additional studies need to be conducted to further investigate the outcomes of reviewing PIM at different levels, as well as assessing the cost-effectiveness of using explicit tools in reducing PIM.
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Affiliation(s)
- Hesah Alshammari
- Department of Clinical and Pharmaceutical Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
- Correspondence: Hesah Alshammari Email
| | - Eman Al-Saeed
- Department of Clinical and Pharmaceutical Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Zamzam Ahmed
- Department of Clinical and Pharmaceutical Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Zoe Aslanpour
- Department of Clinical and Pharmaceutical Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
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Krüger C, Schäfer I, van den Bussche H, Bickel H, Dreischulte T, Fuchs A, König HH, Maier W, Mergenthal K, Riedel-Heller SG, Schön G, Weyerer S, Wiese B, von Renteln-Kruse W, Langebrake C, Scherer M. Comparison of FORTA, PRISCUS and EU(7)-PIM lists on identifying potentially inappropriate medication and its impact on cognitive function in multimorbid elderly German people in primary care: a multicentre observational study. BMJ Open 2021; 11:e050344. [PMID: 34535481 PMCID: PMC8451296 DOI: 10.1136/bmjopen-2021-050344] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES Our study aimed to assess the frequency of potentially inappropriate medication (PIM) use (according to three PIM lists) and to examine the association between PIM use and cognitive function among participants in the MultiCare cohort. DESIGN MultiCare is conducted as a longitudinal, multicentre, observational cohort study. SETTING The MultiCare study is located in eight different study centres in Germany. PARTICIPANTS 3189 patients (59.3% female). PRIMARY AND SECONDARY OUTCOME MEASURES The study had a cross-sectional design using baseline data from the German MultiCare study. Prescribed and over-the-counter drugs were classified using FORTA (Fit fOR The Aged), PRISCUS (Latin for 'time-honoured') and EU(7)-PIM lists. A mixed-effect multivariate linear regression was performed to calculate the association between PIM use patients' cognitive function (measured with (LDST)). RESULTS Patients (3189) used 2152 FORTA PIM (mean 0.9±1.03 per patient), 936 PRISCUS PIM (0.3±0.58) and 4311 EU(7)-PIM (1.4±1.29). The most common FORTA PIM was phenprocoumon (13.8%); the most prevalent PRISCUS PIM was amitriptyline (2.8%); the most common EU(7)-PIM was omeprazole (14.0%). The lists rate PIM differently, with an overall overlap of 6.6%. Increasing use of PIM is significantly associated with reduced cognitive function that was detected with a correlation coefficient of -0.60 for FORTA PIM (p=0.002), -0.72 for PRISCUS PIM (p=0.025) and -0.44 for EU(7)-PIM (p=0.005). CONCLUSION We identified PIM using FORTA, PRISCUS and EU(7)-PIM lists differently and found that PIM use is associated with cognitive impairment according to LDST, whereby the FORTA list best explained cognitive decline for the German population. These findings are consistent with a negative impact of PIM use on multimorbid elderly patient outcomes. TRIAL REGISTRATION NUMBER ISRCTN89818205.
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Affiliation(s)
- Caroline Krüger
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ingmar Schäfer
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hendrik van den Bussche
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Horst Bickel
- Department of Psychiatry, Technical University of Munich, Munchen, Germany
| | - Tobias Dreischulte
- Institute of General Practice, Friedrich-Schiller-Universität Jena, Jena, Germany
- Institute of General Practice and Family Medicine, Ludwig-Maximilians-Universitat Munchen, Munchen, Germany
| | - Angela Fuchs
- Institute of General Practice, Heinrich-Heine-Universitat Dusseldorf, Dusseldorf, Germany
| | - Hans-Helmut König
- Department for Health Economics and Health Services Research, Universitatsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Maier
- Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany
| | - Karola Mergenthal
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | - Gerhard Schön
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Siegfried Weyerer
- Medical Faculty, Central Institute of Mental Health, Mannheim, Germany
| | - Birgitt Wiese
- Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Wolfgang von Renteln-Kruse
- Research Department, Albertinen-Haus Zentrum für Geriatrie und Gerontologie Medizinisch-Geriatrische Klinik, Hamburg, Germany
| | - Claudia Langebrake
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Scherer
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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van der Velde N, Minhas JS. Appropriate deprescribing in older people: a challenging necessityCommentary to accompany themed collection on deprescribing. Age Ageing 2021; 50:1516-1519. [PMID: 34260681 DOI: 10.1093/ageing/afab142] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 05/18/2021] [Indexed: 01/08/2023] Open
Abstract
Older people are often taking several medications for a number of different medical conditions. Although physicians prescribe medications to treat diseases and symptoms, there may be also harmful side effects, especially so in older people taking several medications. Unfortunately, regular review of the benefits or risks of prescribed medications is as of yet not part of standard care. Also, data on how and in whom to stop medications in older people are scarce. The reason this is an important area of work is that medication related issues in older people are a common cause of harm, including both expected and unexpected effects of medications. Research to date tells us that to ensure successful implementation of structured and appropriate deprescribing, careful planning within hospital systems is needed. This includes involving different members of the team to ensure the patients truly benefit. The themed collection published on the Age and Ageing journal website offers key articles providing tools to assist decision-making, implementation strategies and multidisciplinary interventions-all with the aim of improving patient outcome and sustainability of deprescribing approaches.
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Affiliation(s)
- Nathalie van der Velde
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jatinder S Minhas
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester, UK
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Chen LJ, Nguyen TNM, Laetsch DC, Chang-Claude J, Hoffmeister M, Brenner H, Schöttker B. Association of co-medication quality with chemotherapy-related adverse drug reactions and survival in older colorectal cancer patients. J Gerontol A Biol Sci Med Sci 2021; 77:1009-1019. [PMID: 34251458 DOI: 10.1093/gerona/glab198] [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: 04/14/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Evidence about the clinical relevance of appropriate co-medication among older colorectal cancer (CRC) patients is sparse. METHODS A cohort study was conducted with 3,239 CRC patients aged 65 years and older. To assess co-medication quality, we calculated the total Fit fOR The Aged (FORTA) score and its sub-scores for medication overuse, underuse, and potentially inappropriate medication use. Multivariable Cox proportional hazards or logistic regression models were performed to evaluate the association of co-medication quality with up to 5-year overall survival, CRC-specific survival, and chemotherapy-related adverse drug reactions (ADRs). RESULTS Overall, 3,239 and 1,209 participants were included in analyses on survival and ADRs, respectively. The hazard ratios [95%-confidence intervals] for the total FORTA score ≥ 7 vs. 0-1 points were 1.83 [1.40-2.40] and 1.76 [1.22-2.52] for up to 5-year overall and CRC-specific survival, respectively. Worse up to 5-year OS and CSS was also evident for FORTA sub-scores for PIM use and overuse whereas no association was observed for underuse. Although results for the total FORTA and potentially inappropriate medication score were much stronger among patients receiving chemotherapy, no significant associations with chemotherapy-related ADRs were observed. Moreover, associations were particularly strong among men and rectal cancer patients as compared to women and colon cancer patients. CONCLUSIONS Poor total co-medication quality was significantly associated with worse up to 5-year overall and CRC-specific survival. Randomized controlled trials are needed to test whether improved cancer co-medication management in older CRC patients prolongs survival.
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Affiliation(s)
- Li-Ju Chen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Network Aging Research, Heidelberg University, Heidelberg, Germany
| | - Thi Ngoc Mai Nguyen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Network Aging Research, Heidelberg University, Heidelberg, Germany
| | - Dana Clarissa Laetsch
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jenny Chang-Claude
- Unit of Genetic Epidemiology, Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Cancer Epidemiology Group, University Cancer Center Hamburg (UCCH), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Michael Hoffmeister
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Network Aging Research, Heidelberg University, Heidelberg, Germany.,Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany.,German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Ben Schöttker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Network Aging Research, Heidelberg University, Heidelberg, Germany
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Hupfer M, Gosch M. Anticoagulation in Very Old Patients with Atrial Fibrillation (AVOPA): A Descriptive Observational Study. Drugs Real World Outcomes 2021; 8:603-614. [PMID: 34115332 PMCID: PMC8605956 DOI: 10.1007/s40801-021-00263-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND In older patients with nonvalvular atrial fibrillation, oral anticoagulation is challenging, especially among very old patients. Even though positive effects of oral anticoagulation have been described in this age group (> 85 years), there is still a high rate of inappropriate dosing. OBJECTIVE This study examines the quality of care for very old hospitalized patients. The aims of this study were to (1) describe the percentage of patients receiving oral anticoagulation at discharge, (2) describe the quality of drug management at discharge, regarding dosing and contraindications, and (3) provide additional data towards establishing a benchmark for the quality of care in very old patients with atrial fibrillation. METHODS This study is a single-center descriptive observational study. The data from 407 patients aged > 85 years who were hospitalized in 2018 with nonvalvular atrial fibrillation were collected retrospectively from the patient charts. The assessment included specific geriatric aspects, such as falls, the Charlson Comorbidity Index, and nursing categorization. RESULTS During hospitalization, the proportion of anticoagulated patients increased from 57.5% (n = 234) to 67.3% (n = 274). We found an increasing trend in the use of direct oral anticoagulants, with an increase from 39.8% (n = 162) to 46.2% (n = 188). Regarding the quality of drug management, 13.8% (n = 56) of the patients were not anticoagulated even in the absence of a recognizable contraindication, whereas a contraindication was ignored in only 0.8% (n = 2 out of 188). Dosing was appropriate among all patients taking rivaroxaban, edoxaban, and dabigatran. The dose of apixaban was not reduced in 23.6% (n = 21 out of 89), although this dose reduction was necessary according to the dose adjustment criteria. An underdose of a direct oral anticoagulant was found in 26.1% of the patients (n = 49 out of 188). CONCLUSIONS Compared to the results reported in the literature, the percentage of very old patients with atrial fibrillation receiving anticoagulants was high. During hospitalization, the proportion of patients receiving a direct oral anticoagulant increased, which was in contrast to the trend in the proportion of patients taking phenprocoumon. Our results could help to find a benchmark for anticoagulation management among hospitalized very old patients.
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Affiliation(s)
- Maximilian Hupfer
- Faculty of Medicine, Paracelsus Medical University Nuremberg, General Hospital Nuremberg, Prof.-Ernst-Nathan-Str. 1, 90419, Nuremberg, Germany.
| | - Markus Gosch
- Faculty of Medicine, Paracelsus Medical University Nuremberg, General Hospital Nuremberg, Prof.-Ernst-Nathan-Str. 1, 90419, Nuremberg, Germany.,Department of Geriatrics, Paracelsus Medical University Nuremberg, General Hospital Nuremberg, Nuremberg, Germany
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Tkacheva ON, Vorobyeva NM, Kotovskaya YV, Runikhina NK, Strazhesco ID, Villevalde SV, Drapkina OM, Komarov AL, Orlova YA, Panchenko EP, Pogosova NV, Frolova EV, Yavelov IS. Antithrombotic therapy in the elderly and senile age: the consensus opinion of experts of the Russian Association of Gerontologists and Geriatricians and the National Society of Preventive Cardiology. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2021. [DOI: 10.15829/1728-8800-2021-2847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
В данном документе обсуждаются особенности АТТ у лиц пожилого и старческого возраста в различных клинических ситуациях.
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Farhat A, Al-Hajje A, Csajka C, Panchaud A. Clinical and economic impacts of explicit tools detecting prescribing errors: A systematic review. J Clin Pharm Ther 2021; 46:877-886. [PMID: 33765352 DOI: 10.1111/jcpt.13408] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/16/2021] [Accepted: 02/28/2021] [Indexed: 01/15/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Many explicit tools have been developed to reduce prescribing errors and ensure patients' safety. The impact of explicit tools is not well studied. The objective of this study was (a) to conduct a systematic review of systematic reviews listing explicit tools developed to detect prescribing errors and (b) to assess their impact on clinical and economic outcomes. METHODS This project includes two related parts. First, a systematic review of systematic reviews listing explicit tools dedicated to geriatrics or internal medicine was performed to develop an exhaustive list of explicit tools. Then, using the list compiled in the first step, a systematic review of randomized controlled trials (RCT) assessing clinical or economic impacts of tools was performed to evaluate their usefulness. RESULTS AND DISCUSSION The systematic review of systematic reviews identified 49 explicit tools. The systematic review of RCT, using one or more of the 49 explicit tools, identified 5 RCT using explicit tools as intervention (3 STOPP/START and 2 FORTA RCT). The 5 studies evaluated clinical impacts with 3 RCT identifying significant clinical impacts (falls, activities of daily living and/or adverse drug reactions) and 2 STOPP/START RCT identifying significant economic impacts. WHAT IS NEW AND CONCLUSION The systematic review of RCT showed that explicit tools can have some effect in improving patients' safety. Further studies are warranted to better characterize their clinical and economic impact.
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Affiliation(s)
- Akram Farhat
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva and University of Lausanne, Geneva, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Service of Pharmacy, Lausanne University Hospital, Lausanne, Switzerland
| | - Amal Al-Hajje
- Clinical and Epidemiological Research Laboratory, Faculty of Pharmacy, Lebanese University, Hadat, Lebanon
| | - Chantal Csajka
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva and University of Lausanne, Geneva, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Alice Panchaud
- Service of Pharmacy, Lausanne University Hospital, Lausanne, Switzerland
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Underprescription of medications in older adults: causes, consequences and solutions-a narrative review. Eur Geriatr Med 2021; 12:453-462. [PMID: 33709336 DOI: 10.1007/s41999-021-00471-x] [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: 11/21/2020] [Accepted: 02/10/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE Under-prescription is defined as the omission of a medication that is indicated for the treatment of a condition or a disease, without any valid reason for not prescribing it. The aim of this review is to provide an updated overview of under-prescription, summarizing the available evidence concerning its prevalence, causes, consequences and potential interventions to reduce it. METHODS A PubMed search was performed, using the following keywords: under-prescription; under-treatment; prescribing omission; older adults; polypharmacy; cardiovascular drugs; osteoporosis; anticoagulant. The list of articles was evaluated by two authors who selected the most relevant of them. The reference lists of retrieved articles were screened for additional pertinent studies. RESULTS Although several pharmacological therapies are safe and effective in older patients, under-prescription remains widespread in the older population, with a prevalence ranging from 22 to 70%. Several drugs are underused, including cardiovascular, oral anticoagulant and anti-osteoporotic drugs. Many factors are associated with under-prescription, e.g. multi-morbidity, polypharmacy, dementia, frailty, risk of adverse drug events, absence of specific clinical trials in older patients and economic factors. Under-prescription is associated with negative consequences, such as higher risk of cardiovascular events, worsening disability, hospitalization and death. The implementation of explicit criteria for under-prescription, the use of the comprehensive geriatric assessment by geriatricians, and the involvement of a clinical pharmacist seem to be promising options to reduce under-prescription. CONCLUSION Under-prescription remains widespread in the older population. Further studies should be performed, to provide a better comprehension of this phenomenon and to confirm the efficacy of corrective interventions.
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Pazan F, Wehling M. Polypharmacy in older adults: a narrative review of definitions, epidemiology and consequences. Eur Geriatr Med 2021; 12:443-452. [PMID: 33694123 PMCID: PMC8149355 DOI: 10.1007/s41999-021-00479-3] [Citation(s) in RCA: 117] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 02/25/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND The number of older adults has been constantly growing around the globe. Consequently, multimorbidity and related polypharmacy have become an increasing problem. In the absence of an accepted agreement on the definition of polypharmacy, data on its prevalence in various studies are not easily comparable. Besides, the evidence on the potential adverse clinical outcomes related to polypharmacy is limited though polypharmacy has been linked to numerous adverse clinical outcomes. This narrative review aims to find and summarize recent publications on definitions, epidemiology and clinical consequences of polypharmacy. METHODS The MEDLINE database was used to identify recent publications on the definition, prevalence and clinical consequences of polypharmacy using their respective common terms and their variations. Systematic reviews and original studies published between 2015 and 2020 were included. RESULTS One hundred and forty-three definitions of polypharmacy and associated terms were found. Most of them are numerical definitions. Its prevalence ranges from 4% among community-dwelling older people to over 96.5% in hospitalized patients. In addition, numerous adverse clinical outcomes were associated with polypharmacy. CONCLUSION The term polypharmacy is imprecise, and its definition is yet subject to an ongoing debate. The clinically oriented definitions of polypharmacy found in this review such as appropriate or necessary polypharmacy are more useful and relevant. Regardless of the definition, polypharmacy is highly prevalent in older adults, particularly in nursing home residents and hospitalized patients. Approaches to increase the appropriateness of polypharmacy can improve clinical outcomes in older adults.
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Affiliation(s)
- Farhad Pazan
- Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Ruprecht-Karls-Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Martin Wehling
- Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Ruprecht-Karls-Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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Abstract
INTRODUCTION Delirium is a frequent complication in hospitalised patients, often leading to difficulties in patient management and is associated with increased morbidity and mortality. Most patients in intensive care units develop delirium, however, it is also frequently observed in non-intensive care unit settings. Risk factors are, among others, older age, brain pathology, severe trauma, orthopaedic or heart surgery, metabolic or electrolyte dysregulations, infections and polypharmacy. The most important measures to prevent and treat delirium are recognition and removal of risk factors and causes. Although delirium is a very common and serious complication, evidence for pharmacological treatment is poor, and guidelines remain controversial. Accordingly, non-pharmacological treatments have gained increasing attention and should be applied. Based on current literature, guidelines and personal recommendations, we developed a standard operating procedure (SOP) encompassing non-pharmacological and pharmacological treatment of delirium. COMMENTS In order to prevent delirium, risk factors should be identified and taken into account when planning the hospital stay and treatment. Prevention should include multimodal non-pharmacological interventions. The treatment of delirium should encompass the elimination of potential causes and non-pharmacological interventions. Pharmacological treatment should be used in a time-limited manner and in the lowest possible dose for the management of highly stressful symptoms or high-risk behaviour. CONCLUSION The SOP provides a pragmatic algorithm for the non-pharmacological and pharmacological treatment of delirium.
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Affiliation(s)
- Juraj Kukolja
- Department of Neurology and Clinical Neurophysiology, Helios University Hospital Wuppertal, Heusnerstr. 40, 42283 Wuppertal, Germany
- Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany
- Medical Faculty, University of Cologne, 50937 Cologne, Germany
| | - Jens Kuhn
- Department of Psychiatry and Psychotherapy, Medical Faculty, University of Cologne, Cologne, Germany
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Johanniter Hospital Oberhausen, EVKLN, Steinbrinkstraße 96a, 46145 Oberhausen, Germany
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Bauer SH, Gronemeyer S. [Evidence of Improved Patient Safety in Germany]. DAS GESUNDHEITSWESEN 2021; 84:926-934. [PMID: 33607695 DOI: 10.1055/a-1335-4813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Since 2015, the requirement for data transparency has been met in Germany by publishing structured quality reports in licensed hospitals, but one of the main concerns of patients, namely treatment safety, has not been a prominent feature of these reports. Therefore, this study was undertaken to find out what examples of improved patient safety have been published in Germany in the last 10 years. A systematic literature search identified 10 studies which highlight the quantitatively measured success of 13 interventions.
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Affiliation(s)
- Susanne Helene Bauer
- Stabsbereich Qualität & Patientensicherheit, Medizinischer Dienst des Spitzenverbandes Bund der Krankenkassen eV, Essen, Deutschland
| | - Stefan Gronemeyer
- Stabsbereich Qualität & Patientensicherheit, Medizinischer Dienst des Spitzenverbandes Bund der Krankenkassen eV, Essen, Deutschland
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50
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Medication review and reconciliation in older adults. Eur Geriatr Med 2021; 12:499-507. [PMID: 33583002 DOI: 10.1007/s41999-021-00449-9] [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: 10/27/2020] [Accepted: 01/07/2021] [Indexed: 12/19/2022]
Abstract
Older people are frequently exposed to polypharmacy, inappropriate prescribing, and adverse drug events. Two clinical processes can help geriatricians to optimize and increase the safety of drug prescriptions for older adults: medication reconciliation and medication review. Medication reconciliation provides the best possible medication history and identifies and resolves discrepancies in drug prescriptions. During the medication review, the best possible medication history is crosschecked against other data, including morbidities, patient's preferences, or geriatric syndromes, to produce a personalized medication strategy. Alignment of treatment recommendations with patient preferences and goals through shared decision-making is particularly important in medication review. Medication reconciliation and medication review have proven to be effective, but their broad implementation remains difficult. Indeed, these procedures are time-consuming and require specific skills, coordination between different healthcare professionals, organizations and dedicated means. The involvement of geriatricians therefore remains essential for the successful implementation of medication reconciliation and medication review in geriatric settings and among frail older people.
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