Identifying and addressing drug-related problems in nursing homes: an unmet need in Malaysia?

Are pharmacists' knowledge and practice the key to promoting deprescribing of potentially inappropriate medication: a missing link between treatment and outcomes

OBJECTIVES

Deprescribing is a novel strategy whereby medical professionals aim to optimize a patient's prescription program by removing redundant medications. Few studies have looked at the viewpoints of community pharmacists and other healthcare professionals on deprescribing in daily practice. This study's objectives included evaluating community pharmacists' deprescribing knowledge, attitudes and practices, as well as identifying the obstacles to and enablers of deprescribing in daily practice.

METHODS

Five pharmacy students in the last year of their studies polled employees of neighbourhood pharmacies in Abu Dhabi, Dubai, and the Northern Emirates from April 2022 to July 2022. The study's questionnaire was divided into two sections: questions that inquired about the respondents' demographic data and questions that evaluated the respondents' understanding and usage of the deprescribing of potentially harmful medications for patients. The original Bloom's cutoff points were revised and modified to assess the general knowledge and deprescribing practices of United Arab Emirates (UAE) community pharmacists. Multivariate logistic regression identified the variables influencing respondents' deprescribing knowledge and practice.

KEY FINDINGS

The average age of the participants was 30.8 ± 6.4 SD. Of the total, 255 (37.7%) were male and 422 (62.3%) were female. Pharmacists from independent pharmacies constituted 52.9% of the study sample and 47.1% were from Chain pharmacies. Among the participants, 58.8% (n = 398) had 1-5 years of experience and 41.2% (n = 279) had more than 5 years. Nearly three-quarters of the pharmacists (72.1%, 488) graduated from local universities and 27.9% (n = 189) graduated from regional/international universities. The vast majority of the study sample (84.8%, 574) were bachelor's degree holders and 88.3% (n = 598) were pharmacists in charge. Of the total, 69.3% (n = 469) received deprescribing training to treat patients with multimorbid diseases. The knowledge and practice score was 71.3% with a 95% confidence interval [70.2%, 72.4%]. Of the total participants, 113 (16.7%) had poor knowledge and practice about deprescribing, 393 (58.1%) had moderate knowledge and practice and 171 (25.3%) had good knowledge and practice.

CONCLUSION

This study highlights the level of understanding of community pharmacists about deprescribing in the UAE. Although most of the respondents in this study received training on deprescribing, less than half of the community pharmacists were unaware of certain classes (long-acting sulfonylureas, anti-diabetic, antihyperlipidemic and psychotropic drugs) of drugs that are candidates for potential deprescribing. This finding indicates that their knowledge about deprescribing was insufficient. Several barriers community pharmacists face in deprescribing were also identified, with patients' resistance and insufficience being the most prevalent. Therefore, there is a need for improved deprescribing practices to ensure drug safety.

Medication use problems among older adults at a primary care: A narrative of literature review

Appropriate medication use is one of the most significant challenges among the older population. Although medication use problems are well documented at the secondary and tertiary health care level, the evidence at the primary care level of OECD region is limited. A narrative review of existing literature was conducted through a nonsystematic search for original articles through electronic search databases, Ovid Medline, Google Scholar from 2001 to 2021, and a combination of citation references. Medication use problems are prevalent in older adults at the primary care level. The main issues of medication use identified were as follows; nonadherence, adverse drug events, accessibility, polypharmacy, inappropriate medications, belief about medications, lack of knowledge and awareness, and lack of deprescribing. In addition, the current review has identified the possibilities of the problems: many medications, forgetfulness, lack of deprescribing, lack of communication, poor understanding, and limited awareness of inappropriate medications. This review found that various medication use problems subclusters were identified to impact the health care need among older adults. Therefore, effective interventions targeting these issues need to be developed to reduce medication use problems among older adults at a primary care level.

How Willing Are Patients or Their Caregivers to Deprescribe: a Systematic Review and Meta-analysis

BACKGROUND

Polypharmacy is associated with the increased use of potentially inappropriate medications, where the risks of medicine use outweigh its benefits. Stopping medicines (deprescribing) that are no longer needed can be beneficial to reduce the risk of adverse events. We summarized the willingness of patients and their caregivers towards deprescribing.

METHODS

A systematic search was conducted in four databases from inception until April 30, 2021 as well as search of citation of included articles. Studies that reported patients' and/or their caregivers' attitude towards deprescribing quantitatively were included. All studies were independently screened, reviewed, and data extracted in duplicates. Patients and caregivers willingness to deprescribe their regular medication was pooled using random effects meta-analysis of proportions.

RESULTS

Twenty-nine unique studies involving 11,049 participants were included. All studies focused on the attitude of the patients towards deprescribing, and 7 studies included caregivers' perspective. Overall, 87.6% (95% CI: 83.3 to 91.4%) patients were willing to deprescribe their medication, based upon the doctors' suggestions. This was lower among caregivers, with only 74.8% (49.8% to 93.8%) willing to deprescribe their care recipients' medications. Patients' or caregivers' willingness to deprescribe were not influenced by study location, study population, or the number of medications they took.

DISCUSSION

Most patients and their caregivers were willing to deprescribe their medications, whenever possible and thus should be offered a trial of deprescribing. Nevertheless, as these tools have a poor predictive ability, patients and their caregivers should be engaged during the deprescribing process to ensure that the values and opinions are heard, which would ultimately improve patient safety. In terms of limitation, as not all studies may published the methods and results of measurement they used, this may impact the methodological quality and thus our findings. OPEN SCIENCE FRAMEWORK REGISTRATION: https:// osf.io/fhg94.

Pharmacist-led intervention on chronic pain management: A systematic review and meta-analysis

AIMS

Pharmacists have been contributing to the management of chronic pain, ensuring the quality use of medicine. However, there is diversity in the interventions provided by pharmacists and their impact.

METHODS

Six electronic databases were searched from inception until June 2020 for articles published in English examining the intervention provided by the pharmacist in chronic pain management. Studies investigating the impact of pharmacist intervention individually or multidisciplinary teams including pharmacists for chronic pain management were included.

RESULTS

Fourteen studies (2365 participants) were included in the current review. Six studies were randomized controlled trials while the remainder were observational studies in which pharmacists provided intervention individually or in collaboration with other healthcare professionals. Medication review was the most common intervention provided by the pharmacist. The pooled analysis found that pharmacist-led interventions reduced the pain intensity (-0.22; 95% confidence interval [CI]: -0.35 to -0.09; moderate certainty) among participants with chronic pain. Opiate stewardship provided by pharmacists was effective; however, mixed results were noted on the impact of the intervention on physical functioning, anxiety, depression and quality of life. Pharmacist intervention was more expensive than treatment as usual.

CONCLUSIONS

Pharmacists contribute substantially to chronic pain management, ensuring the quality use of medicine, resulting in reduced pain intensity. Further studies with rigorous design are needed to measure the impact of pharmacist-provided intervention individually or in a multidisciplinary team on the economic benefit and other health outcomes.

"Suiting Up" to Enhance Empathy Toward Aging: A Randomized Controlled Study

Background: Healthcare professionals who have a positive attitude and who are more empathetic toward older adults are in a better position to deliver quality healthcare. This study examines the impact of using an aging simulation suit on undergraduate pharmacy students' empathy levels. Methods: One hundred and twenty first-year students enrolled in the Bachelor of Pharmacy course were randomized to either a medication review polypharmacy workshop (control) or an immersive aging simulation suit and medication review polypharmacy workshop (intervention). Intervention participants donned the aging suit and performed a series of tasks, including walking up a flight of stairs and filling up a form to simulate the physical limitations experienced by an older adult. The workshop was delivered at week 10 of semester. Both groups also completed a medication review polypharmacy workshop at week 12 of semester. The primary outcome was a measurement of change on the Jefferson Empathy Scale-Healthcare Professional Questionnaire among both groups at week 12 of semester. Secondary outcomes include the longitudinal impact of intervention after 3 months of the workshop and perceptions on learning. Results: The use of a simulation suit did not increase participants' self-rated empathy compared to control. However, the suit enhanced the ability of participants to understand the physical limitations and visual issues associated with aging. Participants also felt that it enhanced their health advocacy, as it taught them the importance of listening, patience and respect for older adults. Conclusion: The use of an immersive aging suit can be a useful adjunctive tool to help enhance students' understanding of the physical limitations and visual limitations of aging. Further research is needed to understand how these limitations affect other healthcare students. Trial Registration: ClinicalTrials.gov identifier: NCT04133727.

Pharmacist services in nursing homes: A systematic review and meta-analysis

AIMS

Pharmacists have been contributing to the care of residents in nursing homes and play a significant role in ensuring quality use of medicine. However, the changing role of pharmacist in nursing homes and their impact on residents is relatively unknown.

METHODS

Six electronic databases were searched from inception until November 2018 for articles published in English examining the services offered by pharmacists in nursing homes. Studies were included if it examined the impact of interventions by pharmacists to improve the quality use of medicine in nursing homes.

RESULTS

Fifty-two studies (30 376 residents) were included in the current review. Thirteen studies were randomised controlled studies, while the remainder were either pre-post, retrospective or case-control studies where pharmacists provided services such as clinical medication review in collaboration with other healthcare professionals as well as staff education. Pooled analysis found that pharmacist-led services reduced the mean number of falls (-0.50; 95% confidence interval: -0.79 to -0.21) among residents in nursing homes. Mixed results were noted on the impact of pharmacists' services on mortality, hospitalisation and admission rates among residents. The potential financial savings of such services have not been formally evaluated by any studies thus far. The strength of evidence was moderate for the outcomes of mortality and number of fallers.

CONCLUSION

Pharmacists contribute substantially to patient care in nursing homes, ensuring quality use of medication, resulting in reduced fall rates. Further studies with rigorous design are needed to measure the impact of pharmacist services on the economic benefits and other patient health outcomes.

Perspectives of health professionals towards deprescribing practice in Asian nursing homes: a qualitative interview study

OBJECTIVE

To examine the determinants of deprescribing among health professionals in nursing homes, focusing on knowledge, practice and attitude.

DESIGN

This was a qualitative study comprising semi-structured face-to-face interviews guided by 10 open-ended questions. Interviews were conducted until data saturation was achieved and no new ideas were formed. The interviews were audio-recorded, transcribed verbatim and analysed for themes. To derive themes, we employed directed content analysis of transcript data. Coding was completed using a combination of open, axial and selective coding.

SETTING

Four nursing homes in Singapore.

PARTICIPANTS

The study involved 17 participants (comprising 4 doctors, 4 pharmacists and 9 nurses).

RESULTS

Two key themes were identified, enablers and challenges. These were enablers and challenges faced by doctors, pharmacists and nurses towards deprescribing. The identified subthemes for enablers of deprescribing were: (1) awareness of medications that are unnecessary or could be targeted for deprescribing; (2) improving quality of life for patients with limited life expectancy; (3) improving communication between doctors, pharmacists and nurses; (4) systematic deprescribing practice and educational tools and (5) acknowledgement of possible benefits of deprescribing. The identified subthemes for challenges of deprescribing were: (1) symptoms not acknowledged as possibly drug-related; (2) lack of knowledge in patient's and family members' preferences; (3) lack of coordination between health professionals in hospitals and nursing homes and (4) limited tools for deprescribing. The development of a local guideline, mentoring nurses, case discussions, better shared decision-making and improving multidisciplinary communication, may help to support the process of deprescribing.

CONCLUSION

In conclusion, this study highlighted that deprescribing in the nursing homes is perceived by health professionals to be challenging and future research could assess how routine case studies, mentoring and better multidisciplinary communication could improve deprescribing knowledge and process in the nursing homes.

Prevalence of potentially inappropriate medications among geriatric residents in nursing care homes in Malaysia: a cross-sectional study

Background Polypharmacy has been associated with an increased risk of morbidity and mortality among older adults especially those living in nursing homes. Explicit criteria to evaluate the appropriateness of medications have recently been updated. Objective To estimate and compare the prevalence of potentially inappropriate medications (PIMs) among older adults in nursing homes using screening tool for older people's prescription (STOPP-2) and the 2015 Beers criteria. Setting Nursing care homes in the Klang Valley, Malaysia. Method A cross-sectional survey of medications used among residents living in nursing homes was performed. The 2015 Beers criteria and STOPP-2 criteria were used to evaluate the use of PIMs among this population. These PIMs were subsequently classified using the Pharmaceutical Network Europe classification (PCNE). Main outcome measure Number of PIMs among residents using both criteria. Results A total of 155 residents were recruited into the study. The prevalence of PIMs was 9.7% using the STOPP-2 criteria, 17.6% using the 2015 Beers criteria and 21.3% when both tools were used in combination. The PCNE criteria identified a total of 198 drug related issues, with an average of 1.27 issue per resident. Factors associated with higher risk of having PIM include multiple medication use and history of psychiatric disorder. Conclusion The 2015 Beers criteria was able to identify more PIM's compared to STOPP-2 criteria. The findings also support the expansion of pharmacists' services in nursing homes in Malaysia.

Attitudes towards deprescribing among multi-ethnic community-dwelling older patients and caregivers in Malaysia: a cross-sectional questionnaire study

Background Deprescribing describes a process of medication regimen optimization with the aim to reduce adverse events and improve quality of life. There is limited research on perceptions of older adults, defined as those 60 years of age and older, about their willingness to cease a medication in developing countries. Objective To ascertain patients' attitudes, beliefs, perceptions, and experiences regarding the number of medications they were taking and their opinions regarding deprescribing. Setting A primary care health clinic and three community pharmacies in Malaysia. Method A multicenter cross-sectional study was conducted by administering the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire to older adults aged 60 years and over or caregivers attending a health clinic and three community pharmacies in Malaysia. Descriptive results were reported for participants' characteristics and questionnaire responses. Analysis of correlation between participant characteristics and their responses was performed using Spearman's correlation. Main outcome measure Patients' and caregivers' attitudes and beliefs towards reducing medications and characteristics of patients such as age, gender, education level, number of medication taken and number of medical center managing the patient. Results 650 participants were approached and the response rate was 85.2%. A total of 554 participants completed the questionnaire (502 older adults and 52 caregivers). Older adults in the study were taking a median of three medications and/or supplements compared to four in caregiver recipients. 88.1% of older adults were satisfied with their current medication regimen and 67.7% would like to try stopping or reducing the dose of their medicines when their doctor recommended. 82.7% of caregivers were satisfied with their care recipient's current medications and 65.4% were willing to stop taking or reduce the number of drugs taken by their care recipient's upon doctor's recommendation. Older adults (p = 0.003) and those with lower education level (p < 0.001) were more willing to have their medications deprescribed. Other demographic characteristics such as gender, number of medication taken or number of doctors managing patient were not found to be correlated with willingness to stop a medication. Conclusion Older adults taking multiple medications for various medical conditions were largely accepting of a trial of cessation of medication.

Pharmacy student-led health education campaign initiative

BACKGROUND AND PURPOSE

To describe the development and assessment of a health education campaign and determine its potential for integration into a bachelor of pharmacy curriculum.

EDUCATIONAL ACTIVITY AND SETTING

Pharmacy students developed a "hands-on" health campaign for delivery to university students. A health promotion topic was chosen and delivered each year for 2015-2017; sexual health, diabetes, and antimicrobial resistance, respectively. All health campaign participants were screened for cardiovascular risk factors. University students who participated in the health campaign in 2017 also completed a questionnaire assessing their understanding and knowledge of antimicrobial resistance.

FINDINGS

In the three health campaigns conducted from 2015 to 2017, 1010 university students and adults were screened. Pharmacy students expressed a high level of professional achievement and satisfaction and felt that the activities provided a meaningful learning experience. Similarly, supervising pharmacists reported satisfaction with students' competency.

SUMMARY

The use of a health education campaign is an alternative model to educate pharmacy students on communication and critical thinking skills, as well as provide an opportunity for service learning.

A practical approach toward teaching ethics to community pharmacists

Background Pharmacists as highly qualified professionals face ethical dilemmas and conflicts in their daily practice. These issues manifest themselves in the daily practice of pharmacists, which require pharmacists to have the competencies to manage these dilemmas but there is limited formal training in ethical decision making during undergraduate pharmacy education. Objective To describe the implementation and evaluation of a methodological approach to managing ethical dilemma workshop for community pharmacists in Malaysia. Setting Community pharmacists in Klang Valley, Malaysia. Method During the workshop, pharmacists were provided insights into how they could use and apply a methodological approach towards managing a dilemma, followed by a case study and panel discussion. All participants were invited to complete a pre- and post-workshop questionnaire Main outcome measure Number and proportion of respondents answering questions related to practice of ethics and workshop effectiveness Results A total of 37 participants attended the workshop. Most of the participants reported that they had no formal training in professional ethics and often used their own approach to solve an ethical issue. Some of the most common issues mentioned include changing medication to generic. More than three quarter of participants agreed and strongly agreed the content was relevant to their job and they will be able to use what they learned in the program. Conclusion The evidence suggests that a module in ethical decision making should be introduced to community pharmacists in Malaysia. This module can be easily adapted for use in other countries and will help ensure that pharmacist can make a good professional judgement and deliver the deeds of beneficence to all their patients.

Nursing home team-care deprescribing study: a stepped-wedge randomised controlled trial protocol

INTRODUCTION

An ageing population has become an urgent concern for Asia in recent times. In nursing homes, polypharmacy has also become a compounding issue. Deprescribing practice is an evidence-based strategy to provide a better outcome in this group of patients; however, its implementation in nursing homes is often challenging, and prospective outcome data on deprescribing practice in the elderly is lacking. Our study assesses the implementation of team-care deprescribing to understand the benefits of this practice in geriatric setting and to explore the factors affecting deprescribing practice.

METHODS AND ANALYSIS

This multicentre prospective study consists of a prestudy interview questionnaire, and a preintervention and postintervention study to be conducted in the nursing home setting on residents at least 65 years old and on five or more medications. We will employ a cluster randomised stepped-wedge interventional design, based on a five-step (reviewing, checking, discussion, communication and documentation) team-care deprescribing practice coupled with the use of a deprescribing guide (consisting of Beers and STOPP criteria, as well as drug interaction checking), to assess the health and pharmacoeconomic outcome in nursing homes' practice. Primary outcome measures of the intervention will consist of fall risks using a fall risk assessment tool. Other outcomes assessed include fall rates, pill burden including number of pills per day, number of doses per day and number of medications prescribed. Cost-related measures will include the use of cost-benefit analysis, which is calculated from the medication cost savings from deprescribing. For the prestudy interview questionnaire, findings will be analysed qualitatively using thematic analysis.

ETHICS AND DISSEMINATION

This study is approved by the Domain Specific Review Board of National Healthcare Group, Singapore (2016/00422) and Monash University Human Research Ethics Committee (2016-1430-7791). The study findings shall be disseminated in international conferences and peer-reviewed publications. The study is registered with ClinicalTrials.gov (NCT02863341), Pre-results.