Impact of potentially inappropriate psychotropic medicines on falls among older adults in 23 residential aged care facilities in Australia: a retrospective longitudinal cohort study

OBJECTIVE

Falling is common among older adults in residential aged care facilities (RACFs) and potential inappropriate psychotropic medicines (PIPMs) use may increase the risk of falling. This study aimed to determine the impact of PIPMs on falls using longitudinal observational data.

METHODS

A retrospective longitudinal cohort study was conducted using routinely collected electronic health data from 23 RACFs in Sydney, New South Wales, Australia. The study included 3064 permanent residents aged ≥65 (2020-2021). PIPMs were identified using updated Beers criteria 2023. We considered three fall outcome groups: all falls, injurious falls and falls requiring hospitalisation. The falls incidence rates (IRs) were calculated for overall residents in RACFs as well as for central nervous system (CNS)-PIPM users and non-users. We applied a zero-inflated negative binomial regression model to assess the association between falls and CNS-PIPMs.

RESULTS

A total of 40% (n=1224) of long-term care residents used at least one CNS-PIPM and 10% of residents (n=302) used two or more. The falls IRs of CNS-PIPM users were 16.2 falls per 1000 resident days (95% CI 15.9 to 16.5) for all falls, 5.68 falls per 1000 resident days (95% CI 5.48 to 5.88) for injurious falls and 1.77 falls per 1000 resident days (95% CI 1.66 to 1.88) for falls requiring hospitalisation, whereas the falls IRs of non-CNS-PIPM users were 10.8 falls per 1000 resident days (95% CI 10.6 to 11.0) for all falls, 3.65 falls per 1000 resident days (95% CI 3.52 to 3.78) for injurious falls and 1.26 falls per 1000 resident days (95% CI 1.19 to 1.33) for falls requiring hospitalisation. CNS-PIPM users had a significantly greater rate of falls overall compared with non-users (IRR 1.29; 95% CI 1.16 to 1.44) for all outcomes.

CONCLUSIONS

Falls are frequent among CNS-PIPM users resulting in injury and hospitalisation, with 70% of CNS-PIPM users falling at least once and one in three requiring admissions to hospital. Reviewing residents' use of psychotropic medicines should be considered as part of strategies to reduce falls incidence among older adults in RACFs.

Management of fall-risk-increasing drugs in Australian aged care residents: a retrospective cross-sectional study

BACKGROUND

Globally, falls are considered a serious healthcare problem for aged care residents. Fall-risk-increasing drugs (FRIDs) are medications that can increase the risk of falling, given their adverse effects. Medication reviews are advocated to identify potentially inappropriate use of FRIDs. However, their impact on clinical and resident-centered outcomes is unclear. This study explored aged care residents' use of FRIDs and the content of medication review reports concerning these.

METHODS

A retrospective cross-sectional study of medication review reports completed between 1st July 2021 and 30th June 2022 was conducted. Statistical descriptive analysis was used to examine the use of FRIDs (defined as medications listed in the Screening Tool of Older Persons Prescriptions in older adults with high fall risk (STOPPFall)). The resident's medicine experience, identified drug-related problems (DRPs), and related recommendations concerning FRIDs were explored via content analysis. For recommendations to deprescribe FRIDs, clinical situations detailed in the reports were compared to those presented in STOPPFall.

RESULTS

Medication review reports relating to 966 residents were analysed. Of these residents, 83.2% (n = 804) used FRIDs, with 31.2% (n = 301) taking three or more FRIDs. In total, pharmacists made recommendations concerning 2635 identified DRPs, of which 19.7% (n = 520) were the potentially inappropriate use of FRIDs and deprescribing was recommended. The clinical situation for which deprescribing was most frequently recommended was the use of a FRID for an indication of limited clinical benefit 37.9% (n = 197). The clinical situation was not detailed for 130 (25.0%) recommendations to deprescribe FRIDs, and only three reports included the resident's viewpoint on deprescribing.

CONCLUSIONS

FRID use was found to be highly prevalent among aged care residents. Pharmacists frequently identified opportunities to deprescribe FRIDs. However, reports often omitted resident viewpoints and the clinical grounds for deprescribing. Using resident-centered communication in medication review reports could improve their impact on FRID use and resident outcomes.

The influence of beliefs and health literacy on medication-related outcomes in older adults: A cross-sectional study

BACKGROUND

Older adults often manage multiple chronic diseases which necessitates the use of multiple medicines. Nevertheless, they also face an elevated risk of harm when medicines are used inappropriately. Studies indicate that socioeconomic disadvantage, beliefs, and health literacy may correlate with non-adherence and inappropriate medicine use. However, older adults are underrepresented in the current body of literature.

OBJECTIVE

To investigate the influence of beliefs and health literacy on medication-related outcomes in older adults.

METHODS

Participants ≥65 years living in the community were invited to complete a survey. Participants were asked to report demographics, medicines and complete three questionnaires: Self-Efficacy for Appropriate Medication use Scale (SEAMS), Beliefs about Medicines Questionnaire (BMQ) and Health Literacy Questionnaire (HLQ). Descriptive statistics, regressions and correlations were calculated.

RESULTS

A total of 154 participants were included in the analysis (35.7 % male, age range 65-110 y). Mean SEAMS score was 33.2 out of 39 (standard deviation (SD) = 8.0), reflecting high self-efficacy for adherence. Mean HLQ scores were high across the four scales measured in the survey (scales 1, 5, 6, and 9). Sixty-two participants (44.0 %) were using five or more medicines (polypharmacy) and 18 (15.4 %) reported use of a potentially inappropriate medicine. Regarding beliefs, mean BMQ-specific scores were as follows: necessity score 17.5 (SD = 5.1) and concern score 12.0 (SD = 4.0), indicating strong beliefs in the necessity of medicines and few concerns. Results of the regression analysis indicated that where the BMQ-Necessity scores were employed as the independent variable, there was statistical significance with polypharmacy (p < 0.001). Additionally, moderate positive correlations were identified between (1) necessity beliefs and both polypharmacy (r = 0.401, p < 0.001) and adherence (r = 0.477, p < 0.001), and (2) adherence and HLQ scale 5 (r = 0.343, p < 0.001), scale 6 (r = 0.326, p < 0.001) and scale 9 (r = 0.320, p < 0.001).

CONCLUSION

Older adults who perceive their medicines as necessary are more inclined to report use of multiple medicines, leading to polypharmacy. Additionally, older adults with stronger beliefs in the necessity of medicines and higher levels of health literacy demonstrate greater self-efficacy for adherence. Health professionals should consider evaluating necessity beliefs in older adults to manage potential non-adherence, reduce the risk of polypharmacy, and thereby mitigate the risk of suboptimal medicine use.

Best practice in dementia health care: Key clinical practice pointers from a national conference and innovative opportunities for pharmacy practice

OBJECTIVE

Sub-optimal care of people living with dementia has serious consequences for older populations. The 2021 Australian Royal Commission noted that a large proportion of older adults in aged care live with dementia, yet there are limitations in the knowledge and understanding of staff who care for them. In the pursuit of educating pharmacists, physicians, allied health care professionals, researchers, academics, people living with dementia and their carers, and the public, who are facing the challenges of dementia management, the 'Best Practice in Dementia Health Care' conference was held on November 10, 2022 at Western Health (Sunshine Hospital, Melbourne, Australia).

METHODS

Sixteen experts presented on the current practice and challenges associated with delivering best practice dementia health care to older Australians, often highlighting how medication-related challenges impacted on their area of practice.

RESULTS

Presenters highlighted the importance of individualised medication management plans, considerations of culture and Indigenous communities, the role of technology, and the impact of exercise and the physical environment on care of people living with dementia. Key clinical practice messages from each expert presenter fit into four main topics: 'navigating complexities of medication management'; 'enhancing wellbeing'; 'supportive settings and environments'; and 'programs and services improving care'.

CONCLUSIONS

Pharmacists are crucial members of allied health care teams. They have the necessary medication and comorbidity expertise to review medication regimens, liaise with all health care providers, and provide holistic, pharmacological and non-pharmacological patient education. Towards providing best practice dementia health care, pharmacists can contribute in several ways, such as providing health practitioner education to increase understanding about medications and how they can impact on allied health practice, to ensure that medications are prescribed appropriately and safely. Further, pharmacists can make available resources to ensure people living with dementia receive culturally safe and appropriate care, while advocating for greater understanding of the history and experiences of people living with dementia to ensure care aligns with their day-to-day routines. Finally, pharmacists can provide peer-support to other health care professionals and care staff to ensure optimal management of behavioural and psychological symptoms of dementia. The information and insights shared at the conference can serve as a valuable resource for pharmacists and other health care professionals and researchers working to improve the lives of those living with dementia.

Development of a list of Australian potentially inappropriate medicines using the Delphi technique

BACKGROUND

Older people are at high risk of medicines-related harms. otentially inappropriate medicines (PIMs) list has been developed to assist clinicians and researchers to identify medicines with risks that may potentially outweigh their benefits in order to improve medication management and safety.

AIM

To develop a list of PIMs for older people specific to Australia.

METHODS

The study obtained expert consensus through the utilisation of the Delphi technique in Australia. A total of 33 experts partook in the initial round, while 32 experts engaged in the subsequent round. The primary outcomes encompass medicines assessed as potentially inappropriate, the specific contexts in which their inappropriateness arises and potentially safer alternatives.

RESULTS

A total of 16 medicines or medicine classes had one or more medicines deemed as potentially inappropriate in older people. Up to 19 medicines or medicine classes had specific conditions that make them more potentially inappropriate, while alternatives were suggested for 16 medicines or classes.

CONCLUSION

An explicit PIMs list for older people living in Australia has been developed containing 19 drugs/drug classes. The PIMs list is intended to be used as a guide for clinicians when assessing medication appropriateness in older people in Australian clinical settings and does not substitute individualised treatment advice from clinicians.

Longitudinal effects of using and discontinuing central nervous system medications on cognitive functioning

PURPOSE

To investigate the longitudinal effect of using and discontinuing central nervous system (CNS) medications on cognitive performance.

METHODS

Using longitudinal cognitive data from population representative adults aged 25-100 years (N = 2188) from four test waves 5 years apart, we investigated both the link between use of CNS medications (opioids, anxiolytics, hypnotics and sedatives) on cognitive task performance (episodic memory, semantic memory, visuospatial ability) across 15 years, and the effect of discontinuing these medications in linear mixed effects models.

RESULTS

We found that opioid use was associated with decline in visuospatial ability whereas using anxiolytics, hypnotics and sedatives was not associated with cognitive decline over 15 years. A link between drug discontinuation and cognitive improvement was seen for opioids as well as for anxiolytics, hypnotics and sedatives.

CONCLUSIONS

Although our results may be confounded by subjacent conditions, they suggest that long-term use of CNS medications may have domain-specific negative effects on cognitive performance over time, whereas the discontinuation of these medications may partly reverse these effects. These results open up for future studies that address subjacent conditions on cognition to develop a more complete understanding of the cognitive effects of CNS medications.

Automatic breast lesion segmentation in phase preserved DCE-MRIs

We offer a framework for automatically and accurately segmenting breast lesions from Dynamic Contrast Enhanced (DCE) MRI in this paper. The framework is built using max flow and min cut problems in the continuous domain over phase preserved denoised images. Three stages are required to complete the proposed approach. First, post-contrast and pre-contrast images are subtracted, followed by image registrations that benefit to enhancing lesion areas. Second, a phase preserved denoising and pixel-wise adaptive Wiener filtering technique is used, followed by max flow and min cut problems in a continuous domain. A denoising mechanism clears the noise in the images by preserving useful and detailed features such as edges. Then, lesion detection is performed using continuous max flow. Finally, a morphological operation is used as a post-processing step to further delineate the obtained results. A series of qualitative and quantitative trials employing nine performance metrics on 21 cases with two different MR image resolutions were used to verify the effectiveness of the proposed method. Performance results demonstrate the quality of segmentation obtained from the proposed method.

Fall-Risk-Increasing Drugs in People With Dementia Who Live in a Residential Aged Care Facility: A Pilot Study

Background 

Psychotropic medications feature in prescribing guidelines for the treatment of depression in dementia as well as the management of behavioural and psychological symptoms of dementia (BPSD). They include antidepressants, antipsychotics, and benzodiazepines, and are among an established collective of pharmacotherapies known as fall-risk-increasing drugs (FRIDs). These psychoactive medications are known to increase fall risk in elderly adults, including those with a dementia diagnosis. Medication reviews are an integral part of falls prevention programs in residential aged care and provide an opportunity to modify medications to reduce fall risk related to pharmacotherapy.

Objectives 

This pilot study explores the characteristics of a group of elderly people with dementia living in residential care with a focus on patterns of falls and usage of psychotropic medications.

Methods 

This is a retrospective study conducted using data collected from health records. The Neuroscience-based Nomenclature (NbN) classification of psychotropic medicines is employed to highlight relevant pharmacological domains targeted by the medications rather than traditional drug classes.

Results 

Four pharmacological neurotransmitter domains emerged as key players in the pharmacotherapy of study participants. These were serotonin, dopamine, noradrenaline, and gamma-aminobutyric acid A (GABA-A). Serotonin was the most frequently implicated domain as related to observed usage of psychotropic treatments for depression and BPSD. Over the retrospective study period, 75% of participants were taking prescribed psychotropics known to target these four domains, and most (69.4%) were elderly women over the age of 80. Many participants experienced multiple falls, mostly among women, and most falls were rated as harmful to some degree.

Conclusion 

This study observes recurrent falls and frequent usage of psychoactive drugs in elderly people with dementia. We conclude that further investigations are both warranted to support prescribing guidelines for dementia and feasible according to the methodology of this pilot study.

Applicability of explicit potentially inappropriate medication lists to the Australian context: A systematic review

OBJECTIVES

To determine i) the similarity of potentially inappropriate medications specified in and between existing explicit lists and ii) the availability in Australia of medications included on existing lists to determine their applicability to the Australian context.

METHODS

This systematic review identified explicit potentially inappropriate medication lists that were published on EMBASE (1974 - April 2021), MEDLINE (1946 - April 2021) and Elsevier Scopus (2004 - April 2021). The reference lists of seven previously published systematic reviews were also manually reviewed. Lists were included if they were explicit, and the most recent version and the complete list were published in English. Lists based on existing lists were excluded if no new items were added. Potentially inappropriate medications identified on each list were extracted and compared to the medications available on the Australian Register of Therapeutic Goods and Australian Pharmaceutical Benefits Schemes.

RESULTS

Thirty-five explicit published lists were identified. A total of 645 unique potentially inappropriate medications were extracted, of which 416 (64%) were available in Australia and 262 (41%) were subsided by the general Pharmaceutical Benefits Scheme. Applicability of each explicit list ranged from 50-96% according to medications available in Australia and 25-83% according to medications available under subsidy.

CONCLUSIONS

Pooling data from different lists may help to identify potentially inappropriate medications that may be applicable to local settings. However, if selecting a list for use in the Australian context, consideration should also be given to the intended purpose and setting for application.

Medication-related hospital admissions in aged care residents

OBJECTIVE

To determine the prevalence of medication-related hospitalisations preceded by potentially suboptimal processes of care in aged care residents.

METHOD

We conducted a retrospective analysis of administrative claims data from the Australian Government Department of Veterans' Affairs (DVA). We identified all hospital admissions for aged care residents between 1 July 2014 and 30 June 2019. The proportion of hospital admissions preceded by potentially suboptimal medication-related processes of care was determined.

RESULTS

A total of 18 874 hospitalisations were included, and 46% were preceded by potentially suboptimal medication-related care. One-quarter of fracture admissions occurred in residents at risk of fracture who were not using a medicine to prevent fracture, and 87% occurred in residents using falls-risk medicines. Thirty per cent of heart failure admissions occurred in patients who were not using an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker.

CONCLUSION

Nearly half of hospital admissions were preceded by potentially suboptimal medication-related processes of care. Interventions to improve use of medicines for aged care residents in these areas are warranted.

The FRAIL-NH Scale: Systematic Review of the Use, Validity and Adaptations for Frailty Screening in Nursing Homes

OBJECTIVES

To investigate frailty prevalence, cross-sectional associations, predictive validity, concurrent validity, and cross-cultural adaptations of the FRAIL-NH scale.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Frail residents living in nursing homes.

METHODS

MEDLINE, EMBASE, CINAHL, and Cochrane Library were searched from January 2015 to June 2021 for primary studies that used the FRAIL-NH scale, irrespective of study designs and publication language.

RESULTS

Overall, 40 studies conducted across 20 countries utilized the FRAIL-NH scale; majority in Australia (n=14), followed by China (n=6), United States (n=3), and Spain (n=3). The scale has been translated and back-translated into Brazilian Portuguese, Chinese, and Japanese. Various cut-offs have been used, with ≥2 and ≥6 being the most common cut-offs for frail and most frail, respectively. When defined using these cut-offs, frailty prevalence varied from 15.1-79.5% (frail) to 28.5-75.0% (most frail). FRAIL-NH predicted falls (n=2), hospitalization or length of stay (n=4), functional or cognitive decline (n=4), and mortality (n=9) over a median follow-up of 12 months. FRAIL-NH has been compared to 16 other scales, and was correlated with Fried's phenotype (FP), Frailty Index (FI), and FI-Lab. Four studies reported fair-to-moderate agreements between FRAIL-NH and FI, FP, and the Comprehensive Geriatric Assessment. Ten studies assessed the sensitivity and specificity of different FRAIL-NH cut-offs, with ≥8 having the highest sensitivity (94.1%) and specificity (82.8%) for classifying residents as frail based on FI, while two studies reported an optimal cut-off of ≥2 based on FI and FP, respectively.

CONCLUSION

In seven years, the FRAIL-NH scale has been applied in 20 countries and adapted into three languages. Despite being applied with a range of cut-offs, FRAIL-NH was associated with higher care needs and demonstrated good agreement with other well-established but more complex scales. FRAIL-NH was predictive of adverse outcomes across different settings, highlighting its value in guiding care for frail residents in nursing homes.