Effect of treatment gaps in elderly patients with dementia treated with cholinesterase inhibitors

Risk for Health Events After Deprescribing Acetylcholinesterase Inhibitors in Nursing Home Residents With Severe Dementia

BACKGROUND/OBJECTIVE

Reevaluation of the appropriateness of acetylcholinesterase inhibitors (AChEIs) is recommended in older adults with severe dementia, given the lack of strong evidence to support their continued effectiveness and risk for medication-induced adverse events. We sought to evaluate the impact of deprescribing AChEIs on risk of all-cause events (hospitalizations, emergency department visits, and mortality) and serious falls or fractures in older nursing home (NH) residents with severe dementia.

DESIGN

Analysis of 2015 to 2016 data from Medicare claims, Part D prescriptions, Minimum Data Set (MDS) version 3.0, Area Health Resource File, and Nursing Home Compare. Marginal structural models with inverse probability of treatment weights were used to evaluate the association of deprescribing AChEIs and all-cause negative events as well as serious falls or fractures.

SETTING

US Medicare-certified NHs.

PARTICIPANTS

Nonskilled NH residents, aged 65 years and older, with severe dementia receiving AChEIs within the first 14 days of an MDS assessment in 2016 (n = 37 106).

RESULTS

The sample was primarily white (78.7%), female (75.5%), and aged 80 years or older (77.4%). Deprescribing AChEIs was associated with an increased likelihood of all-cause negative events in unadjusted models (odds ratio [OR] = 1.17; 95% confidence interval [CI] = 1.11-1.23; P < .01), but not in fully adjusted models (adjusted OR [aOR] = 1.00; 95% CI = 0.94-1.06; P = .94). By contrast, deprescribing was associated with a reduced likelihood of serious falls or fractures in unadjusted models (OR = 0.59; 95% CI = 0.52-0.66; P < .001) and remained significant in adjusted models (aOR = 0.64; 95% CI = 0.56-0.73; P < .001).

CONCLUSION

Deprescribing AChEIs was not associated with a significant increase in the likelihood for all-cause negative events and was associated with a reduced likelihood of falls and fractures in older NH residents with dementia. Our findings suggest that deprescribing AChEIs is a reasonable approach to reduce the risk of serious falls or fractures without increasing the risk for all-cause events. J Am Geriatr Soc 68:699-707, 2020.

Effect of drug compliance on health care costs in newly-diagnosed dementia: Analysis of nationwide population-based data

BACKGROUND

The cost-effectiveness of both cholinesterase inhibitors and memantine by delaying nursing home placement has been supported by numerous studies. The importance of sustained pharmacological treatment in dementia has been relatively less recognized by public health policies compared to early diagnosis. We investigated the effect of the drug (donepezil, rivastigmine, galantamine, and memantine) compliance on the health care costs in newly-diagnosed dementia.

METHODS

National Health Insurance Service (NHIS) database which covers the entire population of South Korea was used for analysis. Health care expenditure of patients newly-diagnosed with dementia in between 2012 and 2014 was investigated for 3-5 years. For drug compliance, we used Medication Possession Ratio (MPR) that indicates the percentage of time a patient has access to medication. Multivariate linear regression analysis including generalized estimated equation and gamma distribution was used for statistical analysis.

RESULTS

We identified 252,594 patients who were both prescribed with cognitive enhancers and newly diagnosed with dementia. When initial MPR increased 20%, total health care costs decreased 8.4% (RR = 0.916, 95%; CI 0.914 to 0.916). Same relationship was shown with medical costs related to dementia, admission to a general hospital, and emergency room visits. When MPR increased 20% compared to the previous year, the total health care costs, admission to a general hospital, emergency room visits, and admission to a nursing hospital decreased.

CONCLUSIONS

This population-based retrospective cohort study provides evidence that patients newly-diagnosed with dementia who showed higher initial drug compliance or maintained antidementia drugs (Cholinesterase inhibitors and memantine) would benefit in total health-care costs.

Compliance and persistence with Alzheimer's disease treatment: a retrospective analysis of multiregional hospital databases in Thailand

Aims: Due to the lack of studies evaluating compliance or persistence with Alzheimer's Disease (AD) treatment outside High-Income Countries (HICs), this study aimed to assess compliance, persistence, and factors associated with non-compliance and non-persistence by utilizing existing "real-world" information from multiregional hospital databases in Thailand.Materials and methods: Study subjects were retrospectively identified from databases of five hospitals located in different regions across Thailand. AD patients aged ≥60 years who were newly-prescribed with donepezil, galantamine, rivastigmine, or memantine between 2013 and 2017 were eligible for analysis. The Medication Possession Ratio (MPR) was used as a proxy for compliance, while the Kaplan-Meier survival analysis was employed to estimate persistence. Logistic and Cox regressions were used to assess determinants of non-compliance and non-persistence, adjusted for age and gender.Results: Among 698 eligible patients, mean (SD) MPR was 0.83 (0.25), with 70.3% of the patients compliant to the treatment (having MPR ≥ 0.80). Half of the patients discontinued their treatment (having a treatment gap >30 days) within 177 days with a 1-year persistence probability of 21.1%. The patients treated in the university-affiliated hospital were more likely to be both non-compliant (OR = 1.71; 95% CI = 1.21-2.42) and non-persistent (HR = 1.33; 95% CI = 1.12-1.58). In addition, non-compliance was higher for those prescribed with single AD treatment (OR = 2.52; 95% CI = 1.35-4.69), while non-persistence was higher for those unable to reimburse for AD treatment (HR = 1.34; 95% CI = 1.11-1.62).Limitations: By using retrospective databases, a difficulty in validating whether the medications are actually taken after being refilled may over-estimate the levels of compliance and persistence. Meanwhile, possible random coding errors may under-estimate the strength of association findings.Conclusions: This study reveals the situation of compliance and persistence on AD treatment for the first time outside HICs. The determinants of non-compliance and non-persistence underline key areas for improvement.

Medication compliance in Singaporean patients with Alzheimer's disease

INTRODUCTION

Singapore has a rapidly ageing population and an increasing prevalence of Alzheimer's disease (AD). Compliance to AD medications is associated with treatment effectiveness. We investigated compliance to acetylcholinesterase inhibitors (AChEIs) and N-methyl-D-aspartate (NMDA) receptor antagonist and treatment persistence among patients seen at the General Memory Clinic of National University Hospital, Singapore. We also identified the reasons for non-compliance.

METHODS

Patients seen at the General Memory Clinic between 1 January 2013 and 31 December 2014, who were prescribed AChEIs and NMDA receptor antagonist, were included in this retrospective cohort study. Non-compliance to medications was indirectly measured by failure to renew prescription within 60 days of the last day of medication supplied by the previous prescription. The reasons for non-compliance were identified.

RESULTS

A total of 144 patients were included. At one year, 107 patients were compliant to AD medications, while 37 patients were non-compliant. Around 60% of the non-compliant patients discontinued the use of AD medications within the first six months, and the mean persistent treatment period among this group of patients was 10.3 ± 3.5 months. The main reason for non-compliance was patients' and caregivers' perception that memory loss was of lower priority than other coexisting illnesses. Other reasons for non-compliance included side effects of medications (18.9%), perceived ineffectiveness of treatment (16.2%), inability to attend clinic (5.4%) and high cost of medications (2.7%).

CONCLUSION

Our findings suggest that the reasons for medication non-compliance can be identified early. Better compliance may be achieved through a multidisciplinary approach to patient education.

A narrative review of the safety concerns of deprescribing in older adults and strategies to mitigate potential harms

INTRODUCTION

As with prescribing or continuing medications, deprescribing brings with it the potential for harm as well as benefit. Uncertainty and avoidance of harm has been reported as a barrier to deprescribing in practice and may contribute to continuation of inappropriate medications.

AREAS COVERED

This narrative review covers four main safety concerns/potential harms of deprescribing in older adults: adverse drug withdrawal events, return of medical condition(s), reversal of drug-drug interactions and damage to the doctor-patient relationship. These are discussed in relation to medications in general, with some examples of medication classes used to illustrate the potential safety concerns. The majority of these harms can be minimized or even prevented by using a patient-centered, structured deprescribing process with planning, tapering and close monitoring during, and after medication withdrawal.

EXPERT OPINION

More research is needed into the safety concerns of deprescribing, however, avenues exist during drug development and post-marketing surveillance to gain knowledge on this topic. Questions remain about when it is suitable to discontinue certain medications/medication classes and there is uncertainty about the harms and benefits of both medication continuation and discontinuation in complex older adults.

Medication Adherence in Older Patients With Dementia: A Systematic Literature Review

Background:

Older patients with dementia are often unable to take their medications as prescribed due to cognitive and physical impairment.

Objectives:

To review the evidence on medication adherence in older patients with dementia in terms of the level of adherence, outcomes, contributing factors, and available interventions.

Methods:

A systematic literature review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searched databases included CINAHL, Cochrane Library, DARE, MEDLINE, and PubMed.

Results:

Eighteen studies reported levels of medication adherence or discontinuation and related factors. Medication adherence ranged from 17% to 42%, and medication discontinuation before the end of treatment ranged from 37% to 80%. Nonadherence was associated with an increased risk of hospitalization or death, while increasing age, choice of medication, use of concomitant medications, and medicines’ costs were reported to decrease medication adherence. Telehealth home monitoring and treatment modification were the only interventions reported in the literature to improve medication adherence in this population.

Conclusion:

Older patients with dementia have a low level of medication adherence. Future research should focus on the development and implementation of interventions to help older patients with dementia and their caregivers make better use of medications.

Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action

Deprescribing can be defined as the process of withdrawal or dose reduction of medications which are considered inappropriate in an individual. The aim of this narrative review is to provide an overview of "deprescribing"; firstly discussing the potential benefits and harms followed by the barriers to and enablers of deprescribing. We also provide practical recommendations to recognise opportunities and strategies for deprescribing in practice. Studies focused on minimizing polypharmacy indicate that deprescribing may be associated with potential benefits including resolution of adverse drug reactions, improved quality of life and medication adherence and a reduction in drug costs. While the data on the benefits is inconsistent, deprescribing appears to be safe. There are, however, potential harms including return of medical conditions or symptoms and adverse drug withdrawal reactions which emphasise the need for the process to be supervised and monitored by a health care professional. Taking action on deprescribing can be facilitated by knowledge of potential barriers, implementing a deprescribing process (utilising developed tools and resources) and identifying opportunities for deprescribing through engaging with patients and caregivers and other health care professionals and considering deprescribing in a variety of populations. Important areas for future research include the suitability of deprescribing of certain medications in specific populations, how to implement deprescribing processes into clinical care in a feasible and cost effective manner and how to engage consumers throughout the process to achieve positive health and quality of life outcomes.

Proposal of Standardization to Assess Adherence With Medication Records: Methodology Matters

BACKGROUND

Medication adherence is the process by which patients take their medication as prescribed and is an umbrella term that encompasses all aspects of medication use patterns. Ambiguous terminology has emerged to describe a deviation from prescribed regimen, forcing the European ABC Project to define 3 phases of medication use: initiation, implementation, and discontinuation. However, different measures of medication adherence using medication records are currently available that do not always distinguish between these phases. The literature is lacking standardization and operationalization of the assessment methods.

OBJECTIVE

To propose a harmonization of standards as well as definitions of distinct measures and their operationalization to quantify adherence to medication from medication records.

METHODS

Group discussions and consensus process among all coauthors. The propositions were generated using the authors' experiences and views in the field of adherence, informed by theory.

RESULTS

The concepts of adherence measures within the new taxonomy were harmonized, and the standards necessary for the operationalization of adherence measures from medication records are proposed. Besides percentages and time-to values, the addition of a dichotomous value for the reinitiation of treatment is proposed. Methodological issues are listed that should be disclosed in studies on adherence.

CONCLUSIONS

The possible impact of the measures in adherence research is discussed. By doing this, the results of future adherence research should gain in accuracy. Finally, studies will become more transparent, enabling comparison between studies.

Evaluation and management of the elderly patient presenting with cognitive complaints

Cognitive complaints are common in the geriatric population. Older adults should routinely be asked about any concerns about their memory or thinking, and any cognitive complaint from the patient or an informant should be evaluated rather than be attributed to aging. Several screening instruments are available to document objective impairments and guide further evaluation. Management goals for patients with cognitive impairment are focused on maintaining function and independence, providing caregiver support, and advance care planning. There are currently no treatments to effectively prevent or treat dementia. Increasing appreciation of the heterogeneity of Alzheimer disease may lead to novel treatment approaches.

Long-term efficacy and toxicity of cholinesterase inhibitors in the treatment of Alzheimer disease

Though the symptoms of Alzheimer disease go on for years, the phase 3 trials of the cholinesterase inhibitors (ChEIs), the current mainstay of symptomatic pharmacotherapy for this condition, were typically of only 3- to 6-months' duration. We have limited data on long-term (that is, a year or more) therapy with these agents. In this review, we explore the available information on the biological and clinical effects of long-term ChEI therapy, what happens when these agents are discontinued, and examine what others have recommended An individualized approach to deciding on whether to carry on with a ChEI should be taken. If continued, treatment goals should be clarified and patients monitored over time, for both drug-related benefits and adverse effects.

Pharmacological treatment of dementia

PURPOSE OF REVIEW

In this article, we discuss new data on currently licensed drugs for dementia and novel developments in the management of neuropsychiatric symptoms in patients with dementia.

RECENT FINDINGS

During the last years, a large body of evidence has been accumulated to support the use of antidementia medication in patients with severe Alzheimer's disease. Combination therapy with acetylcholinesterase inhibitors and memantine for Alzheimer's disease remains controversial, as controlled trials have yielded conflicting results. Memantine is not indicated in patients with mild Alzheimer's disease. Studies on memantine for Parkinson's disease dementia and dementia with Lewy bodies were inconclusive. In adult patients with dementia in the context of Down syndrome, memantine is not effective, and further studies on acetylcholinesterase inhibitors are warranted. There is still no treatment established for patients with vascular or frontotemporal dementia. The efficacy of antidepressants to treat depression associated with dementia is not proven. Treatment of agitation and psychosis in patients with dementia remains a challenge.

SUMMARY

Recent systematic clinical reviews and new research on currently available treatment options provide valuable assistance for clinicians to deal with frequent clinical problems in the context of dementia.