Nurse-Led Medicines' Monitoring for Patients with Dementia in Care Homes: A Pragmatic Cohort Stepped Wedge Cluster Randomised Trial

Individual Pharmacotherapy Management (IPM-II) for Patient and Drug Safety in Polypharmacy via Clinical Electronic Health Record Is Associated with Significant Fall Prevention

BACKGROUND/OBJECTIVES

Falls and fractures are emerging as a near-pandemic and major global health concern, placing an enormous burden on ageing patients and public health economies. Despite the high risk of polypharmacy in the elderly patients, falls are usually attributed to age-related changes. For the "Individual Pharmacotherapy Management (IPM)" established at the University Hospital Halle, the IPM medication adjustments and their association with in-hospital fall prevention were analysed.

METHODS

On the basis of the most updated digital overall patient view via his inpatient electronic health record (EHR), IPM adapts each drug's Summary of Product Characteristics to the patient's condition. A retrospective pre-post intervention study in geriatric traumatology on ≥70 years old patients compared 200 patients before IPM implementation (CG) with 204 patients from the IPM intervention period (IG) for the entire medication list, organ, cardiovascular and vital functions and fall risk parameters.

RESULTS

Statistically similar baseline data allowed a comparison of the average 80-year-old patient with a mean of 11.1 ± 4.9 (CG) versus 10.4 ± 3.6 (IG) medications. The IPM adjusted for drug-drug interactions, drug-disease interactions, overdoses, anticholinergic burden, adverse drug reactions, esp. from opioids inducing increased intrasynaptic serotonin, psychotropic drugs, benzodiazepines, contraindications and missing prescriptions. IPM was associated with a significant reduction in in-hospital falls from 18 (9%) in CG to 3 (1.5%) in IG, a number needed to treat of 14, relative risk reduction 83%, OR 0.17 [95% CI 0.04; 0.76], p = 0.021 in multivariable regression analysis. Factors associated with falls were antipsychotics, digitoxin, corticosteroids, Würzburg pain drip (combination of tramadol, metamizole, metoclopramide), head injury, cognitive impairment and aspects of the Huhn Fall Risk Scale including urinary catheter.

CONCLUSION

The results indicate medication risks constitute a major iatrogenic cause of falls in this population and support the use of EHR-based IPM in standard care for the prevention of falls in the elderly and for patient and drug safety. In terms of global efforts, IPM contributes to the running WHO and United Nations Decade of Healthy Ageing (2021-2030).

Randomised trials conducted using cohorts: a scoping review

INTRODUCTION

Cohort studies generate and collect longitudinal data for a variety of research purposes. Randomised controlled trials (RCTs) increasingly use cohort studies as data infrastructures to help identify and recruit trial participants and assess outcomes.

OBJECTIVE

To examine the extent, range and nature of research using cohorts for RCTs and describe the varied definitions and conceptual boundaries for RCTs using cohorts.

DESIGN

Scoping review.

DATA SOURCES

Searches were undertaken in January 2021 in MEDLINE (Ovid) and EBM Reviews-Cochrane Methodology Registry (Final issue, third Quarter 2012).

ELIGIBILITY CRITERIA

Reports published between January 2007 and December 2021 of (a) cohorts used or planned to be used, to conduct RCTs, or (b) RCTs which use cohorts to recruit participants and/or collect trial outcomes, or (c) methodological studies discussing the use of cohorts for RCTs.

DATA EXTRACTION AND SYNTHESIS

Data were extracted on the condition being studied, age group, setting, country/continent, intervention(s) and comparators planned or received, unit of randomisation, timing of randomisation, approach to informed consent, study design and terminology.

RESULTS

A total of 175 full-text articles were assessed for eligibility. We identified 61 protocols, 9 descriptions of stand-alone cohorts intended to be used for future RCTs, 39 RCTs using cohorts and 34 methodological papers.The use and scope of this approach is growing. The thematics of study are far-ranging, including population health, oncology, mental and behavioural disorders, and musculoskeletal conditions.Authors reported that this approach can lead to more efficient recruitment, more representative samples, and lessen disappointment bias and crossovers.

CONCLUSION

This review outlines the development of cohorts to conduct RCTs including the range of use and innovative changes and adaptations. Inconsistencies in the use of terminology and concepts are highlighted. Guidance now needs to be developed to support the design and reporting of RCTs conducted using cohorts.

Lower Urinary Tract Symptoms in Depression: A Review

Lower Urinary Tract Symptoms (LUTS) are frequently present in the general population as patients age with approximately a third of individuals experiencing LUTS during their lifetime. LUTS can be further defined as having any of the following symptoms: urinary hesitancy, straining, nocturia, increased urination frequency, and dysuria. LUTS has the potential for patients to contribute their symptoms to what can normally occur as we age. This can lead to a decrease in patients seeking care and could negatively impact patients' health-related quality of life (HRQL). In conjunction with LUTS, we obtained from our analysis that LUTS and depression are closely related and worsening depressive symptoms may increase the severity of LUTS. We also discerned three categories of factors that can yield major depression namely adversity, internalizing, and externalizing factors. Within these categories, trauma, social support, genetic factors, and minimal education appeared to increase the risk of depression in patients. With the recent increase in mental health awareness and more access to mental health care amid the COVID-19 Pandemic, further screening, and collaboration between providers to treat both urological and psychiatric symptoms could improve patient outcomes. It is important for providers to have an increased understanding of the mental and physical impact both LUTS and depression can have on patients' wellbeing. This has the potential to help patients be more open about their symptoms with the aim of better addressing LUTS and depression to positively impact their HRQL.

Systematic Review of Psychotropic Adverse Drug Event Monitoring Tools for Use in Long-Term Care Facilities

OBJECTIVES

To evaluate properties of psychotropic adverse drug event (ADE) monitoring tools intended for use in long-term care facilities.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Adults aged 18 years and older in nursing homes and other long-term care facilities.

METHODS

Medline, CINAHL, Embase, and PsycInfo were searched from inception to August 2022 for studies reporting the development, validation, or application of tools to monitor psychotropic ADEs. Screening, data extraction, and quality assessment were performed independently by 2 authors. Each tool was assessed under the domains of test-retest reliability, interrater reliability, content validity, and construct validity.

RESULTS

Eight studies that described 6 tools were included. Tools were developed in Wales (n = 2), United States (n = 1), Ireland (n = 1), Canada (n = 1), and Singapore (n = 1). Tools monitored 4 to 95 items related to antipsychotics (n = 6 tools), antidepressants (n = 4), benzodiazepines or hypnotics (n = 4), antiepileptics (n = 4), and dementia medications (n = 1). Tools commonly monitored sedation, tiredness, or sleepiness (n = 6); falls (n = 4); and tremor or extrapyramidal symptoms (n = 4). Tools were designed for application by nurses (n = 4), during family conferences (n = 1), and by general medical practitioners before repeat prescribing (n = 1). Two tools were reported to require 10 to 60 minutes to administer. Four tools were determined to have adequate content validity and 2 tools adequate interrater reliability. No tools reported test-retest reliability or construct validity.

CONCLUSIONS AND IMPLICATIONS

Six published psychotropic ADE monitoring tools are heterogeneous in design and intended application. Existing tools are predominately designed for application by nurses with or without direct involvement of the wider multidisciplinary team. Further research is needed into models of care that facilitate psychotropic ADE monitoring in the long-term care facility setting, and the extent to which application of specific tools is associated with reduced medication-related harm.

Tailoring a complex intervention to reduce antidepressants in institutionalized older persons with dementia

INTRODUCTION

First-line treatment for behavioral and psychiatric symptoms of dementia is non-pharmacological. Still, psychotropic medication is widely used, despite its limited effect and harmful side-effects. More than half of all nursing home residents with dementia receive antidepressants, even though deprescribing is safe and feasible. Interventions to promote deprescribing of antidepressants in nursing homes are few and complex. To optimize the deprescribing process through an intervention, transparency for the development of the intervention is needed. We aim to describe the steps in the development and tailoring of an intervention targeting GPs, nursing home staff, and relatives to enhance collaboration on reducing the use of antidepressants in institutionalized older persons with dementia in Denmark.

METHOD

A step-wise process guided by the core elements in the Medical Research Council constituted the tailoring process. Five steps were included; 1) a literature search, 2) interviews with stakeholders, 3) drafting the intervention prototype, 4) professionals' assessment of the intervention, and 5) refinement of the intervention. The steps were conducted from June 2020 to June 2022.

RESULTS

Based on the literature search, interviews with stakeholders, and professionals' assessment of the intervention, four main themes were identified; 1) focusing on antidepressants, 2) importance of professional qualifications, 3) collaboration and communication, and 4) patient and relative involvement. They guided intervention development and refinement of the final intervention, which included 1) a case-based training course and 2) a dialog tool including a symptom assessment scale to be used in a structured consultation at the nursing home.

CONCLUSION

This study presents a detailed account of the tailoring process for a complex intervention to optimize deprescribing of antidepressants for older persons with dementia at nursing homes. By presenting a thorough development process, we expect to achieve increased adherence to the intervention which is currently being tested in an ongoing cluster randomized controlled trial. The transparency of the process will also increase the future development of other similar complex interventions.

Nurses' responsibilities and tasks in pharmaceutical care: A scoping review

AIM

To provide an overview of responsibilities and tasks of nurses in pharmaceutical care.

DESIGN

Scoping review.

METHODS

Two databases were systematically searched (MEDLINE and Scopus) for recent original research papers concerning nurses' responsibilities and tasks in pharmaceutical care. The definition of responsibility was based on literature, moral and ethical discussions. Existing responsibilities and tasks beyond preparation and administration of medication were collected and synthesized. This main study outcome was extracted from titles and abstracts only. Results were reported in accordance with PRISMA-ScR guidelines.

RESULTS

Of the 3,805 titles and abstracts reviewed, 453 abstracts were included. A total of seven responsibilities were identified: (a) management of therapeutic and adverse effects of medication, (b) management of medication adherence, (c) management of patient medication self-management, (d) management of patient education and information about medication, (e) prescription management, (f) medication safety management and (g) (transition of) care coordination. Within these responsibilities, all tasks performed by nurses were described.

Medication reviews and deprescribing as a single intervention in falls prevention: a systematic review and meta-analysis

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.

Actual drug-related harms in residential aged care facilities: a narrative review

INTRODUCTION

Older people in residential aged care facilities (RACFs) have a high risk of safety issues and concerns about the potential quality of care received. This narrative review investigates the types of actual drug-related harms, their prevalence, reporting of any standard definitions for these harms, and their identification methods.

AREAS COVERED

The authors conducted a systematic search on Ovid Embase, Ovid Medline, and PubMed from March 2001 to March 2021. This narrative review included all types of studies targeting aged care residents aged 65 years and above with actual drug-related harms.

EXPERT OPINION

The prevalence of actual drug-related harms in residents ranged from 0.07% to 63.0%. Falls, drug-drug interactions, neuropsychiatric symptoms, anaphylaxis, urinary tract infection, hypoglycemia, hypokalaemia, and acute kidney injury are the most common drug-related harms in older residents. Psychotropic drugs are the most common drug class implicated in these harms. Evidence related to the association between individual psychotropic drugs and injury, or harm is also lacking. Due to the variation in study duration, reported prevalence, identification methods, and absence of a definition for actual drug-related harms in most studies, further research is mandated to understand the prevalence and clinical implications of drug-related harms in older residents.

Clinical Impact of Implementing a Nurse-Led Adverse Drug Reaction Profile in Older Adults Prescribed Multiple Medicines in UK Primary Care: A Study Protocol for a Cluster-Randomised Controlled Trial

(1) Aims: Adverse drug reactions (ADRs) particularly affect older people prescribed multiple medicines. The professional bodies of nursing, medicine and pharmacy have issued guidelines on identification and management of ADRs; however, ADRs continue to account for ~10% unplanned hospital admissions in the UK. Current methods of ADR identification and management could be improved by multidisciplinary collaboration involving nurses. The aim of this study is to examine the impact of implementing the nurse-led Adverse Drug Reaction (ADRe) Profile in UK primary care. (2) Design: A pragmatic cluster-randomised controlled trial (RCT) followed by qualitative interviews in a sequential mixed-methods study. (3) Methods: For the cluster RCT, 60 patients aged ≥65 prescribed ≥5 regular medicines for long-term conditions will be recruited, 10 in each of 6 general practices. The intervention arm (n = 30) will complete the ADRe Profile, whilst the control participants (n = 30) continue to receive usual, standard care. Primary outcomes will include clinical impact on patients, benefit and prescription changes. On completion of the RCT, participants will be invited to semi-structured qualitative interviews, to evaluate the impact of the ADRe Profile from stakeholders’ perspectives, and to describe the contextual factors relevant to ADRe implementation. (4) Results: The findings of this study will evaluate the effectiveness of the ADRe Profile in identifying and resolving potential ADRs in primary care. Trial registration: This study was registered in ClinicalTrials.gov, registration number NCT04663360, date of registration—29 November 2021 (date of initial registration: 26 November 2020), protocol version 2, dated 8 January 2021.

Overcoming Decisional Gaps in High-Risk Prescribing by Junior Physicians Using Simulation-Based Training: Protocol for a Randomized Controlled Trial

BACKGROUND

Gaps between rational thought and actual decisions are increasingly recognized as a reason why people make suboptimal choices in states of heightened emotion, such as stress. These observations may help explain why high-risk medications continue to be prescribed to acutely ill hospitalized older adults despite widely accepted recommendations against these practices. Role playing and other efforts, such as simulation training, have demonstrated benefits to help people avoid decisional gaps but have not been tested to reduce overprescribing of high-risk medications.

OBJECTIVE

This study aims to evaluate the impact of a simulation-based training program designed to address decisional gaps on prescribing of high-risk medications compared with control.

METHODS

In this 2-arm pragmatic trial, we are randomizing at least 36 first-year medical resident physicians (ie, interns) who provide care on inpatient general medicine services at a large academic medical center to either intervention (simulation-based training) or control (online educational training). The intervention comprises a 40-minute immersive individual simulation training consisting of a reality-based patient care scenario in a simulated environment at the beginning of their inpatient service rotation. The simulation focuses on 3 types of high-risk medications, including benzodiazepines, antipsychotics, and sedative hypnotics (Z-drugs), in older adults, and is specifically designed to help the physicians identify their reactions and prescribing decisions in stressful situations that are common in the inpatient setting. The simulation scenario is followed by a semistructured debriefing with an expert facilitator. The trial's primary outcome is the number of medication doses for any of the high-risk medications prescribed by the interns to patients aged 65 years or older who were not taking one of the medications upon admission. Secondary outcomes include prescribing by all providers on the care team, being discharged on 1 of the medications, and prescribing of related medications (eg, melatonin, trazodone), or the medications of interest for the control intervention. These outcomes will be measured using electronic health record data.

RESULTS

Recruitment of interns began on March 29, 2021. Recruitment for the trial ended in Q42021, with follow-up completed by Q12022.

CONCLUSIONS

This trial will evaluate the impact of a simulation-based training program designed using behavioral science principles on prescribing of high-risk medications by junior physicians. If the intervention is shown to be effective, this approach could potentially be reproducible by others and for a broader set of behaviors.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04668248; https://clinicaltrials.gov/ct2/show/NCT04668248.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/31464.

Structured Interventions to Optimize Polypharmacy in Psychiatric Treatment and Nursing Homes: A Systematic Review

BACKGROUND

Polypharmacy is a common clinical issue. It increases in prevalence with older age and comorbidities of patients and has been recognized as a major cause for treatment complications. In psychiatry, polypharmacy is also commonly seen in younger patients and can lead to reduced treatment satisfaction and incompliance. A variety of structured polypharmacy interventions have been investigated. This systematic review provides a comprehensive overview of the field and identifies research gaps.

METHODS

We conducted a systematic review on structured interventions aimed at optimizing polypharmacy of psychotropic and somatic medication in psychiatric inpatient and outpatient settings as well as nursing homes. A search protocol was registered with PROSPERO (CRD42020187304). Data were synthesized narratively.

RESULTS

Fifty-eight studies with a total of 30,554 participants met the inclusion criteria. Interventions were most commonly guided by self-developed or national guidelines, drug assessment scores, and lists of potentially inappropriate medications. Tools to identify underprescribing were less commonly used. Most frequently reported outcomes were quantitative drug-related measures; clinical outcomes such as falls, hospital admission, cognitive status, and neuropsychiatric symptom severity were reported less commonly. Reduction of polypharmacy and improvement of medication appropriateness were shown by most studies.

CONCLUSIONS

Improvement of drug-related outcomes can be achieved by interventions such as individualized medication review and educational approaches in psychiatric settings and nursing homes. Changes in clinical outcomes, however, are often nonsubstantial and generally underreported. Patient selection and intervention procedures are highly heterogeneous. Future investigations should establish standards in intervention procedures, identify and assess patient-relevant outcome measures, and consider long-term follow-up assessments.

Meal-Monitoring Systems Using Weight and Temperature Sensors for Elder Residents in Long-Term Care Facilities

This paper presents a few meal-monitoring systems for elder residents (especially patients) in LTCFs by using electronic weight and temperature sensors. These monitoring systems enable to convey the information of the amount of meal taken by the patients in real-time via wireless communication networks onto the mobile phones of their nurses in charge or families. Thereby, the nurses can easily spot the most patients who need immediate assistance, while the families can have relief in seeing the crucial information for the well-being of their parents at least three times a day. Meanwhile, the patients tend to suffer burns of their tongues because they can hardly recognize the temperature of hot meals served. This situation can be avoided by utilizing the meal temperature-monitoring system, which displays an alarm to the patients when the meal temperature is above the reference. These meal-monitoring systems can be easily implemented by utilizing low-cost sensor chips and Arduino NANO boards so that elder-care hospitals and nursing homes can afford to exploit them with no additional cost. Hence, we believe that the proposed monitoring systems would be a potential solution to provide a great help and relief for the professional nurses working in elder-care hospitals and nursing homes.

Quality standards for safe medication in nursing homes: development through a multistep approach including a Delphi consensus study

OBJECTIVES

The aim of the study was to develop quality standards reflecting minimal requirements for safe medication processes in nursing homes.

DESIGN

In a first step, relevant key topics for safe medication processes were deducted from a systematic search for similar guidelines, prior work and discussions with experts. In a second step, the essential requirements for each key topic were specified and substantiated with a literature-based rationale. Subsequently, the requirements were evaluated with a piloted, two-round Delphi study.

SETTING

Nursing homes in Switzerland.

PARTICIPANTS

Interprofessional panel of 25 experts from science and practice.

PRIMARY AND SECONDARY OUTCOME MEASURES

Each requirement was rated for its relevance for a safer and resident-oriented medication on a 9-point Likert-Scale based on the RAND/UCLA method. The requirements were considered relevant if, in the second round, the median relevance rating was ≥7 and the proportion of ratings ≥7 was ≥80%.

RESULTS

Five key topics with a total of 87 requirements were elaborated and rated in the Delphi study. After the second round (response rate in both rounds 100%), 85 requirements fulfilled the predefined criteria and were therefore included in the final set of quality standards. The five key topics are: (I) 'The medication is reviewed regularly and in defined situations', (II) 'The medication is reviewed in a structured manner', (III) 'The medication is monitored in a structured manner', (IV) 'All healthcare professionals are committed to an optimal interprofessional collaboration' and (V) 'Residents are actively involved in medication process'.

CONCLUSIONS

We developed normative quality standards for a safer and resident-oriented medication in Swiss nursing homes. Altogether, 85 requirements define the medication processes and the behaviour of healthcare professionals. A rigorous implementation may support nursing homes in taking a step towards safer and resident-oriented medication.

Improving caring quality for people with dementia in nursing homes using IPOS-Dem: A stepped-wedge cluster randomized controlled trial protocol

AIMS

We aim to evaluate the effectiveness of the Integrated Palliative Care Outcome Scale for people with dementia-based case studies to improve the caring quality for people with dementia in nursing homes by frontline staff and family members.

BACKGROUND

Swiss nursing homes mostly care for people with dementia. This population is at high risk of receiving little to no palliation for their complex needs. The majority of Swiss frontline healthcare staff do not systematically report on the needs of their residents. Additionally, family members do not routinely participate in assessment processes.

DESIGN

We will conduct a stepped-wedge cluster randomized trial of repeated assessment using the Integrated Palliative Care Outcome Scale for people with dementia (IPOS-Dem) and subsequent case studies. Clusters will consist of Swiss nursing homes randomly assigned to one of three sequential intervention time points.

METHODS

The study population will consist of people with dementia living in nursing homes with and without specialized dementia care facilities. Over 16 months, staff working at the frontline and family members will assess the needs and concerns of people with dementia using IPOS-Dem. Depending on sequence allocation, facilitated case studies will start after 3, 6 or 9 months. The primary outcome will be caring quality measured by QUALIDEM. The secondary outcome will be symptoms and concerns, as indicated by the IPOS-Dem sum-score. The Zürich Ethics Committee approved the study in 2019 (2019-01847).

IMPACT

The results of this study will contribute to improving the effectiveness of person-centred care for people with dementia. Collaboration between healthcare staff and family members will be systematically developed and built upon thorough assessment using the IPOS-Dem and related case studies. The use of IPOS-Dem will offer all frontline staff a systematic approach to have an independent voice within the nursing process, regardless of their qualification or grade.

Pain assessment and management in care homes: understanding the context through a scoping review

BACKGROUND

Internationally, 2-5% of people live in residential or nursing homes, many with multi-morbidities, including severe cognitive impairment. Pain is frequently considered an expected part of old age and morbidity, and may often be either under-reported by care home residents, or go unrecognized by care staff. We conducted a systematic scoping review to explore the complexity of pain recognition, assessment and treatment for residents living in care homes, and to understand the contexts that might influence its management.

METHODS

Scoping review using the methodological framework of Levac and colleagues. Articles were included if they examined pain assessment and/or management, for care or nursing home residents. We searched Medline, CINAHL, ASSIA, PsycINFO, EMBASE, Cochrane Library, and Google Scholar; reference lists were also screened, and website searches carried out of key organisations. Conversations with 16 local care home managers were included to gain an understanding of their perspective.

RESULTS

Inclusion criteria were met by 109 studies. Three overarching themes were identified: Staff factors and beliefs - in relation to pain assessment and management (e.g. experience, qualifications) and beliefs and perceptions relating to pain. Pain assessment - including use of pain assessment tools and assessment/management for residents with cognitive impairment. Interventions - including efficacy/effects (pharmaceutical/non pharmaceutical), and pain training interventions and their outcomes. Overall findings from the review indicated a lack of training and staff confidence in relation to pain assessment and management. This was particularly the case for residents with dementia.

CONCLUSIONS

Further training and detailed guidelines for the appropriate assessment and treatment of pain are required by care home staff. Professionals external to the care home environment need to be aware of the issues facing care homes staff and residents in order to target their input in the most appropriate way.

Nurses and Pharmaceutical Care: Interprofessional, Evidence-Based Working to Improve Patient Care and Outcomes

Pharmaceutical care necessitates significant efforts from patients, informal caregivers, the interprofessional team of health care professionals and health care system administrators. Collaboration, mutual respect and agreement amongst all stakeholders regarding responsibilities throughout the complex process of pharmaceutical care is needed before patients can take full advantage of modern medicine. Based on the literature and policy documents, in this position paper, we reflect on opportunities for integrated evidence-based pharmaceutical care to improve care quality and patient outcomes from a nursing perspective. Despite the consensus that interprofessional collaboration is essential, in clinical practice, research, education and policy-making challenges are often not addressed interprofessionally. This paper concludes with specific advises to move towards the implementation of more interprofessional, evidence-based pharmaceutical care.

Perspectives of nurses' role in interprofessional pharmaceutical care across 14 European countries: A qualitative study in pharmacists, physicians and nurses

OBJECTIVES

To understand healthcare professionals' experiences and perceptions of nurses' potential or ideal roles in pharmaceutical care (PC).

DESIGN

Qualitative study conducted through semi-structured in-depth interviews.

SETTING

Between December 2018 and October 2019, interviews were conducted with healthcare professionals of 14 European countries in four healthcare settings: hospitals, community care, mental health and long-term residential care.

PARTICIPANTS

In each country, pharmacists, physicians and nurses in each of the four settings were interviewed. Participants were selected on the basis that they were key informants with broad knowledge and experience of PC.

DATA COLLECTION AND ANALYSIS

All interviews were conducted face to face. Each country conducted an initial thematic analysis. Consensus was reached through a face-to-face discussion of all 14 national leads.

RESULTS

340 interviews were completed. Several tasks were described within four potential nursing responsibilities, that came up as the analysis themes, being: 1) monitoring therapeutic/adverse effects of medicines, 2) monitoring medicines adherence, 3) decision making on medicines, including prescribing 4) providing patient education/information. Nurses' autonomy varied across Europe, from none to limited to a few tasks and emergencies to a broad range of tasks and responsibilities. Intended level of autonomy depended on medicine types and level of education. Some changes are needed before nursing roles can be optimised and implemented in practice. Lack of time, shortage of nurses, absence of legal frameworks and limited education and knowledge are main threats to European nurses actualising their ideal role in PC.

CONCLUSIONS

European nurses have an active role in PC. Respondents reported positive impacts on care quality and patient outcomes when nurses assumed PC responsibilities. Healthcare professionals expect nurses to report observations and assessments. This key patient information should be shared and addressed by the interprofessional team. The study evidences the need of a unique and consensus-based PC framework across Europe.

Prevalence of adverse drug reactions in the primary care setting: A systematic review and meta-analysis

BACKGROUND

Adverse drug reactions (ADRs) represent a major cause of iatrogenic morbidity and mortality in patient care. While a substantial body of work has been undertaken to characterise ADRs in the hospital setting, the overall burden of ADRs in the primary care remains unclear.

OBJECTIVES

To investigate the prevalence of ADRs in the primary care setting and factors affecting the heterogeneity of the estimates.

METHODS

Studies were identified through searching of Medline, Embase, CINAHL and IPA databases. We included observational studies that reported information on the prevalence of ADRs in patients receiving primary care. Disease and treatment specific studies were excluded. Quality of the included studies were assessed using Smyth ADRs adapted scale. A random-effects model was used to calculate the pooled estimate. Potential source of heterogeneity, including age groups, ADRs definitions, ADRs detection methods, study setting, quality of the studies, and sample size, were investigated using sub-group analysis and meta-regression.

RESULTS

Thirty-three studies with a total study population of 1,568,164 individuals were included. The pooled prevalence of ADRs in the primary care setting was 8.32% (95% CI, 7.82, 8.83). The percentage of preventable ADRs ranged from 12.35-37.96%, with the pooled estimate of 22.96% (95% CI, 7.82, 38.09). Cardiovascular system drugs were the most commonly implicated medication class. Methods of ADRs detection, age group, setting, and sample size contributed significantly to the heterogeneity of the estimates.

CONCLUSION

ADRs constitute a significant health problem in the primary care setting. Further research should focus on examining whether ADRs affect subsequent clinical outcomes, particularly in high-risk therapeutic areas. This information may better inform strategies to reduce the burden of ADRs in the primary care setting.

Did we do everything we could have? Nurses' contributions to medicines optimization: A mixed-methods study

AIM

To explore UK professionals' interpretations of medicines optimization and expansion of nurses' roles.

DESIGN

This mixed-methods study sought professionals' views on nurses' involvement, competency and engagement in monitoring patients for adverse effects of medicines, monitoring adherence, prescribing and patient education.

METHOD

An online survey and interviews were undertaken with nurses, doctors and pharmacists in Wales and England, May 2018 to July 2019.

RESULTS

In all, 220 nurses, 17 doctors and 62 pharmacists responded to the online survey, and 24 professionals were interviewed. Nurses were divided over extending their roles, with 123/220 (55.9%) wishing to extend roles in monitoring patients for possible adverse drug reactions (ADRs), 111/220 (50.5%) in adherence monitoring, 121/220 (55.0%) in prescribing and 122/220 (55.4%) in patient education. The best-qualified nurses were the most willing to increase involvement in monitoring patients for ADRs (aOR 13.00, 1.56-108.01). Interviews revealed that both nurses and doctors assumed the other profession was undertaking this monitoring. Respondents agreed that increasing nurses' involvement in medicines optimization would improve patient care, but expressed reservations about nurses' competencies. Collaboration between nurses and doctors was suboptimal (rated 7/10 at best) and between nurses and pharmacists even more so (6/10 at best).

CONCLUSION

Juxtaposition of datasets identified problems with medicines optimization: although most respondents agreed that increasing nurses' involvement would positively impact practice, their educational preparation was a barrier. Only ~50% of nurses were willing to expand their roles to fill the hiatus in care identified and ensure that at least one profession was taking responsibility for ADR monitoring.

IMPACT

To improve multiprofessional team working and promote patient safety, nurse leaders should ensure patients are monitored for possible ADRs by at least one profession. Initiatives expanding nurses' roles in medicines optimization and prescribing might be best targeted towards the more educated nurses, who have multidisciplinary support.

Dementia and the risk of short-term readmission and mortality after a pneumonia admission

BACKGROUND

At time of discharge after a pneumonia admission, care planning for older persons with dementia is essential. However, care planning is limited by lack of knowledge on the short-term prognosis.

AIM

To investigate 30-day mortality and readmission after hospital discharge for pneumonia in persons with versus without dementia, and to investigate how these associations vary with age, time since discharge, and medication use.

METHODS

Using the Danish registries, we investigated 30-day mortality and readmission in persons (+65 years) discharged after pneumonia in 2000-2016 (N = 298,872). Adjusted mortality rate ratios (aMRRs) and incidence rate ratios (aIRRs) were calculated for persons with versus without dementia, and we investigated if these associations varied with use of benzodiazepines, opioids, and antipsychotics, and with age and time since discharge.

RESULTS

Among 25,948 persons with dementia, 4,524 died and 5,694 were readmitted within 30 days. The risk of 30-day mortality was 129% higher (95% CI 2.21-2.37) in persons with versus without dementia after adjustment for sociodemographic characteristics, admission-related factors, and comorbidities. Further, the highest mortality risk was found in persons with both dementia and use of antipsychotics (aMRR: 3.39, 95% CI 3.19-3.59); 16% of deaths in this group could not be explained by the independent effect of each exposure. In those with dementia, the highest aMRRs were found for the youngest and for the first days after discharge. The risk of 30-day readmission was 7% higher (95% CI 1.04-1.10) in persons with versus without dementia. In those with dementia, the highest aIRRs were found for the first days after discharge.

CONCLUSIONS

Dementia was associated with higher short-term mortality after pneumonia, especially in users of antipsychotics, and with slightly higher readmission, especially in the first days after discharge. This is essential knowledge in the care planning for persons with dementia who are discharged after a pneumonia admission.

Medical error reporting among doctors and nurses in a Nigerian hospital: A cross-sectional survey

AIM

To compare doctors' and nurses' perceptions of factors influencing medical error reporting.

BACKGROUND

In Nigeria, there is limited information on determinants of error reporting and systems.

METHODS

From the total workforce (N = 600), 140 nurses and 90 doctors were selected by random sampling and completed the questionnaire February to March 2017.

RESULTS

All 140 nurses and 90 doctors approached responded. Inter-professional differences in response to sentinel events showed that 55/140, 39.3% nurses and 48/90, 53.3% doctors would never report wrong medicines administered and 49/138, 35.5% nurses and 35/90, 38.9% doctors would never report a haemolytic transfusion error. Some respondents (72/140, 51.4% nurses vs. 29/90, 32.2% doctors) were unaware of reporting systems. Most (77/140, 55% nurses vs. 48/90, 53.3% doctors) considered these to be ineffective and confounded by a 'blame culture'. Perceived barriers included lack of confidentiality; facilitators included clear guidelines about protection from litigation.

CONCLUSIONS

Error reporting is suboptimal. Nurses and doctors have a minimal common understanding of barriers to error reporting and demonstrate inconsistent practice.

IMPLICATIONS FOR NURSING MANAGEMENT

Suboptimal reporting of serious adverse events has implications for patient safety. Managers need to prioritize education in adverse events, clarify reporting procedures and divest the organisation of a 'blame culture'.

Nobody ever questions-Polypharmacy in care homes: A mixed methods evaluation of a multidisciplinary medicines optimisation initiative

BACKGROUND

Nurse-led monitoring of patients for signs and symptoms associated with documented 'undesirable effects' of medicines has potential to prevent avoidable harm, and optimise prescribing.

INTERVENTION

The Adverse Drug Reaction Profile for polypharmacy (ADRe-p) identifies and documents putative adverse effects of medicines commonly prescribed in primary care. Nurses address some problems, before passing ADRe-p to pharmacists and prescribers for review, in conjunction with prescriptions.

OBJECTIVES

We investigated changes in: the number and nature of residents' problems as recorded on ADRe-p; prescription regimens; medicines optimisation: and healthcare costs. We explored aetiologies of problems identified and stakeholders' perspectives.

SETTING AND PARTICIPANTS

In three UK care homes, 19 residents completed the study, December 2018 to May 2019. Two service users, three pharmacists, six nurses gave interviews.

METHODS

This mixed-method process evaluation integrated data from residents' ADRe-ps and medicines charts, at the study's start and 5-10 weeks later.

RESULTS

We recruited three of 27 homes approached and 26 of 45 eligible residents; 19 completed ADRe-p at least twice. Clinical gains were identified for 17/19 residents (mean number of symptoms 3 SD 1.67, range 0-7). Examples included management of: pain (six residents), seizures (three), dyspnoea (one), diarrhoea (laxatives reduced, two), falls (two of five able to stand). One or more medicine was de-prescribed or dose reduced for 12/19 residents. ADRe administration and review cost ~£30 in staff time. ADRe-p helped carers and nurses bring residents' problems to the attention of prescribers.

IMPLICATIONS

ADRe-p relieved unnecessary suffering. It supported carers and nurses by providing a tool to engage with pharmacists and prescribers, and was the only observable strategy for multidisciplinary team working around medicines optimisation. ADRe-p improved care by: a) regular systematic checks and problem documentation; b) information transfer from care home staff to prescribers and pharmacists; c) recording changes.

REGISTRATION

NLM Identifier NCT03955133; ClinicalTrials.gov.

The Utility of Routine Fundus Photography Screening for Posterior Segment Disease: A Stepped-wedge, Cluster-randomized Trial in South India

PURPOSE

To assess whether routine fundus photography (RFP) to screen for posterior segment disease at community eye clinics (vision centers [VCs]) in India increases referral to centralized ophthalmolic care.

DESIGN

Stepped-wedge, cluster-randomized trial.

PARTICIPANTS

Patients aged 40 to 75 years and those aged 20 to 40 years with a known history of hypertension or diabetes mellitus presenting to 4 technician-run VCs associated with the Aravind Eye Care System in India.

METHODS

VCs (clusters) were randomized to standard care or RFP across five 2-week study periods (steps). Patients in each cluster received standard care initially. At the start of each subsequent step, a randomly chosen cluster crossed over to providing RFP to eligible patients. All clusters took part in RFP during the last step. Standard care involved technician eye exams, optional fundus photography, and teleconsultation with an ophthalmologist. RFP involved eye exams, dilation and 40-degree fundus photography, and teleconsultation with an ophthalmologist.

MAIN OUTCOME MEASURES

Standard care and RFP clusters were compared by the proportion of patients referred for in-person evaluation by an ophthalmologist because of fundus photography findings and urgency of referral (urgently in ≤ 2 weeks vs. nonurgently in > 2 weeks). Generalized linear mixed models adjusting for cluster and step were used to estimate the odds of referral due to fundus photography findings compared with standard care.

RESULTS

A total of 1447 patients were enrolled across the VCs, including 737 in the standard care group and 710 in the RFP group. Compared with standard care, the RFP group had a higher proportion of referrals due to fundus photography findings (11.3% vs. 4.4%), nonurgent referrals due to fundus photography (9.3% vs. 3.3%), and urgent referrals due to fundus photography (1.8% vs. 1.1%). The RFP intervention was associated with a 2-fold increased odds of being referred because of photography findings compared with standard care (odds ratio, 2.07; 95% confidence interval, 0.98-4.40; P = 0.058).

CONCLUSIONS

Adding RFP to community eye clinics was associated with an increased odds of referral compared with standard care. This increase in referral was mostly due to nonurgent posterior segment disease.

Looking for the "Little Things": A Multi-Disciplinary Approach to Medicines Monitoring for Older People Using the ADRe Resource

Advances in medicines have increased the effectiveness of treatments and the social and cultural authority of doctors. However, as prescribing has become the dominant modality of treatment, the “pharmaceuticalization” of medical practice has often resulted in treatment “at a distance”, with doctors having limited contact with patients. Older and poorer people, who are socially distanced from medical prescribers, suffer more adverse drug reactions (ADRs) than the general population. A team approach to checking patients systematically for ADRs, as detailed in manufacturers’ literature, can minimise medication errors, but regular review is rare. This paper explains the benefits of medicines monitoring to protect older patients from iatrogenic harm, such as over-sedation, falls, or drug-induced Parkinsonism. We show how multidisciplinary initiatives to optimise prescribing can be supported by using a recognised resource—the adverse drug reaction profile (ADRe). The profile identifies and documents patients’ signs and symptoms of putative ADRs. Better monitoring allows professionals to adjust prescribing and respond to identified problems with agility. Implementation of systematic monitoring will require changes to the regulatory regime and better inter-professional cooperation. Providing carers, nurses and pharmacists with a structured system to monitor patients would democratise relevant medical knowledge and help address ageism and the socio-economic health divide.

Institutionalized elderly people with dementia: an integrative review on nursing care

OBJECTIVE

To ascertain the characteristics of the nursing care provided to institutionalized elderly people with dementia.

METHODS

Integrative review of studies published between 2013 and 2017, in English, Spanish, and Portuguese, from the databases BDENF, LILACS, CINAHL, PubMed, SciELO, TRIP, and National Guideline Clearing House. Thematic data analysis was used.

RESULTS

From the data collected in the 41 included studies, three themes emerged: Care with a focus on the needs of elderly people in LTCIEs; Care based on the work process of the nursing team; and Shared care. Final considerations: Elderly care can take place from different perspectives: that of the elderly; the nursing team; and it can be shared among the different parties involved. The importance of communication must be stressed, as do the development of skills and attitudes of the team, as well as proper training and support, good environment in the care process, and an approach centered on the institutionalized elderly.

Evidence for the impact of interventions and medicines reconciliation on problematic polypharmacy in the UK: A rapid review of systematic reviews

This was a rapid review of systematic reviews (SRs) on problematic polypharmacy (PP) in the UK. The commissioner-defined topics were burden of PP, interventions to reduce PP, implementation activities to increase uptake of interventions, and efficient handover between primary and secondary care to reduce PP. Databases including Medline were searched to June 2019, SR quality was assessed using AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews) and a narrative synthesis was undertaken. Except for burden of PP (SRs had to include UK studies), there were no restrictions on country, location of care or outcomes. Nine SRs were included. On burden, three SRs (including six UK studies) found a high prevalence of polypharmacy in long term care. PP was associated with mortality, although unclear if causal, with no information on costs or health consequences. On interventions, six reviews (27 UK studies) found that interventions can reduce PP, but no effects on health outcomes. On handover between primary and secondary care, one review (two UK studies) found medicine reconciliation activities to reduce medication discrepancies at care transitions reduce PP, although the evidence is low quality. No SRs on implementation activities to increase uptake of interventions were found. SR quality was variable, with some concerns regarding meta-analysis methods. Evidence of the extent of PP in the UK, and what interventions to address it are effective in the UK, is limited. Future UK research is needed on the prevalence and consequences of PP, the effectiveness and cost-effectiveness of interventions to reduce PP, and barriers and activities to ensure uptake.

LIVE@Home.Path-innovating the clinical pathway for home-dwelling people with dementia and their caregivers: study protocol for a mixed-method, stepped-wedge, randomized controlled trial

BACKGROUND

The global health challenge of dementia is exceptional in size, cost and impact. It is the only top ten cause of death that cannot be prevented, cured or substantially slowed, leaving disease management, caregiver support and service innovation as the main targets for reduction of disease burden. Institutionalization of persons with dementia is common in western countries, despite patients preferring to live longer at home, supported by caregivers. Such complex health challenges warrant multicomponent interventions thoroughly implemented in daily clinical practice. This article describes the rationale, development, feasibility testing and implementation process of the LIVE@Home.Path trial.

METHODS

The LIVE@Home.Path trial is a 2-year, multicenter, mixed-method, stepped-wedge randomized controlled trial, aiming to include 315 dyads of home-dwelling people with dementia and their caregivers, recruited from 3 municipalities in Norway. The stepped-wedge randomization implies that all dyads receive the intervention, but the timing is determined by randomization. The control group constitutes the dyads waiting for the intervention. The multicomponent intervention was developed in collaboration with user-representatives, researchers and stakeholders to meet the requirements from the national Dementia Plan 2020. During the 6-month intervention period, the participants will be allocated to a municipal coordinator, the core feature of the intervention, responsible for regular contact with the dyads to facilitate L: Learning, I: Innovation, V: Volunteering and E: Empowerment (LIVE). The primary outcome is resource utilization. This is measured by the Resource Utilization in Dementia (RUD) instrument and the Relative Stress Scale (RSS), reflecting that resource utilization is more than the actual time required for caring but also how burdensome the task is experienced by the caregiver.

DISCUSSION

We expect the implementation of LIVE to lead to a pathway for dementia treatment and care which is cost-effective, compared to treatment as usual, and will support high-quality independent living, at home.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04043364. Registered on 15 March 2019.

Are medications safely used by residents in elderly care homes? - A multi-centre observational study from Sri Lanka

BACKGROUND

Most residents in elderly care homes in Sri Lanka do not receive formal, on-site, patient care services.

OBJECTIVE

To evaluate the appropriateness of prescribing, dispensing, administration, and storage practices of medication used by residents in selected elderly care homes in Colombo District, Sri Lanka.

METHODOLOGY

This was a prospective, cross-sectional, multi-center study of 100 residents with chronic, non-communicable diseases, who resided in nine selected elderly care homes in Sri Lanka. Medication histories were obtained from each resident/caregiver and the appropriateness of medications in their current prescription was reviewed using standard treatment guidelines. Prescriptions were cross-checked against respective dispensing labels to identify dispensing errors. Medication administration was directly observed on two separate occasions per resident for accuracy of administration, and matched against the relevant prescription instructions. Medication storage was also observed in terms of exposure to temperature and sunlight, the suitability of container, and adequacy of separation if using multiple medications.

RESULTS

The mean age of residents was 70±10.5 years and the majority were women (72%). A total of 168 errors out of 446 prescriptions were identified. The mean number of prescribing errors per resident was 1.68±1.23 [median, 2.00 (1.00-3.00)]. Inappropriate dosing frequencies were the highest (37.5%;63/168), followed by missing or inappropriate medications (31.5%;53/168). The mean number of dispensing errors per resident was 15.9±13.1 [median, 14.0 (6.00-22.75)] with 3.6 dispensing errors per every medication dispensed. Mean administration errors per resident was 0.95±1.5 [median, 0.00 (0.00-1.00)], with medication omissions being the predominant error (50.5%;48/95). Another lapse was incorrect storage of medications (143 storage errors), and included 83 medications not properly separated from each other (58.0%).

CONCLUSION

Multiple errors related to prescribing, dispensing, administration, and storage were identified amongst those using medication in elderly care homes. Services of a dedicated consultant pharmacist could improve the quality of medication use in elderly care homes in Sri Lanka.

Respiratory concerns of gabapentin and pregabalin: What does it mean to the pharmacovigilance systems in developing countries?

Gabapentin and pregabalin, commonly known as gabapentinoids, have been widely used globally. This paper highlights the serious breathing problems due to using gabapentin and pregabalin which was warned by the United States Food and Drug Administration on December, 2019. In this article, we tried to recommend suggestions for controlling these adverse drug reactions (ADRs). Safety reports of gabapentin and pregabalin should be obtained from concerned manufacturers and reviewed for respiratory depression effects. There should be strict prescription monitoring and drug use evaluation studies. Concurrent use of gabapentin and pregabalin with other respiratory depressants such as opioids should be strictly monitored. Educating patients can help in the early detection of ADRs due to gabapentin and pregabalin. Anecdotal reports on these medications should be encouraged.

Respiratory concerns of gabapentin and pregabalin: What does it mean to the pharmacovigilance systems in developing countries?

Gabapentin and pregabalin, commonly known as gabapentinoids, have been widely used globally. This paper highlights the serious breathing problems due to using gabapentin and pregabalin which was warned by the United States Food and Drug Administration on December, 2019. In this article, we tried to recommend suggestions for controlling these adverse drug reactions (ADRs). Safety reports of gabapentin and pregabalin should be obtained from concerned manufacturers and reviewed for respiratory depression effects. There should be strict prescription monitoring and drug use evaluation studies. Concurrent use of gabapentin and pregabalin with other respiratory depressants such as opioids should be strictly monitored. Educating patients can help in the early detection of ADRs due to gabapentin and pregabalin. Anecdotal reports on these medications should be encouraged.

Nurse-led medicines' monitoring in care homes, implementing the Adverse Drug Reaction (ADRe) Profile improvement initiative for mental health medicines: An observational and interview study

Introduction

Preventable adverse effects of medicines often pass unnoticed, but lead to real harm.

Intervention

Nurse-led monitoring using the structured Adverse Drug Reaction (ADRe) Profile identifies and addresses adverse effects of mental health medicines.

Objectives

This study investigated the implementation and clinical impact of ADRe, and barriers to and facilitators of sustained utilisation in routine practice.

Methods

Administration of ADRe was observed for 30 residents prescribed mental health medicines in ten care homes. The study pharmacist reviewed completed ADRes against medication records. Policy context was explored in 30 interviews with service users, nurse managers and strategic leads in Wales.

Results

Residents were aged 60–95, and prescribed 1–17 (median 9 [interquartile range (IQR) 7–13]) medicines. ADRe identified a median of 18 [IQR 11.5–23] problems per resident and nurses made 2 [1–2] changes to care per resident. For example: falls were reported for 9 residents, and care was modified for 5; pain was identified in 8 residents, and alleviated for 7; all 6 residents recognised as dyspnoeic were referred to prescribers. Nurses referred 17 of 30 residents to prescribers. Pharmacists recommended review for all 30. Doubts about administering ADRe, sometimes expressed by people who had not yet used it, diminished as it became familiar. ADRe was needed to bridge communication between resident, nurses and prescribers. When barriers of time, complacency, and doctors’ non-availability were overcome, reporting with ADRe made prescribers more likely to heed nurses’ concerns regarding residents’ welfare. Clinical gains were facilitated by one-to-one time, staff-resident relationships, and unification of documentation.

Implications

To our knowledge, ADRe is the only instrument that brings a full account of patients’ problems to medication reviews. This juxtaposition of signs and symptoms against prescriptions facilitates dose adjustments and de-prescribing and leads to: reduced pain and sedation; early identification of problems linked to ADRs, such as falls; and timely medication reviews e.g. for dyspnoea.

[Selected safety-relevant medication processes in Swiss nursing homes: Current state of affairs and optimization potentials]

BACKGROUND

Reducing adverse drug events in nursing homes is a central patient safety concern. The aim of this study was to assess how often selected medication processes to increase medication safety are already implemented in Swiss nursing homes and to examine how nursing homes that have not yet implemented these processes can be characterized based on their organizational features.

METHODS

Cross-sectional survey study among directors of nursing in Swiss nursing homes.

RESULTS

420 of 1,525 invited individuals participated in the survey (response rate: 27.5 %). Of these, 65.0 % stated that regular systematic medication reviews have been provided in their institution. 9.5 % of the nursing homes use a list to identify potentially inappropriate medication, and 6.7 % of the nursing homes have a standardized process to monitor side effects of medications. 66.0 % of the participating nursing homes have implemented at least one of these three processes, 34.0 % of the participating nursing homes have not implemented any of the three processes. Statistically significant differences in process implementation were found according to the geographical location of the nursing home, the type of documentation used for medications, the physician model, the number of external general practitioners, as well as the medication supply channel and the legal obligation to cooperate with pharmacists. No differences were found with regard to the nursing home size.

CONCLUSION

In Swiss nursing homes, central safety-relevant medication processes have not yet been implemented nationwide. In particular, implementation is not widespread in nursing homes where medical care for their residents is provided by many different external general practitioners. The organizational features need to be taken into account to successfully implement quality improvement measures.

Interventions to Optimise Prescribing in Older People with Dementia: A Systematic Review

BACKGROUND

Older adults living with dementia may have a higher risk of medication toxicity than those without dementia. Optimising prescribing in this group of people is a critically important yet challenging process.

OBJECTIVE

Our aim was to systematically review the evidence for the effectiveness of interventions for optimising prescribing in older people with dementia.

METHODS

This systematic review searched the Pubmed, Embase, CINAHL, PsycINFO and Cochrane Library electronic databases for studies that evaluated relevant interventions. Experimental, quasi-experimental and observational studies published in English prior to August 2018 were included. Data were synthesised at a narrative level.

RESULTS

The 18 studies accepted for review included seven randomised, two nonrandomised controlled, five quasi-experimental and four observational studies. Half the studies were conducted in nursing homes and the other half in hospital and community settings. There was great variability in the interventions and outcomes reported and a meta-analysis was not feasible. The three randomised and four nonrandomised studies examining medication appropriateness all reported improvements on at least one measure of the outcome. Six studies reported on interventions that identified and resolved drug-related problems. The results for other outcomes, including the number of medications (10 studies), healthcare utilisation (7 studies), mortality (7 studies), quality of life (3 studies) and falls (3 studies), were mixed and difficult to synthesise because of variability in the study design and measures used.

CONCLUSION

Emerging evidence suggests that interventions in older people with dementia may have positive effects on medication appropriateness and resolution of drug-related problems; however, whether optimisation of medication results in clinically meaningful outcomes remains uncertain.

Health Outcomes of Deprescribing Interventions Among Older Residents in Nursing Homes: A Systematic Review and Meta-analysis

OBJECTIVES

Deprescribing is effective in addressing concerns relating to polypharmacy in residents of nursing homes. However, the clinical outcomes of deprescribing interventions among residents in nursing homes are not well understood. We evaluated the impact of deprescribing interventions by health care professionals on clinical outcomes among the older residents in nursing homes.

DESIGN

Systematic review and meta-analysis of randomized controlled trials. CINAHL, International Pharmaceutical Abstracts, MEDLINE, EMBASE, and Cochrane Library were searched from inception until September 2017; manual searches of reference lists of systematic reviews identified in the electronic search; and online trial registries for unpublished, ongoing, or planned trials. (PROSPERO CRD42016050028).

SETTING AND PARTICIPANTS

Randomized controlled trials in a nursing home setting that included participants of at least 60 years of age.

MEASURES

Falls, all-cause mortality, hospitalization, and potentially inappropriate medication were assessed in the meta-analysis.

RESULTS

A total of 41 randomized clinical studies (18,408 residents) that examined deprescribing (defined as either medication discontinuation, substitution, or reduction) in nursing were identified. Deprescribing interventions significantly reduced the number of residents with potentially inappropriate medications by 59% (odds ratio [OR] 0.41, 95% confidence interval [CI] 0.19-0.89). In subgroup analysis, medication review-directed deprescribing interventions reduced all-cause mortality by 26% (OR 0.74, 95% CI 0.65-0.84), as well as the number of fallers by 24% (OR 0.76, 95% CI 0.62-0.93).

CONCLUSIONS

Compared to other deprescribing interventions, medication review-directed deprescribing had significant benefits on older residents in nursing homes. Further research is required to elicit other clinical benefits of medication review-directed deprescribing practice.

Systematic review showed that stepped-wedge cluster randomized trials often did not reach their planned sample size

OBJECTIVE

To determine how often stepped-wedge cluster randomized controlled trials reach their planned sample size, and what reasons are reported for choosing a stepped-wedge trial design.

STUDY DESIGN AND SETTING

We conducted a PubMed literature search (period 2012 to 2017) and included articles describing the results of a stepped-wedge cluster randomized trial. We calculated the percentage of studies reaching their prespecified number of participants and clusters, and we summarized the reasons for choosing the stepped-wedge trial design as well as difficulties during enrollment.

RESULTS

Forty-six individual stepped-wedge studies from a total of 53 articles were included in our review. Of the 35 studies, for which recruitment rate could be calculated, 69% recruited their planned number of participants, with 80% having recruited the planned number of clusters. Ethical reasons were the most common motivation for choosing the stepped-wedge trial design. Most important difficulties during study conduct were dropout of clusters and delayed implementation of the intervention.

CONCLUSION

About half of recently published stepped-wedge trials reached their planned sample size indicating that recruitment is also a major problem in these trials. Still, the stepped-wedge trial design can yield practical, ethical, and methodological advantages.

Association of Focused Medication Review With Optimization of Psychotropic Drug Prescribing: A Systematic Review and Meta-analysis

IMPORTANCE

Medication review has been proposed to achieve improved use of psychotropic drugs, but benefits have not been confirmed.

OBJECTIVE

To synthesize evidence for focused psychotropic medication review in medication optimization.

DATA SOURCES

Medline, PsycINFO, EMBASE, and CINAHL Plus were searched from inception to February 2018 using the index terms "drug utilization review" and "psychotropic drugs" and synonyms. Additional articles were retrieved using citation tracking and reference checking.

STUDY SELECTION

Full-length, peer-reviewed articles that reported focused psychotropic medication review were included. Inclusion was determined against prespecified criteria and assessed independently.

DATA EXTRACTION AND SYNTHESIS

Study quality was assessed using National Institutes for Health appraisal tools and informed a structured synthesis of results. Meta-analysis using a random effects model was conducted.

MAIN OUTCOMES AND MEASURES

Change in the number or dosage of psychotropic medications, change in clinical parameters, change in patient-reported outcomes, and economic data were collected.

RESULTS

A total of 26 studies met the inclusion criteria. Four studies were randomized clinical trials (n = 712 participants), while the remainder were before-after studies (n = 7844 participants). Most studies were conducted in elderly individuals, people with dementia, and adults with intellectual disability. Focused psychotropic medication review is a complex intervention; the professional(s) involved, target drug, degree of integration with usual care, and participant involvement varied greatly among the studies. Meta-analysis included 3 studies (n = 652 participants). Psychotropic medication review was associated with a reduction in prescribing of psychotropic drugs compared with control (pooled odds ratio, 0.24; 95% CI, 0.14-0.39) in elderly participants with cognitive impairment living in nursing homes. Before-after studies consistently reported a change in psychotropic drug prescribing after medication review, regardless of the population. Studies that reported the effects of psychotropic medication review on clinical outcomes failed to demonstrate benefit. Economic implications of focused psychotropic medication review were not adequately assessed. The quality of evidence is poor and studies are at risk of bias.

CONCLUSIONS AND RELEVANCE

Focused psychotropic medication review was associated with a reduction in prescribing of psychotropic drugs, but has not been shown to improve clinical outcomes or to provide economic benefit. More robust evidence is needed before programs of focused psychotropic medication review can be recommended as part of routine care for any patient group.

Nurse-led medicines' monitoring in care homes study protocol: a process evaluation of the impact and sustainability of the adverse drug reaction (ADRe) profile for mental health medicines

INTRODUCTION

Improved medicines' management could lead to real and sustainable improvements to the care of older adults. The overuse of mental health medicines has featured in many reports, and insufficient patient monitoring has been identified as an important cause of medicine-related harms. Nurse-led monitoring using the structured adverse drug reaction (ADRe) profile identifies and addresses the adverse effects of mental health medicines. Our study investigates clinical impact and what is needed to sustain utilisation in routine practice in care homes.

METHODS AND ANALYSIS

This process evaluation will use interviews and observations with the participants of all five homes involved in earlier research, and five newly recruited homes caring for people prescribed mental health medicines. The ADRe profile is implemented by nurses, within existing resources, to check for signs and symptoms of ADRs, initiate amelioration and share findings with pharmacists and prescribers for medication review. Outcome measures are the numbers and nature of problems addressed and understanding of changes needed to optimise clinical gain and sustain implementation. Data will be collected by 30 observations and 30 semistructured interviews. Clinical gains will be described and narrated. Interview analysis will be based on the constant comparative method.

ETHICS AND DISSEMINATION

Ethical approval was conferred by the National Health Service Wales Research Ethics Committee. If the ADRe profile can be sustained in routine practice, it has potential to (1) improve the lives of patients, for example, by reducing pain and sedation, and (2) assist in early identification of problems caused by ADRs. Therefore, in addition to peer-reviewed publications and conferences, we shall communicate our findings to healthcare professionals, policy-makers and sector regulators.

TRIAL REGISTRATION NUMBER

NCT03110471.

Adverse Drug Reactions, Power, Harm Reduction, Regulation and the ADRe Profiles

The power and influence of healthcare systems comes largely from the ability to prescribe efficacious medicine. However, medicine can sometimes cause harm rather than bring benefits. Systematically checking patients for the adverse effects of medicines, as listed in manufacturers' literature, would protect patients from iatrogenic harm, but this is rarely undertaken. We argue for the benefits of this approach using the example of the prescription of antipsychotics to older adults. Prescribing antipsychotics to control challenging behaviours associated with dementia is a controversial matter, and regulatory intervention is under discussion. Improved regulatory systems could protect against iatrogenic harm, such as over-sedation, falls, tremor, or drug-induced Parkinsonism. However, measuring the impact and outcomes of regulatory interventions has proved difficult, not least because there are rarely systematic records of all adverse effects of medicines. We indicate how regulatory initiatives to reduce antipsychotic prescribing can be supported by systematic monitoring and documentation of patients' signs and symptoms of putative adverse drug reactions. Monitoring documentation then provides the rationale and support for professionals' responses to identified problems. Longitudinal monitoring records would improve understanding of the impact and outcomes of adverse drug reactions (ADRs) on health and wellbeing, and the many costs of ADRs.

Patient Safety and Pro Re Nata Prescription and Administration: A Systematic Review

PRN is the acronym for 'pro re nata,' written against prescriptions whose administration should be based on patients' needs, rather than at set times. The aim of this systematic review was to explore safety issues and adverse events arising from PRN prescription and administration. Electronic databases including Scopus, PubMed [including Medline], Embase, Cinahl, Web of Science and ProQuest were systematically searched to retrieve articles published from 2005 to 2017.

SELECTION CRITERIA

we included all randomized controlled trials (RCTs) and studies with comparison groups, comparing PRN prescription and administration with scheduled administration, where safety issues and adverse events were reported. The authors independently assessed titles, abstracts and full-texts of retrieved studies based on inclusion criteria and risk of bias. Results were summarised narratively. The search identified 7699 articles. Title, abstract and full-text appraisals yielded 5 articles. The included studies were RCTs with one exception, a pre-test post-test experimental design. Patient populations, interventions and outcomes varied. Studies compared patient-controlled or routine administration with PRN and one trial assessed the effect of a practice guideline on implementation of PRN administration. More analgesia was administered in the patient-controlled than the PRN arms but pain reduction was similar. However, there was little difference in administration of psychotropic medicines. No differences between patient-controlled and PRN groups were reported for adverse events. The PRN practice guideline improved PRN patient education but non-documentation of PRN administration increased. This systematic review suggests that PRN safety issues and adverse events are an under-researched area of healthcare practice. Variations in the interventions, outcomes and clinical areas make it difficult to judge the overall quality of the evidence. Well-designed RCTs are needed to identify any safety issues and adverse events associated with PRN administration.

Pharmaceutical care services to people living with dementia in care homes: A qualitative study of community pharmacists' perceptions

There is a paucity of information on the perceptions of community pharmacists about the nature and effectiveness of pharmaceutical care services they provide to people living with dementia in care homes. This paper explores pharmacists’ perceptions of the nature and effectiveness of pharmacy services provided, and their experiences when providing these services. Community pharmacists delivering services to care homes with dementia in Thurrock, Essex and in Medway, Kent, England were invited to participate in the study involving face-to-face interviews. Analysis of semi-structured interviews with 15 community pharmacists revealed that the main pharmaceutical service provided by the pharmacists was prescription processing, normally involving the clinical review and supply of medication into monitored dosage systems (dosette boxes) and delivery to the homes. This was coupled with advice to care homes on the appropriate storage and administration of drugs and appliances supplied, which was in line with the NHS Community Pharmacy Contractual Framework Enhanced Service for care homes. A majority of the community pharmacists interviewed acknowledged that the services they were currently commissioned to provide did not meet the pharmaceutical care needs of dementia patients in care homes, including the monitoring of the appropriateness, safety and effectiveness of drug therapy.

Testing an explanatory model of nurses' intention to report adverse drug reactions in hospital settings

AIM

To test an explanatory model of nurses' intention to report adverse drug reactions in hospital settings, based on the theory of planned behaviour.

BACKGROUND

Under-reporting of adverse drug reactions is an important problem among nurses.

METHODS

A cross-sectional design was used. Data were collected with the adverse drug reporting nurses' questionnaire. Confirmatory factor analysis was performed to test the factor validity of the adverse drug reporting nurses' questionnaire, and structural equation modelling was used to test the explanatory model.

RESULTS

The convenience sample comprised 500 Italian hospital nurses (mean age = 43.52). Confirmatory factor analysis supported the factor validity of the adverse drug reporting nurses' questionnaire. The structural equation modelling showed a good fit with the data. Nurses' intention to report adverse drug reactions was significantly predicted by attitudes, subjective norms and perceived behavioural control (R² = 0.16).

CONCLUSIONS

The theory of planned behaviour effectively explained the mechanisms behind nurses' intention to report adverse drug reactions, showing how several factors come into play.

IMPLICATIONS FOR NURSING MANAGEMENT

In a scenario of organisational empowerment towards adverse drug reaction reporting, the major predictors of the intention to report are support for the decision to report adverse drug reactions from other health care practitioners, perceptions about the value of adverse drug reaction reporting and nurses' favourable self-assessment of their adverse drug reaction reporting skills.

Lessons Learned and Questions Raised by an Atypical Case of Clozapine-Induced Myocarditis

A Caucasian male in his early twenties suffering from treatment resistant schizophrenia was started on clozapine. After three days he developed tachycardia, a common side effect of clozapine induction. He had one temperature spike (38.9°C) on day ten after induction but remained clinically well. An ECG and blood tests were normal. Due to persistent tachycardia and an episode of collapse whilst seated on day 12, he was admitted to hospital for further investigation. A diagnosis of myocarditis was confirmed as a result of elevated cardiac enzyme levels and an echocardiogram. Following withdrawal of clozapine, supportive management, and initiation of cardiac medication, the patient made a successful recovery. He will be followed up with the cardiology team to ensure that his heart function returns to normal. Given the incidence of clozapine-induced myocarditis, the associated mortality risk, and diagnostic difficulties, this case raises questions about whether a formal system for identifying myocarditis should be adopted.

Interprofessional Care in the Management of Alzheimer's Dementia: Leaving Our Silos

As speech-language pathologists (SLPs), we are poised to become leaders in the caring of adults with dementia; however, because of the complexity of this health condition, and its impact on patients and families, we must move beyond discipline-specific approaches to intervention and embrace the opportunities that arise when working across professional silos. The application of principles of interprofessional education (IPE) and interprofessional practice (IPP) can be applied to maximize Alzheimer's dementia care. In this paper, the organizational characteristics supporting IPP will be highlighted, an outline of applications of training procedures to promote IPP in a rehabilitation environment will be reviewed, and real-world case studies will be provided to highlight salient principles.