Healthcare Professionals' Views on the Management of Medication Complexities in the Elderly With Mental Health Disorders: A Cross-Sectional Study

BACKGROUND

Many challenges in elderly pharmacotherapy are identified, including the use of Potentially Inappropriate Medications (PIMs) which may increase the odds of adverse events, especially in elderly patients with mental health disorders (e. g., behavioral, and psychological symptoms of dementia-BPSD, schizophrenia, bipolar disorder). However, information on the knowledge and practice of healthcare professionals (HCPs) about this topic is still scarce.

METHODS

A cross-sectional study was undertaken from July-October 2019. An online questionnaire was specifically designed and validated for this study. We sought HCPs (physicians, pharmacists, and nurses) worldwide, using (a) social media, via Facebook, Twitter, and LinkedIn; and (b) email contacts of the research team (convenience sample). Either way participants were asked to share on their social media or via e-mail the questionnaires with other HCPs (snowballing sample). The survey assessed two main domains: knowledge and practice. Knowledge was evaluated by self-report (perceived knowledge by a 5-item Likert confidence scale) and using three clinical cases, scored between 0 and 30 points (each one rated from 0 to 10 points; real knowledge). Barriers in clinical practice were evaluated using a 5-item Likert scale judging practitioners' opinion.

RESULTS

A total of 165 questionnaires were collected. HCPs were mainly female (n = 114; 69.1%), with a mean age of 35.3 ± 11.3 years old. Seventy-two percent (n = 118) were pharmacists, 21.1% (n = 35) were physicians, and 7.3% (n = 12) nurses. There was a weak correlation, albeit significant, between perceived and real knowledge (r = 0.199; p = 0.001). The mean score of the clinical vignettes regarding elderly patients with dementia and bipolar disorder were 4.59 ± 4.08 and 4.86 ± 2.97 points, respectively. Most HCPs were classified as having an intermediate knowledge (n = 100; 60.6%) about medication complexities in the elderly with mental disorders. Most HCPs agreed that lack of time (81.6%; n = 138), lack of education and training on elderly pharmacotherapy (72.2%; n = 122), and lack of tools adapted to daily practice (61.8%; n = 105) were the main barriers.

CONCLUSIONS

Most of the HCPs felt confident to manage medication complexities in elder patients with mental disorders, but only a minority obtained a good score in the knowledge assessment test. The main barriers identified included structural barriers (tools unfit for practice) and process barriers (time).

The association between receptor binding affinity and metabolic side effect profile of antipsychotics and major cardio- and cerebrovascular events: A case/non-case study using VigiBase

Antipsychotics (APs) have been associated with major adverse cardio- and cerebrovascular events (MACCE), but the underlying mechanisms are unclear. Our aim was to elucidate the association between APs, stratified for receptor affinity and metabolic side effects (MSE), in the reporting of MACCE. A case/non-case study was conducted using data from the WHO global Individual Case Safety Report (ICSR) database, VigiBase, among all reports associated with an AP. Cases were ICSRs of MACCE, while non-cases were all other adverse drug reactions (ADRs). APs were classified by AP group, the degree of receptor affinity for adrenergic, dopaminergic, muscarinic, histaminic, and serotoninergic receptors and by MSE profile. The strength of the association was estimated with logistic regression and expressed as crude and adjusted reporting odds ratios (ROR_adj.) with corresponding 95% confidence intervals (95%CIs). We identified 4987 reports of MACCE and 328,907 reports of other ADRs. Atypical APs (ROR_adj. 2.46; 95%CI 2.20-2.74) were significantly associated with the reporting of MACCE compared to typical ones. APs with high affinity for Adrenergic alfa-1 (ROR_adj. 2.98; 95%CI 1.93-4.59), Histaminic H₁ (ROR_adj. 2.31; 95%CI 1.98-2.68), Muscarinic M₁ (ROR_adj. 1.87; 95%CI 1.74-2.01), and Serotoninergic 5-HT_2A (ROR_adj. 3.19; 95%CI 2.07-4.92) were associated with a higher risk of reporting of MACCE compared to low affinity. APs with higher-risk of MSE were associated with higher risk of reporting of MACCE (ROR_adj. 1.88; 95%CI 1.73-2.05) compared to the lower-risk. APs with high affinity for Adrenergic alfa-1, Histaminic H₁, Muscarinic M₁, and Serotoninergic 5-HT_2A receptors and with high-risk of MSE may explain the occurrence of those events.

Identification of a Set of Patient-Related Features to Foster Safe Prescribing of Specific Antipsychotics in the Elderly With Dementia

Background: Antipsychotics (APs) are widely used to manage behavioral and psychiatric symptoms in dementia, although with a variety of adverse drug reactions. Therefore, it is important to know which patient-related features should be considered to foster a safe prescribing of these medications. Objectives: To compile and validate a set of patient-related features (PRFs) to foster safe prescribing of specific APs in the elderly with dementia; and to evaluate the feasibility of using them in clinical practice by analyzing the exhaustiveness of medical records. Method: A rapid literature review was the starting point, where PRFs were identified through a search in PubMed combined with information from the Summary of Product Characteristics (SmPCs). In the next step, a two-round e-Delphi survey was undertaken, where a total of 450 participants were invited by e-mail, including prescribers and specialists in benefit-risk assessment. Finally, a cross-sectional study was undertaken, where 100 patients were randomly extracted from the psychiatric hospital database. Outcomes were defined as the assessment of the clinical relevance and feasibility of the PRFs, and the level of exhaustiveness of these features in medical records. Data analysis was performed using univariate statistics (IBM SPSS v.23.0). Results: A total of 92 experts participated in the e-Delphi. Forty-seven PRFs obtained consensus, where 12 were applicable to haloperidol, 14 to olanzapine/risperidone, 13 to quetiapine, and 8 to aripiprazole. Age, comorbidities, and co-medications were rated as important features regardless of the prescribed drug. All PRFs were rated as always or frequently available and, if not, they were easy or partially easy to obtain. Age, comorbidities, and co-medications were always available in the medical records, whereas cognitive status (between 41.4 and 78.8%) or hepatic function (between 17.2 and 30.4%) presented a low-level of exhaustiveness. Conclusions: Even though a high number of PRFs were rated as clinically relevant, some of them were identified as frequently missing from medical records. This may suggest that medical records should be complemented with other sources (e.g., nursing and pharmacy records) to ensure a safe prescribing of APs.

Identification of potentially inappropriate medications with risk of major adverse cardiac and cerebrovascular events among elderly patients in ambulatory setting and long-term care facilities

Purpose

Cardiovascular diseases (CVDs) are extremely common among the elderly, but information on the use of potentially inappropriate medications (PIMs) with cardiovascular risk is scarce. We aimed to determine the prevalence of PIMs with risk of cardiac and cerebrovascular adverse events (CCVAEs), including major adverse cardiac and cerebrovascular events (MACCE).

Patients and methods

A cross-sectional study was performed using a convenience sample from four long-term care facilities and one community pharmacy in Portugal. Patients were included if they were aged 65 or older and presented at least one type of medication in their medical and pharmacotherapeutic records from 2015 until December 2017. The main outcome was defined as the presence of PIMs with risk of MACCE and was assessed by applying a PIM-MACCE list that was developed from a previous study. All medications included in this list were assessed for their availability in Portugal.

Results

A total of 680 patients were included. Of those, 428 (63%) were female with a mean age of 78.4±8.1 years. Four-hundred and four (59.4%) patients were taking medications associated with CCVAEs risk (mean =1.7±1.0 drugs/patient), including 264 patients (38.8%) who used drugs with MACCE risk (mean =1.4±0.8 drugs/patient). Fifty percent of patients with a previous history of CVD (n=521) were taking PIMs with risk of CCVAEs, including 30.0% with risk of MACCE.

Conclusion

Our findings show that 50% of patients with previous history of CVD were taking drugs with risk of CCAVEs and 30% with risk of MACCE. More tailored tools for the management of drug therapy in elderly patients with CVD are of major importance in clinical practice.