Pilot study to evaluate the need and implementation of a multifaceted nurse-led antimicrobial stewardship intervention in residential aged care.

Objectives: To evaluate the need and feasibility of a nurse-led antimicrobial stewardship (AMS) programme in two Australian residential aged care homes (RACHs) to inform a stepped-wedged, cluster randomized controlled trial (SW-cRCT). Methods: A mixed-methods pilot study of a nurse-led AMS programme was performed in two RACHs in Victoria, Australia (July-December 2019). The AMS programme comprised education, infection assessment and management guidelines, and documentation to support appropriate antimicrobial use in urinary, lower respiratory and skin/soft tissue infections. The programme was implemented over three phases: (i) pre-implementation education and integration (1 month); (ii) implementation of the intervention (3 months); and (iii) post-intervention evaluation (1 month). Baseline RACH and resident data and weekly infection and antimicrobial usage were collected and analysed descriptively to evaluate the need for AMS strategies. Feedback on intervention resources and implementation barriers were identified from semi-structured interviews, an online staff questionnaire and researcher field notes. Results: Six key barriers to implementation of the intervention were identified and used to refine the intervention: aged care staffing and capacity; access to education; resistance to practice change; role of staff in AMS; leadership and ownership of the intervention at the RACH and organization level; and family expectations. A total of 61 antimicrobials were prescribed for 40 residents over the 3 month intervention. Overall, 48% of antibiotics did not meet minimum criteria for appropriate initiation (respiratory: 73%; urinary: 54%; skin/soft tissue: 0%). Conclusions: Several barriers and opportunities to improve implementation of AMS in RACHs were identified. Findings were used to inform a revised intervention to be evaluated in a larger SW-cRCT.

TANGO: Development of Consumer Information Leaflets to Support TAperiNG of Opioids in Older Adults with Low Back Pain and Hip and Knee Osteoarthritis.

INTRODUCTION: Globally, the rate of opioid prescription is high for chronic musculoskeletal conditions despite guidelines recommending against their use as their adverse effects outweigh their modest benefit. Deprescribing opioids is a complex process that can be hindered by multiple prescriber- and patient-related barriers. These include fear of the process of, or outcomes from, weaning medications, or a lack of ongoing support. Thus, involving patients, their carers, and healthcare professionals (HCPs) in the development of consumer materials that can educate and provide support for patients and HCPs over the deprescribing process is critical to ensure that the resources have high readability, usability, and acceptability to the population of interest. OBJECTIVE: This study aimed to (1) develop two educational consumer leaflets to support opioid tapering in older people with low back pain (LBP) and hip or knee osteoarthritis (HoKOA), and (2) evaluate the perceived usability, acceptability, and credibility of the consumer leaflets from the perspective of consumers and HCPs. DESIGN: This was an observational survey involving a consumer review panel and an HCP review panel. PARTICIPANTS: 30 consumers (and/or their carers) and 20 HCPs were included in the study. Consumers were people older than 65 years of age who were currently experiencing LBP or HoKOA, and with no HCP background. Carers were people who provided unpaid care, support, or assistance to an individual meeting the inclusion criteria for consumers. HCPs included physiotherapists (n = 9), pharmacists (n = 7), an orthopaedic surgeon (n = 1), a rheumatologist (n = 1), nurse practitioner (n = 1) and a general practitioner (n = 1), all with at least three years of clinical experience and who reported working closely with this target patient population within the last 12 months. METHODS: Prototypes of two educational consumer leaflets (a brochure and a personal plan) were developed by a team of LBP, OA, and geriatric pharmacotherapy researchers and clinicians. The leaflet prototypes were evaluated by two separate chronological review panels involving (1) consumers and/or their carers, and (2) HCPs. Data collection for both panels occurred via an online survey. Outcomes were the perceived usability, acceptability, and credibility of the consumer leaflets. Feedback received from the consumer panel was used to refine the leaflets, before circulating the leaflets for further review by the HCP panel. Additional feedback from the HCP review panel was then used to refine the final versions of the consumer leaflets. RESULTS: Both consumers and HCPs perceived the leaflets and personal plan to be usable, acceptable, and credible. Consumers rated the brochure against several categories, which scored between 53 and 97% positive responses. Similarly, the overall feedback provided by HCPs was 85-100% positive. The modified System Usability Scale scores obtained from HCPs was 55-95% positive, indicating excellent usability. Feedback for the personal plan from both HCPs and consumers was largely positive, with consumers providing the highest positive ratings (80-93%). While feedback for HCPs was also high, we did identify that prescribers were hesitant to provide the plan to patients frequently (no positive responses). CONCLUSIONS: This study led to the development of a leaflet and personal plan to support the reduction of opioid use in older people with LBP or HoKOA. The development of the consumer leaflets incorporated feedback provided by HCPs and consumers to maximise clinical effectiveness and future intervention implementation.

Opioids are medications that are often used to treat severe or chronic pain. However, they can have serious adverse effects and are not usually recommended for long-term use. This study aimed to create educational materials for patients with chronic low back pain or hip or knee osteoarthritis who are taking opioids and to evaluate the materials' perceived usability, acceptability, and credibility from the perspective of both healthcare professionals (HCPs) and patients. The materials included a brochure and a personal plan and were developed by a team of researchers and clinicians. Both materials were evaluated by HCPs and patients in separate review panels. The brochure and personal plan were found to be usable, acceptable, and credible by both groups. The materials were created to support patients in reducing their opioid use and were refined based on feedback from both HCPs and patients. The materials may be useful in supporting the complex process of tapering off opioids, which can be hindered by various barriers related to both patients and HCPs.

Multicentre stepped-wedge cluster randomised controlled trial of an antimicrobial stewardship programme in residential aged care: protocol for the START trial.

INTRODUCTION: Antimicrobial resistance is a growing global health threat, driven by increasing inappropriate use of antimicrobials. High prevalence of unnecessary use of antimicrobials in residential aged care facilities (RACFs) has driven demand for the development and implementation of antimicrobial stewardship (AMS) programmes. The Stepped-wedge Trial to increase antibiotic Appropriateness in Residential aged care facilities and model Transmission of antimicrobial resistance (START) will implement and evaluate the impact of a nurse-led AMS programme on antimicrobial use in 12 RACFs. METHODS AND ANALYSIS: The START trial will implement and evaluate a nurse-led AMS programme via a stepped-wedge cluster randomised controlled trial design in 12 RACFs over 16 months. The AMS programme will incorporate education, aged care-specific treatment guidelines, documentation forms, and audit and feedback strategies that will target aged care staff, general practitioners, pharmacists, and residents and their families. The intervention will primarily focus on urinary tract infections, lower respiratory tract infections, and skin and soft tissue infections. RACFs will transition from control to intervention phases in random order, two at a time, every 2 months, with a 2-month transition, wash-in period. The primary outcome is the cumulative proportion of residents within each facility prescribed an antibiotic during each month and total days of antibiotic use per 1000 occupied bed days. Secondary outcomes include the number of courses of systemic antimicrobial therapy, antimicrobial appropriateness, antimicrobial resistant organisms, Clostridioides difficile infection, change in antimicrobial susceptibility profiles, hospitalisations and all-cause mortality. Analyses will be conducted according to the intention-to-treat principle. ETHICS AND DISSEMINATION: Ethics approval has been granted by the Alfred Hospital Human Research Ethics Committee (HREC/18/Alfred/591). Research findings will be disseminated through peer-reviewed publications, conferences and summarised reports provided to participating RACFs. TRIAL REGISTRATION NUMBER: NCT03941509.

Multiple antihypertensive use and risk of mortality in residents of aged care services: a prospective cohort study.

AIMS: The objective of this study is to investigate the association between multiple antihypertensive use and mortality in residents with diagnosed hypertension, and whether dementia and frailty modify this association. METHODS: This is a two-year prospective cohort study of 239 residents with diagnosed hypertension receiving antihypertensive therapy across six residential aged care services in South Australia. Data were obtained from electronic medical records, medication charts and validated assessments. The primary outcome was all-cause mortality and the secondary outcome was cardiovascular-related hospitalizations. Inverse probability weighted Cox models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause mortality. Covariates included age, sex, dementia severity, frailty status, Charlson's comorbidity index and cardiovascular comorbidities. RESULTS: The study sample (mean age of 88.1 ± 6.3 years; 79% female) included 70 (29.3%) residents using one antihypertensive and 169 (70.7%) residents using multiple antihypertensives. The crude incidence rates for death were higher in residents using multiple antihypertensives compared with residents using monotherapy (251 and 173/1000 person-years, respectively). After weighting, residents who used multiple antihypertensives had a greater risk of mortality compared with monotherapy (HR 1.40, 95%CI 1.03-1.92). After stratifying by dementia diagnosis and frailty status, the risk only remained significant in residents with diagnosed dementia (HR 1.91, 95%CI 1.20-3.04) and who were most frail (HR 2.52, 95%CI 1.13-5.64). Rate of cardiovascular-related hospitalizations did not differ among residents using multiple compared to monotherapy (rate ratio 0.73, 95%CI 0.32-1.67). CONCLUSIONS: Multiple antihypertensive use is associated with an increased risk of mortality in residents with diagnosed hypertension, particularly in residents with dementia and among those who are most frail.

Development of consumer information leaflets for deprescribing in older hospital inpatients: a mixed-methods study.

OBJECTIVE: To develop information leaflets for older inpatients and/or their carers to support deprescribing of antipsychotics, benzodiazepines/Z-drugs and proton pump inhibitors (PPIs). DESIGN: An iterative mixed-methods approach involving face-to-face user testing and semi-structured interviews was performed over three rounds with consumers and hospital health professionals. SETTING: Sydney, New South Wales, Australia. PARTICIPANTS: Thirty-seven consumers (or their carers) aged 65 years or older admitted to hospital in the previous 5 years and taking at least one regular medicine (not the medicine tested) completed user testing. Health professionals included a convenience sample of seven pharmacists and five doctors. METHODS: The antipsychotic leaflet was tested in round 1 (consumers, n=10) and revised and retested in round 2 (consumers, n=9; health professionals, n=5). Findings from rounds 1 and 2 informed the design of the benzodiazepine/Z-drug and PPI leaflets tested in round 3 (benzodiazepine/Z-drug consumers, n=9; health professionals, n=7; PPI consumers, n=9). Findings from round 3 informed the final design of all leaflets. Consumer user testing involved 12-13 questions to evaluate consumers' ability to locate and understand information in the leaflet. Usability by health professionals was assessed using the System Usability Scale (SUS). RESULTS: At least 80% of consumers correctly found and understood the deprescribing information in the leaflets (9 of 12 information points in round 1 (antipsychotic); 10 of 12 in round 2; 12 of 13 (benzodiazepine/Z-drug) and 11 of 12 (PPI) in round 3). Consumers perceived the leaflets to be informative, well-designed and useful aids for ongoing medication management. The SUS scores obtained from health professionals were 91.0±3.8 for the antipsychotic leaflet and 86.4±6.6 for the benzodiazepine/Z-drug leaflet, indicating excellent usability. CONCLUSIONS: Understandable and easy-to-use consumer information leaflets were developed and tested by consumers and health professionals. The feasibility and utility of these leaflets to support deprescribing at transitions of care should be explored in clinical practice.

Change in Prescribing for Secondary Prevention of Stroke and Coronary Heart Disease in Finnish Nursing Homes and Assisted Living Facilities.

BACKGROUND: One quarter of residents in long-term care facilities (LTCFs) have a diagnosis of CHD or stroke and over half use at least one preventative cardiovascular medication. There have been no studies that have investigated the longitudinal change in secondary preventative cardiovascular medication use in residents in LTCFs over time. OBJECTIVE: The aim of this study was to investigate the change in cardiovascular medication use among residents with coronary heart disease (CHD) and prior stroke in nursing homes (NHs) and assisted living facilities (ALFs) in Finland over time, and whether this change differs according to dementia status. METHODS: Three comparable cross-sectional audits of cardiovascular medication use among residents aged 65 years and over with CHD or prior stroke in NHs in 2003 and 2011 and ALFs in 2007 and 2011 were compared. Logistic regression analyses adjusted for gender, age, mobility, cancer and length of stay were performed to examine the effect of study year, dementia and their interaction on medication use. RESULTS: Cardiovascular medication use among residents with CHD (NHs: 89% vs 70%; ALFs: 89% vs 84%) and antithrombotic medication use among residents with stroke (NHs: 72% vs 63%; ALFs: 78% vs 69%) declined between 2003 and 2011 in NHs and 2007 and 2011 in ALFs. Decline in the use of diuretics, nitrates and digoxin were found in both groups and settings. Cardiovascular medication use among residents with CHD and dementia declined in NHs (88% [95% CI 85-91] in 2003 vs 70% [95% CI 64-75] in 2011) whereas there was no change among people without dementia. There was no change in cardiovascular medication use among residents with CHD in ALFs with or without dementia over time. Antithrombotic use was lower in residents with dementia compared with residents without dementia in NHs (p < 0.001) and ALFs (p = 0.026); however, the interaction between dementia diagnosis and time was non-significant. CONCLUSIONS: The decline in cardiovascular medication use in residents with CHD and dementia suggests Finnish physicians are adopting a more conservative approach to the management of cardiovascular disease in the NH population.

Harms associated with extramedical use of prescription opioid analgesics in Australia: A scoping review.

BACKGROUND: Evidence is accumulating globally on harms from extramedical prescription opioid analgesic (POA) use. OBJECTIVE: The aim of this scoping review was to explore harms and documented risk factors associated with extramedical POA use in Australia. METHODS: MEDLINE, EMBASE, PsycINFO and CINAHL were searched for original studies published between January 2000 and February 2018. Studies were eligible for inclusion if: 1) POA use was explicitly reported, 2) extramedical use was evident 3) harm was explicitly reported, 4) data were collected in/after 2000, 5) conducted in adults and 6) undertaken in Australia. RESULTS: We identified 560 articles and 16 met the inclusion criteria. Harms reported from extramedical POA use included: increased health service utilization (n = 5), non-fatal overdose (n = 6), fatal overdose (n = 5), injection-related injuries or diseases (n = 4), engagement in crime (n = 2), loss of employment (n = 1), and foreign body pulmonary embolization (n = 1). Multiple drug toxicity was reported as the cause of death in up to 83% of fatal overdose cases. Risk factors for harm included being male, aged 31-49 years, a history of chronic non-cancer pain, mental health disorders and/or substance abuse, and concomitant use of benzodiazepines, antidepressants or other centrally-acting substances. CONCLUSION: Extramedical use of POAs is associated with a range of harms, including fatal and non-fatal overdose. Polysubstance use with other centrally-acting substances was often implicated. No published studies used linked data sources to provide a comprehensive overview of the extent of POA use or harm in Australia. Future research should focus on undertaking longitudinal cohort studies with linked data sources.

A review of coronial investigations into medication-related deaths in residential aged care.

BACKGROUND: Residential aged care is a complex and challenging clinical setting where medication errors continue to occur despite efforts to improve medication safety. No studies have sought to review and synthesize coronial investigations into medication-related deaths in Australian residential aged care facilities (RACFs). OBJECTIVE: To review coronial investigations into medication-related deaths in Australian RACFs. METHODS: A national review of medication-related deaths between July 2000 and July 2013 reported to Australian Coroners was performed. Data were extracted from the National Coronial Information System and errors categorized according to stages of the medication management cycle. RESULTS: The database search identified thirty coronial investigations into deaths. Single medication classes were implicated in 22 deaths; including opioids (n = 7), antipsychotics (n = 4) and antidepressants (n = 3). Eight deaths resulted from two or more medication classes. Thirteen deaths reported stages of medication errors, including administration (n = 9) and monitoring (n = 4). Coroners made recommendations following three deaths; including education and training on dose administration aids, regulation of personal care workers, and protocol-based renal function monitoring for residents taking digoxin. CONCLUSIONS: Deaths involving high-risk medications occurred primarily at the stages of administration and monitoring. Few investigations resulted in specific recommendations, however it is unknown whether these were implemented.

Prevalence and Variability in Medications Contributing to Polypharmacy in Long-Term Care Facilities.

BACKGROUND: Research into which medications contribute to polypharmacy and the variability in these medications across long-term care facilities (LTCFs) has been minimal. OBJECTIVE: Our objective was to investigate which medications were more prevalent among residents with polypharmacy and to determine the variability in prescribing of these medications across LTCFs. METHODS: This was a cross-sectional study of 27 LTCFs in regional and rural Victoria, Australia. An audit of the medication charts and medical records of 754 residents was performed in May 2015. Polypharmacy was defined as nine or more regular medications. Logistic regression was performed to determine the association between medications and resident characteristics with polypharmacy. Analyses were adjusted for age, sex and Charlson's comorbidity index. Variability in the use of the ten most prevalent medication classes was explored using funnel plots. Characteristics of LTCFs with low (< 30%), moderate (30-49%) and high (≥ 50%) polypharmacy prevalence were compared. RESULTS: Polypharmacy was observed in 272 (36%) residents. In adjusted analyses, each of the top ten most prevalent medication classes, with the exception of antipsychotics, were associated with polypharmacy. Between 7 and 23% of LTCFs fell outside the 95% control limits for each of the ten most prevalent medications. LTCFs with ≥ 50% polypharmacy prevalence were predominately smaller. CONCLUSION: Polypharmacy was associated with nine of the ten most prevalent medication classes. There was greater than fourfold variability in nine of the ten most prevalent medications across LTCFs. Further studies are needed to investigate the clinical appropriateness of the variability in polypharmacy.

Prioritizing interventions to manage polypharmacy in Australian aged care facilities.

BACKGROUND: Polypharmacy is highly prevalent in residential aged care facilities (RACFs). Although polypharmacy is sometimes unavoidable, polypharmacy has been associated with increased morbidity and mortality. OBJECTIVE: To identify and prioritize a range of potential interventions to manage polypharmacy in RACFs from the perspectives of health care professionals, health policy and consumer representatives. METHODS: Two nominal group technique (NGT) sessions were convened in August 2015. A purposive sample (n = 19) of clinicians, researchers, managers and representatives of consumer, professional and health policy organizations were asked to nominate interventions to address the prevalence and appropriateness of medication use. Participants were then asked to prioritize five interventions suitable for possible implementation at the system level. RESULTS: Six of 16 potential interventions were prioritized highest for possible implementation in clinical practice, with two interventions prioritized as second highest. The top interventions in rank order were 'implementation of a pharmacist-led medication reconciliation service for new residents,' 'conduct facility-level audits and feedback to staff and health care professionals,' 'develop deprescribing scripts to assist clinician-resident discussion,' 'develop or revise prescribing guidelines specific to older people with multimorbidity in RACFs,' 'implement electronic medication charts and records' and 'better support Medication Advisory Committees (MACs) to address medication appropriateness.' CONCLUSION: This study prioritized a range of potential interventions that may be used to assist clinicians and policy makers develop a comprehensive strategy to manage polypharmacy in RACFs.

Clinical Outcomes Associated with Medication Regimen Complexity in Older People: A Systematic Review.

OBJECTIVES: To systematically review clinical outcomes associated with medication regimen complexity in older people. DESIGN: Systematic review of EMBASE, MEDLINE, International Pharmaceutical Abstracts, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane library. SETTING: Hospitals, home, and long-term care. PARTICIPANTS: English-language peer-reviewed original research published before June 2016 was eligible if regimen complexity was quantified using a metric that considered number of medications and at least one other parameter, regimen complexity was calculated for participants' overall regimen, at least 80% of participants were aged 60 and older, and the study investigated a clinical outcome associated with regimen complexity. MEASUREMENTS: Quality assessment was conducted using an adapted version of the Joanna Briggs Institute critical appraisal tool. RESULTS: Sixteen observational studies met the inclusion criteria. Regimen complexity was associated with medication nonadherence (2/6 studies) and higher rates of hospitalization (2/4 studies). One study found that participants with less-complex medication administration were more likely to stop medications when feeling worse. One study each identified an association between regimen complexity and higher ability to administer medications as directed, medication self-administration errors, caregiver medication administration hassles, hospital discharge to non-home settings, postdischarge potential adverse drug events, all-cause mortality, and lower patient knowledge of their medication. Regimen complexity had no association with postdischarge medication modification, change in medication- and health-related problems, emergency department visits, or quality of life as rated by nursing staff. CONCLUSION: Research into whether medication regimen complexity is associated with nonadherence and hospitalization has produced inconsistent results. Moderate-quality evidence from four studies (two each for nonadherence and hospitalization) suggests that medication regimen complexity is associated with nonadherence and higher rates of hospitalization.

Pharmacist-led medication review in community settings: An overview of systematic reviews.

BACKGROUND: Pharmacist-led medication review is a collaborative service which aims to identify and resolve medication-related problems. OBJECTIVE: To critically evaluate published systematic reviews relevant to pharmacist-led medication reviews in community settings. METHODS: MEDLINE, EMBASE, International Pharmaceutical Abstracts (IPA), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Cochrane Database of Systematic Reviews (CDSR) were searched from 1995 to December 2015. Systematic reviews of all study designs and outcomes were considered. Methodological quality was assessed using the 11-item Assessment of Multiple Systematic Reviews (AMSTAR) tool. Systematic reviews of moderate or high quality (AMSTAR ≥ 4) were included in the data synthesis. Data extraction and quality assessment was performed independently by two investigators. RESULTS: Of the 35 relevant systematic reviews identified, 24 were of moderate and seven of high quality and were included in the data synthesis. The largest overall numbers of unique primary research studies with favorable outcomes were for diabetes control (78% of studies reporting the outcome), blood pressure control (74%), cholesterol (63%), medication adherence (56%) and medication management (47%). Significant reductions in medication and/or healthcare costs were reported in 35% of primary research studies. Meta-analysis was performed in 12 systematic reviews. Results from the meta-analyses suggested positive impacts on glycosylated hemoglobin, blood pressure, cholesterol, and number and appropriateness of medications. Conflicting findings were reported in relation to hospitalization. No meta-analyses reported reduced mortality. CONCLUSION: Moderate and high quality systematic reviews support the value of pharmacist-led medication review for a range of clinical outcomes. Further research including more rigorous cost analyses are required to determine the impact of pharmacist-led medication reviews on humanistic and economic outcomes. Future systematic reviews should consider the inclusion of both qualitative and quantitative studies to comprehensively evaluate medication review.

Why is polypharmacy increasing in aged care facilities? The views of Australian health care professionals.

RATIONALE, AIMS AND OBJECTIVES: The prevalence of polypharmacy in residential aged care facilities (RACFs) is high and increasing. Although not necessarily inappropriate, polypharmacy has been associated with drug interactions, adverse drug events, geriatric syndromes and hospital admissions. The aim of this study was to identify and prioritize factors contributing to the increasing prevalence of polypharmacy in RACFs. METHODS: Seventeen health care professionals from metropolitan and regional Victoria and South Australia identified and prioritized factors using a modified nominal group technique. RESULTS: The top five factors ranked from most important to fifth most important were 'changes in resident mix', 'increasing numbers of prescribers and the reluctance of one prescriber to discontinue a medicine commenced by another prescriber', 'better adherence to clinical practice guidelines', 'increasing reliance on locums' and 'greater recognition and pharmacological management of pain'. CONCLUSIONS: Reasons for the increase in polypharmacy are multifactorial. Understanding the factors contributing to polypharmacy may help to guide future research and develop interventions to manage polypharmacy in RACFs.

A systematic review of the statistical methods in prospective cohort studies investigating the effect of medications on cognition in older people.

BACKGROUND: There is increasing awareness that medications can contribute to cognitive decline. Prospective cohort studies are rich sources of clinical data. However, investigating the contribution of medications to cognitive decline is challenging because both medication exposure and cognitive impairment can be associated with attrition of study participants, and medication exposure status may change over time. The objective of this review was to investigate the statistical methods in prospective cohort studies assessing the effect of medications on cognition in older people. METHODS: A systematic literature search was conducted to identify prospective cohort studies of at least 12 months duration that investigated the effect of common medications or medication classes (anticholinergics, antihistamines, hypnotics, sedatives, opioids, statins, estrogens, testosterone, antipsychotics, anticonvulsants, antidepressants, anxiolytics, antiparkinson agents and bronchodilators) on cognition in people aged 65 years and older. Data extraction was performed independently by two investigators. A descriptive analysis of the statistical methods was performed. RESULTS: A total of 44 articles were included in the review. The most common statistical methods were logistic regression (24.6% of all reported methods), Cox proportional hazards regression (22.8%), linear mixed-effects models (21.1%) and multiple linear regression (14.0%). The use of advanced techniques, most notably linear mixed-effects models, increased over time. Only 6 articles (13.6%) reported methods for addressing missing data. CONCLUSIONS: A variety of statistical methods have been used for investigating the effect of medications on cognition in older people. While advanced techniques that are appropriate for the analysis of longitudinal data, most notably linear mixed-effects models, have increasingly been employed in recent years, there is an opportunity to implement alternative techniques in future studies that could address key research questions.

Clinical medication review in Australia: A systematic review.

BACKGROUND: Clinical medication review (CMR) is a structured and collaborative service aimed at identifying and resolving medication-related problems (MRPs). This is the first systematic review of CMR research in Australia. OBJECTIVE: To systematically review the processes and outcomes of CMR in community-settings in Australia. METHODS: MEDLINE, EMBASE, International Pharmaceutical Abstracts (IPA), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library and the grey literature were searched from 2000 to February 2015. All study designs were considered. Data extraction and quality assessment were performed independently by two investigators. RESULTS: Nine controlled studies, 34 observational and uncontrolled studies, 11 qualitative studies (focus groups and interviews) and nine survey studies were included. The CMRs resulted in identification of MRPs (n = 15 studies, mean 3.6 MPRs per CMR) and improved adherence (n = 3). Reductions in numbers of medications prescribed (n = 3 studies), hospitalizations (n = 3), potentially inappropriate prescribing (n = 3) and costs (n = 6) were demonstrated. Comparisons to a control group, predominately non-recipients of CMR, were made in eleven of 43 studies. Evidence supports additional models that promote interprofessional collaboration and timely referral following hospital discharge. Qualitative research identified low awareness of CMR among eligible non-recipients, while benefits were perceived to outweigh barriers to implementation. Underserved populations include indigenous and culturally and linguistically diverse people, recipients of palliative care, those recently discharged from hospital, people with poor medication adherence, those in rural and remote areas, older males, and younger people with long-term, persistent or serious health problems. CONCLUSION: The available evidence suggests CMR is beneficial in improving the quality use of medications and health outcomes. However, lack of comparator groups in many observational studies limited the strength of conclusions in relation to the impact on clinical outcomes. Addressing access gaps for underserved populations, implementing additional referral pathways, and facilitating greater collaboration between the health professionals represent opportunities for further improvement.

Prevalence of Analgesic Use and Pain in People with and without Dementia or Cognitive Impairment in Aged Care Facilities: A Systematic Review and Meta-Analysis.

Pain is a frequent cause of discomfort and distress in residents in residential aged care facilities (RACFs). Despite the benefits of adequate pain management, there is inconsistency in the literature regarding analgesic use and pain in residents with dementia. The aim of this systematic review was to determine the prevalence of analgesic drug use among residents with and without dementia or cognitive impairment in RACFs. A systematic search of MEDLINE and EMBASE (inception to January 2014) was conducted using Medical Subject Headings and Emtree terms, respectively. Studies were included if they reported prevalence of analgesic use for residents both with and without dementia within the same study. Data extraction and quality assessment was performed independently by two investigators. Data on the prevalence of analgesic use, pain and painful conditions were extracted. Meta-analyses were performed using random effect models. The 7 included studies were of high quality (≥ 5 out of 7 on the adapted Newcastle-Ottawa Scale). Analgesic use in residents with and without dementia or cognitive impairment ranged from 20.2% to 61.2% and 38.8% to 79.6%, respectively. Paracetamol was the most prevalent analgesic in people with and without dementia. Residents with dementia or cognitive impairment had a significantly lower prevalence of analgesic use (odds ratio [OR] 0.576, 95% confidence interval [CI] = 0.406-0.816) and of self-reported and clinician-observed pain (OR 0.355, 95% CI = 0.278-0.454) than residents without cognitive impairment, despite a comparable prevalence of painful conditions. These findings may indicate under-reporting and under-detection of pain in persons with dementia, and subsequent suboptimal treatment.

Alcohol Consumption, Dementia and Cognitive Decline: An Overview of Systematic Reviews.

There is uncertainty in relation to the effect of alcohol consumption on the incidence of dementia and cognitive decline. This review critically evaluated published systematic reviews on the epidemiology of alcohol consumption and the risk of dementia or cognitive decline. MEDLINE, EMBASE and PsycINFO were searched from inception to February 2014. Systematic reviews of longitudinal observational studies were considered. Two reviewers independently completed the 11-item Assessment of Multiple Systematic Reviews (AMSTAR) tool to assess the quality. We identified three moderate quality systematic reviews (AMSTAR score 4-6) that included a total of 45 unique studies. Two of the systematic reviews encompassed a meta-analysis. Light to moderate drinking may decrease the risk of Alzheimer's disease (AD) (pooled risk ratio [RR] 0.72; 95% confidence interval [CI] 0.61-0.86) and dementia (RR 0.74; 95%CI 0.61-0.91) whereas heavy to excessive drinking does not affect the risk (RR 0.92; 95%CI 0.59-1.45 and RR 1.04; 95%CI 0.69-1.56, respectively). One systematic review identified two studies that reported a link between alcohol consumption and the development of AD. No systematic review categorised former drinkers separately from lifetime abstainers in their analysis. Definitions of alcohol consumption, light to moderate drinking and heavy-excessive drinking varied and drinking patterns were not considered. Moderate quality (AMSTAR score 4-6) systematic reviews indicate that light to moderate alcohol consumption may protect against AD and dementia. However, the importance of drinking patterns and specific beverages remain unknown. There is insufficient evidence to suggest abstainers should initiate alcohol consumption to protect against dementia.

A systematic review of medication exposure assessment in prospective cohort studies of community dwelling older australians.

INTRODUCTION: It is not known to what extent medication use has been comprehensively assessed in prospective cohort studies of older Australians. Understanding the varying methods to assess medication use is necessary to establish comparability and to understand the opportunities for pharmacoepidemiological analysis. The objective of this review was to compare and contrast how medication-related data have been collected in prospective cohorts of community-dwelling older Australians. METHODS: MEDLINE and EMBASE (1990-2014) were systematically searched to identify prospective cohorts of ≥1000 older participants that commenced recruitment after 1990. The data collection tools used to assess medication use in each cohort were independently examined by two investigators using a structured approach. RESULTS: Thirteen eligible cohorts were included. Baseline medication use was assessed in participant self-completed surveys (n = 3), by an investigator inspecting medications brought to a clinic interview (n = 7), and by interviewing participants in their home (n = 3). Five cohorts sought participant consent to access administrative claims data. Six cohorts used multiple methods to assess medication use across one or more study waves. All cohorts assessed medication use at baseline and 12 cohorts in follow-up waves. Twelve cohorts recorded prescription medications by trade or generic name; 12 cohorts recorded medication strength; and 9 recorded the daily medication dose in at least one wave of the cohort. Seven cohorts asked participants about their "current" medication use without providing a definition of "current"; and nine cohorts asked participants to report medication use over recall periods ranging from 1-week to 3-months in at least one wave of the cohort. Sixty-five original publications, that reported the prevalence or outcomes of medication use, in the 13 cohorts were identified (median = 3, range 1-21). CONCLUSION: There has been considerable variability in the assessment of medication use within and between cohorts. This may limit the comparability of medication data collected in these cohorts.