Multidisciplinary medication review during older patient hospitalization according to STOPP/START criteria reduces potentially inappropriate prescriptions: MoPIM cohort study.

PURPOSE: Multimorbidity and polypharmacy in older adults converts the detection and adequacy of potentially inappropriate drug prescriptions (PIDP) in a healthcare priority. The objectives of this study are to describe the clinical decisions taken after the identification of PIDP by clinical pharmacists, using STOPP/START criteria, and to evaluate the degree of accomplishment of these decisions. METHODS: Multicenter, prospective, non-comparative cohort study in patients aged 65 and older, hospitalized because of an exacerbation of their chronic conditions. Each possible PIDP was manually identified by the clinical pharmacist at admission and an initial decision was taken by a multidisciplinary clinical committee. At discharge, criteria were re-applied and final decisions recorded. RESULTS: From all patients (n = 674), 493 (73.1%) presented at least one STOPP criteria at admission, significantly reduced up to 258 (38.3%) at discharge. A similar trend was observed for START criteria (36.7% vs. 15.7%). Regarding the top 10 most prevalent STOPP criteria, the clinical committee initially agreed to withdraw 257 (34.2%) prescriptions and to modify 93 (12.4%) prescriptions. However, the evaluation of final clinical decisions revealed that 503 (67.0%) of those STOPP criteria were ultimately amended. For the top 10 START criteria associated PIDP, the committee decided to initiate 149 (51.7%) prescriptions, while a total of 198 (68.8%) were finally introduced at discharge. CONCLUSIONS: The clinical committee, through a pharmacotherapy review, succeeded in identifying and reducing the degree of prescription inadequacy, for both STOPP and START criteria, in older patients with high degree of multimorbidity and polypharmacy. TRIAL REGISTRATION: NCT02830425.

Improving individualized prescription in patients with multimorbidity through medication review.

BACKGROUND: Older patients tend to have multimorbidity, represented by multiple chronic diseases or geriatric conditions, which leads to a growing number of prescribed medications. As a result, pharmacological prescription has become a major concern because of the increased difficulties to ensure appropriate prescription in older adults. The study's main objectives were to characterize a cohort of older adults with multimorbidity, carry out a medication review and compare the pharmacological data before and after the medication review globally and according to the frailty index. METHODS: This was a quasi-experimental (uncontrolled pre-post) study with a cohort of patients ≥ 65 years old with multimorbidity. Data were collected from June 2019 to October 2020. Variables assessed included demographic, clinical, and pharmacological data, degree of frailty (Frail-VIG index), medication regimen complexity index, anticholinergic and or sedative burden index, and monthly drug expenditure. Finally, a medication review was carried out by an interdisciplinary team (primary care team and a consultant team with a geriatrician and a clinical pharmacist) by applying the Patient-Centered Prescription model to align the treatment with care goals. RESULTS: Four hundred twenty-eight patients were recruited [66.6% women; mean age 85.5 (SD 7.67)]. The mean frail index was 0.39 (SD 0.13), corresponding with moderate frailty. Up to 90% of patients presented at least one inappropriate prescription, and the mean of inappropriate prescriptions per patient was 3.14 (SD 2.27). At the three-month follow-up [mortality of 17.7% (n = 76)], the mean chronic medications per patient decreased by 17.96%, varying from 8.13 (SD 3.87) to 6.67 (SD 3.72) (p < 0.001). The medication regimen complexity index decreased by 19.03%, from 31.0 (SD 16.2) to 25.1 (SD 15.1), and the drug burden index mean decreased by 8.40%, from 1.19 (SD 0.82) to 1.09 (SD 0.82) (p < 0.001). A decrease in polypharmacy, medication regimen complexity index, and drug burden index was more frequent among frail patients, especially those with severe frailty (p < 0.001). CONCLUSIONS: An individualized medication review in frail older patients, applying the Patient-Centered Prescription model, decreases pharmacological parameters related to adverse drug effects, such as polypharmacy, therapeutical complexity, and anticholinergic and, or sedative burden. The benefits are for patients with frailty.

Factors associated to potentially inappropriate prescribing in older patients according to STOPP/START criteria: MoPIM multicentre cohort study.

OBJECTIVES: The objectives of the present analyses are to estimate the frequency of potentially inappropriate prescribing (PIP) at admission according to STOPP/START criteria version 2 in older patients hospitalised due to chronic disease exacerbation as well as to identify risk factors associated to the most frequent active principles as potentially inappropriate medications (PIMs). METHODS: A multicentre, prospective cohort study including older patients (≥65) hospitalized due to chronic disease exacerbation at the internal medicine or geriatric services of 5 hospitals in Spain between September 2016 and December 2018 was conducted. Demographic and clinical data was collected, and a medication review process using STOPP/START criteria version 2 was performed, considering both PIMs and potential prescribing omissions (PPOs). Primary outcome was defined as the presence of any most frequent principles as PIMs, and secondary outcomes were the frequency of any PIM and PPO. Descriptive and bivariate analyses were conducted on all outcomes and multilevel logistic regression analysis, stratified by participating centre, was performed on the primary outcome. RESULTS: A total of 740 patients were included (mean age 84.1, 53.2% females), 93.8% of them presenting polypharmacy, with a median of 10 chronic prescriptions. Among all, 603 (81.5%) patients presented at least one PIP, 542 (73.2%) any PIM and 263 (35.5%) any PPO. Drugs prescribed without an evidence-based clinical indication were the most frequent PIM (33.8% of patients); vitamin D supplement in older people who are housebound or experiencing falls or with osteopenia was the most frequent PPO (10.3%). The most frequent active principles as PIMs were proton pump inhibitors (PPIs) and benzodiazepines (BZDs), present in 345 (46.6%) patients. This outcome was found significantly associated with age, polypharmacy and essential tremor in an explanatory model with 71% AUC. CONCLUSIONS: PIMs at admission are highly prevalent in these patients, especially those involving PPIs or BZDs, which affected almost half of the patients. Therefore, these drugs may be considered as the starting point for medication review and deprescription. TRIAL REGISTRATION NUMBER: NCT02830425.

Intervention effectiveness by pharmacists integrated within an interdisciplinary health team on chronic complex patients.

BACKGROUND: Nowadays, it is difficult to establish a specific method of intervention by the pharmacist and its clinical repercussions. Our aim was to identify interventions by pharmacists integrated within an interdisciplinary team for chronic complex patients (CCPs) and determine which of them produce the best results. METHODS: A systematic review (SR) was performed based on PICO(d) question (2008-18): (Population): CCPs; (Intervention): carried out by health system pharmacists in collaboration with an interdisciplinary team; (Comparator): any; (Outcome): clinical and health resources usage outcomes; (Design): meta-analysis, SR and randomized clinical trials. RESULTS: Nine articles were included: one SR and eight randomized clinical trials. The interventions consisted mainly in putting in order the pharmacotherapy and the review of the medication adequacy, medication reconciliation in transition of care and educational intervention for health professionals. Only one showed significant improvements in mortality (27.9% vs. 38.5%; HR = 1.49; P = 0.026), two in health-related quality of life [according to EQ-5D (European Quality of Life-5 Dimensions) and EQ-VAS (European Quality of Life-Visual Analog Scale) tests] and four in other health-related results (subjective self-assessment scales, falls or episodes of delirium and negative health outcomes associated with medication). Significant differences between groups were found in hospital stay and frequency of visits to the emergency department. No better results were observed in hospitalization rate. Otherwise, one study measured cost utility and found a cost of €45 987 per quality-adjusted life year gained due to the intervention. CONCLUSIONS: It was not possible to determine with certainty which interventions produce the best results in CCPs. The clinical heterogeneity of the studies and the short follow-up of most studies probably contributed to this uncertainty.

Adverse drug events in patients with advanced chronic conditions who have a prognosis of limited life expectancy at hospital admission.

PURPOSE: Adverse drug events (ADEs) lead to adverse clinical outcomes such as hospitalization. There is little information about the characteristics of ADEs in patients with advanced chronic conditions and have a prognosis of limited life expectancy. This study aimed to evaluate (i) the prevalence of ADEs at the time of admission to hospital, (ii) the causality, severity, and preventability of the ADEs, and (iii) the clinical and pharmacological characteristics associated with the ADEs. METHODS: This is a prospective cross-sectional study (county of Osona, Catalonia, Spain). We included patients who required palliative care as identified by the NECPAL CCOMS-ICO tool who were hospitalized in an acute geriatric unit (AGU). A system of alerts (trigger tool) was used together with a multidisciplinary review for the detection of the ADEs. RESULTS: Over the course of 10 months, 235 patients were recruited. Seventy-six ADEs affecting 24.68 % of the sample were identified, and of these, 23 (30.26 % of the ADEs; 8.51 % of the sample) were directly related to hospitalization. The multivariate logistic regression analysis identified the following risk factors: presence of extreme polypharmacy (≥10 medications) (OR = 3.02; 95 % CI = 1.48-6.19), anticholinergic burden according to the Anticholinergic Drug Scale (ADS) (OR = 2.32; 95 % CI = 1.13-4.78), and treatment complexity according to the Medication Regimen Complexity Index (MRCI) scale (OR = 2.90; 95 % CI = 1.44-5.83). The vast majority (94.45 %) of the ADEs were considered to be preventable. There were no differences in the survival of the patients. CONCLUSIONS: ADEs are common, largely preventable, and implicated in the hospitalization of patients who require palliative care.

[Spanish translation and cross-cultural adaptation of the ARMS-scale for measuring medication adherence in polypathological patients]. / Traducción y adaptación transcultural al español del cuestionario ARMS para la medida de la adherencia en pacientes pluripatológicos.

AIM: Translate the ARMS scale into Spanish ensuring cross-cultural equivalence for measuring medication adherence in polypathological patients. DESIGN: Translation, cross-cultural adaptation and pilot testing. LOCATION: Secondary hospital. MEASUREMENTS: (i)Forward and blind-back translations followed by cross-cultural adaptation through qualitative methodology to ensure conceptual, semantic and content equivalence between the original scale and the Spanish version. (ii)Pilot testing in non-institutionalized polypathological patients to assess the instrument for clarity. RESULTS: The Spanish version of the ARMS scale has been obtained. Overall scores from translators involved in forward and blind-back translations were consistent with a low difficulty for assuring conceptual equivalence between both languages. Pilot testing (cognitive debriefing) in a sample of 40 non-institutionalized polypathological patients admitted to an internal medicine department of a secondary hospital showed an excellent clarity. CONCLUSIONS: The ARMS-e scale is a Spanish-adapted version of the ARMS scale, suitable for measuring adherence in polypathological patients. Its structure enables a multidimensional approach of the lack of adherence allowing the implementation of individualized interventions guided by the barriers detected in every patient.

Comparison of the 22nd World Health Organization Model List of Essential Medicines with the explicit criteria for the treatment of chronicity in elderly patients.

OBJECTIVES: This study analysed whether the Model List of Essential Medicines is suitable for elderly patients. Furthermore, it investigated the specific issues that should be considered when prescribing a drug and which drugs should be added to improve the list according to the explicit criteria guidelines. METHODS: A qualitative descriptive review was performed comparing the explicit criteria guidelines of Beers 2019, Laroche, McLeod, NORGEP, PRISCUS, STOPP/START 2014 and Winit-Watjana with the 22nd edition of the Model List of Essential Medicines. RESULTS: The Model List of Essential Medicines has 458 drugs. Depending on the explicit criteria considered, there were different numbers of potentially inappropriate medications and potential prescribing omissions. When all explicit criteria were combined, a total of 73 medicines were classified as potentially inappropriate. Using the STOPP/START criteria, 46 potential prescribing omissions were detected. According to these explicit criteria, the Model List of Essential Medicines appeared to lack some medicines. CONCLUSIONS: Explicit criteria guidelines have different potential for detecting potentially inappropriate medications. Our findings suggest that some drugs should be added to the next edition of the Model List of Essential Medicines to cover some therapeutic gaps.

Medication Assessment in an Older Population during Acute Care Hospitalization and Its Effect on the Anticholinergic Burden: A Prospective Cohort Study.

(1) Background: Anticholinergic and sedative drugs (ASDs) contribute to negative health outcomes, especially in the frail population. In this study, we aimed to assess whether frailty increases with anticholinergic burden and to evaluate the effects of medication reviews (MRs) on ASD regimens among patients attending an acute care for the elderly (ACE) unit. (2) Methods: A cohort study was conducted between June 2019 and October 2020 with 150 consecutive patients admitted to our ACE unit. Demographic, clinical, and pharmacological data were assessed. Frailty score was determined using the Frail-VIG index (FI-VIG), and ASD burden was quantified using the drug burden index (DBI). In addition, the MR was performed using the patient-centered prescription (PCP) model. We used a paired T-test to compare the DBI pre- and post-MR and univariate and multivariate regression to identify the factors associated with frailty. (3) Results: Overall, 85.6% (n = 128) of participants showed some degree of frailty (FI-VIG > 0.20) and 84% (n = 126) of patients received treatment with ASDs upon admission (pre-MR). As the degree of frailty increased, so did the DBI (p < 0.001). After the implementation of the MR through the application of the PCP model, a reduction in the DBI was noted (1.06 ± 0.8 versus 0.95 ± 0.7) (p < 0.001). After adjusting for covariates, the association between frailty and the DBI was apparent (OR: 11.42, 95% (CI: 2.77-47.15)). (4) Conclusions: A higher DBI was positively associated with frailty. The DBI decreased significantly in frail patients after a personalized MR. Thus, MRs focusing on ASDs are crucial for frail older patients.

Sex Differences in Multimorbidity, Inappropriate Medication and Adverse Outcomes of Inpatient Care: MoPIM Cohort Study.

There is no published evidence on the possible differences in multimorbidity, inappropriate prescribing, and adverse outcomes of care, simultaneously, from a sex perspective in older patients. We aimed to identify those possible differences in patients hospitalized because of a chronic disease exacerbation. A multicenter, prospective cohort study of 740 older hospitalized patients (≥65 years) was designed, registering sociodemographic variables, frailty, Barthel index, chronic conditions (CCs), geriatric syndromes (GSs), polypharmacy, potentially inappropriate prescribing (PIP) according to STOPP/START criteria, and adverse drug reactions (ADRs). Outcomes were length of stay (LOS), discharge to nursing home, in-hospital mortality, cause of mortality, and existence of any ADR and its worst consequence. Bivariate analyses between sex and all variables were performed, and a network graph was created for each sex using CC and GS. A total of 740 patients were included (53.2% females, 53.5% ≥85 years old). Women presented higher prevalence of frailty, and more were living in a nursing home or alone, and had a higher percentage of PIP related to anxiolytics or pain management drugs. Moreover, they presented significant pairwise associations between CC, such as asthma, vertigo, thyroid diseases, osteoarticular diseases, and sleep disorders, and with GS, such as chronic pain, constipation, and anxiety/depression. No significant differences in immediate adverse outcomes of care were observed between men and women in the exacerbation episode.

Individualized Medication Review in Older People with Multimorbidity: A Comparative Analysis between Patients Living at Home and in a Nursing Home.

(1) Background: aging is associated with complex and dynamic changes leading to multimorbidity and, therefore, polypharmacy. A periodic medication review (MR) in frail older people leads to optimizing medication use. The aims of the study were to perform a comparative analysis of the impact of place of residence (own home versus nursing home) in a cohort of older patients on the characteristics of the baseline therapeutic plan and characteristics of the therapeutic plan after an MR; (2) Methods: Study with paired pre- and post-MR data based on person-centred prescription, with a follow-up assessment at three months. Patients who lived either in their own home or in a nursing home were recruited. We selected patients of 65 years or more with multimorbidity whose General Practitioner identified difficulties with the prescription management and the need for an MR. Each patient's treatment was analysed by applying the Patient-Centred Prescription (PCP) model; (3) Results: 428 patients. 90% presented at least one inappropriate prescription (IP) in both settings. In nursing homes, a higher number of implemented optimization proposals was detected (81.6% versus 65.7% (p < 0.001)). After the MR, nursing-home patients had a greater decrease in their mean number of medications, polypharmacy prevalence, therapeutic complexity, and monthly drug expenditure (p < 0.001); (4) Conclusions: PCP model detected a high number of IP in both settings. However, after an individualized MR, nursing-home patients presented a greater decrease in some pharmacological parameters related to adverse events, such as polypharmacy and therapeutic complexity, compared to those living at home. Nursing homes may be regarded as a highly suitable scenario to carry out a periodic MR, due to its high prevalence of frail people and its feasibility to apply the recommendations of an MR. Prospective studies with a robust design should be performed to demonstrate this quasi-experimental study along with a longitudinal follow-up on clinical outcomes.

Comprehensive Multimorbidity Patterns in Older Patients Are Associated with Quality Indicators of Medication-MoPIM Cohort Study.

Multimorbidity is increasing and poses a challenge to the clinical management of patients with multiple conditions and drug prescriptions. The objectives of this work are to evaluate if multimorbidity patterns are associated with quality indicators of medication: potentially inappropriate prescribing (PIP) or adverse drug reactions (ADRs). A multicentre prospective cohort study was conducted including 740 older (≥65 years) patients hospitalised due to chronic pathology exacerbation. Sociodemographic, clinical and medication related variables (polypharmacy, PIP according to STOPP/START criteria, ADRs) were collected. Bivariate analyses were performed comparing previously identified multimorbidity clusters (osteoarticular, psychogeriatric, minor chronic disease, cardiorespiratory) to presence, number or specific types of PIP or ADRs. Significant associations were found in all clusters. The osteoarticular cluster presented the highest prevalence of PIP (94.9%) and ADRs (48.2%), mostly related to anxiolytics and antihypertensives, followed by the minor chronic disease cluster, associated with ADRs caused by antihypertensives and insulin. The psychogeriatric cluster presented PIP and ADRs of neuroleptics and the cardiorespiratory cluster indicators were better overall. In conclusion, the associations that were found reinforce the existence of multimorbidity patterns and support specific medication review actions according to each patient profile. Thus, determining the relationship between multimorbidity profiles and quality indicators of medication could help optimise healthcare processes. Trial registration number: NCT02830425.

Factors Associated with the Detection of Inappropriate Prescriptions in Older People: A Prospective Cohort.

(1) Background: Ageing is associated with complex and dynamic changes leading to multimorbidity and, therefore, polypharmacy. The main objectives were to study an older community-dwelling cohort, to detect inappropriate prescriptions (IP) applying the Patient-Centred Prescription model, and to evaluate the most associated factors. (2) Methods: This was a prospective, descriptive, and observational study conducted from June 2019 to October 2020 on patients ≥ 65 years with multimorbidity who lived in the community. Demographic, clinical and pharmacological data were assessed. Variables assessed were: degree of frailty, using the Frail-VIG index; therapeutical complexity and anticholinergic and sedative burden; and the number of chronic drugs to determine polypharmacy or excessive polypharmacy. Finally, a medication review was carried out through the application of the Patient-Centred Prescription model. We used univariate and multivariate regression to identify the factors associated with IP. (3) Results: We recruited 428 patients (66.6% women; mean age 85.5, SD 7.67). A total of 50.9% of them lived in a nursing home; the mean Barthel Index was 49.93 (SD 32.14), and 73.8% of patients suffered some degree of cognitive impairment. The prevalence of frailty was 92.5%. Up to 90% of patients had at least one IP. An increase in IP prevalence was detected when the Frail-VIG index increased (p < 0.05). With the multivariate model, the relationship of polypharmacy with IP detection stands out above all. (4) Conclusions: 90% of patients presented one IP or more, and this situation can be detected through the PCP model. Factors with higher association with IP were frailty and polypharmacy.

Factors Associated with Medication Non-Adherence among Patients with Multimorbidity and Polypharmacy Admitted to an Intermediate Care Center.

Identifying determinants of medication non-adherence in patients with multimorbidity would provide a step forward in developing patient-centered strategies to optimize their care. Medication appropriateness has been proposed to play a major role in medication non-adherence, reinforcing the importance of interdisciplinary medication review. This study examines factors associated with medication non-adherence among older patients with multimorbidity and polypharmacy. A cross-sectional study of non-institutionalized patients aged ≥65 years with ≥2 chronic conditions and ≥5 long-term medications admitted to an intermediate care center was performed. Ninety-three patients were included (mean age 83.0 ± 6.1 years). The prevalence of non-adherence based on patients' multiple discretized proportion of days covered was 79.6% (n = 74). According to multivariable analyses, individuals with a suboptimal self-report adherence (by using the Spanish-version Adherence to Refills and Medications Scale) were more likely to be non-adherent to medications (OR = 8.99, 95% CI 2.80-28.84, p < 0.001). Having ≥3 potentially inappropriate prescribing (OR = 3.90, 95% CI 0.95-15.99, p = 0.059) was barely below the level of significance. These two factors seem to capture most of the non-adherence determinants identified in bivariate analyses, including medication burden, medication appropriateness and patients' experiences related to medication management. Thus, the relationship between patients' self-reported adherence and medication appropriateness provides a basis to implement targeted strategies to improve effective prescribing in patients with multimorbidity.

[Prevalence of prescription of anticholinergic/sedative burden drugs among older people with dementia living in nursing homes]. / Prevalencia de prescripción de fármacos con carga anticolinérgica/sedante en adultos mayores institucionalizados con demencia.

BACKGROUND AND OBJECTIVE: Dementia is one of the most frequent diseases in the elderly, being its prevalence of up to 64% in institutionalized people. In this population, in addition to antidementia drugs, it is common to prescribe drugs with anticholinergic/sedative burden that, due to their adverse effects, could worsen their functionality and cognitive status. The objective is to estimate the prevalence of the use of drugs with anticholinergic/ sedative burden in institutionalized older adults with dementia and to assess the associated factors. MATERIALS AND METHODS: A cross-sectional study developed in older with dementia living in nursing homes. The prevalence of prescription of anticholinergic/sedative drugs was estimated according to the Drug Burden Index (DBI). A comparative analysis of the DBI score was performed between different types of dementia as well as among various factors and according to the anticholinergic/sedative risk, establishing as a cut-off point of DBI≥1 (high anticholinergic/sedative risk). RESULTS: 178 residents were included. 83.7% had some drug with anticholinergic/sedative burden according to DBI. 50% had a DBI≥1 score. Residents with vascular dementia had a mean DBI of 1.34 (SD 0.84), a significantly higher score than residents with Alzheimer's disease (0.41, 95% CI 0.04-0.78).). Likewise, a higher DBI was associated with more polypharmacy (3.36; 95% CI 2.64-4.08), more falls, hospital admissions and emergency room visits (P<.05). CONCLUSIONS: Polypharmacy and prescription of anticholinergic/sedative drugs is frequent among institutionalized older adults with dementia, finding an association between DBI, falls and hospital admissions or emergency department visits. Therefore, it is necessary to propose interdisciplinary pharmacotherapeutic optimization strategies.

Pharmaceutical care in hospitalized patients. (Management of the COVID-19 pandemic crisis. A new challenge for pharmacy services).

During the pandemic caused by the SARS-CoV-2 virus, pharmacy services have  had to adapt their service portfolio, and yet ensure efficient, equitable and  quality pharmaceutical care. Given the limited scientific evidence available, most drugs have been used off-label or in the context of clinical trials, which should be the preferred option in order to create new evidence. Among kind different  situations we have faced are the increase in workload, the expansion of  coverage to new wards and ICUs and shortages, which have caused the use of  alternative drugs and even other routes of administration. Given that covid-19  affects elderly population with greater severity and many of them are  polymedicated, great effort have been focused on monitoring interactions, both  pharmacokinetic and pharmacodynamic (specially prolongation of the QT  interval), monitoring correct concentrations of electrolytes, nutritional support,  adaptation of chemotherapy treatment protocols and anticoagulant  management, among others. The use of personal protective equipment added  difficulty for nursing work and some measures had been taken to minimize the  number of entries into the rooms. Eventually, team's split to guarantee care, the challenge of teleworking, remote validation, telemedicine and telepharmacy for  communication between professionals and patients, as well as training in this pandemic situation have been a challenge for our profession. These  difficulties have risen up new learning opportunities we hope will be useful to us  in the event we have to face similar situations in the future.

La pandemia ocasionada por el virus SARS-CoV-2 ha hecho que los servicios de  farmacia hayan tenido que adaptar su cartera de servicios, y sin embargo  asegurar una atención farmacéutica eficiente, equitativa y de calidad. Dada la  escasa evidencia científica disponible, la mayoría de los medicamentos se han  empleado fuera de indicación o en el contexto de ensayos clínicos, que debería  ser la opción preferente para generar nueva evidencia. Entre las diversas  situaciones que se han tenido que afrontar se encuentran el incremento de  trabajo asistencial, la ampliación de la cobertura a nuevas salas y unidades de  cuidados intensivos y los desabastecimientos, que han ocasionado el uso de  fármacos alternativos e incluso otras vías de administración. Dado que la  COVID-19 afecta con mayor gravedad a población de edad avanzada, muchos de ellos polimedicados, se ha tenido que dedicar un gran esfuerzo al seguimiento de interacciones, tanto farmacocinéticas como farmacodinámicas (en especial,  prolongación del intervalo QT), monitorización de concentraciones correctas de  electrolitos, soporte nutricional, adaptación de pautas de quimioterapia y manejo e los anticoagulantes, entre otros. La dificultad adicional para enfermería de la  administración de medicamentos con equipos de protección individual ha  supuesto la adaptación de formas de administración para minimizar el número  de entradas en las habitaciones. Por último, el fraccionamiento del equipo para  garantizar la atención, el reto del teletrabajo, la validación en remoto, la  telemedicina y la telefarmacia para la comunicación entre profesionales y  pacientes, así como la formación en esta situación de pandemia, han supuesto  un reto para nuestra profesión. Estos desafíos han creado nuevas oportunidades  de aprendizaje que esperemos nos puedan ser de utilidad en el caso de que  tuviéramos que afrontar situaciones semejantes en el futuro.

Medication regimen complexity on hospital admission in patients with advanced chronic conditions in need of palliative care.

OBJECTIVES: To evaluate characteristics of the medication complexity, risk factors associated with high medication complexity and their clinical consequences in patients with advanced chronic conditions. METHODS: A 10-month cross-sectional study was performed in an acute-hospital care Geriatric Unit. Patients with advanced chronic conditions were identified by the NECPAL test. Medication complexity was established using the Medication Regimen Complexity Index (MRCI) tool. Demographic, pharmacological and clinical patient data were collected with the objective of determining risk factors related to high medication complexity. Measured clinical outcomes were hospital length of stay, destination on hospital discharge, in-hospital mortality and 2-year survival. RESULTS: Two hundred and thirty-five patients (mean age 86.8, SD 5.37; 65.5% female) were recruited. MRCI's mean score was 38 points (SD 16.54, rank: 2.00-98.50), with 57.9% of patients with high medication complexity (MRCI >35 points).

Prevalence, risk factors and adverse outcomes of anticholinergic burden in patients with advanced chronic conditions at hospital admission.

AIM: To evaluate the anticholinergic burden (ACB), the risk factors associated with its onset and the clinical consequences for patients with advanced chronic conditions. METHODS: A 10-month cross-sectional study was carried out in an acute hospital care geriatric unit. Patients with advanced chronic conditions were identified by the NECessity of PALliative care (NECPAL) test. The ACB was established using the Anticholinergic Drug Scale and Drug Burden Index (DBI) tools. Demographic, pharmacological and clinical patient data were collected with the objective of determining risk factors related to ACB. Measured clinical outcomes were the presence of acute confusional state, bone fractures, length of stay, mortality and 12-month survival rate. RESULTS: A total of 235 patients were recruited (mean age 86.80 years, SD 5.37 years; 65.50% women), and 82.10% (DBI) and 93.6% (Anticholinergic Drug Scale) of the patients were treated with anticholinergic medications. Excessive polypharmacy (≥10 drugs) was identified as a risk factor for the presence of anticholinergic medication (Anticholinergic Drug Scale: OR 6.26, 95% CI 1.38-28.42; DBI: OR 3.44, 95% CI 1.60-7.38). High anticholinergic burden (by DBI >2 points) was an independent risk factor for the presence of acute confusional state on hospital admission (OR 2.98, 95% CI 1.04-8.50). However, ACB was not related to bone fractures on admission, length of stay, mortality or survival. CONCLUSIONS: Patients with advanced chronic conditions are frequently treated with anticholinergic drugs, with excessive polypharmacy as a risk factor. Anticholinergic drugs are a risk factor for the presence of acute confusional state on hospital admission, but have no other effect in terms of morbimortality. Geriatr Gerontol Int 2018; 18: 1159-1165.

Patient-Centered Prescription Model to improve therapeutic adherence in patients with multimorbidity.

To date, interventions to improve medication adherence in patients with multimorbidity have shown modest and inconsistent efficacy among  available studies. Thereby, we should define new approaches aimed at improving medication adherence tailored to effective prescribing, with a multidisciplinary approach and patient-centered.In this regard, the Patient-Centered Prescription Model has shown its usefulness on improving appropriateness of drug treatments in patients with clinical complexity. For that, this strategy addresses the following four steps: 1) Patient-Centered assessment; 2) Diagnosis-Centered assessment; 3) Medication-Centered assessment; and 4) Therapeutic Plan.We propose through a clinical case an adaptation of the Patient-Centered Prescription Model to enhance both appropriateness and medication adherence in patients with multimorbidity. To this end, we have  included on its first step the Spanish version of a cross-culturally adapted scale  for the multidimensional assessment of medication adherence. Furthermore, we suggest a set of interventions to be applied in the three remaining steps of  the model. These interventions were firstly identified by an overview of systematic reviews and then selected by a panel of experts based on Delphi methodology.All of these elements have been considered appropriate in patients with multimorbidity according to three criteria: strength of their supporting  evidence, usefulness in the target population and feasibility of implementation in clinical practice.The proposed approach intends to lay the foundations for an innovative way in  tackling medication adherence in patients with multimorbidity.

Según los estudios disponibles, la eficacia de las intervenciones para mejorar la  adherencia terapéutica en pacientes con multimorbilidad es limitada e  inconsistente; por ello, debemos definir nuevos modelos de intervención que  incorporen como elementos clave la atención centrada en la persona, el abordaje interdisciplinar y la orientación a la mejora de la adecuación terapéutica.En este sentido, el Modelo de Prescripción Centrado en la Persona ha  demostrado su capacidad para adecuar la prescripción a las necesidades de  pacientes con complejidad clínica. Para ello, incorpora cuatro etapas consecutivas: 1) valoración centrada en el paciente; 2) valoración  centrada en el diagnóstico; 3) valoración centrada en el fármaco, y 4) propuesta de plan terapéutico.Proponemos, a través de un caso práctico, una adaptación del Modelo de Prescripción Centrado en la Persona como estrategia para mejorar la  adherencia terapéutica. Para ello, en la primera etapa del modelo hemos  incorporado una herramienta para la valoración multidimensional de la  adherencia adaptada transculturalmente al español. Posteriormente,  proponemos un conjunto de intervenciones a aplicar en las tres etapas restantes del modelo. Dichas intervenciones han sido identificadas en un resumen de  revisiones sistemáticas y posteriormente seleccionadas mediante la metodología  Delphi. Todos estos elementos han sido considerados adecuados en pacientes  con multimorbilidad por la solidez de su evidencia, su utilidad potencial en la población diana y la factibilidad de su aplicación en la práctica clínica. La  aproximación propuesta pretende sentar las bases de un modelo de cambio respecto al abordaje de la adherencia en el paciente con multimorbilidad.

Potentially inappropriate medication in palliative care patients according to STOPP-Frail criteria.

BACKGROUND: Potentially inappropriate medications (PIMs) are common in palliative care patients, but no specific tools have been used to determine these PIMs. OBJECTIVE: To evaluate the prevalence of PIMs according to specific tool 'STOPP-Frail', related factors with its existence and clinical consequences. METHODS: This is a post hoc analysis from a 10-month prospective cross-sectional study. Upon hospital admission in an acute geriatric unit (AGU), demographic and pharmacological data were collected to determine related associated factors. The main outcome was prevalence and type of PIMs (by STOPP-Frail criteria). Measured clinical outcomes were adverse drug events, length of stay, location upon discharge, in-hospital mortality and 1-year survival. RESULTS: Two hundred thirty-five patients (mean age 86.80; 65.50% women) were recruited. Overall, 67.2% of patients had ≥ 1 criterion (mainly 'drugs without clinical indication' due to alimentary tract and metabolism drugs). Related factors associated with PIMs according to STOPP-Frail criteria were moderate polypharmacy (OR 7.16 CI 95% 2.27-22.52) and excessive polypharmacy (OR 7.30 CI 95% 2.34-22.73), but not advanced age (OR 0.26 CI 95% 0.12-0.53) or previous hospitalisations (OR 0.61 CI 95% 0.48-0.79). There were no differences in clinical outcomes. CONCLUSION: PIMs according to STOPP-Frail are often used in palliative care patients. PIMs were associated with polypharmacy, but no related morbidity or mortality effects have been observed.

Potentially inappropriate medication at hospital admission in patients with palliative care needs.

Background Potentially inappropriate medications (PIMs) are common in older patients with polypharmacy, and are related to negative clinical results. Little information is available on the characteristics and consequences of PIMs in patients with advanced chronic conditions and palliative care needs. Objective To evaluate, for this population: (i) the prevalence of PIMs; (ii) the possible risk factors associated with its onset; and (iii) the related clinical consequences. Setting Acute-hospital care Geriatric Unit (AGU) in County of Osona, Spain. Method Ten-month prospective cross-sectional study. Patients with palliative care needs were identified according to the NECPAL CCOMS-ICO® test. Upon hospital admission, a multidisciplinary team consisting of a pharmacist and two AGU physicians determined the PIMs of the routine chronic medication of the patients. Sociodemographic and pharmacological data were collected with the objective of determining possible risk factors related to the existence of PIMs. Main outcome measure Prevalence and type of PIMs according to STOPP version 2 and MAI criteria at the time of hospital admission. Furthermore, days of hospital admission, destination at hospital discharge and survival analysis at 12 months related to PIMs were evaluated. Results Two hundred thirty-five patients (mean age 86.80, SD 5.37; 65.50% women) were recruited. According to the STOPP criteria, 88.50% of patients had ≥1 criterion (mainly 'indication of medication', followed by those that affect the nervous system and psychotropic drugs and risk drugs in people suffering from falls), and according to the MAI tool, 97.40% of the patients had some criterion related to inappropriate medication (mainly, duration of therapy). The following conditions were identified as risk factors for the existence of PIMs: insomnia, anxiety-depressive disorder, falls, pain, excessive polypharmacy and therapeutic complexity. There were no differences among patients in days of hospital stay, discharge's destination or survival at 12 months, regardless of the tool used. Conclusion The presence of PIMs is high in patients requiring palliative care. Some potentially modifiable risk factors such as the pharmacological ones are associated with a greater presence of inappropriate medication. The presence of PIMs does not affect this population in terms of mortality.