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Little is known about caregivers' perspectives on deprescribing bisphosphonates for older adults with dementia. Caregivers agreed that fracture prevention was important for maintaining functional independence but acknowledged that changing goals of care may justify deprescribing. Conversations grounded in "what matters most" can align fracture prevention treatment with goals of care. PURPOSE: The long-term fracture prevention benefits of bisphosphonates may begin to be overshadowed by the potential burden of adverse effects and polypharmacy for older adults living with dementia as the disease progresses. We characterized factors that influence caregiver decision-making for continuing versus deprescribing bisphosphonates for persons living with dementia. METHODS: We conducted 11 interviews with family or informal caregivers of older adults living with dementia in the community or in long-term care who had been treated with bisphosphonates. Interviews focused on experiences caring for someone who has experienced a fracture, perceived benefits and harms of bisphosphonates, and experiences with deprescribing. Analyses were conducted using a qualitative framework methodology guided by the Health Belief Model. RESULTS: Most caregivers were male (n = 8), younger than 65 (n = 8) and were an adult child caregiver (n = 8). Three caregivers were Black and five were Latino/a. Attempts to maintain functional independence despite high likelihood of falls was frequently discussed as contributing to fracture risk, in this population. Many caregivers perceived fracture prevention treatment as important, while several noted that it may become less important near the end of life. Perceived benefits of fracture prevention treatment for persons with dementia included improved quality of life and maintaining independence. Although most indicated that bisphosphonates were well tolerated, gastrointestinal adverse effects, preference for fewer treatments, and dementia-related behaviors that interfere with medication administration may be reasons for deprescribing. CONCLUSION: Conversations grounded in caregiver experiences and "what matters most" may help optimize fracture prevention treatment for older adults with dementia.
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Demência , Desprescrições , Humanos , Masculino , Idoso , Feminino , Cuidadores , Difosfonatos/efeitos adversos , Qualidade de Vida , Demência/tratamento farmacológicoRESUMO
BACKGROUND: Few guidelines address fracture prevention medication use in nursing home (NH) residents with dementia. OBJECTIVE: We sought to identify factors that influence prescriber decision-making for deprescribing of bisphosphonates for older NH residents with dementia. METHODS: We conducted 12 semi-structured interviews with prescribers who care for older adults with dementia in NHs. MAIN MEASURES: Interview prompts addressed experiences treating fractures, benefits, and harms of bisphosphonates, and experiences with deprescribing. Coding was guided by the social-ecological framework including patient-level (intrapersonal) and external (interpersonal, system, community, and policy) influences. RESULTS: Most prescribers were physicians (83%); 75% were female and 75% were White. Most (75%) spent less than half of their clinical effort in NHs and half were in the first decade of practice. Among patient-level influences, prescribers uniformly agreed that a prior bisphosphonate treatment course of several years, emergence of adverse effects, and changing goals of care or limited life expectancy were compelling reasons to deprescribe. External influences were frequently discussed as barriers to deprescribing. At the interpersonal level, prescribers noted that family/informal caregivers are diverse in their involvement in decision-making, and frequently concerned about the adverse effects of bisphosphonates, but perceive deprescribing as "withdrawing care." At the health system level, prescribers felt that frequent transitions make it difficult to determine duration of prior treatment and to implement deprescribing. At the policy level, prescribers highlighted the lack of guidelines addressing residents with limited mobility and dementia or criteria for deprescribing, including uncertainty in the setting of prior fractures and lack of bone densitometry in NHs. CONCLUSION: Systems-level barriers to evaluating bone densitometry and treatment history in NHs may impede person-centered decision-making for fracture prevention. Further research is needed to evaluate the residual benefits of bisphosphonates in medically complex residents with limited mobility and dementia to inform recommendations for deprescribing versus continued use.
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Demência , Desprescrições , Fraturas Ósseas , Médicos , Humanos , Feminino , Idoso , Masculino , Difosfonatos/efeitos adversos , Casas de Saúde , Fraturas Ósseas/prevenção & controle , Fraturas Ósseas/tratamento farmacológico , Demência/tratamento farmacológicoRESUMO
In a national sample of Medicare nursing home residents with dementia treated with bisphosphonates, 20% had bisphosphonates deprescribed. Residents with clinical characteristics representing decreased likelihood for long-term benefit were more likely to have bisphosphonates deprescribed. Future studies are needed to evaluate outcomes of deprescribing bisphosphonates in this population. INTRODUCTION: To determine incidence of deprescribing bisphosphonates among nursing home (NH) residents with dementia and identify factors associated with deprescribing. METHODS: 2015-2016 Medicare claims, Part D prescriptions, Minimum Data Set (MDS) 3.0, and Nursing Home Compare for non-skilled NH residents aged 65 + with dementia and prescriptions for oral bisphosphonates overlapping the first 14 days of the stay. Our primary definition for deprescribing was a 90-day gap in medication supply; we also explored the reliability of different deprescribing definitions (30-, 90-, 180-day gaps). We estimated associations of NH, provider, and resident characteristics with deprescribing bisphosphonates using competing risks regression models. RESULTS: Most NH residents with dementia treated with bisphosphonates (n = 5312) were ≥ 80 years old (72%), white (81%), and female (90%); about half were dependent for transfers (50%) or mobility (45%). Using a 90-day gap in supply, the 180-day cumulative incidence of deprescribing bisphosphonates was 14.8%. This increased to 32.1% using a 30-day gap and decreased to 11.7% using a 180-day gap. Factors associated with increased likelihood for bisphosphonate deprescribing were age ≥ 90 years, newly admitted (vs. prevalent stay), dependent for mobility, swallowing difficulty, > 1 hospitalization in the prior year, CCRC facility, and nurse practitioner primary provider (vs. physician). Cancer and western geographic region were associated with reduced likelihood for deprescribing. CONCLUSION: In a national sample of NH residents with dementia, bisphosphonate deprescribing was uncommon, and associated with clinical characteristics signifying poor prognosis and decreased likelihood for long-term benefit. Future studies should evaluate clinical outcomes of deprescribing bisphosphonates in this population.
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Demência , Desprescrições , Idoso , Idoso de 80 Anos ou mais , Demência/tratamento farmacológico , Difosfonatos/uso terapêutico , Feminino , Humanos , Medicare , Casas de Saúde , Reprodutibilidade dos Testes , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: To examine cross-sectional associations between farmers' market shopping behaviours and objectively measured and self-reported fruit and vegetable (FV) intake among rural North Carolina (NC) and New York City (NYC) shoppers. DESIGN: Cross-sectional intercept surveys were used to assess self-reported FV intake and three measures of farmers' market shopping behaviour: (1) frequency of purchasing FV; (2) variety of FV purchased and (3) dollars spent on FV. Skin carotenoids, a non-invasive biomarker for FV intake, were objectively measured using pressure-mediated reflection spectroscopy. Associations between farmers' market shopping behaviours and FV intake were examined using regression models that controlled for demographic variables (e.g. age, sex, race, smoking status, education, income and state). SETTING: Farmers' markets (n 17 markets) in rural NC and NYC. PARTICIPANTS: A convenience sample of 645 farmers' market shoppers. RESULTS: Farmers' market shoppers in NYC purchased a greater variety of FV and had higher skin carotenoid scores compared with shoppers in rural NC. Among all shoppers, there was a positive, statistically significant association between self-reported frequency of shopping at farmers' markets and self-reported as well as objectively assessed FV intake. The variety of FV purchased and farmers' market spending on FV also were positively associated with self-reported FV intake, but not skin carotenoids. CONCLUSION: Those who shop for FV more frequently at a farmers' markets, purchase a greater variety of FV and spend more money on FV have higher self-reported, and in some cases higher objectively measured FV intake. Further research is needed to understand these associations and test causality.
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Fazendeiros , Verduras , Carotenoides , Estudos Transversais , Dieta , Abastecimento de Alimentos , Frutas , Humanos , Cidade de Nova Iorque , North Carolina , AutorrelatoRESUMO
COVID-19 vaccination rates have been suboptimal in frontline healthcare assistants (HCAs). We sought to characterize contributors to COVID-19 vaccine hesitancy among HCAs. We conducted an analysis of online survey responses from members of the National Association of Health Care Assistants from December 2020-January 2021. Respondents were asked what it would take for them to be vaccinated against COVID-19. Responses from 309 HCAs were coded to characterize respondents' willingness to be vaccinated and identify contributors to vaccine hesitancy. Approximately 60% (n = 185) of HCAs expressed hesitancy but would consider getting vaccinated under certain circumstances. We identified 8 overarching themes for contributors to COVID-19 vaccine hesitancy, the most common being safety concerns (70% of respondents). Others included efficacy (11.4%), workplace requirements (9.7%), societal influence (9.2%), and compensation (8.1%). Interventions to increase vaccine uptake among HCAs may be most effective by addressing concerns regarding the short-term and long-term safety implications of COVID-19 vaccines.
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COVID-19 , Vacinas , Pessoal Técnico de Saúde , COVID-19/prevenção & controle , Vacinas contra COVID-19 , Humanos , VacinaçãoRESUMO
OBJECTIVE: The North Carolina Legislature appropriated funds in 2016-2019 for the Healthy Food Small Retailer Program (HFSRP), providing small retailers located in food deserts with equipment to stock nutrient-dense foods and beverages. The study aimed to: (1) examine factors facilitating and constraining implementation of, and participation in, the HFSRP from the perspective of storeowners and (2) measure and evaluate the impact and effectiveness of investment in the HFSRP. DESIGN: The current analysis uses both qualitative and quantitative assessments of storeowner perceptions and store outcomes, as well as two innovative measures of policy investment effectiveness. Qualitative semi-structured interviews and descriptive quantitative approaches, including monthly financial reports and activity forms, and end-of-programme evaluations were collected from participating HFSRP storeowners. SETTING: Eight corner stores in North Carolina that participated in the two cohorts (2016-2018; 2017-2019) of the HFSRP. PARTICIPANTS: Owners of corner stores participating in the HFSRP. RESULTS: All storeowners reported that the HFSRP benefitted their stores. In addition, the HFSRP had a positive impact on sales across each category of healthy food products. Storeowners reported that benefits would be enhanced with adjustments to programme administration and support. Specific suggestions included additional information regarding which healthy foods and beverages to stock; inventory management; handling of perishable produce; product display; modified reporting requirements and a more efficient process of delivering and maintaining equipment. CONCLUSIONS: All storeowners reported several benefits of the HFSRP and would recommend that other storeowners participate. The barriers and challenges they reported inform potential approaches to ensuring success and sustainability of the HFSRP and similar initiatives underway in other jurisdictions.
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Assistência Alimentar , Abastecimento de Alimentos , Comércio , Alimentos , Humanos , North CarolinaRESUMO
BACKGROUND: The North Carolina Healthy Food Small Retailer Program (NC HFSRP) was established through a policy passed by the state legislature to provide funding for small food retailers located in food deserts with the goal of increasing access to and sales of healthy foods and beverages among local residents. The purpose of this study was to qualitatively examine perceptions of the NC HFSRP among store customers. METHODS: Qualitative interviews were conducted with 29 customers from five NC HFSRP stores in food deserts across eastern NC. Interview questions were related to shoppers' food and beverage purchases at NC HFSRP stores, whether they had noticed any in-store efforts to promote healthier foods and beverages, their suggestions for promoting healthier foods and beverages, their familiarity with and support of the NC HFSRP, and how their shopping and consumption habits had changed since implementation of the NC HFSRP. A codebook was developed based on deductive (from the interview guide questions) and inductive (emerged from the data) codes and operational definitions. Verbatim transcripts were double-coded and a thematic analysis was conducted based on code frequency, and depth of participant responses for each code. RESULTS: Although very few participants were aware of the NC HFSRP legislation, they recognized changes within the store. Customers noted that the provision of healthier foods and beverages in the store had encouraged them to make healthier purchase and consumption choices. When a description of the NC HFSRP was provided to them, all participants were supportive of the state-funded program. Participants discussed program benefits including improving food access in low-income and/or rural areas and making healthy choices easier for youth and for those most at risk of diet-related chronic diseases. CONCLUSIONS: Findings can inform future healthy corner store initiatives in terms of framing a rationale for funding or policies by focusing on increased food access among vulnerable populations.
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Desertos Alimentares , Verduras , Adolescente , Comércio , Alimentos , Abastecimento de Alimentos , Frutas , Humanos , North CarolinaRESUMO
OBJECTIVE: To assess availability, variety, price and quality of different food products in a convenience sample of supermarkets in Germany and the USA. DESIGN: Cross-sectional study using an adapted version of the Bridging the Gap Food Store Observation Form. SETTING: Information on availability, quality, price and variety of selected food products in eight German and seven US supermarkets (discount and full service) was obtained and compared by country. RESULTS: A general tendency for lower prices of fruits and vegetables in Germany was observed, while produce quality and variety did not seem to differ between countries, with the exception of the variety of some vegetables such as tomatoes. Chips and cereals did not differ significantly in variety nor price. In both countries, high energy-dense foods were lower in energy costs than lower energy-dense foods. CONCLUSIONS: The influence of food prices and availability on consumption should be further explored, including the impact of country differences.
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Abastecimento de Alimentos , Supermercados , Bebidas , Comércio , Estudos Transversais , Alimentos , Frutas , Alemanha , Humanos , VerdurasRESUMO
BACKGROUND: More geriatricians are needed to care for the aging population. Geriatric scholarly concentration programs (GSCPs) may promote medical students' interest in this underserved field or careers working with older adults. Additionally, graduates of GSCPs may be more comfortable and competent in providing care for older adults. Surveys were administered to graduates of GSCPs to determine the role of these programs in shaping medical students' careers and views about caring for older adults. Methods: The purpose of this study is to understand the impact of GSCPs on medical graduates' career choices and self-perceived skill and comfort in caring for older adults. A Qualtrics survey (Qualtrics International Inc., Seattle, Washington, United States) was developed and distributed to 83 graduates of four GSCPs in the United States. Data were analyzed using a significance level of p>0.05 for all tests. Descriptive statistics were calculated to summarize the data. Wilcoxon signed-rank tests were used to test for significant differences in interest in pursuing a career in geriatrics or working with older adults. Qualitative responses were coded and analyzed for themes. Results: A total of 34 out of 83 surveyed graduates of GSCPs indicated a higher interest in geriatrics as a career as well as increased comfort and self-perceived skill in caring for older adults after completing the GSCP. The components of the GSCP that most strongly improved the participants' ability to care for older adults included the curriculum (n=31, 91%) and mentoring (n=28, 82%). An overwhelming majority of survey participants felt GSCPs should be offered as part of medical school programming (n=33, 97%). Conclusion: This study suggests that GSCPs increase interest and competence in caring for older adults and increase interest in a career in geriatrics. GSCPs should be implemented across medical schools.
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BACKGROUND: Gold standard dementia assessments are rarely available in large real-world datasets, leaving researchers to choose among methods with imperfect but acceptable accuracy to identify nursing home (NH) residents with dementia. In healthcare claims, options include claims-based diagnosis algorithms, diagnosis indicators, and cognitive function measures in the Minimum Data Set (MDS), but few studies have compared these. We evaluated the proportion of NH residents identified with possible dementia and concordance of these three. METHODS: Using a 20% random sample of 2018-2019 Medicare beneficiaries, we identified MDS admission assessments for non-skilled NH stays among individuals with continuous enrollment in Medicare Parts A, B, and D. Dementia was identified using: (1) Chronic Conditions Warehouse (CCW) claims-based algorithm for Alzheimer's disease and non-Alzheimer's dementia; (2) MDS active diagnosis indicators for Alzheimer's disease and non-Alzheimer's dementias; and (3) the MDS Cognitive Function Scale (CFS) (at least mild cognitive impairment). We compared the proportion of admissions with evidence of possible dementia using each criterion and calculated the sensitivity, specificity, and agreement of the CCW claims definition and MDS indicators for identifying any impairment on the CFS. RESULTS: Among 346,013 non-SNF NH admissions between 2018 and 2019, 57.2% met criteria for at least one definition (44.7% CFS, 40.7% CCW algorithm, 26.0% MDS indicators). The MDS CFS uniquely identified the greatest proportion with evidence of dementia. The CCW claims algorithm had 63.7% sensitivity and 78.1% specificity for identifying any cognitive impairment on the CFS. Active diagnosis indicators from the MDS had lower sensitivity (47.0%), but higher specificity (91.0%). CONCLUSIONS: Claims- and MDS-based methods for identifying NH residents with possible dementia have only partial overlap in the cohorts they identify, and neither is an obvious gold standard. Future studies should seek to determine whether additional functional assessments from the MDS or prescriptions can improve identification of possible dementia in this population.
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Demência , Medicare , Casas de Saúde , Humanos , Estados Unidos , Masculino , Demência/diagnóstico , Feminino , Medicare/estatística & dados numéricos , Idoso de 80 Anos ou mais , Casas de Saúde/estatística & dados numéricos , Idoso , Algoritmos , Disfunção Cognitiva/diagnóstico , Doença de Alzheimer/diagnóstico , Cognição , Revisão da Utilização de Seguros/estatística & dados numéricos , Instituição de Longa Permanência para Idosos/estatística & dados numéricosRESUMO
BACKGROUND: Over 35 million falls occur in older adults annually and are associated with increased emergency department (ED) revisits and 1-year mortality. Despite associations between medications and falls, the prevalence of fall risk-increasing drugs remains high. Our objective was to implement an ED-based medication reconciliation for patients presenting after falls and determine whether an intervention targeting high-risk medications was related to decreased future falls. METHODS: This was an observational prospective cohort study at a single site in the United States. Adults 65 years and older presenting to the ED after falls had a pharmacist review their medicines. Pharmacists made recommendations to taper, stop, or discuss medications with the primary clinician. At 3, 6, and 12 months, we recorded the number of fall-related return ED visits and determined if recommended medication changes had been implemented. We compared the rate of return visits of patients who had followed the medication change recommendations and those who received recommendations but had no change in their medications using chi-square tests. RESULTS: A total of 577 patients (mean age 81 years, 63.6% female) were enrolled of 1509 potentially eligible patients. High-risk medications were identified in 310 patients (53.7%) who received medication recommendations. High-risk medications were associated with repeat fall-related visits at 12 months (risk difference 8.1% [95% confidence interval 0.97-15.0]). A total of 134 (43%) patients on high-risk medications had evidence of medication modification. At 12 months, there was no statistically significant difference in return fall visits between patients who had modifications to medications compared with those who had not implemented changes (p = 0.551). CONCLUSIONS: Our findings identified opportunities for medication optimization in over half of emergency visits for falls and demonstrated that medication counseling in the ED is feasible. However, evaluation of the effect on future falls was limited.
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Acidentes por Quedas , Desprescrições , Serviço Hospitalar de Emergência , Reconciliação de Medicamentos , Humanos , Acidentes por Quedas/estatística & dados numéricos , Acidentes por Quedas/prevenção & controle , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Masculino , Idoso , Estudos Prospectivos , Idoso de 80 Anos ou mais , Estados Unidos/epidemiologia , FarmacêuticosRESUMO
Introduction: The COVID-19 pandemic has necessitated the rapid expansion of telemedicine. However, there has been minimal coverage of telemedicine in traditional undergraduate medicine curricula. Telemedicine presents specific challenges in the geriatric population, including unfamiliarity with technology, cognitive and sensory barriers, inclusion of family and/or caregivers, multimorbidity, and a high degree of medical complexity. Methods: We developed a workshop to allow rising third-year medical students to practice a telemedicine patient encounter while developing skills for assessing and communicating with geriatric patients. This 90-minute workshop consisted of an introductory didactic presentation and a standardized patient activity for small groups of two to five students. Students' level of comfort with telemedicine for assessment of geriatric patients was evaluated with a pre- and postsurvey. Results: Fifty-eight students participated in the workshop and completed the surveys (presurvey = 58, postsurvey = 40), with roughly half (52%) reporting prior experience with telemedicine. A 5-point Likert-type scale (1 = very uncomfortable, 5 = very comfortable) was used. Students reported statistically significant increases in comfort using telemedicine (presurvey = 3.1, postsurvey = 3.9, p < .001) and using telemedicine for patients ≥65 years (presurvey = 2.8, postsurvey = 3.9, p < .001) after completing the workshop. Discussion: Medical students' comfort levels using telemedicine and caring for patients ages 65 and older with a telehealth visit improved after participating in this workshop. To help prepare students for telehealth practice in their future careers, educators should provide them with opportunities to practice and develop this critical skill set.
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COVID-19 , Estudantes de Medicina , Telemedicina , Idoso , Humanos , Pandemias , COVID-19/epidemiologia , CurrículoRESUMO
BACKGROUND: Opioids and benzodiazepines (BZDs) pose a public health problem. Older adults are especially susceptible to adverse events from opioids and BZDs owing to an increased usage of opioids and BZDs, multiple comorbidities, and polypharmacy. Deprescribing is a possible, yet challenging, solution to reducing opioid and BZD use. OBJECTIVE: We aimed to explore older adult patients' knowledge of opioids and BZDs, perceived facilitators and barriers to deprescribing opioids and BZDs, and attitudes toward alternative treatments for opioids and BZDs. METHODS: We conducted 11 semi-structured interviews with patients aged 65+ years with long-term opioid and/or BZD prescriptions. The interview guide was developed by an interprofessional team and focused on patients' knowledge of opioids and BZDs, perceived ability to reduce opioid or BZD use, and attitudes towards alternative treatments. RESULTS: Three patients had taken opioids, either currently or in the past, three had taken BZDs, and five had taken both opioids and BZDs. Generally, knowledge of opioids and BZDs was variable among patients; yet facilitators and barriers to deprescribing both opioids and BZDs were consistent. Facilitators of deprescribing included patient-provider trust and slow tapering of medications, while barriers included concerns about re-emergence of symptoms and a lack of motivation, particularly if medications and symptoms were stable. Patients were generally unenthusiastic about pursuing alternative pharmacologic and non-pharmacologic alternatives to opioids and BZDs for symptom management. CONCLUSIONS: Our findings indicate that patients are open to deprescribing opioids and BZDs under certain circumstances, but overall remain hesitant with a lack of enthusiasm for alternative treatments. Future studies should focus on supportive approaches to alleviate older adults' deprescribing concerns.
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Benzodiazepinas , Desprescrições , Humanos , Idoso , Benzodiazepinas/efeitos adversos , Analgésicos Opioides/efeitos adversos , Atitude , PolimedicaçãoRESUMO
BACKGROUND: Limited COVID-19 vaccination acceptance among healthcare assistants (HCAs) may adversely impact older adults, who are at increased risk for severe COVID-19 infections. Our study objective was to evaluate the perceptions of COVID-19 vaccine safety and efficacy in a sample of frontline HCAs, overall and by race and ethnicity. METHODS: An online survey was conducted from December 2020 to January 2021 through national e-mail listserv and private Facebook page for the National Association of Health Care Assistants. Responses from 155 HCAs, including certified nursing assistants, home health aides, certified medical assistants, and certified medication technicians, were included. A 27-item survey asked questions about experiences and perceptions of COVID-19 vaccines, including how confident they were that COVID-19 vaccines are safe, effective, and adequately tested in people of color. Multivariable regression was used to identify associations with confidence in COVID-19 vaccines. RESULTS: We analyzed data from 155 completed responses. Among respondents, 23.9% were black and 8.4% Latino/a. Most respondents worked in the nursing home setting (53.5%), followed by hospitals (12.9%), assisted living (11.6%), and home care (10.3%). Respondents expressed low levels of confidence in COVID-19 vaccines, with fewer than 40% expressing at least moderate confidence in safety (38.1%), effectiveness (31.0%), or adequate testing in people of color (27.1%). Non-white respondents reported lower levels of confidence in adequate testing of vaccines compared to white respondents. In bivariate and adjusted models, respondents who gave more favorable scores of organizational leadership at their workplace expressed greater confidence in COVID-19 vaccines. CONCLUSION: Frontline HCAs reported low confidence in COVID-19 vaccines. Stronger organizational leadership in the workplace appears to be an important factor in influencing HCA's willingness to be vaccinated. Action is needed to enhance COVID-19 vaccine uptake in this important population with employers playing an important role to build vaccine confidence and trust among employees.
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Pessoal Técnico de Saúde/psicologia , Vacinas contra COVID-19/administração & dosagem , Etnicidade/estatística & dados numéricos , Percepção , Grupos Raciais/estatística & dados numéricos , Adulto , Idoso , Moradias Assistidas/estatística & dados numéricos , COVID-19/prevenção & controle , Feminino , Hospitais/estatística & dados numéricos , Humanos , Internet , Masculino , Pessoa de Meia-Idade , Casas de Saúde/estatística & dados numéricos , Inquéritos e Questionários , Vacinação/estatística & dados numéricos , Hesitação VacinalRESUMO
PURPOSE: Opioids and benzodiazepines (BZDs) are frequently implicated as contributing to falls in older adults. Deprescribing of these medications continues to be challenging. This study evaluated primary-care prescribers' confidence in and perceptions of deprescribing opioids and BZDs for older adults. METHODS: For this study, we conducted a quantitative analysis of survey data combined with an analysis of qualitative data from a focus group. A survey evaluating prescriber confidence in deprescribing opioids and BZDs was distributed to providers at 15 primary-care clinics in North Carolina between March-December 2020. Average confidence (scale 0-100) for deprescribing opioids, deprescribing BZDs, and deprescribing under impeding circumstances were reported. A virtual focus group was conducted in March 2020 to identify specific barriers and facilitators to deprescribing opioids and BZDs. Audio recordings and transcripts were analyzed using inductive coding. RESULTS: We evaluated 61 survey responses (69.3% response rate). Respondents were predominantly physicians (54.8%), but also included nurse practitioners (24.6%) and physician assistants (19.4%). Average overall confidence in deprescribing was comparable for opioids (64.5) and BZDs (65.9), but was lower for deprescribing under impeding circumstances (53.7). In the focus group, prescribers noted they met more resistance when deprescribing BZDs and that issues such as lack of time, availability of mental health resources, and patients seeing multiple prescribers were barriers to deprescribing. CONCLUSION: Findings from quantitative and qualitative analyses identified that prescribers were moderately confident in their ability to deprescribe both opioids and BZDs in older adults, but less confident under potentially impeding circumstances. Future studies are needed to evaluate policies and interventions to overcome barriers to deprescribing opioids and BZDs in primary care.
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Desprescrições , Médicos , Idoso , Analgésicos Opioides/efeitos adversos , Benzodiazepinas/efeitos adversos , Humanos , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Many older adults are prescribed opioids and benzodiazepines (BZDs), despite increased susceptibility to adverse events. Challenges of deprescribing include fragmented care and lack of knowledge or time. Pharmacists are well-positioned to overcome these challenges and facilitate deprescribing of these medications. OBJECTIVES: We sought to evaluate interventions utilizing pharmacists to deprescribe opioids and BZDs in older adults. METHODS: We conducted a rapid review following a comprehensive literature search to identify interventions with pharmacist involvement for deprescribing opioids and BZDs in older adults. Studies were included based on: (1) inclusion of patients ≥ 65 years old receiving BZDs and/or opioids, (2) evaluation of feasibility or outcomes following deprescribing (3) pharmacists as part of the intervention. We included randomized, observational, cohort, and pilot studies. Studies that did not report specific results for BZD or opioids were excluded. RESULTS: We screened 687 abstracts and included 17 studies. Most (n = 13) focused on BZD deprescribing. Few studies focused on opioids (n = 2) or co-prescribing of opioids and BZDs (n = 2). The most common intervention was educational brochures (n = 8), majority being the EMPOWER brochure for deprescribing BZDs. Other interventions included chart review with electronic notes (n = 4), pharmacist-led programs/services (n = 2), and multifactorial interventions (n = 3). Many studies were underpowered or lacked suitable control groups. Generally speaking, interventions utilizing educational materials and those in which pharmacists engaged with patients and providers were more effective. Interventions relying on electronic communication by pharmacists were less successful, due to low acceptance or acknowledgement. CONCLUSIONS: We identified a number of feasible interventions to reduce BZD use, but fewer interventions to reduce opioid use in older adults. An optimal approach for deprescribing likely requires pharmacists to engage directly with patients and providers. Larger well-designed studies are needed to evaluate the effectiveness of deprescribing interventions beyond feasibility.
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Analgésicos Opioides , Benzodiazepinas , Desprescrições , Idoso , Analgésicos Opioides/efeitos adversos , Benzodiazepinas/efeitos adversos , Humanos , FarmacêuticosRESUMO
The COVID-19 pandemic disrupted face-to-face interactions in healthcare research, with many studies shifting to video-based data collection for qualitative research. This study describes the interactivity achieved in a videoconferencing focus group of seven primary care providers discussing deprescribing opioids and benzodiazepines. Researchers reviewed video footage of a focus group conducted via Zoom and assessed interactivity using Morgan's framework for focus group communication processes. Two reviewers categorized the type of exchanges as sharing information, comparing experiences, organizing, and conceptualizing the content, as well as validating each other or galvanizing the discussion with "lightning strike" ideas. The conversation dynamics in this focus group included clear examples of interactivity in each of the categories proposed by Morgan (validating, sharing, comparing, organizing, conceptualizing, and lightning strikes) that were observed by two different reviewers with demonstrated high interrater reliability. Conducting focus groups with a skilled moderator using videoconferencing platforms with primary care providers is a viable option that produces sufficient levels of interaction.
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This study's purpose was to qualitatively examine perceived advantages and disadvantages of online grocery shopping among participants (n = 7) in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Initial in-depth, qualitative interviews were conducted, after which participants completed an episode of online grocery shopping, picked up the online order at the store, and completed an in-store shopping episode and a follow-up in-depth interview. Interviews were audio-recorded, transcribed verbatim, and analyzed deductively. Participants stated that in-store impulse purchases occurred at the check-out and cookie aisles and included chips and candy, but sometimes healthier foods such as fruit. Advantages of online grocery shopping included ease, convenience, and saving time. Disadvantages included inadequate substitutions, the online shopping fee, lack of control over selection of perishable goods, and inability to find good deals online versus in the store. Further research is needed to determine how to encourage healthy grocery purchases online.