District nurses' experiences of using a clinical decision support system and an assessment tool at elderly care units in primary health care: a qualitative study.

AIM: The present study aimed to describe the experience of district nurses (DNs) in using a clinical decision support system (CDSS) and the safe medication assessment (SMA) tool during patient visits to elderly care units at primary health care centres. BACKGROUND: In Swedish primary health care, general practitioners (GPs) prescribe and have the responsibility to regularly review older adults' medications, while DN (nurses specialised in primary health care) play an important role in assessing older adults' ability to manage their medications, detecting potential drug-related problems and communicating with patients and GPs about such problems. In a previous feasibility study, we found that DNs who use a combination of a CDSS and the SMA tool identified numerous potentially harmful or dangerous factors and took a number of nursing care actions to improve the safety and quality of patients' medication use. In telephone interviews, patients indicated that they were positive towards the assessment and interventions. METHODS: Individual interviews with seven DNs who worked at six different primary health care centres in Region Stockholm were carried out in 2018. In 2019, an additional group interview was conducted with two of the seven DNs so they could discuss and comment on preliminary findings. Qualitative content analysis was used to analyse the interview transcripts.Findings: Using the tools, the DNs could have a natural conversation about medication use with older adults. They could get a clear picture of the older adults' medication use and thus obtain information that could facilitate collaboration with GPs about this important component of health care for older adults. However, for the tools to be used in clinical practice, some barriers would have to be overcome, such as the time-consuming nature of using the tools and the lack of established routines for interprofessional collaboration regarding medication discussions.

District nurses' use of a decision support and assessment tool to improve the quality and safety of medication use in older adults: a feasibility study.

AIM: To investigate whether district nurses (DNs) can identify factors related to the quality and safety of medication use among older patients via a clinical decision support system (CDSS) for medication and an instrument for assessing the safety of drug use [the Safe Medication Assessment tool (SMA)]. A secondary aim was to describe patients' experiences of the assessment. BACKGROUND: DNs in Stockholm County have the opportunity to establish special units at primary health care centers (PHCCs) for patients aged 75 years and older. The units conduct drug utilization reviews and create care plans for older adults. METHODS: Nine DNs at 7 PHCCs in Stockholm County used the tools with 45 patients aged 75 years and older who used one or more drugs. Outcome measures were the number of drugs, potential drug-related problems, nursing interventions, and patient satisfaction. Prevalences of drug-related problems and nursing interventions were calculated. Eleven patients answered a telephone questionnaire on their experiences of the assessment. FINDINGS: DNs identified factors indicative of drug-related problems, including polypharmacy (9.8 drugs per person), potential drug-drug interactions (prevalence 40%), potential adverse drug reactions (2.7 per person), and prescribers from more than two medical units (60%). DNs used several nursing interventions to improve the safety of medication use (e.g., patient education, initiating a pharmaceutical review). The patients thought it was meaningful to receive information about their drug use and important to identify potential drug-related problems. With the support of the CDSS and the SMA tool, the DNs could identify several factors related to inappropriate or unsafe medication and initiated a number of interventions to improve medication use. The patients were positive toward the assessments. Using these tools, the DNs may help promote safe medication use in older patients.

Use of Fall-Risk Inducing Drugs in Patients Using Anti-Parkinson Drugs (APD): A Swedish Register-Based Study.

OBJECTIVES: Many drugs increase the risk of falls in old age. Although persons with Parkinson's disease (PD) are at increased risk of experiencing falls and fractures, the use of fall-risk inducing drugs (FRIDs) in this population has not previously been investigated. The objective of this study was to investigate the burden of use of FRIDs in older persons treated with anti-Parkinson drugs (APD; used as a proxy for PD), compared to persons without APD. METHODS: We analyzed individual data on age, sex, type of housing and drug use in 1 346 709 persons aged ≥ 65 years in the Swedish Prescribed Drug Register on the date of 30 September 2008. Main outcome measure was the use of FRIDs. RESULTS: FRIDs were used by 79% of persons with APD and 75% of persons without APD. Persons with APD were more likely to use ≥ 1 FRIDs compared to persons without APD (adjusted OR: 1.09; 95% CI: 1.06-1-12). The association was stronger for concomitant use of ≥ 5 FRIDS (adjusted OR: 1.49; 95% CI: 1.44-1.55). CONCLUSIONS: The high use of FRIDs among persons with APD indicates that these patients may be at increased risk of drug-induced falls. Further studies are needed to investigate how these drugs affect the risk of falling in persons with PD.

Influence of Incipient Dementia on Hospitalization for Primary Care Sensitive Conditions: A Population-Based Cohort Study.

BACKGROUND: Studies have reported that moderate/severe stages of dementia are linked to increased hospitalization rates, but little is known about the influence of incipient dementia on hospitalizations for primary care sensitive conditions (PCSCs). OBJECTIVE: To examine the associations between incipient dementia and hospitalization outcomes, including all-cause and PCSC hospitalization. METHODS: A total of 2,268 dementia-free participants in the Swedish National study on Aging and Care-Kungsholmen were interviewed and clinically examined at baseline. Participants aged ≥78 years were followed for 3 years, and those aged 60-72 years, for 6 years. Number of hospitalizations was retrieved from the National Patient Register. Dementia was diagnosed in accordance with Diagnostic and Statistical Manual of Mental Disorders-IV criteria. Hospitalization outcomes were compared in participants who did and did not develop dementia. Zero-inflated Poisson regressions and logistic regressions were used in data analysis. RESULTS: During the follow-up, 175 participants developed dementia. The unadjusted PCSC admission rate was 88.2 per 1000 person-years in those who developed dementia and 25.6 per 1000 person-years in those who did not. In the fully adjusted logistic regression model, incipient dementia was associated with an increased risk of hospitalization for PCSCs (OR = 2.3, 95% CI 1.3-3.9) but not with the number of hospitalizations or with all-cause hospitalization. Risks for hospitalization for diabetes, congestive heart failure, and pyelonephritis were higher in those who developed dementia than in those who did not. About 10% participants had a PCSC hospitalization attributable to incipient dementia. CONCLUSION: People with incipient dementia are more prone to hospitalization for PCSCs but not to all-cause hospitalization.

The impact of dementia on drug costs in older people: results from the SNAC study.

BACKGROUND: We aimed to investigate the impact of dementia on drug costs in older people, after adjustment for socio-demographic factors, residential setting and co-morbidities. METHODS: We included 4,129 individuals aged ≥ 60 years from The Swedish National Study on Aging and Care (SNAC) in Kungsholmen and Nordanstig 2001-2004. A generalized linear model (GLM) was used to investigate how much dementia was associated with drug costs. RESULTS: Overall drug costs for persons with and without dementia were 6147 SEK (816 USD) and 3810 SEK (506 USD), respectively. The highest drug cost was observed for nervous system drugs among persons with dementia. The adjusted GLM showed that dementia was not associated with higher overall drug costs (ß = 1.119; ns). Comorbidities and residential setting were the most important factors for overall drug costs. CONCLUSION: We found that the observed higher overall drug costs for persons with dementia were due to comorbidities and residential setting.

Coexisting chronic conditions in the older population: Variation by health indicators.

BACKGROUND: This study analyzes the prevalence and patterns of coexisting chronic conditions in older adults. DESIGN: Cross-sectional. PARTICIPANT AND SETTING: A sample of 3363 people ≥60years living in Stockholm were examined from March 2001 through August 2004. MEASUREMENTS: Chronic conditions were measured with: 1) multimorbidity (≥2 concurrent chronic diseases); 2) the Cumulative Illness Rating Scale, 3) polypharmacy (≥5 prescribed drugs), and 4) complex health problems (chronic diseases and/or symptoms along with cognitive and/or functional limitations). RESULTS: A total of 55.6% of 60-74year olds and 13.4% of those ≥85years did not have chronic conditions according to the four indicators. Multimorbidity and polypharmacy were the most prevalent indicators: 38% aged 60-74 and 76% aged ≥85 had multimorbidity; 24.3% aged 60-74 and 59% aged ≥85 had polypharmacy. Prevalence of chronic conditions as indicated by the comorbidity index and complex health problems ranged from 16.5% and 1.5% in the 60-74year olds to 38% and 36% in the 85+ year olds, respectively. Prevalence of participants with 4 indicators was low, varying from 1.6% in those aged 60-74 to 14.9% in those aged ≥85years. Older age was associated with higher odds of each of the 4 indicators; being a woman, with all indicators but multimorbidity; and lower educational level, only with complex health problems. CONCLUSIONS: Prevalence of coexisting chronic conditions varies greatly by health indicator used. Variation increases when age, sex, and educational level are taken into account. These findings underscore the need of different indicators to capture health complexity in older adults.

Impact of Inappropriate Drug Use on Hospitalizations, Mortality, and Costs in Older Persons and Persons with Dementia: Findings from the SNAC Study.

BACKGROUND: Inappropriate drug use (IDU) is an important risk factor for adverse outcomes in older persons. We aimed to investigate IDU and the risk of hospitalizations and mortality in older persons and in persons with dementia and to estimate the costs of IDU-related hospitalizations. METHODS: We analyzed 4108 individuals aged ≥60 years from the Swedish National Study on Aging and Care (SNAC) data from Kungsholmen and Nordanstig (2001-2004). IDU was assessed by indicators developed by the Swedish National Board of Health and Welfare. Hospitalizations and mortality data were collected from Swedish registers. Regression models were used to investigate associations between IDU, hospitalizations, and mortality in the whole population and in the subpopulation of persons with dementia (n = 319), after adjustment for sociodemographics, physical functioning, and co-morbidity. Costs for hospitalizations were derived from the Nord-Diagnose Related Group cost database. RESULTS: IDU was associated with a higher risk of hospitalization [adjusted odds ratio (OR) = 1.46; 95% confidence interval (CI) 1.18-1.81] and mortality [adjusted hazard ratio (HR) = 1.15; 95% CI 1.01-1.31] within 1 year in the whole study population and with hospitalization (adjusted OR = 1.88; 95% CI 1.03-3.43) in the subpopulation of persons with dementia, after adjustment for confounding factors. There was also a tendency for higher costs for hospitalizations with IDU than without IDU, although this was not statistically significant. CONCLUSIONS: Our findings suggest that IDU is associated with an increased risk of hospitalization in older persons and in persons with dementia. IDU is also associated with mortality among older persons. These findings highlight the need for cautious prescribing of long-acting benzodiazepines, anticholinergic drugs, concurrent use of three or more psychotropic drugs and drug combinations that may lead to serious drug-drug interactions to older patients. Further studies are needed to investigate the association between IDU and costs for hospitalizations.

Socioeconomic inequalities in access to specialized psychotropic prescribing among older Swedes: a register-based study.

BACKGROUND: Mental disorders among older adults are mainly treated with psychotropic drugs. Few of these drugs are, however, prescribed by specialized geriatricians or psychiatrists, but rather from general practitioners (GPs). Socioeconomic inequalities in access to specialist prescribing have been found in younger age groups. Hence, we aimed to investigate whether there are socioeconomic differences in access to geriatrician and psychiatrist prescribing of psychotropic drugs among older adults. METHODS: By record-linkage of The Swedish Prescribed Drug Register and The Swedish Education Register, we obtained information for persons aged 75-89 years who had filled a prescription for psychotropic drugs (antipsychotics, anxiolytics, hypnotic/sedatives or antidepressants) with information on prescriber specialty from July to October 2005 (n = 221 579). Multinomial regression analysis was used to investigate whether education was associated with geriatrician and psychiatrist prescribing of psychotropic drugs. RESULTS: The vast majority of the psychotropic drugs were prescribed by 'GPs and other specialists' (∼95% GPs). Older adults with higher educational level were more likely to be prescribed psychotropic drugs from psychiatrists and geriatricians. However, after adjustment for place of residence, the association between patient's education and prescription by a geriatrician disappeared, whereas the association with seeing a psychiatrist was only attenuated. CONCLUSION: Access to specialized prescribing of psychotropics is unequally distributed between socioeconomic groups of older adults in Sweden. This finding was partially confounded by place of residence for geriatrician but not for psychiatrist prescribing. Further research should examine if inequalities in specialized psychotropic prescribing translate into worse outcomes for socioeconomically deprived and non-metropolitan-living older individuals.

Association between multi-dose drug dispensing and quality of drug treatment--a register-based study.

BACKGROUND: In the elderly in Scandinavia, multi-dose drug dispensing (MDD) is a common alternative to ordinary prescriptions (OP). MDD patients receive their drugs in unit bags, one for each dose occasion. The prescribing procedure differs between MDD and OP. The aim of the present study was to investigate the association between MDD and quality of drug treatment (QDT). METHODOLOGY/PRINCIPAL FINDINGS: A cross-sectional study was performed of all inhabitants in Region Västra Götaland alive on December 31st 2007, aged ≥65 years, with ≥1 prescribed drug and ≥2 health care visits for ≥2 diagnoses for obstructive pulmonary disease, diabetes mellitus, and/or cardiovascular disease in 2005-2007 (n = 24,146). For each patient, drug treatment on December 31st 2007 was estimated from drugs registered in the Swedish Prescribed Drug Register. QDT was evaluated according to established quality indicators (≥10 drugs, Long-acting benzodiazepines, Drugs with anticholinergic action, ≥3 psychotropics, and Drugs combinations that should be avoided). Logistic regression, with adjustments for age, sex, burden of disease, and residence, was performed to investigate the association between MDD and QDT. Mean age was 77 years, 51% were females, and 20% used MDD. For all quality indicators, the proportion of patients with poor QDT was greater in patients with MDD than in patients with OP (all P<0.0001). Unadjusted and adjusted odds ratios (95% confidence intervals) for poor QDT (MDD patients vs. OP patients) ranged from 1.47 (1.30-1.65) to 7.08 (6.30-7.96) and from 1.36 (1.18-1.57) to 5.48 (4.76-6.30), respectively. CONCLUSIONS/SIGNIFICANCE: Patients with MDD have poorer QDT than patients with OP. This cannot be explained by differences in age, sex, burden of disease, or residence. These findings must be taken into account when designing alternative prescribing systems. Further research is needed to evaluate causative factors and if the findings also apply to other dose dispensing systems.

Sex differences in inappropriate drug use: a register-based study of over 600,000 older people.

BACKGROUND: Several studies have observed a higher rate of inappropriate drug use in elderly women than in elderly men, although few have focused explicitly on sex differences. Also, educational level (a measure of socioeconomic status) has been associated with both polypharmacy and inappropriate drug use in the elderly population, which could explain sex differences in inappropriate drug use. OBJECTIVE: To investigate whether sex is associated with inappropriate drug use in a large general population of older people, after adjustment for age, socioeconomic status (ie, educational level), and comorbidity (ie, number of drugs). METHODS: We conducted an analysis of data on sex, age, dispensed drugs, and education for people aged 75-89 years who were registered in the Swedish Prescribed Drug Register between July and October 2005 (N = 645,429). The main outcome measures were the filling of prescriptions for anticholinergic drugs or long-acting benzodiazepines, concurrent use of 3 or more psychotropic drugs, and potentially serious drug-drug interactions. RESULTS: Potentially inappropriate drug use was more common in women (24.6%) than in men (19.3%). More women than men were exposed to all types of inappropriate drug use, except for potentially serious drug-drug interactions. Logistic regression analysis showed that women were more likely to be exposed to potentially inappropriate drug use than were men (OR 1.24; 95% CI 1.23 to 1.26) after adjustment for age, education, and number of drugs (used as a proxy for comorbidity). In particular, female sex was highly associated with inappropriate psychotropic use (eg, long-acting benzodiazepines: adjusted OR [ORadjusted] 1.45; 95% CI 1.42 to 1.49; >3 psychotropic drugs: ORadjusted 1.50; 95% CI 1.47 to 1.53). In contrast, women had a lower probability of potentially serious drug-drug interactions than did men (ORadjusted 0.81; 95% CI 0.80 to 0.83). CONCLUSIONS: Inappropriate drug use in the elderly should be monitored separately for women and men. Our results suggest that neither socioeconomic status nor comorbidity seem to explain sex differences in inappropriate drug use. Future research in other large study populations is needed for investigation of other explanations behind these sex differences.

Patient educational level and use of newly marketed drugs: a register-based study of over 600,000 older people.

OBJECTIVE: To examine the association between educational level and the use of newly marketed drugs (NMD) among elderly persons. METHODS: We conducted a register-based, retrospective, cross-sectional study of 626,258 people aged 75-89 years who filled at least one drug prescription from August to October 2005 and who, consequently, were registered in the Swedish Prescribed Drug Register (SPDR). Data from the SPDR were record-linked to the Swedish National Inpatient Register and the Education Register. Newly marketed drugs were defined as new chemical entities that had been approved in Sweden between 2000 and 2004. RESULTS: Overall, NMD were prescribed to 7.3% of the study population. The use of NMD increased with increasing educational level (6.9% for the lowest educated elderly and 8.1% for the highest educated elderly), and education was associated with NMD [odds ratio (OR) 0.82; 95% confidence interval (CI)] 0.80-0.88 for <9 compared with > or =13 years of education) after adjustment for age, sex, type of residential area and number of dispensed drugs. Decreasing educational level was associated with a lower probability of using most of the NMD, especially oseltamivir (adjusted OR 0.16; 95% CI 0.12-0.22 for <9 years of education compared with > or =13 years of education) and ezetimibe. CONCLUSIONS: This study suggests that education-related inequalities in NMD use may exist even in a healthcare system that claims to ensure a high degree of equity. Future research is required to explain why educational level influences the selection of new drugs and whether it has any impact on health outcomes.

Analysis of the association between polypharmacy and socioeconomic position among elderly aged > or =77 years in Sweden.

BACKGROUND: Polypharmacy is an important patient safety concern and has been associated with increased adverse drug reactions, hospitalization, and mortality in the elderly. However, few studies have analyzed the association between socioeconomic position (SEP) and the extent of drug use in older people. OBJECTIVES: The aims of this study were to investigate the prevalence of polypharmacy and the association between polypharmacy and SEP, as measured by education, occupation, and income. METHODS: For this cross-sectional study, data from a nationally representative sample (Swedish Panel Study of Living Conditions of the Oldest Old [SWEOLD] 2002) aged > or =77 years were analyzed (n = 621). Information on drug use was based on personal interviews, and polypharmacy was defined as concurrent use of > or =5 drugs. Other measurements included were age, sex, education, occupation, income, comorbidity, marital status, and living situation. The association between polypharmacy and SEP was assessed by logistic regression. RESULTS: The mean number of drugs used in the sample was 4.4; in less educated patients, 4.6; more educated, 4.0. Polypharmacy was observed in 42.2% of the elderly. Overall, antithrombotic agents (42.5%), P-blocking agents (28.3%), and high-ceiling diuretics (28.0%) were the most prevalent drugs. Low education was associated with polypharmacy (odd ratio [OR], 1.46; 95% CI, 1.02-2.07), after controlling for age and sex. However, the association between low education level and polypharmacy was not significant after adjustment for age, sex, comorbidity, marital status, and living situation (OR, 1.39; 95% CI, 0.95-2.04). Moreover, we did not observe any association between occupation or income and polypharmacy. CONCLUSIONS: The results from this study suggest that >40% of people aged > or =77 years in Sweden are exposed to polypharmacy, defined as the use of > or =5 drugs. There was a higher prevalence of polypharmacy among elderly with low education. However, after controlling for comorbidity, martial status, and living situation, polypharmacy was not related to low education. Further studies in larger populations are needed to elucidate the association between SEP and drug use.

Factors influencing the handling of medicines among very old people living at home in an urban area.

BACKGROUND AND AIMS: Elderly people in Sweden live longer in their own homes, some of them with good health, and others with chronic conditions that require medical treatment. Thus, the aim of this study was to investigate factors influencing elderly people's handling of their medicines. METHODS: Cross-sectional population-based study. Participants were 333, aged 84+ years, living in their own homes. Information on regular drug use was obtained from interviews. Descriptive statistics were used to describe the population, and logistic regression models were used to investigate the factors associated with receiving help in handling medicines. The Mini-Mental State Examination (MMSE) measured cognitive status, and the basic Activities of Daily Living (ADL) assessed functional status. RESULTS: Most participants were women living alone. 88% of this population took medicines on a regular basis and 23% of them received help with medicine handling. Using logistic regression models controlling for sociodemographic variables, cognitive and functional status, female (OR=2.8, 95% CI=1.2-6.5) was the only variable associated with regular use of medicines. Older age and functional disability in ADL increased the risk of receiving help with medicines, while higher cognitive status decreased the odds of receiving help. The only factor related to receiving help from a family member was living alone (OR=0.05; 95% CI=0.01-0.40). CONCLUSIONS: This study indicates that cognitive and functional problems require increased help with handling medicines. These results stress the need for ongoing vigilance of, and support for, people with this high-risk profile.

The difficulty of opening medicine containers in old age: a population-based study.

OBJECTIVES: To investigate elderly people's ability to open medicine containers, and how this ability correlates to some common disorders that may cause functional or cognitive impairment. METHODS: Cross-sectional study of older people age 81 years and older, from the second follow-up (1994-1996) of the Kungsholmen project, a population-based study of very old people in an urban area of Stockholm, Sweden. Six hundred and four persons (mean age 86.7 years) were tested for their ability to open three types of medicine containers. The disorders studied were rheumatoid arthritis, stroke, Parkinson's disease, cognitive impairment (measured by mini-mental state examination, MMSE) and impaired vision. RESULTS: We found that 14% were unable to open a screw cap bottle, 32% a bottle with a snap lid, and 10% a blister pack. Female gender, higher age, living in an institution, Parkinson's disease, rheumatoid arthritis, cognitive impairment and impaired vision were all associated with a decreased ability to open the containers. Less than half of the elderly people who were unable to open one or more of the containers received help with their medication. Among those living in their own homes only 27% received help. CONCLUSION: Older peoples' ability to open medicine containers is impaired by several conditions affecting physical and cognitive functioning. Many elderly people who are unable to open medicine containers do not receive help with their medication, particularly those living in their own homes.

The potential economic consequences of cognitive improvement with losartan.

In a clinical trial, treatment of mild-moderate hypertensive patients with losartan (50 mg) increased Mini-Mental State Examination (MMSE) scores by 4 points from baseline over a 26-month period, compared with a 1-point increase in patients treated with hydrochlorothiazide (25 mg). This study explores the potential economic consequences of this improvement in cognitive function in a population of elderly hypertensive patients in Sweden. Resource use and MMSE data for 437 hypertensive, non-demented subjects aged 75 years and above, were taken from a population-based study in Sweden. MMSE scores were strongly related with costs of care due to higher utilization of home help and special living arrangements in patients with low scores. A 1-point difference in MMSE was associated with a difference in the annual cost of care of approximately 5700 Swedish kronor (SEK). Over 26 months, the potential cost savings from the 4-point improvement observed with losartan was estimated to be between 24700 and 43700 SEK. This can be compared with the acquisition cost of losartan; approximately 5700 SEK over the study period. Thus, an improvement in cognitive function of the magnitude documented in the study of losartan vs hydrochlorothiazide, may translate into economic benefits beyond those expected in terms of blood pressure control.