Potentially inappropriate medications among older patients with Parkinson's disease: a cross-sectional analysis of a national health insurance database in China.

BACKGROUND: With the rapid aging trend of China's population, the issue of drug rational use in older adults has become more and more prominent. Parkinson's disease (PD) is the one of the most common age-related neurodegenerative disorders. Pharmaceutical treatment plays a cardinal role in alleviating motor and non-motor symptoms to improve the quality of life of patients with PD. Patients with PD have complex medical needs yet little is known about the use of potentially inappropriate medications (PIM) among them in China. We quantify the prevalence of PIM use and identify its predictors among older persons with PD in China. METHODS: We conducted a cross-sectional analysis using a national representative database of all medical insurance beneficiaries across China, extracting records of ambulatory visits of older adults with PD between 2015 and 2017. Beneficiaries aged 65 and above were eligible for inclusion. The prevalence of patients exposed to overall PIMs and PIMs related to motor and cognitive impairment was calculated based on Beers Criteria 2015 version. Potential predictors of PIM concerning patients' characteristics were estimated using multivariate logistic regression. RESULTS: A total of 14,452 older adults with PD were included. In total, 8,356 (57.8%) patients received at least one PIM; 2,464 (17.1%) patients received at least one motor-impairing PIM and 6,201 (42.9%) patients received at least one cognition-impairing PIM. The prevalence of overall PIM use was higher in patients of older age group (54.7% [65-74] vs. 59.5% [75-84; OR, 1.22; 95% CI, 1.14-1.31] vs.65.5% [≥ 85; OR, 1.58; 95% CI, 1.38-1.80) and females (61.4% [female] vs. 55.0% [males; OR, 0.77; 95% CI, 0.72-0.82). CONCLUSIONS: Prescribing PIMs for older adults with PD was common in China, especially for females and older age groups, yet younger patients were more inclined to be prescribed with motor or cognition-impaired PIMs. Our findings represent a clear target awaiting multidimensional efforts to promote the rational prescribing of medications for this vulnerable population.

Acceptability of patient-centered, multi-disciplinary medication therapy management recommendations: results from the INCREASE randomized study.

BACKGROUND: Polypharmacy and inappropriate medications may be a modifiable risk factor for Alzheimer's Disease and Related Dementias (ADRD). Medication therapy management (MTM) interventions may mitigate medication-induced cognitive dysfunction and delay onset of symptomatic impairment. The objective of the current study is to describe an MTM protocol for a patient-centered team intervention (pharmacist and non-pharmacist clinician) in a randomized controlled trial (RCT) directed at delaying the symptomatic onset of ADRD. METHODS: Community dwelling adults 65 + years, non-demented, using ≥ 1 potentially inappropriate medications (PIM) were enrolled in an RCT to evaluate the effect of an MTM intervention on improving medication appropriateness and cognition (NCT02849639). The MTM intervention involved a three-step process: (1) pharmacist identified potential medication-related problems (MRPs) and made initial recommendations for prescribed and over-the-counter medications, vitamins, and supplements; (2) study team reviewed all initial recommendations together with the participants, allowing for revisions prior to the finalized recommendations; (3) participant responses to final recommendations were recorded. Here, we describe initial recommendations, changes during team engagement, and participant responses to final recommendations. RESULTS: Among the 90 participants, a mean 6.7 ± 3.6 MRPs per participant were reported. Of the 259 initial MTM recommendations made for the treatment group participants (N = 46), 40% percent underwent revisions in the second step. Participants reported willingness to adopt 46% of final recommendations and expressed need for additional primary care input in response to 38% of final recommendations. Willingness to adopt final recommendations was highest when therapeutic switches were offered and/or with anticholinergic medications. CONCLUSION: The evaluation of modifications to MTM recommendations demonstrated that pharmacists' initial MTM recommendations often changed following the participation in the multidisciplinary decision-making process that incorporated patient preferences. The team was encouraged to see a correlation between engaging patients and a positive overall response towards participant acceptance of final MTM recommendations. TRIAL REGISTRATION: Study registration number: clinicaltrial.gov NCT02849639 registered on 29/07/2016.

What types of information do pharmacists include in comprehensive medication management review reports? A qualitative content analysis.

BACKGROUND: Comprehensive medication management reviews are an established intervention to identify medication-related problems, such as the prescribing of potentially inappropriate medications, and under- and over-prescribing. However, the types of information included in written reports of comprehensive medication management reviews, beyond types of medication-related problems, are unknown. AIM: This study aimed to explore the types of information Australian pharmacists include in their written reports following comprehensive medication management reviews. METHOD: Australian consultant pharmacists were invited to upload their 10 most recent written reports of their domiciliary-based comprehensive medication management reviews. A random selection of the reports, stratified by each pharmacist, were included for qualitative content analysis. RESULTS: Seventy-two de-identified reports from eight consultant pharmacists located in five of the eight Australian States and Territories were included for analysis. From the evaluated reports, four major categories of information were identified: (1) patient details such as date of interview (n = 72, 100%) and medicine history (n = 70, 97%); (2) pharmacist assessment including assessment of the patient (n = 70, 97%), medicines management (n = 68, 94%) and medicine-related issues (n = 60, 83%); (3) pharmacist recommendations, specifically pharmacological recommendations (n = 67, 93%); and (4) patient-centred experiences such as perspectives on medicines (n = 56, 78%). Reporting of patient-centred experiences appeared most variably in the included reports, including patient concerns (n = 38, 53%), willingness for change (n = 27, 38%), patient preferences (n = 13, 18%), and patient goals (n = 7, 10%). CONCLUSION: Pharmacists within our study included a wide variety of information in their comprehensive medication management review reports. Aside from medication-related problems, pharmacists commonly provided a holistic assessment of the patients they care for. However, variability across reports has the potential to impact consistent service delivery.

Deprescribing Education vs Usual Care for Patients With Cognitive Impairment and Primary Care Clinicians: The OPTIMIZE Pragmatic Cluster Randomized Trial.

Background: Individuals with dementia or mild cognitive impairment frequently have multiple chronic conditions (defined as ≥2 chronic medical conditions) and take multiple medications, increasing their risk for adverse outcomes. Deprescribing (reducing or stopping medications for which potential harms outweigh potential benefits) may decrease their risk of adverse outcomes. Objective: To examine the effectiveness of increasing patient and clinician awareness about the potential to deprescribe unnecessary or risky medications among patients with dementia or mild cognitive impairment. Design, Setting, and Participants: This pragmatic, patient-centered, 12-month cluster randomized clinical trial was conducted from April 1, 2019, to March 31, 2020, at 18 primary care clinics in a not-for-profit integrated health care delivery system. The study included 3012 adults aged 65 years or older with dementia or mild cognitive impairment who had 1 or more additional chronic medical conditions and were taking 5 or more long-term medications. Interventions: An educational brochure and a questionnaire on attitudes toward deprescribing were mailed to patients prior to a primary care visit, clinicians were notified about the mailing, and deprescribing tip sheets were distributed to clinicians at monthly clinic meetings. Main Outcomes and Measures: The number of prescribed long-term medications and the percentage of individuals prescribed 1 or more potentially inappropriate medications (PIMs). Analysis was performed on an intention-to-treat basis. Results: This study comprised 1433 individuals (806 women [56.2%]; mean [SD] age, 80.1 [7.2] years) in 9 intervention clinics and 1579 individuals (874 women [55.4%]; mean [SD] age, 79.9 [7.5] years) in 9 control clinics who met the eligibility criteria. At baseline, both groups were prescribed a similar mean (SD) number of long-term medications (7.0 [2.1] in the intervention group and 7.0 [2.2] in the control group), and a similar proportion of individuals in both groups were taking 1 or more PIMs (437 of 1433 individuals [30.5%] in the intervention group and 467 of 1579 individuals [29.6%] in the control group). At 6 months, the adjusted mean number of long-term medications was similar in the intervention and control groups (6.4 [95% CI, 6.3-6.5] vs 6.5 [95% CI, 6.4-6.6]; P = .14). The estimated percentages of patients in the intervention and control groups taking 1 or more PIMs were similar (17.8% [95% CI, 15.4%-20.5%] vs 20.9% [95% CI, 18.4%-23.6%]; P = .08). In preplanned subgroup analyses, adjusted differences between the intervention and control groups were -0.16 (95% CI, -0.34 to 0.01) for individuals prescribed 7 or more long-term medications at baseline (n = 1434) and -0.03 (95% CI, -0.20 to 0.13) for those prescribed 5 to 6 medications (n = 1578) (P = .28 for interaction; P = .19 for subgroup interaction for PIMs). Conclusions and Relevance: This large-scale educational deprescribing intervention for older adults with cognitive impairment taking 5 or more long-term medications and their primary care clinicians demonstrated small effect sizes and did not significantly reduce the number of long-term medications and PIMs. Such interventions should target older adults taking relatively more medications. Trial Registration: ClinicalTrials.gov Identifier: NCT03984396.

[Potentially inappropriate prescribing: Usefulness of STOPP/START criteria version 2 in Catalonian elderly population]. / Prescripción potencialmente inadecuada: utilidad de los criterios STOPP/START versión 2 a nivel poblacional en Cataluña.

OBJECTIVE: To measure the prevalence of potentially inappropriate prescribing (PIP) among the elderly population in Catalonia using criteria Screening Tool of Older Person's Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) version 2. In addition, to evaluate the association between PIP and several factors (polypharmacy, gender, age and sociodemographic conditions). MATERIALS AND METHODS: Design: Retrospective cross sectional population study. SETTINGS: Primary Health Care, Catalonia, Spain. PARTICIPANTS: The study population comprised of participants 70 years old and over, who attended primary health care centres in Catalonia in 2014 (700.058 patients). MAIN ANALYSIS: 55 STOPP and 19 START criteria are applied to analyse PIP prevalence. Logistic regression models are adjusted to determine PIP association with several factors. RESULTS: The mean age is 79. 2±6.5. 58.5% being female. 38.7% of patients have 7 or more prescribed drugs, whereas 50% go to a primary care centre 10 or more times during one year. The most frequent PIP among STOPP criteria are related to nonsteroidal anti-inflammatory drug intake, antiplatelet and anticoagulants use, and benzodiazepines. According to START, the most frequent omissions are vitamin D and calcium supplements, antidepressants, and cardiovascular medications. Factors that increase PIP are: female gender, living in a nursing home, receiving home health care, polypharmacy and frequent visits to primary care centres. CONCLUSIONS: The overall prevalence of PIP is 89.6%. PPI is significantly related to certain drugs and patient's conditions. The knowledge of this association is important for the implementation of security measures for medical prescription.

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.

Evaluation of potentially inappropriate medication in older patients with cardiovascular diseases-STOPP/START-based study.

Objective: This study aims to evaluate the use of STOPP/START criteria in the identification of Potentially inappropriate medication and potential prescribing omissions in older patients with cardiovascular diseases in Bulgaria. Excessive morbidity and mortality has been linked to drug-related problems and increased use of healthcare services and is an understudied problem for Bulgaria. Materials and methods: A prospective, questionnaire-based study was conducted among 543 older patients across 25 pharmacies in Bulgaria. Socio-demographic characteristic, disease profile, symptoms, and medication data were collected. The questionnaire was developed for the purposes of the EUROAGEISM project. Out of all 543 patients, only those with documented cardio-vascular diseases were extracted and the medication profile per patient was evaluated for Potentially inappropriate medication (PIMs) and potentially prescribing omissions (PPOs) using STOPP/START criteria version 2. In addition, several risks for potentially inappropriate prescribing (PIPs), PPOs and PIMs were calculated with the focus being on the Odds and Risks to develop a PIP. Results: Four hundred and twenty eight from 531 patients with known therapy for cardiovascular diseases (CVDs) were included in the analysis of PIP (40.52% aged 65-69 years, 61.88% female, 64% had up to 6 comorbidities, and 21.72% presenting with polypharmacy). A total of 71 PIMs in 64 patients with polypharmacy were identified during applying STOPP criteria. 56% of patients taking above five medicines daily had PIMs. The majority of PIMs (31%) were related to CVDs treatment, followed by PIMs in the treatment of endocrine diseases (22.54%), duplication of medicines (8.46%) and prolonged treatment with benzodiazepines (8.46%). Forty four PPOs were identified with START criteria. 22.72% were related to lack of proton pump inhibitors (PPI) in the presence of gastroesophageal disorders, and the same percentage was for lack of Calcium-vitamin D supplementation in osteoporosis. Applying the methodology of risks calculation the sample risk for PPO was 2.1% and for PIM 3.4%. At sample level the relative risk for PPO was 62% out of the risk for PIM and at population level varied between 42.8 and 89.8% and it is statistically significant. The number needed to treat for the event to happen is 77.5, meaning that at every 78 prescriptions there is a chance to appear PIP. Conclusion: Application of methodologies for detection of potentially inappropriate prescribing is not part of routine clinical practice in Bulgaria. Our study demonstrates a high percentage of potentially inappropriate medication among older patients with polypharmacy. Along with the aging population in Bulgaria, economic burden of polypharmacy and the prevalence of cardiovascular diseases, it is especially important to address potentially inappropriate medication use in cardiovascular patients. There is a considerable necessity for implementation of measures for early detection of potentially inappropriate medication and potentially prescribing omission as a part of de-prescribing strategies in older patients.

Man vs. machine: comparison of pharmacogenetic expert counselling with a clinical medication support system in a study with 200 genotyped patients.

BACKGROUND: Medication problems such as strong side effects or inefficacy occur frequently. At our university hospital, a consultation group of specialists takes care of patients suffering from medication problems. Nevertheless, the counselling of poly-treated patients is complex, as it requires the consideration of a large network of interactions between drugs and their targets, their metabolizing enzymes, and their transporters, etc. PURPOSE: This study aims to check whether a score-based decision-support system (1) reduces the time and effort and (2) suggests solutions at the same quality level. PATIENTS AND METHODS: A total of 200 multimorbid, poly-treated patients with medication problems were included. All patients were considered twice: manually, as clinically established, and using the Drug-PIN decision-support system. Besides diagnoses, lab data (kidney, liver), phenotype (age, gender, BMI, habits), and genotype (genetic variants with actionable clinical evidence I or IIa) were considered, to eliminate potentially inappropriate medications and to select individually favourable drugs from existing medication classes. The algorithm is connected to automatically updated knowledge resources to provide reproducible up-to-date decision support. RESULTS: The average turnaround time for manual poly-therapy counselling per patient ranges from 3 to 6 working hours, while it can be reduced to ten minutes using Drug-PIN. At the same time, the results of the novel computerized approach coincide with the manual approach at a level of > 90%. The holistic medication score can be used to find favourable drugs within a class of drugs and also to judge the severity of medication problems, to identify critical cases early and automatically. CONCLUSION: With the computerized version of this approach, it became possible to score all combinations of all alternative drugs from each class of drugs administered ("personalized medication landscape ") and to identify critical patients even before problems are reported ("medication alert"). Careful comparison of manual and score-based results shows that the incomplete manual consideration of genetic specialties and pharmacokinetic conflicts is responsible for most of the (minor) deviations between the two approaches. The meaning of the reduction of working time for experts by about 2 orders of magnitude should not be underestimated, as it enables practical application of personalized medicine in clinical routine.

Integrated health intervention on polypharmacy and inappropriate prescribing in elderly people with multimorbidity: Results at the end of the intervention and at 6 months after the intervention.

BACKGROUND AND OBJECTIVE: To analyse the impact of an integrated health intervention focused on polypharmacy and inappropriate prescribing (IP) in elderly people with multimorbidity. MATERIAL AND METHODS: Patients were referred for assessment and intervention from primary care or hospital to an interdisciplinary team composed of primary and hospital medical staff and nurses. Pharmacological assessment was centred on polypharmacy and IP using the STOPP/START criteria. Changes in polypharmacy and in IP were analysed at the end of the intervention and at 6 months. RESULTS: One hundred consecutive patients (mean (SD) age 81.5(8.0) years, 54(54%) male) were analysed. Mean prescribed medicines at baseline was > 10. There were no significant changes at the end of the intervention and at 6 months. The proportion of patients with two or more STOPP criteria reduced from 37% at the beginning of the intervention to 18% at the end (p< .001), and the proportion of those with START criteria from 13% to 6% (p = .004). These differences persisted at 6 months. The number of STOPP and START criteria before the intervention was associated with a decrease in the STOPP and START criteria at the end of the intervention and at 6 months. A reduction in polypharmacy (p= .041) and in falls (p= .034) was observed at 6 months in those with a decrease in the STOPP criteria at the end of the intervention. CONCLUSIONS: An integrated health intervention centred on polypharmacy and IP in elderly people improves inappropriate prescribing that persists beyond the intervention.

A multifactorial intervention to lower potentially inappropriate medication use in older adults in Argentina.

BACKGROUND: Adverse drug reactions are a common cause of potentially avoidable harm, particularly in older adults. AIMS: To evaluate the feasibility and efficacy of a pilot multifactorial intervention to reduce potentially inappropriate medication (PIM) use in older adults. METHODS: We conducted a phase 2, feasibility, open-label study in the ambulatory setting of an integrated healthcare network in Buenos Aires, Argentina. We recruited primary care physicians (PCPs) and measured PIM use in a sample of their patients (65 years or older). Educational workshops for PCPs were organized with the involvement of clinician champions. Practical deprescribing algorithms were designed based on Beers criteria. Automatic email alerts based on specific PIMs recorded in each patient's electronic health record were used as a reminder tool. PCPs were responsible for deprescribing decisions. We randomly sampled 879 patients taking PIMs from eight of the most commonly used drug classes at our institution and compared basal (6 months prior to the intervention) and final (12 months after) prevalence of PIM use using a test of proportions. RESULTS: There was a significant reduction (p < 0.05) in all drug classes evaluated. Non-Steroidal Anti-Inflammatory Drugs (basal prevalence 5.92%; final 1.59%); benzodiazepines (10.13%; 6.94%); histamine antagonists (7.74%; 3.07%); opioids (2.16%; 1.25%); tricyclic antidepressants (8.08%; 4.10%); muscle relaxants (7.74%; 3.41%), anti-hypertensives (3.53%; 1.82%) and oxybutynin (2.96%; 1.82%). The absolute reduction in the overall prevalence was 8.5 percentage points (relative reduction of 51.4%). CONCLUSION: This multifactorial intervention is feasible and effective in reducing the use of potentially inappropriate medication in all drug classes evaluated.

Potential prescribing omissions according to START criteria at the time of hospital discharge

The purpose of this study is to describe the frequency of potential drug prescribing omissions (PPOs) for elderly patients at the time of hospital discharge and to compare the frequency PPOs among different medical specialities. This cross-sectional study examined data from elderly patients when they were admitted for >24 h to a northeastern Brazil teaching hospital during June-December 2016. Were included in the study 227 patients, of whom 36.9% had at least one PPO. The highest number of PPOs was identified among those with at least 5 prescribed drugs. In total, 153 PPOs were identified at hospital discharge. In most cases (78.4%), patients were not evaluated by the specialist physician.The most commonly identified PPOs on discharge were: the omission of statin therapy in cases of diabetes mellitus plus one or more cardiovascular-associated factor; calcium and vitamin D supplements in patients with known osteoporosis; and angiotensin converting enzyme inhibitors in cases of chronic heart failure. The results of this study suggest that the frequency of prescribing omissions PPOs during patient discharge was high. This can be avoided by the careful evaluation by prescribers with experience in certain specialties where several prescribed omissions would be common.

The Changes in Medication Prescribing Among the Older People with Cognitive Impairment in the Acute Care Setting.

PURPOSE: Most older people with cognitive impairment usually have multiple comorbidities. In the last decade, the guidelines for the management of chronic diseases have been changed, leading to changes in the patterns of medication prescribing and in the prevalence of drug-related problems (DRPs). The main objectives were to explore the changes in medication use and in the prevalence of polypharmacy (PP), the use of potentially inappropriate medications (PIMs) and drug-drug interactions (DDIs) among older hospitalized adults with cognitive impairment in a 5-year period. PATIENTS AND METHODS: Older hospitalized patients with cognitive impairment diagnosed by cognitive performance scale (CPS) score of 2 or more at tertiary hospital in Brisbane, Australia in 2009 and 2015 to 2016 were enrolled. Prescribed medication use, and exposures to PP, PIM and/or DDI were evaluated at two time points. The associated factors with patients exposed to >1 criteria of PP, PIM or DDI were analyzed by using logistic regression analyses. RESULTS: The median number of prescribed medications was not significantly different between the two periods. The number of medications use as dermatological agents and analgesics substantially increased over 5 years. In contrast, there was a decrease in prescription of drugs for acid-related disorders, drugs used in diabetes, and mineral supplements. Most of the participants were exposed to at least one of PP, PIM or DDI. In multivariate regression analysis, the presence of diabetes diagnosis was a risk factor associated with increased exposure to >1 criteria of PP, PIM or DDI. CONCLUSION: The patterns of many prescribed medications use have altered in a 5-year period. The present study confirms that the majority of older adults with cognitive impairment admitted in an acute care setting are prone to PP, PIM and DDI. Comprehensive medication reviews should be undertaken in clinical care of older patients with cognitive impairment.

Deprescribing: a challenge for clinical cardiologists.

Deprescribing is a holistic process to identify medications that can be ceased, substituted or reduced. This process can improve the health of older patients and also enhance their compliance to the prescribed medications which are actually beneficial. Recommendations and guidelines have been elaborated for extensively prescribed drugs. In clinical cardiology the process of deprescribing is a challenge for doctors because of withdrawal-related adverse effects, but it may be applied in certain clinical conditions such as the discontinuation of statin prescription in patients with advanced senile dementia and those with limited life expectancy. Deprescribing is also focussed on the scarcely known effects of prolonged therapy after the acute phase of a disease is over, especially when continuation may signify potential life-long treatment. There needs to be collaboration between the consultant cardiologist who first prescribes medications and family doctors who are responsible for the long-term care of the patient and reviewing prescribed medications may be necessary.

Effectiveness of Best Practice Alerts for Potentially Inappropriate Medication Orders in Older Adults in the Ambulatory Setting.

INTRODUCTION: Information is limited about the effectiveness of best practice alerts (BPAs) for potentially inappropriate medications (PIMs) in improving clinical outcomes in older adults. OBJECTIVE: To assess clinical outcomes of 11 BPAs for PIMs in older adults in the ambulatory setting. METHODS: A retrospective cohort study was conducted at an integrated health care delivery system with computerized provider order entry. Patients aged 65 years and older were included if they had a BPA triggered when a prescriber attempted to order a sedating PIM in the ambulatory setting. Patients were categorized into dispensed and nondispensed groups if they did and did not, respectively, have the study PIM for which the BPA was triggered dispensed within 30 days of the alert. Rates of fall, fracture, or other injury and cognitive impairment were measured during 180-day follow-up. RESULTS: A total of 2704 patients were included: 1373 (50.8%) and 1331 (49.2%) in the dispensed and nondispensed groups, respectively. The dispensed group had a lower unadjusted rate of fall/fracture/injury (3.4% vs 5.3%, p = 0.019), but this difference was attenuated with multivariable adjustment (adjusted odds ratio = 0.77, 95% confidence interval = 0.51-1.13). There was no difference in the rate of cognitive impairment between groups (4.6% vs 4.4%, adjusted odds ratio = 1.40, 95% confidence interval = 0.95-2.05). CONCLUSION: No association was identified between PIM dispensing after a prescriber was alerted with a BPA and reduced rates of falls/fractures/injuries and cognitive impairment.

Features of anticholinergic prescriptions and predictors of high use in the elderly: Population-based study.

PURPOSE: Older people are especially vulnerable to negative anticholinergic effects. Although anticholinergic drugs are commonly used among older people, drugs with potent antimuscarinic properties are considered as potentially inappropriate medications for older people. Here, we examined features of anticholinergic use and investigated predictors for the high use of strong anticholinergic agents (ACs) in the elderly. METHODS: A total of 388,629 Korean elderly aged ≥70 years were recruited from the 2012 National Health Insurance Service Elderly cohort database. The use of ACs in 2012 was quantitatively assessed by calculating standardized prescribed doses. Multivariate logistic regression was conducted to identify predictors of the high use of strong ACs (≥90 doses). RESULTS: Almost half of the subjects (47.2%) used more than 15 doses of strong ACs during 2012. 17.0% of the subjects had an annual cumulative use of strong ACs over 90 doses. Morbidities such as depression (odds ratio [OR], 95% confidence interval [CI] = 2.56, 2.48-2.63), Parkinson's disease (2.41, 2.26-2.56), genitourinary diseases (2.12, 2.07-2.16), polypharmacy (3.28, 3.21-3.36), and low income (1.29, 1.25-1.33) were strong predictors of their high use. Antihistamines (chlorpheniramine) and antidepressants (amitriptyline) greatly contributed to the total prescription of strong ACs. CONCLUSIONS: Despite the vulnerability of older people to the adverse reactions of strong ACs, their use seems to be at a high level in terms of cumulative usage among some elderly. More attention should be paid to older people with predictive factors of high use of strong ACs. Key points Despite the susceptibility of older people to negative anticholinergic effects, high use of strong anticholinergic agents was is quite frequent; 17.0% of the elderly had an annual cumulative use of these drugs ≥90 doses. Parkinson's disease, depression, genitourinary diseases, low income, and polypharmacy strongly predicted the high use of strong anticholinergic agents. A few strong anticholinergic agents, including antihistamines (chlorpheniramine) and antidepressants (amitriptyline), accounted for the majority of medications prescribed. Understanding the predictors of their high use by medical practitioners may result as more appropriate anticholinergic medications.

Drug interactions among older adults followed up in a comprehensive medication management service at Primary Care.

OBJECTIVE: To estimate the prevalence of drug interactions and associated factors among older adults followed up in a Comprehensive Medication Management Service at Primary Care. METHODS: Firstly, the Beers criteria 2015 was used to define drug interactions; later, drug interactions proposed by Dumbreck for patients with diabetes, depression, and heart failure were evaluated. The associated factors were assessed by univariate (Pearson's χ2) and multivariate analyses (logistic regression). The significance level of 5% was set for all analyses. RESULTS: The mean age of the studied population was 70.2±7.8 years; 52.2% were between 60 and 69 years, and 61.3% were female. Among the older adults, 94.5% used two or more drugs (condition for the occurrence of drug-drug interaction). The prevalence of drug interaction according to the Beers criteria was 4.9%. After multivariate analysis, diseases of the central nervous system, arrhythmia, number of medications, and female sex were positively associated with drug interaction. The prevalence of drug interaction according to Dumbreck was 27.2%. After multivariate analysis, the number of medications, the presence of heart failure, and Charlson comorbidity index greater than 1 were conditions positively associated with drug interactions. CONCLUSION: The holistic and individualized approach used in comprehensive medication management services for older patients is important, considering the prevalence of drug interactions and the need to minimize adverse events.

Assessing an Interprofessional Polypharmacy and Deprescribing Educational Intervention for Primary Care Post-graduate Trainees: a Quantitative and Qualitative Evaluation.

BACKGROUND: Polypharmacy and potentially inappropriate medications (PIMs) are increasingly common and associated with adverse health effects. However, post-graduate education in polypharmacy and complex medication management for older adults remain limited. OBJECTIVE: The Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) polypharmacy clinic was created to provide a platform for teaching internal medicine (IM) and nurse practitioner (NP) residents about outpatient medication management and deprescribing for older adults. We aimed to assess residents' knowledge of polypharmacy and perceptions of this interprofessional education intervention. DESIGN: A prospective cohort study with an internal comparison group. PARTICIPANTS: IM residents and NP residents; Veterans ≥ 65 years and taking ≥ 10 medications. INTERVENTION: IMPROVE consists of a pre-clinic conference, shared medical appointment, individual appointment, and interprofessional precepting model. MAIN MEASURES: We assessed residents' performance on a pre-post knowledge test, residents' qualitative assessment of the educational impact of IMPROVE, and the number and type of medications discontinued or decreased. KEY RESULTS: The IMPROVE intervention group (n = 18) had a significantly greater improvement in test scores than the control group (n = 18) (14% ± 15% versus - 1.3% ± 16%) over a period of 6 months (Wilcoxon rank sum, p = 0.019). In focus groups, residents (n = 17) reported perceived improvements in knowledge and skills, noting that the experience changed their practice in other clinical settings. In addition, residents valued the unique interprofessional experience. Veterans (n = 71) had a median of 15 medications (IQR 12-19), and a median of 2 medications (IQR 1-3) was discontinued. Vitamins, supplements, and cardiovascular medications were the most commonly discontinued medications, and cardiovascular medications were the most commonly decreased in dose or frequency. CONCLUSIONS: Overall, IMPROVE is an effective model of post-graduate primary care training in complex medication management and deprescribing that improves residents' knowledge and skills, and is perceived by residents to influence their practice outside the program.

Polypharmacy in Patients with Ovarian Cancer.

OBJECTIVE: Polypharmacy has been associated with morbidity and mortality in patients with cancer. Data about polypharmacy among patients with ovarian cancer are limited. The primary objective of this study was to evaluate polypharmacy in a cohort of patients with ovarian cancer and to assess the evolution of polypharmacy from initial presentation to 2 years posttreatment. A secondary objective was to evaluate differences in polypharmacy between a subset of patients primarily treated in our comprehensive cancer center (CCC) and our safety net hospital (SNH). METHODS: Women treated for ovarian cancer between January 1, 2011, and December 31, 2016, were included. Data were abstracted from the electronic medical record. Medication safety was assessed using the established Anticholinergic Burden (ACB) scale and the Beers criteria. Statistical analyses were performed using paired t tests and Cox proportional hazards models, with significance set at p < .05. RESULTS: The study included 152 patients. The majority of patients had high-grade serous carcinoma. Hypertension was the most common medical problem. The mean number of medications at the time of diagnosis was 3.72. Paired testing demonstrated significant patient-level increases in the number medications at 2 years following initial diagnosis (4.16 vs. 7.01, p < .001). At the CCC, 47.4% of patients met criteria for polypharmacy at diagnosis compared with 19.4% at the SNH (p < .001). By 2 years postdiagnosis, 77.6% of patients at the CCC met criteria for polypharmacy compared with 43.3% at the SNH (p = .001). The use of any medications on the ACB scale (p < .001) increased significantly between initial diagnosis and 2 years for the entire population. Polypharmacy was not a significant predictor of overall survival. CONCLUSION: Polypharmacy worsens as women go through ovarian cancer treatment. Both at initial presentation and at 2 years postdiagnosis, rates of polypharmacy were higher at the CCC. Polypharmacy did not have an effect on survival in this cohort. IMPLICATIONS FOR PRACTICE: Awareness of escalating numbers of medications and potentially adverse interactions is crucial among women with ovarian cancer, who are at high risk for polypharmacy.

Inappropriate medication use in hospitalised oldest old patients across transitions of care.

BACKGROUND: Oldest old patients aged 85 years and over are at risk of experiencing potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) across transitions of care. Geriatricians also face enormous challenges in prescribing medications for these patients. METHODS: A mixed-methods, sequential explanatory design was undertaken of electronic medical records and semi-structured interviews with geriatricians at a public teaching hospital. Data were collected at four time points using the Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) and Screening Tool to Alert doctors to the Right Treatment (START). RESULTS: Of 249 patients, the prevalence of at least 1 PIM varied between 36.9 and 51.0%, while the prevalence of at least 1 PPO varied between 36.9 and 44.6%. The most common PIM was use of proton pump inhibitors while the most common PPO was omission of vitamin D supplements in housebound patients or patients experiencing falls. Poisson regression analysis showed that PIMs were significantly associated with use of mobility aids, 1.430 (95% CI 1.109-1.843, p = 0.006), and number of medications prescribed at admission, 1.083 (95% CI 1.058-1.108, p < 0.001). PPOs were significantly associated with comorbidities, 1.172 (95% CI 1.073-1.280, p < 0.001), medications prescribed at admission, 0.989 (95% CI 0.978-0.999, p = 0.035), and length of stay, 1.004 (95% CI 1.002-1.006, p < 0.001). Geriatrician interviews (N = 9) revealed medication-related, health professional-related and patient-related challenges with managing medications. CONCLUSIONS: Inappropriate prescribing is common in oldest old patients. Greater attention is needed on actively de-prescribing medications that are not beneficial and commencing medications that would be advantageous. Tailored strategies for improving prescribing practices are needed.

[Updated report on STOPP-START criteria in Primary Care]. / Evaluación de la actualización de los criterios STOPP-START en atención primaria.

INTRODUCTION: The aim of this study is to determine the rate of potentially inappropriate prescriptions (PIP) in people older than 64 years of age in Avilés, Asturias, Spain. MATERIALS AND METHODS: A descriptive cross-sectional study was conducted in six Health Care Centres. A sample of 400 people was selected, obtained by a random sampling proportional to the population registered in each Health Centre. A review was made of the computerised clinical records, and the STOPP-START (version 2014 with 114 items) criteria were applied to evaluate the PIP. RESULTS: The study contained 378 (95.5%) patients with a mean age of 75.4 (SD: 7.4) and of which 57.7% were women. Almost all (94.2%: 95% CI; 91.7-96.7) met some PIP criteria. Taking only the STOPP criteria into consideration, 52.4% (95%CI: 47.2-57.6) met at least one breach, and in the START criteria a 90.5% (95%CI; 87.4-93.6), which was reduced to 40.5% (95%CI; 36.4-45.6) if criteria on vaccination were removed. In the STOPP criteria, the most frequent PIP was taking benzodiazepines followed by the use of medication without indications based on the evidence; in the START, the criteria was the anti-pneumococcus vaccination, and the lack of taking vitamin D supplements and calcium in osteoporosis. CONCLUSIONS: There were high levels of PIP, very superior to the previous version, especially for the START criteria. There is a high level of PIP related to the use of benzodiazepines and the use of medication without any clinic evidence. The STOPP-START criteria are useful in Primary Care to assess the PIP.