Factors affecting Australian aged care facility workers in administering oral medication to residents with swallowing difficulties.

Swallowing difficulties are common in older people and can complicate the administration of oral medications. The aim of this study was to explore factors affecting healthcare workers in their practices of oral medication administration to aged care residents with swallowing difficulties. A purposeful sample of 17 healthcare workers composed of clinical/care managers, registered nurses (RNs), enrolled nurses (ENs), and assistants in nursing (AINs) from three aged care facilities in Queensland, Australia participated in semi-structured interviews. Leximancer was used for quantitative content analysis. The responses centered on three main factors. Participants discussed workprocess-related factors including time, workload, and stress and frustrations resulting from work processes. Medication-related factors included strategies to facilitate medication administration, uncertainties around modifying medications, availability/cost of alternatives, multidisciplinary medication management, prescribing considerations, and polypharmacy. Resident-related factors were discussed around individualized needs of residents especially those with dementia-associated swallowing difficulties. Ideas differed among the four groups of participants. Managers discussed workprocess-related factors pertaining to staff and facility. RNs focused on how clinical aspects of the medication practices were affected by work processes. ENs were task-oriented and their responses focused on work processes. AIN responses centered on reliance on RNs in performing medication tasks. The findings suggest that healthcare workers' practices of medication administration to residents with swallowing difficulties are affected by various factors associated with work processes, medications, and resident characteristics. Although these factors affect all levels of healthcare workers, the needs of each group vary depending on their level of training and responsibilities.

Oral medication delivery in impaired swallowing: thickening liquid medications for safe swallowing alters dissolution characteristics.

Acetaminophen (paracetamol) is available in a wide range of oral formulations designed to meet the needs of the population across the age-spectrum, but for people with impaired swallowing, i.e. dysphagia, both solid and liquid medications can be difficult to swallow without modification. The effect of a commercial polysaccharide thickener, designed to be added to fluids to promote safe swallowing by dysphagic patients, on rheology and acetaminophen dissolution was tested using crushed immediate-release tablets in water, effervescent tablets in water, elixir and suspension. The inclusion of the thickener, comprised of xanthan gum and maltodextrin, had a considerable impact on dissolution; acetaminophen release from modified medications reached 12-50% in 30 min, which did not reflect the pharmacopeia specification for immediate release preparations. Flow curves reflect the high zero-shear viscosity and the apparent yield stress of the thickened products. The weak gel nature, in combination with high G' values compared to G'' (viscoelasticity) and high apparent yield stress, impact drug release. The restriction on drug release from these formulations is not influenced by the theoretical state of the drug (dissolved or dispersed), and the approach typically used in clinical practice (mixing crushed tablets into pre-prepared thickened fluid) cannot be improved by altering the order of incorporation or mixing method.

Crushed tablets: does the administration of food vehicles and thickened fluids to aid medication swallowing alter drug release?

PURPOSE: To evaluate the influence of co-administered vehicles on in vitro dissolution in simulated gastric fluid of crushed immediate release tablets as an indicator for potential drug bioavailability compromise. METHODS: Release and dissolution of crushed amlodipine, atenolol, carbamazepine and warfarin tablets were tested with six foods and drinks that are frequently used in the clinical setting as mixers for crushed medications (water, orange juice, honey, yoghurt, strawberry jam and water thickened with Easythick powder) in comparison to whole tablets. Five commercial thickening agents (Easythick Advanced, Janbak F, Karicare, Nutilis, Viscaid) at three thickness levels were tested for their effect on the dissolution of crushed atenolol tablets. RESULTS: Atenolol dissolution was unaffected by mixing crushed tablets with thin fluids or food mixers in comparison to whole tablets or crushed tablets in water, but amlodipine was delayed by mixing with jam. Mixing crushed warfarin and carbamazepine tablets with honey, jam or yoghurt caused them to resemble the slow dissolution of whole tablets rather than the faster dissolution of crushed tablets in water or orange juice. Crushing and mixing any of the four medications with thickened water caused a significant delay in dissolution. When tested with atenolol, all types of thickening agents at the greatest thickness significantly restricted dissolution, and products that are primarily based on xanthan gum also delayed dissolution at the intermediate thickness level. CONCLUSIONS: Dissolution testing, while simplistic, is a widely used and accepted method for comparing drug release from different formulations as an indicator for in vivo bioavailability. Thickened fluids have the potential to retard drug dissolution when used at the thickest levels. These findings highlight potential clinical implications of the addition of these agents to medications for the purpose of dose delivery and indicate that further investigation of thickened fluids and their potential to influence therapeutic outcomes is warranted.

A study protocol: a community pharmacy-based intervention for improving the management of sleep disorders in the community settings.

BACKGROUND: Sleep disorders are very common in the community and are estimated to affect up to 45% of the world's population. Pharmacists are in a position to give advice and provide appropriate services to individuals who are unable to easily access medical care. The purpose of this study is to develop an intervention to improve the management of sleep disorders in the community. The aims are- (1) to evaluate the effectiveness of a community pharmacy-based intervention in managing sleep disorders, (2) to evaluate the role of actigraph as an objective measure in monitoring certain sleep disorders and (3) to evaluate the extended role of community pharmacists in managing sleep disorders. This intervention is developed to monitor individuals undergoing treatment and overcome the difficulties in validating self-reported feedback. METHOD/DESIGN: This is a community-based intervention, prospective, controlled trial, with one intervention group and one control group, comparing individuals receiving a structured intervention with those receiving usual care for sleep-related disorders at community pharmacies. DISCUSSION: This study will demonstrate the utilisation and efficacy of community pharmacy-based intervention to manage sleep disorders in the community, and will assess the possibility of implementing this intervention into the community pharmacy workflow. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry: ACTRN12612000825853.

Deprescribing Tool for Older PeoPle with Limited-life Expectancy (De-TOPPLE) version 1: Development and validation using a modified Delphi technique.

Deprescribing decision making in older adults with limited life expectancy is often challenging for clinicians. We aimed to develop and validate a Deprescribing Tool for Older People with Limited-life Expectancy (De-TOPPLE). Modified Delphi technique was used to gain experts' consensus on the tool and further develop using their feedback. Experts [Round-1 (n = 13), Round-2 (n = 7)] had clinical and/or research background on geriatric medicine, geriatrics, family medicine or pharmacotherapy. Round-1 consensus was achieved on approach taken by the tool to evaluate risk and benefit; distinguishing medications as preventive, symptom control or dual-purpose; referring to established deprescribing process; stepwise approach to deprescribing; and the overall concept. Common feedback was to reflect upon harm-benefit analysis, distinguish medication types earlier, qualify adverse events, use time-to-benefit (TTB), prioritise symptom relief, monitor post-deprescribing, include shared decision making and define terms for clinical familiarisation. After tool update, Round-2 consensus was achieved on usability in clinical setting, flexibility of implicit judgement, ceasing preventive medication with inadequate TTB, ceasing symptom control medication with inadequate symptom relief, ceasing dual-purpose medication (DPM) with inadequate TTB and symptom relief, and continuing DPM with adequate TTB and symptom relief. De-TOPPLE version 1 was developed and validated through two rounds of the Delphi process. Clinical use of the tool needs final validation following the addition of contextual statements to the tool.

Medication Lubricants for Oral Delivery of Drugs: Oral Processing Reduces Thickness, Changes Characteristics, and Improves Dissolution Profile.

Swallowing oral solid dosage forms is challenging for those who have medication swallowing difficulties, including patients with dysphagia. One option is to mix the drug (whole or crushed) with a thick vehicle (medication lubricant). Previous in vitro studies consistently suggest that thick vehicles could impact the dissolution of solid dosage forms, potentially influencing their therapeutic effectiveness, but do not account for changes that happen during oral processing and swallowing. This study aims to investigate the potential impact of medication lubricants on drug release and examine the effect of oral processing. In vitro dissolution of whole and crushed paracetamol tablets mixed with five commercially available medication lubricants (two IDDSI level 2, two IDDSI level 3, and one IDDSI level 4) were tested with and without oral processing; a medication lubricant with/without paracetamol was placed in the mouth (five healthy volunteers), prepared for swallowing, but then expectorated and assessed for physical characteristics and drug release. Medication lubricants, both alone and mixed with crushed paracetamol tablets, showed a significant decrease in viscosity after oral processing. Without oral processing, IDDSI level 3 and 4 lubricants significantly delayed the dissolution of paracetamol tablets. After oral processing, particularly with crushed tablets, there was a substantial increase in the dissolution rate. These findings suggest that dissolution testing overestimates the impact of medication lubricants on drug dissolution. Therefore, using in vitro dissolution tests to predict the dissolution rate of medications mixed with thick vehicles is discouraged. It is essential to consider ways to incorporate the effects of the oral environment and oral processing on thick vehicles used for oral medication administration.

A systematic review on methods for developing and validating deprescribing tools for older adults with limited life expectancy.

OBJECTIVES: A number of deprescribing tools are available to assist clinicians to make decisions on medication management. We aimed to review deprescribing tools that may be used with older adults that have limited life expectancy (LLE), including those at the palliative and end-of-life stage, and consider the rigour with which the tools were developed and validated. KEY FINDINGS: Literature was searched in PubMed, Embase, CINHAL and Google Scholar until February 2021 for studies involving the development and/or consensus validation of deprescribing tools targeting those aged ≥65 years with LLE. We were interested in the tool development process, tool validation process and clinical components addressed by the tool.Six studies were included. The approaches followed for tool development were systematic review (n = 3), expert-literature review (n = 2) and concept data (n = 1). The content included a list of disease-non-specific medications divided with or without recommendations (n = 4) and disease-specific medications with recommendations (n = 2). The tool validation was performed using the Delphi method (n = 4) or GRADE framework (n = 2) with panel size ranging from 8 to 17 and 60-80% consensus agreement with or without a rating scale. LLE targeted were ≤1 year (n = 2) or ≤3 months (n = 1). SUMMARY: There is a limited number of deprescribing tools with consensus validation available for use in older adults with LLE. These tools are either targeted for disease-specific medication/medication class guided by the GRADE framework or targeted for a list of medications or medication classes irrespective of disease that are developed using a combination of approaches and validated using a Delphi method.

The prevalence and perceived effectiveness of using a medication-swallowing lubricant in aged care facilities across Australia.

Objective: To explore the extent of use and perceived effectiveness of using a medication lubricant that is specifically designed to help people who struggle to swallow their solid medications whole. Method: Health care workers of varying professional levels in aged care facilities (ACFs) across Australia who are involved in medication administration were invited to participate in a structured online survey. Results: Of the 355 health care workers who completed the survey, 48% had used the medication lubricant to aid administration of whole and/or crushed solid oral dosage forms, and of these 89% agreed with the statement that "it is effective method to facilitate medication swallowing in residents." The main benefits of using the medication lubricant were considered to be easier medication administration to residents (49%), reduction in need for crushing of medications (34%), and better adherence with medications (33%). Conclusions: This study showed that using a medication lubricant for aged care residents may facilitate the process of medication administration for health care workers, which they perceive to improve residents' adherence with medications. Serious complications associated with solid dosage form modification may also be decreased by using a medication lubricant, as the need for modifying medications is reduced. Therapeutic Goods Administration (TGA)-approved medication lubricants could therefore be a valuable tool to aid the medication administration for patients who have difficulties swallowing medications. Future research may consider the clinical efficacy and acceptability of medication lubricants specifically for people with swallowing difficulties.

An exploration of hospital pharmacists' engagement with sustainability policy in the NHS England.

OBJECTIVES: NHS England has set itself a target of net zero emissions by 2050. Therefore, to address this gap in the literature, this study aimed to explore engagement with NHS policy on carbon reduction (including awareness of the Sustainable Development Unit [SDU] and the Coalition for Sustainable Pharmaceuticals and Medical Devices [CSPM]) in NHS hospital pharmacists in England. METHODS: Semi-structured interviews were conducted with 23 pharmacists working in six NHS England hospitals across all hierarchical levels. Four interview questions elicited Yes/No responses and one generated qualitative data which were analysed by two methods - Leximancer and manual coding. KEY FINDINGS: Only five (5/23; 21.74%) had heard of the SDU and none knew its purpose. Those who did not wish to learn more about the SDU could not see its relevance to their clinical practice. Barriers identified to the inclusion of sustainability considerations in clinical decision-making were lack of knowledge of the environmental risk profiles for treatment options, lack of quality environmental evidence incorporated into clinical guidelines and lack of time to research for themselves. Many participants did not believe that environmental considerations were part of their job. CONCLUSIONS: For NHS England to successfully deliver on its target of net zero emissions by 2050, immediate action is required from all hospital staff, clinicians included. The challenge for the NHS will be engaging pharmacists and other clinicians with sustainable clinical practice and working with clinicians to reduce identified barriers. As these data were collected in 2016, further research is warranted to determine if pharmacists' attitudes towards sustainable practice are changing.

Development and validation of a tool to understand health care professionals' attitudes towards deprescribing (HATD) in older adults with limited life expectancy.

BACKGROUND: Understanding the perspective of health care professionals (HCPs) is significant to the implementation of deprescribing in older adults with limited life expectancy (LLE) but a tool to assess this is lacking. OBJECTIVE: This study aimed to develop and validate a survey tool for assessing HCPs attitudes towards deprescribing (HATD) in older adults with LLE. METHODS: An online survey was used to collect data to determine the psychometric properties of a 49-item questionnaire generated from literature review, expert opinion and pretesting. 108 HCPs (doctors, nurses and pharmacists) with experience or interest in palliative care or a member of a palliative care team/organisation completed the survey. RESULTS: Principal component analysis of the participants' data resulted in a 23-item questionnaire structured in five factors, named HATD tool. The factors were related to concerns about deprescribing (7 items), perceived burden of medications on patients (7 items), organisational support for deprescribing (4 items), assurance to deprescribing (2 items) and perceived involvement of patients in medication management (3 items). The HATD tool had valid descriptive statistics (Kaiser-Meyer-Olkin measure: 0.708; Bartlett's test of sphericity: p < 0.001, determinant: 1.35E-5; variance explained: 60.4%; nonredundant residuals with absolute values > 0.05: 39%). The reliability statistics of all the factors were ≥0.750 for both Cronbach's alpha (α) and composite reliability (CR) except for the patient-involvement factor (α = 0.644 but CR = 0.787). CONCLUSIONS: The 23-itemed HATD tool is a valid and reliable tool to assess the attitudes and beliefs of HCPs towards deprescribing in older adults with LLE in the Australian setting.

Australian national trends in stimulant dispensing: 2002-2009.

OBJECTIVE: Internationally there has been an increase in the prescriptions of stimulant medication. The aim of this study was to examine longitudinal national trends of stimulant dispensing in Australia between 2002 and 2009. METHOD: Government databases were retrospectively reviewed for all dispensed stimulant prescriptions between 2002 and 2009. Prescriptions were converted to defined daily dose (DDD)/1000 population/day using census data. Utilization of dexamphetamine and methylphenidate were analysed by source (subsidized or non-subsidized), prescriber (general practitioner, psychiatrist or other specialists), gender and age of patient. RESULTS: Between 2002 and 2009, dispensing of stimulants in Australia increased 87% from 2.93 to 5.47 DDD/1000 population/day. Dexamphetamine remained the most commonly dispensed stimulant, with rates of dispensing falling 13% from 2.02 to 1.75 DDD/1000 population/day. Dispensed prescriptions of methylphenidate increased 300% from 0.45 in 2002 to 1.81 DDD/1000 population/day in 2009, attributable to the availability of long-acting preparations. Dispensing of stimulants to males was four-fold greater than to females. There was substantial dispensing of dexamphetamine to those older than 25 years. CONCLUSIONS: Stimulant dispensing in Australia increased between 2002 and 2009 as a result of increased dispensing of long-acting preparations of methylphenidate. Further research is required to determine if the increase in stimulant dispensing in Australia is clinically appropriate.

Deprescribing tool for use in older Australians with life-limiting illnesses and limited life expectancy: a modified-Delphi study protocol.

BACKGROUND: Making a meaningful decision on deprescribing of potentially inappropriate medications in older adults with life-limiting illnesses (LLIs) and limited life expectancy (LLE) is often challenging. Therefore, we aimed to elicit opinion and gain consensus on a deprescribing tool for use in this population. METHODS AND ANALYSIS: A modified-Delphi method will be used to obtain a consensus from a panel of experts in geriatric therapeutics on a deprescribing tool for use in people aged ≥65 years with LLIs and LLE. Through an online survey, in the initial round, the panel will anonymously elicit their opinion on a series of items related to the conceptual model of the deprescribing tool, its practicality and deprescribing of medications, while on the controlled feedback in subsequent rounds till a consensus is reached or the panellists stop revising their answers. In each round, panel members will be using a 5-point Likert scale to rate their agreement with the statement. Consensus will be considered on ≥75% of agreement on the statements. ETHICS AND DISSEMINATION: All the participants will receive an invitation and participant information but they need to consent for the participation. Ethics approval has been granted from the University of Queensland Health and Behavioural Sciences, Low and Negligible Risk Ethics Sub-Committee (reference: 2020001069). The results of this project will be disseminated through conferences and a peer-reviewed clinical journal.

Do legislated carbon reduction targets influence pro-environmental behaviours in public hospital pharmacy departments? Using mixed methods to compare Australia and the UK.

Pharmaceuticals and their packaging have a significant negative impact on the environment providing a very strong argument for action on the part of pharmacists and pharmacy technicians to engage with pro-environmental behaviours (PEBs) in their workplaces. The aims of this research were therefore to investigate in hospital pharmacists and pharmacy technicians, 1) factors affecting engagement with workplace PEBs, and 2) determine if legislated carbon reduction targets in the UK influenced workplace PEBs in the UK compared with Australia which does not have legislated carbon reduction targets. The environmentally responsible disposal of pharmaceutical waste was the PEB of interest in this study. A mixed methods research design was utilised and a conceptual model (key variables: environmental attitude, concern, and knowledge, and organisational factors) was developed to identify factors influencing workplace PEBs. Participants were from five hospitals in Queensland, Australia and five NHS hospitals in England, UK. There was no statistically significant difference in environmental attitude or concern between the two groups-most had a mid-environmental attitude score and low levels of environmental concern. Participants lacked knowledge of the issue and the link between the environment and public health. Both Australian and UK participants reported recycling packaging waste was not a priority in the hospital pharmacy workplace (even in hospitals with recycling capability) as hospitals focused on compliance with clinical (contaminated) and confidential waste streams. Environmental attitude, knowledge, and concern therefore appeared to be weak influences on intention to perform workplace PEBs with workplace social norms (compliance due to audits) appearing to be a significant mediator of action. The key difference between the cohorts was that UK pharmacists felt waste was not in the scope of their role, and therefore not their responsibility. This study identified that legislated carbon reduction targets did not influence hospital pharmacy workplace PEBs-neither cohort reported engaging significantly in workplace PEBs. UK Government and NHS sustainability policy did not appear to have disseminated to pharmacy department level of UK public hospitals to any great extent.

Evaluation of Disaster Preparedness and Preparedness Behaviors among Pharmacists: A Cross-Sectional Study in Australia.

INTRODUCTION: In a disaster aftermath, pharmacists have the potential to provide essential health services and contribute to the maintenance of the health and well-being of their community. Despite their importance in the health care system, little is known about the factors that affect pharmacists' disaster preparedness and associated behaviors. STUDY OBJECTIVE: The goal of this study was to determine the factors that influence disaster preparedness behaviors and disaster preparedness of Australian pharmacists. METHODS: A 70-question survey was developed from previous research findings. This survey was released online and registered Australian pharmacists were invited to participate. Multiple linear regression was used to determine the factors that influenced preparedness and preparedness behaviors among pharmacists. RESULTS: The final model of disaster preparedness indicated that 86.0% of variation in preparedness was explained by disaster experience, perceived knowledge and skills, colleague preparedness, perceived self-efficacy, previous preparedness behaviors, perceived potential disaster severity, and trust of external information sources. The final model of preparedness behaviors indicated that 71.1% of variation in previous preparedness behaviors can be explained by disaster experience, perceived institution responsibility, colleague preparedness, perceived likelihood of disaster, perceived professional responsibility, and years of practice as a pharmacist. CONCLUSION: This research is the first to explore the significant factors affecting preparedness behaviors and preparedness of Australian pharmacists for disasters. It begins to provide insight into potential critical gaps in current disaster preparedness behaviors and preparedness among pharmacists.

Impact of deprescribing dual-purpose medications on patient-related outcomes for older adults near end-of-life: a systematic review and meta-analysis.

INTRODUCTION: The decision to deprescribe medications used for both disease prevention and symptom control (dual-purpose medications or DPMs) is often challenging for clinicians. We aim to establish the impact of deprescribing DPMs on patient-related outcomes for older adults near end-of-life (EOL). METHODS: This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline. Literature was searched on PubMed, EMBASE, CINAHL, PsycINFO and Google Scholar until December 2019 for studies on deprescribing intervention with a control group (with or without randomisation); targeting ⩾65-year olds, at EOL, with at least one life-limiting illness and at least one potentially inappropriate DPM. We were interested in any patient-related outcomes. Studies with similar outcome assessment criteria were subjected to meta-analysis and narrative synthesis otherwise. The risk of bias was assessed using Cochrane Risk of Bias and ROBINS-I tools for randomised controlled trials (RCTs) and quasi-experimental non-randomised controlled studies, respectively. RESULTS: Five studies covering 689 participants with mean age 81.6-85.7 years, the majority (74.6-100%) with dementia were included. The risk of bias was moderate to low. The deprescribing of DPMs lowered the risk of mortality (risk ratio (RR) = 0.59, 95% confidence interval (CI) = 0.44-0.79) and referral to acute care facilities (RR = 0.40, 95% CI = 0.22-0.73), but did not have a significant impact on the risk of falls, non-vertebral fracture, emergency presentation, unplanned hospital admission, or general practitioner visits. No significant difference was observed in the quality of life, physical and cognitive functions between the intervention and control groups. CONCLUSION: There is some evidence that deprescribing of DPMs for older adults near the EOL can lower the risk of mortality and referral to acute care facilities, but there are insufficient good-quality studies powered to confirm a benefit in terms of quality of life, physical or cognitive function, health service utilisation and adverse events. PLAIN LANGUAGE SUMMARY: What is the health impact of withdrawal or dose reduction of medication used for disease prevention and symptom control in older adults near end-of-life? Introduction: Older adults (aged ⩾ 65 years) with advanced diseases such as cancer, dementia, and organ failure tend to have a limited life expectancy. With the progression of these diseases towards the end-of-life, the intensity for day-to-day supportive care becomes increasingly necessary. The use of medications for symptom management is a critical part of such care, but the use of medications for long-term disease prevention can become irrelevant due to the already shortened life expectancy and may become harmful due to alterations in physiology and pharmacology associated with age and frailty. This necessitates the withdrawal or dose reduction of inappropriate medications, the process called deprescribing. The decision to deprescribe medications used for both disease prevention and symptom control (DPMs) in this population is often challenging for clinicians. In this context, whether deprescribing of DPMs can improve patient-related health outcomes is unknown.Methods: Evidence from the literature was reviewed and analysed, and the quality of studies was assessed. Five studies were identified, which had 689 participants with an average age above 80 years and mostly suffering from dementia.Results: The analysis of these studies showed deprescribing of DPMs lowered the risk of death and referral to acute care facilities at 12 months but had no significant impact on falls, non-vertebral fractures, emergency presentations, unplanned hospital admission, general practitioner visits, quality of life, physical and mental functions.Conclusion: In conclusion, there were insufficient numbers of high-quality studies powered to confirm whether deprescribing of DPMs reduces adverse events, health service use, or improves the quality of life or functioning in older adults near the end of life.

A Difficult Pill to Swallow: An Investigation of the Factors Associated with Medication Swallowing Difficulties.

BACKGROUND: Many medications are available as solid oral dosage forms such as tablets and capsules; however, some people find these medications difficult to swallow. AIM: To identify whether certain psychological, oral sensory, and oral motor characteristics contribute to medication swallowing difficulties. METHODS: A sample of healthy adults from two academic institutions in Brisbane were assessed for their experiences with swallowing solid oral dosage forms, food preferences, and food neophobia. The gag reflex, oral cavity size, fungiform papillae count, and chewing efficacy were also evaluated followed by a capsule-swallowing task. Primary outcome was the incidence of medication swallowing difficulties. Secondary outcomes were the association of medication swallowing difficulties with psychological, oral sensory, and oral motor factors. RESULTS: Of 152 subjects, 32% reported difficulty swallowing tablets or capsules whole. This group was significantly more likely to have had a memory of choking on medications compared to those without medication swallowing difficulties (OR = 7.25, p < 0.05). Current medication swallowing difficulties were significantly associated with a smaller mouth cavity size (OR = 2.98, p < 0.05), a higher density of taste receptors on the tongue (OR = 3.27, p < 0.05), and were higher among those who chewed a jelly candy to non-homogenous particle size (OR = 4.1, p < 0.05). Current medication swallowing difficulties were associated with lower confidence in swallowing large capsules (000 size: OR = 0.47, 00 size: OR = 0.39, p < 0.05). No associations were found between medication swallowing difficulties and the gag reflex or food neophobia. CONCLUSION: A combination of heightened oral perception characterized by a small oral cavity and high taste sensitivity compounded by a past choking episode on medications may be precipitating factors for medication swallowing difficulties. These factors may be helpful in identifying individuals who are more likely to experience difficulty swallowing medications.

Home medicines reviews: a national survey of Australian accredited pharmacists' health service time investment.

BACKGROUND: In Australia, polypharmacy and medication-related problems are prevalent in the community. Therefore, medicines safety initiatives such as the Home Medicines Review (HMR) service are critical to health care provision. While the evidence continues to expand around HMR service, little is known of accredited pharmacists' experiences of HMR time investment. OBJECTIVE: This study aimed to explore accredited pharmacists' experiences of HMR practice regarding time investment in the study's defined HMR Stages: 1 (initial paper-based assessment and review), 2 (in-home patient-accredited pharmacist consultation), and 3 (HMR report collation, generation, completion, and provision to the patient's General Practitioner, including any liaison time). METHODS: An electronic survey was developed and piloted by a panel of reviewers. Convenience sampling was used to distribute the final anonymous survey nationally via professional pharmacy organisations. Data were analyzed for frequency distributions and a chi-square test of independence was performed to evaluate any association between demographic variables relating to HMR time investment. RESULTS: There was a total of 255 survey respondents, representing approximately 10% of national accredited pharmacist membership. The majority were experienced accredited pharmacists who had completed >100 HMRs (73%), were female (71%), and aged >40 years (60%). Regarding time investment for a typical instance of HMR, most spent: <30 minutes performing Stage 1 (46.7%), and 30-60 minutes performing Stage 2 (70.2%). In Stage 3, 40.0% invested 1-2 hours, and 27.1% invested 2-3 hours in HMR report collation and completion. Quantitative analysis revealed statistically significant (p=0.03) gender findings where females performed longer patient consultations than males (Stage 2). More HMR career experience resulted in statistically significant (p=0.01) less time performing Stage 1 (initial paper-based assessment and review); with a trend to less time performing Stage 3 (HMR report writing). CONCLUSIONS: Accredited pharmacists invest significant time in performing comprehensive HMRs, especially during in-home patient consultations and during HMR report collation and completion. Their significant HMR time investment as medicines experts provides insight for program and workforce considerations and warrants further research to better understand their work processes for optimizing medicines use and improving health.

Factors that affect health-care workers' practices of medication administration to aged care residents with swallowing difficulties: An Australia-wide survey study.

OBJECTIVES: To understand the barriers and facilitators of medication administration to aged care residents with swallowing difficulties. METHODS: Health-care workers in aged care facilities across Australia involved in medication administration to residents completed an online survey. RESULTS: Of 355 respondents, 90.9% reported 'everyday' encounters with residents with swallowing difficulties and 94.1% modified medications to facilitate administration. Time constraints (63.4%) and workload (69.0%) were common barriers. Only 39.0% believed swallowing abilities are considered at the prescribing stage. Pill size (95.8%), polypharmacy (75.2%) and lack of alternative formulations (74.9%) contributed to these challenges. Support from other health-care professionals (91.5%) and training (85.9%) were the most favoured facilitators. CONCLUSION: Health-care workers are faced with various challenges when caring for residents with swallowing difficulties. Promoting multidisciplinary collaborations, provision of training and medication review services, and improving skill mix and staffing composition in aged care facilities are needed to address these challenges.

Preliminary study of the plasma and cerebrospinal fluid concentrations of IL-6 and IL-10 in patients with chronic pain receiving intrathecal opioid infusions by chronically implanted pump for pain management.

OBJECTIVE: This preliminary study assessed possible relationships between plasma and/or cerebrospinal fluid (CSF) concentrations of the pleiotropic cytokine, interleukin (IL)-6, the anti-inflammatory cytokine, IL-10, and levels of pain reported by patients receiving intrathecal (i.t.) opioids. DESIGN: A prospective study quantifying IL-6 and IL-10 concentrations using enzyme-linked immunoassays in samples of plasma and CSF as well as assessment of pain scores in patients receiving intrathecal opioids for management of chronic noncancer pain. SETTING: Outpatient pain clinics. PATIENTS: Patients with chronic pain receiving intrathecal morphine or hydromorphone alone or in combination with local anesthetics. INTERVENTIONS: Two groups of patients were studied. The first group (n = 50) had been receiving long-term i.t. opioids by chronically implanted pump for approximately 5 years; paired samples of plasma and CSF were collected at the time of i.t. pump refill. For the second patient group (n = 10), possible temporal changes in the plasma and/or CSF concentrations of IL-6 and IL-10 were investigated for 3 months after initiation of i.t. opioid infusions. RESULTS: For patients receiving long-term i.t. opioid infusions, there were significant inverse correlations (P < or = 0.05) between pain intensity and the plasma (but not CSF) IL-10 and IL-6 concentrations. Despite the considerable inter-patient variability in the CSF concentrations of IL-6 in the long-term cohort, the mean CSF IL-6 concentration was approximately fivefold higher in patients receiving long-term i.t. opioids relative to those receiving i.t. opioids for only 3 months. CONCLUSIONS: The significant inverse correlations observed between pain intensity and the plasma IL-6 and IL-10 concentrations in patients receiving longterm i.t. opioids for chronic pain management, suggests that these cytokines are worthy of further investigation as possible biomarkers of persistent pain.