Impact of the Goal-directed Medication Review Electronic Decision Support System on Drug Burden Index: A cluster-randomised clinical trial in primary care.

AIMS: The Goal-directed Medication Review Electronic Decision Support System (G-MEDSS) assesses and reports a patient's goals, attitudes to deprescribing and Drug Burden Index (DBI) score, a measure of cumulative exposure to anticholinergic and sedative medications. This study evaluated the effect of implementing G-MEDSS in home medicines reviews (HMRs) on DBI exposure and clinical outcomes. METHODS: A cluster-randomised clinical trial was performed across Australia. Accredited clinical pharmacists were randomised into intervention (G-MEDSS with usual care HMR) or comparison groups (usual care HMR alone). Patients were recruited by pharmacists from those routinely referred by general practitioners for HMR. The primary outcome was the proportion of patients with any reduction in DBI at 3-months follow-up. Secondary outcomes included change in DBI continuous score at 3-months, HMR recommendations to change DBI and clinical outcomes. RESULTS: There were 201 patient participants at baseline (n = 88 intervention, n = 113 comparison), with 159 followed-up at 3-months (n = 63 intervention, n = 96 comparison). The proportion of patients with a reduction in DBI was not significantly different at 3-months (intervention 17%, comparison 11%; adjusted odds ratio 1.44, 95% confidence interval 0.56-3.80). Regarding secondary outcomes, there was no difference in change in DBI score at 3-months. However, the HMR report made recommendations to reduce DBI for a significantly greater proportion of patients in the intervention than in the comparison group (intervention 37%, comparison 14%; adjusted odds ratio 3.20, 95% confidence interval 1.50-6.90). No changes were observed in clinical outcomes. CONCLUSION: Implementation of G-MEDSS within HMR did not reduce patients' DBI at 3 months compared with usual care HMR.

Development and dissemination of the national strategic action plan for reducing inappropriate polypharmacy in older Australians.

A cohesive, national approach is needed to address inappropriate polypharmacy in older adults and promote deprescribing. We describe the dissemination of the Quality Use of Medicines to Optimise Ageing in Older Australians: Recommendations for a National Strategic Action Plan to Reduce Inappropriate Polypharmacy, and the initiatives taken to date that align with, and assist in operationalising this plan.

Implementation of the Goal-directed Medication review Electronic Decision Support System (G-MEDSS)© into home medicines review: a protocol for a cluster-randomised clinical trial in older adults.

BACKGROUND: Older people living in the community have a high prevalence of polypharmacy and are vulnerable to adverse drug events. Home Medicines Review (HMR) is a collaborative medication review service involving general practitioners (GPs), accredited clinical pharmacists (ACPs) and patients, which aims to prevent medication-related problems. This study aims to evaluate the implementation of a Computerised Clinical Decision Support System (CCDSS) called G-MEDSS© (Goal-directed Medication Review Electronic Decision Support System) in HMRs to deprescribe anticholinergic and sedative medications, and to assess the effect of deprescribing on clinical outcomes. METHODS: This study consists of 2 stages: Stage I - a two-arm parallel-group cluster-randomised clinical trial, and Stage II - process evaluation of the CCDSS intervention in HMR. Community-dwelling older adults living with and without dementia who are referred for HMR by their GP and recruited by ACPs will be included in this study. G-MEDSS is a CCDSS designed to provide clinical decision support for healthcare practitioners when completing a medication review, to tailor care to meet the patients' goals and preferences. The G-MEDSS contains three tools: The Goals of Care Management Tool, The Drug Burden Index (DBI) Calculator©, and The revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. The G-MEDSS produces patient-specific deprescribing reports, to be included as part of the ACPs communication with the patient's GP, and patient-specific reports for the patient (or carer). ACPs randomised to the intervention arm of the study will use G-MEDSS to create deprescribing reports for the referring GP and for their patient (or carer) when submitting the HMR report. ACPs in the comparison arm will provide the usual care HMR service (without the G-MEDSS). OUTCOMES: The primary outcome is reduction in DBI exposure 3 months after HMR ± G-MEDSS intervention between comparison and intervention groups. The secondary outcomes include changes in clinical outcomes (physical and cognitive function, falls, institutionalisation, GP visits, medication adherence and mortality) 3-months after HMR. DISCUSSION: This study is expected to add to the evidence that the combination of CCDSS supporting medication review can improve prescribing and clinical outcomes in older adults. TRIAL REGISTRATION: The trial was registered on the Australian New Zealand Clinical Trials Registry ACTRN12617000895381 on 19th June 2017.

Psychotropic medications in older people in residential care facilities and associations with quality of life: a cross-sectional study.

BACKGROUND: Psychotropic medications have been associated with many adverse outcomes in older people living in residential care. Home-like models of residential care may be preferable to traditional models of care and we hypothesized that this model may impact on the prevalence of psychotropic medications. The objectives were to: 1) examine associations between psychotropic medications and quality of life in older adults living in residential care facilities with a high prevalence of cognitive impairment and dementia and 2) determine if there was a difference in prevalence of psychotropic medications in facilities which provide a small group home-like model of residential care compared to a 'standard model' of care. METHODS: Participants included 541 residents from 17 residential aged care facilities in the Investigating Services Provided in the Residential Environment for Dementia (INSPIRED) study. Cross-sectional analyses were completed to examine the above objectives. Quality of life was measured with the dementia quality of life questionnaire (DEMQOL) and the EQ-5D-5L completed by the resident or a proxy. RESULTS: Overall, 70.8% (n = 380) of the population had been prescribed/dispensed at least one psychotropic medication in the 100 days prior to recruitment. An increased number of psychotropic medications was associated with lower quality of life according to DEMQOL-Proxy-Utility scores (ß (SE): - 0.012 (0.006), p = 0.04) and EQ-5D-5L scores (- 0.024 (0.011), p = 0.03) after adjustment for resident-level and facility-level characteristics. Analysis of the individual classes of psychotropic medications showed antipsychotics were associated with lower DEMQOL-Proxy-Utility scores (- 0.030 (0.014), p = 0.03) and benzodiazepines were associated with lower EQ-5D-5L scores (- 0.059 (0.024), p = 0.01). Participants residing in facilities which had a home-like model of residential care were less likely to be prescribed psychotropic medications (OR (95% CI): 0.24 (0.12, 0.46), p < 0.001). CONCLUSIONS: An increased number of psychotropic medications were associated with lower quality of life scores. These medications have many associated adverse effects and the use of these medications should be re-examined when investigating approaches to improve quality of life for older people in residential care. Home-like models of residential care may help to reduce the need for psychotropic medications, but further research is needed to validate these findings.

Pharmacists working in residential aged care: a survey of pharmacist interest and perceived preparedness.

BACKGROUND: Pharmacists involvement in residential aged care facilities has traditionally been limited to that of an external contractor providing medication reviews, or medication supply. AIM: To explore Australian pharmacists' interest and perceived preparedness to work as on-site pharmacists in residential aged care. METHOD: National cross-sectional anonymous online survey open for two weeks (September 17th to October 1st 2022) consisting of Likert-type, multiple choice and multiple selection questions. Australian pharmacists were recruited using a broad advertising strategy which included social and traditional media platforms, and snowball sampling. Data were collected on pharmacist self-reported interest and perceived preparedness to work as on-site aged care pharmacists in residential aged care. Data were analysed using descriptive statistics. RESULTS: Responses were received from 720 participants, 643 were eligible. Most participants were female (n = 466, 73%) and mean (SD) age was 43.5 (SD 12.5) years. Over half the participants were interested or extremely interested in working as an on-site aged care pharmacist (56%, n = 360), and agreed or strongly agreed (n = 475, 76%) that they felt prepared to work as an on-site aged care pharmacist. Most pharmacists felt prepared to engage in a variety of roles within the facilities (> 73% for each role), including resident and system level roles, and the majority agreed they felt prepared to engage with stakeholders, including general practitioners (93%) and medical specialists (86%). CONCLUSION: Pharmacists reported they are interested and feel prepared to work as on-site aged care pharmacists. These findings will inform the roll-out of this new model of care to enhance multidisciplinary collaboration in residential aged care.

Association of the Drug Burden Index (DBI) exposure with outcomes: A systematic review.

BACKGROUND: The Drug Burden Index (DBI) measures an individual's total exposure to anticholinergic and sedative medications. This systematic review aimed to investigate the association of the DBI with clinical and prescribing outcomes in observational pharmaco-epidemiological studies, and the effect of DBI exposure on functional outcomes in pre-clinical models. METHODS: A systematic search of nine electronic databases, citation indexes and gray literature was performed (April 1, 2007-December 31, 2022). Studies that reported primary data on the association of the DBI with clinical or prescribing outcomes conducted in any setting in humans aged ≥18 years or animals were included. Quality assessment was performed using the Joanna Briggs Institute critical appraisal tools and the Systematic Review Centre for Laboratory animal Experimentation risk of bias tool. RESULTS: Of 2382 studies screened, 70 met the inclusion criteria (65 in humans, five in animals). In humans, outcomes reported included function (n = 56), cognition (n = 20), falls (n = 14), frailty (n = 7), mortality (n = 9), quality of life (n = 8), hospitalization (n = 7), length of stay (n = 5), readmission (n = 1), other clinical outcomes (n = 15) and prescribing outcomes (n = 2). A higher DBI was significantly associated with increased falls (11/14, 71%), poorer function (31/56, 55%), and cognition (11/20, 55%) related outcomes. Narrative synthesis was used due to significant heterogeneity in the study population, setting, study type, definition of DBI, and outcome measures. Results could not be pooled due to heterogeneity. In animals, outcomes reported included function (n = 18), frailty (n = 2), and mortality (n = 1). In pre-clinical studies, a higher DBI caused poorer function and frailty. CONCLUSIONS: A higher DBI may be associated with an increased risk of falls and decreased function and cognition. Higher DBI was inconsistently associated with increased mortality, length of stay, frailty, hospitalization or reduced quality of life. Human observational findings with respect to functional outcomes are supported by preclinical interventional studies. The DBI may be used as a tool to identify older adults at higher risk of harm.

Pharmacist-led screening for mental illness: A systematic review.

BACKGROUND: Early identification and treatment of mental illnesses is imperative for optimal patient outcomes. Pharmacists may play an important role in mental healthcare through the provision of screening services for mental illnesses. OBJECTIVE: (s): To systematically review the impact of pharmacist-led mental illness screening on clinical or patient-reported outcomes and identify and report any follow-up or referral systems used in pharmacist-led screening interventions for mental illnesses. METHODS: A systematic review was conducted by searching MEDLINE, CINAHL, Embase and APA PsycInfo via EBSCOhost from inception to 9 March 2023 to identify studies involving pharmacist-led screening interventions for mental illnesses. Data was collected on the mental illness in question, setting and population characteristics, screening tools used, clinical or patient-reported outcomes, and follow-up and referral systems reported. RESULTS: Twenty six studies were identified that related to screening for mental illnesses, such as depressive disorders and substance use disorders. There were a variety of study designs, including uncontrolled studies (n = 23), pre-post studies (n = 2) and randomised controlled trials (n = 1). Screening was conducted in different settings, with most studies conducted in community pharmacies (n = 21/26, 87.8 %) and focusing on depression screening (n = 12/26, 46.1 %). A range of follow-up and referral methods to other healthcare professionals were reported, including verbal (n = 3/26, 11.5 %), both written and verbal (n = 3/26, 11.5 %), communications via electronic health record (n = 2/26, 7.7 %) and written (n = 1/26, 3.8 %). CONCLUSIONS: Pharmacists provide screening for a variety of mental illnesses in different settings. Various referral methods and follow-up pathways may be utilised for post-screening patient care. However, current evidence is insufficient to establish improvements in early detection, treatment, or outcomes. Further large, well-designed studies are required to support the role of pharmacists in mental illness screening, provide evidence on the impact of pharmacist-led mental illness screening services and inform the most effective follow up and referral methods.

Clinical pharmacists' reported approaches and processes for undertaking Home Medicines Review services: A national survey.

INTRODUCTION: Comprehensive medicines reviews are a strategy to reduce medicines-related harm. In Australia, Home Medicines Review services (HMRs) are provided by consultant pharmacists to community-dwelling consumers, on referral from the consumer's medical practitioner. Limited research exists on the processes undertaken by consultant pharmacists when delivering HMRs, particularly as it relates to the information types received, collected, and reported. OBJECTIVE: Describe the types of information consultant pharmacists report receiving in HMR referrals, collect before and during consumer consultations, and include in their written reports. MATERIALS AND METHODS: We conducted a national online survey of Australian consultant pharmacists who deliver HMRs. Participants were recruited using a broad advertising strategy, including social and traditional media platforms, and snowballing. Data were analysed descriptively. RESULTS: Of the 248 eligible participants, 179 (72%) completed the survey. The most commonly included information in the referral was medication list (97%), the least were details of hospitalisations (8%) and specialist letters (5%). Information pertaining to hospitalisation and specialist letters were collected by 20% of participants prior to the consultation. Details of, and history from, community pharmacy was the most sought information prior to consultations. Less than a quarter of participants 'most of the time' or 'always' formally assess adherence using a validated instrument during the consultation. Participants commonly (80%) report consumer concerns in the written report. CONCLUSIONS: Consultant pharmacists collect a broad variety of information, beyond medicines-related content. Written HMR reports by consultant pharmacists were often reported to be consumer-centric.

Pharmacist-led medication review in a residential in-reach service leads to deprescribing.

OBJECTIVE: To examine the effect of a pharmacist-led medication review on deprescribing medications in a Residential In-Reach (RIR) service which provides acute care substitution to residential aged care residents. METHODS: A pre-post observational study was conducted. Patient characteristics and admission and discharge medications were collected over two 3-month phases before (prephase) and after (postphase) the introduction of a pharmacist who performed a comprehensive medication review and provided deprescribing recommendations. The Screening Tool of Older Persons' Prescriptions (STOPP) version 2 was used to identify potentially inappropriate medications (PIMs). The Drug Burden Index (DBI) was used to measure cumulative anticholinergic and sedative medication burden. Outcome of deprescribing was measured by the reduction in the number of PIMs, DBI scores and proportion of polypharmacy from admission to discharge. RESULTS: The prephase included 59 patients (mean age 87.3 years, 63% female), and the postphase included 88 patients (mean age 87.3 years, 63% female). There was a significant reduction in the mean number of PIMs (pre +0.05 ± 2.59 vs. post -0.78 ± 2.32, p = 0.04) and median DBI (pre -0.004 ± 0.17 vs. post -0.07 ± 0.2, p = 0.03) in postphase compared to prephase. The proportion of polypharmacy at discharge was reduced in the postphase (pre-100% vs. post-90%, p = 0.01). The most deprescribed PIMs as measured by STOPP in postphase were drugs without indication, cardiovascular system drugs and gastrointestinal system drugs. CONCLUSIONS: The introduction of a pharmacist-led medication review in RIR service was associated with a significant reduction in the mean number of PIMs, median DBI and polypharmacy. Future studies are needed to determine whether deprescription is sustained to examine correlations to long-term patient outcomes.

Development, validation and evaluation of the Goal-directed Medication review Electronic Decision Support System (G-MEDSS)©.

OBJECTIVES: 1) To understand and investigate the experiences of accredited clinical pharmacists (ACP) using computerised clinical decision support systems (CCDSS) during medication reviews for older people, including those living with dementia; 2) To design, develop, validate, and evaluate a CCDSS that incorporates pharmacological and other deprescribing tools to aid person-centred management of high-risk medications in older adults living with and without dementia. METHODS: This study consisted of three phases and was designed on scenario-based methodology: a) the development phase, which included an exploratory survey and prototype building; b) the validation phase, which included qualitative data collection and usability testing with ACPs, general practitioners (GPs) and carers for people living with dementia; and c) the evaluation phase, using mixed-methods analyses. RESULTS: The exploratory survey found that ACPs required a flexible, and reliable CCDSS to support them with clinical decisions regarding high-risk medication use in older adults. The Goal-directed Medication review Electronic Decision Support System (G-MEDSS)© was developed and validated using quantitative and qualitative feedback received from ACPs, GPs and carers for people with dementia. The mean (SD) System Usability Scale score was 69.0 (12.9), which indicated fair-good usability. DISCUSSION AND CONCLUSIONS: Involving end-users in the design process refined and improved the design of G-MEDSS, allowing for a person-centred and goal-directed delivery of pharmaceutical care. G-MEDSS allows healthcare practitioners conducting medication reviews for older adults living with and without dementia to tailor pharmaceutical care to meet their goals and preferences. Future studies may explore integration of G-MEDSS with prescribing or dispensing software.

Deprescribing in the Older Patient: A Narrative Review of Challenges and Solutions.

Polypharmacy is a major challenge in healthcare for older people, and is associated with increased risks of adverse outcomes, such as delirium, falls, frailty, cognitive impairment and hospitalization. There is significant public and professional interest in the role of deprescribing in reducing medication-related harms in older people. We aim to provide a narrative review of 1) the safety and efficacy of deprescribing interventions, 2) the challenges and solutions of deprescribing research and implementation in clinical practice, and 3) the benefits of using Computerized Clinical Decision Support Systems (CCDSS) and Quality Indicators (QIs) in deprescribing research and practice. Deprescribing is an established management strategy to minimize polypharmacy and potentially inappropriate medications. There is limited clinical evidence for its efficacy on global and geriatric outcomes. Various challenges at patient, healthcare professional and healthcare system levels may impact on the success of deprescribing interventions in research and practice. Management strategies that target all levels of the healthcare system are required to overcome these challenges. Future studies may consider large multicenter prospective designs to establish the effects and sustainability of deprescribing interventions on clinical outcomes.

Perspectives of residential aged care facilities' staff on the identification and recording of residents' medication-related goals of care.

OBJECTIVE: This study primarily aims to explore residential aged care facility (RACF) staff views on the utility of a computerised clinical decision support system (CCDSS) that incorporates validated goal-directed deprescribing tools and guides to identify residents' goals for medications. METHODS: A qualitative study was conducted in four RACFs. Semi-structured interviews or focus groups were conducted with 19 participants, representing various types of clinical and care staff. RESULTS: According to staff, the use of a CCDSS was useful as it facilitated resident (including people with dementia), and caregiver engagement to obtain comprehensive information about the residents' goals and medication concerns. Staff perceptions of the increased workload and that some residents and caregivers would have limited involvement in discussions were barriers to the adoption of a CCDSS. CONCLUSION: Integration of a CCDSS into practice, accompanied with staff training and education, has the potential to improve goal-directed pharmaceutical care.

Pharmacist-led intervention to improve medication use in older inpatients using the Drug Burden Index: a study protocol for a before/after intervention with a retrospective control group and multiple case analysis.

INTRODUCTION: Polypharmacy and potentially inappropriate medication use is common in older adults and is associated with adverse outcomes such as falls and hospitalisations. METHODS AND ANALYSIS: This study is a pharmacist-led medication optimisation initiative using an electronic tool (the Drug Burden Index (DBI) Calculator) in four hospital sites in the Canadian province of Nova Scotia. The study aims to enrol 160 participants between the preintervention and intervention groups. The Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT 2013 checklist) was used to develop the protocol for this prospective interventional implementation study. A preintervention retrospective control cohort and a multiple case study analysis will also be used to assess the effect of intervention implementation. Statistical analysis will involve change in DBI scores and assessment of clinical outcomes, such as rehospitalisation and mortality using appropriate statistical tests including t-test, χ2, analysis of variance and unadjusted and adjusted regression methods. ETHICS AND DISSEMINATION: Ethics approval has been granted by the Nova Scotia Health Authority Research Ethics Board. The findings of this study will be published in peer-reviewed journals and presented at local, national and international conferences. TRIAL REGISTRATION NUMBER: NCT03698487.

Integration of an electronic Drug Burden Index risk assessment tool into Home Medicines Reviews: deprescribing anticholinergic and sedative medications.

BACKGROUND: Our aim in this research was to establish whether integrating an electronically generated calculation and report on the Drug Burden Index (DBI) in the Home Medicines Review (HMR) setting is an accurate, feasible and useful risk assessment tool to assess risk of anticholinergic and sedative medications; and to establish whether the intervention of DBI together with HMR is associated with a reduced use of anticholinergic and sedative medications in older community-dwelling adults in Australia. METHODS: An interventional feasibility study was conducted. Accredited clinical pharmacists (APs) were recruited to participate. Each AP was educated on implementation of the DBI into HMR practice and given access to the DBI Calculator© web-based software to generate the DBI report for inclusion in HMR reports for general practitioners (GPs). APs recruited patients (⩾65 years) who were referred to them for HMRs. Patients were sent a letter about their DBI exposure, and a prompt to visit their GP to discuss their medication management options. GPs, APs and patients were asked to evaluate the feasibility and utility of the DBI report. A medication inventory was collected from patients at the time of the HMR and at 3 months to determine whether the intervention affected deprescribing of medications with anticholinergic and sedative effects. RESULTS: Regarding the feasibility of the DBI report as a risk assessment tool within HMR, 89% of APs and 67% of GPs agreed that it would be feasible. The DBI Calculator© was potentially inaccurate, as 26% of DBI scores were underestimated and 7% were overestimated (at baseline). At 3 months, the median (interquartile range) DBI for patients (n = 100) significantly decreased from 0.82 (0-1.33) to 0.67 (0-1.29) (p = 0.014). Additionally, of patients with a DBI > 0 (n = 66), 36.4% had their DBI score decrease, and 6.1% had a score increase. CONCLUSION: This study demonstrated that integration of the DBI Calculator© into HMR is a feasible and useful method to prompt deprescribing of anticholinergic and sedative medications in older adults. There is potential for the accuracy of the web-based platform to be improved. REGISTRATION OF TRIAL: Name: Feasibility study of the Drug Burden Index with Home Medicines Review.Website: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368523Trial ID: ACTRN 12615000539538.

Health professionals' and researchers' opinions on conducting clinical deprescribing trials.

While clinical deprescribing trials are increasingly being performed, there is no guidance on the optimum conduction of such studies. The aim of this survey was to explore the perspectives, attitudes, interests, barriers, and enablers of conducting clinical deprescribing trials among health professionals and researchers. An anonymous survey was developed, reviewed, and piloted by all investigators and informed by consultation with experts, as well as current deprescribing guidelines. The questions were formulated around current clinical trial frameworks and incorporated identified enablers and barriers of performing deprescribing studies. The survey was sent to members of Australian and international deprescribing, pharmacological, and pharmacy organizations, and other researchers published in deprescribing. A total of 96 respondents completed the survey (92.3% completion rate). Respondents indicated the main deprescribing trial rationale is to generate evidence to optimize patient-centered outcomes (79.2%). Common barriers identified included the time and effort required (18.2%), and apprehension of health professionals involved in trials (17.1%). Studies are enabled by positive attitudes toward deprescribing of treating prescribers (24.4%) and patients (20.9%). Classical randomized controlled trials (RCTs) were deemed the most appropriate methodology (93.2%). Sixty percent of participants indicated a good clinical practice framework is required to guide the conduct of deprescribing trials. There were no significant differences in responses based on previous experience in conducting clinical deprescribing trials. In conclusion, clinical deprescribing trials should be conducted to investigate whether deprescribing medications improves patient care. A future deprescribing trial framework should use classical RCTs as a model, ensure participant safety, and target patient-centered outcomes.

Is the Drug Burden Index Related to Declining Functional Status at Follow-up in Community-Dwelling Seniors Consulting for Minor Injuries? Results from the Canadian Emergency Team Initiative Cohort Study.

BACKGROUND: The Canadian Emergency Team Initiative (CETI) cohort showed that minor injuries like sprained ankles or small fractures trigger a downward spiral of functional decline in 16% of independent seniors up to 6 months post-injury. Such seniors frequently receive medications with sedative or anticholinergic properties. The Drug Burden Index (DBI), which summarises the drug burden of these specific medications, has been associated with decreased physical and cognitive functioning in previous research. OBJECTIVES: We aimed to assess the contribution of the DBI to functional decline in the CETI cohort. METHODS: CETI participants were assessed physically and cognitively at baseline during their consultations at emergency departments (EDs) for their injuries and up to 6 months thereafter. The medication data were used to calculate baseline DBI and functional status was measured with the Older Americans Resources and Services (OARS) scale. Multivariate linear regression models assessed the association between baseline DBI and functional status at 6 months, adjusting for age, sex, baseline OARS, frailty level, comorbidity count, and mild cognitive impairment. RESULTS: The mean age of the 846 participants was 77 years and their mean DBI at baseline was 0.24. Complete follow-up data at 3 or 6 months was available for 718 participants among whom a higher DBI at the time of injury contributed to a lower functional status at 6 months. Each additional point in the DBI lead to a loss of 0.5 points on the OARS functional scale, p < 0.001. Among those with a DBI ≥ 1, 27.4% were considered 'patients who decline' at 3 or 6 months' follow-up, compared with 16.0% of those with a DBI of 0 (p = 0.06). CONCLUSIONS: ED visits are considered missed opportunities for optimal care interventions in seniors; Identifying their DBI and adjusting treatment accordingly may help limit functional decline in those at risk after minor injury.

A narrative review of the safety concerns of deprescribing in older adults and strategies to mitigate potential harms.

INTRODUCTION: As with prescribing or continuing medications, deprescribing brings with it the potential for harm as well as benefit. Uncertainty and avoidance of harm has been reported as a barrier to deprescribing in practice and may contribute to continuation of inappropriate medications. AREAS COVERED: This narrative review covers four main safety concerns/potential harms of deprescribing in older adults: adverse drug withdrawal events, return of medical condition(s), reversal of drug-drug interactions and damage to the doctor-patient relationship. These are discussed in relation to medications in general, with some examples of medication classes used to illustrate the potential safety concerns. The majority of these harms can be minimized or even prevented by using a patient-centered, structured deprescribing process with planning, tapering and close monitoring during, and after medication withdrawal. EXPERT OPINION: More research is needed into the safety concerns of deprescribing, however, avenues exist during drug development and post-marketing surveillance to gain knowledge on this topic. Questions remain about when it is suitable to discontinue certain medications/medication classes and there is uncertainty about the harms and benefits of both medication continuation and discontinuation in complex older adults.

Development and pilot testing of the revised Patients' Attitudes Towards Deprescribing questionnaire for people with cognitive impairment.

OBJECTIVES: (i) To develop a version of the revised Patients' Attitude Towards Deprescribing (rPATD) questionnaire for people with mild cognitive impairment (MCI) and mild-to-moderate dementia (rPATDcog); and (ii) to capture the beliefs and attitudes of this population and their carers about deprescribing through a pilot study. METHODS: First, the rPATDcog was modified from the rPATD and tested in a small group of participants with MCI or mild dementia, and then, we conducted a pilot study of the rPATDcog and the carers' rPATD. RESULTS: Twenty-one participants with cognitive impairment and 11 carer participants (forming dyads) participated in this study. Eighty-one per cent (17/21) of participants said that they would stop one or more of their medications if their doctor said it was possible. There was an excellent agreement of corresponding questions between dyads. CONCLUSION: The rPATDcog was feasible to administer in this study. Further work is required to provide generalisable results and determine utility in practice.

Associations between the Drug Burden Index, Potentially Inappropriate Medications and Quality of Life in Residential Aged Care.

BACKGROUND: Inappropriate polypharmacy may negatively impact the quality of life of residents in aged care facilities, but it remains unclear which medications may influence this reduced quality of life. OBJECTIVE: The objective of this study was to examine whether the Drug Burden Index and potentially inappropriate medications were associated with quality of life in older adults living in residential care with a high prevalence of cognitive impairment and dementia. METHODS: We conducted cross-sectional analyses of 541 individuals recruited from 17 residential aged care facilities in Australia in the Investigating Services Provided in the Residential Environment for Dementia (INSPIRED) study. Quality of life was measured using the EuroQol Five Dimensions Questionnaire (a measure of generic quality of life) and the Dementia Quality of Life Questionnaire completed by the participant or a proxy. RESULTS: In the 100 days prior to recruitment, 83.1% of the participants received at least one anticholinergic or sedative medication included in the Drug Burden Index and 73.0% received at least one potentially inappropriate medication according to the Beers Criteria. Multi-level linear models showed there was a significant association between a higher Drug Burden Index and lower quality of life according to the EuroQol Five Dimensions Questionnaire [ß (standard error): - 0.034 (0.012), p = 0.006] after adjustment for potential confounding factors. Increasing numbers of potentially inappropriate medications were also associated with lower EuroQol Five Dimensions Questionnaire scores [- 0.030 (0.010), p = 0.003] and Dementia Quality of Life Questionnaire-Self-Report-Utility scores [- 0.020 (0.009), p = 0.029]. Exposure to both Drug Burden Index-associated medications and potentially inappropriate medications was associated with lower Dementia Quality of Life Questionnaire-Self-Report-Utility scores [- 0.034 (0.017), p = 0.049]. CONCLUSION: Exposure to anticholinergic and sedative medications and potentially inappropriate medications occurred in over three-quarters of a population of older adults in residential care and was associated with a lower quality of life.