Antipsychotic prescription to identify delirium: results from two cohorts.

OBJECTIVES: Detection of delirium in hospitalized patients remains challenging. The objective was to determine if the prescription of antipsychotic medications was associated with delirium. PATIENTS AND METHODS: Two patient cohorts were utilized from a tertiary Veterans Affairs hospital: a palliative care retrospective cohort and a prospective medical cohort. Patients prescribed outpatient antipsychotics were excluded. Retrospectively, delirium was identified using a validated medical record-review instrument. Prospectively, a clinical expert assessed patients for delirium daily using a standardized interview. Acute antipsychotic medication administration was recorded from the electronic medical record. RESULTS: In the retrospective cohort (n=217), delirium was found in 31% (n=67) and antipsychotic use in 18% (n=40) of patients. Acute antipsychotic use indicated delirium with 54% sensitivity and 97% specificity. In the prospective cohort (n=100), delirium developed in 23% (n=23) and antipsychotics were used in 5% (n=5) of patients. The sensitivity and specificity of acute antipsychotic use was 22% and 100%, respectively. CONCLUSION: Hospitalized patients who are acutely prescribed antipsychotics are likely to have delirium, but not all patients with delirium will be identified with this method. In health systems, utilization of the prescription of acute antipsychotics can be an efficient and specific method to identify delirious patients for targeted intervention.

Pharmacist calls to older adults with cognitive difficulties after discharge in a Tertiary Veterans Administration Medical Center: a quality improvement program.

OBJECTIVES: To evaluate the effect of the Pharmacological Intervention in Late Life (PILL) Service, which provides pharmacist telephone follow-up after discharge of older adults from the hospital, on postdischarge acute care utilization. DESIGN: Retrospective, secondary data analysis of a quality improvement project from 2010 to 2012. SETTING: Tertiary Veterans Affairs hospital. PARTICIPANTS: Participants were inpatients aged 65 and older with delirium risk or prescribed a dementia medication (N=501, mean age 79.5±8.0; 98% male). MEASUREMENTS: PILL Service pharmacist telephone follow-up included a medication review and reconciliation within 5 days after hospital discharge. The time of the pharmacist call was examined in relation to the outcomes of emergency and urgent care encounters, readmissions, and mortality within 60 days. RESULTS: The average number of discharge medications was 14.8±5.7 with 2.8±2.2 medication changes and 1.4±1.8 discrepancies between medication order and instruction. After adjustment for age, number of medication changes, and number of discrepancies, every additional 5 minutes of pharmacist call was associated with a 15% reduction in 60-day readmission (adjusted odds ratio (OR)=0.85, 95% confidence interval (95% CI)=0.75-0.97) but was not associated with emergency or urgent care encounters (adjusted OR=1.03, 95% CI=0.91-1.17) or mortality (adjusted OR=0.84, 95% CI=0.58-1.20). CONCLUSION: Pharmacist-led medication review, reconciliation, and telephone calls after hospital discharge were associated with fewer 60-day hospital readmissions in this quality improvement program.

Epidemiology of drug-disease interactions in older veteran nursing home residents.

OBJECTIVES: To describe the prevalence of and factors associated with drug-disease interactions (DDIs) in older nursing home residents according to the American Geriatrics Society 2012 Beers Criteria. DESIGN: Cross-sectional. SETTING: Fifteen Veterans Affairs Community Living Centers. PARTICIPANTS: Individuals aged 65 and older with a diagnosis of dementia or cognitive impairment, a history of falls or hip fracture, heart failure (HF), a history of peptic ulcer disease (PUD), or Stage IV or V chronic kidney disease (CKD). MEASUREMENTS: Medications that could exacerbate the above conditions (DDIs). RESULTS: Three hundred sixty-one of 696 (51.9%) eligible residents had one or more DDIs. None involved residents with a history of PUD, one involved a resident with CKD, and four occurred in residents with HF. Of 540 residents with dementia or cognitive impairment, 50.7% took a drug that could exacerbate these conditions; the most commonly involved medications were antipsychotics (35.4%) and benzodiazepines (14.4%). Of 267 with a history of falls or hip fracture, 67.8% received an interacting medication, with selective serotonin reuptake inhibitors (33.1%), antipsychotics (30.7%), and anticonvulsants (25.1%) being most commonly involved. Using separate multivariable logistic regression models, factors associated with DDIs in dementia or cognitive impairment and falls or fractures included age 85 and older (adjusted odds ratio (aOR) = 0.38, 95% confidence interval (CI) = 0.24-0.60 and aOR = 0.48, 95% CI = 0.24-0.96, respectively), taking five to eight medications (aOR = 2.06, 95% CI = 1.02-4.16 and aOR = 4.76, 95% CI = 1.68-13.5, respectively), taking nine or more medications (aOR = 1.99, 95% CI = 1.03-3.85 and aOR = 3.68, 95% CI = 1.41-9.61, respectively), and being a long-stay resident (aOR = 1.80, 95% CI = 1.04-3.12 and aOR = 2.35, 95% CI = 1.12-4.91, respectively). CONCLUSION: DDIs were common in older nursing home residents with dementia or cognitive impairment or a history of falls or fractures.

Risk versus risk: a review of benzodiazepine reduction in older adults.

INTRODUCTION: Benzodiazepines (BZD) are potentially inappropriate for older adults, yet their use persists. Patients and providers may hesitate to discontinue BZDs due to concerns for withdrawal or relapse. We reviewed the literature for BZD reduction protocols to examine common elements, safety and efficacy. A framework is proposed for clinicians to address BZD reduction challenges. AREAS COVERED: Following a systematic literature review, this analysis included 28 studies of older out-patients tapering chronic BZDs. Populations included insomnia, depression and anxiety. Protocols included taper alone (32%), taper plus cognitive behavioral therapy (32%) and taper plus medication substitution (36%). Success rates were favorable for all modalities (mean 60%, median 67%, range 25 - 85%) and independent of dose or duration of use. Common schedules included a 25% dose reduction over 1 - 2 weeks until drug-free. Withdrawal symptoms included mainly mild psychological and somatic concerns. No serious safety events were reported. EXPERT OPINION: BZD reduction protocols among older adults are feasible and successful. Given unique cognitive and functional abilities and comorbidities of older adults, a patient-centered approach to reduction is needed. Our framework guides clinicians in planning and persisting with BZD reduction, while our checklist addresses tailored tapers. Monitoring and support is emphasized, and taper modifications are proposed for struggling patients.

Increasing anticholinergic burden and delirium in palliative care inpatients.

BACKGROUND: Delirium may complicate the hospital course and adversely impact remaining quality of life for palliative care inpatients. Medications with anticholinergic properties have been linked to delirium within elderly populations via serum anticholinergic assays. AIM: The aim of this study is to determine whether increasing anticholinergic burden, as measured using a clinical assessment tool, is associated with an increase in delirium among palliative care inpatients. DESIGN: This study was completed as a retrospective, case-control study. SETTING/PARTICIPANTS: Veterans admitted to the Veterans Affairs Boston Healthcare System and consulted to the palliative care service were considered for inclusion. Increase in anticholinergic burden from admission through hospital day 14 was assessed using the Anticholinergic Risk Scale. Presence of delirium was determined by use of a validated chart review instrument. RESULTS: A total of 217 patients were analyzed, with a mean age of 72.9 (±12.8) years. The overall delirium rate was 31% (n = 67). Patients with an increase in Anticholinergic Risk Scale (n = 72 (33%)) were 40% more likely to experience delirium (odds ratio = 1.44, 95% confidence interval = 1.07-1.94) compared to those without increase (n = 145 (67%)). After adjustment for age, brain metastasis, intensive care unit admission, illness severity, opiate use, and admission Anticholinergic Risk Scale using multivariable modeling, delirium risk remained significantly higher in patients with an Anticholinergic Risk Scale increase compared to those without increase (adjusted odds ratio = 1.43, 95% confidence interval = 1.04-1.94). CONCLUSION: An increase in Anticholinergic Risk Scale from admission was associated with delirium in palliative care inpatients. While additional study is needed, anticholinergic burden should be increased cautiously in palliative inpatients, and those with increases should be closely followed for delirium.

Engaging patients in medication reconciliation via a patient portal following hospital discharge.

Few ambulatory medication reconciliation tools exist. Transitions between inpatient and outpatient care can result in medication discrepancies. An interdisciplinary team designed a new 'Secure Messaging for Medication Reconciliation Tool' (SMMRT) within a patient web portal and piloted it among 60 patients at a Veterans Affairs hospital, an integrated system with a shared electronic health record. Recently discharged patients used SMMRT to view their medications in a secure email message and replied using SMMRT's interactive form, verifying their medication regimens and clarifying any inaccuracies. In total, 108 medication discrepancies and 23 potential adverse drug events (ADEs) were seen. Nearly 50% of the potential ADEs were classified as serious. Overall, participants were enthusiastic about SMMRT; 90% said they would use SMMRT again. Enabling patients to conduct medication reconciliation through a web portal is feasible in the transition from inpatient to outpatient care and may improve medication safety.

Aligning medication reconciliation and secure messaging: qualitative study of primary care providers' perspectives.

BACKGROUND: Virtual (non-face-to-face) medication reconciliation strategies may reduce adverse drug events (ADEs) among vulnerable ambulatory patients. Understanding provider perspectives on the use of technology for medication reconciliation can inform the design of patient-centered solutions to improve ambulatory medication safety. OBJECTIVE: The aim of the study was to describe primary care providers' experiences of ambulatory medication reconciliation and secure messaging (secure email between patients and providers), and to elicit perceptions of a virtual medication reconciliation system using secure messaging (SM). METHODS: This was a qualitative study using semi-structured interviews. From January 2012 to May 2012, we conducted structured observations of primary care clinical activities and interviewed 15 primary care providers within a Veterans Affairs Healthcare System in Boston, Massachusetts (USA). We carried out content analysis informed by the grounded theory. RESULTS: Of the 15 participating providers, 12 were female and 11 saw 10 or fewer patients in a typical workday. Experiences and perceptions elicited from providers during in-depth interviews were organized into 12 overarching themes: 4 themes for experiences with medication reconciliation, 3 themes for perceptions on how to improve ambulatory medication reconciliation, and 5 themes for experiences with SM. Providers generally recognized medication reconciliation as a valuable component of primary care delivery and all agreed that medication reconciliation following hospital discharge is a key priority. Most providers favored delegating the responsibility for medication reconciliation to another member of the staff, such as a nurse or a pharmacist. The 4 themes related to ambulatory medication reconciliation were (1) the approach to complex patients, (2) the effectiveness of medication reconciliation in preventing ADEs, (3) challenges to completing medication reconciliation, and (4) medication reconciliation during transitions of care. Specifically, providers emphasized the importance of medication reconciliation at the post-hospital visit. Providers indicated that assistance from a caregiver (eg, a family member) for medication reconciliation was helpful for complex or elderly patients and that patients' social or cognitive factors often made medication reconciliation challenging. Regarding providers' use of SM, about half reported using SM frequently, but all felt that it improved their clinical workflow and nearly all providers were enthusiastic about a virtual medication reconciliation system, such as one using SM. All providers thought that such a system could reduce ADEs. CONCLUSIONS: Although providers recognize the importance and value of ambulatory medication reconciliation, various factors make it difficult to execute this task effectively, particularly among complex or elderly patients and patients with complicated social circumstances. Many providers favor enlisting the support of pharmacists or nurses to perform medication reconciliation in the outpatient setting. In general, providers are enthusiastic about the prospect of using secure messaging for medication reconciliation, particularly during transitions of care, and believe a system of virtual medication reconciliation could reduce ADEs.

Complexity perplexity: a systematic review to describe the measurement of medication regimen complexity.

INTRODUCTION: Complex medication regimens are error prone and challenging for patients, which may impact medication adherence and safety. No universal method to assess the complexity of medication regimens (CMRx) exists. The authors aim to review literature for CMRx measurements to establish consistencies and, secondarily, describe CMRx impact on healthcare outcomes. AREAS COVERED: A search of EMBASE and PubMed for studies analyzing at least two medications and complexity components, among those self-managing medications, was conducted. Out of 1204 abstracts, 38 studies were included in the final sample. The majority (74%) of studies used one of five validated CMRx scales; their components and scoring were compared. EXPERT OPINION: Universal CMRx assessment is needed to identify and reduce complex regimens, and, thus, improve safety. The authors highlight commonalities among five scales to help build consensus. Common components (i.e., regimen factors) included dosing frequency, units per dose, and non-oral routes. Elements (e.g., twice daily) of these components (e.g., dosing frequency) and scoring varied. Patient-specific factors (e.g., dexterity, cognition) were not addressed, which is a shortcoming of current scales and a challenge for future scales. As CMRx has important outcomes, notably adherence and healthcare utilization, a standardized tool has potential for far-reaching clinical, research, and patient-safety impact.

Aging, antiretrovirals, and adherence: a meta analysis of adherence among older HIV-infected individuals.

INTRODUCTION: Older adults are generally considered to be at greater risk for medication non-adherence due to factors such as medication complexity, side effects, cost, and cognitive decline. However, this generalization may not apply to older adults with human immunodeficiency virus (HIV). Regardless of age, suboptimal adherence to antiretroviral therapy (ART) can lead to increased viral load, immunosuppression, drug-resistant viral strains, co-morbidities, and opportunistic infections. Understanding trends of adherence to ART among older adults is critical, especially as the population of people living with HIV grows older. OBJECTIVES: The purpose of this systematic review and meta-analysis is to determine if older individuals with HIV are less likely to be non-adherent to antiretroviral therapy than younger individuals with HIV. DESIGN: A systematic search in PubMed, Embase, and PsycINFO was conducted to identify peer-reviewed articles evaluating adherence to ART in older adults. Two independent reviewers screened abstracts, applied inclusion criteria, and appraised study quality. The bibliographies of qualifying studies were searched. Data were abstracted from studies by two independent authors. Meta-analyses were conducted, and adherence levels were reported as the relative risk of non-adherence in older individuals compared to younger individuals. RESULTS: The systematic search yielded 1,848 abstracts. Twelve studies met full inclusion criteria. The overall meta-analysis found that older age reduced risk for nonadherence by 27 % (relative risk (RR) 0.72, 95 % confidence interval (CI) 0.64­0.82). Studies assessing both short-term and long-term adherence demonstrated a significant reduction in non-adherence among older patients (RR 0.75, 95 % CI 0.64­0.87 and RR 0.65, 95 % CI 0.50­0.85, respectively). CONCLUSIONS: Older adults with HIV have a reduced risk for non-adherence to ART than their younger counterparts. Future studies should seek to elucidate contributing factors of adherence among older individuals with HIV.