Top 10 Signs and Symptoms of Psychotropic Adverse Drug Events to Monitor in Residents of Long-Term Care Facilities.

OBJECTIVES: To produce a consensus list of the top 10 signs and symptoms suggestive of adverse drug events (ADEs) for monitoring in residents of long-term care facilities (LTCFs) who use antipsychotics, benzodiazepines, or antidepressants. DESIGN: A 3-round Delphi study. SETTING AND PARTICIPANTS: Geriatricians, psychiatrists, pharmacologists, general practitioners, pharmacists, nurses, and caregivers from 13 Asia Pacific, European, and North American countries. METHODS: Three survey rounds were completed between April and June 2023. In Round 1, participants indicated their level of agreement on a 9-point Likert scale on whether 41 signs or symptoms identified in a systematic review should be routinely monitored. Participants considered signs and symptoms that reduce quality of life or cause significant harm, are observable or measurable by nurses or care workers, and can be assessed at a single time point. Round 1 statements were included in a list for prioritization in Round 3 if ≥ 70% of participants responded ≥7 on the Likert scale. Statements were excluded if ≤ 30% of participants responded ≥7. In Round 2, participants indicated their level of agreement with statements that did not reach initial consensus, plus amended statements based on Round 1 participant feedback. Round 2 statements were included in Round 3 if ≥ 50% of the participants responded ≥7 on the Likert scale. In Round 3, participants prioritized the signs and symptoms. RESULTS: Forty-four participants (93.6%) completed all 3 rounds. Four of 41 signs and symptoms reached consensus for inclusion after Round 1, and 9 after Round 2. The top 10 signs and symptoms prioritized in Round 3 were recent falls, daytime drowsiness or sleepiness, abnormal movements (eg, shaking or stiffness), confusion or disorientation, balance problems, dizziness, postural hypotension, reduced self-care, restlessness, and dry mouth. CONCLUSIONS AND IMPLICATIONS: The top 10 signs and symptoms provide a basis for proactive monitoring for psychotropic ADEs.

Development and validation of the Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE).

BACKGROUND: Residents of aged care facilities use increasingly complex medication regimens. Reducing unnecessary medication regimen complexity (eg, by consolidating the number of administration times or using alternative formulations) may benefit residents and staff. OBJECTIVE: To develop and validate an implicit tool to facilitate medication regimen simplification in aged care facilities. METHOD: A purposively selected multidisciplinary expert panel used modified nominal group technique to identify and prioritize factors important in determining whether a medication regimen can be simplified. The five prioritized factors were formulated as questions, pilot-tested using non-identifiable medication charts and refined by panel members. The final tool was validated by two clinical pharmacists who independently applied the tool to a random sample of 50 residents of aged care facilities to identify opportunities for medication regimen simplification. Inter-rater agreement was calculated using Cohen's kappa. RESULTS: The Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE) was developed as an implicit tool comprising of five questions about 1) the resident; 2) regulatory and safety requirements; 3) drug interactions; 4) formulation; and 5) facility and follow-up considerations. Using MRS GRACE, two pharmacists independently simplified medication regimens for 29/50 and 30/50 residents (Cohen's kappa=0.38, 95% CI 0.12-0.64), respectively. Simplification was possible for all residents with five or more administration times. Changing an administration time comprised 75% of the two pharmacists' recommendations. CONCLUSIONS: Using MRS GRACE, two clinical pharmacists independently simplified over half of residents' medication regimens with fair agreement. MRS GRACE is a promising new tool to guide medication regimen simplification in aged care.

Medication regimen complexity and prevalence of potentially inappropriate medicines in older patients after hospitalisation.

Background There is a relative paucity of information to characterise potential changes in medication regimen complexity and prevalence of prescribing of potentially inappropriate medications after hospitalisation, both in Australia and elsewhere. Objective To evaluate medication regimen complexity and the prevalence of potentially inappropriate medications before and after admission to hospital. Setting General medical units of a tertiary care hospital in Australia. Methods Retrospective cohort study of patients aged 65 years and above. Medication complexity was measured by using the Medication Regimen Complexity Index (MRCI). Main outcome measure The primary outcome was the change in the Medication Regimen Complexity Index for all prescribed medications after hospitalization. Results A convenience sample of 100 patients was included in the study. There was a significant change in the mean medication complexity score (as measured using the MRCI), increasing from 29 at the time of admission to 32 at the time of discharge (p < 0.05). Factors such as baseline medication regimen complexity (pre-admission MRCI) and length of stay in the hospitals appear to influence the change in medication complexity. However, the proportion of patients prescribed at least one potentially inappropriate medicine (PIM) decreased significantly, from 52% pre-hospitalization to 42% at discharge (p = 0.04). Conclusions Relative to the time of admission, overall medication complexity increased and the proportion of patients who were prescribed PIMs decreased after hospitalisation.

Probable Drug-Related Meningioma Detected During the Course of Medication Review Services.

There is evidence to support a link between treatment with high-dose cyproterone acetate and the development of meningioma. This report describes a case where an elderly man with intellectual disability who was treated with cyproterone for problematic sexual behavior developed a meningioma. The case was the subject of a residential medication management review provided under the auspices of a program funded by the Commonwealth Government of Australia. A discussion of clinical and ethical implications of the case is provided.

Potential Cross-Reactivity Between Penicillin Derivatives and Cephalosporins.

Allergic reactions to both penicillins and cephalosporins are relatively common. Patients who have had a previous allergic reaction to a penicillin derivative may also be prone to a further reaction if treated with cephalosporins. This case illustrates several important points about potential cross-reactivity between penicillin derivatives and cephalosporins, as well as the benefits of an extended-hours pharmacy service in a longterm care facility.

Effect of an ACE inhibitor on allergic reaction to a bee sting.

An 83-year-old man being treated with combination product containing perindopril and indapamide had a systemic reaction after being stung by a bee. An angiotensin-converting enzyme inhibitor may significantly increase the severity of allergic reactions after being stung by bees, ants, or wasps. Clinicians should be aware of the potential for this phenomenon if assisting people who have been stung.

Syndrome of inappropriate antidiuretic hormone secretion associated with desvenlafaxine.

OBJECTIVE: To report a case of syndrome of inappropriate anti-diuretic hormone (SIADH) secretion associated with desvenlafaxine. CASE SUMMARY: A 57-year old female with hyponatraemia. Her medications included desvenlafaxine, and symptoms included nausea, anxiety and confusion. The serum sodium at this time was 120 mmol/L, serum osmolality was 263 mosmol/kg, urine osmolality 410 mosmol/kg and urine sodium 63 mmol/L, consistent with a diagnosis of SIADH. Desvenlafaxine was ceased and fluid restriction implemented. After 4 days the sodium increased to 128 mmol/L and fluid restriction was relaxed. During her further 3 weeks inpatient admission the serum sodium ranged from 134 to 137 mmol/L during treatment with mirtazapine. DISCUSSION: SIADH has been widely reported with a range of antidepressants. This case report suggests that desvenlafaxine might cause clinically significant hyponatremia. CONCLUSIONS: Clinicians should be aware of the potential for antidepressants to cause hyponatremia,and take appropriate corrective action where necessary.

Prescribing for older people with chronic renal impairment.

BACKGROUND: Renal function is an important prescribing consideration. On average, glomerular filtration rate declines by about 10 mL/min every 10 years after the age of 40. Renal impairment may cause medicines to accumulate or cause toxicity, especially if the medicine has a narrow therapeutic index. OBJECTIVE: To present an overview of prescribing considerations in the primary care setting for patients with chronic renal impairment. DISCUSSION: Serum creatinine considered in isolation is not a reliable indicator of renal function. The estimated glomerular filtration rate provided in pathology reporting can alert prescribers to possible renal impairment and the need to consider dose adjustments. The Cockcroft-Gault equation should be used to adjust medicine doses. Renal function monitoring is recommended for patients using medicines that can impair renal function or cause nephrotoxicity (eg. NSAIDs, ACEIs, ARBs).

Prevalence of concomitant use of alcohol and sedative-hypnotic drugs in middle and older aged persons: a systematic review.

OBJECTIVE: To systematically review the prevalence of concomitant alcohol and sedative-hypnotic use among middle-aged and older persons. DATA SOURCES: A bibliographic search of English-language literature was performed using MEDLINE, EMBASE, and PsycINFO (January 1990-August 2012). The reference lists of all included articles were screened for additional relevant articles not identified by any of the bibliographic searches. STUDY SELECTION AND DATA EXTRACTION: Population-based studies in which the mean age of participants was 40 years or older were included. For a study to be included in the review, alcohol use had to be reported in terms of the quantity or frequency consumed. Data from included articles were extracted using a standardized data extraction tool. DATA SYNTHESIS: Five population-based studies conducted in North America, 10 in Europe, and 1 in Australia were included in the review. Up to 88% of men and 79% of women who used sedative-hypnotics also consumed alcohol. Up to 28% of those who consumed alcohol were concomitant users of sedative-hypnotics. Alcohol was consumed at higher levels among middle-aged than older persons. Risky drinking (eg, binge drinking, heavy drinking) was more prevalent among middle-aged than older persons. In contrast, sedative-hypnotic use was more prevalent among older persons. CONCLUSIONS: Our review identified a higher prevalence of alcohol consumption among middle-aged than older persons. However, middle-aged persons may experience harm from alcohol/sedative-hypnotic drug interactions due to risky drinking behavior. Despite lower levels of alcohol consumption, older persons may be more susceptible to addictive central nervous system effects than younger persons because of physiologic changes in psychotropic drug and alcohol metabolism. Clinicians should consider patients' alcohol consumption patterns before prescribing sedative-hypnotic drugs.

Survey of Australian inpatients on vaccination status and perceptions of influenza vaccination.

OBJECTIVE: To assess vaccination status, potential influences upon vaccination status, and attitudes and beliefs about vaccination among hospital inpatients. DESIGN: This prospective, cross-sectional audit assessed vaccination status for important communicable diseases, patient perceptions about the influenza vaccination, and possible influences on vaccination status. Information was collected during face-to-face interviews using a structured questionnaire. SETTING: This study was undertaken in a general teaching hospital in suburban Adelaide, South Australia. PARTICIPANTS: The study participants comprised a convenience sample of 50 inpatients at the hospital from April 25, 2011, to May 18, 2011. INTERVENTION: Interview and structured questionnaire at bedside. MAIN OUTCOME MEASURES: Vaccination status for seasonal influenza, pneumococcal vaccine, diphtheriatetanus-pertussis/diphtheria-tetanus vaccination, herpes zoster virus, and hepatitis B were assessed for inpatients. Qualitative information regarding patient perceptions about the influenza vaccination was also surveyed. Possible influences on vaccination status including comorbidities or high-risk conditions, area of residence, age, and gender were also assessed. RESULTS: The self-reported vaccination rates were: seasonal influenza vaccine 2010 (64%), seasonal influenza vaccine 2011 (52%), pneumococcal vaccine (46%), diphtheria-tetanuspertussis/ diphtheria-tetanus vaccination (70%), herpes zoster vaccination (34%), and hepatitis B vaccination (40%). Vaccination was significantly more common among those older than 64 years of age (P = 0.01), with 46% of patients older than 64 years vaccinated against influenza. There was no significant association between vaccination status and other characteristics such as gender, number of risk factors, recent hospital admission, and living in a residential facility. Regarding perceptions toward the influenza vaccine, the only factor associated with significantly increased likelihood of vaccination was self-reported risk perception (P = 0.03). The majority of patients described positive views about influenza vaccine efficacy and expressed willingness to receive the vaccine if recommended by their doctor. CONCLUSIONS: In this audit, vaccination status appeared to be age-dependent, with higher vaccination coverage among older patients. Those who perceived that the influenza vaccine is associated with many side effects were less likely to be vaccinated. Pharmacists may have a role in encouraging older adults to be vaccinated.

Osteoporosis - pharmacological prevention and management in older people.

BACKGROUND: Osteoporosis remains undertreated in Australian primary care, with as few as 30% of postmenopausal women with a fracture and 10% of men with osteoporosis receiving pharmacological treatment. OBJECTIVE: This article presents an overview of the pharmacological management of osteoporosis in older people in the general practice setting. DISCUSSION: Lifestyle factors and ensuring adequate calcium and vitamin D intake are important in preventing and treating osteoporosis. Pharmacological treatments are recommended for patients with a minimal trauma fracture, for those aged 70 years or over with a T-score of -3.0 or lower, or for those who are currently taking prolonged high dose corticosteroids and who have a T-score of -1.5 or lower. Bisphosphonates are recommended as first line therapy for established postmenopausal osteoporosis. Medicine selection is guided by patient gender, menopausal status, medical and fracture history, patient preference and eligibility for government subsidy.

Anticholinergic and sedative medicines - prescribing considerations for people with dementia.

BACKGROUND: Older people with dementia may be particularly susceptible to cognitive impairment associated with anticholinergic and sedative medicines. This impairment may be misattributed to the disease process itself. OBJECTIVE: This review examines clinical considerations associated with using anticholinergic and sedative medicines in people with dementia or incipient cognitive impairment. It highlights issues associated with concomitant use of cholinesterase inhibitors and anticholinergic medicines, and pharmacotherapy of conditions that commonly occur in people with dementia. DISCUSSION: Use of medicines with anticholinergic or sedative properties may result in adverse events by increasing the overall anticholinergic or sedative load. Patients may benefit from clinicians reviewing the anticholinergic load of the current medicine regimen before the initiation of cholinesterase inhibitors or memantine. Reducing the number and dose of anticholinergic and sedative medicines may improve cognitive function and reduce the likelihood of adverse events.

Suicidal behavior and psychotropic medications for adolescents: an uneasy association, as yet not clarified.

Despite considerable recent attention and wide-scale interventions by regulatory authorities that have changed drug usage patterns, the possible relationship between psychotropic pharmacotherapy and suicidal behavior among children and adolescents remains unclear. Confounding by diagnosis adds to confusion in the interpretation of the relationship between antidepressant use and suicidal behavior among young people. Recent research suggests that antidepressants may be protective against early readmission after hospitalization for suicide attempts or ideation, but that psychotropic polypharmacy (although common) may be associated with increased risk of rehospitalization. There remains an urgent need for high-quality, ongoing research into these clinical dilemmas.