Prevalence of Drugs and Drug Combinations that Increase Risk of Prolonged QT Time Among People with Major Neurocognitive Disorder Living in Sweden: A Cross-Sectional Registry Study.

BACKGROUND: People with major neurocognitive disorder might be susceptible to drug-induced QT interval prolongation due to the presence of a number of concomitant risk factors. OBJECTIVE: The aim of this study was to investigate the prevalence of QT-prolonging drugs and QT-prolonging drug-drug interactions and associated factors among older people with major neurocognitive disorder. METHODS: In this register-based study, we obtained information regarding QT-prolonging drug use in a large population of older people with major neurocognitive disorder, through record linkage between the Swedish registry for cognitive/dementia disorders, and the Swedish Prescribed Drug Register. QT-prolonging drugs were identified according to the CredibleMeds online database and interactions using the Janusmed interaction database. Drug use was defined as one or more filled prescriptions during a 6-month timeframe, July 01 to December 31, 2017. Associations between people with a QT-prolonging drug and the factors of age and gender were analysed through multiple logistic regression. RESULTS: Of 35,212 people included in the study, 41.6% had one or more QT-prolonging drug prescribed. The most commonly prescribed drug was donepezil, with a prevalence of 25.0%, followed by citalopram and escitalopram, representing 14.5% and 3.9% of prescriptions in the study population, respectively. Significant associations were found between QT-prolonging drug use and the factors of younger age and female gender. The most prevalent interaction was between citalopram and donepezil (2.7%), followed by the combination of escitalopram and donepezil (0.7%). CONCLUSIONS: In this population of older people with major neurocognitive disorder, QT-prolonging drugs and interactions that increase the risk of torsade de pointes were prevalent. Due to the presence of many risk factors in this population, it is important to continuously evaluate current QT-prolonging drugs and concomitant drug treatment in each individual.

Time to initiation of lipid-lowering drugs for subclinical atherosclerosis: sub-study of VIPVIZA randomized controlled trial, with single-arm cross-over.

Aims: Visual information about subclinical atherosclerosis was provided to physicians and participants in the VIPVIZA trial, inclusion 2013-16 in northern Sweden, aiming to improve adherence to cardiovascular disease (CVD) prevention guidelines. Pictorial risk information may be more actionable. The aim of this study was to investigate the effect of intervention with pictorial risk information on time to first dispensing of statins. Methods and results: Asymptomatic atherosclerotic disease was screened for by carotid ultrasound examination in 3532 participants enrolled in VIPVIZA, of those 3000 met the criteria for this study. Participants were randomly assigned to receive pictorial risk information consisting of graphical representation of atherosclerosis as compared to a control group without intervention. Time to initiation of statins was assessed during 5 years of follow-up through the National prescribed drug register. After 3 years, both groups were re-examined and received the intervention information. In the intervention group, initiation of statins increased considerably for the first 3 years and a smaller increase was also seen after re-intervention. After the cross-over, the control group showed a sharp increase in initiation of statins, almost reaching the same proportion treated at 5 years. The propensity to initiate statin treatment increased over the study period and there was no difference between men and women. Conclusions: The pictorial information had an effect on time to initiation of statins, both as original and repeated intervention and also in the control group after single-arm cross-over. The current study supports pictorial information as a tool to shorten time to initiation of statins for CVD prevention.The VIPVIZA study is registered with ClinicalTrials.gov, number NCT01849575.

Potentially Inappropriate Medications Pre- and Post-Diagnosis of Major Neurocognitive Disorders Among Older People in Sweden: A Register-Based, 6-Year Longitudinal Study.

OBJECTIVE: The aim of the present study was to investigate how potentially inappropriate medication usage and anti-dementia drug use change from 3 years prior to, up until 3 years post-diagnosis of major neurocognitive disorders among older people living in Sweden. METHODS: People registered in the Swedish registry for cognitive/dementia disorders from 1 July, 2008 to 31 December, 2017, and aged 68 years or older at diagnosis, were included (n = 67,226). Data were combined with the Swedish Prescribed Drug Registry to obtain information about drugs collected in 6-month periods at Swedish pharmacies from 3 years pre-diagnosis until 3 years post-diagnosis. Potentially inappropriate medications were identified according to Swedish national guidelines. A generalised estimating equation regression model and estimated marginal means were used. RESULTS: Of the 67,226 people included in the study population, 59.2% were women and the mean age ± standard deviation was 81.5 ± 6.4 years, 47.0% lived together with a spouse or partner, and 88.9% were living at home at the time of diagnosis. The proportions of people using potentially inappropriate medications continuously decreased pre- and post-diagnosis, except for antipsychotic drug use, which continuously increased both pre- and post-diagnosis. Moreover, anticholinergic drug use increased pre-diagnosis and declined post-diagnosis. When comparing the periods pre- and post-diagnosis date, the adjusted proportion of people using potentially inappropriate medications was significantly lower post-diagnosis compared with pre-diagnosis, except for the adjusted proportion using antipsychotics, which was significantly higher post-diagnosis, 10.6%, compared with the period before, 3.1% (adjusted odds ratio 3.71; 95% confidence interval 3.59-3.83). The adjusted proportion of people using anticholinergic drugs was significantly lower post-diagnosis, 7.2%, compared with the pre-diagnosis period, 8.9% (adjusted odds ratio 0.80; 95% confidence interval 0.78-0.82). Anti-dementia drug use was significantly higher post-diagnosis, 52.6%, when compared with the pre-diagnosis period, 3.5% (adjusted odds ratio 30.13; 95% confidence interval 29.19-31.10). CONCLUSIONS: Overall, the prevalence of people using potentially inappropriate medications decreased and was significantly lower post-diagnosis of major neurocognitive disorders, except for antipsychotics. This indicates that potentially inappropriate medication use should be noticed and reviewed among all older people. The small decrease in the prevalence of anticholinergic drug users and the increasing proportions of people using antipsychotic drugs post-diagnosis are of special concern because of the adverse drug reactions associated with these types of potentially inappropriate medications. Consequently, it is important to identify and regularly question anticholinergic and antipsychotic drug treatment to prevent unnecessary and serious adverse drug reactions among a vulnerable group of people.

Self-reported medication adherence and pharmacy refill adherence among persons with ischemic stroke: a cross-sectional study.

PURPOSE: To describe and compare self-reported medication adherence assessed with the 5-item version of Medication Adherence Report Scale (MARS-5) and pharmacy refill adherence based on data from the Swedish Prescribed Drug Register (SPDR) among persons with ischemic stroke, and to investigate independent predictors associated with respective assessments. METHODS: A study questionnaire was sent to persons with ischemic stroke registered in the Swedish Stroke Register between Dec 2011 and March 2012, and who lived at home 3 months after discharge. The primary outcome was dichotomized to adherent/non-adherent based on MARS-5 and SPDR and analyzed with multivariable logistic regression. Adherence according to MARS-5 was defined as score 23 or higher (out of 25). Adherence according to SPDR was defined as at least one filled statin prescription recorded in SPDR in each 6-month interval during 2 years of follow-up. RESULTS: Of 420 participants, 367 (87%) and 329 (78%) were adherent according to MARS-5 and SPDR, respectively, and 294 (70%) participants were adherent according to both assessments. A significant association was shown between medication adherence according to the two assessments (p = 0.020). Independent predictors associated with medication adherence according to MARS-5 were female sex, while factors associated with SPDR were male sex and being younger. CONCLUSIONS: The majority of participants were classified as adherent, 87% according to MARS-5 and 78% based on data from SPDR. However, only 70% were adherent according to both MARS-5 and SPDR, and different predictors were associated with the different measurements, suggesting that these assessments are measuring different aspects of adherence.

Primary Non-Adherence to Preventive Drugs and Associations with Beliefs About Medicines in Stroke Survivors.

BACKGROUND: Medication non-adherence is a common problem in clinical practice. Little is known about stroke survivors' primary non-adherence to preventive drugs, and we hypothesised that their beliefs about medicines are associated with primary non-adherence. The objective was to describe primary non-adherence among stroke survivors and to assess associations between primary non-adherence to preventive drugs and beliefs about medicines. METHODS: Questionnaires were sent to 797 individuals 3 months after stroke to assess beliefs about medicines through the Beliefs about Medicines Questionnaire (BMQ). All participants were registered in the Swedish Stroke Register (Riksstroke), and prescriptions for new preventive drugs during the hospital stay were identified through data from Riksstroke. Primary non-adherers were those who failed to fill one or more new prescriptions within 1 month of hospital discharge based on data from the Swedish Prescribed Drug Register. Differences between primary non-adherers and adherers were assessed by 2 tests and associations between the BMQ subscales and primary non-adherence were analysed using independent two-sample t-tests and multivariable logistic regression models. RESULTS: A total of 594 individuals responded to the survey, of which 452 received new prescriptions of preventive drugs. Overall, 53 (12%) participants were classified as primary non-adherent. Primary non-adherers were more often dependent on help or support from next of kin (p=0.032) and had difficulties with memory more often (p=0.002) than the primary adherent individuals. No statistically significant differences in BMQ subscale-scores were found between the two groups (p>0.05). CONCLUSION: Primary non-adherence to preventive drugs was low, and no associations were found between primary non-adherence and beliefs about medicines. Associations with cognitive impairments such as difficulties with memory and need for help from next of kin suggest that more effort is needed to help stroke survivors to start important preventive drug treatments after discharge from hospital.

Psychotropic drug use among older people with major neurocognitive disorder: a cross-sectional study based on Swedish national registries.

AIM: Psychotropic medications include many drugs that may be inappropriate for older individuals with cognitive impairment. In Sweden, many people become registered in the Swedish Dementia Registry when they are diagnosed with major neurocognitive disorder (NCD). In this study, we aim to describe psychotropic drug use and associated factors among older Swedish people with major NCD. METHODS: This study included 38,251 people ≥ 65 years from the Swedish registry for cognitive/dementia disorders diagnosed during 2007-2017. Drug use was defined as one or more filled prescription(s) recorded in the Swedish Prescribed Drug Register during 1 July to 31 December 2017. Associations between psychotropics and age, sex, diagnosis date, Mini-Mental State Examination score and major NCD subtype were analysed through multiple logistic regression. RESULTS: We found that 12.0% of the individuals filled at least one prescription for antipsychotics, 22.0% for anxiolytics, 23.0% for sedatives or hypnotics, 43.2% for antidepressants and 56.7% for antidementia drugs. In brief, psychotropic use was associated with female sex, higher age, longer time since diagnosis and specific subtypes of major NCD; the strongest association was found between antipsychotics and Lewy body dementia (odds ratio 2.40, 95% confidence interval 2.04-2.82). CONCLUSION: Psychotropic drugs were frequently dispensed among older Swedish people with major NCD. The use of antipsychotics and medications with sedative properties warrants concern, especially among those with Lewy body dementia who are severely sensitive to antipsychotics. A more restrictive prescribing pattern regarding these medications might reduce the risk of drug-related problems in this vulnerable group of people.

Pharmacological Pain Treatment in 2012 and 2017 Among Older People with Major Neurocognitive Disorder.

BACKGROUND AND OBJECTIVE: Pain is highly prevalent among older people, and treatment is complicated because of comorbidities and polypharmacy. Among people with major neurocognitive disorder additional difficulties might arise. The aim of this study was to describe analgesic drug use in 2012 and 2017 and associated factors among older people with major neurocognitive disorder. METHODS: In this register-based study, the Swedish Dementia Registry and the Swedish Prescribed Drug Register were combined in order to obtain data regarding analgesic drug use among older people with major neurocognitive disorder. One or more filled prescriptions during the timeframe of 6 months (1 July-31 December 2012 and 1 July-31 December 2017) defined drug use during the respective period. A comparison between 2012 and 2017 was made, including a total of 56,101 people (20,889 and 35,212 respectively) with a mean age of 81.9 and 82.7 years, respectively. RESULTS: The overall use of analgesic drugs increased significantly from 41.6% of individuals to 46.0% between the years 2012 and 2017. Users of opioid analgesics (15.2% vs 17.3%) and paracetamol (37.0% vs 42.3%) increased, while the users of non-steroidal anti-inflammatory drugs (4.9% vs 2.7%) declined between the two data collections. Multiple logistic regression analyses were performed for different drugs and drug classes, and it was found that the use of opioids and paracetamol was associated with older age and a longer time since diagnosis. In contrast, non-steroidal anti-inflammatory drugs were associated with younger age and a shorter time since diagnosis. CONCLUSIONS: The results indicate that on a population level, pharmacological drug treatment has changed in line with guidelines between 2012 and 2017, with an increase in paracetamol and strong opioids and a decrease in non-steroidal anti-inflammatory drugs and tramadol. The relatively high prevalence of opioids warrants concern given the significant risk of adverse effects among older people with major neurocognitive disorder.

Prescription of Lipid-Lowering and Antihypertensive Drugs Following Pictorial Information About Subclinical Atherosclerosis: A Secondary Outcome of a Randomized Clinical Trial.

Importance: Preventive drugs are often underused. Carotid intima-media thickness and carotid plaques are associated with cardiovascular disease (CVD), and their detection could possibly improve estimation of the likelihood of CVD and prescription of preventive drugs. Objective: To evaluate whether pictorial information on participants' asymptomatic atherosclerosis based on carotid ultrasonographic examinations to participants and their physicians had an effect on prescribing of lipid-lowering or antihypertensive drugs during the following 465 days. Design, Setting, and Participants: Visualization of Asymptomatic Atherosclerotic Disease for Optimum Cardiovascular Prevention is a pragmatic randomized clinical trial nested within the Västerbotten Intervention Program, a CVD screening and prevention program in Sweden with 60% to 70% participation rates and small social selection bias. A total of 4177 individuals aged 40, 50, or 60 years participating in the Västerbotten Intervention Program who had low to moderate risk of CVD were invited to enroll in this trial from April 29, 2013, to June 7, 2016. Prescriptions for all participants were monitored for 465 days after the intervention. Data analysis was conducted from December 6, 2019, to April 2, 2020. Interventions: Participants and their family physicians were randomly assigned 1:1 to receive or not receive pictorial information from carotid ultrasonographic determination of vascular age, assessed as carotid intima-media thickness and the presence of carotid plaques, combined with a follow-up call to participants by nurses. Main Outcomes and Measures: Two outcome measures of prescriptions of antihypertensive and lipid-lowering drugs within 465 days after ultrasonography was performed. Data obtained through intention-to-treat analysis are presented as proportions of individuals with a prescription among those who had no baseline prescription for agents from these drug classes. Results: Of the 4177 individuals invited to enroll, 3532 participants were randomized and included in the analysis; 1870 (52.9%) were women, 2278 (64.5%) were aged 60 years, 978 (27.7%) were 50 years, and 276 (7.8%) were 40 years. First prescriptions of lipid-lowering drugs were higher in the intervention group vs the control group among men (118 of 639 [18.5%] vs 38 of 692 [5.5%]; P < .001) and women (126 of 804 [15.5%] vs 38 of 817 [4.7%]; P < .001). There were no significant differences in the proportion with prescription of antihypertensive drugs in the intervention vs control groups after ultrasonography among men (58 of 482 [12.0%] vs 56 of 528 [10.6%]; P = .47) and women (60 of 612 [9.8%] vs 64 of 615 [10.4%]; P = .73). Conclusions and Relevance: The findings of this trial demonstrate that provision of pictorial information on vascular age and carotid plaques based on the results of ultrasonographic examination increased physician prescription of lipid-lowering drugs but not antihypertensive drugs within the following 465 days. Trial Registration: ClinicalTrials.gov Identifier: NCT01849575.

Investigating the effect of clinical pharmacist intervention in transitions of care on drug-related hospital readmissions among the elderly: study protocol for a randomised controlled trial.

INTRODUCTION: Drug-related problems (DRPs) are a major cause of unplanned hospital admissions among elderly people, and transitions of care have been emphasised as a key area for improving patient safety. We have designed a complex clinical pharmacist intervention that targets people ≥75 years of age undergoing transitions of care from hospital to home and primary care. The main objective is to investigate if the intervention can reduce the risk of unplanned drug-related readmission within the first 180 days after the person is discharged from hospital. METHODS AND ANALYSIS: This is a randomised, controlled, superiority trial with two parallel arms. A total of 700 people ≥75 years will be assigned to either intervention or routine care (control). The intervention, which aims to find and manage DRPs, is initiated within a week of the person being discharged from hospital and combines repeated medical chart reviews, phone interviews and in some cases medication reviews. People in both study arms may have been the subject of a medication review during their ward stay. As the primary outcome, we will measure time until unplanned drug-related readmission within 180 days of leaving hospital and use log rank tests and Cox proportional hazard models to analyse differences between the groups. Further investigations of subgroup effects and adjustments of the regression models will be based on heart failure and cognitive impairment as prognostic factors. ETHICS AND DISSEMINATION: The study has been approved by the Regional Ethical Review Board in Umeå (registration numbers 2017-69-31M, 2018-83-32M and 2018-254-32M). We intend to publish the results with open access in international peer-reviewed journals and present our findings at international conferences. The trial is expected to result in more than one published article and form part of two PhD theses. TRIAL REGISTRATION NUMBER: NCT03671629.

Impact of clinical pharmacist engagement in ward teams on the number of drug-related readmissions among older patients with dementia or cognitive impairment: An economic evaluation.

BACKGROUND: Clinical pharmacists play an increasing role in the pharmacological treatment of hospital-admitted older patients with dementia or cognitive impairment. In an earlier randomised controlled trial, clinical pharmacist involvement in the ward team could significantly reduce drug-related readmissions in patient subgroups. However, the economic impact of the intervention has not been addressed so far. OBJECTIVES: To evaluate the economic impact of clinical pharmacist engagement in hospital ward teams for medication therapy management in older patients with dementia or cognitive impairments. METHODS: Economic evaluation of a randomised controlled trial conducted in two hospitals in Northern Sweden between January 2012 and December 2014. Participants included 460 hospital-admitted older patients with dementia or cognitive impairments. Patients were randomly assigned to usual care, or usual care with pharmacist intervention; the intervention consisted of medication reconciliation, medication review, and participation in ward rounds. The outcomes were measured as drug-related readmissions to hospital as assessed by a group of external experts, 180 and 30 days after discharge. Costs included pharmacists' direct labour costs for the interventions, average costs for drug-related readmissions, and from this the total cost per person was calculated. RESULTS: The effect of the intervention on drug-related readmissions within 180 days was significant in patients without heart failure (subgroup analysis), and the intervention resulted in cost savings of €950 per person in this subgroup. Drug-related readmissions within 30 days were reduced in the total sample (post-hoc analysis), and the cost-savings in this intervention group were €460 per person. CONCLUSIONS: Post-hoc and subgroup analyses indicate that engagement of pharmacists in hospital ward teams reduced the number of drug-related readmissions, and that the cost per person was lower in the intervention group compared to the control group. Including clinical pharmacists created savings in the subgroups of older patients with dementia or cognitive impairments.

Clinically relevant drug-drug interactions among elderly people with dementia.

PURPOSE: Increased numbers of drugs and changes in pharmacokinetic and pharmacodynamic parameters among elderly people contribute to increased prevalence of adverse drug reactions. Drug-drug interactions (DDIs) are an important reason for admission to hospital and elderly people with dementia are particularly vulnerable. The aims of the present study were to assess the occurrence and characteristics of clinically relevant DDIs and to investigate potential risk factors associated with DDIs among elderly people with dementia. METHODS: People ≥ 65 years with dementia, admitted to two hospitals in Northern Sweden, were included. The medical records of 458 patients were reviewed. Clinically relevant DDIs were identified using the Janusmed interactions database. Pharmacological classification was conducted using Stockley's classification system. RESULTS: A total of 401 DDIs were identified among 43.2% of the study population, of which 98.5% had interactions that may require dose adjustment and 7.6% had drug combinations that should be avoided. Pharmacodynamic interactions were most common, of which furosemide-citalopram (n = 35) were most frequently observed. Omeprazol-citalopram (n = 25) was the most common drug combination among pharmacokinetic interactions. Citalopram and warfarin were the most commonly involved drug substances. An association was found between a higher number of medications being prescribed and having at least one DDI. CONCLUSION: Clinically relevant drug-drug interactions are prevalent among elderly people with dementia living in Northern Sweden. Drug-drug interactions should be identified in order to manage and prevent adverse outcomes. This is particularly important among this group of people especially when multiple medications are being prescribed.

Effects of Pharmacists' Interventions on Inappropriate Drug Use and Drug-Related Readmissions in People with Dementia-A Secondary Analysis of a Randomized Controlled Trial.

Age-associated physiological changes and extensive drug treatment including use of potentially inappropriate medications (PIMs) pose a significant risk of drug-drug interactions and adverse drug events among elderly people with dementia. This study aimed at analysing the effects of clinical pharmacists' interventions on use of PIMs, risk of emergency department visits, and time to institutionalization. Furthermore, a descriptive analysis was conducted of circumstances associated with drug-related readmissions. This is a secondary analysis of data from a randomized controlled intervention study conducted in two hospitals in Northern Sweden. The study included patients (n = 460) 65 years or older with dementia or cognitive impairment. The intervention consisted of comprehensive medication reviews conducted by clinical pharmacists as part of a healthcare team. There was a larger decrease in PIMs in the intervention group compared with the control group (p = 0.011). No significant difference was found in time to first all-cause emergency department visits (HR = 0.994, 95% CI = 0.755-1.307 p = 0.963, simple Cox regression) or time to institutionalization (HR = 0.761, 95% CI = 0.409-1.416 p = 0.389, simple Cox regression) within 180 days. Common reasons for drug-related readmissions were negative effects of sedatives, opioids, antidepressants, and anticholinergic agents, resulting in confusion, falling, and sedation. Drug-related readmissions were associated with living at home, heart failure, and diabetes. Pharmacist-provided interventions were able to reduce PIMs among elderly people with dementia and cognitive impairment.

Doctors' and nurses' perceptions of a ward-based pharmacist in rural northern Sweden.

Background This project is part of the prospective quasi experimental proof-of-concept investigation of clinical pharmacist intervention study to reduce drug-related problems among people admitted to a ward in a rural hospital in northern Sweden. Objective To explore doctors' and nurses' perceptions and expectations of having a ward-based pharmacist providing clinical pharmacy services. Setting Medical ward in a rural hospital in northern Sweden. Method Eighteen face-to-face semi-structured interviews were conducted with a purposive sample of doctors and nurses working on the ward where the clinical pharmacy service was due to be implemented. Semi-structured interviews were digitally recorded, transcribed and analysed using thematic analysis. Main outcome measure Perceptions and expectations of nurses and doctors. Results Doctors and nurses had limited experience of working with pharmacists. Most had a vague idea of what pharmacists can contribute within a ward setting. Participants, mainly nurses, suggested inventory and drug distribution roles, but few were aware of the pharmacists' skills and clinical competence. Different views were expressed on whether the new clinical pharmacy service would have an impact on workload. However, most participants took a positive view of having a ward-based pharmacist. Conclusion This study provided an opportunity to explore doctors' and nurses' expectations of the role of clinical pharmacists before a clinical pharmacy service was implemented. To successfully implement a clinical pharmacy service, roles, clinical competence and responsibilities should be clearly described. Furthermore, it is important to focus on collaborative working relationships between doctors, nurses and pharmacists.

Pharmacist participation in hospital ward teams and hospital readmission rates among people with dementia: a randomized controlled trial.

PURPOSE: To assess whether comprehensive medication reviews conducted by clinical pharmacists as part of a healthcare team reduce drug-related hospital readmission rates among people with dementia or cognitive impairment. METHODS: This randomized controlled trial was carried out between January 9, 2012, and December 2, 2014. Patients aged ≥65 years with dementia or cognitive impairment admitted to three wards at two hospitals located in Northern Sweden were included. RESULTS: Of the 473 deemed eligible for participation, 230 were randomized to intervention and 230 to control group by block randomization. The primary outcome, risk of drug-related hospital readmissions, was assessed at 180 days of follow-up by intention-to-treat analysis. During the 180 days of follow-up, 18.9% (40/212) of patients in the intervention group and 23.0% (50/217) of those in the control group were readmitted for drug-related reasons (HR = 0.80, 95% CI = 0.53-1.21, p = 0.28, univariable Cox regression). Heart failure was significantly more common in the intervention group. After adjustment for heart failure as a potential confounder and an interaction term, multiple Cox regression analysis indicated that pharmacist participation significantly reduced the risk of drug-related readmissions (HR = 0.49, 95% CI = 0.27-0.90, p = 0.02). A post-hoc analysis showed a significantly reduced risk of 30-day readmissions due to drug-related problems in the total sample (without adjustment for heart failure). CONCLUSION: Participation of clinical pharmacists in healthcare team conducting comprehensive medication reviews did not significantly reduce the risk of drug-related readmissions in patients with dementia or cognitive impairment; however, post-hoc and subgroup analyses indicated significant effects favoring the intervention. More research is needed. TRIAL REGISTRATION: Clinical trials NCT01504672.

An evaluation of the prevalence of potentially inappropriate medications in older people with cognitive impairment living in Northern Sweden using the EU(7)-PIM list.

PURPOSE: As people get older, their sensitivity to drugs and adverse drug reactions can increase due to pharmacokinetic and pharmacodynamic changes. Older people with dementia are a particularly vulnerable group of people. They are at an increased risk of being prescribed potentially inappropriate medications, which may lead to harmful consequences. The aim of this study was to investigate the prevalence of potentially inappropriate medications among older patients with cognitive impairment. METHODS: Medical records for patients aged ≥65 years admitted to two hospitals in Northern Sweden were reviewed. Potentially inappropriate medications were identified using the EU(7)-PIM list as an identification tool. RESULTS: Of 428 patients included in the study, 40.9% had one or more potentially inappropriate medication prescribed. The most commonly represented potentially inappropriate medication classes were hypnotics and sedatives, cardiovascular drugs and laxatives. The most commonly involved potentially inappropriate medications were zopiclone, digoxin and sodium picosulfate. There was an association seen between having a higher number of medications prescribed and having one or more potentially inappropriate medication. CONCLUSION: Potentially inappropriate medications are prevalent among older people with cognitive impairment living in Northern Sweden. It is important to continuously evaluate the need for potentially inappropriate medications in this patient group, in order to prevent adverse drug reactions, especially among those who have a higher number of medications prescribed.

Inappropriate Prescription and Renal Function Among Older Patients with Cognitive Impairment.

BACKGROUND: Older people are more sensitive to drugs and adverse drug reactions than younger people because of age-related physiological changes such as impaired renal function. As people with dementia are particularly vulnerable to the effects of drugs, it is especially important to evaluate the dosages of renally cleared medications in this group. OBJECTIVE: The aim of this study was to estimate the prevalence of impaired renal function and inappropriate prescriptions on the basis of renal function among older patients with dementia or cognitive impairment. METHODS: The medical records of 428 patients aged ≥65 years who were admitted to two hospitals in northern Sweden were reviewed and renally cleared medications were identified. The Cockcroft-Gault equation was used to evaluate renal function. Doses were evaluated according to the Geriatric Dosage Handbook. RESULTS: Renal function was impaired (estimated glomerular filtration rate <60 ml/min) in 65.4 % of the study population. Impaired renal function was associated with increasing age. Among 547 prescriptions identified as renally cleared medications, 9.1 % were inappropriate based on the patient's renal function; 13.5 % of the 326 patients prescribed renally cleared medications had inappropriate prescriptions. Inappropriate prescriptions were more common among patients living in nursing homes. CONCLUSIONS: Impaired renal function is common and inappropriate prescription is prevalent among old people with cognitive impairment in northern Sweden. Continuous consideration of renal function is important when prescribing medications to this group.

Drug-related hospital admissions among old people with dementia.

PURPOSE: Drug treatment associated problems are common and are the cause of a large proportion of hospitalizations in old people. People with dementia are especially at risk of drug-related problems. The objectives of this study were to assess the occurrence and character of drug-related problems that lead to acute hospital admissions among old people (≥65 years) with dementia or cognitive impairment. METHODS: This study was conducted in orthopedic and internal medicine wards in two hospitals in Northern Sweden. Information about acute admissions was collected from the medical records. A total of 458 people aged 65 years or older with dementia or cognitive impairment were included in the study. The contribution of drug-related problems to each hospitalization was assessed. RESULTS: Of 458 acute hospital admissions, 189 (41.3 %) were determined to be drug-related. The most common drug-related problem (86/189; 45.5 %) was an adverse drug reaction. In total, 264 drugs were judged to be involved in 189 drug-related admissions, of which cardiovascular (29.5 %) and psychotropic (26.9 %) drugs were the most commonly involved drug classes. The relationship between the drug-related problem and the admission was judged certain in 25 cases, probable in 78 cases, and possible in 86 cases. Drug-related admissions were more common among people taking more drugs (p = 0.035) and among younger patients (p = 0.031). CONCLUSION: Drug-related problems appear to be responsible for a major proportion of hospitalizations among old people with dementia or cognitive impairment. Targeted interventions such as education and medication reviews may be warranted to reduce drug-related problems.

Inequalities in medication adherence to statin treatment after stroke: A nationwide observational study.

INTRODUCTION: The objective was to investigate differences in adherence to statins after stroke based on age, sex, socioeconomic status and country of birth. PATIENTS AND METHODS: Patients with ischemic stroke in 2009-2010 were included from the Swedish stroke register. Adherence to statin treatment was measured over two years as proportion of days covered with 80% as cut-off for adherence. Income, education, and country of birth were obtained from official registers. Factors associated with adherence were controlled for in multivariable logistic regression. RESULTS: Of 15,192 included patients, 73.9% had an adherence rate ≥80%. The oldest (85+ years) and youngest (18-54 years) had the lowest adherence, and a smaller proportion of women were adherent (odds ratio (OR) 0.84; 95% confidence interval (CI) 0.77-0.92). Adherence was less common in patients born in Nordic countries (OR 0.82; 95% CI (0.68-0.97), Europe (OR 0.78; 95% CI 0.65-0.93), and in non-European countries (OR 0.65; 95% CI 0.50-0.84) compared to Sweden-born. Patients with university education were to a lower extent adherent compared to patients with primary school education (OR 0.81; 95% CI 0.72-0.91). There was no association between adherence and income. DISCUSSION: The study was based on individual level real-life data with national coverage. Adherence was estimated from data on filled prescriptions, but filled prescription does not mean that drugs are used as intended. CONCLUSION: Adherence to statin treatment over two years was suboptimal, and adherence was less common among women, patients born outside of Sweden and patients with university education.

Socioeconomic Inequalities in the Prescription of Oral Anticoagulants in Stroke Patients With Atrial Fibrillation.

BACKGROUND AND PURPOSE: Oral anticoagulants (OACs) are effective against ischemic stroke in patients with atrial fibrillation. Our aim was to investigate differences in the prescribing of OACs after ischemic stroke in patients with atrial fibrillation based on age, sex, country of birth, and socioeconomic status. METHODS: Patients with first-ever ischemic stroke and atrial fibrillation without OAC treatment were included from the Swedish stroke register from 2009 to 2012. The outcome was OAC prescribed at discharge. Income, education, country of birth, and risk factors were obtained from official registers. Risk factors and health status were controlled for in multivariable logistic regression. RESULTS: Of 12 088 stroke patients, 36.3% were prescribed an OAC. Prescribing was less common with older age and, in patients born in other Nordic countries (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.68-0.98) or countries outside of Europe (OR, 0.65; 95% CI, 0.42-0.99) compared with those born in Sweden. University education (OR, 1.20; 95% CI, 1.05-1.36) and highest income (OR, 1.19; 95% CI, 1.06-1.33) were associated with higher levels of OAC prescribing compared with those with primary school education or lowest income level. CONCLUSION: Differences by age, income, education, and country of birth were found in the prescribing of OACs after stroke. Differences were not explained by common risk factors. This indicates socioeconomic inequalities in the prescribing of preventive treatment after stroke.