Adverse Outcomes in Relation to Polypharmacy in Robust and Frail Older Hospital Patients.

OBJECTIVE: To explore the relationship between polypharmacy and adverse outcomes among older hospital inpatients stratified according to their frailty status. DESIGN AND SETTING: A prospective study of 1418 patients, aged 70 and older, admitted to 11 hospitals across Australia. MEASUREMENTS: The interRAI Acute Care (AC) assessment tool was used for all data collection, including the derivation of a frailty index calculated using the deficit accumulation method. Polypharmacy was categorized into 3 groups based on the number of regular drugs prescribed. Recorded adverse health outcomes were falls, delirium, functional and cognitive decline, discharge to a higher level of care and in-hospital mortality. RESULTS: Patients had a mean (SD) age of 81 (6.8) years and 55% were women. Polypharmacy (5-9 drugs per day) was observed in 48.2% (n = 684) and hyper-polypharmacy (≥10 drugs) in 35.0% (n = 497). Severe cognitive impairment was significantly associated with nonpolypharmacy compared with polypharmacy and hyper-polypharmacy groups combined (P = .004). In total, 591 (42.5%) patients experienced at least 1 adverse outcome. The only adverse outcome associated with polypharmacy was delirium. Within each polypharmacy category, frailty was associated with adverse outcomes and the lowest overall incidence was among robust patients prescribed 10 or more drugs. CONCLUSION: While polypharmacy may be a useful signal for medication review, in this study it was not an independent predictor of adverse outcomes for older inpatients. Assessing the frailty status of patients better appraised risk. Extensive de-prescribing in all older inpatients may not be an intervention that directly improves outcomes.

Algorithm of medication review in frail older people: Focus on minimizing the use of high-risk medications.

AIM: Frail older people typically suffer several chronic diseases, receive multiple medications and are more likely to be institutionalized in residential aged care facilities. In such patients, optimizing prescribing and avoiding use of high-risk medications might prevent adverse events. The present study aimed to develop a pragmatic, easily applied algorithm for medication review to help clinicians identify and discontinue potentially inappropriate high-risk medications. METHODS: The literature was searched for robust evidence of the association of adverse effects related to potentially inappropriate medications in older patients to identify high-risk medications. Prior research into the cessation of potentially inappropriate medications in older patients in different settings was synthesized into a four-step algorithm for incorporation into clinical assessment protocols for patients, particularly those in residential aged care facilities. RESULTS: The algorithm comprises several steps leading to individualized prescribing recommendations: (i) identify a high-risk medication; (ii) ascertain the current indications for the medication and assess their validity; (iii) assess if the drug is providing ongoing symptomatic benefit; and (iv) consider withdrawing, altering or continuing medications. Decision support resources were developed to complement the algorithm in ensuring a systematic and patient-centered approach to medication discontinuation. These include a comprehensive list of high-risk medications and the reasons for inappropriateness, lists of alternative treatments, and suggested medication withdrawal protocols. CONCLUSIONS: The algorithm captures a range of different clinical scenarios in relation to potentially inappropriate medications, and offers an evidence-based approach to identifying and, if appropriate, discontinuing such medications. Studies are required to evaluate algorithm effects on prescribing decisions and patient outcomes. Geriatr Gerontol Int 2016; 16: 1002-1013.

Geriatrician interventions on medication prescribing for frail older people in residential aged care facilities.

OBJECTIVE: In Australian residential aged care facilities (RACFs), the use of certain classes of high-risk medication such as antipsychotics, potent analgesics, and sedatives is high. Here, we examined the prescribed medications and subsequent changes recommended by geriatricians during comprehensive geriatric consultations provided to residents of RACFs via videoconference. DESIGN: This is a prospective observational study. SETTING: Four RACFs in Queensland, Australia, are included. PARTICIPANTS: A total of 153 residents referred by general practitioners for comprehensive assessment by geriatricians delivered by video-consultation. RESULTS: Residents' mean (standard deviation, SD) age was 83.0 (8.1) years and 64.1% were female. They had multiple comorbidities (mean 6), high levels of dependency, and were prescribed a mean (SD) of 9.6 (4.2) regular medications. Ninety-one percent of patients were taking five or more medications daily. Of total medications prescribed (n=1,469), geriatricians recommended withdrawal of 9.8% (n=145) and dose alteration of 3.5% (n=51). New medications were initiated in 47.7% (n=73) patients. Of the 10.3% (n=151) medications considered as high risk, 17.2% were stopped and dose altered in 2.6%. CONCLUSION: There was a moderate prevalence of potentially inappropriate high-risk medications. However, geriatricians made relatively few changes, suggesting either that, on balance, prescription of these medications was appropriate or, because of other factors, there was a reluctance to adjust medications. A structured medication review using an algorithm for withdrawing medications of high disutility might help optimize medications in frail patients. Further research, including a broader survey, is required to understand these dynamics.

Deciding when to stop: towards evidence-based deprescribing of drugs in older populations.

Minimising the harm from inappropriate prescribing in older populations is a major urgent concern for modern healthcare systems. In everyday encounters between prescribers and patients, opportunities should be taken to identify patients at high risk of harm from polypharmacy and reappraise their need for specific drugs. Attempts to reconcile life expectancy, comorbidity burden, care goals and patient preferences with the benefits and harms of medications should be made in every patient at significant risk. Drugs identified by this process of reconciliation as conferring little or no benefit and/or excessive risk of harm should be candidates for discontinuation. Evidence supporting a structured approach to drug discontinuation (or deprescribing) is emerging, and while many barriers to deprescribing exist in routine practice, various enabling strategies can help overcome them.

Effects of a drug minimization guide on prescribing intentions in elderly persons with polypharmacy.

BACKGROUND: While frameworks exist to assist clinicians in prescribing appropriately in older patients at risk of adverse drug reactions, their impact on prescribing is uncertain. OBJECTIVE: The aim of the study was to determine the effects of a ten-step drug minimization guide on clinician prescribing intentions involving a hypothetical older patient receiving multiple drugs. METHODS: A total of 61 hospital clinicians were presented with clinical information about a hypothetical case: an 81-year-old female with 12 chronic diseases, receiving 19 different medications. On a standardized, anonymous form, each participant indicated, as a pre-test, which drugs they felt strongly inclined to discontinue or continue, and which drugs they were uncertain about. The ten-step guide was then presented and applied to the case, and participants repeated the drug selection process. RESULTS: Sixty evaluable forms were analysed from 19 consultant physicians, 17 medical registrars, 7 interns/residents and 17 pharmacists. Among the entire cohort, the mean (±SD) number of drugs selected for discontinuation increased from 6.0 (±2.7) pre-test to 9.6 (±3.2) post-test (p < 0.001), with the greatest increases seen among consultant physicians (6.6 [±2.3] to 11.5 [±2.9], p < 0.001) and clinical pharmacists (5.3 [±2.6] to 8.9 [±2.2], p < 0.001). The number of drugs associated with uncertainty decreased from 3.7 (±2.9) pre-test to 1.8 (±2.3) post-test (p < 0.001) for the whole cohort, with the greatest decreases seen among consultant physicians (4.8 [±2.6] to 1.8 [±2.5], p < 0.001) and clinical pharmacists (4.5 [±3.3] to 1.9 [±2.0], p = 0.003). CONCLUSION: This self-report study involving a hypothetical case provides evidence that a drug minimization guide may reduce inappropriate prescribing and uncertainty around drug indications.

Minimizing inappropriate medications in older populations: a 10-step conceptual framework.

The increasing burden of harm resulting from the use of multiple drugs in older patient populations represents a major health problem in developed countries. Approximately 1 in 4 older patients admitted to hospitals are prescribed at least 1 inappropriate medication, and up to 20% of all inpatient deaths are attributable to potentially preventable adverse drug reactions. To minimize this drug-related iatrogenesis, we propose a quality use of medicine framework that comprises 10 sequential steps: 1) ascertain all current medications; 2) identify patients at high risk of or experiencing adverse drug reactions; 3) estimate life expectancy in high-risk patients; 4) define overall care goals in the context of life expectancy; 5) define and confirm current indications for ongoing treatment; 6) determine the time until benefit for disease-modifying medications; 7) estimate the magnitude of benefit versus harm in relation to each medication; 8) review the relative utility of different drugs; 9) identify drugs that may be discontinued; and 10) implement and monitor a drug minimization plan with ongoing reappraisal of drug utility and patient adherence by a single nominated clinician. The framework aims to reduce drug use in older patients to the minimum number of essential drugs, and its utility is demonstrated in reference to a hypothetic case study. Further studies are warranted in validating this framework as a means for assisting clinicians to make more appropriate prescribing decisions in at-risk older patients.

Standardising practices through form design and education improves insulin management.

Diabetes is common in hospitalised patients and insulin is frequently required for management. Insulin is a high-risk drug, accounting for about 15% of reported medication-related incidents. Despite its complexity, insulin management in hospitals is often undertaken by junior and non-specialist staff. Improving insulin management requires addressing safe prescribing and administration as well as quality use of insulin. Common errors in insulin use are well documented and can be addressed through form design and enhancing decision support. We undertook to improve insulin management using a locally proven improvement methodology. New forms were developed for intravenous and subcutaneous insulin and blood glucose management. Audited pilot studies in four hospitals confirmed improved insulin management without adversely impacting on overall diabetes management as assessed using Glucometrics. Subsequently, the forms have been introduced to 70% of Queensland public hospitals with roll-out to remaining hospitals continuing. Large-scale standardisation of insulin management is feasible.

Safe medication practice: attitudes of medical students about to begin their intern year.

OBJECTIVES: Interns are expected to prescribe effectively and safely. This study aimed to assess medical students' perceptions of their readiness to prescribe, associated risks and outcome if involved in an error, as well as their perceptions of available support. METHODS: We carried out a survey of 101 students prior to their intern year using a structured questionnaire. An indication of agreement with 21 closed statements was sought. Thematic clusters were identified by factor analysis. RESULTS: Most students (84) felt they would be able to prescribe for most simple complaints and complete discharge prescriptions (81). In high-risk situations, fewer students felt comfortable with prescribing: only 54 felt sufficiently confident to prescribe warfarin and 66 felt confident enough to order i.v. fluids. Many felt support such as guidelines was available (87) and that, if in doubt, they could clarify instructions and seek advice. Students were aware of errors occurring within the medication system; however, most (99) believed that the medicines they prescribed would be safely administered. There was a mixed perception of medication errors: 40 felt that their prescribing errors would not be dealt with constructively and 79 indicated that a culture existed at their hospitals where clinicians would be blamed if they made a prescribing error. CONCLUSIONS: At the end of medical school education and prior to assuming responsibility for prescribing, students felt unprepared and perceived that negative outcomes would result if they were involved in errors. These findings indicate that much more work is needed to prepare doctors to prescribe safely, improve the safety of prescribing systems and address the issue of blame.