Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review.

BACKGROUND: Hospital discharge has a significant impact on the continuity of care for people living with dementia. Clear guidance on medication management should be provided to caregivers of people living with dementia to ensure appropriate use of medications post-discharge. AIM: Identify and appraise the impact of interventions at hospital discharge to guide caregivers in the medication management for people living with dementia. METHOD: A systematic search of original studies was performed in Medline, Embase, PsycINFO, and CINAHL. Articles published in English that reported on interventions to guide caregivers in medication management for people living with dementia were included. Two authors independently reviewed titles and abstract. Full-text articles were assessed for eligibility and quality assessment was conducted by two authors. RESULTS: A total of five studies were included with a range of interventions that were typically delivered post-discharge by a multidisciplinary team and most targeted administration of medications by caregivers. Overall, three types of discharge interventions were identified including a pre-discharge caregiver educational intervention, a post-discharge multidisciplinary team intervention, and discharge summary documentation intervention at transitions of care. Of these, a pre-discharge caregiver education led to shorter hospital stay (25 days vs. 31 days, p = 0.005). A post-discharge intervention that included follow-up visits resulted in lower use of high-risk medications (19% vs. 40%), and reduction in 30-day re-hospitalization rates (11% vs. 20%). In contrast, in another post-discharge intervention study, no difference in one-month re-hospitalization rates (8.4% vs. 8.0%, p = 0.82) was demonstrated. In another study, a post-discharge hospital educational program provided to caregivers  led to significantly reduced caregiver burden (31.7 ± 17.6 (SD) pre-intervention to 27.7 ± 16.9 (SD) post-intervention (p = 0.037)). DISCUSSION: Current findings suggest there is a need for well-designed interventions to guide caregivers in all aspects of medication management for people living with dementia, and should include support for caregivers in care coordination.

Prevalence of adverse drug events and adverse drug reactions in hospital among older patients with dementia: A systematic review.

AIMS: This systematic review aimed to quantify the prevalence of adverse drug events (ADEs) and adverse drug reactions (ADRs) in older inpatients with dementia. METHODS: A systematic search of observational studies was performed in Embase, Medline, PsycINFO, International Pharmaceutical Abstracts, Scopus and Informit. Articles published in English that reported the prevalence of ADEs or ADRs in hospital patients aged 65 years or older with dementia were included. Two authors reviewed titles and abstracts and all eligible full-text articles. Relevant information relating to ADEs, ADRs and dementia was obtained from each article. RESULTS: In total, 5 articles were included. One study reported the prevalence of ADEs to be 81.5%, defined using the Naranjo algorithm. Four studies assessed the prevalence of ADRs, ranging from 12.7 to 24.0%, assessed using various methods. One study defined ADRs according to the World Health Organization-Uppsala Monitoring Centre criteria, 2 studies employed the World Health Organization definition and 1 study did not explicitly define ADRs. The most frequently reported drug classes implicated in ADEs and ADRs were psychotropic, antihypertensive and analgesic drugs. CONCLUSION: Our findings suggest a high prevalence of ADEs and ADRs in older inpatients with dementia. However, only 1 study documented ADEs and there was variability in approaches to ADR assessment. A greater understanding of ADEs and ADRs, as well as tailored assessment tools, will promote prevention of ADEs and ADRs in people with dementia.

The Effectiveness of Stewardship Interventions to Reduce the Prescribing of Extended-Release Opioids for Acute Pain: A Systematic Review.

OBJECTIVE: To evaluate the effectiveness of stewardship interventions in reducing the prescribing of extended-release opioids for acute pain. DESIGN: Systematic review of randomized controlled trials, pre-post intervention studies, cohort studies and case-control studies. METHODS: A search was conducted using Medline, Scopus, Cochrane Central Register of Controlled Trials, International Pharmaceutical Abstracts, and PsycINFO from inception to March 24, 2019. Search terms included opioids, interventions, extended-release, and acute pain. Included articles were original research articles outlining the impact of stewardship interventions on reducing the prescribing of extended-release opioids for acute pain. RESULTS: The search resulted in 1,264 articles after the removal of duplicates. Of these, 141 full texts were assessed, with three eligible for inclusion. One additional article was obtained via a manual search. Three studies explored forcing function interventions; two included prior authorization policies, which saw decreases in extended-release/long-acting scripts by 18-36%, while another evaluated order restrictions producing increased adherence to guidelines by 36%. One study explored the impact of education targeting prescribers and patients through a risk mitigation and evaluation strategy, which decreased extended-release/long-acting quarterly script volumes by 4.3%. All studies were performed at system levels. Forcing function interventions decreased extended-release/long-acting prescriptions and increased adherence to guidelines to a greater extent than less restrictive interventions such as education. CONCLUSIONS: Forcing function interventions implemented at system levels show promise in decreasing the prescribing of extended-release opioids for acute pain. The current lack of literature warrants future research to increase understanding of the effectiveness of such interventions.

The Prevalence of Adverse Drug Reactions and Adverse Drug Events from Heart Failure Medications in Frail Older Adults: A Systematic Review.

INTRODUCTION: Frailty is highly prevalent in heart failure populations and a major risk factor for adverse drug reactions (ADRs) and adverse drug events (ADEs). This review aimed to describe the prevalence, causality and severity of ADRs or ADEs from heart failure medications among frail compared with non-frail older adults. METHODS: A systematic search of CENTRAL, MEDLINE, Embase, Ageline, CINAHL, International Pharmaceutical Abstracts, PsychInfo, Scopus, registries and citations prior to 18 May 2021 was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist. Risk of bias and quality of evidence were assessed. Eligible studies included randomised controlled trials (RCTs) and observational studies of people diagnosed with heart failure, aged ≥ 65 years, with frailty defined by an objective measurement, and reported ADRs/ADEs from/with heart failure medications. RESULTS: Two reviewers screened 2419 articles; interrater reliability kappa = 0.88. Three observational studies (n = 2596), a secondary analysis of two RCTs (n = 2098) and two cohort studies (n = 498) were included in a narrative synthesis. Frail patients in randomised trials of sacubitril/valsartan, aliskiren, or enalapril had twice the risk of mortality (hazard ratio [HR] 2.09, 1.62-2.71) and hospitalisations (HR 1.82, 1.37-2.41) compared with robust patients, which may reflect responsiveness to medications and/or factors unrelated to medication use. Hospitalisations from falls, tiredness and nausea were probably attributable to digoxin and possibly preventable according to the Naranjo and Hallas scales, respectively. CONCLUSION: The potential harms from heart failure medications in frail older people are poorly studied and understood. Clinical trials and pharmacovigilance studies should include frailty as a covariate to inform medication optimisation for this vulnerable and growing population. REGISTRATION: Prospero registration number: CRD 42021253762.