BackgroundThe potential harms of some medications may outweigh their potential benefits (inappropriate medication use). Despite recommendations to avoid the use of potentially inappropriate medications (PIMs) in older adults, the prevalence of PIM use is high in different settings including residential aged care. However, it remains unclear what the costs of these medications are in this setting. The main objective of this study was to determine the costs of PIMs in older adults living in residential care. A secondary objective was to examine if there was a difference in costs of PIMs in a home-like model of residential care compared to an Australian standard model of care.MethodsParticipants included 541 participants from the Investigation Services Provided in the Residential Environment for Dementia (INSPIRED) Study. The INSPIRED study is a cross-sectional study of 17 residential aged care facilities in Australia. 12 month medication costs were determined for the participants and PIMs were identified using the 2015 updated Beers Criteria for older adults.ResultsOf all of the medications dispensed in 1 year, 15.9% were PIMs and 81.4% of the participants had been exposed to a PIM. Log-linear models showed exposure to a PIM was associated with higher total medication costs (Adjusted β = 0.307, 95% CI 0.235 to 0.379, p < 0.001). The mean proportion (±SD) of medication costs that were spent on PIMs in 1 year was 17.5% (±17.8) (AUD$410.89 ± 479.45 per participant exposed to a PIM). The largest PIM costs arose from proton-pump inhibitors (34.4%), antipsychotics (21.0%) and benzodiazepines (18.7%). The odds of incurring costs from PIMs were 52% lower for those residing in a home-like model of care compared to a standard model of care.ConclusionsThe use of PIMs for older adults in residential care facilities is high and these medications represent a substantial cost which has the potential to be lowered. Further research should investigate whether medication reviews in this population could lead to potential cost savings and improvement in clinical outcomes. Adopting a home-like model of residential care may be associated with reduced prevalence and costs of PIMs.Electronic supplementary materialThe online version of this article (10.1186/s12877-018-0704-8) contains supplementary material, which is available to authorized users.

Background: Inappropriate polypharmacy may negatively impact quality of life of residents in aged care facilities, but it remains unclear which medications may influence this reduced quality of life.Objective: The objective was to examine whether the Drug Burden Index (DBI) and potentially inappropriate medications (PIMs), were associated with quality of life in older adults living in residential care with a high prevalence of cognitive impairment and dementia.Methods: Cross-sectional analyses of 541individuals recruited from 17 residential aged care facilities in Australia in the Investigating Services Provided in the Residential Environment for Dementia (INSPIRED) study. Quality of life was measured using the EQ-5D-5L (a measure of generic quality of life) and the DEMQOL (a measure developed for use in dementia) completed by the participant or a proxy.Results: In the 100 days prior to recruitment, 83.1% of the participants received at least one anticholinergic or sedative medication included in the DBI and 82.7% received at least one PIM according to the Beers Criteria. Multi-level linear models showed there was a significant association between higher DBI and lower quality of life according to the EQ-5D-5L (β (SE): -0.034 (0.012), p=0.006) after adjustment for potential confounding factors. Increasing numbers of PIMs were also associated with lower EQ-5D-5L scores (-0.030 (0.010), p=0.003) and DEMQOL-Self-Report-Utility scores (-0.020 (0.009), p=0.029). Exposure to both DBI-associated medications and PIMs was associated with lower DEMQOL-SelfReport-Utility scores (-0.034 (0.017), p=0.049).Conclusion: Exposure to anticholinergic and sedative medications and PIMs occurred in over three-quarters of a population of older adults in residential care and was associated with a lower quality of life.  This study provides evidence to support that there is a need for greater adherence to recommendations for appropriate medication use in residential aged care.

As with prescribing or continuing medications, deprescribing brings with it the potential for harm as well as benefit. Uncertainty and avoidance of harm has been reported as a barrier to deprescribing in practice and may contribute to continuation of inappropriate medications. Areas covered: This narrative review covers four main safety concerns/potential harms of deprescribing in older adults: adverse drug withdrawal events, return of medical condition(s), reversal of drug-drug interactions and damage to the doctor-patient relationship. These are discussed in relation to medications in general, with some examples of medication classes used to illustrate the potential safety concerns. The majority of these harms can be minimized or even prevented by using a patient-centered, structured deprescribing process with planning, tapering and close monitoring during, and after medication withdrawal. Expert opinion: More research is needed into the safety concerns of deprescribing, however, avenues exist during drug development and post-marketing surveillance to gain knowledge on this topic. Questions remain about when it is suitable to discontinue certain medications/medication classes and there is uncertainty about the harms and benefits of both medication continuation and discontinuation in complex older adults.

Polypharmacy is a major challenge in healthcare for older people, and is associated with increased risks of adverse outcomes, such as delirium, falls, frailty, cognitive impairment and hospitalization. There is significant public and professional interest in the role of deprescribing in reducing medication-related harms in older people. We aim to provide a narrative review of 1) the safety and efficacy of deprescribing interventions, 2) the challenges and solutions of deprescribing research and implementation in clinical practice, and 3) the benefits of using Computerized Clinical Decision Support Systems (CCDSS) and Quality Indicators (QIs) in deprescribing research and practice. Deprescribing is an established management strategy to minimize polypharmacy and potentially inappropriate medications. There is limited clinical evidence for its efficacy on global and geriatric outcomes. Various challenges at patient, healthcare professional and healthcare system levels may impact on the success of deprescribing interventions in research and practice. Management strategies that target all levels of the healthcare system are required to overcome these challenges. Future studies may consider large multicenter prospective designs to establish the effects and sustainability of deprescribing interventions on clinical outcomes.

The rPATDcog was feasible to administer in this study. Further work is required to provide generalisable results and determine utility in practice.

Background Current information on the patterns of medication use in nursing home residents living with dementia is conflicting. Aim The aim of this study was to investigate medication use and its associations with dementia diagnosis in Australian nursing home residents. Methods A cross‐sectional study of 541 residents from 17 Australian nursing homes was performed. Results Over 12 months, nursing home residents were prescribed a mean (±SD) of 14.5 ± 6.8 medications each. Approximately 95% of residents were prescribed medications for the nervous system, and 94% were prescribed medications for the alimentary tract and metabolism. After adjustment for potential confounders, those with dementia were less likely to be prescribed medications for the cardiovascular system (odds ratio (OR) 0.45, 95% confidence interval (CI) 0.27–0.77, p = 0.0032) and respiratory system (OR 0.38, 95% CI: 0.25–0.60, p < 0.0001). Further analysis of specific medications showed that residents with dementia were more likely to be prescribed risperidone (OR: 9.38, 95% CI: 4.01–21.94, p < 0.0001), buprenorphine (OR 3.37, 95% CI: 1.78–6.36, p = 0.0002) and trimethoprim (OR 1.78, 95% CI: 1.06–2.97, p = 0.0282), but less likely to be prescribed glyceryl trinitrate (OR 0.42, 95% CI: 0.19–0.94, p = 0.0340) and salbutamol (OR 0.34, 95% CI: 0.2–0.6, p = 0.0002) in addition to other specific medications. Conclusions Increased awareness of possible undertreatment of cardiovascular and respiratory conditions, and possible overtreatment of urinary tract infection, in those living with dementia in nursing home settings may improve management of this vulnerable population.

Background: Our aim in this research was to establish whether integrating an electronically generated calculation and report on the Drug Burden Index (DBI) in the Home Medicines Review (HMR) setting is an accurate, feasible and useful risk assessment tool to assess risk of anticholinergic and sedative medications; and to establish whether the intervention of DBI together with HMR is associated with a reduced use of anticholinergic and sedative medications in older community-dwelling adults in Australia. Methods: An interventional feasibility study was conducted. Accredited clinical pharmacists (APs) were recruited to participate. Each AP was educated on implementation of the DBI into HMR practice and given access to the DBI Calculator© web-based software to generate the DBI report for inclusion in HMR reports for general practitioners (GPs). APs recruited patients (⩾65 years) who were referred to them for HMRs. Patients were sent a letter about their DBI exposure, and a prompt to visit their GP to discuss their medication management options. GPs, APs and patients were asked to evaluate the feasibility and utility of the DBI report. A medication inventory was collected from patients at the time of the HMR and at 3 months to determine whether the intervention affected deprescribing of medications with anticholinergic and sedative effects. Results: Regarding the feasibility of the DBI report as a risk assessment tool within HMR, 89% of APs and 67% of GPs agreed that it would be feasible. The DBI Calculator© was potentially inaccurate, as 26% of DBI scores were underestimated and 7% were overestimated (at baseline). At 3 months, the median (interquartile range) DBI for patients ( n = 100) significantly decreased from 0.82 (0–1.33) to 0.67 (0–1.29) ( p = 0.014). Additionally, of patients with a DBI > 0 ( n = 66), 36.4% had their DBI score decrease, and 6.1% had a score increase. Conclusion: This study demonstrated that integration of the DBI Calculator© into HMR is a feasible and useful method to prompt deprescribing of anticholinergic and sedative medications in older adults. There is potential for the accuracy of the web-based platform to be improved. Registration of trial: Name: Feasibility study of the Drug Burden Index with Home Medicines Review. Website: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368523 Trial ID: ACTRN 12615000539538.

Anticholinergic medications are frequently used in older adults to manage a wide range of chronic diseases. Anticholinergic burden associated with the use of multiple medications with anticholinergic effects is cumulative within an individual, and older adults are particularly susceptible to the adverse effects of these medications. These include dry mouth resulting in poor oral health, constipation, urinary retention and confusion. Use of anticholinergic medications has been associated with impaired cognitive and physical function, increased risk of falls, vascular events and hospitalisation. Consideration of anticholinergic burden is an important component of medication management for older adults. Several measures have been developed and validated to quantify anticholinergic burden, such as the Anticholinergic Drug Scale, Anticholinergic Risk Scale and the Anticholinergic Cognitive Burden scale. However, the evidence for translation of these measures into clinical practice is limited. This narrative review provides a brief clinical overview of the pharmacology of anticholinergic medications in the context of older adults, summarises approaches to measure anticholinergic burden, reviews recent evidence of the clinical impact of anticholinergic medications and discusses deprescribing strategies to manage anticholinergic burden for older adults in clinical practice.