Medication management for older persons can be complex. With over 50% of all hospital admissions being for people aged over 65 years, understanding age-related functional, cognitive and social factor changes and their impact on medication use is critical for pharmacists working in most adult medicine areas. This paper provides an overview of critical elements of medication management for older persons for pharmacists. Key elements include age-related changes impacting medication effectiveness and safety, frailty, geriatric syndromes, polypharmacy and deprescribing, minimising medication-related harm at transitions of care, dose administration aids and other strategies to support individuals in medication management and multidisciplinary comprehensive geriatric assessment.
ObjectivePricing for safety and quality was introduced into Australian hospitals using a defined list of hospital-acquired complications (HACs). Medication-related HACs include drug-related respiratory complications (DRRC), haemorrhagic disorder due to circulating anticoagulants (HDDCA) and hypoglycaemia. The aim of this study was to determine the probability, severity and preventability of medication-related HACs, common contributory medications and themes, and whether medication-related HACs are a suitable data source to inform risk associated with medicines use. MethodsMedical notes were reviewed retrospectively for all patients discharged from a tertiary referral metropolitan hospital between 1 July and 31 December 2018 who were flagged as experiencing a medication-related HAC. Naranjo, Hartwig’s and Schumock and Thornton tools were used to assess the probability, severity and preventability of medication-related HACs. ResultsOver the 6-month period, 88 patients experienced a medication-related HAC. An HAC was not identified in five (5.7%) patient charts. The most common HAC was hypoglycaemia (n=59; 67%), followed by HDDCA (n=23; 26%) and DRRC (n=6; 7%). Fifteen patients (17%) flagged with a hypoglycaemia HAC were not on a medicine associated with hypoglycaemia. Overall, 6% (n=4) of HACs were severe, 72% (n=49) were moderate and 22% (n=15) were mild. Where the HAC and causal medication(s) were identified (n=68), over half were probable (51.5%, n=35) and 44.1% (n=30) were possible causes of the adverse drug reaction; only two (2.9%) were definite causes. None of the DRRC HACs was preventable. Over half the HDDCA HACs (52.2%; n=12) and almost half the hypoglycaemia HACs (46.2%; n=18) were not preventable. Common themes included appropriate anticoagulant agent, dose and monitoring, as well as periprocedural hypoglycaemic management, which considers oral intake and comorbidities. ConclusionNot all patients who experience medication-related HACs were on causative medications. Of those who were, medications were probable causal agents in over 50% of cases. Only a small number of HACs were severe and under half of medication-related HACs were preventable. What is known about the topic?The relationship between pricing for safety and quality and improvements in patient outcomes has shown mixed results. Medication-related harm is a problem within Australia and system-wide changes should be considered to improve patient care. What does this paper add?This paper adds evidence to the use of medication-related HACs as a source of data to inform risk associated with medicines use and provides details on the preventability and severity of medication-related HACs and the likelihood that medicines contribute to these complications. What are the implications for practitioners?This paper provides clinicians and policy makers details on the utility of using medication-related HACs as a measure of risk associated with medicines use. It discusses merit in using HACs as a source for quality improvement, but recommends that definitions may need to be reviewed to enhance utility.
Background Hospital-based Residential Aged-care Support Service (RaSS) teams typically consist of doctors and nurses who provide emergency and hospital substitutive care to residents of residential aged care facilities (RACF). While evidence supports the role of community pharmacist-led medication reviews in RACFs, there is limited literature evaluating the role of pharmacists integrated into aged care support teams. The purpose of this study was to analyse the effect of RaSS pharmacist-led medication reviews on polypharmacy, drug burden index, potentially inappropriate medications and potential prescribing omissions for residents living in RACFs. Methods Residents were referred to a Residential Aged-care Support Service pharmacist for medication review over a 12-month period. Medication-related problems and recommendations identified by the pharmacist were communicated to the resident’s general practitioner and RaSS medical practitioner for review. Residents’ medication histories were obtained at baseline and at one-month post-intervention. The number of medications prescribed to RACF residents, their associated drug burden indices, potentially inappropriate medications, and potential prescribing omissions identified at baseline and post-intervention were compared to evaluate the effects of RaSS pharmacist-led medication reviews. Results 175 residents with a mean age of 84 years were referred to a hospital-based Residential Aged-care Support Service pharmacist for medication review. Median time to post-intervention evaluation was 29 days. The mean total number of medications prescribed were reduced from 18 medications at baseline to 17 medications post-intervention (p<0.001). The mean drug burden index score was reduced from 1.53 (at baseline) to 1.35 post-intervention (p<0.001). There were more residents that experienced a decrease in inappropriate medications (p<0.001) and prescribing omissions (p=0.008) compared to those that had an increase. Conclusions This study suggests that medication reviews performed by pharmacists embedded in hospital-based residential aged care support services may improve medication use and prescribing practices in aged care. Future research needs to be prioritised to corroborate this.
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