ObjectivePolypharmacy occurs in approximately 30% of older adults aged 65 years or more, particularly among those with multimorbidity. With polypharmacy, there is an associated risk of potentially inappropriate prescribing (PIP). The aims of this scoping review were to (1) identify the intervention elements that have been adopted to reduce PIP in the outpatient setting and (2) determine the behaviour change wheel (BCW) intervention functions performed by each of the identified intervention elements.DesignScoping reviewData sourcesPubMed, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Web of Science and Cochrane Library databases, grey literature sources, six key geriatrics journals and the reference lists of review papers.Study selectionAll studies reporting an intervention or strategy that addressed PIP in the older adult population (age ≥65) with multimorbidity in the outpatient setting and in which the primary prescriber is the physician.Data extractionData extracted from the included studies can be broadly categorised into (1) publication details, (2) intervention details and (3) results. This was followed by data synthesis and analysis based on the BCW framework.ResultsOf 8195 studies yielded, 80 studies were included in the final analysis and 14 intervention elements were identified. An average of two to three elements were adopted in each intervention. The three most frequently adopted intervention elements were medication review (70%), training (26.3%) and tool/instrument(s) (22.5%). Among medication reviews, 70% involved pharmacists. The 14 intervention elements were mapped onto five intervention functions: ‘education’, ‘persuasion’, ‘training’, ‘environmental restructuring’ and ‘enablement’.ConclusionPIP is a multifaceted problem that involves multiple stakeholders. As such, interventions that address PIP require multiple elements to target the behaviour of the various stakeholders. The intervention elements and their corresponding functions identified in this scoping review will serve to inform the design of complex interventions that aim to reduce PIP.
Background As the population ages, potentially inappropriate prescribing (PIP) in the older adults may become increasingly prevalent. This undermines patient safety and creates a potential source of major morbidity and mortality. Understanding the factors that influence prescribing behaviour may allow development of interventions to reduce PIP. The aim of this study is to apply the Theoretical Domains Framework (TDF) to explore barriers to effective prescribing for older adults in the ambulatory setting. Methods A scoping review was performed based on the five-stage methodological framework developed by Arksey and O’Malley. From 30 Aug 2018 to 5 Sep 2018, we conducted our search on PubMed, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews, and Web of Science. We also searched five electronic journals, Google and Google Scholar to identify additional sources and grey literature. Two reviewers applied eligibility criteria to the title and abstract screening, followed by full text screening, before systematically charting the data. Results A total of 5731 articles were screened. Twenty-nine studies met the selection criteria for qualitative analysis. We mapped our results using the 14-domain TDF, eventually identifying 10 domains of interest for barriers to effective prescribing. Of these, significant domains include physician-related factors such as “Knowledge”, “Skills”, and “Social/Professional Role and Identity”; issues with “Environmental Context and Resources”; and the impact of “Social Influences” and “Emotion” on prescribing behaviour. Conclusion The TDF elicited multiple domains which both independently and collectively lead to barriers to effective prescribing for older adults in the ambulatory setting. Changing the prescribing climate will thus require interventions targeting multiple stakeholders, including physicians, patients and hospital/clinic systems. Further work is needed to explore individual domains and guide development of frameworks to aid guide prescribing for older adults in the ambulatory setting.
Background: As the population ages, potentially inappropriate prescribing (PIP) in the older adults may become increasingly prevalent. This undermines patient safety and creates a potential source of major morbidity and mortality. Understanding the factors that influence prescribing behaviour may allow development of interventions to reduce PIP. The aim of this study is to apply the Theoretical Domains Framework (TDF) to explore barriers to effective prescribing for older adults in the ambulatory setting. Methods: A scoping review was performed based on the five-stage methodological framework developed by Arksey and O’Malley. From 30 Aug 2018 to 5 Sep 2018, we conducted our search on PubMed, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews, and Web of Science. We also searched five electronic journals, Google and Google Scholar to identify additional sources and grey literature. Two reviewers applied eligibility criteria to the title and abstract screening, followed by full text screening, before systematically charting the data. Results: A total of 5,731 articles were screened. 29 studies met the selection criteria for qualitative analysis. We mapped our results using the 14-domain TDF, eventually identifying 10 domains of interest for barriers to effective prescribing. Of these, significant domains include physician-related factors such as “Knowledge”, “Skills”, and “Social/Professional Role and Identity”; issues with “Environmental Context and Resources”; and the impact of “Social Influences” and “Emotion” on prescribing behaviour. Conclusion: The TDF elicited multiple domains which both independently and collectively lead to barriers to effective prescribing for older adults in the ambulatory setting. Changing the prescribing climate will thus require interventions targeting multiple stakeholders, including physicians, patients and hospital/clinic systems. Further work is needed to explore individual domains and guide development of frameworks to aid guide prescribing for older adults in the ambulatory setting.
As the newer oral anticoagulants (NOACs) are increasingly used in older patients, clinical scenarios when they may need to be discontinued temporarily or indefinitely, may be encountered. Similarly with increasing use of permanent pacemakers and other intra-cardiac devices, there is an increased risk of upper limb venous thrombosis even few years after their insertion. We report a case of a patient with a permanent pacemaker, on rivaroxaban (NOAC) for atrial fibrillation, who developed an upper extremity deep vein thrombosis after its temporary withdrawal following a traumatic acute subdural haematoma. Physicians should be aware of the possibility of rebound hypercoagulability and venous thrombosis soon after the withdrawal of NOACs.
We report a serendipitously discovered initiator-free photohydrogelation of linear poly(ethylene glycols) (PEGs) containing coumarin and methacrylate end groups. The mechanistic studies by NMR spectroscopic reaction monitoring with various control experiments and by real-time UV curing rheology reveal that hydrogelation occurs via a 3-reaction, 1-step process, involving two [2 + 2]-cycloadditions between coumarin and coumarin and coumarin and methacrylate groups and an initiator-free radical polymerization of the methacrylate. We also elucidate the important role of PEGs in this initiator-free UV-induced gelation. Coumarin groups are shown to rheologically impact the network strength and flexibility of hydrogels through [2 + 2]-cycloaddition spacing elongation. Using this methodology, coumarin-containing PEG methacrylates of various molecular weights afford a range of hydrogels G1–G8 with good yields after purification and drying. Interestingly, the same chemistry can be applied to react a dicoumarin containing PEG with a PEG dimethacrylate at various weight ratios (G9–G11). The gels could be partially broken down under several types of ultrasound triggers. In polymer solution, coumarin photodimers (CPDs) are shown to return partially to the coumarin state in response to 30 kHz ultrasound. In gel states, the breakdowns triggered by 30 kHz sonication and by 1.1 MHz high-intensity focused ultrasound are observed at PEG chains without any conversion of CPDs into coumarin. Our methodology may be applicable to the development of a controlled delivery system for hydrophobic actives where a conventional photohydrogelation with the use of a photoinitiator and the subsequent presence of its byproduct can cause migration and toxicity concerns to the surrounding environment.
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