Hospital admission as a deprescribing triage point for patients discharged to Residential Aged Care Facilities

Roberts, Greg; Pegoli, Matthew; Grzeskowiak, Luke E.; Benger, Sophie; Forbes, Harriet; Hunt, Kathryn; Jafari, Shabnam; Koeper, Ivanka; McDonald, Cameron; Nguyen, H. Bryant; Rawther, Khadeeja; Taeuber, Lauren; Tran, Evelyn; Vu, Peter; Wisdom, Alice; Russell, Patrick

doi:10.1093/ageing/afab082

Cited by 5 publications

(5 citation statements)

References 15 publications

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“…Several systematic reviews of deprescribing have not demonstrated a benefit associated with reducing medication burden. 3,4 Our study found no deterioration in HRQOL for the group who had medications deprescribed, but a faster readmission. Furthermore, we found worse mortality in those patients ceasing antihypertensives and statins.…”

Section: Discussionmentioning

confidence: 50%

“…2 An unplanned hospitalisation becomes a conduit of new prescriptions to treat symptoms and prevent major clinical events. 3 Therefore, it is no surprise that the hospital is a common source of potentially inappropriate medications (PIM) and can exacerbate, rather than reduce exposure to polypharmacy. 2 Deprescribing, whether inpatient or outpatient, has been promoted as a solution to the vexing problem of polypharmacy and a way to improve the negative outcomes attending polypharmacy, 4 but systematic reviews of this approach have been unable to support a clear and consistent benefit.…”

Section: Introduction/backgroundmentioning

confidence: 99%

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Prospective cohort study of nonspecific deprescribing in older medical inpatients being discharged to a nursing home

Russell

Hewage²,

McDonald³

et al. 2021

Therapeutic Advances in Drug Safety

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Background: Older patients from nursing homes are commonly exposed to polypharmacy before a hospital admission. Deprescribing has been promoted as a solution to this problem, though systematic reviews have not found benefit. The aim of this study was to understand if in-hospital deprescribing of certain classes of medications is associated with certain benefits or risks. Methods: We conducted a prospective, multicentre, cohort study in 239 medical inpatients ⩾75 years (mean age 87.4 years) who were exposed to polypharmacy (⩾5 medications) prior to admission and discharged to a nursing home for permanent placement. Patients were categorised by whether deprescribing occurred, mortality and readmissions were assessed 30 and 90 days after hospital discharge. The EQ-5D-5 L health survey assessed changes in health-related quality of life (HRQOL) at 90 days, with comparison to EQ-5D-5 L results at day 30. Latent class analysis (LCA) was used to investigate associations between patterns of prescribed and deprescribed medications and mortality. Results: Patients for whom deprescribing occurred had a higher Charlson Index; there were no differences between the groups in principal diagnosis, total or Beers list number of medications on admission. The number of Beers list medications increased in both groups before discharge. Patients who had medications deprescribed had nonsignificantly greater odds of dying within 90 days [odds ration (OR) = 3.23 (95% confidence interval (CI): 0.68, 14.92; p = 0.136]. Deprescribing of certain classes was associated with higher 90-day mortality: antihypertensives (OR = 2.27, 95% CI: 1.004, 5; p = 0.049) and statins (OR = 5, 95% CI: 1.61, 14.28; p = 0.005). Readmissions and 1-year mortality rates were similar. There was no deterioration in HRQOL when medications were deprescribed. LCA showed that patients with the least medication changes had the lowest mortality. Conclusion: Deprescribing certain classes of medications during hospitalisation was associated with worse mortality, but not readmissions or overall HRQOL. Larger controlled deprescribing studies targeting specific medications are warranted to further investigate these findings. This study was registered with the Australian and New Zealand Clinical Trials Registry, ACTRN1 2616001336471. Plain language summary Background: When an older person living in a nursing home is admitted to hospital, does stopping long-term medications help them? Many older people from nursing homes take a large number of medications each day to treat symptoms and prevent adverse events. “Polypharmacy” is a term used to describe taking multiple long-term medications, and it is associated with many negative outcomes such as increased number of falls, cognitive decline, hospital readmission, even death. Deprescribing of nonessential medications – whether stopping or reducing the dose – is promoted as good hospital practice and is assumed to help older frail people live longer and feel better. However, we often don’t fully understand what is and is not essential. We wanted to better understand the effect of deprescribing long-term medications for older frail patients during an unplanned hospital admission as they were going to a nursing home to live. Methods: While admitted to hospital, medications are often reviewed by a clinical pharmacist and specialist physician. Sometimes medications are ceased; sometimes they are not. This gave us the opportunity to study two groups of older frail people from nursing homes: those who had regular, long-term medications ceased or reduced and those who did not. We wanted to see if one group did better. For example, did they feel worse if we stopped certain medications? Did they suffer other bad events compared with those patients for whom no medications were ceased? Were they readmitted to hospital earlier or more often? Results and conclusion: Despite the assumption that stopping medications for this type of patient is good practice, we found no benefit. We were also surprised to find stopping or reducing certain drug classes (e.g. antihypertensives and cholesterol-lowering drugs) was associated with greater mortality. Larger, randomised studies will better answer these important questions.

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Section: Discussionmentioning

confidence: 50%

Section: Introduction/backgroundmentioning

confidence: 99%

Prospective cohort study of nonspecific deprescribing in older medical inpatients being discharged to a nursing home

Russell

Hewage²,

McDonald³

et al. 2021

Therapeutic Advances in Drug Safety

Self Cite

View full text Add to dashboard Cite

show abstract

“…Potential limitations also need to be acknowledged. In particular, medication changes during hospitalization, including targeted deprescribing strategies (Tay et al, 2014;Russell et al, 2019;Kaminaga et al, 2021;Roberts et al, 2021;Russell et al, 2021;Scott et al, 2021), inevitably lead to deviations from the medication list on admission. This, however, could be rectified by additional linkage to discharge and/or readmission data.…”

Section: Discussionmentioning

confidence: 99%

Using electronic admission data to monitor temporal trends in local medication use: Experience from an Australian tertiary teaching hospital

et al. 2022

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Background and aims: Medication usage varies according to prescribing behavior, professional recommendations, and the introduction of new drugs. Local surveillance of medication usage may be useful for understanding and comparing prescribing practices by healthcare providers, particularly in countries such as Australia that are in the process of enhancing nationwide data linkage programs. We sought to investigate the utility of electronic hospital admission data to investigate local trends in medication use, to determine similarities and differences with other Australian studies, and to identify areas for targeted interventions.Methods: We performed a retrospective longitudinal analysis using combined data from a hospital admissions administrative dataset from a large tertiary teaching hospital in Adelaide, South Australia and a hospital administrative database documenting medication usage matched for the same set of patients. All adult admissions over a 12-year period, between 1 January 2007 and 31st December 2018, were included in the study population. Medications were categorized into 21 pre-defined drug classes of interest according to the ATC code list 2021.Results: Of the 692,522 total admissions, 300,498 (43.4%) had at least one recorded medication. The overall mean number of medications for patients that were medicated increased steadily from a mean (SD) of 5.93 (4.04) in 2007 to 7.21 (4.98) in 2018. Results varied considerably between age groups, with the older groups increasing more rapidly. Increased medication usage was partly due to increased case-complexity with the mean (SD) Charlson comorbidity index increasing from 0.97 (1.66) in 2007-to-2012 to 1.17 (1.72) in 2013-to-2018 for medicated patients. Of the 21 medication classes, 15 increased (p < 0.005), including antithrombotic agents; OR = 1.18 [1.16–1.21], proton pump inhibitors; OR = 1.14 [1.12–1.17], statins; OR = 1.12; [1.09–1.14], and renin-angiotensin system agents; OR = 1.06 [1.04–1.08], whilst 3 decreased (p < 0.005) including anti-inflammatory drugs (OR = 0.55; 99.5% CI = 0.53–0.58), cardiac glycosides (OR = 0.81; 99.5% CI = 0.78–0.86) and opioids (OR = 0.82; 99.5% CI = 0.79–0.83). The mean number of medications for all admissions increased between 2007 and 2011 and then declined until 2018 for each age group, except for the 18-to-35-year-olds.Conclusion: Increased medication use occurred in most age groups between 2007 and 2011 before declining slightly even after accounting for increased comorbidity burden. The use of electronic hospital admission data can assist with monitoring local medication trends and the effects of initiatives to enhance the quality use of medicines in Australia.

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“…Excessive polypharmacy (e.g., 10 or more medications) is especially prevalent in nursing homes and was also associated with excessive death [adjusted OR 1.96 (1.42–2.71)] [9 ▪ ,10]. Excessive polypharmacy was also common at the hospital admission in elderly patients aged at least 75 from nursing homes settings (49.4%), and therefore deprescribing strategies are recommended [20 ▪ ]. Dementia incidence has been increased significantly with the increase in the number of prescribed drugs and polypharmacy (cohort study in South Korea, n = 1025 340), which represents a serious risk for dementia (5–<10 drugs: 2.64, 95% CI: 2.32–3.05; ≥10 drugs: 3.35, 95% CI: 2.38–4.71; <1 drug used as reference) [21].…”

Section: Polypharmacy In Elderly Patients With Schizophreniamentioning

confidence: 99%

Antipsychotic treatment in elderly patients on polypharmacy with schizophrenia

Štuhec¹

2022

Current Opinion in Psychiatry

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Purpose of reviewElderly patients with schizophrenia (SCH) are treated with antipsychotics and are often on different comedications, including polypharmacy (five or more medications). Evidence-based guidelines and randomized controlled trials do not include patients on polypharmacy, something that represents a 'gap' between evidence-based recommendations and clinical prescribing patterns. In this context, narrative reviews are needed to help clinicians in daily practice. Recent findingsAntipsychotic treatment efficacies in meta-analyses are similar in the elderly with SCH compared with the general population (medium effect size). Long-term cohort studies show that antipsychotic treatment reduces overall mortality, hospitalizations, and cardiovascular death. These studies are limited because polypharmacy was not studied. The prevalence of antipsychotic use as potentially inappropriate medications was very high in nursing homes (25%). The prevalence of antipsychotic polypharmacy was 40%. Different strategies to manage these problems are available, including collaboration with clinical pharmacists, leading to reduced polypharmacy and better adherence to treatment guidelines. SummaryElderly patients with SCH on polypharmacy are less frequently studied, although they represent many patients with SCH. Different potentially inappropriate medication lists and collaboration with clinical pharmacists represent effective strategies for medication optimization. More studies are needed on this topic (e.g., prospective nonrandomized studies).

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Hospital admission as a deprescribing triage point for patients discharged to Residential Aged Care Facilities

Cited by 5 publications

References 15 publications

Prospective cohort study of nonspecific deprescribing in older medical inpatients being discharged to a nursing home

Prospective cohort study of nonspecific deprescribing in older medical inpatients being discharged to a nursing home

Using electronic admission data to monitor temporal trends in local medication use: Experience from an Australian tertiary teaching hospital

Antipsychotic treatment in elderly patients on polypharmacy with schizophrenia

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