Reducing Inappropriate Polypharmacy

Scott, Ian A; Hilmer, Sarah N.; Reeve, Emily; Potter, Kathleen; Couteur, David Le; Rigby, Debbie; Gnjidic, Danijela; Mar, Chris B Del; Roughead, Elizabeth E.; Page, Amy; Jansen, Jesse; Martin, Jennifer

doi:10.1001/jamainternmed.2015.0324

Cited by 1,090 publications

(1,062 citation statements)

References 48 publications

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“…Deprescribing involves a completion of a review of an individual's current medications and subsequent withdrawal of inappropriate medications with supervision from a healthcare professional after careful consideration of the likelihood of adverse events with a goal of improving clinical outcomes [26,27]. Interventions for deprescribing have been trialled in residential aged care facilities, however the effects of these interventions as shown in randomised controlled trials (RCTs) have been mixed and further studies are required [28][29][30][31][32][33]26]. The high prevalence of DBIassociated medications and PIMs according to the Beers Criteria in the current study suggests that current recommendations for appropriate medication use in older adults may need to be better implemented in residential aged care settings.…”

Section: Discussionmentioning

confidence: 99%

Associations between the Drug Burden Index, Potentially Inappropriate Medications and Quality of Life in Residential Aged Care

et al. 2018

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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.

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Section: Discussionmentioning

confidence: 99%

Associations between the Drug Burden Index, Potentially Inappropriate Medications and Quality of Life in Residential Aged Care

et al. 2018

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“…However, the expert responses to the Round 1 questions emphasised individualising treatment and the importance of reviewing treatments for co‐morbidities as the dementia progresses. The MATCH‐D criteria reported here may add value if used alongside other prescribing criteria designed for older adults and provide health professionals with guidance on when it may be appropriate to de‐prescribe specific medications for co‐morbidities in people with dementia 62. The MATCH‐D criteria also provide guidance on specific issues to discuss with patients and their families when individualising care in dementia.…”

Section: Discussionmentioning

confidence: 99%

Medication appropriateness tool for co‐morbid health conditions in dementia: consensus recommendations from a multidisciplinary expert panel

Page

Potter

Clifford

et al. 2016

Internal Medicine Journal

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BackgroundMedication management for people living with dementia is a complex task as it is unclear what constitutes optimal medication management in this population due to the shifting focus of health priorities and the balance between the benefits and harms of medications.AimThis study sought expert opinion to create a consensus list to define appropriate medication management of co‐morbidities for people with dementia.MethodsThis study used the Delphi technique. We invited multidisciplinary experts in geriatric therapeutics including pharmacists, doctors, nurse practitioners, a patient advocate and a psychologist to participate. Participants were asked to engage into three or more rounds of questioning. Round 1 was a questionnaire comprised of one question defining dementia and seven open‐ended questions about appropriate management of co‐morbidities in people with dementia. Two investigators qualitatively analysed the responses to questions from Round 1 using thematic analysis. The results of this analysis were provided to participants as statements in the Round 2 survey. The participants were asked to rate their agreement with each statement on a 5‐point Likert scale. The median and interquartile range (IQR) were calculated for the responses to each statement. Consensus was pre‐specified as an IQR less than or equal to 1. Statements where consensus was not achieved were presented to participants in Round 3. The Round 2 median and IQR values were provided and participants were again asked to rate their agreement with each statement on a 5‐point Likert scale. The statements where participants agreed or strongly agreed were included in the Medication Appropriateness Tool for Co‐morbid Health conditions in Dementia criteria.ResultsFifty‐seven experts agreed to participate in the study, of whom 58% were pharmacists and 36% were medical practitioners. Fifty‐five participants completed the Round 1 (95% response rate). A total of 128 statements was included in the Round 2 survey. Consensus was reached on 93 statements in Round 2 (n = 48 responders, 84% response rate) and on 18 statements in Round 3 (n = 43 responders, 75% response rate). The participants reached consensus on 111 of 128 statements. Of these statements, 67 statements were included in the Medication Appropriateness Tool for Co‐morbid Health conditions in Dementia criteria. The statements were in the broad themes of preventative medication, symptom management, disease progression, psychoactive medication, treatment goals, principles of medication use, side‐effects and medication reviews.DiscussionThis research provides consensus‐based guidance for clinicians who manage co‐morbid health conditions in people with dementia.

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“…5 There are several frameworks for deprescribing; one systematic stepwise approach was proposed by Scott and colleagues in 2015. 6 Their five-step process starts with a review of all drugs being taken by a patient and establishing the specific indication; the potential for druginduced harm; setting a priority list for deprescribing; and, finally, establishing a system to monitor and detect adverse effects related to withdrawal of the drug. In this case, we highlight a less common and less recognized adverse effect of deprescribing drugs: that cessation of one drug might result in changes in the metabolism of another, either increasing or decreasing its potency or effectiveness.…”

Section: Discussionmentioning

confidence: 99%

Rebound adrenal insufficiency after withdrawal of ritonavir in a 65-year-old man using inhaled budesonide

Veilleux

Lee

McDonald

2017

CMAJ

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A 65-year-old man with a 14-year history of well-controlled HIV infection presented to the emergency department with three weeks of nausea, abdominal pain and confusion. His medical history included chronic obstructive pulmonary disease with features of asthma and infrequent exacerbations, allergic rhinitis, hypertension, dyslipidemia, chronic kidney disease (estimated glomerular filtration rate [eGFR] 30 mL/min/m 2 ), osteopenia, gastresophageal reflux disease, and a remote history of depression. His viral load had been undetectable, with a CD4 count above 400 (normal range 356-1573) cells/µL for many years on a ritonavir-containing antiretroviral regimen. He was also taking intranasal budesonide (total daily dose 128 µg), as well as inhaled budesonide (total daily dose 800 µg) in combination with formoterol. In response to a decline in his bone mineral density, recent progressive renal dysfunction (eGFR had decreased from 60 to 30 mL/min/m 2 over the course of the year) and worsening dyslipidemia, his antiretroviral therapy was changed to abacavir, lamivudine and dolutegravir eight weeks before he presented to the emergency department.Following this change in treatment, the patient was seen in the chronic viral illness clinic, and he reported asthenia, anorexia, nausea and intermittent episodes of crampy epigastric abdominal pain. He was afebrile, his seated blood pressure was 110/70 mm Hg, with a pulse rate at 100 beats/min. The remainder of the physical exam was unremarkable. A contrast-enhanced computed tomography (CT) scan of the abdomen did not show a cause for his abdominal pain.The patient's new antiretroviral regimen was put on hold, and genetic testing for a predisposition to abacavir hypersensitivity was conducted as a possible explanation for his symptoms. Because the patient was volume depleted, treatment with intravenous saline was started. After receiving 3 L of crystalloid, he felt better and was discharged home, with all antiretroviral treatments suspended and follow-up scheduled in clinic.Two weeks after discharge, the patient presented to the emergency department. In addition to intermittent epigastric pain, he now reported five days of headache, worsening fatigue, diffuse arthralgias, myalgias and fever. His wife also reported that he had been having difficulty with difficulty with planning and organizing his daily tasks, short-term memory and finding words. Upon physical examination, his body temperature was 38.9°C, and he had sinus tachycardia of 110 beats/min and a blood pressure of 100/60 mm Hg, which fell to 90/50 mm Hg after one minute of standing. Jugular venous pressure was 0 cm above the sternal angle. The remainder of the physical examination was normal. His Montreal Cognitive Assessment was 14/30, indicating substantially impaired cognitive function.The patient had a CD4 count of 350 cells/µL, and his plasma HIV RNA level had risen from previously undetectable to 1.5 million copies /mL. A plain CT scan of his head was unremarkable. A lumbar puncture was performed and showed an iso...

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Reducing Inappropriate Polypharmacy

Abstract: Prevalence of potentially preventable unplanned hospitalizations caused by therapeutic failures and adverse drug withdrawal events among older veterans.

Cited by 1,090 publications

References 48 publications

Associations between the Drug Burden Index, Potentially Inappropriate Medications and Quality of Life in Residential Aged Care

Associations between the Drug Burden Index, Potentially Inappropriate Medications and Quality of Life in Residential Aged Care

Medication appropriateness tool for co‐morbid health conditions in dementia: consensus recommendations from a multidisciplinary expert panel

Rebound adrenal insufficiency after withdrawal of ritonavir in a 65-year-old man using inhaled budesonide

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