Systems to identify potentially inappropriate prescribing in people with advanced dementia: a systematic review

Abstract

BackgroundSystems for identifying potentially inappropriate medications in older adults are not immediately transferrable to advanced dementia, where the management goal is palliation. The aim of the systematic review was to identify and synthesise published systems and make recommendations for identifying potentially inappropriate prescribing in advanced dementia.MethodsStudies were included if published in a peer-reviewed English language journal and concerned with identifying the appropriateness or otherwise of medications in advanced dementia or dementia and palliative care. The quality of each study was rated using the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) checklist. Synthesis was narrative due to heterogeneity among designs and measures. Medline (OVID), CINAHL, the Cochrane Database of Systematic Reviews (2005 – August 2014) and AMED were searched in October 2014. Reference lists of relevant reviews and included articles were searched manually.ResultsEight studies were included, all of which were scored a high quality using the STROBE checklist. Five studies used the same system developed by the Palliative Excellence in Alzheimer Care Efforts (PEACE) Program. One study used number of medications as an index, and two studies surveyed health professionals’ opinions on appropriateness of specific medications in different clinical scenarios.ConclusionsFuture research is needed to develop and validate systems with clinical utility for improving safety and quality of prescribing in advanced dementia. Systems should account for individual clinical context and distinguish between deprescribing and initiation of medications.

Potentially Inappropriate Prescribing in Australian Nursing Home Residents with Advanced Dementia: A Substudy of the IDEAL Study

“…The PEACE criteria categories offer a 'one size fits all' approach to identifying inappropriate medications and do not take into account clinical factors and context that may be at play in individual cases. Holmes et al (2008) identified a need for future research focusing on larger sample populations which can better showcase the relationship between comorbidities and medication use, as well as identify distinct medication classes that may be overused 14 . Dependence on IDEAL Study data meant that some variables found predictive by previous studies (especially those at the nursing home level) could not be included in the current analyses.…”

“…12 A recent systematic review identified only one currently available dementia-specific criteria for identifying potentially inappropriate medications, which were developed through the Palliative Excellence in Alzheimer Care Efforts Program (PEACE) 13 and classify medications as 'never', 'rarely', 'sometimes' or 'always' appropriate based on a Delphi process carried out with 12 geriatricians. 14 Six international studies have used these criteria to examine the prevalence of inappropriate prescribing in nursing home residents with advanced dementia and associated factors. [15][16][17][18][19][20] These studies were undertaken in European countries, [17][18][19] the USA 15,16 and Canada, 20 and found that proportions of nursing home residents with advanced dementia receiving 'never' appropriate medications ranged from 3% 17 to 45% 20 of study populations.…”

Palliative Care in Patients Living with Dementia: The Role of Deprescribing

“…Data suggest that older adults with dementia are commonly prescribed potentially unsafe medications. [2][3][4] Deprescribing refers to supervised tapering or cessation of drugs, aiming to minimize inappropriate polypharmacy and improve patient outcomes. 2 Most research on potentially inappropriate prescribing is focused on the elderly in general rather than dementia specifically.…”

“…3 However, studies are increasingly focusing on prescribing in people with dementia. The PEACE program 4 has produced criteria that seem promising in terms of identifying potentially inappropriate medications in advanced dementia, including anticholinesterase inhibitors and lipid-lowering agents. There is a growing body of evidence showing that discontinuing specific medications in certain patient populations does not worsen outcomes.…”

Caregivers’ perspectives and experiences of withdrawing acetylcholinesterase inhibitors and memantine in advanced dementia: a qualitative analysis of an online discussion forum

“…As dementia progresses, cognitive and physical decline can adversely impact on the ability of people with dementia to conduct basic and instrumental activities of daily living, often leaving them dependent on others for care [2, 9–11]. Caregivers of people with dementia are often presented with challenging and complex needs, higher levels of dependency and morbidity in the more severe stages of the condition [2, 12, 13]. People with advanced dementia often cannot participate in decision-making about their care; consequently decisions often have to be made by their caregivers (family members, friends and next of kin) [14–20].…”