Polypharmacy, Medication Possession, and Deprescribing of Potentially Non-Beneficial Drugs in Hospice Patients

2020 ◽  
Vol 37 (12) ◽  
pp. 1076-1085
Author(s):  
Ian Duncan ◽  
Terri L. Maxwell ◽  
Nhan Huynh ◽  
Marisa Todd
Keyword(s):  
Prescription Drugs ◽  
Adverse Drug Events ◽  
Medication Management ◽  
Primary Diagnosis ◽  
Potentially Inappropriate Medications ◽  
Negative Consequences ◽  
Drug Classes ◽  
Increased Risk ◽  
Incidence Functions ◽  
Almost All

Patients frequently have comorbidities that when combined with their primary diagnosis qualifies the patient for hospice. Consequently, patients are at risk for polypharmacy due to the number of medications prescribed to treat both the underlying conditions and the related symptoms. Polypharmacy is associated with negative consequences, including increased risk for adverse drug events, drug–drug and drug–disease interactions, reduced functional status and falls, multiple geriatric syndromes, medication nonadherence, and increased mortality. Polypharmacy also increases the complexity of medication management for caregivers and contributes to the cost of prescription drugs for hospices and patients. Deprescribing or removing nonbeneficial or ineffective medications can reduce polypharmacy in hospice. We study medication possession ratios and rates of deprescribing of commonly prescribed but potentially nonbeneficial classes of medication using a large hospice pharmacy database. Prevalence of some classes of potentially inappropriate medications is high. We report possession ratios for 10 frequently prescribed classes, and, because death and prescription termination are competing events, we calculate prescription termination rates using Cumulative Incidence Functions. Median duration of antifungal and antiviral medications is brief (5 and 7 days, respectively), while statins and diabetes medications have slow discontinuance rates (median termination durations of 93 and 197 days). Almost all patients with a proton pump inhibitor prescription have the drug for their entire hospice stay. Data from this study identify those drug classes that are commonly deprescribed slowly, suggesting drug classes and diagnoses that hospices may wish to focus on more closely, as they act to limit polypharmacy and reduce prescription costs.

Association Between Potentially Inappropriate Medications and 30-Day Post–Hospital Discharge Outcomes in US Veterans

2021 ◽  
pp. 106002802110320
Author(s):  
Heather G. Allore ◽  
Danijela Gnjidic ◽  
Melissa Skanderson ◽  
Ling Han
Keyword(s):  
Hospital Discharge ◽  
Adverse Drug Events ◽  
Primary Care Clinic ◽  
Care Utilization ◽  
Potentially Inappropriate Medications ◽  
Care Hospital ◽  
Care Clinic ◽  
Risk Of Mortality ◽  
Increased Risk ◽  
Reduced Risk

Background Potentially inappropriate medication (PIMs) use is common in older inpatients and it may lead to increased risk of adverse drug events. Objectives To examine prevalence of PIMs at hospital discharge and its contribution to health care utilization and mortality within 30-days of hospital discharge. Methods This was a prospective cohort of 117 570 veterans aged ≥65 years and hospitalized in 2013. PIMs at discharge were categorized into central nervous system acting (CNS) and non-CNS. Outcomes within 30-days of hospital discharge were: (1) time to first acute care hospital readmission, and all-cause mortality, (2) an emergency room visit, and (3) ≥3 primary care clinic visits. Results The cohort’s mean age was 74.3 years (SD 8.1), with 51.3% exposed to CNS and 62.8% to non-CNS PIMs. Use of CNS and non-CNS PIMs, respectively, was associated with a reduced risk of readmission, with an adjusted hazard ratio (aHR) of 0.93 (95% CI = 0.89-0.96) for ≥2 (vs 0) CNS PIMs and an aHR of 0.85 (95% CI = 0.82-0.88) for ≥2 (vs 0) non-CNS PIMs. Use of CNS PIMs (≥2 vs 0) was associated with increased risk of mortality (aHR = 1.37 [95% CI = 1.25-1.51]), whereas non-CNS PIMs use was associated with a reduced risk of mortality (aHR = 0.75 [95% CI = 0.69-0.82]). Conclusion and Relevance PIMs were highly common in this veteran cohort, and the association with outcomes differed by PIMs. Thus, it is important to consider whether PIMs are CNS acting to optimize short-term posthospitalization outcomes.

Potentially inappropriate medications in older adults: A review of the 2012 Beers Criteria and the implications in persons with dementia

2014 ◽  
Vol 4 (4) ◽  
pp. 166-169 ◽  
Author(s):  
Nicole J. Brandt ◽  
Traci Turner
Keyword(s):  
Older Adults ◽  
Adverse Drug Events ◽  
Beers Criteria ◽  
Potentially Inappropriate Medications ◽  
Clinical Tool ◽  
Drug Classes ◽  
Information Set ◽  
Sliding Scale ◽  
Institutionalized Patients ◽  
Inappropriate Medications

In 2012, the American Geriatrics Society (AGS), along with a panel of 11 experts, updated the Beers Criteria which has evolved significantly since its inception in 1991. The Beers Criteria, in general, classifies medications/medication classes as: (1) potentially inappropriate for use in all older adults, (2) potentially inappropriate for older adults with certain diseases or symptoms and (3) requiring extra caution when used in older adults. Although each patient must be evaluated individually, the Beers Criteria is a useful clinical tool that can be used when initiating pharmacologic agents in both ambulatory and institutionalized patients. The concept behind use of the Beers Criteria is that it allows prescribers to readily identify, and avoid, medications associated with negative outcomes in older adults therefore decreasing the risk of adverse drug events (ADEs). Within this review article, there will be a highlight of potentially inappropriate medications (PIMs) commonly seen in clinical practice settings such as antipsychotics, benzodiazepines, non-benzodiazepine sedative-hypnotics, anticholinergics and sliding scale insulin. The focus will be to outline the risk-benefits of these drug classes within the context of persons with dementia. Furthermore, the use of PIMs has both clinical and financial implications in Medicare Star ratings and Healthcare Effectiveness Data and Information Set (HEDIS) measures.

Outcomes of Medication Misadventure Among People With Cognitive Impairment or Dementia: A Systematic Review and Meta-analysis

2020 ◽  
pp. 106002802094912
Author(s):  
Anum Saqib Zaidi ◽  
Gregory M. Peterson ◽  
Luke R.E. Bereznicki ◽  
Colin M. Curtain ◽  
Mohammed Salahudeen
Keyword(s):  
Systematic Review ◽  
Cognitive Impairment ◽  
Adverse Drug Events ◽  
Data Extraction ◽  
Meta Analysis ◽  
Published Data ◽  
Potentially Inappropriate Medications ◽  
Cochrane Central Register ◽  
Increased Risk ◽  
Meta Analyses

Objective: To investigate mortality and hospitalization outcomes associated with medication misadventure (including medication errors [MEs], such as the use of potentially inappropriate medications [PIMs], and adverse drug events [ADEs]) among people with cognitive impairment or dementia. Data Sources: Ovid MEDLINE, Ovid EMBASE, Ovid International Pharmaceutical Abstracts, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials were searched from inception to December 2019. Study Selection and Data Extraction: Relevant studies using any study design were included. Reviewers independently performed critical appraisal and extracted relevant data. Data Synthesis: The systematic review included 10 studies that reported the outcomes of mortality or hospitalization associated with medication misadventure, including PIMs (n=5), ADEs (n=2), a combination of MEs and ADEs (n=2), and drug interactions (n=1). Five studies examining the association between PIMs and mortality/hospitalization were included in the meta-analyses. Exposure to PIMs was not associated with either mortality (odds ratio [OR]=1.36; 95%CI=0.79-2.35) or hospitalization (OR=1.02; 95%CI=0.83-1.26). In contrast, single studies indicated that ADEs with cholinesterase inhibitors were associated with mortality and hospitalization. Relevance to Patient Care and Clinical Practice: Individuals with cognitive impairment or dementia are at increased risk of medication misadventure; based on relatively limited published data, this does not necessarily translate to increased mortality and hospitalization. Conclusions: Overall, medication misadventure was not associated with mortality or hospitalization in people with cognitive impairment or dementia, noting the limited number of studies, difficulty in controlling potential confounding variables, and that most studies focus on PIMs.

scholarly journals Risk of Hospitalization for Adverse Drug Events in Women and Men: A Post-Hoc Analysis of an Active Pharmacovigilance Study in Italian Emergency Departments

2021 ◽  
Author(s):  
Giada Crescioli ◽  
Ennio Boscia ◽  
Alessandra Bettiol ◽  
Silvia Pagani ◽  
Giulia Spada ◽  
...  
Keyword(s):  
Adverse Drug Events ◽  
Vitamin K Antagonists ◽  
Multivariate Logistic Regression ◽  
Digitalis Glycosides ◽  
Post Hoc Analysis ◽  
Adverse Event Following Immunization ◽  
Drug Classes ◽  
Increased Risk ◽  
Post Hoc ◽  
Reduced Risk

This post-hoc analysis of an Italian active pharmacovigilance study describes pharmacological differences of ADEs leading to emergency department (ED) visit and hospitalization in women and men. During the study period (January 2007 – December 2018), 61,855 reports of ADE leading to ED visit were collected. Overall, 30.6% of ADEs resulted in hospitalization (30% in women and 31% in men). Multivariate logistic regression showed that, among women, drug classes significantly associated with an increased risk of hospitalization were heparins (ROR 1.41, CI 1.13-176), antidepressants (ROR 1.12, CI 1.03-1.23) and antidiabetics (ROR 1.13, CI 1.02-1.24). Among men only vitamin K antagonists (ROR 1.28, CI 1.09-1.50), opioids (ROR 1.30, CI 1.06-1.60) and digitalis glycosides (ROR 1.32, CI 1.09-1.59) were associated with a higher risk of hospitalization. Overall, older age, multiple suspected drugs and the presence of comorbidi-ties were significantly associated with a higher risk of hospitalization. A significantly reduced risk of hospitalization was observed in both women and men experiencing and adverse event following immunization (ROR 0.36, CI 0.27-0.48 and 0.83, 0.42-0.74, respectively) compared to drugs. Results obtained from this real-world analysis highlight important aspects of drug safety between sexes.

scholarly journals Use of potentially inappropriate medication and polypharmacy in older adults: a repeated cross-sectional study

2020 ◽  
Author(s):  
Kristine Thorell ◽  
Patrik Midlöv ◽  
Johan Fastbom ◽  
Anders Halling
Keyword(s):  
Chronic Conditions ◽  
Adverse Drug Events ◽  
Inappropriate Medication ◽  
Cross Sectional Study ◽  
P Value ◽  
Potentially Inappropriate Medications ◽  
Sectional Study ◽  
Cross Sectional ◽  
Increased Risk ◽  
Inappropriate Medications

Abstract Background: With age, the number of chronic conditions increases along with the use of medications. For several years, polypharmacy has been found to be on the increase in western societies. Polypharmacy is associated with an increased risk of adverse drug events (ADE). Medications called potentially inappropriate medications (PIM) have also been found to increase the risk of ADEs in an older population. In this study, which we conducted during a national information campaign to reduce PIM, we analysed the prevalence of PIM in an older adult population and in different strata of the variables age, gender, number of chronic conditions and polypharmacy and how that prevalence changed over time. Methods: This is a registry-based repeated cross-sectional study including two cohorts. Individuals aged 75 or older listed at a primary care centre in Blekinge on the 31st March 2011 (cohort 1, 15 361 individuals) or on the 31st December 2013 (cohort 2, 15 945 individuals) were included in the respective cohorts. Using a chi2 test, the two cohorts were compared on the variables age, gender, number of chronic conditions and polypharmacy. Use of five or more medications at the same time was the definition for polypharmacy. Results: Use of PIM decreased from 10.60% to 7.04% (p-value <0.001) between 2011 and 2013, while prevalence of five to seven chronic conditions increased from 20.55% to 23.66% (p-value <0.001). Use of PIM decreased in all strata of the variables age, gender number of chronic conditions and polypharmacy. Except for age 80-84 and males, where it increased, prevalence of polypharmacy was stable in all strata of the variables. Conclusions: Use of potentially inappropriate medications had decreased in all variables between 2011 and 2013; this shows the possibility to reduce PIM with a focused effort. Polypharmacy does not increase significantly compared to the rest of the population.

scholarly journals Use of potentially inappropriate medication and polypharmacy in older adults: a repeated cross-sectional study

2020 ◽  
Author(s):  
Kristine Thorell ◽  
Patrik Midlöv ◽  
Johan Fastbom ◽  
Anders Halling
Keyword(s):  
Chronic Conditions ◽  
Adverse Drug Events ◽  
Inappropriate Medication ◽  
Cross Sectional Study ◽  
P Value ◽  
Potentially Inappropriate Medications ◽  
Sectional Study ◽  
Cross Sectional ◽  
Increased Risk ◽  
Inappropriate Medications

Abstract Background: With age, the number of chronic conditions increases along with the use of medications. For several years, polypharmacy has been found to be on the increase in western societies. Polypharmacy is associated with an increased risk of adverse drug events (ADE). Medications called potentially inappropriate medications (PIM) have also been found to increase the risk of ADEs in an older population. In this study, which we conducted during a national information campaign to reduce PIM, we analysed the prevalence of PIM in an older adult population and in different strata of the variables age, gender, number of chronic conditions and polypharmacy and how that prevalence changed over time. Methods: This is a registry-based repeated cross-sectional study including two cohorts. Individuals aged 75 or older listed at a primary care centre in Blekinge on the 31st March 2011 (cohort 1, 15 361 individuals) or on the 31st December 2013 (cohort 2, 15 945 individuals) were included in the respective cohorts. Using a chi2 test, the two cohorts were compared on the variables age, gender, number of chronic conditions and polypharmacy. Use of five or more medications at the same time was the definition for polypharmacy. Results: Use of PIM decreased from 10.60% to 7.04% (p-value <0.001) between 2011 and 2013, while prevalence of five to seven chronic conditions increased from 20.55% to 23.66% (p-value <0.001). Use of PIM decreased in all strata of the variables age, gender number of chronic conditions and polypharmacy. Except for age 80-84 and males, where it increased, prevalence of polypharmacy was stable in all strata of the variables. Conclusions: Use of potentially inappropriate medications had decreased in all variables between 2011 and 2013; this shows the possibility to reduce PIM with a focused effort. Polypharmacy does not increase significantly compared to the rest of the population.

scholarly journals Risk of Hospitalization for Adverse Drug Events in Women and Men: A Post Hoc Analysis of an Active Pharmacovigilance Study in Italian Emergency Departments

2021 ◽  
Vol 14 (7) ◽  
pp. 678
Author(s):  
Giada Crescioli ◽  
Ennio Boscia ◽  
Alessandra Bettiol ◽  
Silvia Pagani ◽  
Giulia Spada ◽  
...  
Keyword(s):  
Adverse Drug Events ◽  
Vitamin K Antagonists ◽  
Multivariate Logistic Regression ◽  
Post Hoc Analysis ◽  
Adverse Event Following Immunization ◽  
Drug Classes ◽  
Increased Risk ◽  
Ed Visits ◽  
Post Hoc ◽  
Reduced Risk

This post hoc analysis of an Italian active pharmacovigilance study describes pharmacological differences of ADEs leading to emergency department (ED) visits and hospitalization in women and men. During the study period (January 2007–December 2018), 61,855 reports of ADEs leading to ED visits were collected. Overall, 30.6% of ADEs resulted in hospitalization (30% in women and 31% in men). Multivariate logistic regression showed that, among women, drug classes significantly associated with an increased risk of hospitalization were heparins (ROR 1.41, CI 1.13–176), antidepressants (ROR 1.12, CI 1.03–1.23) and antidiabetics (ROR 1.13, CI 1.02–1.24). Among men, only vitamin K antagonists (ROR 1.28, CI 1.09–1.50), opioids (ROR 1.30, CI 1.06–1.60) and digitalis glycosides (ROR 1.32, CI 1.09–1.59) were associated with a higher risk of hospitalization. Overall, older age, multiple suspected drugs and the presence of comorbidities were significantly associated with a higher risk of hospitalization. A significantly reduced risk of hospitalization was observed in both women and men experiencing an adverse event following immunization (ROR 0.36, CI 0.27–0.48 and 0.83, 0.42–0.74, respectively) compared to drugs. Results obtained from this real-world analysis highlight important aspects of drug safety between sexes.

scholarly journals Effects of a pilot multidisciplinary clinic for frequent attending elderly patients on deprescribing

2016 ◽  
Vol 40 (1) ◽  
pp. 86 ◽  
Author(s):  
Alison Mudge ◽  
Katherine Radnedge ◽  
Karen Kasper ◽  
Robert Mullins ◽  
Julie Adsett ◽  
...  
Keyword(s):  
Pilot Study ◽  
Elderly Patients ◽  
Adverse Drug Events ◽  
Hospital Admissions ◽  
Medication Management ◽  
Management Plan ◽  
Transitions Of Care ◽  
Potentially Inappropriate Medications ◽  
Medical Patients ◽  
Medication History

Objective Multimorbidity and associated polypharmacy are risk factors for hospital re-admission. The Targeting Hospitalization Risks in Vulnerable Elders (THRIVE) clinic is a novel multidisciplinary out-patient clinic to improve transitions of care and decrease re-admission risk for older medical patients with frequent hospital admissions. This pilot study examined the effect of the THRIVE model on medication count, tablet load and potentially inappropriate medicines (PIMs). Methods Participants with frequent medical admissions were referred within 2 weeks of discharge from hospital and assessed at baseline and then at 4 and 12 weeks by the THRIVE team. A thorough reconciliation of all medications was performed collaboratively by a clinical pharmacist and a physician. Optimising medications, including deprescribing, was in collaboration with the participants’ general practitioner. The complete medication history of each patient was compared retrospectively by an independent assessor at baseline and after the 12-week clinic, comparing total number of regular medications, tablet load and PIMs (measured using the Screening Tool of Older Persons Prescriptions (STOPP) tool). Results All 17 participants attending the pilot THRIVE clinic were included in the study. At 12 weeks, there was a significant reduction in mean medication count (from 14.3 to 11.2 medications; P < 0.001) and mean tablet load (from 20.5 to 16.9 tablets; P < 0.01). There was an absolute reduction in the total number of PIMs from 38 to 14. Common medications deprescribed included opioids, tricyclic antidepressants, benzodiazepines and diuretics. Conclusions Patients who attended the THRIVE clinic had a significant reduction in medication count and tablet load. The pilot study demonstrates the potential benefits of a multidisciplinary out-patient clinic to improve prescribing and reduce unwarranted medications in an elderly population. An adequately powered comparative study would allow assessment of clinical outcomes and costs. What is known about the topic? Elderly patients are prone to polypharmacy. The identification and deprescribing of potentially inappropriate medications is effective in reducing adverse drug events in this population. However, acute hospitalisation is not always the ideal setting to initiate deprescribing. What does the paper add? Intensive multidisciplinary out-patient care for frequently re-admitted patients optimises their medication management plan and helps reduce the use of unwarranted medications. What are the implications for practitioners? Effective deprescribing in elderly patients can be achieved after hospital discharge using a multidisciplinary collaborative model, but costs and clinical benefits require further investigation.

scholarly journals Use of potentially inappropriate medication and polypharmacy in older adults: a repeated cross-sectional study

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Kristine Thorell ◽  
Patrik Midlöv ◽  
Johan Fastbom ◽  
Anders Halling
Keyword(s):  
Chronic Conditions ◽  
Adverse Drug Events ◽  
Adult Population ◽  
Inappropriate Medication ◽  
Cross Sectional Study ◽  
Potentially Inappropriate Medications ◽  
Sectional Study ◽  
Cross Sectional ◽  
Increased Risk ◽  
Inappropriate Medications

Abstract Background With age, the number of chronic conditions increases along with the use of medications. For several years, polypharmacy has been found to be on the increase in western societies. Polypharmacy is associated with an increased risk of adverse drug events (ADE). Medications called potentially inappropriate medications (PIM) have also been found to increase the risk of ADEs in an older population. In this study, which we conducted during a national information campaign to reduce PIM, we analysed the prevalence of PIM in an older adult population and in different strata of the variables age, gender, number of chronic conditions and polypharmacy and how that prevalence changed over time. Methods This is a registry-based repeated cross-sectional study including two cohorts. Individuals aged 75 or older listed at a primary care centre in Blekinge on the 31st March 2011 (cohort 1, 15,361 individuals) or on the 31st December 2013 (cohort 2, 15,945 individuals) were included in the respective cohorts. Using a chi2 test, the two cohorts were compared on the variables age, gender, number of chronic conditions and polypharmacy. Use of five or more medications at the same time was the definition for polypharmacy. Results Use of PIM decreased from 10.60 to 7.04% (p-value < 0.001) between 2011 and 2013, while prevalence of five to seven chronic conditions increased from 20.55 to 23.66% (p-value < 0.001). Use of PIM decreased in all strata of the variables age, gender number of chronic conditions and polypharmacy. Except for age 80–84 and males, where it increased, prevalence of polypharmacy was stable in all strata of the variables. Conclusions Use of potentially inappropriate medications had decreased in all variables between 2011 and 2013; this shows the possibility to reduce PIM with a focused effort. Polypharmacy does not increase significantly compared to the rest of the population.

scholarly journals A Qualitative Analysis to Understand Perception about Medication-Related Problems among Older Minority Adults in a Historically Black Community

Pharmacy ◽  
2022 ◽  
Vol 10 (1) ◽  
pp. 14
Author(s):  
Ivy O. Poon ◽  
Felicia Skelton ◽  
Lena R. Bean ◽  
Dominique Guinn ◽  
Terica Jemerson ◽  
...  
Keyword(s):  
Older Adults ◽  
Historically Black ◽  
Adverse Drug Events ◽  
Ecological Model ◽  
Group Discussion ◽  
Medication Management ◽  
Unmet Need ◽  
Community Setting ◽  
Patient Centered ◽  
Increased Risk

Older adults taking multiple chronic medications experience an increased risk of adverse drug events and other medication-related problems (MRP). Most current literature on medication management involves researcher-driven intervention, yet few studies investigate patients’ understanding of MRP in a diverse community setting. This report investigates patients’ perception of MRP and patient-centered strategies among a cohort of the older adult group in a historically Black urban community. The study design is qualitative using structured open-ended questions in a multidisciplinary patient-centered focus group. Patients (age 65 years or older) taking seven or more medications were recruited. The group comprises patients, caregivers, pharmacists, health educators, a physician, and a nurse. Recordings of the group discussion are transcribed verbatim and analyzed using thematic content analysis and categorized by codes developed from the social-ecological model. The group reports patient-provider relationships, previous experience, fear of side effects played important roles in medication adherence. There is an unmet need for medication management education and tools to organize complex medication lists from multiple providers. This study provides important insights into MRP experienced by minority older adults and provided researchers with potential strategies for future interventions.

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