Polypharmacy and potentially inappropriate medications (PIMs) in older adults referred to a memory clinic

AimsThe older adult is more likely to be prescribed a lot of medications (polypharmacy) on account of multi-morbidity and consequently being under the care of several specialists. Adverse drug events and reactions account for significant morbidity and mortality in this population group. Common sequelae include confusional episodes, dementia syndromes, falls, and higher rates of acute hospital admissions.Medications are not routinely reviewed in elderly care. We sought to estimate the prevalence of polypharmacy, and potentially inappropriate medications (e.g. anticholinergics or medications with central anticholinergic effects) in those referred to the Cognitive Impairment and Dementia Service (Elm Lodge), Older Persons Mental Health, West London NHS Trust.MethodAll referrals between 01/10/2020 and 30/11/2020 were screened for medications prescribed. Polypharmacy was defined as prescription of 5 or more medications. Medications with anticholinergic properties were considered examples of Potentially Inappropriate Medications (PIMs). The Anticholinergic Effect on Cognition (AEC) Tool, ‘Medichec’, was used to identify and rate anticholinergic burden. Anticholinergic load was also compared using the Anticholinergic Burden Scale (ABS).ResultTotal number of patients referred – 19311 patients excluded due to unavailable/incomplete medication records.Study number: 182Polypharmacy: 79.67% (n = 145) were prescribed 5 or more medications.44.51% (n = 81) prescribed 5–9 medications.23.08% (n = 42) prescribed 10–14 medications.8.79% (n = 16) prescribed 15–19 medications.1.67% (n = 3) prescribed more than 20 medications.Anticholinergics prescribed (AEC Tool): 37.36% (n = 68) prescribed an anticholinergic.6.59% (n = 12) prescribed more than 1 anticholinergic.Anticholinergics (ABS): 29.67% (n = 54) prescribed an anticholinergic.7.699% (n = 14) prescribed more than 1 anticholinergic.ConclusionPolypharmacy and potentially inappropriate prescribing (e.g. anticholinergics) remain widespread within the older adult population. Anticholinergic load was broadly similar with the Anticholinergic Effect on Cognition tool and the Anticholinergic Burden Scale. Increased anticholinergic burden further compounds risks of cognitive impairment, delirium and death.Other categories of Potentially Inappropriate Medications, including those no longer needed, ought to be identified and reviewed. Over-the-counter medications also need to be screened for.Elimination or reduction of anticholinergic burden may improve quality of life for patients, as well as cost burden on services.Pharmacovigilance, collaborative working, and regular training are needed across services providing care for the older adult.

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Polypharmacy and potentially inappropriate medications (PIMS) in older adults referred to a liaison psychiatry service

BJPsych Open ◽

10.1192/bjo.2021.811 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S306-S307

Author(s):

Anietie Akpan ◽

Omolade Longe

Keyword(s):

Cognitive Impairment ◽

Older Adult ◽

Adverse Drug Events ◽

Adult Population ◽

Inappropriate Medication ◽

Inappropriate Prescribing ◽

Potentially Inappropriate Medications ◽

Liaison Psychiatry ◽

Anticholinergic Burden ◽

Inappropriate Medications

AimsThe older adult is more likely to be prescribed a lot of medications (polypharmacy) on account of multi-morbidity and being under the care of several specialists. Adverse drug events and reactions account for a significant number of acute hospital presentations in this population group with increased risks of delirium, lasting cognitive impairment, falls and death.Medications are not routinely reviewed or rationalised in the elderly, often contributing to preventable harm.We sought to estimate the prevalence of polypharmacy and potentially inappropriate medications, anticholinergics in particular, in patients (65 years and older) referred to the St Mary's Hospital Liaison Psychiatry Department over a 3-month period.MethodBetween 01/06/2019 and 31/08/2019 all referral forms (from in-patient wards and A&E) for patients aged 65+ years were screened for medications currently prescribed and administered. The medications were confirmed via the St. Mary's Hospital electronic records, pharmacists’ completed Medicines Reconciliation and GP Summary Care Records. Polypharmacy was defined as patients prescribed 5 or more medications. Drugs with anticholinergic properties were considered as an example of Potentially Inappropriate Medication (PIMs) using the Anticholinergic Burden Scale. 77 patients were referred in the time period. 9 were excluded due to incomplete/unreconciled medication information.Result77.94% (n = 53) were prescribed 5 or more medications.38.24% (n = 26) were prescribed over 10 medications.10.29% (n = 7) prescribed over 15 medications.69% of (n = 47) prescribed an anticholinergic.42.65% (n = 29) prescribed more than 1 anticholinergic.ConclusionPolypharmacy and potentially inappropriate prescribing remain widespread within the older adult population.Increased anticholinergic burden further compounds risks of cognitive impairment, delirium and death.Other categories of Potentially Inappropriate Medications, including those no longer needed, ought to be identified and reviewed. Over-the-counter medications also need to be screened for.Elimination or reduction of anticholinergic burden may improve quality of life for patients, as well as cost burden on services.Pharmacovigilance, collaborative working, regular and systematic medication reviews, and on-going training are needed across services providing care for the older adult.

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Safe prescribing in cognitively vulnerable patients: the use of the anticholinergic effect on cognition (AEC) tool in older adult mental health services

BJPsych Bulletin ◽

10.1192/bjb.2019.43 ◽

2019 ◽

Vol 44 (1) ◽

pp. 26-30

Author(s):

Delia Bishara ◽

Charlotte Scott ◽

Robert Stewart ◽

David Taylor ◽

Daniel Harwood ◽

...

Keyword(s):

Older People ◽

Older Adult ◽

Anticholinergic Effect ◽

Anticholinergic Medication ◽

Routine Practice ◽

Accurate Identification ◽

Adult Services ◽

Vulnerable Patients ◽

Burden Scale ◽

Anticholinergic Burden

Aims and methodMedication with anticholinergic action is associated with potentially serious adverse effects in older people. We present an evaluation of a novel anticholinergic burden scale introduced into routine practice in older adult services in the South London and Maudsley (SLaM) NHS Foundation Trust. Our aim was to assess whether this tool improved the accurate identification of anticholinergic medication and guided safer prescribing in cognitively vulnerable older people.ResultsThe introduction of the anticholinergic effect on cognition (AEC) tool into clinical practice led to an increase in the identification and reporting to general practitioners of anticholinergic medication from 11 to 85% of cases (P = 0.0015).Clinical implicationsApplication of the AEC tool led to improved detection of anticholinergic medication and advice to primary care on when a medication review is necessary. This is an important step towards improving the safety of prescribing in this patient group.

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Comparison of Potentially Inappropriate Medications for People with Dementia at Admission and Discharge during An Unplanned Admission to Hospital: Results from the SMS Dementia Study

Healthcare ◽

10.3390/healthcare7010008 ◽

2019 ◽

Vol 7 (1) ◽

pp. 8 ◽

Cited By ~ 3

Author(s):

Ashley Kable ◽

Anne Fullerton ◽

Samantha Fraser ◽

Kerrin Palazzi ◽

Carolyn Hullick ◽

...

Keyword(s):

Cognitive Impairment ◽

Controlled Trial ◽

Cognitive Status ◽

Potentially Inappropriate Medications ◽

Unplanned Admission ◽

Hospital Data ◽

Targeted Interventions ◽

People With Dementia ◽

Anticholinergic Burden ◽

Inappropriate Medications

People with dementia (PWD) and cognitive impairment are particularly vulnerable to medication problems, and unplanned admission to hospital presents an opportunity to address polypharmacy, potentially inappropriate medications (PIMs) and anticholinergic burden. This study aimed to compare PIMS and other medication data for PWD to determine whether these changed during hospitalization. Medications documented in patient’s records at admission and discharge were evaluated for PWD recruited to phase one of a prospective quasi-experimental pre/post-controlled trial that was conducted at two regional hospitals in NSW, Australia. The study sample included PWD or cognitive impairment having an unplanned admission to hospital. Data were collected using a purpose developed audit tool for medications and PIMs, and a Modified Anticholinergic Burden Scale. Total participants were 277, and results determined that the cognitive status of PWD is not always detected during an unplanned admission. This may make them more vulnerable to medication problems and poor outcomes. Polypharmacy and PIMS for PWD were high at admission and significantly reduced at discharge. However, PWD should be routinely identified as high risk at admission; and there is potential to further reduce polypharmacy and PIMs during admission to hospital, particularly psychotropic medications at discharge. Future studies should focus on evaluating targeted interventions designed to increase medication safety for PWD.

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Use of potentially inappropriate medications among ambulatory home-dwelling elderly patients with dementia: A review of the literature

Canadian Pharmacists Journal / Revue des Pharmaciens du Canada ◽

10.1177/1715163517701770 ◽

2017 ◽

Vol 150 (3) ◽

pp. 169-183 ◽

Cited By ~ 12

Author(s):

Tejal Patel ◽

Karen Slonim ◽

Linda Lee

Keyword(s):

Older Adults ◽

Cognitive Impairment ◽

Adverse Events ◽

Inappropriate Medication ◽

Medication Use ◽

Adverse Outcomes ◽

Potentially Inappropriate Medication ◽

Potentially Inappropriate Medications ◽

Inappropriate Medication Use ◽

Inappropriate Medications

Background: Older adults with dementia are at high risk for drug-related adverse outcomes. While much is known about potentially inappropriate medication use in older adults, its prevalence and characteristics among those with dementia are not as well elucidated. We conducted a literature review to examine the prevalence of potentially inappropriate medication use among home-dwelling older adults with dementia. Our secondary aim was to determine the most frequently implicated medications and factors associated with potentially inappropriate medication use. Methods: MEDLINE, EMBASE, CINAHL, and International Pharmaceutical Abstracts were searched between 1946 and 2014 for articles that referenced potentially inappropriate medication use and types of dementia. One reviewer screened all titles and abstracts from the initial search and full-text articles after the initial screen for eligibility, then 2 reviewers independently abstracted data from included studies. Results: Searches yielded 81 articles, of which 7 met inclusion criteria. Prevalence of potentially inappropriate medication use varied from 15% to 46.8%. No single drug or drug class was reported consistently across all studies as the most frequent potentially inappropriate medication, but anticholinergics and benzodiazepines, drugs that affect cognition, were among the most common medications or pharmacological classes listed. Discussion: Older adults with dementia may be particularly vulnerable to potentially inappropriate medications because of cognitive impairment from their condition and the greater likelihood of experiencing adverse events from medications. Given this population’s greater susceptibility to adverse events, more intense medication and patient monitoring may be warranted, especially among those taking anticholinergics and benzodiazepines, as these drugs can contribute to cognitive impairment.

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An evaluation of the prevalence of potentially inappropriate medications in older people with cognitive impairment living in Northern Sweden using the EU(7)-PIM list

European Journal of Clinical Pharmacology ◽

10.1007/s00228-017-2218-2 ◽

2017 ◽

Vol 73 (6) ◽

pp. 735-742 ◽

Cited By ~ 16

Author(s):

Eva Sönnerstam ◽

Maria Sjölander ◽

Maria Gustafsson

Keyword(s):

Cognitive Impairment ◽

Older People ◽

Potentially Inappropriate Medications ◽

Northern Sweden ◽

Inappropriate Medications ◽

The Eu

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P3-119: Potentially inappropriate medications and cognitive impairment in older women

Alzheimer s & Dementia ◽

10.1016/j.jalz.2012.05.1339 ◽

2012 ◽

Vol 8 (4S_Part_13) ◽

pp. P493-P494

Author(s):

Alain Koyama ◽

Michael Steinman ◽

Kristine Ensrud ◽

Teresa Hillier ◽

Kristine Yaffe

Keyword(s):

Cognitive Impairment ◽

Older Women ◽

Potentially Inappropriate Medications ◽

Inappropriate Medications

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Less is more: a project to reduce the number of PIMs (potentially inappropriate medications) on an elderly care ward

BMJ Quality Improvement Reports ◽

10.1136/bmjquality.u207857.w4260 ◽

2015 ◽

Vol 5 (1) ◽

pp. u207857.w4260

Author(s):

Tin Htun Aung ◽

Adèle Judith Beck ◽

Thomas Siese ◽

Richard Berrisford

Keyword(s):

Elderly Care ◽

Potentially Inappropriate Medications ◽

Less Is More ◽

Care Ward ◽

Inappropriate Medications

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Evaluation of the Effect of an Intervention on Potentially Inappropriate Medications (PIMS), Polypharmacy and Anticholinergic Burden Scores for People with Dementia; Results from the SMS Dementia Study†: A Quasi-Experimental Study

10.21203/rs.3.rs-45859/v1 ◽

2020 ◽

Author(s):

Ashley Kable ◽

Samantha Fraser ◽

Anne Fullerton ◽

Carolyn Hullick ◽

Kerrin Palazzi ◽

...

Keyword(s):

Treatment Effect ◽

Medication Safety ◽

Medication Reconciliation ◽

Hospital Admissions ◽

Potentially Inappropriate Medications ◽

Post Intervention ◽

People With Dementia ◽

Quasi Experimental ◽

Anticholinergic Burden ◽

Inappropriate Medications

Abstract Background People with dementia (PWD) are at risk for medication related harm due to their impaired cognition and frequently being prescribed many medications. Few previous studies of PWD inpatients have been focused on medication safety interventions.This study aimed to evaluate an intervention designed to improve medication safety for people with dementia (PWD) and their carers during an unplanned admission to hospital. This article reports the effect of the intervention on potentially inappropriate medications (PIMs), polypharmacy and anticholinergic burden scores for PWD in the study. Methods A quasi-experimental pre-post design using an intervention site and a control site was conducted in 2017-2019, in a regional area in New South Wales, Australia. PIMs, polypharmacy and anticholinergic burden were measured at admission, discharge and three months after discharge. In addition, medication reconciliation at admission and scoring of pharmacists recommendations using severity and relevance scores were measured. Results There were 628 participants including 350 in the post-intervention phase. Polypharmacy for these admissions was high, and there was approximately 30% reduction in the number of medications at discharge. PIMs at admission were also high, and decreased significantly at discharge however there was no treatment effect associated with the intervention. The mean anticholinergic burden score also decreased significantly between admission and discharge, however, no treatment effect was seen. Conclusions High rates of polypharmacy and PIMs in this study indicate this study population was admitted with multiple comorbidities. Reduced PIMs at discharge were correlated with reduced anticholinergic burden. Medication reconciliation resulted in many recommendations that contributed to the reductions in medications. Although the study did not report a treatment effect, reductions in the number of medications and PIMs reduced medication related risk for PWD. Reduced risks associated with inappropriate or unnecessary medications can reduce hospital admissions and adverse events for PWD. This intervention was feasible to implement, and future multisite studies should be designed to recruit larger study samples to evaluate interventions for improving medication safety for PWD. They should also adopt routine screening for cognitive impairment to identify PWD at admission.

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