Results of Optimize: A Cluster Randomized Trial of Patient, Family, and Provider Education in Primary Care

Individuals with cognitive impairment frequently have multiple chronic conditions (MCC), increasing their risk for polypharmacy and associated adverse outcomes. Optimizing medications through deprescribing (reducing or stopping the use of inappropriate medications or medications unlikely to be beneficial) may improve outcomes for this population. Optimize was a pragmatic, 12-month cluster-randomized trial of deprescribing in primary care within a not-for-profit integrated delivery system. Participants were age 65+ with dementia or mild cognitive impairment (MCI), 2+ chronic conditions, and 5+ chronic medications. The intervention consisted of a deprescribing educational brochure for patients/caregivers, and Tip Sheets for primary care clinicians. Outcomes were the number of chronic medications and presence of potentially inappropriate medications (PIM). In total, 1,433 patients received, and 1,579 control clinic patients would have been eligible to receive, the intervention (N=3,012). After 6 months, mean estimates of chronic medications were 6.23 in the intervention group and 6.33 in the control group adjusting for baseline counts, age, and gender (p=0.13). Excluding those without complete 90 days follow-up increased the adjusted effect size to 0.14 (p=0.08). In sub-analyses of individuals with 7+ medications at baseline (N= 1,434), the adjusted effect size was 0.19 (p=0.07) at 6 months and 0.21 (p=0.045) when excluding those without complete 90 days’ follow-up. Change in proportions of PIM did not differ between intervention and control groups. An educational intervention for patients, caregivers and clinicians may prompt reductions in chronic medications. The relatively small effect size highlights the complexity of medication management for individuals with dementia or MCI and MCC.

Intervention Design With Cognitively Impaired Populations: The Optimize Deprescribing Intervention

Older adults with cognitive impairment and multiple other chronic conditions often have polypharmacy which increases their risks of medication related cognitive effects, adverse drug events, hospitalization and death and leads to higher health care costs. Deprescribing, the process of reducing or stopping potentially inappropriate medications may improve outcomes for those older adults with cognitive impairment and multiple chronic conditions. The OPTIMIZE trial examined whether a primary care-based, patient- and family-centered intervention educating and activating patients, family members, and clinicians about deprescribing reduces numbers of chronic medications and potentially inappropriate medications for older adults with dementia or mild cognitive impairment and multiple chronic conditions. We explored the mechanisms of intervention effectiveness through post hoc qualitative stakeholder interviews and surveys with 15 patients, 7 family caregivers, and 28 clinicians. All stakeholder groups endorsed the acceptability of the intervention. Success of the intervention was affected by contextual factors including prior knowledge and openness to deprescribing, cognition and prognosis. Positive outcomes included patients and care partners scheduling specific appointments to discuss deprescribing and providers remembering to consider deprescribing in cognitively impaired older adults. Recollection of intervention materials was inconsistent over time but highest shortly after intervention delivery. The time required to mail intervention materials to patients prior to a scheduled appointment limited the reach of the intervention by excluding persons with rapidly scheduled appointments. Our work identifies key learnings in intervention roll out which can guide future translation of our intervention to other settings and other pragmatic intervention studies in this vulnerable population.

Polypharmacy and Potentially Inappropriate Medications in Stroke Rehabilitation: Prevalence and Impact

BackgroundEvidence is scarce regarding the polypharmacy and potentially inappropriate medications (PIMs) in rehabilitation medicine.AimTo investigate the prevalence and impact on outcomes of polypharmacy and PIMs in stroke rehabilitation.MethodsA retrospective cohort study was conducted with 849 older inpatients after stroke.Polypharmacy was defined as six or more medications, and PIMs were defined based on Beers criteria 2019. Study outcomes included Functional Independence Measure (FIM)-motor, FIM-cognitive, energy intake, dysphagia, length of hospital stay and the rate of home discharge. To consider the impact of pharmacotherapy during rehabilitation, multivariate analyses were used to determine whether the presence of polypharmacy or PIMs at discharge was associated with outcomes.ResultsAfter enrollment, 361 patients (mean age 78.3 ± 7.7 years; 49.3% male) were analyzed. Polypharmacy was observed in 43.8% and 62.9% of patients, and any PIMs were observed 64.8% and 65.4% of patients at admission and discharge, respectively. The most frequently prescribed PIMs included antipsychotics, benzodiazepines, and proton pump inhibitors. Polypharmacy was negatively associated with FIM-motor score (β = -0.072, P = 0.017), FIM-cognitive score (β = -0.077, P = 0.011), energy intake (β = -0.147, P = 0.004), and home discharge (OR: 0.499; 95% CI: 0.280, 0.802; P = 0.015). PIMs were negatively associated with energy intake (β = -0.066, P = 0.042) and home discharge (OR: 0.452; 95% CI: 0.215, 0.756; P = 0.005).ConclusionsPolypharmacy and PIMs are commonly found among older patients undergoing stroke rehabilitation. Moreover, polypharmacy and PIMs are negatively associated with outcomes.

Importance of medication reconciliation in cancer patients

Cancer patients are a complex and vulnerable population whose medication history is often extensive. Medication reconciliations in this population are especially essential, since medication discrepancies can lead to dire outcomes. This commentary aims to describe the significance of conducting medication reconciliations in this often-forgotten patient population. We discuss additional clinical interventions that can arise during this process as well. Medication reconciliations provide the opportunity to identify and prevent drug–drug and herb–drug interactions. They also provide an opportunity to appropriately adjust chemotherapy dosing according to renal and hepatic function. Finally, reconciling medications can also provide an opportunity to identify and deprescribe inappropriate medications. While clinical impact appears evident in this landscape, evidence of economic impact is lacking. As more cancer patients are prescribed a combination of oral chemotherapies, intravenous chemotherapies and non-anticancer medications, future studies should evaluate the advantages of conducting medication reconciliations in these patient populations across multiple care settings.

Effects of an interprofessional deprescribing intervention in Swiss nursing homes: the Individual Deprescribing Intervention (IDeI) randomised controlled trial

Background Deprescribing polypharmacy and potentially inappropriate medications (PIMs) has been shown to be beneficial to nursing home (NH) residents' health. Medication reviews are the most widely studied deprescribing intervention; in a previous trial, we showed that another intervention, a deprescribing-focused interprofessional quality circle, can reduce the use of inappropriate medications at the NH level. However, this intervention cannot account for the variety of the residents’ clinical situations. Therefore, we trialled a subsequent intervention in NH that enacted the quality circle intervention in the previous year. Methods In 7 NHs, the most heavily medicated residents were recruited and randomised to receive usual care or the intervention. The intervention was a pharmacist-led, deprescribing-focused medication review, followed by the creation of an individualised treatment modification plan in collaboration with nurses and physicians. Intervention’s effects were assessed after four months on the number and dose of PIMs used, quality of life, and safety outcomes (mortality, hospitalisations, falls, and use of physical restraints). Data were analysed using Poisson multivariate regression models. Results Sixty-two NH residents participated, falling short of the expected 100 participants; 4 died before initial data collection. Participants used a very high number of drugs (median 15, inter-quartile range [12-19]) and PIMs (median 5, IQR [3-7]) at baseline. The intervention did not reduce the number of PIMs prescribed to the participants; however, it significantly decreased their dose (incidence rate ratio 0.763, CI95 [0.594; 0.979]), in particular for chronic drugs (IRR 0.716, CI95 [0.546; 0.938]). No adverse effects were seen on mortality, hospitalisations, falls, and restraints use, but, in the intervention group, three participants experienced adverse events that required the reintroduction of withdrawn treatments, and a decrease in quality of life is possible. Conclusions As it did not reach its recruitment target, this trial should be seen as exploratory. Results indicate that, following a NH-level deprescribing intervention, a resident-level intervention can further reduce some aspects of PIMs use. Great attention must be paid to residents’ well-being when further developing such deprescribing interventions, as a possible reduction in quality of life was found in the intervention group, and some participants suffered adverse events following deprescribing. Trial registration ClinicalTrials.gov (NCT03688542, https://clinicaltrials.gov/ct2/show/NCT03688542), registered on 31.08.2018.

Assessment of Prescriptions in Elderly Patients Hospitalized in Medicine Departments

Drug-related iatrogenesis is an important issue in the elderly population, and preventing iatrogenic accidents helps to reduce hospitalizations (6). Our study’s objective was to evaluate prescriptions in the geriatric population of our establishment. The study conducted is a targeted clinical audit. Ten criteria were tested on the hospital prescriptions of people over 75 years old in 11 medical departments, before and after improvement actions. The non-compliance threshold was set at 10% of prescriptions for each criterion. In each phase, 165 patients were included. Four criteria were non-compliant (NC) in the first phase: the presence of Potentially Inappropriate Medications for the Elderly (PIMs) (NC = 57.6%), the adaptation of the medication to renal clearance (NC = 24.9%), the presence of illogical combination (NC = 9.7%), and the total anti-cholinergic score of the prescription (NC = 12.1%). After the implementation of improvement actions, the number of non-compliant criteria decreased between the two phases, from four to two. We obtained a significant improvement for three of the four criteria found to be non-compliant in the first phase. The criterion adaptation to renal function is close to compliance (NC = 10.1%) and the PIMs criterion remained non-compliant after reassessment (NC = 32.1%). Vigilance must be ongoing in order to limit drug iatrogeny, particularly in frail elderly patients.

Potentially inappropriate medications in nursing homes of iraqi elders: Pharmacists’ assessment and intervention based on 2019 beers criteria

The number of elderly people worldwide is growing with the increasing life expectancy of the human population; in Iraq, the number of elderly people aged ≥65 years was estimated to be 1.34 million in 2019. The use of potentially inappropriate medications (PIMs) is high among older adults, which is associated with an increased risk of adverse drug reactions. This study investigated the use of PIMs among elderly nursing home (NH) residents in Iraq based on 2019 Beers criteria and the application of the criteria and intervention by pharmacists. An interventional study was conducted from January 2019 to April 2019 at 2 NHs in Baghdad, Iraq. A total of 109 NH residents aged ≥65 years that were using ≥1 daily medicine were included. Patients discharged before completion of the assessment were excluded. Patients with PIMs were using significantly more medications (5.7±3.2) than those without PIMs (2.0 ±1.46) (p<0.0001). The total number of PIMs identified according to the 2019 Beers criteria was 163; for 140 of these (85.9%), pharmacists recommended changing the prescription, with 112 (68.7%) discontinued/changed as a result for an acceptance rate of 80% by physicians. Our results indicate that the use of PIMs for the treatment of Iraqi NH residents is associated with polypharmacy. Thus, prescriptions for elderly people in Iraq with polypharmacy or multiple concurrent diagnoses should be reviewed for PIMs by pharmacists to reduce the risk of adverse events.