Purpose
Benzodiazepines are effective medicines for insomnia and anxiety but are commonly used beyond recommended treatment time frames, which may lead to adverse drug events. The aim of this ...systematic review was to critically evaluate the success of interventions used to reduce benzodiazepines and ‘Z-drug’ use, and the impact of these interventions on clinical outcomes in older adults.
Methods
A search was conducted in PubMed, Embase, Informit, International Pharmaceutical Abstracts, Scopus, PsychINFO, Cochrane Central Register of Controlled Trials (CENTRAL) and CINAHL. Studies conducted in older adults (≥65 years) and published between January 1995 and July 2015 were included. Two authors independently reviewed all articles for eligibility and extracted the data.
Results
Seven studies of benzodiazepines and Z-drug withdrawal were identified. Benzodiazepine discontinuation rates were 64.3% in one study that employed pharmacological substitution with melatonin and 65.0% in a study that employed general practitioner-targeted intervention. Mixed interventions including patient education and tapering (
n
= 2), pharmacological substitution with psychological support (
n
= 1) and tapering with psychological support (
n
= 1) yielded discontinuation rates between 27.0 and 80.0%. Five studies measured clinical outcomes following benzodiazepine discontinuation. Most (
n
= 4) observed no difference in prevalence of withdrawal symptoms or sleep quality, while one study reported decline in quality of life in those who continued taking benzodiazepine vs. those who discontinued over 8 months.
Conclusions
Current evidence shows that benzodiazepine withdrawal is feasible in the older population, but withdrawal rates vary according to the type of intervention. As the benefits and sustainability of these interventions are unclear, further studies should be conducted to assess this.
Background
Hospital discharge has a significant impact on the continuity of care for people living with dementia. Clear guidance on medication management should be provided to caregivers of people ...living with dementia to ensure appropriate use of medications post-discharge.
Aim
Identify and appraise the impact of interventions at hospital discharge to guide caregivers in the medication management for people living with dementia.
Method
A systematic search of original studies was performed in Medline, Embase, PsycINFO, and CINAHL. Articles published in English that reported on interventions to guide caregivers in medication management for people living with dementia were included. Two authors independently reviewed titles and abstract. Full-text articles were assessed for eligibility and quality assessment was conducted by two authors.
Results
A total of five studies were included with a range of interventions that were typically delivered post-discharge by a multidisciplinary team and most targeted administration of medications by caregivers. Overall, three types of discharge interventions were identified including a pre-discharge caregiver educational intervention, a post-discharge multidisciplinary team intervention, and discharge summary documentation intervention at transitions of care. Of these, a pre-discharge caregiver education led to shorter hospital stay (25 days vs. 31 days,
p
= 0.005). A post-discharge intervention that included follow-up visits resulted in lower use of high-risk medications (19% vs. 40%), and reduction in 30-day re-hospitalization rates (11% vs. 20%). In contrast, in another post-discharge intervention study, no difference in one-month re-hospitalization rates (8.4% vs. 8.0%,
p
= 0.82) was demonstrated. In another study, a post-discharge hospital educational program provided to caregivers led to significantly reduced caregiver burden (31.7 ± 17.6 (SD) pre-intervention to 27.7 ± 16.9 (SD) post-intervention (
p
= 0.037)).
Discussion
Current findings suggest there is a need for well-designed interventions to guide caregivers in all aspects of medication management for people living with dementia, and should include support for caregivers in care coordination.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Drugs with anticholinergic effects are known to cause adverse effects such as dry mouth, constipation and urinary retention. In older people drugs with anticholinergic effects may contribute to ...cognitive decline and a loss of functional capacity. Many drugs that are not in the anticholinergic drug class also have anticholinergic effects. They include antidepressants, antipsychotics and antihistamines. Taking multiple drugs with anticholinergic effects creates an anticholinergic burden. It is important that clinicians identify which patients are at risk. There are several tools to assess the anticholinergic burden. Clinicians can use these tools to make a pharmacological risk assessment when reviewing a patient’s medicines. This can assist decisions about continuing or stopping drugs with anticholinergic effects. Deprescribing drugs with anticholinergic effects has several potential benefits in older people. In addition to reversing adverse effects, deprescribing may prevent problems such as falls.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
This descriptive study aimed to examine whether student past coursework performance, student or research supervisor characteristics, and the type of research project are related to the overall ...academic performance of a pharmacy student completing an honours research program.
Data on undergraduate honours students who completed a Bachelor of Pharmacy degree at The University of Sydney, Sydney, Australia, between Jan 2015 and Dec 2020 was collected. This included socio-demographic characteristics, type of project undertaken, and academic outputs. Data was also collected on each supervisor's academic role, level of experience, research area, and where they completed their PhD. Descriptive statistics were used to describe the study cohort and correlation analysis and unpaired t-tail analyses were conducted using SPSS software.
This five year study included 130 students of which 67% were female and 60% were domestic students. Each student was supervised by one of 48 individual academics who were a mix of early- (31%), mid-career (29%), and experienced researchers (40%) for pharmaceutical science (50%), clinical (45%), and education (5%) projects. Just less than half (49%) of students published one peer-reviewed journal article. Female students outperformed male students (p = 0.031) with female students also twice as likely (15%) to receive a university medal eligible mark compared with male students (7.0%). Similarly, domestic students were twice as likely (15%) to receive a university medal eligible mark when compared with international students (7.7%). Students who undertook a pharmaceutical science-based project outperformed education-based project students (p = 0.0235). Students who had published at least one peer-reviewed journal article outperformed those who had not published (p = 0.0014).
Factors that affected honours performance were student gender, residential status, type of project undertaken, and whether a student had published a peer-reviewed journal article.
Summary
This clinical review summarizes the evidence in relation to clinical outcomes from drug–drug and drug–disease interactions in older people.
Exposure to drug–drug interactions is associated ...with increased risk of hospitalization‐related outcomes in older people. Drug–disease interactions have been linked with adverse drug interactions and adverse drug events in studies of older people.
Although the prevalence of drug–drug and drug–disease interactions is common in older people, there are very limited empirical data on important clinical outcomes from drug–drug and drug–disease interactions.
Clinical implications of interactions between drugs and geriatric syndromes such as frailty, falls, cognitive impairment, immobility and urinary incontinence should also be considered in older people.
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BFBNIB, DOBA, FSPLJ, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
Different styles of interventions can reduce medication exposure in older adults. However, the evidence for their clinical effectiveness and sustainability is conflicting and lacking. There are some ...data to guide clinicians on which medicines are more likely to be inappropriate in older people, which medicines are more likely to cause ADWEs, and which medicines should be tapered slowly rather than stopped. To reduce the likelihood of clinically significant adverse events, clinicians should undertake a step-wise approach to discontinuing medications and do so under appropriate supervision. Further research to determine the most effective ways to discontinue medications, and to provide a better understanding of the clinical benefits of various interventions is required. Large RCTs evaluating multidisciplinary interventions and clinical outcomes of changes in medicines regimen across different settings are required to confirm the findings of the studies performed so far.
Background
Caregivers often undertake medication management for people living with dementia without formal training. There is a need to evaluate caregiver medication management practices for people ...living with dementia to identify and address the key issues that contribute to caregiver burden.
Objectives
This study aimed to identify and summarize approaches that evaluate medication management for caregivers of people living with dementia and appraise caregiver's involvement in aspects of medication management.
Search Strategy
A systematic search was undertaken in five databases: Medline, Embase, PsycINFO, Scopus and International Pharmaceutical s. Studies written in English that contained tools and surveys that evaluated aspects of medication management for caregivers of PWD were included.
Results
A total of 10 studies were included. Medication selection was assessed in six studies, supply and monitoring/review was captured in seven studies, with administration assessed in nine studies. Caregivers were commonly involved in decision‐making for medication changes (77.1%–86.8%) and in the ordering (55.9%–86.0%) and collection (87.0%–92.4%) of medications. Reported caregiver involvement in medication administration showed a wide range (44%–94.7%) between the studies. Challenges in administration were commonly related to polypharmacy and dosage regimen complexity.
Conclusions
Current tools capture specific aspects of medication management, with medication administration the most evaluated aspect of medication management. Future research is needed to develop a tool to holistically evaluate the complexities of medication management for caregivers of people living with dementia to minimize adverse events at transitions of care.
Public Contribution
From the authors' previous research, caregivers highlighted the need to address key issues in medication management for people living with dementia.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Evidence is lacking about outcomes associated with the cumulative use of anticholinergic and sedative drugs in people with Alzheimer's disease (AD). This retrospective cohort study investigated the ...relationship between cumulative exposure to anticholinergic and sedative drugs and hospitalization and mortality in people with and without AD in Finland.
Community-dwelling people aged 65 years and over, with AD on December 31(st) 2005 (n = 16,603) and individually matched (n = 16,603) comparison persons (age, sex, region of residence) were identified by the Social Insurance Institution of Finland. Drug utilization data were extracted from the Finnish National Prescription Register. Exposure to anticholinergic and sedative drugs was defined using the Drug Burden Index (DBI). Hospitalization and mortality data were extracted from national registers. Cox and zero-inflated negative binomial analyses were used to investigate the relationship between DBI and hospitalization and mortality over a one-year follow-up.
In total, 5.8% of people with AD and 3.7% without AD died during 2006. For every unit increase in DBI, the adjusted hazard ratio for mortality was 1.21 (95% confidence intervals CI: 1.09-1.33) among people with AD, and 1.37 (95%CI: 1.20-1.56) among people without AD. Overall, 44.3% of people with AD and 33.4% without AD were hospitalized. When using no DBI exposure as the reference group, the adjusted incidence rate ratio for length of hospital stay among high DBI group (≥1) in people with AD was 1.15 (95%CI: 1.05-1.26) and 1.63 (95%CI: 1.41-1.88) in people without AD.
There is a dose-response relationship between cumulative anticholinergic and sedative drug use and hospitalization and mortality in people with and without AD.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Background:
The aim of this study was (1) to apply the current United Kingdom (UK) National Institute for Health and Care Excellence (NICE) clinical practice guidelines to a hypothetical older ...patient with multimorbidity and life-limiting illness; (2) consider how treatment choices could be influenced by NICE guidance specifically related to multimorbidity; and, (3) ascertain if such clinical practice guidelines describe how and when medication should be reviewed, reduced and stopped.
Methods:
Based upon common long-term conditions in older people, a hypothetical older patient was constructed. Relevant NICE guidelines were applied to the hypothetical patient to determine what medication should be initiated in three treatment models: a new patient model, a treatment-resistant model, and a last-line model. Medication complexity for each model was assessed according to the medication regimen complexity index (MRCI).
Results:
The majority of the guidelines recommended the initiation of medication in the hypothetical patient; if the initial treatment approach was unsuccessful, each guideline advocated the use of more medication, with the regimen becoming increasingly complex. In the new patient model, 4 separate medications (9 dosage units) would be initiated per day; for the treatment-resistant model, 6 separate medications (15 dosage units); and, for the last-line model, 11 separate medications (20 dosage units). None of the guidelines used for the hypothetical patient discussed approaches to stopping medication.
Conclusions:
In a UK context, disease-specific clinical practice guidelines routinely advocate the initiation of medication to manage long-term conditions, with medication regimens becoming increasingly complex through the different steps of care. There is often a lack of information regarding specific treatment recommendations for older people with life-limiting illness and multimorbidity. While guidelines frequently explain how and when a medication should be initiated, there is often no information concerning when and how the medications should be reduced or stopped.
Aims
Anticholinergic drug exposure is associated with adverse outcomes in older people. While a number of tools have been developed to measure anticholinergic drug exposure, there is limited ...information about the agreement and overlap between the various scales. The aim of this study was to investigate the agreement and overlap between different measures of anticholinergic drug exposure in a cohort of community‐dwelling older men.
Methods
A cross‐sectional study was used to compare anticholinergic drug exposure calculated using the Anticholinergic Risk Scale (ARS), the Anticholinergic Drug Scale (ADS), the Anticholinergic Cognitive Burden (ACB) and the Drug Burden Index anticholinergic subscale (DBI‐ACH) in a cohort of community‐dwelling men aged 70 years and older (n = 1696). Statistical agreement, expressed as Cohen's kappa (κ), between these measurements was calculated.
Results
Differences were found between the tools regarding the classification of anticholinergic drug exposure for individual participants. Thirteen percent of the population used a drug listed as anticholinergic on the ARS, 39% used a drug listed on the ADS and the ACB, and 18% of the population used one or more anticholinergic drugs listed on the DBI‐ACH. While agreement was good between the ACB and ADS (κ = 0.628, 95% CI 0.593, 0.664), little agreement was found between remaining tools (κ = 0.091–0.264).
Conclusions
With the exception of the ACB and ADS, there was poor agreement regarding anticholinergic drug exposure among the four tools compared in this study. Great care should be taken when interpreting anticholinergic drug exposure using existing scales due to the wide variability between the different scales.
Full text
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
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