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Optimizing drug therapy among people with dementia: the role of clinical pharmacists
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine. Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Pharmacology. Umeå University, Faculty of Medicine, Department of Nursing.
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Drugs are one of the cornerstones in the management of many diseases. In general, drugs are used for diagnosis, prevention, mitigation of symptoms, and, sometimes, to cure disease. However, drug treatment in elderly people, especially those with dementia and cognitive impairments, may involve significant risk of adverse drug events.  The aim of this thesis was to identify the extent of potentially inappropriate drug treatment among people with dementia and cognitive impairment and to assess the occurrence and character of drug-related problems that lead to acute hospital admissions. Another aim was to assess the potential impact of a comprehensive medication review conducted by clinical pharmacists as part of a health care team on quality of patients’ drug therapy and drug-related hospital readmission rates.

Method: Long-term use of antipsychotic/psychotropic drugs and associated factors were investigated among 344 and 278 people respectively with dementia living in specialized care units. Trends in the prescribing of potentially inappropriate drugs between 2007 and 2013, comprising 2772 and 1902 people, living in nursing homes in the county of Västerbotten, were assessed using six national quality indicators. Data on drug use, function in the activities of daily living, cognitive function and behavioral and psychological symptoms were collected using the Multi-Dimensional Dementia Assessment Scale. Further, an investigation of a separate corresponding population from 2012 was done, where potentially inappropriate drug use was measured before and after a total of 895 medication reviews. Finally, a randomized, controlled trial was carried out among people 65 years or older with dementia or cognitive impairment in internal medicine and orthopedic wards at two hospitals in northern Sweden. The proportion of hospital admissions that were drug-related were estimated, and also whether comprehensive medication reviews conducted by clinical pharmacists as part of a health care team could affect the risk of drug-related hospital readmissions.

Results: Antipsychotic and other psychotropic drugs were frequently prescribed to people with dementia living in specialized care units for prolonged periods. Associations were found between behavioral and psychological symptoms and different psychotropic drugs. The extent of potentially inappropriate drug use declined between 2007 and 2013. In the separate corresponding population from 2012, the frequency of potentially inappropriate drug use was significantly reduced among people who underwent medication reviews. Hospitalizations due to drug-related problems among old people with dementia or cognitive impairment were prevalent. We found that inclusion of a clinical pharmacist in the health care team significantly reduced the risk of drug-related 30-day and 180-day readmissions. However, in a subset of patients with concomitant heart failure no effect was seen.

Conclusion: Among patients with dementia or cognitive impairment long-term treatment with antipsychotic and other psychotropic drugs is common. The results indicate that these drugs are prescribed to treat behavioral and psychological symptoms among cognitively impaired individuals, despite limited evidence of their efficacy and the high risk of adverse effects. Drug-related problems, such as adverse drug reactions, constituted a major cause of hospital admissions. By reducing potentially inappropriate drug use and optimizing overall drug therapy, inclusion of clinical pharmacists in a health care team might improve the quality of patient care and reduce the risk of hospital readmissions among people with dementia.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2016. , 104 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1789
Keyword [en]
Psychotropic drugs, potentially inappropriate drugs, drug-related problems, old people, dementia, nursing homes, drug-related hospitalizations, medication reviews, clinical pharmacists
National Category
Geriatrics
Research subject
Geriatrics
Identifiers
URN: urn:nbn:se:umu:diva-118309ISBN: 978-91-7601-436-3 (print)OAI: oai:DiVA.org:umu-118309DiVA: diva2:912099
Public defence
2016-04-08, Hörsal B, byggnad 1A, Tandläkarhögskolan våning 9, Umeå universitetssjukhus, Umeå, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2016-03-18 Created: 2016-03-15 Last updated: 2016-05-10Bibliographically approved
List of papers
1. Inappropriate long-term use of antipsychotic drugs is common among people with dementia living in specialized care units
Open this publication in new window or tab >>Inappropriate long-term use of antipsychotic drugs is common among people with dementia living in specialized care units
2013 (English)In: BMC pharmacology & toxicology, ISSN 2050-6511, Vol. 14, 10- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Antipsychotic drugs are widely used for the treatment of Behavioral and Psychological Symptoms of Dementia (BPSD), despite their limited efficacy and concerns about safety. The aim of this study was to describe antipsychotic drug therapy among people with dementia living in specialized care units in northern Sweden.

METHODS: This study was conducted in 40 specialized care units in northern Sweden, with a total study population of 344 people with dementia. The study population was described in regard to antipsychotic drug use, ADL function, cognitive function and BPSD, using the Multi-Dimensional Dementia Assessment Scale (MDDAS). These data were collected at baseline and six months later. Detailed data about antipsychotic prescribing were collected from prescription records.

RESULTS: This study showed that 132 persons (38%) in the study population used antipsychotic drugs at the start of the study. Of these, 52/132 (39%) had prescriptions that followed national guidelines with regard to dose and substance.After six months, there were 111 of 132 persons left because of deaths and dropouts. Of these 111 people, 80 (72%) were still being treated with antipsychotics, 63/111 (57%) with the same dose. People who exhibited aggressive behavior (OR: 1.980, CI: 1.515-2.588), or passiveness (OR: 1.548, CI: 1.150-2.083), or had mild cognitive impairment (OR: 2.284 CI: 1.046-4.988), were at increased risk of being prescribed antipsychotics.

CONCLUSION: The prevalence of antipsychotic drug use among people with dementia living in specialized care units was high and inappropriate long-term use of antipsychotic drugs was common.

Keyword
Antipsychotic prescribing, Dementia, BPSD, Inappropriate prescribing, Aggression, Passiveness
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-70117 (URN)10.1186/2050-6511-14-10 (DOI)000319696500001 ()23391323 (PubMedID)
Available from: 2013-05-06 Created: 2013-05-06 Last updated: 2016-03-15Bibliographically approved
2. Psychotropic drug use among people with dementia - a six-month follow-up study
Open this publication in new window or tab >>Psychotropic drug use among people with dementia - a six-month follow-up study
2013 (English)In: BMC pharmacology & toxicology, ISSN 2050-6511, Vol. 14, 56- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Psychotropic drugs are widely used among old people with dementia but few studies have described long-term treatment in this group of patients. The purpose of this study was to explore the long-term use of psychotropic drugs in old people with dementia.

METHODS: Data on psychotropic drug use, functioning in the activities of daily living (ADL), cognitive function and behavioral and psychological symptoms were collected at baseline and six months later, using the Multi-Dimensional Dementia Assessment Scale (MDDAS). The data were collected in 2005-2006. Detailed data about the prescribing of psychotropic drugs were collected from prescription records. This study was conducted in 40 specialized care units in northern Sweden, with a study population of 278 people with dementia.

RESULTS: At the start of the study, 229 of the participants (82%) were prescribed at least one psychotropic drug; 150 (54%) used antidepressants, 43 (16%) used anxiolytics, 107 (38%) used hypnotics and sedatives, and 111 (40%) used antipsychotics. Among the baseline users of antidepressants, anxiolytics, hypnotics and sedatives and antipsychotics, 67%, 44%, 57% and 57% respectively, still used the same dose of the same psychotropic drug after six months. Associations were found between behavioral and psychological symptoms and different psychotropic drugs.

CONCLUSION: Psychotropic drug use was high among people with dementia living in specialized care units and in many cases the drugs were used for extended periods. It is very important to monitor the effects and adverse effects of the prescribed drug in this frail group of people.

Place, publisher, year, edition, pages
BioMed Central, 2013
Keyword
Psychotropic drugs, Dementia, BPSD, Psychotropic prescribing
National Category
Endocrinology and Diabetes
Identifiers
urn:nbn:se:umu:diva-84826 (URN)10.1186/2050-6511-14-56 (DOI)24196341 (PubMedID)
Funder
Swedish Research Council, K2005-27-VX-15357-01A
Available from: 2014-01-20 Created: 2014-01-20 Last updated: 2016-03-15Bibliographically approved
3. Reduction in the use of potentially inappropriate drugs among old people living in geriatric care units between 2007 and 2013
Open this publication in new window or tab >>Reduction in the use of potentially inappropriate drugs among old people living in geriatric care units between 2007 and 2013
Show others...
2015 (English)In: European Journal of Clinical Pharmacology, ISSN 0031-6970, E-ISSN 1432-1041, Vol. 71, no 4, 507-515 p.Article in journal (Refereed) Published
Abstract [en]

PURPOSE: The aims of this study were to investigate trends in the prevalence of potentially inappropriate drug use among old people living in geriatric care units in the county of Västerbotten between 2007 and 2013 using six national quality indicators and to assess the impact of medication reviews on those quality indicators.

METHODS: Data were collected concerning potentially inappropriate drug use, function in the activities of daily living (ADL) and cognitive function, using the Multi-Dimensional Dementia Assessment Scale (MDDAS). A comparison was made between the years 2007 and 2013, comprising 2772 and 1902 people, respectively, living in geriatric care in the county of Västerbotten, Sweden. We conducted a parallel investigation of a separate corresponding population in Västerbotten County from 2012, where potentially inappropriate drug use was measured before and after 895 medication reviews which involved a clinical pharmacist.

RESULTS: After controlling for age, sex, ADL and cognitive impairment, there was a significant improvement in five out of six quality indicators between 2007 and 2013. While 44 % of the people were exposed to one or more potentially inappropriate medications in 2007, this number had declined to 26 % by 2013. In the separate population from 2012, the frequency of potentially inappropriate drug use was significantly reduced amongst the people who had a medication review performed.

CONCLUSION: The extent of potentially inappropriate drug use declined between 2007 and 2013 according to the quality indicators used. Medication reviews involving clinical pharmacists might be an important factor in reducing potentially inappropriate drug use and improving drug treatment among old people.

Keyword
Potentially inappropriate drug use, Medication reviews, Clinical pharmacist, Nursing home, Dementia
National Category
Nursing Pharmacology and Toxicology
Identifiers
urn:nbn:se:umu:diva-100807 (URN)10.1007/s00228-015-1825-z (DOI)000351224600013 ()25716889 (PubMedID)
Available from: 2015-03-10 Created: 2015-03-10 Last updated: 2017-05-23Bibliographically approved
4. Drug-related hospital admissions among old people with dementia
Open this publication in new window or tab >>Drug-related hospital admissions among old people with dementia
Show others...
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Purpose: Drug treatment associated problems, including medication errors and adverse drug events, are common, and are the cause of a large proportion of hospital admissions in old people. People with dementia are especially at risk of drug-related problems. The objectives of this study were to assess the occurrence and character of drug-related problems that lead to acute hospital admissions among old people with dementia or cognitive impairment.

 

Methods: This study was conducted in orthopedic and internal medicine wards in two hospitals in Northern Sweden. Information about acute admissions was collected from the medical records of the study population. A total of 458 people aged 65 years or older with dementia or cognitive impairment were included in the study. The contribution of drug related problems to each hospitalization was assessed.

 

Results: Of 458 acute hospital admissions, 189 (41.3%) were determined to be drug-related. The most common drug-related problem (86/189; 45.5%) was an adverse drug reaction. In total, 264 drugs were judged to be involved in 189 drug-related admissions, of which cardiovascular (29.5%) and psychotropic (26.9%) drugs were the most commonly involved drug classes. The relationship between the drug-related problem and the admission was judged certain in 25 cases, probable in 78 cases, and possible in 86 cases. Drug-related admissions were more common among people taking more drugs and among younger patients.

 

Conclusion: Drug-related problems appear to be responsible for a major proportion of hospitalizations among old people with dementia or cognitive impairment. Targeted interventions may be warranted to reduce drug-related problems.

 

National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-118305 (URN)
Available from: 2016-03-15 Created: 2016-03-15 Last updated: 2016-03-15
5. Pharmacist participation in hospital ward teams and hospital readmission rates among people with dementia: a randomized controlled trial
Open this publication in new window or tab >>Pharmacist participation in hospital ward teams and hospital readmission rates among people with dementia: a randomized controlled trial
Show others...
2017 (English)In: European Journal of Clinical Pharmacology, ISSN 0031-6970, E-ISSN 1432-1041, Vol. 7, no 73, 827-835 p.Article in journal (Refereed) Published
Abstract [en]

Purpose: To assess whether comprehensive medication reviews conducted by clinical pharmacists as part of a healthcare team reduce drug-related hospital readmission rates among people with dementia or cognitive impairment.

Methods: This randomized controlled trial was carried out between January 9, 2012, and December 2, 2014. Patients aged ≥65 years with dementia or cognitive impairment admitted to three wards at two hospitals located in Northern Sweden were included.

Results: Of the 473 deemed eligible for participation, 230 were randomized to intervention and 230 to control group by block randomization. The primary outcome, risk of drug-related hospital readmissions, was assessed at 180 days of follow-up by intention-to-treat analysis.

During the 180 days of follow-up, 18.9% (40/212) of patients in the intervention group and 23.0% (50/217) of those in the control group were readmitted for drug-related reasons (HR = 0.80, 95% CI = 0.53–1.21, p = 0.28, univariable Cox regression). Heart failure was significantly more common in the intervention group. After adjustment for heart failure as a potential confounder and an interaction term, multiple Cox regression analysis indicated that pharmacist participation significantly reduced the risk of drug-related readmissions (HR = 0.49, 95% CI = 0.27–0.90, p = 0.02). A post-hoc analysis showed a significantly reduced risk of 30-day readmissions due to drug-related problems in the total sample (without adjustment for heart failure).

Conclusion: Participation of clinical pharmacists in healthcare team conducting comprehensive medication reviews did not significantly reduce the risk of drug-related readmissions in patients with dementia or cognitive impairment; however, post-hoc and subgroup analyses indicated significant effects favoring the intervention. More research is needed.

Trial registration: Clinical trials NCT01504672.

Place, publisher, year, edition, pages
Springer, 2017
Keyword
Medication reviews, Clinical pharmacists, Drug-related readmissions, Dementia, Old people
National Category
Geriatrics Social and Clinical Pharmacy
Identifiers
urn:nbn:se:umu:diva-118307 (URN)10.1007/s00228-017-2249-8 (DOI)000405666100005 ()
Available from: 2016-03-15 Created: 2016-03-15 Last updated: 2017-08-18Bibliographically approved

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