Systems to identify potentially inappropriate prescribing in people with advanced dementia: a systematic review

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Abstract

Background

Systems for identifying potentially inappropriate medications in older adults are not immediately transferrable to advanced dementia, where the management goal is palliation. The aim of the systematic review was to identify and synthesise published systems and make recommendations for identifying potentially inappropriate prescribing in advanced dementia.

Methods

Studies were included if published in a peer-reviewed English language journal and concerned with identifying the appropriateness or otherwise of medications in advanced dementia or dementia and palliative care. The quality of each study was rated using the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) checklist. Synthesis was narrative due to heterogeneity among designs and measures. Medline (OVID), CINAHL, the Cochrane Database of Systematic Reviews (2005 – August 2014) and AMED were searched in October 2014. Reference lists of relevant reviews and included articles were searched manually.

Results

Eight studies were included, all of which were scored a high quality using the STROBE checklist. Five studies used the same system developed by the Palliative Excellence in Alzheimer Care Efforts (PEACE) Program. One study used number of medications as an index, and two studies surveyed health professionals’ opinions on appropriateness of specific medications in different clinical scenarios.

Conclusions

Future research is needed to develop and validate systems with clinical utility for improving safety and quality of prescribing in advanced dementia. Systems should account for individual clinical context and distinguish between deprescribing and initiation of medications.

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Most cited references 23

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The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.

Erik von Elm, Douglas G Altman, Matthias Egger … (2007)

Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalisability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case-control and cross-sectional studies. We convened a 2-day workshop in September 2004, with methodologists, researchers, and journal editors to draft a checklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE Statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles. 18 items are common to all three study designs and four are specific for cohort, case-control, or cross-sectional studies. A detailed Explanation and Elaboration document is published separately and is freely available on the websites of PLoS Medicine, Annals of Internal Medicine and Epidemiology. We hope that the STROBE Statement will contribute to improving the quality of reporting of observational studies.

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Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy.

Doron Garfinkel, Derelie Mangin (2010)

Polypharmacy and inappropriate medication use is a problem in elderly patients, who are more likely to experience adverse effects from multiple treatments and less likely to obtain the same therapeutic benefit as younger populations. The Good Palliative-Geriatric Practice algorithm for drug discontinuation has been shown to be effective in reducing polypharmacy and improving mortality and morbidity in nursing home inpatients. This study reports the feasibility of this approach in community-dwelling older patients. The Good Palliative-Geriatric Practice algorithm was applied to a cohort of 70 community-dwelling older patients to recommend drug discontinuations. Success rates of discontinuation, morbidity, mortality, and changes in health status were recorded. The mean (SD) age of the 70 patients was 82.8 (6.9) years. Forty-three patients (61%) had 3 or more and 26% had 5 or more comorbidities. The mean follow-up was 19 months. Participants used a mean (SD) of 7.7 (3.7) medications. Protocol indicated that discontinuation was recommended for 311 medications in 64 patients (58% of drugs; mean [SD], 4.4 [2.5] drugs per patient overall, 4.9 per patient who had discontinuation). Of the discontinued drug therapies, 2% were restarted because of recurrence of the original indication. Taking nonconsent and failures together, successful discontinuation was achieved in 81%. Ten elderly patients (14%) died after a mean follow-up of 13 months, with the mean age at death of 89 years. No significant adverse events or deaths were attributable to discontinuation, and 88% of patients reported global improvement in health. It is feasible to decrease medication burden in community-dwelling elderly patients. This tool would be suitable for larger randomized controlled trials in different clinical settings.

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Polypharmacy and prescribing quality in older people.

Michael A Steinman, C. Seth Landefeld, Gary Rosenthal … (2006)

To evaluate the relationship between inappropriate prescribing, medication underuse, and the total number of medications used by patients. Cross-sectional study. Veterans Affairs Medical Center. One hundred ninety-six outpatients aged 65 and older who were taking five or more medications. Inappropriate prescribing was assessed using a combination of the Beers drugs-to-avoid criteria (2003 update) and subscales of the Medication Appropriateness Index that assess whether a drug is ineffective, not indicated, or unnecessary duplication of therapy. Underuse was assessed using the Assessment of Underutilization of Medications instrument. All vitamins and minerals, topical and herbal medications, and medications taken as needed were excluded from the analyses. Mean age was 74.6, and patients used a mean+/-standard deviation of 8.1+/-2.5 medications (range 5-17). Use of one or more inappropriate medications was documented in 128 patients (65%), including 73 (37%) taking a medication in violation of the Beers drugs-to-avoid criteria and 112 (57%) taking a medication that was ineffective, not indicated, or duplicative. Medication underuse was observed in 125 patients (64%). Together, inappropriate use and underuse were simultaneously present in 82 patients (42%), whereas 25 (13%) had neither inappropriate use nor underuse. When assessed by the total number of medications taken, the frequency of inappropriate medication use rose sharply from a mean of 0.4 inappropriate medications in patients taking five to six drugs, to 1.1 inappropriate medications in patients taking seven to nine drugs, to 1.9 inappropriate medications in patients taking 10 or more drugs (P<.001). In contrast, the frequency of underuse averaged 1.0 underused medications per patient and did not vary with the total number of medications taken (P=.26). Overall, patients using fewer than eight medications were more likely to be missing a potentially beneficial drug than to be taking a medication considered inappropriate. Inappropriate medication use and underuse were common in older people taking five or more medications, with both simultaneously present in more than 40% of patients. Inappropriate medication use is most frequent in patients taking many medications, but underuse is also common and merits attention regardless of the total number of medications taken.

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Author and article information

Contributors

Domenica Disalvo: +61 2 9514 4862 , domenica.m.disalvo@student.uts.edu.au

Journal

Journal ID (nlm-ta): BMC Geriatr

Journal ID (iso-abbrev): BMC Geriatr

Title: BMC Geriatrics

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2318

Publication date (Electronic): 31 May 2016

Publication date PMC-release: 31 May 2016

Publication date Collection: 2016

Volume: 16

Electronic Location Identifier: 114

Affiliations

[ ]Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney (UTS), 235-253 Jones St, Ultimo, NSW 2007 Australia

[ ]Ingham Institute of Applied Medical Research, Sydney, NSW Australia

[ ]HammondCare, Sydney, NSW Australia

[ ]South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW Australia

[ ]NSW Therapeutic Advisory Group, Sydney, NSW Australia

[ ]St Vincent’s Hospital, Sydney, Australia

[ ]School of Nursing, Johns Hopkins University (JHU), Baltimore, USA

Article

Publisher ID: 289

DOI: 10.1186/s12877-016-0289-z

PMC ID: 4888427

PubMed ID: 27245843

SO-VID: aca7c86e-fcfa-4f6d-b05a-3f35b6674392

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 1 March 2016

Date accepted : 23 May 2016

Custom metadata

ScienceOpen disciplines: Geriatric medicine

Keywords: dementia,polypharmacy,deprescribing,inappropriate prescribing,medication review,palliative care

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ScienceOpen disciplines: Geriatric medicine

Keywords: dementia, polypharmacy, deprescribing, inappropriate prescribing, medication review, palliative care

Systems to identify potentially inappropriate prescribing in people with advanced dementia: a systematic review

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Abstract

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Karger: Neurology and Neuroscience

Most cited references 23

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.

Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy.

Polypharmacy and prescribing quality in older people.

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