A systematic review of prescribing criteria to evaluate appropriateness of medications in frail older people

This study systematically reviews the published literature regarding inappropriate prescribing in frail individuals aged at least 65 years. Twenty-five of 466 identified studies met the inclusion criteria. All papers measured some surrogate indicators of frailty, such as performance-based tests, cognitive function and functional dependency. Beers criteria were used in 20 studies (74%) to evaluate inappropriate medication use and 36% (9/25) studies used more than one criterion. The prevalence of inappropriate medications ranged widely from 11 to 92%. Only a few studies reported the relationship between potentially inappropriate medication use and surrogate measures of frailty. These diverse findings indicate the need for a standardized measure for assessing appropriateness of medication in frail older individuals. Prescribing tools should address both medication and patient-related factors such as life expectancy and functional status to minimize inappropriate prescribing in frail individuals.

Algorithm of medication review in frail older people: Focus on minimizing the use of high-risk medications

Aim Frail older people typically suffer several chronic diseases, receive multiple medications and are more likely to be institutionalized in residential aged care facilities. In such patients, optimizing prescribing and avoiding use of high-risk medications might prevent adverse events. The present study aimed to develop a pragmatic, easily applied algorithm for medication review to help clinicians identify and discontinue potentially inappropriate high-risk medications. Methods The literature was searched for robust evidence of the association of adverse effects related to potentially inappropriate medications in older patients to identify high-risk medications. Prior research into the cessation of potentially inappropriate medications in older patients in different settings was synthesized into a four-step algorithm for incorporation into clinical assessment protocols for patients, particularly those in residential aged care facilities. Results The algorithm comprises several steps leading to individualized prescribing recommendations: (i) identify a high-risk medication; (ii) ascertain the current indications for the medication and assess their validity; (iii) assess if the drug is providing ongoing symptomatic benefit; and (iv) consider withdrawing, altering or continuing medications. Decision support resources were developed to complement the algorithm in ensuring a systematic and patient-centered approach to medication discontinuation. These include a comprehensive list of high-risk medications and the reasons for inappropriateness, lists of alternative treatments, and suggested medication withdrawal protocols. Conclusions The algorithm captures a range of different clinical scenarios in relation to potentially inappropriate medications, and offers an evidence-based approach to identifying and, if appropriate, discontinuing such medications. Studies are required to evaluate algorithm effects on prescribing decisions and patient outcomes.

Geriatrician interventions on medication prescribing for frail older people in residential aged care facilities

Objective: In Australian residential aged care facilities (RACFs), the use of certain classes of high-risk medication such as antipsychotics, potent analgesics, and sedatives is high. Here, we examined the prescribed medications and subsequent changes recommended by geriatricians during comprehensive geriatric consultations provided to residents of RACFs via videoconference. Design: This is a prospective observational study. Setting: Four RACFs in Queensland, Australia, are included. Participants: A total of 153 residents referred by general practitioners for comprehensive assessment by geriatricians delivered by video-consultation. Results: Residents’ mean (standard deviation, SD) age was 83.0 (8.1) years and 64.1% were female. They had multiple comorbidities (mean 6), high levels of dependency, and were prescribed a mean (SD) of 9.6 (4.2) regular medications. Ninety-one percent of patients were taking five or more medications daily. Of total medications prescribed (n=1,469), geriatricians recommended withdrawal of 9.8% (n=145) and dose alteration of 3.5% (n=51). New medications were initiated in 47.7% (n=73) patients. Of the 10.3% (n=151) medications considered as high risk, 17.2% were stopped and dose altered in 2.6%. Conclusion: There was a moderate prevalence of potentially inappropriate high-risk medications. However, geriatricians made relatively few changes, suggesting either that, on balance, prescription of these medications was appropriate or, because of other factors, there was a reluctance to adjust medications. A structured medication review using an algorithm for withdrawing medications of high disutility might help optimize medications in frail patients. Further research, including a broader survey, is required to understand these dynamics.

‘All in a day’s work’ : the lifeworld of older people in New Zealand rest homes

This doctoral thesis contributes to critical gerontology research by investigating the lived experiences of residents in the everyday world of New Zealand rest homes. There is a need to understand how frail rest home residents experience "age". This study focuses on describing and understanding residents lived experiences. As the New Zealand population is ageing, this phenomenological focus adds clarity to the poorly understood lived experiences about being aged in rest homes. Policy initiatives such as the Positive Ageing Strategy with its emphasis on keeping older people living in the community largely ignore the life practices of the increasing proportions of frail older people who require long-term residential care. My mixed-methods modified framework approach draws on the lifeworld as understood by Max van Manen (1990) and Alfred Schütz (1972). The lifeworld is made up of thematic strands of lived experience: these being lived space, lived time, lived body and lived relations with others, which are both the source and object of phenomenological research (van Manen, 1990). These strands are temporarily unravelled and considered in-depth for 27 residents who took part in audio-recorded interviews, before being interwoven through a multiple-helix model, into an integrated interpretation of the residents‟ lifeworld. Supplementing and backgrounding the interviews with these residents, are descriptive data including written interview summaries and survey findings about the relationships and pastimes of 352 residents living in 21 rest homes, which are counted and described. The residents day-to-day use of rest home space, mediated temporal order, self-managed bodies and minds, and negotiated relationships are interpreted. The mythology of the misery of rest home life is challenged, and a more constructive critical gerontology approach is offered. Findings of this research reveal how meanings around daily work practices are constructed by the residents. These elders participate in daily rest home life, from the sidelines or not at all, as they choose or are able, and this always involves work for the residents. They continue to actively manage satisfactory and fulfilling pastimes and relationships, because in their ordinary, everyday lifeworld it is “all in a day‟s work”.

Prescribing for older people discharged from the acute sector to residential aged-care facilities

For frail older people, admission to hospital is an opportunity to review the indications for specific medications. This research investigates prescribing for 206 older people discharged into residential aged care facilities from 11 acute care hospitals in Australia. Patients had multiple comorbidities (mean 6), high levels of dependency, and were prescribed a mean of 7.2 regular medications at admission to hospital and 8.1 medications on discharge, with hyper-polypharmacy (≥10 drugs) increasing from 24.3% to 32.5%. Many drugs were preventive medications whose time until benefit was likely to exceed the expected lifespan. In summary, frail patients continue to be exposed to extensive polypharmacy and medications with uncertain risk–benefit ratio.

Frailty: A key indicator to minimize inappropriate medication in older people

Older populations are more likely to have multiple co-morbid diseases that require multiple treatments, which make them a large consumer of medications. As a person grows older, their ability to tolerate medications becomes less due to age-related changes in pharmacokinetics and pharmacodynamics often heading along a path that leads to frailty. Frail older persons often have multiple co-morbidities with signs of impairment in activities of daily living. Prescribing drugs for these vulnerable individuals is difficult and is a potentially unsafe activity. Inappropriate prescribing in older population can be detected using explicit (criterion-based) or implicit (judgment-based) criteria. Unfortunately, most current therapeutic guidelines are applicable only to healthy older adults and cannot be generalized to frail patients. These discrepancies should be addressed either by developing new criteria or by refining the existing tools for frail older people. The first and foremost step is to identify the frail patient in clinical practice by applying clinically validated tools. Once the frail patient has been identified, there is a need for specific measures or criteria to assess appropriateness of therapy that consider such factors as quality of life, functional status and remaining life expectancy and thus modified goals of care.

Transition to day care for older people in Taiwan : a grounded theory study

Adult day care centres provide a means whereby frail or disabled older people can remain living at home particularly when their family care-givers engage in waged work. In Taiwan, adult day care services appear to meet the cultural needs of both older people and their families for whom filial care is vital. Little research attention has been paid to the use of day care services in Taiwan, the uptake rate of which is low. This grounded theory study explored the ways in which older people and family care-givers construct meanings around the use of day care services in Taiwan. Forty-four semi-structured interviews were undertaken with older people, care-givers and day care centre managers. The findings from grounded theory data analysis bring focus to the assumptions and structures that underpin the process of transition to day care services. A key feature of this process is the reconstruction of personal identity as both the older people and family care-givers work to make sense of the relationship between the self and a changing social structure. Reconstructing identity in a shifting world is the core category of the study and reflects a process of reframing whereby older people came to new definitions of social responsibility and independence within the context of the day care centre. Similarly, the family care-givers actively reformulated the concept of filial piety as they interacted with and interpreted the changes in economic and social conditions in Taiwan.

Comprehensive assessment of the fitness of older people for chemotherapy

Purpose: To present the results of a mixed-method study comparing the level of agreement of a two-phased, nurse-administered Comprehensive Geriatric Assessment (CGA) with current methods that assess the fitness for chemotherapy of older cancer patients. A nurse-led model of multidisciplinary cancer care based on the results is also described. Methods: The two phases comprised initial screening by a nurse with the Vulnerable Elders Survey-13 [VES-13], followed by nurse administration of a detailed CGA. Both phases were linked to a computerised algorithm categorising the patient as ‘fit’, ‘vulnerable’ or ‘frail’. The study determined the level of agreement between VES-13- and CGA-determined categories; and between the CGA and the physicians’ assessments. It also compared the CGA’s predictive abilities in terms of subsequent treatment toxicity; while interviews determined the acceptability of the nurse-led procedure from key stakeholders' perspectives. Results: Data collection was completed in December 2011. The results will be presented at the conference. A consecutive-series n=170 will be enrolled, 33% of whom are ‘fit’; 33% ‘vulnerable’; and 33% ‘too frail’ for treatment. This sample can detect, with 90% power, kappa coefficients of agreement of ≥ 0.70 or higher (“substantial agreement”). Fitness sub-group comparisons of agreement between the medical oncologist and the nurse assessments can detect kappa estimates of Κ ≥ 0.80 with the same power. Conclusion: The results have informed a nurse-led model of cancer care. It meets a clear need to develop, implement and test a nurse-led, robust, evidence-based, clinically-justifiable and economically-feasible CGA process that has relevance in national and international contexts.

Reconstructing identity of older people in using day care services in Taiwan: A grounded theory study

Adult day care centers provide a means whereby frail or disabled older people can remain living at home particularly when their family care-givers engage in waged work. In Taiwan, adult day care services appear to meet the cultural needs of both older people and their families for whom filial care is vital. Little research attention has been paid to the use of day care services in Taiwan, the uptake rate of which is low. This grounded theory study explored the ways in which older people and family care-givers construct meanings around the use of day care services in Taiwan. The research methodology drew on the theoretical tenets of symbolic interactionism and methods were informed by the grounded theory. In-depth interviews with 30 participants were undertaken. Reconstructing identity in a shifting world is the core category of the study and reflects a process of reframing whereby older people came to new definitions of social responsibility and independence within the context of the day care center. The implications of the findings is that the older people, rather than seeking to be relieved of social responsibilities, worked very hard to frame and reframe a social role. Rather than letting the institutions undermine or disrupt their identity, the older people worked to actively negotiate and redefine the meaning of self. Thus, although reluctant to come to use the services at the outset, they found a way to manage their lives independently. Social roles and responsibilities as older parents were retained. This study explored the process of meaning construction of day care use and the ways in which this process entailed a reconstruction of the identities of the participants. The evidence from this study underlines the importance of recognizing and acknowledging subjectively conceived identities as work that older people undertake, when in care, to render their lives meaningful.

Levels of cardiac knowledge and cardiopulmonary resuscitation training among older people in Queensland

Objectives: The current study was conducted to determine levels of cardiac knowledge and cardiopulmonary resuscitation (CPR) training in older people in Queensland, Australia.---------- Methods: A telephone survey of 4490 Queensland adults examined respondents’ knowledge of coronary heart disease (CHD) risk factors, knowledge of heart attack symptoms, knowledge of the local emergency telephone number, as well as respondents’ rates and recency of training in CPR.---------- Results: Older participants, aged 60 years and over, were approximately one and a half times more likely than the 30–39 year-old reference group to have limited knowledge of heart disease risk factors (OR = 1.53), and low knowledge of heart attack symptoms (OR = 1.60). Knowledge of the local emergency telephone number also decreased with age. Older participants had significantly lower rates of training in CPR, with almost three quarters (71.7%) reporting that they had never been trained. Older people who had completed CPR training were significantly less likely to have done so recently.---------- Conclusions: Cardiac knowledge levels and CPR training rates in older Queensland persons were lower than those found in the younger population.

Poor functional health literacy : the silent disability for older people

In this information age, people are confronted by verbal, visual and written information. This is especially important in the health field, where information is needed to follow directions, understand prescriptions and undertake preventive behaviours. If provided in written form, much of this information may be inaccessible to people who cannot adequately read. Although poor literacy skills affect all groups in the population, older adults with fewer years of education seem to be particularly disadvantaged by an increasing reliance on written communication of health information. With older age comes a higher risk of illness and disability and a greater potential need to access the health system. As a result, poor literacy skills of older individuals may directly impact their health status. This paper explores the link between functional literacy and health, particularly for the older population, provides strategies to practitioners for the management of this problem, and suggests research initiatives in this area.

End-of-life decision making for older people

This chapter deals with the increasing issues surrounding end-of-life decision making. As the life trajectory for older people changes, the need for open discussion about their health problems and treatment becomes more critical. Acceptance of the ageing process itself is often not easy so the matter of a good death is even more distressing for some people to consider. The vignette provides an excellent discussion on the need for open dialogue with the older person and their families, whether they are acutely ill or have chronic health problems. How a person wishes to be treated when quality of life is not going to improve, no matter what interventions are put in place, seems essential for person-centred care. The issue of competency is one that must be determined before any decision is made by any person involved in care.

The population approach to falls injury prevention in older people : findings of a two community trial

Background: There is a sound rationale for the population-based approach to falls injury prevention but there is currently insufficient evidence to advise governments and communities on how they can use population-based strategies to achieve desired reductions in the burden of falls-related injury.---------- Aim: To quantify the effectiveness of a streamlined (and thus potentially sustainable and cost-effective), population-based, multi-factorial falls injury prevention program for people over 60 years of age.---------- Methods: Population-based falls-prevention interventions were conducted at two geographically-defined and separate Australian sites: Wide Bay, Queensland, and Northern Rivers, NSW. Changes in the prevalence of key risk factors and changes in rates of injury outcomes within each community were compared before and after program implementation and changes in rates of injury outcomes in each community were also compared with the rates in their respective States.---------- Results: The interventions in neither community substantially decreased the rate of falls-related injury among people aged 60 years or older, although there was some evidence of reductions in occurrence of multiple falls reported by women. In addition, there was some indication of improvements in fall-related risk factors, but the magnitudes were generally modest.---------- Conclusion: The evidence suggests that low intensity population-based falls prevention programs may not be as effective as those are intensively implemented.