Polypharmacy and inappropriate medication use in patients with dementia: an underresearched problem

Multimorbidity and polypharmacy are increasingly prevalent across healthcare systems and settings as global demographic trends shift towards increased proportions of older people in populations. Numerous studies have demonstrated an association between polypharmacy and potentially inappropriate prescribing (PIP), and have reported high prevalence of PIP across settings of care in Europe and North America and, as a consequence, increased risk of adverse drug reactions, healthcare utilisation, morbidity and mortality. These studies have not focused specifically on people with dementia, despite the high risk of adverse drug reactions and PIP in this patient cohort. This narrative review considers the evidence currently available in the area, including studies examining prevalence of PIP in older people with dementia, how appropriateness of prescribing is assessed, the medications most commonly implicated, the clinical consequences, and research priorities to optimise prescribing for this vulnerable patient group. Although there has been considerable research effort to develop criteria to assess medication appropriateness in older people in recent years, the majority of tools do not focus on people with dementia. Of the limited number of tools available, most focus on the advanced stages of dementia in which life-expectancy is limited. The development of tools to assess medication appropriateness in people with mild-to-moderate dementia or across the full spectrum of disease severity represents an important gap in the research literature and is beginning to attract research interest, with recent studies considering the medication regimen as a whole, or misprescribing, overprescribing or underprescribing of certain medications/medication classes including anticholinergics, psychotropics, antibiotics and analgesics. Further work is required in development and validation of criteria to assess prescribing appropriateness in this vulnerable patient population, to determine prevalence of PIP in large cohorts of people with the full spectrum of dementia variants and severities and to examine the impact of PIP on health outcomes.

Education as a Predictor of Antidepressant and Anxiolytic medication use after Bereavement: a population based record linkage study.

Purpose: Educational attainment has been shown to be positively associated with mental health and a potential buffer to stressful events. One stressful life event likely to affect everyone in their lifetime is bereavement. This paper assesses the effect of educational attainment on mental health post bereavement.
Methods: By utilising large administrative datasets, linking Census returns to death records and prescribed medication data, we analysed the bereavement exposure of 208,332 individuals aged 25-74 years. Two-level multi-level logistic regression models were constructed to determine the likelihood of antidepressant medication use (a proxy of mental ill-health) post bereavement given level of educational attainment.
Results: Individuals who are bereaved have greater antidepressant use than those who are not bereaved, with over a quarter (26.5%) of those bereaved by suicide in receipt of antidepressant medication compared to just 12.4% of those not bereaved. Within individuals bereaved by a sudden death those with a University Degree or higher qualifications are 73% less likely to be in receipt of antidepressant medication compared to those with no qualifications, after full adjustment for demographic, socio-economic and area factors (OR=0.27, 95% CI 0.09,0.75). Higher educational attainment and no qualifications have an equivalent effect for those bereaved by suicide.
Conclusions: Education may protect against poor mental health, as measured by the use of antidepressant medication, post bereavement, except in those bereaved by suicide. This is likely due to the improved cognitive, personal and psychological skills gained from time spent in education.

Behavior change theory, content and delivery of interventions to enhance adherence in chronic respiratory disease: A systematic review

Background: We sought to describe the theory used to design treatment adherence interventions, the content delivered, and the mode of delivery of these interventions in chronic respiratory disease. Methods: We included randomized controlled trials of adherence interventions (compared to another intervention or control) in adults with chronic respiratory disease (8 databases searched; inception until March 2015). Two reviewers screened and extracted data: post-intervention adherence (measured objectively); behavior change theory, content (grouped into psychological, education and self-management/supportive, telemonitoring, shared decision-making); and delivery. “Effective” studies were those with p < 0.05 for adherence rate between groups. We conducted a narrative synthesis and assessed risk of bias. Results: 12,488 articles screened; 46 included studies (n = 42,91% in OSA or asthma) testing 58 interventions (n = 27, 47% were effective). Nineteen (33%) interventions (15 studies) used 12 different behavior change theories. Use of theory (n = 11,41%) was more common amongst effective interventions. Interventions were mainly educational, self-management or supportive interventions (n = 27,47%). They were commonly delivered by a doctor (n = 20,23%), in face-to-face (n = 48,70%), one-to-one (n = 45,78%) outpatient settings (n = 46,79%) across 2–5 sessions (n = 26,45%) for 1–3 months (n = 26,45%). Doctors delivered a lower proportion (n = 7,18% vs n = 13,28%) and pharmacists (n = 6,15% vs n = 1,2%) a higher proportion of effective than ineffective interventions. Risk of bias was high in >1 domain (n = 43, 93%) in most studies. Conclusions: Behavior change theory was more commonly used to design effective interventions. Few adherence interventions have been developed using theory, representing a gap between intervention design recommendations and research practice.

Associations of the FTO rs9939609 and the MC4R rs17782313 polymorphisms with type 2 diabetes are modulated by diet, being higher when adherence to the Mediterranean diet pattern is low

[EN]Although the Fat Mass and Obesity (FTO) and Melanocortin-4 Receptor (MC4R) genes have been consistently associated with obesity risk, the association between the obesity-risk alleles with type 2 diabetes is still controversial. In some recent meta-analyses in which significant results have been reported, the associations disappeared after adjustment for body mass index (BMI). However gene-diet interactions with dietary patterns have not been investigated. Our main aim was to analyze whether these associations are modulated by the level of adherence to the Mediterranean Diet (MedDiet).

Knowledge of the patients regarding leprosy and adherence to treatment

Leprosy is a chronic infectious disease caused by Mycobacterium leprae. It is known for its great disfiguring capacity and is considered an extremely serious disease to public health worldwide. The state of Ceará ranks 13th in number of cases of leprosy in Brazil, and fourth in Northeastern region, with an average of 2,149 new cases diagnosed every year. This study aimed to evaluate the knowledge of leprosy patients regarding treatment, and to assess the level of treatment adherence and its possible barriers. The study was conducted in the reference center for dermatology, from September 2010 to October 2010, in Fortaleza, Ceará. The study data were collected by means of a structured interview, along with the Morisky-Green test, in order to assess treatment adherence and barriers to adherence. A total of 70 patients were interviewed, out of whom 66 were new cases. The majority of patients were between 42 and 50 years old, and 37 (52.9%) were male. Most patients were clinically classified as presentingmultibacillary leprosy (80%), and 78.6% of them were from Fortaleza, Brazil. The Morisky-Green test indicated that 62.9% of patients presented a low level of adherence (p < 0.005), despite claiming to aware of the disease risks. However, it was observed that 57.1% of the patients had no difficulty adhering to treatment, while 38.6% reported little difficulty. This study shows that despite the patients claiming to be familiar with leprosy and its treatment, the Morisky-Green test clearly demonstrated that they actually were not aware of the principles of therapy, which is evidenced by the low degree of treatment adherence

Recovering Natural History: Modeling Cardiovascular Biomarkers in the Presence of Endogenous Medication Use

Thesis (Ph.D.)--University of Washington, 2016-08

Medication competence of nursing students in Finland

Lääkehoidon turvallinen toteuttaminen edellyttää sairaanhoitajalta hyvää lääkehoidon osaamisperustaa. Sairaanhoitajakoulutuksen tehtävänä on mahdollistaa tämän osaamisen kehittyminen. Kansainvälisissä tutkimuksissa on kuitenkin osoitettu, että lääkehoidon opetuksen laajuudessa, sisällössä ja toteutuksessa on vaihtelevuutta. Aikaisemmissa tutkimuksissa on raportoitu myös puutteita lääkehoidon osaamisessa sekä sairaanhoitajilla että sairaanhoitajaopiskelijoilla. Koulutuksen ja lääkehoidon osaamisen kehittämiseksi lääkehoidon opetuksen ja sairaanhoitajaopiskelijoiden lääkehoidon osaamisen monipuolinen arviointi ja osaamista selittävien tekijöiden tarkastelu on tarpeen. Tämän tutkimuksen tarkoituksena oli i) arvioida lääkehoidon opetusta suomalaisessa sairaanhoitajakoulutuksessa, ii) arvioida sairaanhoitajaopiskelijoiden lääkehoidon osaamista sekä iii) tunnistaa sairaanhoitajaopiskelijan lääkehoidon osaamiseen yhteydessä olevat tekijät. Tutkimus toteutettiin kolmessa vaiheessa. Ensimmäisessä vaiheessa kahden integroidun kirjallisuuskatsauksen kautta määriteltiin tutkimuksen kohteena oleva sairaanhoitajan lääkehoidon osaaminen ja aiemmin tunnistetut sairaanhoitajaopiskelijan lääkehoidon osaamiseen yhteydessä olevat tekijät. Toisessa vaiheessa toteutettiin valtakunnallinen lääkehoidon opetukseen liittyvä kysely hoitotyön koulutusohjelmasta vastaaville koulutuspäälliköille (n=22) ja opettajille (n=136). Tutkimuksen kolmannessa vaiheessa opintojensa alku‐ (n=328) ja loppuvaiheessa olevien sairaanhoitajaopiskelijoiden (n=338) lääkehoidon osaaminen arvioitiin ja osaamiseen yhteydessä olevat tekijät tunnistettiin. Aineistojen analyysissä käytettiin pääosin tilastollisia menetelmiä. Tulosten perusteella lääkehoidon opetuksen laajuus vaihteli eri ammattikorkeakouluissa, mutta opetuksen sisältö oli kuitenkin monipuolista. Lisää huomiota tulisi kiinnittää lääkehoidon teoreettiseen perustaan ja itsehoitoon sekä lääkehoidon ohjaukseen liittyviin sisältöalueisiin. Opiskelijoiden lääkehoidon osaamista arvioitiin säännöllisesti kaikissa ammattikorkeakouluissa. Sairaanhoitajaopiskelijan lääkehoidon osaamista arvioitiin tutkimuksessa tietotestillä, lääkelaskentatehtävillä ja lyhyiden potilastapausten ratkaisemisen avulla. Lääkehoidon osaamiseen yhteydessä olevia tekijöitä tarkasteltiin kolmesta näkökulmasta: 1) yksilölliset tekijät, 2) kliiniseen oppimisympäristöön ja 3) ammattikorkeakouluun liittyvät tekijät. Lääkehoidon teoreettista osaamista arvioivassa tietotestissä opiskelijat vastasivat keskimäärin 72 prosenttiin kysymyksistä täysin oikein; lääkelaskuista täysin oikein oli 74 % ja potilastapauksissa 57 % valitsi parhaan mahdollisen toimintatavan. Tulosten perusteella sairaanhoitajaopiskelijan osaamista selittivät eniten yksilölliset tekijät. Lääkehoidon osaamiseen yhteydessä olevien tekijöiden välillä oli eroa opintojen alussa ja lopussa. Opintojen alkuvaiheessa opiskelijan aikaisempi opintomenestys oli yhteydessä lääkehoidon osaamiseen, kun taas opintojen loppuvaiheessa siihen olivat yhteydessä opiskelijan kyky itseohjautuvaan oppimiseen sekä opiskelumotivaatio. Johtopäätöksenä voidaan todeta tutkimuksen tulosten olevan samansuuntaisia kuin aikaisemmissa tutkimuksissa. Lääkehoidon opetuksen laajuus vaihtelee opetussuunnitelmatasolla, mutta täsmällinen arviointi on vaikeaa opetuksen sisältöjen integroimisen takia. Sairaanhoitajaopiskelijoiden lääkehoidon osaaminen oli hieman parempaa kuin aikaisemmissa tutkimuksissa, mutta osaamisessa on edelleen puutteita. Lääkehoidon opetuksen ja osaamisen kehittäminen edellyttää kansallista ja kansainvälistä tutkimus‐ ja kehittämisyhteistyötä. Tutkimuksen tulokset tukevat lääkehoidon opetuksen sekä osaamisen tutkimusta ja kehittämistä.

Statin Adherence, Utilisation, and Prescribing Patterns. Improving effectiveness of treatment

Statins are one of the most widely studied and evidence-based medications. Randomised controlled trials have provided convincing evidence on the benefits of statin therapy in preventing cardiovascular events. Despite proven benefits, low costs, and few adverse effects, everyday effectiveness of statins is limited, since adherence to statin therapy is poor. This thesis was conducted as four pharmacoepidemiological studies using register data on statin users in real clinical care. The main purpose of the study was to evaluate prescribing patterns and to discover the lifestyle factors predicting statin nonadherence and discontinuation. This knowledge is essential in order to help physicians to motivate the adherence of their patients to treatment. In Finland, from 1998 to 2004, the number of statin initiators nearly doubled. The discovered channelling of atorvastatin and simvastatin may have affected the treatment outcomes at the public health level. It is possible that money spent on statins in Finland in 1998‒2004 could have been used in a more cost-effective way. In 2015, the percentage of patients receiving reimbursement for statins was 12% of the total population. Thus, it is a major public health and economic challenge to improve statin effectiveness and allocate therapy correctly. Among the participants with cardiovascular comorbidities, risky alcohol use or clustering of lifestyle risks were predictors of nonadherence. In addition, the prevalence of nonadherence to statins increased after retirement among both men and women. This increase in post-retirement nonadherence was highest among those receiving statins for secondary prevention. Discontinuation of statin therapy was predicted by high patient co-payment, and in women, by risky alcohol use. Recognising the predictors of nonadherence to statins is important because nonadherence is associated with an increased risk of adverse cardiovascular outcomes and higher healthcare costs. In conclusion, optimal outcomes in medical therapy require both efficacious medications and adherence to those treatments. When prescribing statins to eligible patients, the physician’s clinical expertise in recognising patients at risk of statin discontinuation and nonadherence, as well as their ability to increase adherence, may have a great effect on public health.

Usability and Security in Medication Administration Applications

The traditional process of filling the medicine trays and dispensing the medicines to the patients in the hospitals is manually done by reading the printed paper medicine chart. This process can be very strenuous and error-prone, given the number of sub-tasks involved in the entire workflow and the dynamic nature of the work environment. Therefore, efforts are being made to digitalise the medication dispensation process by introducing a mobile application called Smart Dosing application. The introduction of the Smart Dosing application into hospital workflow raises security concerns and calls for security requirement analysis. This thesis is written as a part of the smart medication management project at Embedded Systems Laboratory, A° bo Akademi University. The project aims at digitising the medicine dispensation process by integrating information from various health systems, and making them available through the Smart Dosing application. This application is intended to be used on a tablet computer which will be incorporated on the medicine tray. The smart medication management system include the medicine tray, the tablet device, and the medicine cups with the cup holders. Introducing the Smart Dosing application should not interfere with the existing process carried out by the nurses, and it should result in minimum modifications to the tray design and the workflow. The re-designing of the tray would include integrating the device running the application into the tray in a manner that the users find it convenient and make less errors while using it. The main objective of this thesis is to enhance the security of the hospital medicine dispensation process by ensuring the security of the Smart Dosing application at various levels. The methods used for writing this thesis was to analyse how the tray design, and the application user interface design can help prevent errors and what secure technology choices have to be made before starting the development of the next prototype of the Smart Dosing application. The thesis first understands the context of the use of the application, the end-users and their needs, and the errors made in everyday medication dispensation workflow by continuous discussions with the nursing researchers. The thesis then gains insight to the vulnerabilities, threats and risks of using mobile application in hospital medication dispensation process. The resulting list of security requirements was made by analysing the previously built prototype of the Smart Dosing application, continuous interactive discussions with the nursing researchers, and an exhaustive stateof- the-art study on security risks of using mobile applications in hospital context. The thesis also uses Octave Allegro method to make the readers understand the likelihood and impact of threats, and what steps should be taken to prevent or fix them. The security requirements obtained, as a result, are a starting point for the developers of the next iteration of the prototype for the Smart Dosing application.

Self-management of coronary heart disease in angina patients after percutaneous coronary intervention: A mixed methods study.

After having elective percutaneous coronary intervention (PCI) patients are expected to self-manage their coronary heart disease (CHD) by modifying their risk factors, adhering to medication and effectively managing any recurring angina symptoms but that may be ineffective. Objective: Explore how patients self-manage their coronary heart disease (CHD) after elective PCI and identify any factors that may infl uence that. Design and method: This mixed methods study recruited a convenience sample of patients (n=93) approximately three months after elective PCI. Quantitative data were collected using a survey and were subject to univariate, bivariate and multi-variate analysis. Qualitative data from participant interviews was analysed using thematic analysis. Findings: After PCI, 74% of participants managed their angina symptoms inappropriately. Younger participants and those with threatening perceptions of their CHD were more likely to know how to effectively manage their angina symptoms. Few patients adopted a healthier lifestyle after PCI. Qualitative analysis revealed that intentional non-adherence to some medicines was an issue. Some participants felt unsupported by healthcare providers and social networks in relation to their self-management. Participants reported strong emotional responses to CHD and this had a detrimental effect on their self-management. Few patients accessed cardiac rehabilitation.

Determinants of self-medication with NSAIDs in a Portuguese community pharmacy

Background: Non-steroid anti-inflammatory drugs (NSAIDs) are a widely used therapeutic group in the world, and particularly in the Portuguese population. Objective: To compare NSAID’s use by prescription and self-medication acquisition and to determine the pattern of indication of NSAIDs, their usage profile and possible implications for patients’ safety. Methods: A cross-sectional design was used where individuals presenting at a community pharmacy requesting NSAIDs during the study period (one month) were invited to answer a face-to-face interview where socio-demographic characteristics, the indication pattern and previous experience of side effects were assessed. A follow-up interview was performed one week later to assess the incidence of adverse effects. The study was ethically approved. Results: A sample of 130 NSAIDs users was recruited, comprising mostly women (n=87; 66.9%), actively employed (n=77; 59.2%) and presenting a mean age of 49.5 years old (SD=20.49). An equal proportion of individuals acquired NSAIDs by self-medication and with medical prescription (n=65; 50%). Over 4/5 of patients (n=57; 87.7%) acquiring NSAIDs without a prescription were self-medicated by their own initiative, and only 10.8% (n=7) had been advised by the pharmacist. The most commonly acquired active substances were ibuprofen and diclofenac. Self-medicated users more frequently resorted to topical NSAIDs following short term treatments. The major underlying condition motivating NSAIDs sought were musculoskeletal disorders (45.0%), regardless of the regimen. An important proportion of prevalent users of NSAIDs reported previous experience of adverse effects (11.3%). One week after initiating NSAID therapy, a small proportion of patients reported incidence of adverse effects. Conclusion: Self-medication with NSAIDs is sought for numerous medical conditions. Reported adverse effects (prevalent and incident) confirm the need for a more rational use of NSAIDs and ongoing pharmacovigilance.

Medication reconciliation at patient admission: a randomized controlled trial

Objective: To measure length of hospital stay (LHS) in patients receiving medication reconciliation. Secondary characteristics included analysis of number of preadmission medications, medications prescribed at admission, number of discrepancies, and pharmacists interventions done and accepted by the attending physician. Methods: A 6 month, randomized, controlled trial conducted at a public teaching hospital in southern Brazil. Patients admitted to general wards were randomized to receive usual care or medication reconciliation, performed within the first 72 hours of hospital admission. Results: The randomization process assigned 68 patients to UC and 65 to MR. LHS was 10±15 days in usual care and 9±16 days in medication reconciliation (p=0.620). The total number of discrepancies was 327 in the medication reconciliation group, comprising 52.6% of unintentional discrepancies. Physicians accepted approximately 75.0% of the interventions. Conclusion: These results highlight weakness at patient transition care levels in a public teaching hospital. LHS, the primary outcome, should be further investigated in larger studies. Medication reconciliation was well accepted by physicians and it is a useful tool to find and correct discrepancies, minimizing the risk of adverse drug events and improving patient safety.

Inclusion of salt form on prescription medication labeling as a source of patient confusion: a pilot study

Background: It has been estimated that 10,000 patient injuries occur in the US annually due to confusion involving drug names. An unexplored source of patient misunderstandings may be medication salt forms. Objective: The objective of this study was to assess patient knowledge and comprehension regarding the salt forms of medications as a potential source of medication errors. Methods: A 12 item questionnaire which assessed patient knowledge of medication names on prescription labels was administered to a convenience sample of patients presenting to a family practice clinic. Descriptive statistics were calculated and multivariate analyses were performed. Results: There were 308 responses. Overall, 41% of patients agreed they find their medication names confusing. Participants correctly answered to salt form questions between 12.1% and 56.9% of the time. Taking more prescription medications and higher education level were positively associated with providing more correct answers to 3 medication salt form knowledge questions, while age was negatively associated. Conclusions: Patient misconceptions about medication salt forms are common. These findings support recommendations to standardize the inclusion or exclusion of salt forms. Increasing patient education is another possible approach to reducing confusion.