Nursing home staff recognize the value of reducing antipsychotic medications; however, they also experience multiple barriers to reduction in routine clinical practice. Achievement of further reductions in antipsychotic medication use will require significant additional efforts and adequate clinical personnel to address these barriers.

Background: Polypharmacy is prevalent among hospitalized older adults, particularly those being discharged to a post-care care facility (PAC). The aim of this randomized controlled trial is to determine if a patient-centered deprescribing intervention initiated in the hospital and continued in the PAC setting reduces the total number of medications among older patients. Methods: The Shed-MEDS study is a 5-year, randomized controlled clinical intervention trial comparing a patientcentered describing intervention with usual care among older (≥50 years) hospitalized patients discharged to PAC, either a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IPR). Patient measurements occur at hospital enrollment, hospital discharge, within 7 days of PAC discharge, and at 60 and 90 days following PAC discharge. Patients are randomized in a permuted block fashion, with block sizes of two to four. The overall effectiveness of the intervention will be evaluated using total medication count as the primary outcome measure. We estimate that 576 patients will enroll in the study. Following attrition due to death or loss to follow-up, 420 patients will contribute measurements at 90 days, which provides 90% power to detect a 30% versus 25% reduction in total medications with an alpha error of 0.05. Secondary outcomes include the number of medications associated with geriatric syndromes, drug burden index, medication adherence, the prevalence and severity of geriatric syndromes and functional health status.Discussion: The Shed-MEDS trial aims to test the hypothesis that a patient-centered deprescribing intervention initiated in the hospital and continuing through the PAC stay will reduce the total number of medications 90 days following PAC discharge and result in improvements in geriatric syndromes and functional health status. The results of this trial will quantify the health outcomes associated with reducing medications for hospitalized older adults with polypharmacy who are discharged to post-acute care facilities.Trial registration: This trial was prospectively registered at clinicaltrials.gov (NCT02979353). The trial was first registered on 12/1/2016, with an update on 09/28/17 and 10/12/2018.

Background Dehydration is typically associated with underweight and malnutrition in long term care (LTC) settings. Evidence is lacking regarding the influence of the rising prevalence of overweight and obesity on risk factors, prevalence and presentation of dehydration. Objective The aim of this study was to objectively assess hydration status and the adequacy of total water intake, and determine relationships between hydration status, total water intake, and body mass index (BMI) in LTC residents. Design A cross-sectional analysis of baseline data was performed. Participants and setting Baseline data from 247 subjects recruited from 8 community-based LTC facilities participating in two randomized trials comparing nutrient and cost efficacy of between-meal snacks versus oral nutrition supplements. Main outcomes Hydration status was assessed by serum osmolality concentration and total water intakes were quantified by weighed food, beverage, water and oral nutrition supplement (ONS) intake. Statistical analyses Simple and multiple linear regression methods were applied. Results Forty-nine (38.3%) subjects were dehydrated (>300 mOsm/kg) and another 39 (30.5%) had impending dehydration (295–300 mOsm/kg). The variance in serum osmolality was significantly accounted for by blood urea nitrogen level, mental status score, and having diabetes (R2 = 0.46, P < 0.001). Total water intake averaged 1147.2 ± 433.1 mL/d. Thus, 96–100% subjects did not meet estimated requirements, with a deficit range of 700–1800 mL/d. The variance in total water intake was significantly accounted for by type of liquid beverages (thin vs thick), type of ONS, total energy intake, total activities of daily living dependence, sex and BMI (R2 = 0.56, P < 0.001). Conclusions Dehydration and inadequate total water intake is prevalent in LTC residents across all BMI categories. Type of liquid beverages, type of ONS, and type of between-meal snacks are factors that could be targeted for nutrition interventions designed to prevent or reverse dehydration.

ImportanceDeprescribing is a promising approach to addressing the burden of polypharmacy. Few studies have initiated comprehensive deprescribing in the hospital setting among older patients requiring ongoing care in a postacute care (PAC) facility.ObjectiveTo evaluate the efficacy of a patient-centered deprescribing intervention among hospitalized older adults transitioning or being discharged to a PAC facility.Design, Setting, and ParticipantsThis randomized clinical trial of the Shed-MEDS (Best Possible Medication History, Evaluate, Deprescribing Recommendations, and Synthesis) deprescribing intervention was conducted between March 2016 and October 2020. Patients who were admitted to an academic medical center and discharged to 1 of 22 PAC facilities affiliated with the medical center were recruited. Patients who were 50 years or older and had 5 or more prehospital medications were enrolled and randomized 1:1 to the intervention group or control group. Patients who were non–English speaking, were unhoused, were long-stay residents of nursing homes, or had less than 6 months of life expectancy were excluded. An intention-to-treat approach was used.InterventionsThe intervention group received the Shed-MEDS intervention, which consisted of a pharmacist- or nurse practitioner–led comprehensive medication review, patient or surrogate-approved deprescribing recommendations, and deprescribing actions that were initiated in the hospital and continued throughout the PAC facility stay. The control group received usual care at the hospital and PAC facility.Main Outcomes and MeasuresThe primary outcome was the total medication count at hospital discharge and PAC facility discharge, with follow-up assessments during the 90-day period after PAC facility discharge. Secondary outcomes included the total number of potentially inappropriate medications at each time point, the Drug Burden Index, and adverse events.ResultsA total of 372 participants (mean [SD] age, 76.2 [10.7] years; 229 females [62%]) were randomized to the intervention or control groups. Of these participants, 284 were included in the intention-to-treat analysis (142 in the intervention group and 142 in the control group). Overall, there was a statistically significant treatment effect, with patients in the intervention group taking a mean of 14% fewer medications at PAC facility discharge (mean ratio, 0.86; 95% CI, 0.80-0.93; P &amp;lt; .001) and 15% fewer medications at the 90-day follow-up (mean ratio, 0.85; 95% CI, 0.78-0.92; P &amp;lt; .001) compared with the control group. The intervention additionally reduced patient exposure to potentially inappropriate medications and Drug Burden Index. Adverse drug event rates were similar between the intervention and control groups (hazard ratio, 0.83; 95% CI, 0.52-1.30).Conclusions and RelevanceResults of this trial showed that the Shed-MEDS patient-centered deprescribing intervention was safe and effective in reducing the total medication burden at PAC facility discharge and 90 days after discharge. Future studies are needed to examine the effect of this intervention on patient-reported and long-term clinical outcomes.Trial RegistrationClinicalTrials.gov Identifier: NCT02979353

Background: Hospitalized older adults have a high prevalence of polypharmacy and medication inaccuracies. Gathering the best possible medication history (BPMH) is necessary to accurately identify each medication for multimorbid older adults. The objective was to describe a multipronged approach to obtaining the BPMH for hospitalized older adults, quantify the medication discrepancies identified through these sources, and explore factors associated with these discrepancies. Methods: Cross-sectional analysis of 372 hospitalized older adults (age ≥ 50) transitioning to post-acute care as part of a randomized controlled trial to reduce medication burden. We used four information sources to yield a BPMH. Medication discrepancies at hospital admission were categorized as omissions, additions, and dose discrepancies after comparing alternate sources with the electronic medical record (EMR). Multivariate regression analysis, including patient factors (e.g., age, prehospital medication count, number of pharmacies), was performed to identify factors associated with the total count of medication discrepancies.Results: Ninety percent of participants had at least one medication discrepancy and 46% used more than one pharmacy. The majority of discrepancies were omissions. Among the entire cohort, there was a median of two omitted medications per patient across two alternate sources-pharmacy refill history and bedside interview. Lower age, greater total number of prehospital medications, and admission from assisted living or skilled nursing facility were significantly associated with greater medication discrepancies. Conclusion:A multipronged and consistent approach to obtain a BPMH during hospitalization for multimorbid older adults revealed medication discrepancies that should be addressed prior to hospital discharge to support safe prescribing practices.