Development and Application of Medication Appropriateness Indicators for Persons with Advanced Dementia: A Feasibility Study

Abstract

USA) for their advice regarding study design. The authors would also like to thank the physicians who participated in the Delphi consensus panel survey, and the residents, their relatives and care home staff who participated in the feasibility study. AbstractBackground: No studies have been conducted in the United Kingdom (UK) context to date which categorise medications in terms of appropriateness for patients with advanced dementia, or which examine medication use in these vulnerable patients.Objectives: To categorise the appropriateness of a comprehensive list of medications and medication classes for use in patients with advanced dementia; to examine the feasibility of conducting a longitudinal prospective cohort study to collect clinical and medication use data;and to determine the appropriateness of prescribing for nursing home residents with advanced dementia in Northern Ireland (NI), using the categories developed.Methods: Three-round Delphi consensus panel survey of expert clinicians, to categorise the appropriateness of medications for patients with advanced dementia (defined as having Functional Assessment Staging [FAST] scores ranging from 6E to 7F). This was followed by a longitudinal prospective cohort feasibility study which was conducted in three nursing homes in NI. Clinical and medication use for participating residents with advanced dementia (FAST scores ranging from 6E to 7F) were collected and a short test of dementia severity administered.These data were collected at baseline and every three months for up to nine months or until death. For those residents who died during the study period, data were also collected within 14 days of death. The appropriateness ratings from the consensus panel survey were retrospectively applied to residents' medication data at each data collection timepoint to determine the appropriateness of medications prescribed for these residents.Results: Consensus was achieved for 87 (90%) of the 97 medications and medication classes included in the survey. Fifteen residents were recruited to participate in the longitudinal prospective cohort feasibility study, four of whom died during the data collection period. Mean numbers of medications prescribed per resident were 16.2 at baseline, 19.6 at three months, 17.4 at six months and 16.1 at nine months respectively. Fourteen residents at baseline were taking at least one medication considered by the consensus panel to be never appropriate, and approximately 25% of medications prescribed were considered to be never appropriate. Postdeath data collection indicated a decrease in the proportion of never appropriate medications and an increase in the proportion of always appropriate medications for those residents who died. Conclusions

Potentially Inappropriate Prescribing in Australian Nursing Home Residents with Advanced Dementia: A Substudy of the IDEAL Study

“…14 Six international studies have used these criteria to examine the prevalence of inappropriate prescribing in nursing home residents with advanced dementia and associated factors. [15][16][17][18][19][20] These studies were undertaken in European countries, [17][18][19] the USA 15,16 and Canada, 20 and found that proportions of nursing home residents with advanced dementia receiving 'never' appropriate medications ranged from 3% 17 to 45% 20 of study populations. Lipid-lowering agents, 15,16,18,20 antiplatelet agents, 17,18,20 antihypertensives, 17 and anti-dementia drugs, specifically acetylcholinesterase inhibitors 15,16,18,20 and memantine, 15 were found to be the most commonly prescribed 'never' appropriate medications.…”

Recent Literature on Medication Errors and Adverse Drug Events in Older Adults

“…Unnecessary drug use in individuals with limited life expectancy has drawn considerable attention over the past decade . This study is among the first to examine this problem in such a large representative sample (N = 5,406).…”

“…Unnecessary drug use in individuals with limited life expectancy has drawn considerable attention over the past decade. [12][13][14][15][16] This study is among the first to examine this problem in such a large representative sample (N = 5,406). The only prior study, which included 1,449 Italian nursing home residents with dementia 17 and used the same explicit criteria, found a lower rate of potentially unnecessary drugs (26.8%).…”

“…Moreover, the criteria used to measure unnecessary drug use did not include certain medication classes that other experts consider relevant, including cardiovascular drugs (angiotensin-converting enzyme inhibitors, anticoagulants, angiotensin receptor blockers, antihypertensives), anticholinergics (e.g., antivertigo, tricyclic antidepressants), anti-infectives, bisphosphonates, central nervous system stimulants, diabetes mellitus drugs, expectorants, genitourinary antispasmodics, minerals, proton pump inhibitors, and vitamins. [14][15][16] Using only explicit criteria as opposed to valid and reliable implicit measures such as the Medication Appropriateness Index does not take patient-specific factors or preferences of individuals or caregiver into account. Finally, neither study examined the consequences of discontinuing these questionable medications.…”

Developing and implementing dementia policy in ireland

“…There is no doubt that the medical and functional needs of residents continues to dominate the care landscape within residential care settings. While, to some extent, this is understandable, psychosocial approaches are also needed to complement medical and neurological models of service delivery, but with some few exceptions, they are largely absent in residential care settings in Ireland or when used sometimes tacked on almost by way of an after-thought and often, as in the case of reminiscence, conducted by staff with no specialist expertise or training in the area (Parsons et al, 2015). In particular, psychosocial interventions can assist in developing meaningful communication with patients, using all of the senses, through reminiscence, music, art, dance and various therapeutic and time-intensive activities.…”