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Rational prescribing is essential for adequate patient compliance and proper therapeutic outcome. Often medicines are prescribed randomly to take care of the drug induced adverse reactions without changing the culprit drug or modifying it抯 dose, rather commonly by adding another drug towards amelioration of the presenting complain, ignoring it抯 drug related occurrence. This 慞rescribing Cascade� turns out to be a vicious cycle by promoting polypharmacy thus leading to it抯 adverse consequences. This can happen to any person at any age but elderly population are more vulnerable because of their age related physiological changes and co-morbidities. There are several ways to curb the vicious cycle down like anticholinergic burden assessment, selecting the right drug for the right person, medication reconciliation etc.
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Objective:To analyze drug-related problems (DRPs) of hospitalized elderly patients with limited life expectancy.Methods:A total of 261 patients aged ≥ 70 years with limited life expectancy according to the 1-year mortality prediction index, who were admitted in the geriatric ward of Peking Union Medical College Hospital from January 2015 to December 2021 were included. According to Strand system, the categories, medications and interventions of DRPs were analyzed.Results:Among 261 patients, 187 (71.6%) had 672 DRPs. The most common DRPs were related to drug safety, including 271 (40.3%) adverse drug reactions and 149 over dosages (22.2%). A total of 207 drugs were involved in DRPs, and the top 5 classes with higher frequency of DRPs were antiinfectives for systemic use(20.7%,139/672), nervous system drugs(19.4%,130/672), alimentary tract and metabolism drugs(16.5%,111/672), cardiovascular system drugs(16.1%,108/672), and blood and hemopoietic organs drugs(13.7%,92/672). The recommendations were given by pharmacists for all 672 DRPs, and 643 were accepted by physicians (95.7%). The therapy need to be adjusted in 564 recommendations and the medications need to be monitored in 108 recommendations. In recommendations of therapy adjustment, 49.6%(280/564) were related to deprescribing. The deprescribing with higher frequency included antiinfectives for systemic use(29.6%, 83/280), lipid modifying agents(7.9%,22/280) and antithrombotic agents(7.9%,22/280). Patients with severe disability had significantly higher average DRPs(2 vs. 1) and average deprescribing(1 vs. 0) than patients without severe disability( Z=-4.83, Z=-3.61, all P<0.001). Conclusion:Drug safety is the most common DRP in limited life expectancy elderly inpatients, particularly for those with severe disability.
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OBJECTIVE: To elaborate and validate an instrument on barriers and enablers to deprescribing benzodiazepines in the patient's perspective. METHODS: This study was conducted in 3 stages: (1) a methodological stage, (2) a semi-structured pilot interview with 25 older adults undergoing clonazepam deprescribing, and (3) content validation with the Delphi technique. Content validation was performed by 50 specialists with degrees and/or experience with primary health care and/or health care of older adults, such as physicians, pharmacists, and nurses. For evaluating the obtained results, we analyzed the concordance of evaluations with the coefficient of content validity (CCV). We considered values equal to or higher than 0.8 as acceptable levels of concordance. RESULTS: The instrument was considered validated in the first round of evaluation, where all items obtained a CCV of more than 0.8 in the specialists' assessment. Nevertheless, they proposed improvements that were incorporated to the final version of the questionnaire. CONCLUSION: The instrument represents an important tool to be used by health care professionals for optimizing benzodiazepine deprescribing, with suitable levels of clarity and validity.
OBJETIVO: Elaborar e validar um instrumento sobre facilitadores e dificultadores do processo de desprescrição de benzodiazepínicos na perspectiva do paciente. METODOLOGIA: Estudo desenvolvido em três etapas, quais sejam: (1) metodológica, (2) entrevista piloto semiestruturada com 25 idosos em desprescrição de clonazepam e (3) validação de conteúdo por meio da técnica de Delphi. A validação deu-se por 50 especialistas com formação e/ou experiência na área da Atenção Primária à Saúde e/ou Saúde do Idoso, entre eles médicos, farmacêuticos e enfermeiros. Como medidas para avaliar os resultados obtidos, foi analisada a concordância da avaliação por meio do coeficiente de validade de conteúdo (CVC). Considerou-se como nível aceitável de concordância o valor maior ou igual a 0,8. RESULTADOS: O instrumento foi considerado validado na primeira rodada de avaliação, em que todos os itens avaliados obtiveram CVC superior a 0,8 na avaliação dos especialistas. Entretanto, estes propuseram sugestões de melhorias que foram incorporadas na versão final do questionário. CONCLUSÃO: O instrumento apresenta-se como uma importante ferramenta a ser utilizada pelos profissionais de saúde para a otimização do processo de desprescrição de benzodiazepínicos, possuindo índice de clareza e de validade adequados.
Subject(s)
Humans , Aged , Benzodiazepines/administration & dosage , Surveys and Questionnaires , Deprescriptions , Health Services for the Aged , Reproducibility of Results , Delphi TechniqueABSTRACT
De acuerdo a las estimaciones mundiales, el año 2050, habrá más de 2000 millones de personas mayores (PM) de 60 años. En Chile, la situación no es distinta, el país está envejeciendo y esta situación nos expone a nuevos desafíos. Las PM, suelen presentar una mayor carga de enfermedad con el consiguiente aumento en la utilización de medicamentos para controlar su comorbilidad y multimorbilidad. Esta polifarmacia (uso de 5 o más medicamentos) trae consigo riesgos tales como el aumento de caídas, mayor fragilidad, aumento de los costos, entre otros. Para abordar estos riesgos en las PM, aparece el concepto de deprescripción como la práctica de retiro de medicamentos considerados inapropiados, supervisado por un profesional de la salud con el objetivo de gestionar la polifarmacia y mejorar los resultados clínicos. La deprescripción de medicamentos tales como las benzodiazepinas podrían mejorar la calidad del sueño y la calidad de vida, el retiro de analgésicos antinflamatorios no esteroidales y betabloqueadores disminuyen las caídas entre otros resultados. Esta práctica, debiese plantearse, por ejemplo, cuando los síntomas o síndromes coinciden con los efectos adversos a algunos de los medicamentos, cuando el paciente se encuentra en estadío avanzado de su enfermedad, con extrema fragilidad, con demencia avanzada o en cuidados de fin de vida. A pesar de que cada vez aparece más literatura que muestra la utilidad de deprescribir, queda aún pendiente expandir el conocimiento para generar evidencia de mejor calidad metodológica que oriente en qué escenarios se obtienen los mejores resultados para los pacientes.
According to global estimates, in the year 2050, there will be more than 2000 million older people (OP) of 60 years. In Chile, the situation is no different, the country is aging and this situation exposes us to new challenges. The OP, usually present a greater burden of disease resulting in an increase in the use of medications to control their comorbidity and multimorbility. This polypharmacy (the use of 5 or more drugs) it brings risks such as the increase in falls, greater fragility, increased costs, among others. To address these risks in the OP, the term deprescribing appears as the process of withdrawal of inappropriate medication, supervised by a health care professional with the goal of managing polypharmacy and improve clinical outcomes. Deprescribing medications such as benzodiazepines could improve the quality of sleep and quality of life, the withdrawal of non-steroidal anti-inflammatory analgesics and beta-blockers decrease falls among other results. This practice should arise, for example, when the symptoms or syndromes coincide with adverse effects to some of the medicines, when the patient is in advanced stage of their illness, with extreme fragility, with advanced dementia or end-of-life care. Despite the fact that every time appears more literature that shows the usefulness of deprescribir, to expand the knowledge to generate evidence of better quality that show in which scenarios are obtained the best results for patients.
Subject(s)
Humans , Aged , Polypharmacy , DeprescriptionsABSTRACT
Polypharmacy, which is the practice of prescribing five or more medicines to the same patient is associated withmany problems like adverse drug reactions and poor adherence to therapy and can be harmful. Recently, the termdeprescribing is used to describe the systematic process of identifying and discontinuing medicines in situationsin which potential or existing harms outweigh potential or existing benefits for the seek of individual patient caregoals and preferences. Many studies assessed the attitude of patients or perceptions of health care practitionerstowards deprescribing, others evaluated barriers or factors affecting deprescribing. Since the practice ofdeprescribing is growing, this study aimed to review the harms, benefits, and barriers of deprescribing. Somestudies reported that patients may be interested in withdrawing one or more of their medicines if advised by theirtreating doctors and at the same time costs and experiencing medication adverse effects may result in awillingness to decrease the number of medications taken. Harms that may occur due to deprescribing can beminimized or even prevented by using a structured and patient-specific deprescribing process with properplanning and careful monitoring during and after medication withdrawal.
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AIM: To measure medication consumption and the prevalence of potentially inappropriate medications (PIMs) during hospitalization and hospital discharge in the geriatric condition of frailty and to provide bases for rational medications use and further deprescribing. METHODS: A clinical data questionnaire, including the basic situation of patients and medications was designed. Charlesson comorbidity index was used to determine the patient's burden and status and the number of medication consumption in the geriatric condition of frailty. The medication consumption was determined by examining Hospital Medication Administration Records. PIMs were defined using STOPPFrail deprescribing criteria and McLeod criteria, whose sensitivity was compared to determine the PIMs independent related factors. RESULTS: This study included 169 patients. The mean age of participants was 83.49±6.73, 42.6% were female. The median number of days spent in hospital was 19 (interquartile range (IQR)12-33). During the first 24 hours of hospitalization, the mean number of individual medications consumed was 9.01 (standard deviation 4.12). Of hospital discharge, the mean number of individual medications consumed was 11.27 (standard deviation 4.57). Over 60% of patients were prescribed at least one PIM at discharge and 7.69% had ≥3 PIMs. Leukotriene antagonists, proton pump inhibitors (PPIs), lipid-lowering medications and diabetic oral agents accounted for major PIMs. Compared with McLeod's criteria, STOPPfrail criteria was a more sensitive tool for 24-hour hospitalization and hospital discharge PIMs screening (t=6.78, P=0.00<0.01; t=10.10, P=0.00<0.01). Full implementation of STOPPFrail recommendations would have resulted in one-in-seven long-term medications being discontinued. CONCLUSION: High levels of medication consumption in the geriatric condition of frailty will result in high burden experienced by patients in the condition of frailty and continued prescribing of futile medications. It is necessary to improve and pay more attention to the safety of medications. The STOPPFrail criteria is highly sensitive, simple and easy to use. Screening for medication consumption in geriatric condition of frailty with STOPPFrail tool will decrease medication burden.
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Objective: The study aimed to analyze the Quality of Life (QoL) of patients utilizing benzodiazepines (BZDs). Methods: A prospective interventional study was conducted among 109 patients who met the inclusion criteria. The patients consuming BZDs more than the prescribed duration were identified and deprescribed. Deprescribing plan was advised after discussing with the prescribing psychiatrist and inappropriate BZD users. The QoL of patient’s pre and post-intervention amongst both the continuing and deprescribed groups was evaluated by WHO-QoL BREF questionnaire. Results: Mean scores in the domains of physical health (71.48), psychological health (68.74), social relationships (65.15) and environmental health (68) among the deprescribed group was higher compared to the maintenance group. Independent t-test statistic for QoL showed a statistical significance in all 4 domains with p value<0.05. Conclusion: The current study emphasizes that deprescribing of BZDs as shared decision model involving the physician, pharmacist and patients improves the QoL of the patient.
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INTRODUCTION@#Polypharmacy and inappropriate prescribing are associated with negative health outcomes in the elderly. Several prescribing tools have been developed to assess medication appropriateness. Explicit (criteria-based) tools often do not take into account patients' preferences and comorbidities, and have little room for individualised clinical judgement.@*METHODS@#A cross-sectional observational study was conducted in 243 elderly patients admitted to the Geriatric Medicine service in a Singapore tertiary hospital over one month. We incorporated an implicit (judgement-based) tool developed by Scott et al into a mnemonic, 'S-I-R-E', to assess medication appropriateness: S = symptoms ('Have symptoms resolved?'), I = indication ('Is there a valid indication?'), R = risks ('Do risks outweigh benefits?') and E = end of life ('Is there short life expectancy limiting clinical benefit?').@*RESULTS@#Inappropriate prescribing was present in 27.6% of patients. The most common reason for inappropriateness of medications was lack of valid indication (62.2%), followed by high risk-benefit ratio (20.7%). The most common medications that lacked valid indication were supplements and proton pump inhibitors. Polypharmacy was found in 93% of patients and was significantly associated with inappropriate prescribing (p = 0.047).@*CONCLUSION@#Inappropriate prescribing and polpharmacy are highly prevalent in the hospitalised elderly. The 'S-I-R-E' mnemonic can be used as a memory aid and practical framework to guide appropriate prescribing in the elderly.
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OBJECTIVE:To provide reference for promoting smoothly implementation of deprescribing. METHODS:A total of 335 elderly patients with chronic disease were randomly selected from 4 communities and 9 village clinic of a Chongqing community health service center. Questionnaire survey was conducted about general information of respondents,disease and drug use condition and attitude to deprescribing by using Australian Patients'Attitudes Towards Deprescribing questionnaire as reference. The results of questionnaire survey were analyzed statistically. The cognitive function was assessed by Hastgawa Dementia Scale. The degree of weakness was evaluated by Chinese edition of Edmonton Frail Scale. The quality of life was evaluated by Chinese edition of European Five Dimensional Health (EQ-5D) Scale. RESULTS:Totally 311 valid questionnaires were obtained,with effective recovery rate of 92.8％. Overall,311 participants were recruited,with a median age of 70 years,5 types of median disease (hypertension was most common) and 5 types of median medication (mainly calcium channel blocker and non-insulin hypoglycemic agent);54.7％(170 cases)participants took multiple drugs. The attitudes towards deprescribing were that 39.5％ of respondents believed that they took too many drugs;73.9％ had a desire to reduce their drugs;83.6％ reported that they would be willing to reduce drugs if their doctor said it was possible. The patients taking multiple drugs preferred to use less drugs (P=0.001) and reduce current drugs (P=0.001),and were more willing to reduce drug cost by reducing drug use;they were also more worried about drug side effects than those without taking multiple drugs (P=0.005). CONCLUSIONS:The phenomenon of elderly chronic diseases patients with multiple diseases and multiple drug use are popular in community. It is necessary to simpilfy prescription. Most elderly patients would like to reduce their medications if doctors say it is possible;the patients with multiple drug use are more willing to simplify prescription than those without multiple drug use.
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Se buscaron pacientes con prescripciones inapropiadas de alendronato de 70 mg y mediante una intervención educativa reducir los errores de medicación. Métodos: Se realizó un estudio cuasiexperimental, prospectivo, antes y después, sin grupo control, donde se llevó a cabo una intervención en prescriptores de pacientes que se encontraban en manejo farmacológico con alendronato de 70 mg en el período comprendido entre el 1 de julio de 2013 y el 30 de junio de 2014, incluyendo todos los sujetos que recibían más de 4 tabletas por mes. La intervención consistió en suministrar información actualizada a los responsables de la atención sanitaria y evaluar, meses después, si se modificó o no la prescripción de los pacientes identificados. Resultados: De un total de 2.283 usuarios que recibían alendronato, se hallaron, en promedio, 105 pacientes mensuales con diagnóstico de osteoporosis que estaban recibiendo la presentación de 70 mg, con edad promedio de 66,0 ± 5,5 años y predominio femenino (n =159; 95,8%). En promedio a 22 pacientes se les dispensaba más de 4 tabletas por mes (rango: 8-38 tabletas/mes). La intervención consiguió reducir a 8 pacientes con dosis superiores a las recomendadas, (63,6% de casos). Los aseguradores estaban pagando en promedio COP $459.166 más, cada mes, por el exceso de tabletas dispensadas y la intervención logró un ahorro de COP $3.491.592 al año. Conclusiones: Las intervenciones educativas sobre los médicos prescriptores pueden conseguir disminuir el número de prescripciones potencialmente inapropiadas y de errores de medicación para reducir el riesgo sobre los pacientes y costes de atención en salud
The aim of the study is to identify patients with inappropriate prescriptions of alendronate (70 mg) and to use an educational intervention to reduce medication errors. Methods: A quasi-experimental, prospective before and after study was conducted, without a control group, where an intervention was conducted on prescribers of patients on pharmacological treatment with alendronate 70 mg in the period from 1 July 2013 to 30 June 2014. All subjects receiving more than 4 tablets per month were included. The intervention was to provide updated information to those responsible for health care and then assess whether or not they modified the patient prescription. Results: Out of a total of 2,283 patients receiving alendronate, it was found that a mean of 105 patients per month diagnosed with osteoporosis received the presentation of 70 mg. The mean age was 66.0 ± 5.5 years, and the large majority (n =159; 95.8%) were female. A mean of 22 patients were dispensed with more than 4 tablets per month (range: 8-38 tablets/month). The intervention managed to reduce those with a higher than recommended doses to 8 patients (63.6% of cases). Insurers were paying COP $459,166 more on average each month for excess tablets dispensed, and the intervention achieved savings of COP $3,491,592 per year. Conclusions: Educational interventions on prescribers can reduce the number of potentially inappropriate prescribing and medication errors and reduce the risk to patients and health care costs
Subject(s)
Humans , Alendronate , Pharmacovigilance , Medication ErrorsABSTRACT
Las consecuencias de una medicación inadecuada son diversas y con gran repercusión a nivel clínico: desde efectos adversos e interacciones medicamentosas a fracturas por caídas y aumento de morbi-mortalidad. Para evitar o mejorar dichas consecuencias, así como para abordar sus causas y con la seguridad del paciente en mente, nace la deprescripción para conseguir una prescripción más segura, más prudente y más humana. La atención primaria se sitúa en un lugar privilegiado para hacer frente a este reto que debería formar parte de cualquier estrategia de prevención cuaternaria.
As consequências de uma medicação inadequada são diversas e com grande repercussão clínica: desde efeitos adversos e interações medicamentosas até fraturas por quedas e aumento da morbidade e mortalidade. Para se evitar ou amenizar essas consequências, bem como abordar as suas causas, levando-se em conta a segurança dos pacientes, surge a desprescrição para se obter uma prescrição mais segura, mais prudente e mais humana. A atenção primária está em uma posição privilegiada para enfrentar o desafio da desprescrição e esta deveria fazer parte de qualquer estratégia de prevenção quaternária.
The consequences of inappropriate medication are diverse and have great clinical impact: from adverse effects and medication interactions to fractures from falls and increased morbidity and mortality. To avoid or ameliorate such consequences, as well as to address its causes, bearing in mind patients' safety, deprescription has emerged as a safer, more prudent and humane practice. Primary care is in a privileged position to address this challenge of deprescription and it should be part of any strategy of quaternary prevention.