Healthcare Professionals' Views on the Management of Medication Complexities in the Elderly With Mental Health Disorders: A Cross-Sectional Study.

Background: Many challenges in elderly pharmacotherapy are identified, including the use of Potentially Inappropriate Medications (PIMs) which may increase the odds of adverse events, especially in elderly patients with mental health disorders (e. g., behavioral, and psychological symptoms of dementia-BPSD, schizophrenia, bipolar disorder). However, information on the knowledge and practice of healthcare professionals (HCPs) about this topic is still scarce. Methods: A cross-sectional study was undertaken from July-October 2019. An online questionnaire was specifically designed and validated for this study. We sought HCPs (physicians, pharmacists, and nurses) worldwide, using (a) social media, via Facebook, Twitter, and LinkedIn; and (b) email contacts of the research team (convenience sample). Either way participants were asked to share on their social media or via e-mail the questionnaires with other HCPs (snowballing sample). The survey assessed two main domains: knowledge and practice. Knowledge was evaluated by self-report (perceived knowledge by a 5-item Likert confidence scale) and using three clinical cases, scored between 0 and 30 points (each one rated from 0 to 10 points; real knowledge). Barriers in clinical practice were evaluated using a 5-item Likert scale judging practitioners' opinion. Results: A total of 165 questionnaires were collected. HCPs were mainly female (n = 114; 69.1%), with a mean age of 35.3 ± 11.3 years old. Seventy-two percent (n = 118) were pharmacists, 21.1% (n = 35) were physicians, and 7.3% (n = 12) nurses. There was a weak correlation, albeit significant, between perceived and real knowledge (r = 0.199; p = 0.001). The mean score of the clinical vignettes regarding elderly patients with dementia and bipolar disorder were 4.59 ± 4.08 and 4.86 ± 2.97 points, respectively. Most HCPs were classified as having an intermediate knowledge (n = 100; 60.6%) about medication complexities in the elderly with mental disorders. Most HCPs agreed that lack of time (81.6%; n = 138), lack of education and training on elderly pharmacotherapy (72.2%; n = 122), and lack of tools adapted to daily practice (61.8%; n = 105) were the main barriers. Conclusions: Most of the HCPs felt confident to manage medication complexities in elder patients with mental disorders, but only a minority obtained a good score in the knowledge assessment test. The main barriers identified included structural barriers (tools unfit for practice) and process barriers (time).

Identification of a Set of Patient-Related Features to Foster Safe Prescribing of Specific Antipsychotics in the Elderly With Dementia.

Background: Antipsychotics (APs) are widely used to manage behavioral and psychiatric symptoms in dementia, although with a variety of adverse drug reactions. Therefore, it is important to know which patient-related features should be considered to foster a safe prescribing of these medications. Objectives: To compile and validate a set of patient-related features (PRFs) to foster safe prescribing of specific APs in the elderly with dementia; and to evaluate the feasibility of using them in clinical practice by analyzing the exhaustiveness of medical records. Method: A rapid literature review was the starting point, where PRFs were identified through a search in PubMed combined with information from the Summary of Product Characteristics (SmPCs). In the next step, a two-round e-Delphi survey was undertaken, where a total of 450 participants were invited by e-mail, including prescribers and specialists in benefit-risk assessment. Finally, a cross-sectional study was undertaken, where 100 patients were randomly extracted from the psychiatric hospital database. Outcomes were defined as the assessment of the clinical relevance and feasibility of the PRFs, and the level of exhaustiveness of these features in medical records. Data analysis was performed using univariate statistics (IBM SPSS v.23.0). Results: A total of 92 experts participated in the e-Delphi. Forty-seven PRFs obtained consensus, where 12 were applicable to haloperidol, 14 to olanzapine/risperidone, 13 to quetiapine, and 8 to aripiprazole. Age, comorbidities, and co-medications were rated as important features regardless of the prescribed drug. All PRFs were rated as always or frequently available and, if not, they were easy or partially easy to obtain. Age, comorbidities, and co-medications were always available in the medical records, whereas cognitive status (between 41.4 and 78.8%) or hepatic function (between 17.2 and 30.4%) presented a low-level of exhaustiveness. Conclusions: Even though a high number of PRFs were rated as clinically relevant, some of them were identified as frequently missing from medical records. This may suggest that medical records should be complemented with other sources (e.g., nursing and pharmacy records) to ensure a safe prescribing of APs.

The association between receptor binding affinity and metabolic side effect profile of antipsychotics and major cardio- and cerebrovascular events: A case/non-case study using VigiBase.

Antipsychotics (APs) have been associated with major adverse cardio- and cerebrovascular events (MACCE), but the underlying mechanisms are unclear. Our aim was to elucidate the association between APs, stratified for receptor affinity and metabolic side effects (MSE), in the reporting of MACCE. A case/non-case study was conducted using data from the WHO global Individual Case Safety Report (ICSR) database, VigiBase, among all reports associated with an AP. Cases were ICSRs of MACCE, while non-cases were all other adverse drug reactions (ADRs). APs were classified by AP group, the degree of receptor affinity for adrenergic, dopaminergic, muscarinic, histaminic, and serotoninergic receptors and by MSE profile. The strength of the association was estimated with logistic regression and expressed as crude and adjusted reporting odds ratios (RORadj.) with corresponding 95% confidence intervals (95%CIs). We identified 4987 reports of MACCE and 328,907 reports of other ADRs. Atypical APs (RORadj. 2.46; 95%CI 2.20-2.74) were significantly associated with the reporting of MACCE compared to typical ones. APs with high affinity for Adrenergic alfa-1 (RORadj. 2.98; 95%CI 1.93-4.59), Histaminic H1 (RORadj. 2.31; 95%CI 1.98-2.68), Muscarinic M1 (RORadj. 1.87; 95%CI 1.74-2.01), and Serotoninergic 5-HT2A (RORadj. 3.19; 95%CI 2.07-4.92) were associated with a higher risk of reporting of MACCE compared to low affinity. APs with higher-risk of MSE were associated with higher risk of reporting of MACCE (RORadj. 1.88; 95%CI 1.73-2.05) compared to the lower-risk. APs with high affinity for Adrenergic alfa-1, Histaminic H1, Muscarinic M1, and Serotoninergic 5-HT2A receptors and with high-risk of MSE may explain the occurrence of those events.

Identification of potentially inappropriate medications with risk of major adverse cardiac and cerebrovascular events among elderly patients in ambulatory setting and long-term care facilities.

PURPOSE: Cardiovascular diseases (CVDs) are extremely common among the elderly, but information on the use of potentially inappropriate medications (PIMs) with cardiovascular risk is scarce. We aimed to determine the prevalence of PIMs with risk of cardiac and cerebrovascular adverse events (CCVAEs), including major adverse cardiac and cerebrovascular events (MACCE). PATIENTS AND METHODS: A cross-sectional study was performed using a convenience sample from four long-term care facilities and one community pharmacy in Portugal. Patients were included if they were aged 65 or older and presented at least one type of medication in their medical and pharmacotherapeutic records from 2015 until December 2017. The main outcome was defined as the presence of PIMs with risk of MACCE and was assessed by applying a PIM-MACCE list that was developed from a previous study. All medications included in this list were assessed for their availability in Portugal. RESULTS: A total of 680 patients were included. Of those, 428 (63%) were female with a mean age of 78.4±8.1 years. Four-hundred and four (59.4%) patients were taking medications associated with CCVAEs risk (mean =1.7±1.0 drugs/patient), including 264 patients (38.8%) who used drugs with MACCE risk (mean =1.4±0.8 drugs/patient). Fifty percent of patients with a previous history of CVD (n=521) were taking PIMs with risk of CCVAEs, including 30.0% with risk of MACCE. CONCLUSION: Our findings show that 50% of patients with previous history of CVD were taking drugs with risk of CCAVEs and 30% with risk of MACCE. More tailored tools for the management of drug therapy in elderly patients with CVD are of major importance in clinical practice.

Potentially inappropriate medications with risk of cardiovascular adverse events in the elderly: A systematic review of tools addressing inappropriate prescribing.

WHAT IS KNOWN AND OBJECTIVE: In the last decades, many lists have been developed to screen for inappropriate prescribing. However, information on which potentially inappropriate medications (PIMs) could increase the cardiovascular risk in the elderly is not objectively presented. This review aimed to identify and quantify those PIMs by extracting information from published PIM-lists. METHODS: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement (PRISMA), a systematic review of PIM-lists was conducted. The search strategy was run in PubMed, MEDLINE and Google Scholar (1991-09/2017). All PIMs described in those lists were extracted and stratified by their potential cardiovascular risk (including major adverse cardiovascular events-MACE). The number of times each PIM was reported on those lists was also assessed. RESULTS AND DISCUSSION: We identified 724 papers, and 24 were retained. From those, a total of 17 PIMs to be avoided by the elderly and 21 drug-disease interactions were retrieved. The reporting of PIMs with risk of cardiovascular adverse events was 15.3%, whereas the reporting of those with MACE risk was 7.2%. PIMs most frequently described were tricyclic antidepressants (TCAs; 12/24), centrally acting antiadrenergic agents (11/24), NSAIDs (7/24), antiarrhythmics (Class I and III; 6/24), peripherally acting antiadrenergic agents (6/24) and antithrombotic agents (5/24). Most frequently described PIMs with MACE risk were NSAIDs (7/24), antiarrhythmics (Class I and III) (7/24), selective calcium channel blockers with vascular effects (6/24) and antipsychotics (4/24). WHAT IS NEW AND CONCLUSION: Data suggest that PIM-lists focus mainly on common adverse events and often poorly describe the potential consequence for MACE occurrence. This systematic review could help healthcare professionals in the identification and deprescribing of these medicines in older patients with high cardiovascular risk during medication review.

Psicofármacos y riesgo de caídas en ancianos: resultados preliminares del estudio piloto casocontrol anidado en una residencia de ancianos portuguesa / Psychopharmaceuticals and the risk of falls among elderly people: preliminary results of the nested case-control pilot study in a Portuguese care home

Introducción: Las caídas son frecuentes entre los ancianos, los cuales toman muchos medicamentos y algunos de ellos, como los psicofármacos, pueden aumentar el riesgo de caídas. Objetivos: Investigar la relación entre el uso de psicofármacos y la aparición de caídas en pacientes ancianos institucionalizados e identificar los fármacos más utilizados en estos pacientes. Además, se estudió el riesgo asociado al número de psicofármacos que el paciente estaba tomando y el riesgo de caídas que provocaron. Material y métodos: Se realizó un estudio caso-control anidado a partir de una cohorte de pacientes polimedicados internados en una residencia. Los casos fueron pacientes con caídas, entre agosto de 2014 y diciembre de 2015, y los controles aquellos que no cayeron. La exposición a psicofármacos fue investigada en los 2 grupos retrospectivamente. La información fue recogida de la base de datos de la residencia por personal sanitario. El análisis se centró en las OR de caídas por grupo terapéutico, usando un IC de 95%. Resultados: Se analizó una muestra de 22 pacientes, 9 casos y 13 controles: mayoría mujeres, y edad media 82,3 años (DE=6,5). Cada residente tomó una media de 11 medicamentos (DE=4,6). El grupo farmacoterapéutico y el fármaco más utilizados fueron antipsicóticos y quetiapina (59,1%, n=13; 45,5%, n=10, respectivamente). Los OR calculados demuestran no haber ninguna asociación estadísticamente significativa entre los subgrupos terapéuticos y/o fármacos con un elevado riesgo de caídas (p. ej. quetiapina: OR=4.5; IC=0,730-27,739; antipsicóticos atípicos: OR=3,2; IC=0,540-18,980). Conclusión: Como los resultados fueron obtenidos de una muestra limitada, no se demostraron relaciones significativas, aunque sí una clara relación entre el uso de psicofármacos y el riesgo de caídas, identificando aquellos grupos farmacoterapéuticos más influyentes en caídas (AU)

Introduction: Falls are frequent in the elderly, because they take medication that may increase the risk of falls, including psychotropic drugs. Aims: To explore the relationship between the use of psychotropic drugs and the occurrence of falls in institutionalized patients, and to identify the most used drugs in these patients. In addition, it was studied the risk associated with the psychotropic drugs and the risk of falls that they caused. Methods: A nested case-control study was performed from a cohort of polypharmacy patients residing in a nursing home. Cases were those having suffered a fall from August 2014 to December 2015, and controls were those without falls recorded. The exposure of psychoactive drugs was explored retrospectively in both groups. Information was collected in the database of the nursing home. Analysis focused on the odds ratio of falling per pharmacotherapy group, using confidence intervals set at 95%. Results: A sample of 22 patients, 9 cases and 13 controls, was analyzed: most patients were women, and the mean age was 82.3 years (SD=6.45). Residents used a mean of 11 medicines (SD=4.64). The most used pharmaceutical group and drug respectively were antipsychotics and quetiapine (59.1%, n=13; 45.5%, n=10). The OR determined in this study did not evidence any statistically significant association between the pharmacotherapeutic subgroups and/or drugs and increased risk of falling (quetiapine: OR=4.5; IC=0.730-27.739; atypical antipsychotics: OR=3.2; IC=0.540-18.980). Conclusion: Results were obtained in a restricted sample, leading to the incapacity of demonstrating significant associations. However, a trend between the use of psychotropic drugs and the risk of falls in the elderly was shown, identifying the most influential pharmacotherapeutic groups in falls (AU)