Psychotropic medicines' prevalence, patterns and effects on cognitive and physical function in older adults with intellectual disability in Ireland: longitudinal cohort study, 2009-2020.

BACKGROUND: The frequent prescribing of psychotropics and high prevalence of polypharmacy among older adults with intellectual disabilities require close monitoring. AIMS: To describe change in prevalence, predictors and health outcomes of psychotropic use during the four waves (2009/2010, 2013/2014, 2016/2017, 2019/2020) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA). METHOD: Eligible participants were adults (≥40 years) with intellectual disabilities who participated in all four waves of IDS-TILDA and who reported medication use for the entire period. Differences between groups were tested using Cochran's Q test for binary variables and the McNemar-Bowker test for variables with more than two categories. Generalised estimating equation models were used to assess associations between psychotropic use, participants' characteristics and health outcomes. RESULTS: Across waves (433 participants) there were no significant differences in prevalence of psychotropic use (61.2-64.2%) and psychotropic polypharmacy (42.7-38.3%). Antipsychotics were the most used subgroup, without significant change in prevalence between waves (47.6-44.6%). A significant decrease was observed for anxiolytics (26.8-17.6%; P < 0.001) and hypnotics/sedatives (14.1-9.0%; P < 0.05). A significant increase was recorded for antidepressants (28.6-35.8%; P < 0.001) and mood-stabilising agents (11.5-14.6%; P < 0.05). Psychotropic polypharmacy (≥2 psychotropics) was significantly associated with moderate to total dependence in performing activities of daily living over the 10-year period (OR = 1.80, 95% CI 1.21-2.69; P < 0.05). CONCLUSIONS: The study indicates an increase in usage of some classes of psychotropic, a reduction in others and no change in the relatively high rate of antipsychotic use over 10 years in a cohort of older adults with intellectual disabilities and consequent risk of psychotropic polypharmacy and medication-related harm.

Rating scales to measure adverse effects of medications in people with intellectual disability: a scoping review.

PURPOSE: Intellectual disability (ID) is a chronic neurodevelopmental condition characterised by limitations in intelligence and adaptive skills with an onset prior to the age of 18 years. People with ID have complex healthcare needs and are more likely than the general population to experience multiple comorbidities and polypharmacy, with subsequent increased risk of adverse medication effects. The aim of this scoping review is to characterise rating scales used to measure adverse effects of medication in people with ID. METHODS: Four online databases (PsycINFO, Medline, Web of Science and OpenGrey) were searched in April 2020. Studies were assessed for inclusion against pre-specified eligibility criteria. Reference lists of included studies were hand searched. Data extraction was carried out by two independent reviewers and key findings were tabulated for consideration. Studies were assessed for quality using the Mixed Methods Appraisal Tool. RESULTS: The search resulted in 512 unique records, of which fifteen met the inclusion criteria. Fourteen scales were identified. All scales assessed adverse effects of psychotropics only. Of the scales, only one, the Matson Evaluation of Drug Side Effects, which focuses on psychotropic medications, was originally developed for use in a population with ID. CONCLUSION: The Matson Evaluation of Drug Side Effects scale appears to be the most reliable and well-researched scale in people with ID. However, a scale which measures adverse effects across multiple medication classes would be valuable for use in this population.

Defensive pharmacy practice: a gap in our understanding.

Defensive practice is prevalent across healthcare disciplines and much study has been performed on this behaviour in medicine and nursing. However, little research has been carried out on defensive practice in pharmacy, despite its potential to increase healthcare costs, reduce quality of care and affect pharmacist job satisfaction. With a more litigious society emerging and greater level of regulation, the pharmacy profession shares many of the influences of defensive practice identified in other healthcare professions. As a result, pharmacists too may engage in defensive practice behaviours in order to protect themselves from the perceived risk of litigation. Research in this area is necessary to identify how this phenomenon affects the profession and to develop methods of improving pharmacy practice. While this type of research would not be without challenges, it could form the basis for policy change and greater professional representation, ultimately improving quality of care for patients.

Measuring drug burden in older adults with intellectual disabilities: Critical issues for consideration in finding the optimal measure to improve safety of medicines use.

Older adults with Intellectual Disability have been described as among the most medicated groups in society, with rates of polypharmacy significantly exceeding that of the general population. They are at heightened risk of medication-related harm and have high exposure to high-risk medications, for example, anticholinergic ad sedative medicines. There has been significant controversy internationally relating to the inappropriate use of antipsychotics for challenging behavior, often in the absence of a psychiatric diagnosis. Despite this, the evidence base of the safety of use of medicines in this population is lacking, the provision of healthcare is often suboptimal and this population is often excluded from Randomized Controlled Trials. In this editorial, we describe the unique challenges in ensuring safe and appropriate medicines in this population. We describe tools to date that has been used in this population to measure the burden of medicines that increase the risk of adverse outcomes. We outline current and future developments required to improve the quality and safety of medicines use in this population, for example, longitudinal cohort studies.

Medication burden and frailty in older adults with intellectual disability: An observational cross-sectional study.

PURPOSE: Recently, efforts have been made to quantify frailty among older adults with intellectual disability (ID). Medication exposure is associated with frailty among older adults without ID. However, there is little research on this association among older adults with ID. The aim of this study was to examine specifically in people with ID the association between frailty and medication exposure, including anticholinergic and sedative medication exposure. METHODS: Data were drawn from Wave 2 (2013/2014) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA), a nationally representative study of older adults with ID in Ireland. A modified version of Fried's frailty phenotype was constructed. Drug burden measures were polypharmacy, Drug Burden Index (DBI), Anticholinergic Cognitive Burden (ACB) and Sedative Load Model. Multinomial logistic regression was used to calculate odds ratios (ORs) and identify associations between frailty and drug burden. RESULTS: This study included 570 participants with ID. Excessive polypharmacy (use of ≥10 medications) was significantly associated with being pre-frail (P = .017; OR = 2.56; 95% confidence interval [CI] 1.19-5.50) and frail (P < .001; OR 7.13; 95% CI 2.81-18.12), but DBI, ACB or Sedative Load score were not significantly associated with frailty status (P > .05). CONCLUSIONS: This is the first study to examine frailty and its association with medication use including anticholinergic and sedative medication burden among older adults with ID. Further research is required to investigate frailty as measured by other frailty models in relation to medication burden in older adults with ID.

Association of Drug Burden Index with grip strength, timed up and go and Barthel index activities of daily living in older adults with intellectual disabilities: an observational cross-sectional study.

BACKGROUND: Drug Burden Index (DBI), a measure of exposure to medications with anticholinergic and sedative activity, has been associated with poorer physical function in older adults in the general population. While extensive study has been conducted on associations between DBI and physical function in older adults in the general population, little is known about associations in older adults with intellectual disabilities (ID). This is the first study which aims to examine the association between DBI score and its two sub-scores, anticholinergic and sedative burden, with two objective measures of physical performance, grip strength and timed up and go, and a measure of dependency, Barthel Index activities of daily living, in older adults with ID. METHODS: Data from Wave 2 (2013/2014) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA) was analysed. Analysis of Covariance (ANCOVA) was used to detect associations and produce adjusted means for the physical function and dependency measures with respect to categorical DBI scores and the anticholinergic and sedative sub-scores (DBA and DBS). RESULTS: After adjusting for confounders (age, level of ID, history of falls, comorbidities and number of non-DBI medications, Down syndrome (grip strength only) and gender (timed up and go and Barthel Index)), neither grip strength nor timed up and go were significantly associated with DBI, DBA or DBS score > 0 (p > 0.05). Higher dependency in Barthel Index was associated with DBS exposure (p < 0.001). CONCLUSIONS: DBI, DBA or DBS scores were not significantly associated with grip strength or timed up and go. This could be as a result of established limitations in physical function in this cohort, long-term exposure to these types of medications or lifelong sedentary lifestyles. Higher dependency in Barthel Index activities of daily living was associated with sedative drug burden, which is an area which can be examined further for review.

Prevalence and patterns of antipsychotic use and their associations with mental health and problem behaviours among older adults with intellectual disabilities.

BACKGROUND: There are concerns that antipsychotics may be used inappropriately in adults with intellectual disability for problem behaviours in the absence of a diagnosed mental health condition. The aim was to examine the prevalence and patterns of antipsychotic use and their association with problem behaviours and mental health conditions in older adults with intellectual disability. METHODS: Cross-sectional data were drawn from Wave 2 (2013/2014) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA). Medication data were available for 95.6% (n = 677). Those who reported antipsychotic use and reported psychotic or other mental health conditions and those who reported problem behaviours were compared. RESULTS: In total, 45.1% (n = 305) had antipsychotics, and of those with antipsychotic use and diagnosis information (n = 282), 25.9% (73) had a psychotic disorder. 58% of those exposed to antipsychotics reported problem behaviours. CONCLUSION: Reported use of antipsychotics significantly exceeded reported doctor's diagnosis of psychotic conditions in this study.

Drug burden index to define the burden of medicines in older adults with intellectual disabilities: An observational cross-sectional study.

AIMS: The drug burden index (DBI) is a dose-related measure of anticholinergic and sedative drug exposure. This cross-sectional study described DBI in older adults with intellectual disabilities (ID) and the most frequently reported therapeutic classes contributing to DBI and examined associations between higher DBI scores and potential adverse effects as well as physical function. METHODS: This study analysed data from Wave 2 (2013/2014) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA), a representative study on the ageing of people with ID in Ireland. Self- and objectively-reported data were collected on medication use and physical health, including health conditions. The Barthel index was the physical function measure. RESULTS: The study examined 677 individuals with ID, of whom 644 (95.1%) reported taking medication and 78.6% (n = 532) were exposed to medication with anticholinergic and/or sedative activity. 54.2% (n = 367) were exposed to high DBI score (≥1). Adjusted multivariate regression analysis revealed no significant association between DBI score and daytime dozing, constipation or falls. After adjusting for confounders (sex, age, level of ID, comorbidities, behaviours that challenge, history of falls), DBI was associated with significantly higher dependence in the Barthel index (P = 0.002). CONCLUSIONS: This is the first time DBI has been described in older adults with ID. Scores were much higher than those observed in the general population and higher scores were associated with higher dependence in Barthel index activities of daily living.