Simplifying medication regimens for residents of aged care facilities: Pharmacist and physician use of a structured five-step medication simplification tool.

BACKGROUND: Pharmacist-led medication regimen simplification using a structured approach can reduce unnecessary medication regimen complexity in residential aged care facilities (RACFs), but no studies have investigated simplification by different health professionals, nor the extent to which simplification is recommended during comprehensive medication reviews. OBJECTIVES: To compare medication regimen simplification opportunities identified by pharmacists, general medical practitioners (GPs), and geriatricians and to determine if pharmacists identified simplification opportunities during routinely conducted comprehensive medication reviews in RACFs for these same residents. METHODS: Three pharmacists, three GPs and three geriatricians independently applied the Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE) to medication data for 83 residents taking medications at least twice daily. Interrater agreement was calculated using Fleiss's kappa. Pharmacist medication review reports for the same 83 residents were then examined to identify if the pharmacists conducting these reviews had recommended any of the simplification strategies. RESULTS: Overall, 77 residents (92.8 %) taking medications at least twice daily could have their medication regimen simplified by at least one health professional. Pharmacists independently simplified 53.0-77.1 % of medication regimens (Κ = 0.60, 95%CI 0.46-0.75, indicating substantial agreement), while GPs simplified 74.7-89.2 % (Κ = 0.44, 95%CI 0.24-0.64, moderate agreement) and geriatricians simplified 41.0-66.3 % (Κ = 0.30, 95%CI 0.16-0.44, fair agreement). No simplification recommendations were included in the reports previously prepared by pharmacists as part of the comprehensive medication reviews undertaken for these residents. CONCLUSION: Pharmacists, GPs, and geriatricians can all identify medication regimen simplification opportunities, although these opportunities differ within and between professional groups. Although opportunities to simplify medication regimens during comprehensive medication reviews exist, simplification is not currently routinely recommended by pharmacists performing these reviews in Australian RACFs.

Comparison of polypharmacy and potentially inappropriate medication use in older adults with and without dementia receiving residential medication management reviews.

OBJECTIVES: Among residents who had a residential medication management review (RMMR), there is a lack of studies assessing exposure to polypharmacy and potentially inappropriate medications (PIMs) in people with dementia. This study compared the exposure to polypharmacy and PIMs in residents with dementia and without dementia receiving RMMR. METHODS: A retrospective analysis was performed using data of 16,261 residents living in 343 Australian residential aged care facilities who had an RMMR in 2019. Medication use was assessed as polypharmacy (defined as ≥9 medications) and use of ≥1 PIMs using the 2019 updated Beers criteria. Dementia diagnosis was determined with ICD-10 coding from medical records. Descriptive analyses reported resident demographics and patterns of medication use. Pearson's χ2 tests and logistic regression analysis were conducted to compare medication exposure between residents with and without dementia. RESULTS: Among 16,261 residents, 6781 (42%) had dementia. Residents with dementia were significantly more likely to be exposed to polypharmacy and PIMs, compared to those without dementia (74% vs. 70% and 83% vs. 73%, p < .001 respectively). Residents with dementia had 1.31 times the odds of exposure to polypharmacy (adjusted OR: 1.31, 95% CI: 1.22-1.41, p < .001) and 1.88 times the odds of being prescribed ≥1 PIMs than people without dementia (adjusted OR: 1.88, 95% CI: 1.73-2.04, p < .001). CONCLUSIONS: In a study of residents receiving RMMR, polypharmacy and PIMs were highly common, and those with dementia were more likely to be exposed to inappropriate polypharmacy. There is a need for targeted deprescribing strategies to immediately address inappropriate prescribing in residents, particularly those living with dementia.

Too many pills, too many sick older Australians: Working together is key.

BACKGROUND: Australians living in aged care facilities are clinically complex, with multiple comorbidities treated with multiple medicines. Over the past 12 months, there has been unprecedented focus on harm from medications in aged care. This led the Australian Government to fund enhancements to the Residential Medication Management Review (RMMR) program. OBJECTIVE: The aim of this article is to discuss how the enhanced RMMR program will address barriers and support general practitioners to make medication changes for older Australians. DISCUSSION: These enhancements are intended to provide a complete cycle of care over nine months, with ongoing collaboration within the healthcare team including residents. This will allow a team approach to medication changes and monitoring resident response over time. Progress reports will provide a history of outcomes with respect to successful and unsuccessful medication changes. Successful outcomes for residents rely on the healthcare team working together.

Safety and effectiveness of cannabinoids for the treatment of neuropsychiatric symptoms in dementia: a systematic review.

BACKGROUND: Neuropsychiatric symptoms (NPS) in dementia impact profoundly on the quality of life of people living with dementia and their care givers. Evidence for the effectiveness and safety of current therapeutic options is varied. Cannabinoids have been proposed as an alternative therapy, mainly due to their activity on CB1 receptors in the central nervous system. However, little is known regarding the safety and effectiveness of cannabinoid therapy in people with dementia. A literature review was undertaken to identify, describe and critically appraise studies investigating cannabinoid use in treating NPS in dementia. METHODS: We undertook a systematic review adhering to PRISMA guidelines. Twenty-seven online resources were searched, including Medline, PsycINFO and Embase. Studies assessing the safety and or effectiveness of cannabinoids in treating NPS in dementia in people aged ⩾ 65 years were included. Study quality was assessed using the Johanna Briggs Institute and Cochrane Collaboration critical appraisal tools. RESULTS: Twelve studies met the inclusion criteria. There was considerable variability across the studies with respect to study design (50% randomized controlled trials), intervention [dronabinol (33%), nabilone (25%) or delta-9 tetrahydrocannabinol (THC; 42%)] and outcome measures. Dronabinol (three studies) and THC (one study) were associated with significant improvements in a range of neuropsychiatric scores. The most common adverse drug event (ADE) reported was sedation. A high risk of bias was found in eight studies. The highest-quality trial found no significant improvement in symptoms or difference in ADE rate between treatment arms. Included studies used low doses of oral cannabinoids and this may have contributed to the lack of demonstrated efficacy. CONCLUSION: While the efficacy of cannabinoids was not proven in a robust randomized control trial, observational studies showed promising results, especially for patients whose symptoms were refractory. In addition, the safety profile is favourable as most of the ADEs reported were mild. Future trials may want to consider dose escalation and formulations with improved bioavailability.

Potential Cross-Reactivity Between Penicillin Derivatives and Cephalosporins.

Allergic reactions to both penicillins and cephalosporins are relatively common. Patients who have had a previous allergic reaction to a penicillin derivative may also be prone to a further reaction if treated with cephalosporins. This case illustrates several important points about potential cross-reactivity between penicillin derivatives and cephalosporins, as well as the benefits of an extended-hours pharmacy service in a longterm care facility.

What is the best method for measuring renal function in adults and children with cystic fibrosis?

AIMS: To measure the glomerular filtration rate (GFR) in adults and children with cystic fibrosis (CF) using a radio-isotope technique as the gold standard and to compare this to serum creatinine based equations, serum cystatin C levels and tobramycin clearance, and to determine which method correlates most closely with measured GFR in this population.

Renal dysfunction in cystic fibrosis: is there cause for concern?

Most people associate cystic fibrosis (CF) with lung disease. Although this is the major cause of morbidity and mortality, CF is in fact a multi-organ disease. Patients with CF are living longer. Accompanying their increased life expectancy are complications not previously encountered. One of the less obvious concerns is that of renal dysfunction associated with long-term exposure to aminoglycosides as well as renally toxic immunosuppressants in lung transplant recipients. This article reviews what is known about the extent of the problem, summarizes what the current practices of measuring and monitoring renal function in patients with CF, and makes suggestions for alternative approaches. In particular, the potential role of cystatin C will be discussed.

Pharmacist elicited medication histories in the Emergency Department: Identifying patient groups at risk of medication misadventure

The Australian Pharmaceutical Advisory Committee guidelines call for a detailed medication history to be taken at the first point of admission to an Emergency Department (ED). The elderly, in particular those residing in Residential Aged Care Facilities and those with a non-English speaking background, have been identified as patient groups vulnerable to medication misadventure. Objective: to analyse the incidence of discrepancies in medication histories in these demographic groups when pharmacist elicited medication histories were compared with those taken by ED physicians. It also aimed to investigate the incidence of medication related ED presentations. Methods: The study was conducted over a six week period and included 100 patients over the age of 70, who take five or more regular medications, have three or more clinical co-morbidities and/or have been discharged from hospital in three months prior to the study. Results: Twenty four participants were classified as 'language barrier'; 12 participants were from residential aged care facilities, and 64 participants were classified as 'general'. The number of correctly recorded medications was lowest in the 'language barrier' group (13.8%) compared with 18% and 19.6% of medications for 'general' patients and patients from residential aged care facilities respectively. Seven of the patients (29.2%) with 'language barrier'; 1 from a residential aged care facility (8.3%) and 13 of the (20.3%) patients from the 'general' category were suspected as having a medication related ED presentation. Conclusion: This study further highlights the positive contribution an ED pharmacist can make to enhancing medication management along the continuum of care. This study also confirms the vulnerability of patients with language barrier to medication misadventure and their need for interpreter services at all stages of their hospitalisation, in particular at the point of ED presentation (AU)

Las guías del Comité Consultivo Farmacéutico Australiano establecen que se lleve una historia de medicación detallada desde el primer punto de entrada en un servicio de urgencias (SU). Los ancianos, en particular los que residen en Residencias de Ancianos y los que no son hablantes nativos ingleses, se han identificado como grupos de pacientes vulnerables a las desgracias medicamentosas. Objetivo: Analizar la incidencia de discrepancias en las historias de medicación en estos grupos demográficos cuando el farmacéutico obtuvo el historial farmacoterapéutico comparado con los recopilados por los médicos del Servicio de Urgencias. También trató de investigar la incidencia de visitas al SU relacionadas con medicamentos. Métodos. Este estudio se condujo en un periodo de seis semanas e incluyó 100 pacientes de edad superior a 70 años, que tomaban regularmente 5 o más medicamentos, tenían 3 o mas comorbilidades clínicas y/o habían sido dados de alta del hospital en los 3 meses anteriores al estudio. Resultados: 24 participantes fueron calificados con 'barreras lingüísticas'; 12 participantes estaban en residencias de ancianos, y 64 participantes fueron calificados de 'generales'. El número de medicaciones correctamente registradas fue menor en los de 'barreras lingüísticas' (13,8%) comparado con el 18% y el 19,6% de las medicaciones para los 'generales' y los pacientes de residencias de ancianos, respectivamente. En 7 de los pacientes (29,2%) con 'barreras lingüísticas', 1 de residencias de ancianos (8,3%) y 13 (20,3%) de los 'generales' se sospechó que tenían una visita al SU relacionada con los medicamentos. Conclusiones: Este estudio ensalza la contribución positiva que un farmacéutico de urgencias puede realizar para elevar la gestión de la medicación en el continuum de cuidados. Este estudio también confirma la vulnerabilidad e los pacientes con barreras lingüísticas ante las desgracias medicamentosas y su necesidad de servicios de interpretes en todas las etapas de su hospitalización, en particular en el punto de entrada al SU (AU)

Eliciting comprehensive medication histories in the emergency department: the role of the pharmacist

The Australian Pharmaceutical Advisory Committee guidelines call for a detailed medication history to be taken at the first point of admission to hospital. Accurate medication histories are vital in optimising health outcomes and have been shown to reduce mortality rates. This study aimed to examine the accuracy of medication histories taken in the Emergency Department of the Royal Adelaide Hospital. Medication histories recorded by medical staff were compared to those elicited by a pharmacy researcher. The study, conducted over a six-week period, included 100 patients over the age of 70, who took five or more regular medications, had three or more clinical co-morbidities and/or had been discharged from hospital in three months prior to the study. Following patient interviews, the researcher contacted the patient's pharmacist and GP for confirmation and completion of the medication history. Out of the 1152 medications recorded as being used by the 100 patients, discrepancies were found for 966 medications (83.9%). There were 563 (48.9%) complete omissions of medications. The most common discrepancies were incomplete or omitted dosage and frequency information. Discrepancies were mostly medications that treated dermatological and ear, nose and throat disorders but approximately 29% were used to treat cardiovascular disorders. This study provides support for the presence of an Emergency Department pharmacist who can compile a comprehensive and accurate medication history to enhance medication management along the continuum of care. It is recommended that the patient's community pharmacy and GP be contacted for clarification and confirmation of the medication history (AU)

Las guías del Comité Consultivo Farmacéutico Australiano piden que se realice un historial de medicación detallado en el punto de ingreso del hospital. Para optimizar los resultados en salud son vitales los historiales de medicación fiables que han demostrado reducir las tasas de mortalidad. Este estudio trató de examinar la fiabilidad de los historiales de medicación tomados en el Servicio de Urgencias del Hospital Real de Adelaida registradas por el personal médicos y se compararon con las extraídas por un investigador de farmacia. El estudio, conducido durante seis semanas, incluyó 100 pacientes de mas de 70 años que tomaban cinco o mas medicamentos habituales, tenían tres o más comorbilidades y/o habían sido dados de alta del hospital en los tres meses anteriores al estudio. Después de las entrevistas a los pacientes, el investigador contactaba al farmacéutico y al médico del paciente para la confirmación y compleción del historial. Del as 1152 medicaciones registradas como utilizadas por los 100 pacientes, se encontraron discrepancias en 966 (83,9%). Hubo 563 (48,9%) omisiones completas de medicación. Las discrepancias más comunes fueron la omisión de dosis y frecuencia. Las discrepancias eran mayoritariamente medicaciones dermatológicas y para problemas de oído, nariz y garganta, pero alrededor del 29% eran usadas para tratar problemas cardiovasculares. Este estudio da apoyo a la presencia de un farmacéutico en un Servicio de Urgencias que pueda compilar un historial de medicación intensivo y fiable para mejorar la gestión del a medicación en el continuum de la atención. Es recomendable contactar con el farmacéutico comunitario y el médico del paciente para la clarificación y confirmación del historial de medicación (AU)

Pharmacist elicited medication histories in the Emergency Department: Identifying patient groups at risk of medication misadventure.

UNLABELLED: The Australian Pharmaceutical Advisory Committee guidelines call for a detailed medication history to be taken at the first point of admission to an Emergency Department (ED). The elderly, in particular those residing in Residential Aged Care Facilities and those with a non-English speaking background, have been identified as patient groups vulnerable to medication misadventure. OBJECTIVE: to analyse the incidence of discrepancies in medication histories in these demographic groups when pharmacist elicited medication histories were compared with those taken by ED physicians. It also aimed to investigate the incidence of medication related ED presentations. METHODS: The study was conducted over a six week period and included 100 patients over the age of 70, who take five or more regular medications, have three or more clinical co-morbidities and/or have been discharged from hospital in three months prior to the study. RESULTS: Twenty four participants were classified as 'language barrier'; 12 participants were from residential aged care facilities, and 64 participants were classified as 'general'. The number of correctly recorded medications was lowest in the 'language barrier' group (13.8%) compared with 18% and 19.6% of medications for 'general' patients and patients from residential aged care facilities respectively. Seven of the patients (29.2%) with 'language barrier'; 1 from a residential aged care facility (8.3%) and 13 of the (20.3%) patients from the 'general' category were suspected as having a medication related ED presentation. CONCLUSION: This study further highlights the positive contribution an ED pharmacist can make to enhancing medication management along the continuum of care. This study also confirms the vulnerability of patients with language barrier to medication misadventure and their need for interpreter services at all stages of their hospitalisation, in particular at the point of ED presentation.

Eliciting comprehensive medication histories in the emergency department: the role of the pharmacist.

The Australian Pharmaceutical Advisory Committee guidelines call for a detailed medication history to be taken at the first point of admission to hospital. Accurate medication histories are vital in optimising health outcomes and have been shown to reduce mortality rates. This study aimed to examine the accuracy of medication histories taken in the Emergency Department of the Royal Adelaide Hospital. Medication histories recorded by medical staff were compared to those elicited by a pharmacy researcher. The study, conducted over a six-week period, included 100 patients over the age of 70, who took five or more regular medications, had three or more clinical co-morbidities and/or had been discharged from hospital in three months prior to the study. Following patient interviews, the researcher contacted the patient's pharmacist and GP for confirmation and completion of the medication history. Out of the 1152 medications recorded as being used by the 100 patients, discrepancies were found for 966 medications (83.9%). There were 563 (48.9%) complete omissions of medications. The most common discrepancies were incomplete or omitted dosage and frequency information. Discrepancies were mostly medications that treated dermatological and ear, nose and throat disorders but approximately 29% were used to treat cardiovascular disorders. This study provides support for the presence of an Emergency Department pharmacist who can compile a comprehensive and accurate medication history to enhance medication management along the continuum of care. It is recommended that the patient's community pharmacy and GP be contacted for clarification and confirmation of the medication history.