Top 10 Signs and Symptoms of Psychotropic Adverse Drug Events to Monitor in Residents of Long-Term Care Facilities.

OBJECTIVES: To produce a consensus list of the top 10 signs and symptoms suggestive of adverse drug events (ADEs) for monitoring in residents of long-term care facilities (LTCFs) who use antipsychotics, benzodiazepines, or antidepressants. DESIGN: A 3-round Delphi study. SETTING AND PARTICIPANTS: Geriatricians, psychiatrists, pharmacologists, general practitioners, pharmacists, nurses, and caregivers from 13 Asia Pacific, European, and North American countries. METHODS: Three survey rounds were completed between April and June 2023. In Round 1, participants indicated their level of agreement on a 9-point Likert scale on whether 41 signs or symptoms identified in a systematic review should be routinely monitored. Participants considered signs and symptoms that reduce quality of life or cause significant harm, are observable or measurable by nurses or care workers, and can be assessed at a single time point. Round 1 statements were included in a list for prioritization in Round 3 if ≥ 70% of participants responded ≥7 on the Likert scale. Statements were excluded if ≤ 30% of participants responded ≥7. In Round 2, participants indicated their level of agreement with statements that did not reach initial consensus, plus amended statements based on Round 1 participant feedback. Round 2 statements were included in Round 3 if ≥ 50% of the participants responded ≥7 on the Likert scale. In Round 3, participants prioritized the signs and symptoms. RESULTS: Forty-four participants (93.6%) completed all 3 rounds. Four of 41 signs and symptoms reached consensus for inclusion after Round 1, and 9 after Round 2. The top 10 signs and symptoms prioritized in Round 3 were recent falls, daytime drowsiness or sleepiness, abnormal movements (eg, shaking or stiffness), confusion or disorientation, balance problems, dizziness, postural hypotension, reduced self-care, restlessness, and dry mouth. CONCLUSIONS AND IMPLICATIONS: The top 10 signs and symptoms provide a basis for proactive monitoring for psychotropic ADEs.

Understanding Long-Stay Gabapentin Use Increases: A National Nursing Home Clinician Survey on Prescribing Intent.

OBJECTIVES: Explore the indications for long-stay gabapentin use and elucidate the factors spurring the rapid increase in gabapentin prescribing in nursing homes (NHs). METHODS: National cross-sectional survey of NH prescribers distributed anonymously using SurveyMonkey. Sampling for convenience was obtained through crowdsourcing, leveraging collaborations with NH clinician organizations. Developed by a multidisciplinary team, pilot data/existing literature informed survey content. RESULTS: A total of 131 surveys completed. Participants: 71% white, 52% female, 71% physicians. Off-label gabapentin prescribing was ubiquitous. Nearly every clinician used gabapentin for neuropathic pain, most for any form of pain. Many clinicians also prescribe gabapentin to moderate psychiatric symptoms and behaviors. Clinicians' prescribing was influenced by opioid, antipsychotic, and anxiolytic reduction policies because gabapentin was perceived as an unmonitored and safer alternative. CONCLUSIONS: Off-label gabapentin increases are closely linked to opioid reduction efforts as more NH clinicians utilize gabapentin as an unmonitored opioid alternative. Our results highlight, however, the less recognized significance of long-stay prescribing for psychiatric symptoms and the similar contribution of psychotropic reduction initiatives, a phenomenon warranting further scrutiny. CLINICAL IMPLICATIONS: Clinicians perceive gabapentin as safer than the drugs it is replacing. Whether this is true remains unclear; the individual- and population-level risks of increased gabapentin use are largely unknown.

Quality Gap in Long-Stay Antipsychotic Quality Measure Performance Widens Over the Pandemic, Reversing Past Gains.

The Centers for Medicare & Medicaid Services (CMS) grades nursing home performance in antipsychotic prescribing quarterly, publishing findings as a quality measure. While scores have improved since 2011, marked performance variation between facilities persists. To assess quality gap changes between best- and worst-performing deciles, we compared quarterly prescribing changes between these groups pre-pandemic (April 2011 to March 2020) and during the pandemic (April 2020 to March 2022). Antipsychotic quality measure scores, improving pre-pandemic, deteriorated during the pandemic. The pre-pandemic quality gap between the best- and worst-performing deciles narrowed as the worst-performing decile improved faster than the best-performing decile. During the pandemic, the quality gap widened as the worst-performing decile relapsed more than the best-performing decile (p < .0001). The pandemic disrupted quality performance gains and compounded disparities between facilities. A better understanding of the factors allowing high performers to weather pandemic stressors better than poor performers may reveal opportunities to improve nursing home quality and equity for all residents.

Nursing Home Characteristics Associated with Antipsychotic Prescribing After Implementation of the National Antipsychotic Reduction Initiative (ARI).

OBJECTIVES: To describe nursing home (NH) characteristics associated with antipsychotic use and test whether associations changed after implementation of the National Partnership to Improve Dementia Care's antipsychotic reduction initiative (ARI). METHODS: Longitudinal quasi-experimental design using data from multiple sources and piecewise linear mixed models were used for statistical analyses. RESULTS: There was a significant decrease in monthly antipsychotic use across the study period (pre-ARI b = -0.0003, p <.001; post-ARI b = -0.0012, p <.001), which held after adjusting for NH characteristics. Registered nurse hours (b = -0.0026, p <.001), licensed practical nurse hours (b = -0.0019, p <.001), facility chain membership (b = -0.0013, p <.01), and health inspection ratings (b = -0.0003, p >.01) were associated with decreased antipsychotic use. Post-ARI changes in associations between NH characteristics and antipsychotic use were small and not statistically significant. CONCLUSIONS: Decreases in antipsychotic use were associated with most NH characteristics, and associations persisted post-ARI. Further research is warranted to examine the interactions between ARI policy and NH characteristics on antipsychotic prescribing, as well as other NH factors, such as facility prescribing cultures and clinical specialty of staff. CLINICAL IMPLICATIONS: Decreases in monthly antipsychotic use were observed following the ARI. The decreases in monthly antipsychotic use were associated with most NH characteristics, and these associations persisted during the post-ARI period.

Age-Friendly Health Systems 4Ms: Implementing Medication Management in Hamad Medical Corporation, Qatar.

PURPOSE: To implement the Age-Friendly Health Systems (AFHS) 4Ms framework, focusing on Medication and its impact on Mobility, Mentation, and What Matters, within Hamad Medical Corporation in Qatar. METHOD: A quality improvement approach was used to implement, extend, and sustain the AFHS 4Ms framework at Hamad Medical Corporation. The Medication "M" was described as the use case to illustrate the impact of high-risk medications on Mobility, Mentation, and What Matters, using an evidence-based, interdisciplinary approach. RESULTS: Implementation of the AFHS 4Ms framework revealed success in aligning multidisciplinary teams to prioritize patient-centered care and caregiver engagement. Through this collaboration, a process map, modified medication screening tool, documentation templates, and educational efforts were developed. CONCLUSION: Applying the AFHS 4Ms framework into health care settings is crucial to improve the care of older adults. Medication management is a cornerstone, involving interdisciplinary team input during screening and act phases to ensure proper medication prescribing and use in older adults. [Journal of Gerontological Nursing, 50(6), 6-9.].

Preparation Times and Estimated Costs for Vancomycin Formulations: Does the Difference Matter?

Objective Infections from methicillin-resistant Staphylococcus aureus are increasingly treated in longterm care facilities, but long-term care pharmacies face high costs in the provision of sterile vancomycin for intravenous administration. This study compares pharmaceutical costs of outsourced, compounded, and room temperature premixed vancomycin formulations in a long-term care pharmacy. Design This retrospective observational study reviewed 124 orders of vancomycin. Means for total pharmacy preparation time, pharmacist labor time, and extrapolated time over complete course of treatment were compared for three vancomycin preparations: outsourced, compounded by pharmacy, and room temperature premixed vancomycin formulations. Cost calculations were generated using ingredient costs as reported by the pharmacy and median pharmacist labor costs as published from national sources. Results Mean total preparation times and pharmacist preparation times were shortest for premixed vancomycin. Over full courses of treatment, mean pharmacy preparation time for compounded was 5 hours 3 minutes (mean of 28 treatments) and 2 hours 8 minutes for premixed (mean of 54 treatments). Data on pharmacist time in outsourced orders were not available. Total pharmacy costs were $993.94 for compounded vancomycin, $2220.34 for outsourced, and $809.36 for room temperature premixed vancomycin. Conclusion There were reduced preparation times for room temperature premixed vancomycin compared with compounded and outsourced formulations for skilled nursing facilities. As multiple drug-resistant organism infections are increasingly treated in long-term care, finding cost-effective approaches to medication provision from pharmacies is critical.

Discovering "What Matters" to patients: A quality improvement project.

PURPOSE: Age-Friendly Health Systems were developed to provide an evidenced based framework to provide high-quality care to older adults. The purpose of this quality improvement initiative was to increase the completion of the "What Matters" section of the "Get to Know Me" boards. METHODS: Face-to-face training was provided to staff via individual sessions on "What Matters" to patients and how to complete the boards. Re-education continued weekly over a 15 week period. Board Completion rates were collected weekly. RESULTS: 60 nurses participated in this project. The "What Matters" completion rates increased from 27 % to 59 % over the intervention period on the SACU and 16 % to 32 % on the SIMC . CONCLUSIONS: The "Get to Know Me Boards" are a visible way to describe "What Matters" to patients. Education helped to increase the completion rate of the boards allowing for "What Matters" to be accessible to members of the healthcare team.

Mapping potentially inappropriate medications in older adults using the Anatomical Therapeutic Chemical (ATC) classification system.

BACKGROUND: Potentially inappropriate medications (PIMs) in older adults are medications in which risks often outweigh benefits and are suggested to be avoided. Worldwide, many distinct guidelines and tools classify PIMs in older adults. Collating these guidelines and tools, mapping them to a medication classification system, and creating a crosswalk will enhance the utility of PIM guidance for research and clinical practice. METHODS: We used the Anatomical Therapeutic Chemical (ATC) Classification System, a hierarchical classification system, to map PIMs from eight distinct guidelines and tools (2019 Beers Criteria, Screening Tool for Older Person's Appropriate Prescriptions [STOPP], STOPP-Japan, German PRISCUS, European Union-7 Potentially Inappropriate Medication [PIM] list, Centers for Medicare & Medicaid Services [CMS] High-Risk Medication, Anticholinergic Burden Scale, and Drug Burden Index). Each PIM was mapped to ATC Level 5 (drug) and to ATC Level 4 (drug class). We then used the crosswalk (1) to compare PIMs and PIM drug classes across guidelines and tools to determine the number of PIMs that were index (drug-induced adverse event) or marker (treatment of drug-induced adverse event) drug of prescribing cascades, and (2) estimate the prevalence of PIM use in older adults continuously enrolled with fee-for-service Medicare in 2018 as use cases. Data visualization and descriptive statistics were used to assess guidelines and tools for both use cases. RESULTS: Out of 480 unique PIMs identified, only three medications-amitriptyline, clomipramine, and imipramine and two drug classes-N06AA (tricyclic antidepressants) and N06AB (selective serotonin reuptake inhibitors), were noted in all eight guidelines and tools. Using the crosswalk, 50% of classes of index drugs and 47% of classes of marker drugs of known prescribing cascades were PIMs. Additionally, 88% of Medicare beneficiaries were dispensed ≥1 PIM across the eight guidelines and tools. CONCLUSION: We created a crosswalk of eight PIM guidelines and tools to the ATC classification system and created two use cases. Our findings could be used to expand the ease of PIM identification and harmonization for research and clinical practice purposes.

Medication use quality and safety in older adults: 2022 update.

Improving the quality of medication use and medication safety are important priorities for healthcare providers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2022. We selected high-quality studies from an OVID search and hand searching of major high impact journals that advanced the field of research forward. The chosen articles cover domains related to deprescribing, medication safety, and optimizing medication use. The MedSafer Study, a cluster randomized clinical trial in Canada, evaluated whether patient specific deprescribing reports generated by electronic decision support software resulted in reduced adverse drug events in the 30 days post hospital discharge in older adults (domain: deprescribing). The second study, a retrospective cohort study using data from Premier Healthcare Database, examined in-hospital adverse clinical events associated with perioperative gabapentin use among older adults undergoing major surgery (domain: medication safety). The third study used an open-label parallel controlled trial in 39 Australian aged-care facilities to examine the effectiveness of a pharmacist-led intervention to reduce medication-induced deterioration and adverse reactions (domain: optimizing medication use). Lastly, the fourth study engaged experts in a Delphi method process to develop a consensus list of clinically important prescribing cascades that adversely affect older persons' health to aid clinicians to identify, prevent, and manage prescribing cascades (domain: optimizing medication use). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens.

Crushed Tablet Administration for Patients with Dysphagia and Enteral Feeding: Challenges and Considerations.

Dysphagia is increasingly common in older adults; it is especially prevalent in long-term care settings. Patients with dysphagia likely require pharmacologic treatment for multiple comorbidities but may find it difficult or impossible to swallow oral medications. Administering crushed medications mixed with a soft food or liquid vehicle, or via a feeding tube, is a common strategy to circumvent swallowing difficulties in patients with dysphagia. However, inappropriate medication use and improper crushing technique can reduce the medication dose a patient receives, alter medication pharmacokinetics and pharmacodynamics, and compromise treatment efficacy and patient safety. Clinical judgment is needed to identify medications that can and cannot be crushed, select a crushing methodology and vehicle for administering crushed medications, and create a strategy for administering multiple medications. A coordinated effort from the entire care team-including physicians, pharmacists, nurses, advanced practice providers, speech therapists, patients, and caregivers-is necessary to develop and implement an individualized plan for administering medications to patients with dysphagia. This review details the current literature regarding the administration of medications that have been altered, such as by crushing tablets or opening capsules, for patients with dysphagia or who are receiving enteral feeding and provides recommendations on best practices.

Dysphagia, or difficulty swallowing, is common in hospitals and in places that provide long-term care. People who live at home may also have a hard time swallowing pills. In this review, we talk about how people who have a hard time swallowing pills can best take their medicines. A speech-language pathologist can help people with dysphagia find ways to eat and drink safely. Their healthcare provider and pharmacist should make sure all their medicines are needed and check if any of their medicines come in a form that does not need to be swallowed, like a patch. It is sometimes okay to take a medicine by crushing a pill and then mixing with food. However, some medicines may be dangerous or less effective if they are crushed or mixed with some foods. Mixing multiple crushed medicines may also be unsafe or make them less effective. People in hospitals and long-term care settings who have a hard time swallowing pills should have an individual plan in place for taking medicines. Physicians, pharmacists, speech-language pathologists, and front-line care staff should work with patients and caregivers to make the plan. The plan should be written down in their patient record. People who have a hard time swallowing medicines should talk to their doctor or pharmacist about how best to take their medicines. People should not alter their medicines without talking to a healthcare professional.

Unintended impacts of a national antipsychotic reduction initiative among nursing facility residents with and without Alzheimer's disease.

BACKGROUND: In July 2012, the Centers for Medicare & Medicaid services launched an antipsychotic reduction initiative (ARI) to improve care for nursing facility residents with Alzheimer's disease and related dementias (ADRD). We examined the impact of this policy on antipsychotic and psychotropic medication (PM) utilization and diagnosis patterns in long-stay nursing facility residents with ADRD and other conditions in which antipsychotics are indicated. METHODS: Using an 80% sample of fee-for-service Medicare beneficiaries with Part D, we conducted a retrospective cohort study of nursing facility residents with ADRD, bipolar disorder, psychosis, Parkinson's disease, and residents exempt from the policy due to diagnoses of schizophrenia, Tourette syndrome, and/or Huntington's disease. We used interrupted time-series analyses to compare changes in diagnoses, antipsychotic use, and PM utilization before (January 1, 2011-June 30, 2012) and after (July 1, 2012-September 30, 2015) ARI implementation. RESULTS: We identified 874,487 long-stay nursing facility residents with a diagnosis of ADRD (n = 358,518), exempt (n = 92,859), bipolar (n = 128,298), psychosis (n = 93,402), and Parkinson's disease (n = 80,211). In all cohorts, antipsychotic use declined prior to the ARI; upon policy implementation, antipsychotic use reductions were sustained throughout the study period, including statistically significant ARI-associated accelerated declines in all cohorts. PM changes varied by cohort, with ARI-associated increases in non-benzodiazepine sedatives and/or muscle relaxants noted in ADRD, psychosis, and Parkinson's cohorts. Although anticonvulsant use increased throughout the study period in all groups, with the exception of the bipolar cohort, these increases were not associated with ARI implementation. Findings are minimally explained by increased post-ARI membership in the psychosis and Parkinson's cohorts. CONCLUSIONS: Our study documents antipsychotic use significantly declined in non-ADRD clinical and exempt cohorts, where such reductions may not be clinically warranted. Furthermore, ARI-associated compensatory increases in PMs do not offset these reductions. Changes in PM utilization and diagnostic make-up of residents using PMs require further investigation to assess the potential for adverse clinical and economic outcomes.

Navigating Disease-Modifying Treatments for Alzheimer's Disease: Focusing on Medications in Phase 3 Clinical Trials.

Over the past 18 months, there has been scrutiny and controversy over the U.S. Food and Drug Administration's accelerated approval of aducanumab, a novel monoclonal antibody to treat Alzheimer's disease and prevent disease progression. As clinicians, educators, and advocates for our patients and caregivers impacted daily by this debilitating illness, this approval reinforces the need to maintain vigilance and awareness about emerging agents. The intent of the current article is to highlight some of the medications in Phase 3 clinical trials and share resources and updates on disease-modifying agents and their unique pharmacology. [Journal of Gerontological Nursing, 49(1), 6-10.].

Comparing risk prediction models aimed at predicting hospitalizations for adverse drug events in community dwelling older adults: a protocol paper.

Background: The objective of this paper is to describe the creation, validation, and comparison of two risk prediction modeling approaches for community-dwelling older adults to identify individuals at highest risk for adverse drug event-related hospitalizations. One approach will use traditional statistical methods, the second will use a machine learning approach. Methods: We will construct medication, clinical, health care utilization, and other variables known to be associated with adverse drug event-related hospitalizations. To create the cohort, we will include older adults (≥ 65 years of age) empaneled to a primary care physician within the Cedars-Sinai Health System primary care clinics with polypharmacy (≥ 5 medications) or at least 1 medication commonly implicated in ADEs (certain oral hypoglycemics, anti-coagulants, anti-platelets, and insulins). We will use a Fine-Gray Cox proportional hazards model for one risk modeling approach and DataRobot, a data science and analytics platform, to run and compare several widely used supervised machine learning algorithms, including Random Forest, Support Vector Machine, Extreme Gradient Boosting (XGBoost), Decision Tree, Naïve Bayes, and K-Nearest Neighbors. We will use a variety of metrics to compare model performance and to assess the risk of algorithmic bias. Discussion: In conclusion, we hope to develop a pragmatic model that can be implemented in the primary care setting to risk stratify older adults to further optimize medication management.

Social determinants predict whether Medicare beneficiaries are offered a Comprehensive Medication Review.

BACKGROUND: Medication reviews through Medicare's Medication Therapy Management (MTM) program may improve patient outcomes and lower health system costs, but these effects could be limited by a program design that does not address social determinants of health. OBJECTIVE: To analyze the effects of social determinants of health on the odds of an eligible Medicare beneficiary not being offered Comprehensive Medication Review (CMR). METHODS: Using the full 100% sample of the 2016 Part D Medication Therapy Management Data File linked to Medicare Master Beneficiary Summary File, a retrospective, cross-sectional analysis was conducted to determine which social and demographic variables are most strongly associated with being eligible for a CMR but not being offered one. Descriptive statistics were generated using SAS studio 3.8. RESULTS: Variables associated with the highest odds of not receiving a CMR when eligible are residence in Louisiana OR 1.79 (95%CI 1.70-1.88), receiving the LIS OR 1.76 (1.73-1.79), dual eligibility for Medicare and Medicaid OR 1.25 (1.12-1.41), and Black race OR 1.19 (1.16-1.21). CONCLUSIONS: Social determinants of health, most strongly geography and low-income status, predict being eligible for but not being offered CMR. Race continues to be a factor in disparate access to MTM services.

Examining transitions of care among nursing home residents with and without antipsychotic medication use.

OBJECTIVES: This study examines the association between antipsychotic (AP) medication use and care transitions in the nursing home (NH) population. METHODS: This cross-sectional study used data from a 5% random sample of Medicare beneficiaries between 2011 and 2015. Propensity score adjusted negative binomial regression was performed and conditional probabilities of having a first transition from the NH to specific locations were calculated. RESULTS: Among 150,284 eligible beneficiaries, the majority were female (67%), white (84%), and >75 years old (63%). Controlling for resident characteristics, the odds of having any transition was 5% lower among those with AP use [IRR (95% confidence interval (CI))=0.95(0.94-0.96)] relative to those with no AP use. Residents with AP use had higher proportions of transitions to hospital (22.7% vs. 19.5%, p < 0.01), emergency department (19.6% vs. 10.7%, p < 0.01), and different NH (1.5% vs. 0.4%, p < 0.01), and lower proportions of transition to non-healthcare locations compared to those without AP use. CONCLUSIONS: Findings demonstrate that residents with AP use had higher probabilities of transitions to more costly care settings such as the emergency department and hospital compared to those without AP use. Future longitudinal studies will help to inform clinical interventions aimed at improving the quality of care for this population.

Sodium-Glucose Cotransporter-2 Inhibitors: Risks vs. Rewards When Caring for Older Adults.

Managing multiple comorbidities is common in older adults. Thus, when a medication class, such as sodium-glucose cotransporter-2 (SGLT2) inhibitors, can potentially treat multiple conditions and prevent progression of chronic kidney disease, multiple guidelines must be followed when using these agents. The current article discusses risks and benefits of SGLT2 inhibitors, especially in the context of new evidence, and presents a case example. [Journal of Gerontological Nursing, 48(10), 7-13.].

Racial Differences in Antidepressant Use in Nursing Facility Residents With Moderate to Severe Cognitive Impairment.

Objective To describe and compare the use of antidepressants between Black or African descent and White nursing facility residents with moderate to severe cognitive impairment. Design This was a secondary data analysis using baseline data from the Function and Behavior Focused Care for Nursing Facility Residents with Dementia randomized control trial. Setting Participants were recruited from 10 urban and two rural nursing facilities from Maryland. Methods Participants had to be 55 years of age or older, English-speaking, reside in long-term care at time of recruitment, and score a 15 or less on the Mini Mental-State Examination. A total of 336 residents participated at baseline. Data were collected by a research evaluator through observation, proxy report from staff caring for the resident the day of testing, and patient charts. Main Outcomes A significant difference of antidepressant use between Black or African descent and White nursing facility residents with moderate to severe cognitive impairment would be noted when controlling for depression, age, gender, functional status, agitation, and number of co-morbidities. Results In adjusted models, Black or African descent residents were less likely to be prescribed antidepressants compared with White residents. Conclusion Racial differences were noted regarding antidepressant use among nursing facility residents with moderate to severe cognitive impairment, but it is unknown if race could impact prescribing practices when indications for use are known. Further research is needed to ascertain if knowing the specific indications for use might contribute to racial disparities with antidepressant prescribing in nursing facility residents with moderate to severe cognitive impairment.

Interprofessional Education and Older Adults in the Shared Virtual Classroom: Lessons Learned During the COVID-19 Pandemic.

The current article provides an overview of an interprofessional service-learning course that became virtual in the setting of the coronavirus disease 2019 pandemic. Telehealth video technologies were used to build an intergenerational, virtual classroom and increase engagement of older adults with interdisciplinary health professional students. The virtual classroom involved group health education sessions, individualized Medicare wellness visits, and a clinical huddle. The course addressed the public health need for reliable health information during the early days of the pandemic, social connection, and meeting the educational goals for health care students and older adults in a novel virtual setting. Lessons learned for the interdisciplinary team and for engaging older adults included the need for preparation reading, team building exercises, training videos, and telehealth competency checklists. Beyond the pandemic, adoption of virtual methods enables hybrid approaches to interprofessional education and builds competencies for delivery of telehealth and computer-based visits in professional practice settings. [Journal of Gerontological Nursing, 48(8), 52-56.].