Impact of a passive clinical decision support tool on potentially inappropriate medications (PIM) use in older adult patients.

BACKGROUND: Medication related clinical decision support (CDS) interventions may improve patient safety. In older patient populations, there has been effort placed in reducing exposure to potentially inappropriate medications (PIMs). After years of reducing exposure of older adults in our hospitals to PIMs through multi-component interventions, our system chose to expand the scope and attempt a new strategy to lessen alert burden for providers and pharmacists. Based on the American Geriatric Society Beers Criteria and internal data, a passive CDS approach, termed "geriatric context" was established to recommend appropriate medication selection including lower dosage amounts and frequency of administration in older adults. METHODS: Retrospective descriptive study examining change in a pre and post implementation analysis of medication usage patterns between two 9-month time periods in 2019 and 2021 in patients age ≥65 years across an 8-hospital health system. The primary endpoint is the percentage of each medication intervened with an ordered dose and frequency outside of alignment with recommended context parameters. Secondary endpoints include total daily dose (TDD) and average dose (AD) per patient of the individual PIMs. Exploratory endpoints include frequency of active alerts fired by the CPOE and overridden by providers. RESULTS: A total of 62,738 older adult hospital admissions are included in the overall study period, with 32,969 pre-implementation and 29,769 post-implementation. Haloperidol showed the greatest reduction in inappropriate doses from 41.5% to 21.4% (p < 0.001) of orders, followed by reduction in inappropriate frequencies in orders for diphenhydramine from 57.2% to 39.7% (p < 0.001). Secondary endpoints showed favorable reductions across 11 of the 16 medications in both TDD and AD administered. Exploratory analysis with select medications showed reductions in frequency of alerts fired and overridden. CONCLUSIONS: Utilization of a passive CDS positively influences prescribing patterns for older adults and reduces the alert burden to ordering providers.

Prevalence of Cognitive Impairment Among Elderly Patients Upon Hospital Admission Using Mini-Cog™ Assessments Performed by Advanced Pharmacy Practice Experience Students.

BACKGROUND: Older adults with cognitive impairment may have difficulty understanding and complying with medical or medication instructions provided during hospitalization which may adversely impact patient outcomes. OBJECTIVE: To evaluate the prevalence of cognitive impairment among patients aged 65 years and older within 24 hours of hospital admission using Mini-Cog™ assessments performed by advanced pharmacy practice experience (APPE) students. METHODS: Students on APPE rotations were trained to perform Mini-Cog™ assessments during routine medication education sessions from February 2017 to April 2017. The primary end point was the prevalence of cognitive impairment indicated by a Mini-Cog™ score of ≤3. Secondary end points were the average number of observed Mini-Cog™ practice assessments required for APPE students to meet competency requirements, caregiver identification, and 30-day hospital readmissions. RESULTS: Twelve APPE students completed the training program after an average of 4.4 (standard deviation [SD] = 1.0) graded Mini-Cog™ assessments. Of the 1159 admissions screened, 273 were included in the analysis. The prevalence of cognitive impairment was 55% (n = 149, 95% confidence interval [CI]: 48%-61%). A caregiver was identified for 41% (n = 113, 95% CI: 35%-47%) of patients, and 79 patients had a caregiver present at bedside during the visit. Hospital readmission within 30 days of discharge was 15% (n = 41, 95% CI: 11%-20%). CONCLUSION: Cognitive impairment could substantially impair a patient's ability to comprehend education provided during hospitalization. Pharmacy students can feasibly perform Mini-Cog™ assessments to evaluate cognitive function, thereby allowing them to tailor education content and involve caregivers when necessary.