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OBJECTIVES: To evaluate the use of a risk stratification tool and explore the contributing factors to variation in practice by clinical pharmacists. METHODS: The quantitative phase was a prospective evaluation of adherence to the risk stratification tool. Patients were selected by convenience sampling from medical wards across two hospital sites. Researchers applied the risk stratification tool to each patient, documented the code, accessed health records in subsequent days, and recorded the code assigned by the pharmacist. These codes were compared. The kappa (κ) coefficient test was performed using SPSS software as a statistical measure of agreement. The qualitative phase was designed using focus groups with clinical pharmacists. One focus group was conducted at each of the two study sites. Participants were grouped to ensure a mix of experience levels. To augment the discussion, participants completed a short survey. Focus groups were recorded and a thematic analysis undertaken. RESULTS: The final cohort for quantitative analysis was 73. Researchers and pharmacists allocated the same code to 19 (26%) patients. The highest match rate was observed between researchers and rotational pharmacists. The κ coefficient was 0.039 (slight agreement) with p value=0.52 (not significant). Ten pharmacists participated in the focus groups: three from site 1 and seven from site 2. All participants reported using the principles of the risk stratification tool every day, but they rarely accessed the tool. Pharmacists reported using the tool as a workload management and communication system. CONCLUSIONS: Variation in application of the risk stratification tool exists among pharmacists. Focus group participants described multiple scenarios where non-patient factors were considered in assigning a priority code for the patient. A schedule of regular review of the criteria; training and peer review; tool validation; and research identifying the relationship between structured professional judgement and risk stratification tools is recommended.
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BACKGROUND: With the older adult population in the USA increasing, so is the population of those with Alzheimer's disease and related dementias (ADRD). Older adults are vulnerable to the effects of potentially inappropriate medications as established by the Beers Criteria; however, some medications continue to be prescribed against recommendations. OBJECTIVES: Our objectives were to describe potentially inappropriate medication (PIM) use linked to cognitive impairment or decline (referred to as Cog-PIM) in older adults with and without ADRD and to investigate whether the odds of Cog-PIM report differ by ADRD status in ambulatory care (i.e., outpatient care) in the USA. METHODS: A cross-sectional analysis was performed using a nationally representative sample of non-perioperative, office-based ambulatory care visits by adults aged ≥ 65 years in 2016 (n = 218,182,131). Data were collected from the National Ambulatory Medical Care Survey. Cog-PIMs were identified as defined in the 2015 Beers Criteria recommendations for medications that may be potentially inappropriate in older adults with cognitive impairment or dementia. ADRD status was determined by clinician report using free text, the ADRD flag, or the presence of a diagnosis code indicating dementia. Multivariable logistic regressions were used to estimate the odds of Cog-PIM use overall and by medication class. RESULTS: In 2016, 2.1% (n = 4,651,563) of outpatient visits were made by older adults with ADRD, 33.2% of which reported at least one Cog-PIM. Anticholinergic Cog-PIMs were noted in 20.5% of ADRD visits compared with 8.1% of non-ADRD visits. Antipsychotic PIMs were noted in 15.5% of ADRD visits compared with 0.8% of non-ADRD visits. Benzodiazepine and non-benzodiazepine receptor agonist hypnotic (Z drug) Cog-PIMs were reported in 10.9% of ADRD visits and 10.7% of non-ADRD visits. ADRD status was a significant predictor of Cog-PIM report overall (adjusted odds ratio [aOR] 2.74 [95% confidence interval {CI} 1.20-6.27]) and for anticholinergics and antipsychotics specifically (aOR 3.35 [95% CI 1.24-9.03] and aOR 22.80 [95% CI 5.80-89.50], respectively). CONCLUSION: This study demonstrated a high prevalence of Cog-PIM use and increased odds of Cog-PIM use in older adults with ADRD. Future work should investigate opportunities in the ambulatory care setting for safer prescribing and de-escalation of Cog-PIMs.
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Background: There is currently insufficient data describing how new medications are provided to older adult ambulatory patients with dementia in the United States (US). Objectives: To describe characteristics of ambulatory care visits for adults ≥65 years old and investigate differences in prescribing of new medications between patients with and without dementia. Methods: We conducted a population-based cross-sectional study using the 2016 National Ambulatory Medical Care Survey (NAMCS) in the US. Non-perioperative ambulatory care visits of patients ≥65 years old with sampling weights were used to provide national estimates of visits. Baseline characteristics were compared between visits for patients with and without dementia using Pearson's chi square or Student's t-tests. We used multivariable logistic regression to estimate the odds of receiving a new medication. Results: 218,182,131 non-perioperative ambulatory care visits of patients ≥65 years old were included, 2.1% of which were for patients with dementia; these patients were older on average and had more comorbidities and higher ambulatory care utilization than those without dementia. New medications were provided at 26.3% of visits for patients with dementia. After adjusting for confounders, there was no statistically significant difference in odds of a new medication being provided between visits for patients with and without dementia (odds ratio [OR], 0.555; 95% confidence interval [CI], 0.183-1.678). Differences were seen in the provision of cholinesterase inhibitors, antipsychotics, and central nervous system agents at visits for patients with dementia (p = 0.0011, <0.0001, and 0.0011 respectively). Conclusion: While fewer visits for patients with dementia provided new medications compared to patients without dementia, after adjusting for confounders no significant difference were identified. Significant differences were seen in the classes of new medications provided. Further investigation is needed to evaluate new medication usage and the utility of pharmacists in the care of patients with dementia at an outpatient setting.
