An International Consensus List of Potentially Clinically Significant Drug-Drug Interactions in Older People.

Objectives We aimed to establish an explicit list of potentially clinically significant drug-drug interactions (DDIs) in people aged ≥65 years. Design A preliminary list of potentially clinically significant DDIs was compiled, based on 154 DDIs identified from literature review. Subsequently, a 2-round online Delphi survey was undertaken with a multidisciplinary expert panel. A consensus meeting and a final round were conducted to validate the final DDI list and the scope of information provided. Setting and Participants Twenty nine experts, including geriatricians and clinical pharmacists from 8 European countries. Measures For each DDI, in the first 2 rounds, experts were asked to score the severity of potential harm on a 5-point Likert-type scale. DDIs were directly included on the final list if the median score was 4 (major) or 5 (catastrophic). DDIs with a median score of 3 (moderate) were discussed at a consensus meeting and included if ≥75% of participants voted for inclusion in the final round. Results Consensus was achieved on 66 potentially clinically significant DDIs (28 had a median score of 4/5 and 48 of 3 in the Delphi survey). Most concerned cardiovascular, antithrombotic, and central nervous system drugs. The final list includes information on the mechanism of interaction, harm, and management. Treatment modification is recommended for three-quarters of DDIs. Conclusion and Implications We validated a list of potentially clinically significant DDIs in older people, which can be used in clinical practice and education to support identification and management of DDIs or to assess prevalence in epidemiologic and intervention studies.pre-print896 K

Teaching geriatric medicine through gamification: a tool for enhancing postgraduate education in geriatric medicine

Background Polypharmacy is becoming increasingly common and all doctors must be prepared to manage it competently. Aims The aim of this project is to evaluate the feasibility and use of a novel gamification-based teaching intervention on polypharmacy among doctors undergoing advanced geriatric training. Among others, one of the learning goals for the students was to be able to describe the adherence to medication. Methods Electronic questionnaire sent to students of the third session “evidence-based medicine in geriatrics” of advanced postgraduate course in geriatrics of the European Academy for Medicine of Ageing. Results Most students reported issues with forgetting doses and remembering sufficiently to establish a medication routine due to busy schedules as well as social influences around medication taking. Reflecting on the challenges of the game, most students reported that their own prescribing practice was likely to change. Discussion and conclusion The current model of learning appears to be a feasible approach for postgraduate medical education or in other areas of healthcare such as nursing or physiotherapy. Learning through action and reflection promotes deeper thinking and can lead to behavioral change, in this case thus enhancing the attitudes and understanding regarding pharmacological issues associated with ageing. Recommendations for future research in medical education about medication adherence are outlined.publishedVersio

Detectability of Medication Errors With a STOPP/START-Based Medication Review in Older People Prior to a Potentially Preventable Drug-Related Hospital Admission.

INTRODUCTION Multimorbidity and polypharmacy are risk factors for drug-related hospital admissions (DRAs) in the ageing population. DRAs caused by medication errors (MEs) are considered potentially preventable. The STOPP/START criteria were developed to detect potential MEs in older people. OBJECTIVE The aim of this study was to assess the detectability of MEs with a STOPP/START-based in-hospital medication review in older people with polypharmacy and multimorbidity prior to a potentially preventable DRA. METHODS Hospitalised older patients (n = 963) with polypharmacy and multimorbidity from the intervention arm of the OPERAM trial received a STOPP/START-based in-hospital medication review by a pharmacotherapy team. Readmissions within 1 year after the in-hospital medication review were adjudicated for drug-relatedness. A retrospective assessment was performed to determine whether MEs identified at the first DRA were detectable during the in-hospital medication review. RESULTS In total, 84 of 963 OPERAM intervention patients (8.7%) were readmitted with a potentially preventable DRA, of which 72 patients (n = 77 MEs) were eligible for analysis. About half (48%, n = 37/77) of the MEs were not present during the in-hospital medication review and therefore were not detectable at that time. The pharmacotherapy team recommended a change in medication regimen in 50% (n = 20/40) of present MEs, which corresponds to 26% (n = 20/77) of the total identified MEs at readmission. However, these recommendations were not implemented. CONCLUSION MEs identified at readmission were not addressed by a prior single in-hospital medication review because either these MEs occurred after the medication review (~50%), or no recommendation was given during the medication review (~25%), or the recommendation was not implemented (~25%). Future research should focus on optimisation of the timing and frequency of medication review and the implementation of proposed medication recommendations. REGISTRATION ClinicalTrials.gov identifier: NCT02986425. December 8, 2016. FUNDING European Union HORIZON 2020, Swiss State Secretariat for Education, Research and Innovation (SERI), Swiss National Science Foundation (SNSF)

Detectability of Medication Errors With a STOPP/START-Based Medication Review in Older People Prior to a Potentially Preventable Drug-Related Hospital Admission

Introduction Multimorbidity and polypharmacy are risk factors for drug-related hospital admissions (DRAs) in the ageing population. DRAs caused by medication errors (MEs) are considered potentially preventable. The STOPP/START criteria were developed to detect potential MEs in older people.Objective The aim of this study was to assess the detectability of MEs with a STOPP/START-based in-hospital medication review in older people with polypharmacy and multimorbidity prior to a potentially preventable DRA.Methods Hospitalised older patients (n = 963) with polypharmacy and multimorbidity from the intervention arm of the OPERAM trial received a STOPP/START-based in-hospital medication review by a pharmacotherapy team. Readmissions within 1 year after the in- hospital medication review were adjudicated for drug-relatedness. A retrospective assessment was performed to determine whether MEs identified at the first DRA were detectable during the in-hospital medication review.Results In total, 84 of 963 OPERAM intervention patients ( 8.7%) were readmitted with a potentially preventable DRA, of which 72 patients (n = 77 MEs) were eligible for analysis. About half (48%, n = 37/77) of the MEs were not present during the in-hospital medication review and therefore were not detectable at that time. The pharmacotherapy team recommended a change in medication regimen in 50% ( n = 20/40) of present MEs, which corresponds to 26% (n = 20/77) of the total identified MEs at readmission. However, these recommendations were not implemented.Conclusion MEs identified at readmission were not addressed by a prior single in-hospital medication review because either these MEs occurred after the medication review (similar to 50%), or no recommendation was given during the medication review (similar to 25%), or the recommendation was not implemented (similar to 25%). Future research should focus on optimisation of the timing and frequency of medication review and the implementation of proposed medication recommendations

Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial.

OBJECTIVE To examine the effect of optimising drug treatment on drug related hospital admissions in older adults with multimorbidity and polypharmacy admitted to hospital. DESIGN Cluster randomised controlled trial. SETTING 110 clusters of inpatient wards within university based hospitals in four European countries (Switzerland, Netherlands, Belgium, and Republic of Ireland) defined by attending hospital doctors. PARTICIPANTS 2008 older adults (≥70 years) with multimorbidity (≥3 chronic conditions) and polypharmacy (≥5 drugs used long term). INTERVENTION Clinical staff clusters were randomised to usual care or a structured pharmacotherapy optimisation intervention performed at the individual level jointly by a doctor and a pharmacist, with the support of a clinical decision software system deploying the screening tool of older person's prescriptions and screening tool to alert to the right treatment (STOPP/START) criteria to identify potentially inappropriate prescribing. MAIN OUTCOME MEASURE Primary outcome was first drug related hospital admission within 12 months. RESULTS 2008 older adults (median nine drugs) were randomised and enrolled in 54 intervention clusters (963 participants) and 56 control clusters (1045 participants) receiving usual care. In the intervention arm, 86.1% of participants (n=789) had inappropriate prescribing, with a mean of 2.75 (SD 2.24) STOPP/START recommendations for each participant. 62.2% (n=491) had ≥1 recommendation successfully implemented at two months, predominantly discontinuation of potentially inappropriate drugs. In the intervention group, 211 participants (21.9%) experienced a first drug related hospital admission compared with 234 (22.4%) in the control group. In the intention-to-treat analysis censored for death as competing event (n=375, 18.7%), the hazard ratio for first drug related hospital admission was 0.95 (95% confidence interval 0.77 to 1.17). In the per protocol analysis, the hazard ratio for a drug related hospital admission was 0.91 (0.69 to 1.19). The hazard ratio for first fall was 0.96 (0.79 to 1.15; 237 v 263 first falls) and for death was 0.90 (0.71 to 1.13; 172 v 203 deaths). CONCLUSIONS Inappropriate prescribing was common in older adults with multimorbidity and polypharmacy admitted to hospital and was reduced through an intervention to optimise pharmacotherapy, but without effect on drug related hospital admissions. Additional efforts are needed to identify pharmacotherapy optimisation interventions that reduce inappropriate prescribing and improve patient outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT02986425

Farmacotherapie bij ouderen

De snelle toename van het aantal ouderen met multimorbiditeit wereldwijd en daaraan gerelateerde polyfarmacie vormt een belangrijke uitdaging voor de gezondheidszorg en meer specifiek voor een veilig geneesmiddelengebruik. Nederlands onderzoek heeft aangetoond dat 10% van de acute ziekenhuisopnames bij ouderen geneesmiddelgerelateerd is, de helft hiervan zou vermijdbaar zijn (VWS 2017). Het is van groot belang dat voorschrijvers op de hoogte zijn van de specifieke aspecten die het gebruik van geneesmiddelen bij ouderen anders maken dan bij jongere patiënten. Aangezien veel ouderen chronische aandoeningen hebben, gebruiken zij een geneesmiddel vaak langdurig. Verschillende factoren beïnvloeden de reactie op en de dosering van geneesmiddelen bij ouderen. De fysiologische homeostase is bij gezonde ouderen minder robuust dan bij jonger volwassenen en dat heeft zijn weerslag op de farmacokinetiek en farmacodynamiek van geneesmiddelen. Bij ouderen met multimorbiditeit zijn cel- en orgaanfuncties vaak nog sterker achteruitgegaan. Polyfarmacie en het risico op ongewenste interacties vergroot de incidentie van bijwerkingen. Een bijkomend probleem bij geriatrische patiënten is dat symptomen worden gemaskeerd, omgekeerd of achterwege blijven. Dit bemoeilijkt niet alleen de diagnose, maar ook de evaluatie van de werking en bijwerkingen van een geneesmiddel. De arts moet daarom extra kritisch zijn bij het selecteren en voorschrijven van een geneesmiddel. Daarbij moeten de dosering en de duur van de farmacotherapie voortdurend gemonitord worden

General practitioners' attitudes towards decision-supported prescribing: An analysis of the Dutch primary care sector

The use of multiple drugs by patients increases the risk of medical problems. Clinical decision support could assist general practitioners with prescribing but is underused. This article aims to investigate the attitudes of general practitioners towards using decision support systems. A survey was distributed among 500 Dutch general practitioners. Virtually all 184 respondents indicated having a clinical information system, while only 21 percent indicated having a decision support plug-in; this correlated with their use of medical formularies. Only use of one of the medical formularies correlated with the number of recognized underprescription problems. General practitioners' attitudes toward a newly proposed system aiding them with polypharmacy prescribing were mainly positive (57%); the perceived usefulness correlated with output quality (p = .000), time investment (p = .000), and financial stimuli (payability: p = .000 and reimbursement: p = .015) but not with job relevance. Dutch general practitioners are thus likely to adopt the proposed system under the conditions that it improves prescription quality and does not require extensive investments of time or money

Teaching geriatric medicine through gamification: a tool for enhancing postgraduate education in geriatric medicine

Background Polypharmacy is becoming increasingly common and all doctors must be prepared to manage it competently. Aims The aim of this project is to evaluate the feasibility and use of a novel gamification-based teaching intervention on polypharmacy among doctors undergoing advanced geriatric training. Among others, one of the learning goals for the students was to be able to describe the adherence to medication. Methods Electronic questionnaire sent to students of the third session “evidence-based medicine in geriatrics” of advanced postgraduate course in geriatrics of the European Academy for Medicine of Ageing. Results Most students reported issues with forgetting doses and remembering sufficiently to establish a medication routine due to busy schedules as well as social influences around medication taking. Reflecting on the challenges of the game, most students reported that their own prescribing practice was likely to change. Discussion and conclusion The current model of learning appears to be a feasible approach for postgraduate medical education or in other areas of healthcare such as nursing or physiotherapy. Learning through action and reflection promotes deeper thinking and can lead to behavioral change, in this case thus enhancing the attitudes and understanding regarding pharmacological issues associated with ageing. Recommendations for future research in medical education about medication adherence are outlined