Caregivers’ experiences of medication management advice for people living with dementia at discharge

Acknowledgments: StepUp for Dementia Research, which is funded by the Australian Government Department of Health and implemented by a dedicated team at the University of Sydney. Journal of Evaluation in Clinical Practice Funding : The project and DG was supported by the Australian National Health and Medical Research Council Dementia Leadership Fellowship.Peer reviewedPostprin

Development of a tool to evaluate medication management guidance provided to carers of people living with dementia at hospital discharge : a mixed methods study

Acknowledgements We thank our research advisory group and the members of the Sydney Dementia Network Lived Experience Expert Advisory Panel for their valuable feedback, and StepUp for Dementia Research, which is funded by the Australian Government Department of Health and implemented by a dedicated team at the University of Sydney. Funding This article was supported by a grant from the National Health and Medical Research Council Dementia Leadership Fellowship (grant number 1136849) and Dementia Centre for Research Postdoctoral Fellowship.Peer reviewedPublisher PD

Consumer and Healthcare Professional Led Priority Setting for Quality Use of Medicines in People with Dementia: Gathering Unanswered Research Questions

Background: Historically, research questions have been posed by the pharmaceutical industry or researchers, with little involvement of consumers and healthcare professionals. Objective: To determine what questions about medicine use are important to people living with dementia and their care team and whether they have been previously answered by research. Methods: The James Lind Alliance Priority Setting Partnership process was followed. A national Australian qualitative survey on medicine use in people living with dementia was conducted with consumers (people living with dementia and their carers including family, and friends) and healthcare professionals. Survey findings were supplemented with key informant interviews and relevant published documents (identified by the research team). Conventional content analysis was used to generate summary questions. Finally, evidence checking was conducted to determine if the summary questions were 'unanswered'. Results: A total of 545 questions were submitted by 228 survey participants (151 consumers and 77 healthcare professionals). Eight interviews were conducted with key informants and four relevant published documents were identified and reviewed. Overall, analysis resulted in 68 research questions, grouped into 13 themes. Themes with the greatest number of questions were related to co-morbidities, adverse drug reactions, treatment of dementia, and polypharmacy. Evidence checking resulted in 67 unanswered questions. Conclusion: A wide variety of unanswered research questions were identified. Addressing unanswered research questions identified by consumers and healthcare professionals through this process will ensure that areas of priority are targeted in future research to achieve optimal health outcomes through quality use of medicines

Investigating organisational culture to understand psychotropic prescribing practices in nursing homes: The perspective of on-site and visiting staff

Psychotropic medicines have a role in the management of behavioural and psychological disturbances to treat distressing symptoms. However, a balance is required to be achieved between benefits of these medicines, which are often modest, and the risk of harm, which has the potential to be significantly detrimental to the resident. Controversy exists over the high-level use of psychotropic medicines and there is significant variation in the use of psychotropic medicines across nursing homes. Organisational culture has been proposed as a factor influencing psychotropic prescribing decisions in nursing homes. However, what is known of culture and the use of psychotropic medicines is limited. The overall aim of the research was to identify how and why organisational culture influences psychotropic prescribing practices in nursing homes from the perspective of on-site (nursing home managers, licensed registered nurses, enrolled nurses and nursing assistants) and visiting staff (GPs, community pharmacists, accredited pharmacists, specialist medical practitioners, nurse practitioners and clinical nurse consultant). The research presented in this thesis was underpinned by a detailed theoretical framework – Schein’s Theory of Organisational Culture. This theory conceptualises culture into three levels: i) artifacts (visible artifacts and organisational climate), ii) espoused values and iii) basic assumptions. Findings from the systematic review confirmed that a more in-depth understanding of how and why organisational culture influences psychotropic prescribing was required. Three qualitative studies that involved on-site and visiting staff from diverse backgrounds and roles established an in-depth understanding of the role of organisational culture in the use of psychotropic medicines. The research showed that visible artifacts of culture that influenced the use of psychotropic medicines were drugs and therapeutics committee meetings, pharmacist led medication management reviews and formal and informal meetings with residents and their families. The investigation of organisational climate identified a number of factors which played an important role in the use of psychotropic medicines: perceptions of staffing, managerial expectations and teamwork and communication among on-site and visiting staff. Two basic assumptions explained the in/consistencies between the ideal standards and actual use of psychotropic medicines described by participants. These were: locus of control and necessity for efficiency or comprehensiveness. Locus of control pertained to whether staff believed they could control decisions when facing negative work experiences or helpless to attempt control. The Necessity for efficiency or comprehensiveness related to how much time and effort was spent on a given task. The qualitative studies collectively highlighted that organisational culture is an important factor that shaped psychotropic prescribing decisions. Informed by a systematic review and qualitative data, a tool was developed and then content validated using a rigorous process involving key experts with knowledge and experience in nursing homes. The tool is the first to be developed that specifically addressed all three levels of culture related to the use of psychotropic medicines. While the survey will help nursing homes build a culture of appropriate psychotropic prescribing, further validation of the tool using psychometric testing is needed

Now is the time to address the Culture of Residential Aged Care Facilities to support Pharmacists in reducing psychotropic prescribing

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A systems approach to identifying the challenges of implementing deprescribing in older adults across different health care settings and countries: a narrative review

Introduction: There is increasing recognition of the need for deprescribing of inappropriate medications in older adults. However, efforts to encourage implementation of deprescribing in clinical practice have resulted in mixed results across settings and countries. Area covered: Searches were conducted in PubMed, Embase and Google Scholar in June 2019. Reference lists, citation checking, and personal reference libraries were also utilised. Studies capturing the main challenges of, and opportunities for, implementing deprescribing into clinical practice across selected health care settings internationally, and international deprescribing-orientated policies were included and summarised in this narrative review. Expert Opinion: Deprescribing intervention studies are inherently heterogeneous because of the complexity of interventions employed and often do not reflect the real-world. Further research investigating enhanced implementation of deprescribing into clinical practice and across health care settings is required. Process evaluations in deprescribing intervention studies are needed to determine the contextual factors that are important to the translation of the interventions in the real-world. Deprescribing interventions may need to be individually tailored to target the unique barriers and opportunities to deprescribing in different clinical settings. Introduction of national policies to encourage deprescribing may be beneficial, but need to be evaluated to determine if there are any unintended consequences

Withdrawal of antihypertensive drugs in older people (Review)

BACKGROUND: Hypertension is an important risk factor for subsequent cardiovascular events, including ischaemic and haemorrhagic stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Overall, the use of antihypertensive medications has led to reduction in cardiovascular disease, morbidity rates and mortality rates. However, the use of antihypertensive medications is also associated with harms, especially in older people, including the development of adverse drug reactions, drug‐drug interactions and can contribute to increasing medication‐related burden. As such, discontinuation of antihypertensives may be considered and appropriate in some older people. OBJECTIVES: To investigate whether withdrawal of antihypertensive medications is feasible, and evaluate the effects of withdrawal of antihypertensive medications on mortality, cardiovascular outcomes, hypertension and quality of life in older people. SEARCH METHODS: The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to April 2019: the Cochrane Hypertension Specialised Register, CENTRAL (2019, Issue 3), Ovid MEDLINE, Ovid Embase, the WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also conducted reference checking, citation searches and, when appropriate, contacted study authors to identify any additional studies. The searches had no language restrictions. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of withdrawal versus continuation of antihypertensive medications used for hypertension or primary prevention of cardiovascular disease in older adults (defined as 50 years and over). Participants were eligible if they lived in the community, residential aged care facilities, or were based in hospital settings. We sought to include trials looking at the complete withdrawal of the antihypertensive medication, and those focusing on a dose reduction of the antihypertensive medicine. DATA COLLECTION AND ANALYSIS: We compared the intervention of discontinuing or reducing antihypertensive medication to usual treatment using mean differences (MD) and 95% confidence intervals (95% CIs) for continuous variables and we used Peto odds ratios (ORs) and 95% CI for binary variables. Our primary outcomes included: mortality, myocardial infarction, development of adverse drug reactions or adverse drug withdrawal reactions. Secondary outcomes included: blood pressure, hospitalisation, stroke, success of withdrawing from antihypertensives, quality of life, and falls. Two authors independently, and in duplicate, conducted all stages of study selection, data extraction and quality assessment. MAIN RESULTS: Six RCTs met the inclusion criteria and were included in the review (1073 participants). Study duration and follow‐up ranged from 4 weeks to 56 weeks. Meta‐analysis of studies showed that, in the discontinuation group compared to continuation, the odds for all‐cause mortality were 2.08 (95% CI 0.79 to 5.46; low certainty of evidence), for myocardial infarction 1.86 (95% CI 0.19 to 17.98; very low certainty of evidence) and for stroke 1.44 (95% CI 0.25 to 8.35; low certainty of evidence). Blood pressure was higher in the discontinuation group than the continuation group (systolic blood pressure: MD = 9.75 mmHg, 95% CI 7.33 to 12.18; and diastolic blood pressure: MD = 3.5 mmHg, 95% CI 1.82 to 5.18; low certainty of evidence). For the development of adverse events, meta‐analysis was not possible; antihypertensive discontinuation did not appear to increase the risk of adverse events and may lead to resolution of adverse drug reactions, although eligible studies had limited reporting of adverse effects of drug withdrawal (very low certainty of evidence). One study reported hospitalisation with an odds ratio of 0.83 for discontinuation compared to continuation (95% CI 0.33 to 2.10; low certainty of evidence). No studies were identified which reported falls. Between 10.5% and 33.3% of participants in the discontinuation group compared to 9% to 15% in the continuation group experienced raised blood pressure or other clinical criteria (as pre‐defined by the studies) that would require restarting of therapy/removal from the study. The sources of bias included selective reporting (reporting bias), lack of blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), and lack of blinding of participants and personnel (performance bias). AUTHORS' CONCLUSIONS: There is no evidence of an effect of discontinuing compared with continuing antihypertensives used for hypertension or primary prevention of cardiovascular disease in older adults on all‐cause mortality and myocardial infarction. The evidence was low to very low certainty mainly due to small studies and low event rates. These limitations mean that we cannot make any firm conclusions about the effect of deprescribing antihypertensives on these outcomes. Future research should focus on populations with the greatest uncertainty of the benefit:risk ratio for use of antihypertensive medications, such as those with frailty, older age groups and those taking polypharmacy, and measure clinically important outcomes such as falls, quality of life and adverse drug events