Impact of deprescribing dual-purpose medications on patient-related outcomes for older adults near end-of-life: a systematic review and meta-analysis

Introduction: The decision to deprescribe medications used for both disease prevention and symptom control (dual-purpose medications or DPMs) is often challenging for clinicians. We aim to establish the impact of deprescribing DPMs on patient-related outcomes for older adults near end-of-life (EOL). Methods: This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline. Literature was searched on PubMed, EMBASE, CINAHL, PsycINFO and Google Scholar until December 2019 for studies on deprescribing intervention with a control group (with or without randomisation); targeting ⩾65-year olds, at EOL, with at least one life-limiting illness and at least one potentially inappropriate DPM. We were interested in any patient-related outcomes. Studies with similar outcome assessment criteria were subjected to meta-analysis and narrative synthesis otherwise. The risk of bias was assessed using Cochrane Risk of Bias and ROBINS-I tools for randomised controlled trials (RCTs) and quasi-experimental non-randomised controlled studies, respectively. Results: Five studies covering 689 participants with mean age 81.6–85.7 years, the majority (74.6–100%) with dementia were included. The risk of bias was moderate to low. The deprescribing of DPMs lowered the risk of mortality (risk ratio (RR) = 0.59, 95% confidence interval (CI) = 0.44–0.79) and referral to acute care facilities (RR = 0.40, 95% CI = 0.22–0.73), but did not have a significant impact on the risk of falls, non-vertebral fracture, emergency presentation, unplanned hospital admission, or general practitioner visits. No significant difference was observed in the quality of life, physical and cognitive functions between the intervention and control groups. Conclusion: There is some evidence that deprescribing of DPMs for older adults near the EOL can lower the risk of mortality and referral to acute care facilities, but there are insufficient good-quality studies powered to confirm a benefit in terms of quality of life, physical or cognitive function, health service utilisation and adverse events. Plain Language Summary What is the health impact of withdrawal or dose reduction of medication used for disease prevention and symptom control in older adults near end-of-life? Introduction: Older adults (aged ⩾ 65 years) with advanced diseases such as cancer, dementia, and organ failure tend to have a limited life expectancy. With the progression of these diseases towards the end-of-life, the intensity for day-to-day supportive care becomes increasingly necessary. The use of medications for symptom management is a critical part of such care, but the use of medications for long-term disease prevention can become irrelevant due to the already shortened life expectancy and may become harmful due to alterations in physiology and pharmacology associated with age and frailty. This necessitates the withdrawal or dose reduction of inappropriate medications, the process called deprescribing. The decision to deprescribe medications used for both disease prevention and symptom control (DPMs) in this population is often challenging for clinicians. In this context, whether deprescribing of DPMs can improve patient-related health outcomes is unknown. Methods: Evidence from the literature was reviewed and analysed, and the quality of studies was assessed. Five studies were identified, which had 689 participants with an average age above 80 years and mostly suffering from dementia. Results: The analysis of these studies showed deprescribing of DPMs lowered the risk of death and referral to acute care facilities at 12 months but had no significant impact on falls, non-vertebral fractures, emergency presentations, unplanned hospital admission, general practitioner visits, quality of life, physical and mental functions. Conclusion: In conclusion, there were insufficient numbers of high-quality studies powered to confirm whether deprescribing of DPMs reduces adverse events, health service use, or improves the quality of life or functioning in older adults near the end of life

Efficacy of Combined Antithrombotic, Statins and Anti-Hypertensive Drugs in Acute Ischemic Stroke

Introduction: Anti-thrombotic, statins and antihypertensive drugs are commonly used for the management of acute ischemic stroke in Nepal but there is no evidence regarding their efficacy in our context. This study aims to explore the efficacy of these combined medications (anti-thrombotic, statins and antihypertensive drugs) in acute ischemic stroke patients for the first time and to assess the risk factors present in those patients. Methods: The study was conducted on 37 acute ischemic stroke patients admitted and treated at the Neurology Department of College of Medical Sciences-Teaching Hospital, Chitwan, Nepal and they were followed at three months (90±10 days). The initial stroke severity and functional disability were evaluated at admission and at 3 months using National Institute of Health Stroke Scale (NIHSS) and Modified Rankin Scale (mRS) respectively. The outcome parameters were functional independence (mRS≤2) and mortality at three months (mRS=6). Frequency distribution, Mann-Whitney U-test and χ2 test were performed for statistical analysis. Results: Out of 37 patients, 27 (73%) were Smoker, 22 (59.5%) had hypertension and 19 (51.4%) were alcohol consumer. The stroke severity on admission was statistically significant with functional independence (P=0.003) and mortality (P=0.015) at three month. Similarly, Rankin grade on admission was statistically significant with functional independence (P=0.001) and mortality (P=0.048) at three month. At three months, 20 (69%) survived patients were independent while mortality was seen in eight (21.6%) patients. Conclusions: The management of acute ischemic stroke with combined anti-thrombotic, statins and antihypertensive drugs seems promising and efficacious in mild to moderately severe ischemic stroke. Keywords: antihypertensive; anti-thrombotic; efficacy ; statins; stroke

Evidence-based Medication knowledge Brokers in Residential Aged CarE (EMBRACE) : protocol for a helix-counterbalanced randomised controlled trial

Introduction: Clinical practice guidelines recommend against the routine use of psychotropic medications in residential aged care facilities (RACFs). Knowledge brokers are individuals or groups who facilitate the transfer of knowledge into practice. The objective of this trial is to evaluate the effectiveness and cost-effectiveness of using knowledge brokers to translate Australia’s new Clinical Practice Guidelines for the Appropriate Use of Psychotropic Medications in People Living with Dementia and in Residential Aged Care. Methods and analysis: The Evidence-based Medication knowledge Brokers in Residential Aged CarE (EMBRACE) trial is a helix-counterbalanced randomised controlled trial. The 12-month trial will be conducted in up to 19 RACFs operated by four Australian aged care provider organisations in Victoria, New South Wales, Western Australia and Queensland. RACFs will be randomised to receive three levels of implementation strategies (knowledge broker service, pharmacist-led quality use of medications education activities and distribution of the Guidelines and supporting materials) across three medication contexts (antipsychotics, benzodiazepines and antidepressants). Implementation strategies will be delivered by an embedded on-site aged care pharmacist working at a system level across each participating RACF. All RACFs will receive all implementation strategies simultaneously but for different medication contexts. The primary outcome will be a composite dichotomous measure of 6-month RACF-level concordance with Guideline recommendations and good practice statements among people using antipsychotics, benzodiazepines and antidepressants for changed behaviours. Secondary outcomes will include proportion of residents with Guideline concordant use of antipsychotics, benzodiazepines and antidepressants measured at the RACF-level and proportion of residents with psychotropic medication use, hospitalisation, falls, falls with injury, polypharmacy, quality of life, activities of daily living, medication incidents and behavioural incidents measured at the RACF-level. Discussion: The EMBRACE trial investigates a novel guideline implementation strategy to improve the safe and effective use of psychotropic medications in RACFs. We anticipate that the findings will provide new information on the potential role of knowledge brokers for successful and cost-effective guideline implementation

Wellington Cordon Project

INTRODUCTION This project falls under the Flagship 3: Wellington Coordinated Project. It supports other projects within FP3 to create a holistic understanding of risks posed by collapsed buildings due to future earthquake/s and the secondary consequences of cordoning in the short, mid and long term. Cordoning of the Christchurch CBD for more than two years and its subsequent implications on people and businesses had a significant impact on the recovery of Christchurch. Learning from this and experiences from the Kaikōura earthquake (where cordons were also established around selected buildings, Figure 3) have highlighted the need to understand the effects of cordons and plan for it before an earthquake occur

To cordon or not to cordon: The inherent complexities of post-earthquake cordons learned from New Zealand Experiences

The use of post-earthquake cordons as a tool to support emergency managers after an event has been documented around the world. However, there is limited research that attempts to understand the use, effectiveness, inherent complexities, impacts and subsequent consequences of cordoning once applied. This research aims to fill that gap by providing a detailed understanding of first, the cordons and associated processes, and their implications in a post-earthquake scenario. We use a qualitative method to understand cordons through case studies of two cities where it was used in different temporal and spatial scales: Christchurch (2011) and Wellington (Kaikōura earthquake 2016), New Zealand. Data was collected through 21 expert interviews obtained through purposive and snowball sampling of key informants who were directly or indirectly involved in a decision-making role and/or had influence in relation to the cordoning process. The participants were from varying backgrounds and roles i.e. emergency managers, council members, business representatives, insurance representatives, police and communication managers. The data was transcribed, coded in Nvivo and then grouped based on underlying themes and concepts and then analyzed inductively. It is found that cordons are used primarily as a tool to control access for the purpose of life safety and security. But cordons can also be adapted to support recovery. Broadly, it can be synthesized and viewed based on two key aspects, ‘decision-making’ and ‘operations and management’, which overlap and interact as part of a complex system. The underlying complexity arises in large part due to the multitude of sectors it transcends such as housing, socio-cultural requirements, economics, law, governance, insurance, evacuation, available resources etc. The complexity further increases as the duration of cordon is extended

Open spaces and risk perception in post-earthquake Kathmandu city

Open Spaces and Risk Perception in Post-Earthquake Kathmandu city Abstract Perceptions of seismic risks, among other factors, are influenced by urban environments. This relationship is investigated in this paper, in relation to open spaces. A comparative study of two communities in Kathmandu, Nepal with the context of 2015 earthquake was conducted using data gathered from household surveys and expert interviews. Escape behaviour in relation to open spaces was examined by analysing the correlation with a risk perception index (RPI) which is a novel approach in seismic risk perception studies. Additionally, point density analysis of surveyed houses and visualization of escape routes and destination followed by the respondents offer insights into the spatial relationship with perceived risk. Furthermore, expert interviews were used to validate the findings and highlight the important relationship between perceived risks and open spaces. The findings suggest that open spaces are a key component of disaster response as they are safe locations and offer spaces for community that enables mutual coping among its members. As such it directly or indirectly affect people's perception of seismic risk. It was found that medium sized communal spaces are preferred within a distance of 200m as immediate safe destinations. The choices for such spaces are dependent on the built environment of the site given by its layout, landmarks, building density and building height. The choices of open spaces as shelter locations are influenced by duration of stay such as availability of drinking water, public lavatory and electricity are crucial for short term stay where as ownership and economic capabilities are vital for long term stay