Deprescribing: a self-portrait about the reduction of polypharmacy in Portugal

Drug use in older adults’ patients (≥65 years) is extensive, increases substantially with age, and is associated with many adverse outcomes. Polypharmacy is commonly defined as taking 5 or more medications daily and affects between 30 and 70% of older adults. Potentially inappropriate medication (PIM) refers to medication of which the harms outweigh the benefits, and its prevalence is 20 to 65%. Several strategies have been developed to identify inappropriate prescription patterns, the most common are Beers and STOPP/START criteria. Deprescription is a systematic process to of identifying and discontinuing drugs that are not beneficial or are not aligned with the patient’s care goal. Many deprescribing processes have been proposed, but none is widely used. This thesis aims to assess the knowledge of older adults about the deprescription, its effect on willingness to have regular medications deprescribed and their quality of life outcome. To achieve these objectives, we proposed to divide the project into three phases. The first two would be cross-sectional studies carried out at the national level and the last a non-pharmacological random clinical trial in the centre region of Portugal. Of the three phases, we have completed only the first two, the last has been postponed. In the first phase, we assessed the prevalence and patterns of polypharmacy and PIM in the Portuguese older adult population. In the second phase, we evaluated the barriers and facilitators of deprescribing perceived by Portuguese polymedicated older adults and their willingness to have regular medications deprescribed and to self-medicate. In the first study, we found that 77% of the sample had polypharmacy and 68.6% used at least one PIM. The likelihood of having polypharmacy increased with age, number of chronic health problems and number of prescribers; and the likelihood of having PIM increased with being female, number of chronic health problems, number of drugs and number of prescribers. The most common PIM were proton-pump inhibitors, nonsteroidal anti-inflammatory drugs, and benzodiazepines. In the second study, we found that 74% of the sample believed that drugs were generally beneficial. However, 19.9% indicated a high belief that drugs were harmful and 33.4% that they were generally overused. We also found that 61.8% were against the idea of deprescribing (against 24.6% who were in favour) and that 40% had a need to self-medicate. Those against being deprescribed had lower education level and a higher number of perceived morbidities than those not against being deprescribed; and the need to self-medication was associated with higher formal education, lower feeling of overuse of medication by doctors and a lower belief that medicines are harmful. Our results show that polypharmacy and PIM are very common occurrence in Portugal; and that most Portuguese older adults see mediation as beneficial and, therefore, are against the idea of being subject to deprescription. Self-medication is also common. These results will increase general practitioners, society and policy makers awareness for these problems and help them to better start addressing them. However, more research is needed to clarify the impact of deprescribing process in the Portuguese population health and well-being or, alternatively, to improve the process of prescription drugs, avoiding their excess.O consumo de medicamentos pelos idosos (≥65 anos) é elevado, aumenta substancialmente com a idade e está associado a muitos efeitos adversos. A polifarmácia é comummente definida como a toma diária de 5 ou mais medicamentos e afeta entre 30 e 70% dos idosos. Os medicamentos potencialmente inapropriados (MPI) referem-se a medicamentos cujos malefícios são superiores aos benefícios e ocorre em 20 a 65% dos idosos. Várias estratégias foram desenvolvidas para identificar padrões de prescrição inadequada, sendo os mais comuns os critérios de Beers e STOPP/START. A desprescrição é um processo sistemático de identificação e descontinuação de medicamentos que não são benéficos ou não estão alinhados com os objetivos de saúde do paciente. Muitos processos de desprescrição foram propostos, mas nenhum é amplamente utilizado. Esta tese teve como objetivo avaliar o conhecimento dos idosos acerca da desprescrição e o seu efeito sobre a vontade de ter medicação habitual desprescrita e na qualidade de vida. Para alcançar os objetivos propostos foi proposto a divisão do projeto em três fases, as duas primeiras seriam estudos transversais de âmbito nacional e a última um ensaio clínico randomizado não farmacológico. Das três fases apenas as duas primeiras foram realizadas, tendo sido a última adiada. Na primeira fase avaliámos a prevalência e os padrões da polifarmácia e MPI na população idosa portuguesa. Na segunda fase avaliámos as barreiras e facilitadores da desprescrição percecionados pelos idosos portugueses polimedicados e a sua vontade de ter medicação habitual desprescrita e de se automedicar. No primeiro estudo encontrámos que 77% da amostra apresentava polifarmácia e 68,6% apresentavam pelo menos um MPI. A probabilidade de ter polifarmácia aumentou com a idade, número de doenças crónicas e número de prescritores e a de ter MPI aumentou com o ser do género feminino, com o número de problemas crónicos de saúde, o número de medicamentos prescritos e o número de prescritores. Os MPI mais comuns foram os inibidores da bomba de protões, os anti-inflamatórios não esteroides e as benzodiazepinas. No segundo estudo encontrámos que 74% da amostra acreditava que os medicamentos eram geralmente benéficos. No entanto, 19,9% indicaram uma grande crença de que os medicamentos eram prejudiciais e 33,4% de que eram usados em excesso. Também descobrimos que 61,8% eram contra a ideia de serem sujeitos a desprescrição (contra 24,6% que eram a favor) e que 40% tinham necessidade de se automedicar. Os que eram contra a desprescrição tinham menor nível de escolaridade e maior número de doenças crónicas percecionadas do que aqueles que não eram contra a desprescrição; e a necessidade de automedicação estava associada a uma maior educação formal, uma menor crença de uso excessivo de medicamentos pelos médicos e a uma menor crença de que os medicamentos são prejudiciais. Os nossos resultados revelam que a polifarmácia e a MPI são muito comuns em Portugal; e que a maioria dos idosos portugueses vê a mediação como benéfica e, portanto, é contra a ideia de ser sujeito a desprescrição. A automedicação também é frequente. Estes resultados aumentarão a consciencialização dos médicos de família, da sociedade e dos agentes políticos acerca destes problemas e ajudá-los-ão a começar a resolvê-los melhor. No entanto, são necessários mais estudos para esclarecer o impacto do processo de desprescrição na saúde e bem-estar da população portuguesa, ou em alternativa melhorar o processo de prescrição de medicamentos evitando o seu excesso

Carta ao Editor a Propósito do Artigo: “Prescrição Inapropriada em Idosos numa Enfermaria de Medicina Interna”

Dear Editor, We read with interest an article about inappropriate prescribing to elderly patients in an internal medicine ward and a letter to the editor regarding the same paper. We developed a similar study in the Portuguese primary care setting with a nation-wide representative sample of 757 elderly patients in accordance to its distribution in Portuguese health regions and we found that 77% of them were on ≥ 5 medications (with a mean of 8.2) and that 68% had at least one potentially inappropriate medication according the to 2015 Beers Criteria (with a mean of 1.72). The most common potentially inappropriate pharmacological classes were proton pump inhibitors (45.6%), non-steroid anti-inflammatory agents (34.5%) and benzodiazepines (27.3%). As such, we were also surprised with the low proportion of inappropriate prescribing at admission and at discharge reported in the study. One of the explanations, that was already reported, is the restricted number of pharmacologica classes used. This does raise many questions. Are we managing the various problems of our population in the best way? Is it necessary to rethink the polypharmacy cut-off since with the aging of the population there is an increase in the number of chronic diseases and consequently an increase in the number of drugs necessary to control them? Do we have to practice according to the guidelines or according to our clinical judgement of pathophysiology? Does this defnition of fve drugs for polypharmacy put people at a higher risk of undermedication, instead of overmedication?5 Shouldn’t we think of a new defnition for polypharmacy that isn’t the same for all people, but which takes into account the burden of disease that it is subject to? E.g. does it make sense to use the same polypharmacy cut-off for a healthy individual and a post-myocardial infarction patient? We consider this issue as fundamental, since as already mentioned the management of multimorbidity and polypharmacy (more specifcally of potentially inappropriate medication) are essential pillars in the provision of health care nowadays, both in primary and secondary care. So this raises the question of time since, in medical education, when should this topic be addressed and by whom? It is also important to analyze if there are differences between the work at the different health care levels regarding the management of multimorbidity, polymedication and potentially inappropriate medication. Are we all working towards the same goal?info:eu-repo/semantics/publishedVersio

Prevalence of polypharmacy in the older adult population within primary care in Portugal: a nationwide cross-sectional study

Introduction Polypharmacy is commonly defined as the simultaneous use of five or more medications; however, there is a lack of consensus regarding the most appropriate definition. It is a significant predictor of morbidity and mortality. The aim of this study was to determine the prevalence of polypharmacy in the population of older adults attending primary care in Portugal and to identify associated sociodemographic and clinical factors. Material and methods We conducted a cross-sectional, analytical study in primary care centres from the five Portuguese healthcare administrative regions and the two autonomous regions. We used a random sample of 757 older adult patients provided by the information department of the ministry of health (SPMS) and family doctors from the autonomous regions. Data collection occurred in March 2018. The variables utilised were sociodemographic characteristics, clinical profile and medication. For each patient, polypharmacy was measured either by the concurrent use of ≥ 5 drugs or by the median number of drugs at the time of data collection. Logistic regression analyses were performed to determine associations between polypharmacy and other variables. Results Polypharmacy (≥ 5 drugs) was present in 77% of the sample. A cut-off of over the median number of drugs was present in 55%. The likelihood of having polypharmacy increased significantly with age (OR = 1.05 (1.02–1.08)), number of chronic health problems (OR = 1.24 (1.07–1.45)) and number of prescribers (OR = 4.71 (3.42–6.48)). Cardiovascular, metabolic and musculoskeletal medications were the most commonly involved in polypharmacy. Conclusions Polypharmacy was a very common occurrence in Portugal. Future primary healthcare policies should address polypharmacy.info:eu-repo/semantics/acceptedVersio

Prevalence Of Potentially Inappropriate Medication In The Older Adult Population Within Primary Care In Portugal: A Nationwide Cross-Sectional Study

Background: In potentially inappropriate medications harm potentially outweighs benefits. Even appropriately prescribed medications may become inappropriate. They can lead to a high risk of adverse drug reactions, morbidity and mortality. The aim of this study was to determine the prevalence of potentially inappropriate medication in the older adult population attending primary care in Portugal and to identify associated sociodemographic and clinical factors. Methods: We conducted a cross-sectional, analytical study in primary care centres from the five Portuguese healthcare administrative regions and the two autonomous regions. We used a random sample of 757 older patients provided by the information department of the ministry of health (SPMS) and family doctors from the autonomous regions. Data collection occurred March 2018 and we studied sociodemographic characteristics, clinical profile and medication. We used 2015 Beers Criteria to assess potentially inappropriate medications. Logistic regression analyses were performed to determine associations between potentially inappropriate medications’ prescriptions and other variables. Results: Potentially inappropriate medication was present in 68.6% and 46.1% of the sample had two or more. The likelihood of having potentially inappropriate medication increased significantly with being female (OR=1.56 [1.05 to 2.31]), number of chronic health problems (OR=1.06 [1.01 to 1.13]), number of pharmacological subclasses (OR=1.40 [1.30 to 1.51]) and number of prescribers (OR=1.34 [1.09 to 1.65]). Proton-pump inhibitors, nonsteroidal anti-inflammatory drugs and benzodiazepines were the most commonly found ones. Conclusion: Potentially inappropriate medication in older adults was found to be a common occurrence in Portugal. It is important that doctors are aware of this problem, namely in the primary care setting due to the longitudinal care.info:eu-repo/semantics/publishedVersio

COVID-19 or threat of a nuclear war in Europe? A cross-sectional study of anxiety levels in adults living in Portugal

Background: Since 2019, Europe has experienced ongoing stressors with the emergence of the COVID-19 pandemic and the Russian–Ukrainian War, which have had social, financial, physical, and psychological impacts. Studies suggest that anxiety, fear, post-traumatic stress disorder, depression, and other psychological disorders are common in such situations, and there is a need for more research on the impact of the war on mental health in Portugal. The main goal of the present study was to assess the impact of the fear of COVID-19 and anxiety related to nuclear war on the general anxiety levels of adult individuals living in Portugal. Methods: A cross-sectional study was conducted from May to July 2022 using an online questionnaire built on the Google Forms platform. Portuguese-speaking male and female individuals aged 18 years or older, who provided informed consent and agreed to participate, were included. The outcome variable was defined using the Portuguese version of the GAD-7 scale, while the main predictors were the FCV-19S and the NWA Scale in Portuguese. Linear and logistic regression models were used to test associations between predictors and outcome variable. Results: The study included 1,182 participants, with a mean age of 46.5 (±11.7) years, mostly women (80.6%). The global mean GAD-7 score was 5.8 (±4.5) points, and 17.9% of the participants scored above the 10-point cutoff. Higher scores were found in both the FCV-19S and the NWA scale among participants with anxiety, as measured by both a 10-point cutoff (p < 0.001), and GAD-7 scale mean scores (p < 0.001). The study showed that fear of COVID-19 [OR of 1.133 (95%CI: 1.097–1.170)] and, at a lesser extent, nuclear war anxiety [OR of 1.020 (95%CI, 1.009–1.031)] contribute to anxiety in the general population. This is also true for those with a personal history of anxiety, revealed by multiple regression. Discussion: This study contributes to the research on COVID-19’s impact on anxiety and provides the first comprehensive assessment of nuclear war anxiety in Portugal. Results highlight the need for long-term care for anxiety, as prevalence is expected to increase due to the pandemic and war, even in non-conflict areas like Portugal.info:eu-repo/semantics/publishedVersio

Letter to the Editor concerning the Letter to the Editor "Polypharmacy and the Use of Potentially Inappropriate Medication in the Elderly Aged 75 and Over: The Case of a Family Health Unit"

Caro Editor, Lemos com interesse a carta ao editor acerca da polifarmácia e utilização de medicação potencialmente inapropriada (MPI) no idoso com idade igual ou superior a 75 anos.Num estudo similar, desenvolvido no âmbito dos Cuidados de Saúde Primários a nível nacional e com uma amostra representativa de 757 idosos com idade igual ou superior a 65 anos de acordo com a distribuição a nível nacional da população idosa, verificámos uma prevalência de polifarmácia de 77% (sobe para 82,6% quando consideramos a faixa etária ≥ 75 anos) e uma média de 8,2 medicamentos (8,7 medicamentos se ≥ 75 anos). A prevalência de pelo menos uma MPI foi de 68,6% (sobe para 72,1% se considerarmos apenas ≥ 75 anos), e os MPI mais prevalentes foram os inibidores da bomba de protões (presentes em 45,6% da nossa amostra), anti-inflamatórios não esteroides (em 34,5%) e benzodia-zepinas (em 27,3%). As diferenças encontradas dever-se-ão, provavelmente, às caraterísticas específicas da população estudada, bem como aos métodos de recolha de dados, informações que não ficam claras numa exposição tão curta como a feita em formato de carta ao editor. No nosso estudo verificámos que a probabilidade de um idoso estar sujeito a polifarmácia au-menta com a idade, número de doenças crónicas e o número de prescritores; enquanto que a probabilidade de um idoso estar sujeito a medicação potencialmente inapropriada aumenta com o ser mulher, número de doenças crónicas, número de medicamentos e número de prescritores. Concordamos e sublinhamos a importância dada à necessidade de ser revista periodicamente a medicação dos nos-sos utentes, principalmente dos mais idosos que têm maior probabilidade de sofrer eventos adversos aos medicamentos. Salientamos a necessidade de prescrição criteriosa dos medicamentos, com a utilização de ferramentas de apoio, sendo os critérios de Beers um bom exemplo de tal. Mas o uso de critérios implícitos que envolvam o nosso juízo clínico, de que os exemplos mais conhecidos são o Medication Appropriateness Index e o algoritmo de Garfinkel, devem ser referidos para utilização criteriosa. Uma vez que em muitos casos a medicação prescrita é apenas a ponta do iceberg do que os utentes tomam, devendo também considerar-se a toma de medicação de venda livre e de suplementos, cuja prevalência de consumo tem vindo a aumentar, mais importante ainda se torna este tema que deve ser baseado no conhecimento a adquirir ao nível pré--graduado e modelado pelas ferramentas acima referidas como auxiliares da melhor prática.info:eu-repo/semantics/publishedVersio

Determining factors associated with inhaled therapy adherence on asthma and COPD: A systematic review and meta-analysis of the global literature

Background Adherence to therapy has been reported worldwide as a major problem, and that is particularly relevant on inhaled therapy for Asthma and Chronic Obstructive Pulmonary Disease (COPD), considering its barriers and features. We reviewed the global literature reporting the main determinants for adherence on these patients. Methods Searches were made using the Cochrane Library, MEDLINE, EMBASE and ISI Web of Science databases. Analytical, observational and epidemiological studies (cohort, case-control and cross-sectional studies) were included, reporting association between any type of determinant and the adherence for inhaler therapy on Asthma or COPD. Random-effects meta-analysis were used to summarise the numerical effect estimates. Results 47 studies were included, including a total of 54.765 participants. In meta-analyses, the significant determinants of adherence to inhaled therapy were: older age [RR = 1.07 (1.03–1.10); I2 = 94; p < 0.0001] good disease knowledge/literacy [RR = 1.37 (1.28–1.47); I2 = 14; p = 0.33]; obesity [RR = 1.30 (1.12–1.50); I2 = 0; p = 0.37]; good cognitive performance [RR = 1.28 (1.17–1.40); I2 = 0; p = 0.62]; higher income [RR = 1.63 (1.05–2.56); I2 = 0; p = 0.52]; being employed [RR = 0.87 (0.83–0.90); I2 = 0; p = 0.76] and using multiple drugs/inhalers [RR = 0.81 (0.79–0.84); I2 = 0; p = 0.80]. Overall, the strength of the underlying evidence was only low to moderate. Conclusions Many determinants may be associated to patient's adherence, and personalised interventions should be taken in clinical practice to address it by gaining an understanding of their individual features.info:eu-repo/semantics/publishedVersio

COVID-19-Related Fear and Anxiety: Spiritual-Religious Coping in Healthcare Workers in Portugal

The COVID-19 pandemic has negatively affected the mental health of the general population, and for healthcare workers (HCWs) it has been no different. Religiosity and spirituality are known coping strategies for mental illnesses, especially in stressful times. This study aimed to describe the role of spiritual-religious coping regarding fear and anxiety in relation to COVID-19 in HCWs in Portugal. A cross-sectional quantitative online survey was performed. Socio-demographic and health data were collected as well as the Duke University Religion Index, Spirituality Scale, Fear of COVID-19 Scale, and Coronavirus Anxiety Scale. Two hundred and twenty-two HCWs participated in the study, 74.3% were female and 81.1% were physicians. The median age was 37 years (Q1, Q3: 31, 51.3). Religiosity was neither a significant factor for coronavirus-related anxiety nor it was for fear of COVID-19. Participants with higher levels in the hope/optimism dimension of the Spirituality Scale showed less coronavirus-related anxiety. Female HCWs, non-physicians, and the ones with a previous history of anxiety presented higher levels of fear and/or anxiety related to COVID-19. HCWs’ levels of distress should be identified and reduced, so their work is not impaired.info:eu-repo/semantics/publishedVersio

Communication and health: doctor-patient relationship in patients with multimorbidity, an exploratory study

Background. With the increase of average life expectancy and the aging of the population, an increase in multimorbidity has also been observed. Effective communication in the doctor–patient relationship is directly related to the promotion of health of patents with multimorbidity. One of the fundamental foundations of this doctor-patient relationship is the physician’s ability to establish an empathic relationship with the patent. Objectives. The objective of this study is to compare Family Medicine consultations and Hospital consultations in terms of empathic communication and the doctor-patient relationship in patents with multimorbidity. Material and methods. An exploratory observational cross-sectional study was carried out using elderly people with multimorbidity and applying the JSPE scale. Statistical analysis was performed using descriptive statistics and the non-parametric Mann–Whitney u test. Results. For all questions on the JSPE scale, the family physician scored higher than the hospital physician. Between the specialties, statistically significant differences were obtained. Conclusions. The differences between Family Medicine consultations and Hospital consultations has an impact on the results of the medical empathy felt by the patents. Other studies demonstrate the importance of empathy in the doctor-patient relationship, and in this study, we concluded that there is a greater degree of empathy felt by the patients in Family Medicine consultations compared to the lower degree of empathy felt by the patents in Hospital consultations.info:eu-repo/semantics/publishedVersio

Physician empathy and patient enablement: survey in the Portuguese primary health care

Background: Empathy is the capacity to understand and resonate with the experiences of other people. Patient enablement is the degree to which a patient feels strengthened in terms of being able to deal with, understand and manage their disease. Methods: Secondary cross-sectional analysis of existing data from 2 independent datasets (456 primary health care patients), with the application of two validated questionnaires, Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE) and Patient Enablement Instrument (PEI). Objective: Evaluate medical empathy and patients’ enablement after consultation with their family doctors and to verify if there was an association between these two concepts. Results: The median value of JSPPPE-VP score was 6.60 (interquartile range 1.00) and of PEI/ICC score was of 1.83 (interquartile range 0.67). Regarding empathy (JSPPPE-VP), patients taking chronic medication had a slight but significantly higher median score than patients not taking them (6.70 versus 6.60, P = 0.049), although regression modelling did not confirm any relevant predictor of JSPPPE-VP score. Regarding enablement (PEI/ICC), we found significantly higher scores on younger patients, as well as, on more educated and professionally active ones (P < 0.001). Multivariable linear regression and Poisson regression modelling confirmed such variables as statistically significant potential predictors. Conclusions: A significant positive association was found between empathy score (JSPPPE-VP) and enablement score (PEI/ICC), when adjusted to sociodemographic cofactors. On this linear regression model, age category and educational level were also significantly associated with empathy score, with the same pattern found on bivariate analysis.info:eu-repo/semantics/publishedVersio