Reducing medication error and polypharmacy in older people

Introduction Polypharmacy and anticholinergic burden are associated with falls in older people. A longitudinal study found patients with five or more drugs had 21% increased falls over 2 years. [Dhalwani, Fahami, Sathanapally et al, BMJ Open, 2017,7(10), e016358]. A cohort study identified a 1.51 odds of recurrent falls with anticholinergic medication, while taking multiple anticholinergics resulted in 100% likelihood of recurrent falls. [Marcum, Wirtz, Pettinger, et al, BMC Geriatrics, 2016,16,76]. Methods Retrospective study of polypharmacy in older people in Brunei based on data from Bru-HIMS, the Brunei public healthcare sector electronic prescribing and pharmacy management system. In this national study, stratified sampling was done by district, with patients randomly selected within each district. Active medications were identified from Bru-HIMS. The Anticholinergic Cognitive Burden (ACB) Scale was used to calculate anticholinergic burden. Findings for two districts (Tutong and Temburong) are described. Results For the 327 patients, 142 (43%) were male and 185 (57%) female. Median age was 72 years (Range 65 to 103 years). 234 (72%) had 5 drugs or more prescribed. Of the 2332 prescriptions, 268 (11.5%) had anticholinergic activity on the ACB scale. Median ACB score was 1. The most commonly prescribed were Orphenadrine, Chlorpheniramine, Diphenhydramine, Cinnarizine and Amitriptyline. There was a positive correlation between polypharmacy and anticholinergic burden (r = 0.4593). Conclusion There was a high rate of polypharmacy in older people, with anticholinergic drug burden identified. It may be useful to educate clinicians and patients regarding risks of polypharmacy and anticholinergic burden, including falls.

Electronic Prescribing and Other Forms of Technology to Reduce Inappropriate Medication Use and Polypharmacy in Older People: A Review of Current Evidence

Introduction Older people encounter challenges when taking polypharmacy. Different interventions have been applied to improve adherence to polypharmacy. However, there are few high-quality studies, and little consideration has been given to the outcomes selected to measure the effectiveness of interventions.[1] To produce high-quality studies and accurately report adherence-related outcomes, developing a Core Outcome Set (COS) is important.[2] A COS is the minimum number of outcomes that should be reported and measured in future trials in a specific health field to reduce outcomes’ inconsistencies across trials.[2] Aim This study aimed to develop a COS for use in clinical trials aiming at improving adherence to appropriate polypharmacy in older patients. Methods A list of outcomes related to adherence to polypharmacy (n=13) was compiled from previous semi-structured interviews with stakeholders. The Delphi panel consisted of experts in adherence, polypharmacy and gerontology, including journal editors, academics, non-National Health Service doctors, nurses and pharmacists who were identified by searching researchers’ publication profiles using Google Scholar and Scopus. Senior editors and editor-in-chief of peer-reviewed journals were identified by searching journal information. Public members were identified by searching for contact emails of staff members in public charities/organisations representing older people’s healthcare needs (e.g. AgeUK). Additionally, identified participants received invitation emails asking them to forward the email to other participants and experts who might be interested in this study (i.e. snowball sampling). The 13 outcomes were distributed in three online Delphi questionnaires between February and April 2023 using an online SoGoSurvey® platform. All outcomes were rated according to their degree of importance using a nine-point Likert scale (1 to 3 = unimportant; 4 to 6 = important but not critical; 7 to 9 = critical). Following each round, response rates and the distribution of scores were calculated to classify outcomes into ‘consensus in’, ‘consensus out’ and ‘no consensus’. An outcome was considered very important if ≥80% of participants scored it as ‘critical’ and ≤15% scored it as ‘unimportant’. Results The Delphi panel (Round 1, n=57; Round 2, n=53; Round 3, n=50) comprised different professionals, including 38 academics, 23 pharmacists, 12 doctors, six journal editors, three nurses and four public members, some of whom had multiple roles, e.g. doctor and academic. Participants were distributed over four continents, mostly from Europe (n=39). Both Australia and America had identical representation (n=8), while two participants represented Asia. Consensus was reached following the third round on seven outcomes, namely: medication adherence across multiple medications (100.0%), treatment burden (96.2%), health-related quality of life (96.2%), healthcare utilisation (83.0%), adverse events and side effects (83.0%), patient-carer satisfaction (82%), and cost-effectiveness (81.1%). Conclusion Seven outcomes were considered of critical importance to stakeholders. This study is the first to develop a COS for interventions targeting adherence to appropriate polypharmacy in older patients. However, most of our participants were academics and pharmacists from Europe, whilst other participant categories and continents were less well-represented. A future nominal group technique study will be conducted to discuss the results obtained from previous Delphi questionnaires, followed by selecting the appropriate outcome measurement instruments to measure these outcomes.

To develop a core outcome set (COS) for use in effectiveness trials of interventions aiming to improve the appropriateness of polypharmacy in older people in primary care. Standard COS development methodology was followed, comprising identification of outcomes of studies from an update of a Cochrane systematic review and previously collected qualitative data and an online Delphi consensus exercise involving three rounds. An international panel of 160 stakeholders comprising 120 healthcare experts and a public participant panel of 40 older people. Outcomes identified from studies included in the Cochrane review and secondary analysis of previously collected qualitative data were scored on a 9-point Likert scale using the GRADE scoring system anchored at 1 (not important) and 9 (critical). Consensus criteria for the COS were defined as 70% or more of participants scoring the outcome as critical and 15% or fewer scoring the outcome as not important. Twenty-nine outcomes identified from the Cochrane review and existing qualitative data were included in the Delphi exercise. The final COS comprised 16 outcomes. The 7 highest-ranked outcomes were serious adverse drug reactions, medication appropriateness, falls, medication regimen complexity, quality of life, mortality, and medication side effects. A COS for interventions aiming to improve the appropriateness of polypharmacy for older people in primary care has been developed. Future work will focus on identifying appropriate tools to measure.

BackgroundThe PolyPrime intervention is a theory-based intervention aimed at improving appropriate polypharmacy in older people (aged ≥65 years) in primary care. The intervention consists of an online video which demonstrates how general practitioners (GPs) can prescribe appropriate polypharmacy during a consultation with an older patient and a patient recall process, whereby patients are invited to scheduled medication review consultations with GPs. The aim of the process evaluation is to further examine the implementation of the PolyPrime intervention in primary care. This will involve investigating whether the PolyPrime intervention can be delivered as intended across two healthcare systems, how acceptable the intervention is to GPs, practice staff and patients, and to identify the intervention’s likely mechanisms of action.MethodsThe PolyPrime study is an external pilot cluster randomised controlled trial (cRCT) which aims to recruit 12 GP practices across Northern Ireland [NI] (n=6) and the six counties in the Republic of Ireland (ROI) that border NI (n=6). Practices have been randomised to intervention or usual care. An embedded process evaluation will assess intervention fidelity (i.e. was the intervention delivered as intended), acceptability of the intervention to GPs, practice staff and patients and potential mechanisms of action (i.e. what components of the intervention were perceived to be effective). Quantitative data will be collected from data collection forms completed by GPs and practice staff and a feedback questionnaire completed by patients from intervention arm practices, which will be analysed using descriptive statistics. Qualitative data will be collected through semi-structured interviews with GPs and practice staff and audio-recordings of medication review appointments from the intervention arm practices which will be transcribed and analysed using the framework method. Quantitative and qualitative data will be triangulated to provide an overall assessment of intervention fidelity, intervention acceptability, and mechanisms of action.DiscussionThis process evaluation will add to feasibility data from the pilot cRCT by providing evidence on the fidelity of implementing the intervention package across two healthcare systems, the acceptability of the intervention and potential mechanisms of action.Trial registrationClinicalTrials.govISRCTN41009897. Registered on 19 November 2019. ClinicalTrials.govNCT04181879. Registered 02 December 2019.

Low- to moderate-certainty evidence suggests that, compared to usual care, medication reconciliation, CPOE/CDSS, barcoding, feedback and dispensing systems in surgical wards may reduce medication errors and ADEs. However, the results are imprecise for some outcomes related to medication reconciliation and CPOE/CDSS. The evidence for other interventions is very uncertain. Powered and methodologically sound studies are needed to address the identified evidence gaps. Innovative, synergistic strategies -including those that involve patients- should also be evaluated.

The aim of this article is to explore prescribing and medicines management in older people. The author discusses the physiological changes that occur as people age and how these changes affect the use of drugs in this group. Additionally, inappropriate prescribing with specific reference to polypharmacy in older people is explored. Finally, drugs that should be used with care are highlighted.

ABSTRACTIntroduction: Single disease state led evidence-based guidelines do not provide sufficient coverage of issues of multimorbidities, with the cumulative impact of recommendations often resulting in overwhelming medicines burden. Inappropriate polypharmacy increases the likelihood of adverse drug events, drug interactions and non-adherence.Areas covered: A detailed description of a pan-European initiative, ‘Stimulating Innovation Management of Polypharmacy and Adherence in the Elderly, SIMPATHY’, which is a project funded by the European Commission to support innovation across the European Union. This includes a systematic review of the literature aiming to summarize and review critically current policies and guidelines on polypharmacy management in older people. The policy driven, evidence-based approach to managing inappropriate polypharmacy in Scotland is described, with consideration of a change management strategy based on Kotter’s eight step process for leading sustainable change.Expert opinion: The challenges around promoting appropriate polypharmacy are on many levels, primarily clinical, organisational and political, all of which any workable solution will need to address. To be effective, safe and efficient, any programme that attempts to deal with the complexities of prescribing in this population must be patient-centred, clinically robust, multidisciplinary and designed to fit into the healthcare system in which it is delivered.

Multi-morbidity and polypharmacy are common in older people and pose a challenge for health and social care systems, especially in the context of global population ageing. They are complex and interrelated concepts in the care of older people that require early detection and patient-centred shared decision making underpinned by multi-disciplinary team-led comprehensive geriatric assessment (CGA) across all health and social care settings. Personalised care plans need to remain responsive and adaptable to the needs and wishes of the patient, enabling the individual to maintain their independence. In this review, we aim to give an up-to-date account of the recognition and management of multi-morbidity and polypharmacy in the older person.

Introduction: The prevalence of polypharmacy in older people contributes to potentially inappropriate prescribing, which is evaluated using various criteria. Depressive disorders are serious issues for older adults. In this study, the prescribing rates of potentially inappropriate antidepressants in older age groups in Türkiye were compared with younger age groups. Materials and Method: All electronic prescriptions including those for antidepressants, in Türkiye, issued by family physicians in 2019 were obtained using the Prescription Information System. Data were analyzed using the Beers Criteria 2019 update. Results: Of all prescriptions, 0.63% written for older people (65 years and over) were “Potentially Inappropriate Medication” classified antidepressant medications. A significantly lower percentage of “Potentially Inappropriate Medication” classified prescriptions, was observed for older people compared to the rate of total prescriptions (30.6% vs 32%). Paroxetine and amitriptyline had the highest prescription rates for older people. Older people received significantly more “Drugs to be Used With Caution” (35.6% vs. 32%). The top five most frequently prescribed “Drugs to be Used With Caution” for older people were escitalopram, sertraline, duloxetine, citalopram, and mirtazapine. Conclusions: There was a lower rate of prescribing of “Potentially Inappropriate Medication” for older people (65 years and over) than for younger (between 18-65 years) people. This suggests that family physicians are aware of the potential inappropriateness of specific antidepressants and prescribe them less frequently. Additionally, increased prescribing of “Drugs to be Used With Caution” in elderly can be associated with the limited availability of completely safe drugs in this population. Keywords: Antidepressive Agents; Geriatrics; Potentially Inappropriate Medication List; Prescriptions.

Background and Aims:Medication errors occur at any point of the medication management process, and are a major cause of death and harm globally. The objective of this review was to compare the effectiveness of different interventions in reducing prescribing, dispensing and administration medication errors in acute medical and surgical settings.Methods:The protocol for this systematic review was registered in PROSPERO (CRD42019124587). The library databases, MEDLINE, CINAHL, EMBASE, PsycINFO, Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were searched from inception to February 2019. Studies were included if they involved testing of an intervention aimed at reducing medication errors in adult, acute medical or surgical settings. Meta-analyses were performed to examine the effectiveness of intervention types.Results:A total of 34 articles were included with 12 intervention types identified. Meta-analysis showed that prescribing errors were reduced by pharmacist-led medication reconciliation, computerised medication reconciliation, pharmacist partnership, prescriber education, medication reconciliation by trained mentors and computerised physician order entry (CPOE) as single interventions. Medication administration errors were reduced by CPOE and the use of an automated drug distribution system as single interventions. Combined interventions were also found to be effective in reducing prescribing or administration medication errors. No interventions were found to reduce dispensing error rates. Most studies were conducted at single-site hospitals, with chart review being the most common method for collecting medication error data. Clinical significance of interventions was examined in 21 studies. Since many studies were conducted in a pre–post format, future studies should include a concurrent control group.Conclusion:The systematic review identified a number of single and combined intervention types that were effective in reducing medication errors, which clinicians and policymakers could consider for implementation in medical and surgical settings. New directions for future research should examine interdisciplinary collaborative approaches comprising physicians, pharmacists and nurses.Lay summaryActivities to reduce medication errors in adult medical and surgical hospital areasIntroduction:Medication errors or mistakes may happen at any time in hospital, and they are a major reason for death and harm around the world.Objective:To compare the effectiveness of different activities in reducing medication errors occurring with prescribing, giving and supplying medications in adult medical and surgical settings in hospital.Methods:Six library databases were examined from the time they were developed to February 2019. Studies were included if they involved testing of an activity aimed at reducing medication errors in adult medical and surgical settings in hospital. Statistical analysis was used to look at the success of different types of activities.Results:A total of 34 studies were included with 12 activity types identified. Statistical analysis showed that prescribing errors were reduced by pharmacists matching medications, computers matching medications, partnerships with pharmacists, prescriber education, medication matching by trained physicians, and computerised physician order entry (CPOE). Medication-giving errors were reduced by the use of CPOE and an automated medication distribution system. The combination of different activity types were also shown to be successful in reducing prescribing or medication-giving errors. No activities were found to be successful in reducing errors relating to supplying medications. Most studies were conducted at one hospital with reviewing patient charts being the most common way for collecting information about medication errors. In 21 out of 34 articles, researchers examined the effect of activity types on patient harm caused by medication errors. Many studies did not involve the use of a control group that does not receive the activity.Conclusion:A number of activity types were shown to be successful in reducing prescribing and medication-giving errors. New directions for future research should examine activities comprising health professionals working together.

The association between polypharmacy, frailty and disability-free survival in community-dwelling healthy older individuals

Nurse PrescribingVol. 10, No. 6 Research RoundupTackling polypharmacy in older peopleMark GreenerMark GreenerSearch for more papers by this authorMark GreenerPublished Online:16 Aug 2013https://doi.org/10.12968/npre.2012.10.6.304bAboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Patterson SM, Hughes C, Kerse N, Cardwell CR, Bradley MC (2012) Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database of Systematic Reviews. 2012: CD008165 Google Scholar FiguresReferencesRelatedDetails 1 June 2012Volume 10Issue 6ISSN (print): 1479-9189ISSN (online): 2052-2924 Metrics History Published online 16 August 2013 Published in print 1 June 2012 Information© MA Healthcare LimitedPDF download

Polypharmacy, common in patients with diabetes, may cause adverse drug reactions. The number of antidiabetic and non-antidiabetic drugs prescribed to patients in different age groups remains unclear. The aim of this study was to examine the number and class of antidiabetics and non-antidiabetics prescribed to Japanese patients with diabetes, stratified by age for reducing polypharmacy. This cross-sectional study examined all prescriptions of patients prescribed antidiabetics at 257 pharmacies of Matsumotokiyoshi Holdings in Japan from May 2018 to March 2019. Total prescription numbers including antidiabetic drugs were 263,915 in this study. Mean numbers of antidiabetic drugs per prescription were 1.71, 2.17, and 1.52 in the patient age groups of 10-19, 50-59, and 90-99 years, respectively. Count of antidiabetics was not related to age. However, the mean total number of drugs prescribed increased with age, which was 2.22 and 7.99 in the age groups of 10-19 and 90-99 years, respectively. The linear regression coefficient (b) according to age was 0.07 (p < 0.001) for 10-99 years. The mean non-antidiabetic number of agents prescribed increased with age among 10-99 years (b = 0.07, p < 0.001). Among outpatients treated for diabetes, dipeptidyl peptidase-4 inhibitors (29%) and antihypertensive, β-blocking and renin-angiotensin system blocking drugs (32%) were the most prescribed antidiabetics and non-antidiabetics in all ages, respectively. The number of prescribed antidiabetic agents did not increase with age, whereas the total and non-antidiabetic numbers of medications prescribed increased linearly. For reduction of polypharmacy in older people with diabetes, we need to focus on non-antidiabetics.

The original version of this paper unfortunately contains errors, the fourth sentence of the second paragraph in the results section incorrectly reads as: “The most prevalent comorbidities were hypertension (62.0 %), hypercholesterolemia (34.4 %), arthritis (31.1 %), diabetes (27.0 %), airways diseases (26.2 %), gastrointestinal disorders (22.0 %) and coronary artery disease (17.9 %).” Where it should have read as: “The most prevalent comorbidities were hypertension (58.4 %), hypercholesterolemia (32.5 %), arthritis (29.4 %), diabetes (25.5 %), airways diseases (24.6 %), gastrointestinal disorders (22.0 %) and coronary artery disease (16.9 %).”