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Drug treatment is central in the management of most chronic conditions, leading to extensive drug use in older people. The risk of medication-related problems (MRPs), including under-prescribing, is pronounced in older people, especially among those with cognitive impairment.

The aim of the thesis was to describe cardiovascular drug treatment and to develop an intervention to improve drug treatment among older people.

Paper I and II had similar overall aims to describe cardiovascular drug use and associated factors among older people. Paper I was based on the AC2007 (n=2494) and AC2013 (n=1654) data collections comprising people 65 years and older living in nursing homes. In paper II, the study population consisted of 2186 persons from the Umeå 85+/GERDA database. The four data collections, conducted in 2000-2002, 2005-2007, 2010-2012 and 2015-2017, included very old people regardless of living conditions. The results showed increased use of guidelines-recommended drug classes for cardiovascular diseases over time. Nevertheless, older age and cognitive impairment were associated with lower use of guidelines-recommended treatment of heart failure and atrial fibrillation, indicating under-prescribing linked to these factors.

Paper III described a randomized controlled trial (RCT), where a clinical pharmacist-led follow-up programme was developed with the purpose to reduce medication-related hospital readmission among people 75 years and older in transitions of care. Among the 194 participants, for which data collection was complete, approximately 60% received all components of the follow-up programme, with a minimum deliverance of 78% of an isolated component. The mean number of identified MRPs (0.88) and discrepancies (0.42) per person were lower compared to similar studies, likely due to prior medication reviews during hospitalisation. 

In paper IV, where semi-structured interviews were conducted with nine participants from the RCT, the experiences were diverse in some respects. A few participants appreciated the help they had received and thought their treatment had improved, while others did not recall the intervention and saw limited benefit of it. Telephone follow-up was well-accepted by the majority participants, and the clinical pharmacists were considered knowledgeable with good communication skills. However, the role of the clinical pharmacist seemed unclear. 

In conclusion, the findings indicate improved adherence to treatment guidelines for cardiovascular diseases over time and increased awareness among prescribers of previously reported under-prescribing to older people. The results also suggest that clinical pharmacists could play a more active role in optimising medication treatment during transitions of care. This thesis highlights the importance of tailoring medication therapy and information to each individual.

Background: Medication-related problems (MRPs) are common during transitions of care and can lead to hospital readmissions. This patient safety issue is especially pronounced among geriatric patients. In a randomised controlled trial (RCT), the effect of a pharmacist-led follow-up programme after discharge from hospital for people ≥75 years in the north of Sweden was investigated. One of the components in the programme was telephone calls to study participants, to find and manage MRPs.

Objective: To explore study participants' views on follow-up telephone calls by a clinical pharmacist in the RCT.

Methods: Semi-structured interviews were conducted with participants who had received an intervention in the RCT. The interviews were transcribed verbatim and thematically analysed. Results: In total, nine participants were interviewed. Four main themes were generated: 1. Experiences of the telephone counselling by the clinical pharmacist, 2. Acceptability of receiving telephone follow-up from a clinical pharmacist, 3. Communication with health care providers, and 4. Medication management and views about medications.

Conclusions: The study revealed varying perceptions of the clinical pharmacists' telephone calls, with participants expressing diverse experiences and preferences regarding the service. Most participants said they considered the content relevant and comprehensible in the conversations. The effect of the follow-up programme may have improved if the role of the clinical pharmacist had been explained in more detail to the participants and if the service would have had a more person-centred focus. More research is needed regarding how to best support geriatric patients with their medication treatment in transitions of care.

Introduction: Comorbidities are common among older people, and during the last decade, a strong association between heart failure (HF) and cognitive impairment has been found. As much as 40–50% of individuals with HF will also have some degree of cognitive impairment. Previous studies report an undertreatment for some cardiovascular diseases in patients with major neurocognitive disorder (NCD).

Objective: The aim of this present study was to explore differences in pharmacological treatment of HF in individuals diagnosed with HF with or without comorbidity of major NCD.

Methods: This study combined data from three different Swedish national registers: the Swedish National Patient Register, the Swedish registry for cognitive/dementia disorders (SveDem), and the Swedish Prescribed Drug Register. A logistic regression model including variables for age, sex, major NCD, and nursing home residency was used to analyze associations between drug use and major NCD.

Results: We found a lower prevalence of filled prescriptions of renin-angiotensin system (RAS) inhibitors, β-blockers (BBs), and mineralocorticoid receptor antagonists (MRAs) among patients with major NCD. Living in a nursing home was associated with lower prevalence of RAS inhibitors, BBs, digitalis glycosides, and sodium-glucose cotransporter-2 (SGLT2) inhibitors. Females were found to have higher odds of using BBs, loop diuretics and digitalis glycosides, and lower odds of using RAS inhibitors and SGLT2 inhibitors than males.

Conclusion: Our findings indicate that there is possible undertreatment among individuals with HF identified in specialized care with co-occurring major NCD. Major NCD was associated with less filled prescriptions of basal pharmacological treatments such as RAS inhibitors, BBs, and MRAs. Future research needs to not only investigate this relationship further but also focus on reasons for the undertreatment of HF and other comorbidities within this group.

Purpose: The aim of this study was to describe a population of very old people with heart failure (HF), to analyse the use of cardiovascular drugs over time, and to explore factors influencing cardiovascular drug treatment for this group.

Methods: All participants with information regarding HF diagnosis were selected from the Umeå 85+/Gerontological Regional Database (GERDA). The people in GERDA are all ≥85 years old. Trained investigators performed structured interviews and assessments. Information regarding medications and diagnoses was obtained from the participants and from medical records. Medical diagnoses were reviewed and confirmed by an experienced geriatrician.

Results: In this very old population, the prevalence of HF was 29.6% among women and 30.7% among men. Between 2000 and 2017, there was an increase in the use of renin-angiotensin (RAS) inhibitors (odds ratio [OR] 1.107, 95% confidence interval [CI] 1.072–1.144) and beta-blockers (BBs) (OR 1.123, 95% CI 1.086–1.161) among persons with HF, whereas the prevalence of loop diuretics (OR 0.899, 95% CI 0.868–0.931) and digitalis (OR 0.864, 95% CI 0.828–0.901) decreased (p < 0.001 for all drug classes). Higher age was associated with lower use of RAS inhibitors and BBs.

Conclusion: In this HF population, the use of evidence-based medications for HF increased over time. This may be a sign of better awareness among prescribers regarding the under-prescribing of guidelines-recommended treatment to old people. Higher age associated with a lower prevalence of RAS inhibitors and BBs. This might indicate that further improvement is possible but could also represent a more cautious prescribing among frail very old individuals.

Purpose: The aim of this study was to describe changes in the pattern of cardiovascular agents used in elderly people living in nursing homes between 2007 and 2013. Further, the aim was to analyse the use of cardiovascular drugs in relation to cognitive impairment and associated factors within the same population, where prescription of loop diuretics was used as a proxy for heart failure.

Methods: Two questionnaire surveys were performed including 2494 people in 2007 and 1654 people in 2013 living in nursing homes in northern Sweden. Data were collected concerning drug use, functioning in activities of daily living (ADL) and cognition, using the Multi-Dimensional Dementia Assessment Scale (MDDAS). The use of different drugs and drug classes among people at four different levels of cognitive function in 2007 and 2013 were compared.

Results: The proportion of people prescribed ASA and diuretics was significantly lower at all four levels of cognitive function in 2013 compared to 2007. Among people prescribed loop diuretics, the use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARBs) increased from 37.8 to 45.6%, β-blockers from 36.0 to 41.8% and warfarin from 4.4 to 11.4%. The use of warfarin, ACEI/ARBs, β-blockers and mineralocorticoid receptor antagonists (MRAs) were less common among individuals with more severe cognitive impairment.

Conclusion: The results indicate that cardiovascular drug treatment has improved between 2007 and 2013, but there is room for further improvement, especially regarding adherence to guidelines for heart failure. Increasing cognitive impairment had an effect on treatment patterns for heart failure and atrial fibrillation.

Introduction: Drug-related problems (DRPs) are a major cause of unplanned hospital admissions among elderly people, and transitions of care have been emphasised as a key area for improving patient safety. We have designed a complex clinical pharmacist intervention that targets people >= 75 years of age undergoing transitions of care from hospital to home and primary care. The main objective is to investigate if the intervention can reduce the risk of unplanned drug-related readmission within the first 180 days after the person is discharged from hospital.

Methods and analysis: This is a randomised, controlled, superiority trial with two parallel arms. A total of 700 people >= 75 years will be assigned to either intervention or routine care (control). The intervention, which aims to find and manage DRPs, is initiated within a week of the person being discharged from hospital and combines repeated medical chart reviews, phone interviews and in some cases medication reviews. People in both study arms may have been the subject of a medication review during their ward stay. As the primary outcome, we will measure time until unplanned drug-related readmission within 180 days of leaving hospital and use log rank tests and Cox proportional hazard models to analyse differences between the groups. Further investigations of subgroup effects and adjustments of the regression models will be based on heart failure and cognitive impairment as prognostic factors.

Ethics and dissemination: The study has been approved by the Regional Ethical Review Board in Umea (registration numbers 2017-69-31M, 2018-83-32M and 2018-254-32M). We intend to publish the results with open access in international peer-reviewed journals and present our findings at international conferences. The trial is expected to result in more than one published article and form part of two PhD theses.