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Medication-related problems and psychotropic drug use in vulnerable older populations: a focus on acute hospital admissions and cognitive impairment
Umeå universitet, Medicinska fakulteten, Institutionen för integrativ medicinsk biologi (IMB).ORCID-id: 0000-0002-9422-5125
2023 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)Alternativ titel
Läkemedelsrelaterade problem och användning av psykofarmaka i populationer av sårbara äldre personer, med fokus på akuta sjukhusinläggningar och kognitiv nedsättning (Svenska)
Abstract [en]

The ageing process involves several physiological changes that affect both pharmacodynamics and pharmacokinetics and that, in combination with a heavier disease burden and more extensive use of medicines, put older people at higher risk of medication-related problems and associated clinical outcomes. The older population is often treated as a homogenous group, when in fact there are factors that render certain individuals more vulnerable to adverse drug effects and other types of medication-related problems. Older people encountered in the acute medical care setting and/or individuals with varying degrees of cognitive impairment are especially vulnerable in that context. 

The overall aim of this thesis was to describe and understand medication use in certain vulnerable subgroups of older people, which in turn might identify suitable target populations in which medication-related problems can be prevented or managed through interventions or similar efforts.

Paper I presented, in the form of a study protocol, a clinical pharmacist intervention intended to reduce the risk of medication-related readmission to hospital among people aged 75 years or older during transitions of care. Based on 300 participants from the intervention study, approximately 50% had been readmitted to hospital within 180 days of being discharged from the hospital. Both heart failure and cognitive impairment, the latter identified through a four-item test, were predictors of early readmission. Altogether, the study population seems relevant for the purpose of the intervention; whether the intervention model is effective remains to be determined.

Based on the same sample of study participants, paper II found that approximately one third of the 300 index hospital admissions were possibly medication related. Moreover, possibly medication-related hospital admissions were negatively associated with the fewest positive/correct answers on the four-item screening tool for cognitive impairment, which suggests that those clinical events might be less prevalent among people with cognitive impairment when exploring the association cross-sectionally. 

Both papers III and IV were registry-based studies, and their overall objective can be summarized as to describe psychotropic drug use and associated factors among older people with major neurocognitive disorder (NCD). Paper III focused on differences between major NCD subtypes, whereas paper IV compared people with major NCD against matched references from the total older population. 

In brief, overall psychotropic drug use was notably higher among people with major NCD, although generally in line with national treatment guidelines in terms of individual drugs of choice. The use of hypnotic drugs was also extensive in the reference group, and deprescribing efforts seem warranted, although longitudinal studies that focus on long-term use could provide a better picture of the potential problem. 

Nursing home stay was also positively associated with psychotropic drug use for all classes of psychotropic drugs, and the difference was most prominent for antipsychotic drugs. In that context, over 1,200 people in the reference population, most of them nursing home residents, had filled prescriptions for antipsychotic drugs, a figure indicating that the management of neuropsychiatric symptoms might also be an issue among older people who, due to various circumstances, have not been examined and diagnosed with neurocognitive disorders. 

Regarding major NCD subtypes, individuals with Lewy body dementia had, except for antidementia drugs, higher odds of psychotropic drug use than did those with Alzheimer’s disease. For example, the odds of antipsychotic drug use were more than twice as high, which is a worrying figure given that people with Lewy body dementia are extremely sensitive to the adverse effects of those specific drugs.

In conclusion, this thesis illustrates the heterogeneity of demographics and drug use among older people and indicates that certain types of medication-related problems may be more relevant in certain older subpopulations. Medicines appear to be involved in many hospital admissions of older people, and the acute medical setting and subsequent care transitions are likely an important focus of pharmaceutical interventions. However, psychotropic drugs are probably not a major issue in that specific context. Efforts to reduce psychotropic drug use are likely more relevant to people with major NCD, especially in the nursing home setting. Antipsychotic drug exposure among persons with Lewy body dementia could be one such focus, especially since there are other better-balanced pharmacological treatment options for these individuals in terms of efficacy and safety profile.

Ort, förlag, år, upplaga, sidor
Umeå: Umeå University , 2023. , s. 102
Serie
Umeå University medical dissertations, ISSN 0346-6612 ; 2258
Nyckelord [en]
older people, cognitive impairment, medication-related problems, psychotropic drugs
Nationell ämneskategori
Geriatrik
Forskningsämne
klinisk farmakologi
Identifikatorer
URN: urn:nbn:se:umu:diva-214658ISBN: 9789180701389 (tryckt)ISBN: 9789180701396 (digital)OAI: oai:DiVA.org:umu-214658DiVA, id: diva2:1799777
Disputation
2023-10-20, BIO.A.206 – Aula Anatomica, Biologihuset, Johan Bures väg 12, Umeå, 09:00 (Svenska)
Opponent
Handledare
Tillgänglig från: 2023-09-29 Skapad: 2023-09-24 Senast uppdaterad: 2023-09-25Bibliografiskt granskad
Delarbeten
1. Investigating the effect of clinical pharmacist intervention in transitions of care on drug-related hospital readmissions among the elderly: study protocol for a randomised controlled trial
Öppna denna publikation i ny flik eller fönster >>Investigating the effect of clinical pharmacist intervention in transitions of care on drug-related hospital readmissions among the elderly: study protocol for a randomised controlled trial
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2020 (Engelska)Ingår i: BMJ Open, E-ISSN 2044-6055, Vol. 10, nr 4, artikel-id e036650Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

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.

Ort, förlag, år, upplaga, sidor
BMJ Publishing Group Ltd, 2020
Nationell ämneskategori
Hälso- och sjukvårdsorganisation, hälsopolitik och hälsoekonomi Geriatrik
Identifikatorer
urn:nbn:se:umu:diva-172828 (URN)10.1136/bmjopen-2019-036650 (DOI)000538150800125 ()32345700 (PubMedID)2-s2.0-85084170223 (Scopus ID)
Tillgänglig från: 2020-06-29 Skapad: 2020-06-29 Senast uppdaterad: 2023-09-24Bibliografiskt granskad
2. Exploring medication-related hospital admissions and their association with cognitive impairment among acutely admitted older people
Öppna denna publikation i ny flik eller fönster >>Exploring medication-related hospital admissions and their association with cognitive impairment among acutely admitted older people
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2023 (Engelska)Ingår i: Research in Social and Administrative Pharmacy, ISSN 1551-7411, E-ISSN 1934-8150, Vol. 19, nr 7, s. 1048-1053Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Introduction: Medication-related hospital admissions (MRAs) are common among older people. Persons with cognitive impairment are especially vulnerable to adverse drug effects. At the same time, increased home health care and social support could theoretically prevent medication-related problems. This study aims to estimate the proportion of MRAs and explore their relationship with cognitive impairment in a population of acutely admitted older people.

Methods: This cross-sectional study comprised 300 individuals aged 75 years or older admitted to an acute medical ward. Two assessors identified possibly MRAs using the Assessment Tool for Hospital Admissions Related to Medications 10 (AT-HARM10). Screening for cognitive impairment was performed during ward stay using a 4-item test related to time orientation. Prevalence odds ratios between cognitive test scores and MRAs were analysed through logistic regression.

Results: Using AT-HARM10, 108 out of 300 admissions (36%) were classified as possibly MRAs by both assessors. Moreover, MRAs were least common among patients with the lowest cognitive test scores. There was an association regarding MRAs when the lowest test score was treated as a cut-off and compared against a reference category comprising all other scores (OR, 0.31 [95% CI 0.10–0.93]; p = 0.037) in a logistic regression model adjusted for cohabitation and home health care.

Conclusion: Approximately one-third of the hospital admissions among acutely admitted older people were considered at least possibly medication-related. Hence, there is still a great need to manage medication-related problems and reduce MRAs in this vulnerable population. Using a 4-item instrument to screen for cognitive impairment, there was a negative association between MRA and lowest cognitive test score. Further exploration of the relationship between MRAs and cognitive impairment may indicate appropriate components and target populations for interventions that aims to reduce the risk of MRA.

Ort, förlag, år, upplaga, sidor
Elsevier, 2023
Nyckelord
Cognitive impairment, Hospital admissions, Medication-related problems, Older people
Nationell ämneskategori
Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi Geriatrik
Identifikatorer
urn:nbn:se:umu:diva-207881 (URN)10.1016/j.sapharm.2023.04.117 (DOI)001001988900001 ()37105774 (PubMedID)2-s2.0-85153801441 (Scopus ID)
Forskningsfinansiär
Vetenskapsrådet, 2019-01078Forte, Forskningsrådet för hälsa, arbetsliv och välfärd, 2017-01438Region Västerbotten
Tillgänglig från: 2023-05-09 Skapad: 2023-05-09 Senast uppdaterad: 2023-09-24Bibliografiskt granskad
3. Psychotropic drug use among older people with major neurocognitive disorder: a cross-sectional study based on Swedish national registries
Öppna denna publikation i ny flik eller fönster >>Psychotropic drug use among older people with major neurocognitive disorder: a cross-sectional study based on Swedish national registries
2022 (Engelska)Ingår i: European Journal of Clinical Pharmacology, ISSN 0031-6970, E-ISSN 1432-1041, Vol. 78, nr 3, s. 477-487Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Aim: Psychotropic medications include many drugs that may be inappropriate for older individuals with cognitive impairment. In Sweden, many people become registered in the Swedish Dementia Registry when they are diagnosed with major neurocognitive disorder (NCD). In this study, we aim to describe psychotropic drug use and associated factors among older Swedish people with major NCD.

Methods: This study included 38,251 people ≥ 65 years from the Swedish registry for cognitive/dementia disorders diagnosed during 2007–2017. Drug use was defined as one or more filled prescription(s) recorded in the Swedish Prescribed Drug Register during 1 July to 31 December 2017. Associations between psychotropics and age, sex, diagnosis date, Mini-Mental State Examination score and major NCD subtype were analysed through multiple logistic regression.

Results: We found that 12.0% of the individuals filled at least one prescription for antipsychotics, 22.0% for anxiolytics, 23.0% for sedatives or hypnotics, 43.2% for antidepressants and 56.7% for antidementia drugs. In brief, psychotropic use was associated with female sex, higher age, longer time since diagnosis and specific subtypes of major NCD; the strongest association was found between antipsychotics and Lewy body dementia (odds ratio 2.40, 95% confidence interval 2.04–2.82).

Conclusion: Psychotropic drugs were frequently dispensed among older Swedish people with major NCD. The use of antipsychotics and medications with sedative properties warrants concern, especially among those with Lewy body dementia who are severely sensitive to antipsychotics. A more restrictive prescribing pattern regarding these medications might reduce the risk of drug-related problems in this vulnerable group of people.

Ort, förlag, år, upplaga, sidor
Springer, 2022
Nyckelord
Drug utilization, Neurocognitive disorders, Older people, Psychotropic drugs
Nationell ämneskategori
Geriatrik
Identifikatorer
urn:nbn:se:umu:diva-189581 (URN)10.1007/s00228-021-03241-7 (DOI)000714506200001 ()34738182 (PubMedID)2-s2.0-85118537901 (Scopus ID)
Tillgänglig från: 2021-11-16 Skapad: 2021-11-16 Senast uppdaterad: 2023-09-25Bibliografiskt granskad
4. Psychotropic drugs among older people in relation to major neurocognitive disorder and nursing home residency: a comparative registry-based study
Öppna denna publikation i ny flik eller fönster >>Psychotropic drugs among older people in relation to major neurocognitive disorder and nursing home residency: a comparative registry-based study
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(Engelska)Manuskript (preprint) (Övrigt vetenskapligt)
Nationell ämneskategori
Geriatrik
Identifikatorer
urn:nbn:se:umu:diva-214657 (URN)
Anmärkning

Alternative title: Psychotropic drug use among older people in relation to major neurocognitive disorder and nursing home residency: a comparative registry-based study

Tillgänglig från: 2023-09-22 Skapad: 2023-09-22 Senast uppdaterad: 2023-09-25

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