Optimising prescribing in older people with dementia

Abstract

BackgroundWhile pharmacotherapy in older people has some clear-cut benefits, it has the potential to provide significant harms. Older people with dementia, specifically, are at a higher risk of medication harms than those without the disease. The reasons for this are complex and include multiple morbidities and the consequent prescription of multiple medications, changes in pharmacokinetic and pharmacodynamics, and gaps in evidence. Optimising medication prescribing in older people with dementia is an important yet challenging process. Different interventions can be used to reduce inappropriate prescribing, but evidence supporting successful interventions to optimise medication use among older people with dementia is lacking. Using novel ways of delivering health services, such as telehealth, may have a role in improving medication prescribing in older people, including those living with dementia.AimThe overall aim was to examine potential ways to optimise prescribing in older people, with a particular focus on people with dementia and on telehealth interventions.Methods and ResultsA series of review and research studies were conducted to achieve the aim. First, in a descriptive study, the patterns of medication prescribing of 720 residents of Australian residential aged care facilities (RACFs) were investigated based on their cognitive status (Chapter 2). High prevalence of polypharmacy, and high rates of anticholinergic/sedative medications and potentially inappropriate medications (PIMs) use showed the presence of suboptimal prescribing in RACF residents, including those with impaired cognition. This study highlighted the need for effective interventions to tackle this problem.In Chapter 3, to summarise the evidence around the available interventions for optimising prescribing in older people with dementia, a systematic review was conducted. Eighteen studies were identified but because of the low quality of the evidence and variability in interventions and outcomes, no robust conclusion could be made. There was some evidence for the possible effects of interventions on medication appropriateness, but weak evidence for their effects on clinical outcomes. Overall, this review showed that the evidence to support interventions to optimise prescribing in older people with dementia is relatively sparse.In Chapter 4, because of the focus of this Thesis on telehealth to deliver strategies for medication optimisation, a scoping review of the literature on telehealth medication reviews was performed. This review aimed to examine the evidence on the use and impact of these interventions and identified 29 studies reporting on them. It concluded that telehealth medication reviews seem to be feasible, and to have potential positive impact on medication and clinical outcomes and cost. However, the need for more rigorous evidence on reliability, safety and cost of these interventions was also identified.One of the interventions to optimise prescribing in older people is comprehensive geriatric assessment (CGA). In Chapter 5, the effects of CGA interventions delivered via telehealth on medication appropriateness in a group of RACF residents with high rates of dementia and cognitive impairment were evaluated. This involved a secondary analysis of data from a cluster-randomised controlled trial (RCT) conducted to examine the effect of this intervention on external health services use by 413 residents. The intervention, however, showed no effect on medication appropriateness measured by the use of anticholinergic/sedative medications and PIMs.In Chapter 6, based on the assumption that collaborative medication reviews might produce better outcomes, a new telehealth model was proposed and tested. Through a mixed methods study, the telehealth platform was tested for delivering residential medication reviews by pharmacists to enable collaboration of pharmacists and geriatricians. The tested telehealth platform showed the potential of being used in routine practice to improve accessibility of the service and to enable collaboration among healthcare professionals. Bringing together the expertise of pharmacists and geriatricians, this model may have the potential to improve appropriateness of prescribing in residents with dementia.The final study aimed to explore if improvement in medication appropriateness, which often is the main goal of interventions to optimise prescribing, can translate to more meaningful outcomes for older people with dementia (Chapter 7). This study used the data from the aforementioned cluster-RCT and looked at the associations between change in medication appropriateness (using the Drug Burden Index (DBI)) and clinical outcomes including cognitive and daily functions, hospitalisation and mortality. An increase in the DBI was associated with a significant deterioration in cognitive function. The findings of this study highlighted the need for further research on improvement in medication appropriateness and associated clinical outcomes.ConclusionWith an aim to explore potential ways to optimise prescribing in older people with dementia, this Thesis synthesised the evidence around the available interventions for this purpose, reviewed the literature on telehealth medication reviews, evaluated two telehealth strategies and investigated if improved prescribing appropriateness can translate to improved health outcomes. The findings increased our understanding of medication safety in older people with dementia and provided opportunities for future research, which may ultimately lead to improved care for older people.