Kieran A. Walsh

Thyroid Hormone Therapy for Older Adults with Subclinical Hypothyroidism

BACKGROUND The use of levothyroxine to treat subclinical hypothyroidism is controversial. We aimed to determine whether levothyroxine provided clinical benefits in older persons with this condition. METHODS We conducted a double‐blind, randomized, placebo‐controlled, parallel‐group trial involving 737 adults who were at least 65 years of age and who had persisting subclinical hypothyroidism (thyrotropin level, 4.60 to 19.99 mIU per liter; free thyroxine level within the reference range). A total of 368 patients were assigned to receive levothyroxine (at a starting dose of 50 μg daily, or 25 μg if the body weight was <50 kg or the patient had coronary heart disease), with dose adjustment according to the thyrotropin level; 369 patients were assigned to receive placebo with mock dose adjustment. The two primary outcomes were the change in the Hypothyroid Symptoms score and Tiredness score on a thyroid‐related quality‐of‐life questionnaire at 1 year (range of each scale is 0 to 100, with higher scores indicating more symptoms or tiredness, respectively; minimum clinically important difference, 9 points). RESULTS The mean age of the patients was 74.4 years, and 396 patients (53.7%) were women. The mean (±SD) thyrotropin level was 6.40±2.01 mIU per liter at baseline; at 1 year, this level had decreased to 5.48 mIU per liter in the placebo group, as compared with 3.63 mIU per liter in the levothyroxine group (P<0.001), at a median dose of 50 μg. We found no differences in the mean change at 1 year in the Hypothyroid Symptoms score (0.2±15.3 in the placebo group and 0.2±14.4 in the levothyroxine group; between‐group difference, 0.0; 95% confidence interval [CI], ‐2.0 to 2.1) or the Tiredness score (3.2±17.7 and 3.8±18.4, respectively; between‐group difference, 0.4; 95% CI, ‐2.1 to 2.9). No beneficial effects of levothyroxine were seen on secondary‐outcome measures. There was no significant excess of serious adverse events prespecified as being of special interest. CONCLUSIONS Levothyroxine provided no apparent benefits in older persons with subclinical hypothyroidism. (Funded by European Union FP7 and others; TRUST ClinicalTrials.gov number, NCT01660126.)

The effect of pharmacist-led interventions in optimising prescribing in older adults in primary care: A systematic review

Objective: To evaluate studies of pharmacist-led interventions on potentially inappropriate prescribing among community-dwelling older adults receiving primary care to identify the components of a successful intervention. Data sources: An electronic search of the literature was conducted using the following databases from inception to December 2015: PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, MEDLINE (through Ovid), Trip, Centre for Reviews and Dissemination databases, Cochrane Database of Systematic Reviews, ISI Web of Science, ScienceDirect, ClinicalTrials.gov, metaRegister of Controlled Trials, ProQuest Dissertations & Theses Database (Theses in Great Britain, Ireland and North America). Review methods: Studies were included if they were randomised controlled trials or quasi-randomised studies involving a pharmacist-led intervention compared to usual/routine care which aimed to reduce potentially inappropriate prescribing in older adults in primary care. Methodological quality of the included studies was independently assessed. Results: A comprehensive literature search was conducted which identified 2193 studies following removal of duplicates. Five studies met the inclusion criteria. Four studies involved a pharmacist conducting a medication review and providing feedback to patients or their family physician. One randomised controlled trial evaluated the effect of a computerised tool that alerted pharmacists when elderly patients were newly prescribed potentially inappropriate medications. Four studies were associated with an improvement in prescribing appropriateness. Conclusion: Overall, this review demonstrates that pharmacist-led interventions may improve prescribing appropriateness in community-dwelling older adults. However, the quality of evidence is low. The role of a pharmacist working as part of a multidisciplinary primary care team requires further investigation to optimise prescribing in this group of patients.

Patterns of psychotropic prescribing and polypharmacy in older hospitalized patients in Ireland: the influence of dementia on prescribing.

BACKGROUND Neuropsychiatric Symptoms (NPS) are ubiquitous in dementia and are often treated pharmacologically. The objectives of this study were to describe the use of psychotropic, anti-cholinergic, and deliriogenic medications and to identify the prevalence of polypharmacy and psychotropic polypharmacy, among older hospitalized patients in Ireland, with and without dementia. METHODS All older patients (≥ 70 years old) that had elective or emergency admissions to six Irish study hospitals were eligible for inclusion in a longitudinal observational study. Of 676 eligible patients, 598 patients were recruited and diagnosed as having dementia, or not, by medical experts. These 598 patients were assessed for delirium, medication use, co-morbidity, functional ability, and nutritional status. We conducted a retrospective cross-sectional analysis of medication data on admission for 583/598 patients with complete medication data, and controlled for age, sex, and co-morbidity. RESULTS Of 149 patients diagnosed with dementia, only 53 had a previous diagnosis. At hospital admission, 458/583 patients experienced polypharmacy (≥ 5 medications). People with dementia (PwD) were significantly more likely to be prescribed at least one psychotropic medication than patients without dementia (99/147 vs. 182/436; p < 0.001). PwD were also more likely to experience psychotropic polypharmacy (≥ two psychotropics) than those without dementia (54/147 vs. 61/436; p < 0.001). There were no significant differences in the prescribing patterns of anti-cholinergics (23/147 vs. 42/436; p = 0.18) or deliriogenics (79/147 vs. 235/436; p = 0.62). CONCLUSIONS Polypharmacy and psychotropic drug use is highly prevalent in older Irish hospitalized patients, especially in PwD. Hospital admission presents an ideal time for medication reviews in PwD.

General practitioners' knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia: A mixed-methods systematic review

To synthesise the existing published literature on general practitioners (GP)s knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia (BPSD) with a view to informing future interventions.

General practitioners’ knowledge, attitudes and experiences of managing behavioural and psychological symptoms of dementia: protocol of a mixed methods systematic review and meta-ethnography

BackgroundIn the context of rising dementia prevalence, the workload of general practitioners (GPs) in dementia care is set to increase. However, there are many aspects of dementia care that GPs find challenging. Behavioural and psychological symptoms of dementia (BPSD) affect the majority of people with dementia and is an aspect of dementia care that GPs find particularly difficult to manage. The aim of this mixed methods systematic review is to undertake a synthesis of qualitative and quantitative studies on GPs’ knowledge, attitudes and experiences of managing BPSD.MethodsSeven electronic bibliographic databases will be searched from inception to present. All qualitative or quantitative studies that explore the knowledge, attitude or experiences of GPs towards the management of BPSD in community and/or residential settings will be eligible for inclusion. A meta-ethnography will be conducted to synthesise included studies. Primary outcome measures will include GPs’ experiences of managing BPSD, GPs’ knowledge of BPSD and their attitude to different approaches to the management of BPSD, in particular their attitude to non-pharmacological approaches. All included papers will be independently assessed for methodological validity by two reviewers using the following tools: the Joanna Briggs Institute checklist for qualitative research, the Effective Public Health Practice Project (EPHPP) tool for intervention studies and the National Institute of Health (NIH) quality assessment tool for observational and analytical cross-sectional studies. As there is no agreed quality assessment tool for descriptive cross-sectional studies, an original tool will be developed. Two independent reviewers will apply the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) tool to the review findings. The results will be reported in line with the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement.DiscussionThis study will be the first systematic review that synthesises the existing literature of GPs’ knowledge, attitudes and experiences of managing BPSD in community and residential care. This review will improve our understanding of GPs’ perspectives on the management of BPSD, and the results will be used to inform the development of an intervention to improve the management of BPSD in general practice.Systematic review registrationPROSPERO CRD42017054916.

Prevalence of potentially inappropriate prescribing in a subpopulation of older European clinical trial participants: a cross-sectional study.

Objectives To estimate and compare the prevalence and type of potentially inappropriate prescribing (PIP) and potential prescribing omissions (PPOs) among community-dwelling older adults (≥65 years) enrolled to a clinical trial in three European countries. Design A secondary analysis of the Thyroid Hormone Replacement for Subclinical Hypothyroidism Trial dataset. Participants A subset of 48/80 PIP and 22/34 PPOs indicators from the Screening Tool of Older Persons Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) V2 criteria were applied to prescribed medication data for 532/737 trial participants in Ireland, Switzerland and the Netherlands. Results The overall prevalence of PIP was lower in the Irish participants (8.7%) compared with the Swiss (16.7%) and Dutch (12.5%) participants (P=0.15) and was not statistically significant. The overall prevalence of PPOs was approximately one-quarter in the Swiss (25.3%) and Dutch (24%) participants and lower in the Irish (14%) participants (P=0.04) and the difference was statistically significant. The hypnotic Z-drugs were the most frequent PIP in Irish participants, (3.5%, n=4), while it was non-steroidal anti-inflammatory drug and oral anticoagulant combination, sulfonylureas with a long duration of action, and benzodiazepines (all 4.3%, n=7) in Swiss, and benzodiazepines (7.1%, n=18) in Dutch participants. The most frequent PPOs in Irish participants were vitamin D and calcium in osteoporosis (3.5%, n=4). In the Swiss and Dutch participants, they were bone antiresorptive/anabolic therapy in osteoporosis (9.9%, n=16, 8.6%, n=22) respectively. The odds of any PIP after adjusting for age, sex, multimorbidity and polypharmacy were (adjusted OR (aOR)) 3.04 (95% CI 1.33 to 6.95, P<0.01) for Swiss participants and aOR 1.74 (95% CI 0.79 to 3.85, P=0.17) for Dutch participants compared with Irish participants. The odds of any PPOs were aOR 2.48 (95% CI 1.27 to 4.85, P<0.01) for Swiss participants and aOR 2.10 (95% CI 1.11 to 3.96, P=0.02) for Dutch participants compared with Irish participants. Conclusions This study has estimated and compared the prevalence and type of PIP and PPOs among this cohort of community-dwelling older people. It demonstrated a significant difference in the prevalence of PPOs between the three populations. Further research is urgently needed into the impact of system level factors as this has important implications for patient safety, healthcare provision and economic costs.

CONCEPTUALIZING THE INFLUENCES ON DECISION-MAKING REGARDING THE PRESCRIPTION OF ANTIPSYCHOTICS TO NURSING HOME RESIDENTS WITH DEMENTIA: A META-ETHNOGRAPHY STUDY

domain, and Institute of Medicine (IOM) Domains of Quality. Results: From 10,487 unique records screened, 41 met inclusion criteria. We digitally searched the grey literature for organization websites that generated reports of quality indicators, yielding an additional 12 reports. Overall, 326 QIs (n1⁄4 266 established and n1⁄4 60 developing) were identified, including 35 (11%) structure, 212 (65%) process, and 79 (25%) outcome indicators. This included indicators categorized into Timeliness (25%), Safety (21%), Effectiveness (n1⁄424%), Patient-centeredness (19%), Efficiency (10%) and Equity (<1%). These indicators will be evaluated in two rounds of electronic surveys for relevance, feasibility, and scientific soundness using a Delphi process. This will allow expert panellists to categorize indicators into “maintain”, “consider” or “discard” groups. Conclusions:QIs provide benchmarks for monitoring and decision-making on quality improvement in healthcare systems. By identifying indicators and knowledge gaps that exist in quality measurement, policy makers, knowledge-users and researchers can collaborate to improve care for vulnerable older persons across settings.

092Staff, Volunteer and Family Experiences of Life Story Work with Residents who Have Moderate to Severe Cognitive Impairment

Background: There is some evidence to suggest that life story work is an effective intervention with people with dementia however, there is a paucity of research exploring its potential benefits from a staff and family perspective in the Republic of Ireland. The aim of this study is to explore the experience of staff, volunteers and family members of residents involved in life story work. Additionally, the study aims to gather data that will inform the future approach to life story work in the residential care service and support the continuation of the life story books as part of usual care. Methods: The research was conducted following recent implementation of life story books for people with moderate to severe cognitive impairment in a residential care setting in Ireland. A qualitative research design was employed using a constructivist approach. Focus groups were the primary data collection tool. Results: Separate focus groups were completed with three groups of participants: staff across four wards (N = 24; 4 focus groups), volunteers (N = 5) and family members (N = 5). All groups perceived benefits to life story work. Consistent themes emerged: remembering the person (humanising the person; knowing the person better), communication and engagement (more meaningful conversations; enjoyable to share the moment; demonstrating that staff cared) and observed resident responses (“face lights up”; calming effect). Participants also gave feedback that will inform the approach in practice, such as updating books to promote resident interest. Conclusion: This qualitative study contributes to the evolving literature on life story work for people with dementia and should support the continuation of life story work in this setting. Although it is difficult to generalise these findings, this research study suggests that life story work could be beneficial for similar populations in residential care. Further research is required to explore the resident perspective.

208Ageing in Diverse Urban Neighbourhoods: Social Exclusion and Life-Course Relationships with Place

Background: Dominant urban settlement patterns mean that questions about enhancing multidimensional social inclusion across the life course need to be explored in the context of urban neighbourhoods. There is a growing body of evidence that place of residence impacts on participation in a range of different areas of life, and subsequently on different forms of health and well-being. Less, however, is known about how placed-based mechanisms either protect against or intensify experiences of exclusion. Further, an understanding of how these mechanisms interact with key events in people’s lives is largely unknown, as is what this interaction might mean for people at different life stages and different social locations. In this paper, we investigate how characteristics of urban settings combine with life-course experiences and positions to construct inclusion and exclusion for children and youth, older people and people with disabilities. Methods: This paper draws on data from the 3-Cities Project which used an explorative participatory approach and focused on six different kinds of neighbourhoods across Dublin, Galway and Limerick. Analysis is based on life-course and go-along interviews with children and youth, older people and people with disabilities. Results: Life-course transitions are embedded in, and influenced by, the neighbourhoods in which people live. As such, changes in neighbourhoods, such as demographic, social and economic shifts, and changes in the lives of children and youth, older people and people with disabilities combine to shape group and cross-group needs. Findings point to different mechanisms within neighbourhoods that can determine the degree to which experiences/transitions impact on the lives of children and youth, older people and people with disabilities. Conclusions: A holistic idea of participation and a fuller assessment of how people live their lives within their neighbourhoods and cities needs to be embraced for children and youth, older people and people with disabilities.