Kristin M. Zimmerman

Risk versus risk: a review of benzodiazepine reduction in older adults

Introduction: Benzodiazepines (BZD) are potentially inappropriate for older adults, yet their use persists. Patients and providers may hesitate to discontinue BZDs due to concerns for withdrawal or relapse. We reviewed the literature for BZD reduction protocols to examine common elements, safety and efficacy. A framework is proposed for clinicians to address BZD reduction challenges. Areas covered: Following a systematic literature review, this analysis included 28 studies of older out-patients tapering chronic BZDs. Populations included insomnia, depression and anxiety. Protocols included taper alone (32%), taper plus cognitive behavioral therapy (32%) and taper plus medication substitution (36%). Success rates were favorable for all modalities (mean 60%, median 67%, range 25 – 85%) and independent of dose or duration of use. Common schedules included a 25% dose reduction over 1 – 2 weeks until drug-free. Withdrawal symptoms included mainly mild psychological and somatic concerns. No serious safety events were reported. Expert opinion: BZD reduction protocols among older adults are feasible and successful. Given unique cognitive and functional abilities and comorbidities of older adults, a patient-centered approach to reduction is needed. Our framework guides clinicians in planning and persisting with BZD reduction, while our checklist addresses tailored tapers. Monitoring and support is emphasized, and taper modifications are proposed for struggling patients.

Complexity perplexity: a systematic review to describe the measurement of medication regimen complexity

Introduction: Complex medication regimens are error prone and challenging for patients, which may impact medication adherence and safety. No universal method to assess the complexity of medication regimens (CMRx) exists. The authors aim to review literature for CMRx measurements to establish consistencies and, secondarily, describe CMRx impact on healthcare outcomes. Areas covered: A search of EMBASE and PubMed for studies analyzing at least two medications and complexity components, among those self-managing medications, was conducted. Out of 1204 abstracts, 38 studies were included in the final sample. The majority (74%) of studies used one of five validated CMRx scales; their components and scoring were compared. Expert opinion: Universal CMRx assessment is needed to identify and reduce complex regimens, and, thus, improve safety. The authors highlight commonalities among five scales to help build consensus. Common components (i.e., regimen factors) included dosing frequency, units per dose, and non-oral routes. Elements (e.g., twice daily) of these components (e.g., dosing frequency) and scoring varied. Patient-specific factors (e.g., dexterity, cognition) were not addressed, which is a shortcoming of current scales and a challenge for future scales. As CMRx has important outcomes, notably adherence and healthcare utilization, a standardized tool has potential for far-reaching clinical, research, and patient-safety impact.

Increasing anticholinergic burden and delirium in palliative care inpatients

Background: Delirium may complicate the hospital course and adversely impact remaining quality of life for palliative care inpatients. Medications with anticholinergic properties have been linked to delirium within elderly populations via serum anticholinergic assays. Aim: The aim of this study is to determine whether increasing anticholinergic burden, as measured using a clinical assessment tool, is associated with an increase in delirium among palliative care inpatients. Design: This study was completed as a retrospective, case-control study. Setting/participants: Veterans admitted to the Veterans Affairs Boston Healthcare System and consulted to the palliative care service were considered for inclusion. Increase in anticholinergic burden from admission through hospital day 14 was assessed using the Anticholinergic Risk Scale. Presence of delirium was determined by use of a validated chart review instrument. Results: A total of 217 patients were analyzed, with a mean age of 72.9 (±12.8) years. The overall delirium rate was 31% (n = 67). Patients with an increase in Anticholinergic Risk Scale (n = 72 (33%)) were 40% more likely to experience delirium (odds ratio = 1.44, 95% confidence interval = 1.07–1.94) compared to those without increase (n = 145 (67%)). After adjustment for age, brain metastasis, intensive care unit admission, illness severity, opiate use, and admission Anticholinergic Risk Scale using multivariable modeling, delirium risk remained significantly higher in patients with an Anticholinergic Risk Scale increase compared to those without increase (adjusted odds ratio = 1.43, 95% confidence interval = 1.04–1.94). Conclusion: An increase in Anticholinergic Risk Scale from admission was associated with delirium in palliative care inpatients. While additional study is needed, anticholinergic burden should be increased cautiously in palliative inpatients, and those with increases should be closely followed for delirium.

Improving delirium care: prevention, monitoring, and assessment.

Delirium is an acute change in awareness and attention and is common, morbid, and costly for patients and health care systems. While hyperactive delirium is easily identifiable, the hypoactive form is more common and carries a higher mortality. Hospital systems to address delirium should consist of 3 critical steps. First, hospitals must identify patients who develop or are at intermediate or high risk for delirium. Delirium risk may be assessed using known patient-based and illness-based risk factors, including preexisting cognitive impairment. Delirium diagnosis remains a clinical diagnosis that requires a clinical assessment that can be structured using diagnostic criteria. Hospital systems may be useful to efficiently allocate delirium resources to prevent and manage delirium. Second, it is crucial to develop a systematic approach to prevent delirium using multimodal nonpharmacologic delirium prevention methods and to monitor all high-risk patients for its occurrence. Tools such as the modified Richmond Agitation and Sedation Scale can aid in monitoring for changes in mental status that could indicate the development of delirium. Third, hospital systems can utilize established methods to assess and manage delirium in a standardized fashion. The key lies in addressing the underlying cause/causes of delirium, which often involve medical conditions or medications. With a sustained commitment, standardized efforts to identify and prevent delirium can mitigate the long-term morbidity associated with this acute change. In the face of changes in health care funding, delirium serves as an example of a syndrome where care coordination can improve short-term and long-term costs.

Delirium in Palliative Care Patients: Focus on Pharmacotherapy

Patients receiving palliative care often possess multiple risk factors and predisposing conditions for delirium. The impact of delirium on patient care in this population may also be far-reaching: affecting not only quality of remaining life but the dying process experienced by patients, caregivers, and the medical team as well. As palliative care focuses on comfort and symptom management, the approach to assessment and subsequent treatment of delirium in palliative care patients may prove difficult for providers to navigate. This article summarizes the multifactorial nature, numerous predisposing medical risk factors, neuropsychiatric adverse effects of palliative medications, pharmacokinetic changes, and challenges complicating delirium assessment and provides a systematic framework for assessment. The benefits, risks, and patient-specific considerations for treatment selection are also discussed.

Medication Complexity, Medication Number, and Their Relationships to Medication Discrepancies

Background: Medication reconciliation to identify discrepancies is a National Patient Safety Goal. Increasing medication number and complex medication regimens are associated with discrepancies, nonadherence, and adverse events. The Medication Regimen Complexity Index (MRCI) integrates information about dosage form, dosing frequency, and additional directions. Objective: This study evaluates the association of MRCI scores and medication number with medication discrepancies and commissions, a discrepancy subtype. Methods: This was a retrospective cohort study of a convenience sample of 104 ambulatory care patients seen from April 2010 to July 2011 within the Department of Veterans Affairs. Primary outcomes included any medication discrepancy and commissions. Primary exposures included MRCI scores and medication number. Multivariable logistic regression models associated MRCI scores and medication number with discrepancies. Receiver operating characteristic (ROC) curves provided discrepancy thresholds. Results: For the 104 patients analyzed, the median MRCI score was 25 (interquartile range [IQR] = 14-43), and the median medication number was 8 (IQR = 5-13); 60% of patients had any discrepancy, whereas 36% had a commission. In adjusted analyses, patients with MRCI scores ≥25 or medication number ≥8 were more likely to have commissions (odds ratio [OR] = 3.64, 95% CI = 1.41-9.41; OR = 4.51, 95% CI = 1.73-11.73, respectively). The unadjusted ROC threshold for commissions was 36 for MRCI (sensitivity, 59%; specificity, 82%) and 9 for medication number (sensitivity 68%; specificity 67%). Conclusion: Patients with either MRCI scores ≥25 or ≥8 medications were more likely to have commissions. Given equal performance in predicting discrepancies, the efficiency and simplicity of medication number supports its use in identifying patients for intensive medication review beyond medication reconciliation.

A Prescription for Prescribing: Ensuring Continued Pharmacist Preparedness:

The scope of practice for pharmacists in the United States increasingly includes elements of prescribing under collaborative practice agreements and statewide protocols. However, as a result of continued health care access concerns, we believe that pharmacists will be called on to serve as independent prescribers in the future. For this anticipated practice expansion to become a successful reality, the assurance of pharmacist preparedness and continuous professional development through profession-wide standards will be imperative.

Provider and System-Level Barriers to Deprescribing: Interconnected Problems and Solutions

Driven by an ambition to provide high-quality care, the U. S. healthcare system is focused on safe and appropriate medication use. With an aging population and a high rate of multimorbidity, there has been a concomitant rise in polypharmacy, often defined as five or more medications (Anderson, 2010). Polypharmacy has steadily and significantly risen over the past decade (Kantor, Rehm, Haas, Chan, & Giovannucci, 2015), and potentially inappropriate medications (PIMs) may be seen in up to 79% of older adults (Hill-Taylor et al., 2013). Categories of PIMs include unwarranted medicationrelated risks, low likelihood of benefit, or treatment misaligned with patients’ goals of care. Polypharmacy and PIMs are each associated with negative health outcomes, including reduced quality of life and increased risk of falls, hospitalizations, and mortality (Reeve, Thompson, & Farrell, 2017). One mechanism by which exposure to polypharmacy and PIMs can be reduced is deprescribing. Deprescribing has been defined as the “systematic process of identifying and discontinuing drugs when existing or potential harms outweigh existing or potential benefits within the context of an individual patient’s care goals, functional status, life expectancy, values, and preferences” (p. 827) (Scott et al., 2015). Deprescribing has been shown to be generally safe and effective. Additionally, in a consumer-driven (i.e., patient-driven) healthcare system, many patients prefer fewer medicines (Linsky, Simon, & Bokhour, 2015). Defining deprescribing as a process highlights the challenges to proactive, intentional discontinuation. There are patient-, provider-, and system-level barriers to deprescribing, many of which are interconnected. Therefore, innovations and initiatives to address these barriers will frequently require a multi-level approach. While patientlevel barriers are important to address—especially given that patient involvement has been identified as a key component of successful deprescribing interventions (Reeve et al., 2017)—they are not the sole barriers to safe medication use. Herein, we explore the barriers and opportunities to improve deprescribing at both the provider and system levels.

Medication Reconciliation vs Medication Review

In Reply Dr Colloff correctly points out that moving high-cost patients from private exchanges to Medicare would save money immediately for the federal government, but potentially at the expense of hospitals and physicians. The alternatives currently being debated in Congress to replace the Affordable Care Act, however, would be far worse. With 22 million newly uninsured people seeking health care under the bill recently considered by the Senate,1 hospitals and physicians would be faced with treating uninsured patients who cannot pay anything. Under that alternative, the relatively generous Medicare reimbursements, especially for the more profitable medical procedures,2 would be far more appealing.

Antipsychotic prescription to identify delirium: results from two cohorts

Objectives Detection of delirium in hospitalized patients remains challenging. The objective was to determine if the prescription of antipsychotic medications was associated with delirium. Patients and methods Two patient cohorts were utilized from a tertiary Veterans Affairs hospital: a palliative care retrospective cohort and a prospective medical cohort. Patients prescribed outpatient antipsychotics were excluded. Retrospectively, delirium was identified using a validated medical record-review instrument. Prospectively, a clinical expert assessed patients for delirium daily using a standardized interview. Acute antipsychotic medication administration was recorded from the electronic medical record. Results In the retrospective cohort (n=217), delirium was found in 31% (n=67) and antipsychotic use in 18% (n=40) of patients. Acute antipsychotic use indicated delirium with 54% sensitivity and 97% specificity. In the prospective cohort (n=100), delirium developed in 23% (n=23) and antipsychotics were used in 5% (n=5) of patients. The sensitivity and specificity of acute antipsychotic use was 22% and 100%, respectively. Conclusion Hospitalized patients who are acutely prescribed antipsychotics are likely to have delirium, but not all patients with delirium will be identified with this method. In health systems, utilization of the prescription of acute antipsychotics can be an efficient and specific method to identify delirious patients for targeted intervention.