Maarten Wauters

Polypharmacy in a Belgian cohort of community-dwelling oldest old (80+)

Abstract Objectives: Polypharmacy is highly prevalent among older people (65+), but little is known on the medication use of the oldest old (80+). This study explores the medication use of the Belgian community-dwelling oldest old in relation to their demographic, clinical and functional characteristics. Methods: Baseline data was used from the BELFRAIL study; a prospective, observational population-based cohort of Belgian community-dwelling patients (80+). General practitioners recorded clinical problems and medications. Medications were coded by the Anatomic Therapeutic Chemical classification. Results: Participants’ (n = 503) mean age was 84.4 years (range 80–102) and 61.2% was female. Median chronic medication use was 5 (range 0–16). Polypharmacy (≥5 medications) was high (57.7%), with excessive polypharmacy (≥10 medications) in 9.1%. Most commonly used medication group were antithrombotics, but also benzodiazepines and antidepressants were frequently consumed. Demographics related to polypharmacy (univariate analysis) were female gender, low education and moderate alcohol use. Age, care dependency and cognitive impairment showed no association with polypharmacy. In multivariate analysis, the predominant association with polypharmacy was found for multimorbidity (OR 1.78, 95% CI 1.5–2.1), followed by depression (OR 3.7, 95% CI 4.4–9.7) and physical activity (OR 0.8, 95% CI 0.7–0.9). Conclusions: Polypharmacy was high among Belgian community-dwelling oldest old (80+). Determinants of polypharmacy were interrelated, but dominated by multimorbidity. On top of the burden of multimorbidity, polypharmacy was independently associated with less physical activity, and with depressive symptoms.

A quality improvement initiative on the use of psychotropic drugs in nursing homes in Flanders

Introduction: Government-funded quality improvement projects aimed to reduce the high psychotropic medication use in Belgian long-term care settings. Design: A pilot project (2013–2014) with a pre–post and follow-up intervention design. Methods: Two nursing homes received three educational courses. In the intervention nursing home (INH) additionally, a transition towards person-centred care through professional support was applied. Drug use was recorded at baseline, after 10 months (post) and after 22 months (follow-up), and coded into the Anatomical Therapeutic Chemical classification. Results: At baseline, the INH residents’ (n = 118) mean age at baseline was 82 years, with 71% females. The control nursing home residents’ (CNH, n = 275) mean age was 82.7 years, with 75% females. At baseline, mean drug use was 9 (range 1–21) and 8 (range 0–20), predominantly with a high proportion of psychotropic drug users of 73 and 65%, in INH and CNH respectively. At the time of post-measurement, only the proportion of hypno-sedative users decreased significantly in the INH (by 13%, p = 0.048). No significant changes were found in the CNH. At time of the follow-up, the proportion of hypno-sedative (51% vs. 31%; p = 0.005) and antidepressant users (42% vs. 25%, p = 0.007) decreased significantly in the INH. The decrease of antipsychotic drug users was less distinct. In the CNH, the proportion of hypno-sedative, antidepressant and overall psychotropic drug users did not change significantly. Conclusion: This quality improvement initiative led to a significant decrease in the use of psychotropic drugs in the INH, even after 1-year follow-up. Education only had a limited effect.

Availability and actual use in the Belgian market of potentially inappropriate medications (PIMs) from the EU(7)-PIM list

Inappropriate prescribing puts older adults (≥65 years) at risk for adverse drug reactions [1]. Recently, a European list of potentially inappropriate medications (PIMs) was developed, the EU(7)-PIM list [2]. Experts from the seven participating countries (EE, NL, FI, ES, FR, SE, DE) screened their medication market for PIMs, using existing lists of explicit criteria [1, 3–5]. The experts developed the EU(7)-PIM list using a two-round Delphi panel. See Annex 1 for more details on the development and content. Our first aim was to check the Belgian market on the availability of potentially inappropriate medications as listed in the EU(7)-PIM list. Second, we studied the actual use of PIM products in a cohort of oldest old (≥80 years). To check the availability, we cross-referenced the official register of medications in Belgium (coded in Anatomical Therapeutic Chemical (ATC)) to the EU(7)-PIM list. Of the 275 active substances in the EU(7)-PIM list, 157 were available in Belgium. Of those, 139 products were only available on prescription. The seven medication classes in the EU(7)PIM list contain a total of 60 active substances in the ATC classification, of which 21 were available in Belgium (three antacid combinations and complexes, five proton-pump inhibitors, two iron supplements, four estrogens, and seven triptanes). The medication classes of antacids containing aluminium compounds, and quinine and derivates, were not available in Belgium as registered medications. To check the actual use of PIM products, we used the Belfrail-MED cohort of 503 Belgian community-dwelling oldest old (≥80 years, range 80–102 years) [6, 7]. See Annex 2 for more background on the Belfrail-Med cohort. For this, all prescribed, chronic medications with systemic action in this population were recorded, coded into ATC, and crossreferenced to the EU(7)-PIM list. In the oldest old, the mean number of medications was 5.4 (range 0–16). Of the possible 157 PIM products in Belgium, 77 were identified in this cohort. All five available medication classes were identified as well. In this cohort, 72.8 % of patients took at least one PIM product. Lorazepam was the most prescribed PIM product (10.7 % of patients) and proton pump inhibitors the most prescribed medication class (17.3 % of patients). See Annex 3 for background on the PIMs identified in Belgium. While scanning the Belgian medication market, we identified a few other potentially inappropriate medications, not considered in the EU(7)-PIM list, because possibly not available in the participating countries. See Annex 4 for possible additions to the EU(7)-PIM list. Also, PIM products available in combination products should be discussed. For instance, loperamide (A07DA03) is listed as a PIM product, but the combination of loperamide in the same dose with simethicone (A07DA53) is not. For the Belgian situation, there are 61 combinations containing a PIM product (see Annex 3). We encourage other European countries, not (yet) participating in the EU(7)-PIM list, to repeat this exercise to gain insights in remaining overlaps or gaps of PIMs available in each national medication market. We urge the authors of the EU(7)-PIM list to (1) explicitly list all active substances in the medication classes and (2) to address the problem of combinations containing PIMs. Also, (3) a procedure must be Electronic supplementary material The online version of this article (doi:10.1007/s00228-015-1947-3) contains supplementary material, which is available to authorized users.

The psychotropic education and knowledge test for nurses in nursing homes: Striving for PEAK performance

Objectives: The psychotropic education and knowledge test for nurses in acute geriatric care (PEAK-AC) measures knowledge of psychotropic indications, doses and adverse drug reactions in older inpatients. Given the low internal consistency and poor discrimination of certain items, this study aims to adapt the PEAK-AC, validate it in the nursing home setting and identify factors related to nurses’ knowledge of psychotropics. Method: This study included nurses and nurse assistants employed by nursing homes (n = 13) and nursing students at educational institutions (n = 5) in Belgium. A Delphi technique was used to establish content validity, the known groups technique for construct validity (nrespondents = 550) and the test–retest procedure for reliability (nrespondents = 42). Internal consistency and item analysis were determined. Results: The psychotropic education and knowledge test for nurses in nursing homes (PEAK-NH) (nitems = 19) demonstrated reliability (κ = 0.641) and internal consistency (Cronbachs α = 0.773). Significant differences between-group median scores were observed by function (p < 0.001), gender (p = 0.019), educational background (p < 0.001), work experience (p = 0.008) and continuing education (p < 0.001) for depression, delirium and pharmacotherapy topics. Items were acceptably difficult (nitems = 15) and well-functioning discriminators (nitems = 17). Median PEAK-NH score was 9/19 points (interquartile range 6–11 points). Respondents’ own estimated knowledge was related to their PEAK-NH performance (p < 0.001). Conclusion: The PEAK-NH is a valid and reliable instrument to measure nurses’ knowledge of psychotropics. These results suggest that nurses have limited knowledge of psychotropic use in nursing homes and are aware of their knowledge deficits. The PEAK-NH enables educational initiatives to be targeted and their impact on nurses’ knowledge to be tracked.

A Novel Scale Linking Potency and Dosage to Estimate Anticholinergic Exposure in Older Adults: the Muscarinic Acetylcholinergic Receptor ANTagonist Exposure Scale

Quantification of the anticholinergic exposure insufficiently or imprecisely incorporates dosage information, leading to inaccurate estimations. The aim was to construct a novel scale, including potency and dosage for the quantification of the anticholinergic exposure in older adults. Potency information was retrieved from a previous systematic review. The dosage range for each drug was delineated in minimal, maintenance and maximal dosage for adults and older adults. Dosage information was collected from authoritative sources and reviewed in an expert panel. The Muscarinic Acetylcholinergic Receptor ANTagonist Exposure (MARANTE) scale was tested for clinimetric properties using cohorts of community‐dwelling older adults and nursing home residents. After three data collection rounds, data for the dosage ranges remained incomplete for 32 active substances. Remaining gaps were filled in, and 11 dosage adjustments were proposed during the expert panel meeting. We chose the values {0; 1; 2) for the categories of potency and {0; 0.5; 1; 1.5; 2) for the levels of dosage ranges, showing good clinimetric properties. Forty‐one anticholinergic drugs were prescribed in the two cohorts. Most (61%) were low potency anticholinergics and used for depression (19%, e.g. citalopram). There were 31.8% (median MARANTE 1.5, IQR 1.5–2.5) and 37.6% (median 2, IQR 1.5–2.5) anticholinergic users in the community‐dwelling cohort and nursing home cohort, respectively. The MARANTE scale combines potency with the dosage spectrum, to quantify the anticholinergic exposure in older adults. An open feedback system on the list of anticholinergic and proposed anticholinergic potency and dosage values is advised.

European repository of explicit criteria of potentially inappropriate medications in old age: European repository of PIM criteria

Lack of electronic assessment of medication lists in electronic health records is a barrier for more generalized use of potentially inappropriate medications (PIM) lists, designed for older adults. The aim was to construct a European repository of explicit criteria on PIM, suitable for electronic assessment.

Medication use in a cohort of newly admitted nursing home residents (Ageing@NH) in relation to evolving physical and mental health

BACKGROUND Medication use is high among nursing home (NH) residents, but there is a lack of longitudinal studies, determining medication use at admission and its evolution over time. AIM Describing the evolution of the medication use two years after entering a NH, compared to the baseline observations and exploring the relation to the physical and mental health. METHODS Data from the observational prospective Ageing@NH study, based on an inception cohort of newly admitted residents at NHs (65+) was used, selecting those consenting and with medication chart available. Information about socio-demographic, functional and mental characteristics, as well as medication use, was collected at baseline, year 1 and year 2. RESULTS Medication chart was available for n = 741 at baseline (mean age 83.8, 66% female), and for n = 342 residents in year 2. The mean number of total medications increased from 8.9 to 10.1 (p-value < 0.001). Polypharmacy was high, with an increase in extreme polypharmacy from 23% to 32%. The biggest increase was noted in the respiratory (from 17% to 27%) and alimentary medications (from 80% to 87%). Cardiovascular medication use in year 2, was lower in those with stable high dependency (77%) and those evolving from low to high dependency (79%), than those with stable low dependency (89%) (p < 0.025). For residents with or evolving to dementia symptoms, decline in most medication groups was observed, especially in pain and sleeping medications, while antipsychotics use increased. CONCLUSION Although medication use was high, signs of deprescribing were noted when the physical and mental health of the residents declined.

Anticholinergic exposure in a cohort of adults aged 80 years and over : associations of the MARANTE scale with mortality and hospitalisation

Anticholinergics are frequently prescribed for older adults and can lead to adverse drug events. The novel MARANTE (Muscarinic Acetylcholinergic Receptor ANTagonist Exposure) scale measures the anticholinergic exposure by incorporating potency and dosages of each medication into its calculations. The aims were to assess prevalence and intensity of the anticholinergic exposure in a longitudinal cohort study of community‐dwelling patients aged 80 years and over (n = 503) and to study the impact on mortality and hospitalization. Chronic medication use at baseline (November 2008–September 2009) was entered and codified with the Anatomical Therapeutic Chemical classification. Time‐to‐event analysis until first hospitalization or death was performed at 18 months after inclusion, using Kaplan–Meier curves. Cox regression was performed to control for covariates. Mean age was 84 years (range 80–102), and mean number of medications was 5 (range 0–16). Prevalence of anticholinergic use was 31.8%, with 9% taking ≥2 anticholinergics (range 0–4). Main indications for anticholinergics were depression, pain and gastric dysfunction. Female gender, the level of multi‐morbidity and the number of medications were associated with anticholinergic use. Mortality and hospitalization rate were 8.9% and 31.0%, respectively. After adjustment for the level of multi‐morbidity and medication intake, multi‐variable analysis showed increased risks of mortality (HR 2.3, 95% CI: 1.07–4.78) and hospitalization (HR 1.7; 95% CI: 1.13–2.59) in those with high anticholinergic exposure. The longitudinal study among Belgian community‐dwelling oldest old demonstrated great anticholinergic exposure, which was associated with increased risk of mortality and hospitalization after 18 months.