Rohan A Elliott

A Systematic Review of Interventions to Improve Medication Taking in Elderly Patients Prescribed Multiple Medications

A range of behavioural, educational and provider-focused strategies have been tested, individually or in combination, for improving medication adherence. The results of various interventions in different patient groups, including the elderly, have been subjected to systematic reviews and meta-analyses, but because most studies have focused on improving adherence to one drug or drug group, they may have limited applicability to the general elderly population who more commonly use multiple medications for multiple co-morbidities.A systematic review of controlled studies aimed at improving adherence in community-living elderly patients prescribed at least three, or a mean/median of four or more, long-term medications was undertaken. Only studies which included a minimum of 60 patients in each group, followed patients for ≥4 weeks after intervention, and measured adherence to all medications at baseline and at the conclusion of the study were considered for inclusion in the review. Eight studies met the inclusion criteria. All eight studies used verbal and/or written medication information in combination with behavioural strategies with or without provider-focused strategies. Pharmaceutical care was the theoretical framework of the interventions used in the majority of the studies. Only four studies demonstrated a significant improvement in adherence as a result of the interventions. The relative change in adherence in the intervention groups was highly variable, ranging from–13% to +55.5% (mean +11.4%). Regular scheduled patient follow-up along with a multi-compartment dose administration aid was an effective strategy for maintaining adherence in one study, while group education combined with individualized medication cards was successful in another study. Medication review by pharmacists with a focus on regimen simplification was found to be effective in two studies.Overall, as a result of inconsistent methodology and findings across the eight studies, we were unable to draw firm conclusions in favour of any particular intervention. Innovative strategies for enhancing medication adherence in the elderly and reliable measures of adherence are needed. Until further evidence from single-intervention strategies becomes available, combinations of educational and behavioural strategies should be used to improve medication adherence in the elderly.

Pharmacist services provided in general practice clinics: A systematic review and meta-analysis

BACKGROUND Integration of pharmacists into primary care general practice clinics has the potential to improve interdisciplinary teamwork and patient care; however this practice is not widespread. OBJECTIVE The aim of this study was to review the effectiveness of clinical pharmacist services delivered in primary care general practice clinics. METHODS A systematic review of English language randomized controlled trials cited in the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and International Pharmaceutical Abstracts was conducted. Studies were included if pharmacists had a regular and ongoing relationship with the clinic; delivered an intervention aimed at optimizing prescribing for, and/or medication use by, clinic patients; and were physically present within the clinic for all or part of the intervention, or for communication with staff. The search generated 1484 articles. After removal of duplicates and screening of titles and abstracts against inclusion criteria, 131 articles remained. A total of 38 studies were included in the review and assessed for quality. Seventeen studies had common endpoints (blood pressure, glycosylated hemoglobin, cholesterol and/or Framingham risk score) and were included in meta-analyses. RESULTS Twenty-nine of the 38 studies recruited patients with specific medical conditions, most commonly cardiovascular disease (15 studies) and/or diabetes (9 studies). The remaining 9 studies recruited patients at general risk of medication misadventure. Pharmacist interventions usually involved medication review (86.8%), with or without other activities delivered collaboratively with the general practitioner (family physician). Positive effects on primary outcomes related to medication use or clinical outcomes were reported in 19 studies, mixed effects in six studies, and no effect in 13 studies. The results of meta-analyses favored the pharmacist intervention, with significant improvements in blood pressure, glycosylated hemoglobin, cholesterol and Framingham risk score in intervention patients compared to control patients. CONCLUSIONS Pharmacists co-located in general practice clinics delivered a range of interventions, with favorable results in various areas of chronic disease management and quality use of medicines.

Improving benzodiazepine prescribing for elderly hospital inpatients using audit and multidisciplinary feedback.

Abstract

Pharmacist-Led Medication Review to Identify Medication-Related Problems in Older People Referred to an Aged Care Assessment Team

BackgroundAged Care Assessment Teams (ACATs) in Australia assess the care needs of frail older people. Despite being at high risk of medication-related problems (MRPs), ACAT patients do not routinely receive a comprehensive medication review.ObjectivesThe aims of the study were to compare three methods for facilitating a pharmacist-led comprehensive medication review for people referred to an ACAT, and compare MRPs identified via ACAT usual care with those identified via pharmacist-led medication reviews.MethodsA prospective, randomized, comparative study involving 80 community-dwelling patients (median age 84 years) referred to an ACAT in Melbourne, Australia, was conducted.Following ACAT assessment (usual care), a clinical pharmacist reviewed all participating patients’ ACAT files to identify potential MRPs not identified by the ACAT (medication review method 1). Patients were then randomized into two groups. Group A received information about the Australian government-funded, general practitioner (GP)-initiated Home Medicines Review (HMR) programme, and a letter was sent to their GP recommending an HMR (GPHMR; medication review method 2). Group B patients were referred directly to a clinical pharmacist associated with the ACAT for an ACAT-initiated pharmacist home medicines review (APHMR; medication review method 3); the pharmacist arranged a home visit, obtained a thorough medication history and conducted a comprehensive medication review.The main outcome measures were the proportion of patients who received a pharmacist home visit within 28 days; the number of MRPs identified by ACAT usual care, pharmacist review of ACAT files, and APHMR, and their clinical risk (assessed by a geriatrician-pharmacist panel); and patients’, GPs’ and ACAT clinicians’ opinions about pharmacist medication review.ResultsThree hundred patients were referred to the ACAT, and 80 were recruited into the study. Thirty-six of 40 APHMR patients (90.0%) received a pharmacist home visit within 28 days, compared with 7/40 GPHMR patients (17.5%) [p<0.001].Twenty-one MRPs were identified via ACAT usual care. Pharmacist review of ACAT files identified a further 164 potential MRPs (median 2.0 per patient; inter-quartile range [IQR] 1.0–3.0); however, in patients who received an APHMR, 35/82 potential MRPs (42.7%) turned out not to be actual problems, most commonly because of discrepancies between the patient’s ACAT medication list and the medications currently being used by the patient (median 3.0 discrepancies per patient; IQR 2.0–5.5). APHMR identified a further 79 MRPs (median 2.0; IQR 1.0–3.0).One hundred and twenty-two MRPs were included in APHMR reports sent to patients’ GPs. Of these, 94 (77.0%) were assessed as being associated with a moderate, high or extreme risk of an adverse event. Sixty-four APHMR recommendations (52.5%) led to changes to patients’ medication regimens or medication management.Thirty-six of 39 GPs (92.3%) who provided feedback reported that pharmacist medication reviews were useful. Patients (or their carers) also reported that pharmacist home visits were useful: median rating 4.25 out of 5 (IQR 4.0–5.0). Seven of 11 ACAT clinicians (77.8%) agreed that pharmacist-led medication review should be a standard component of ACAT assessments.ConclusionsACAT assessments without pharmacist involvement detected fewer MRPs than any of the evaluated pharmacist-led medication review methods. APHMR was more effective than pharmacist review of routinely collected ACAT data, and more reliable and timely than referral to the patients’ GP for a GPHMR.

Impact of a self‐administration of medications programme on elderly inpatients’ competence to manage medications: a pilot study

What is known and objectives:  Changes to medication regimens and failure to involve patients in management of their medications whilst in hospital may result in medication errors or non‐adherence at home after discharge. Self‐administration of medications programmes (SAMP) have been used to address this issue. The objective of this study was to assess the impact of a SAMP on elderly hospital inpatients’ competence to manage medications and their medication adherence behaviours.

Ability of older people with dementia or cognitive impairment to manage medicine regimens: a narrative review

Impaired cognition has a significant impact on a person’s ability to manage their medicines. The aim of this paper is to provide a narrative review of contemporary literature on medicines management by people with dementia or cognitive impairment living in the community, methods for assessing their capacity to safely manage medicines, and strategies for supporting independent medicines management. Studies and reviews addressing medicines management by people with dementia or cognitive impairment published between 2003 and 2013 were identified via searches of Medline and other databases. The literature indicates that as cognitive impairment progresses, the ability to plan, organise, and execute medicine management tasks is impaired, leading to increased risk of unintentional non-adherence, medication errors, preventable medication-related hospital admissions and dependence on family carers or community nursing services to assist with medicines management. Impaired functional capacity may not be detected by health professionals in routine clinical encounters. Assessment of patients’ (or carers’) ability to safely manage medicines is not undertaken routinely, and when it is there is variability in the methods used. Self-report and informant report may be helpful, but can be unreliable or prone to bias. Measures of cognitive function are useful, but may lack sensitivity and specificity. Direct observation, using a structured, standardised performance-based tool, may help to determine whether a person is able to manage their medicines and identify barriers to adherence such as inability to open medicine packaging. A range of strategies have been used to support independent medicines management in people with cognitive impairment, but there is little high-quality research underpinning these strategies. Further studies are needed to develop and evaluate approaches to facilitate safe medicines management by older people with cognitive impairment and their carers.

Medication-related problems in patients referred to aged care and memory clinics at a tertiary care hospital.

Aim:  To investigate the prevalence of medication‐related problems (MRPs) in patients attending aged care and memory disorder clinics and explore the potential role of a clinical pharmacist to obtain medication histories and identify unresolved MRPs.

Integration of pharmacists into general practice clinics in Australia: the views of general practitioners and pharmacists

Pharmacists working collaboratively with general practitioners (GPs) in primary‐care settings can improve patient outcomes; however, there are challenges to the implementation of collaborative services. A possible solution is the co‐location of pharmacists within general practice clinics.

Gaps in continuity of medication management during the transition from hospital to residential care: An observational study (MedGap Study)

Aim:  To assess continuity of medication management during transition from hospital to residential care facilities (RCFs).

Prevalence of medication-related risk factors among retirement village residents: a cross-sectional survey

BACKGROUND information on medication use and risk factors among older people residing in retirement villages and their uptake of medication reviews are scant. OBJECTIVES to identify medication use issues and risk factors for medication-related problems among retirement village residents and to evaluate the uptake of government-subsidised Home Medicines Review (HMR) services in this population. DESIGN cross-sectional, mail survey. SETTING retirement villages in Victoria, Australia. PARTICIPANTS members of the Residents of Retirement Villages of Victoria residing in retirement villages (2,116, aged 54-100 years). METHODS a questionnaire was developed incorporating validated scales and items to measure medication risk, medication adherence, co-morbidity, disability, information on medication use, health and the uptake of HMR services. Questionnaires were mailed to participants for self-completion and returned using reply-paid envelopes. RESULTS of the 2,116 respondents (70.7% response rate), 2,006 (94.8%; 95% confidence interval (CI) 93.9-95.7%) reported using prescribed medications. Three or more health conditions were present in 993 (46.9%; 95% CI 44.8-49.0%) respondents. Five or more regular medications were used by 988 (46.7%; 95% CI 44.6-48.8%) respondents. Twelve or more tablets/capsules per day were used by 229 (10.8%; 95% CI 9.5-12.1%) respondents. The use of narrow therapeutic index medications was reported by 264 (12.5%; 95% CI 11.1-13.9%) respondents. Changes to medication regimens in the previous 3 months were reported by 356 (16.8%; 95% CI 15.2-18.4%) respondents. One or more medication-related risk factors were seen in 1,374 (64.9%; 95% CI 62.9-66.9%) respondents. Of these at-risk residents, 76 (5.5%; 95% CI 4.5-6.5%) reported receiving an HMR in the previous 12 months, who were older (P < 0.001), were using more medicines (P < 0.001) and had greater disability (P = 0.002). CONCLUSIONS reasons for the low uptake of medication reviews in retirement village residents despite the high prevalence of medication risk require further investigation.