Medication reviews in elderly patients: Substantial variation in daily practice

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9th congress of the EUGMS / European Geriatric Medicine 4 (2013) S142–S216

Key conclusion.– The high elderly’s drug consumption continue to increase, cardiovascular drugs remain the most prescribed. Many medications are not consumed anymore as they are being delisted. http://dx.doi.org/10.1016/j.eurger.2013.07.607 P540

Prevalence of xerostomia and its relationship with underlying diseases, medication and nutrition, a descriptive observational study J.P.C.M. van Campen a,b , H. van der Jagt a,b , J.H. Beijnen a,b , L.R. Tulner a,b a Slotervaart Hospital, Amsterdam, The Netherlands b GGZ-Oost Brabant, Oss, Boekel, The Netherlands Introduction.– We examined the prevalence of xerostomia and other mouthcomplaints in 223 geriatric outpatients in the Slotervaart Hospital in the Netherlands, and the possible relationship between xerostomia on the one hand and medication, comorbidity and malnutrition on the other. Methods.– The prevalence of xerostomia and oral symptoms was measured in geriatric outpatients using a questionnaire and the GOHAI (Geriatric Oral Health Assessment Index). Malnutrition was assessed with the MNA (Mini Nutritional Assessment). Medications and comorbidity were recorded. Multiple regression analysis was used to determine the possible causes of xerostomia. Results.– The prevalence of xerostomia and oral symptoms is 45% and 61%, respectively. Xerostomia is associated with the use of benzodiazepines (P 0.015) and antidepressants (P 0.031). No significant relationship was found between xerostomia and malnutrition. Malnutrition, though, was frequently observed. Geriatric specialists reported oral symptoms in only 4.5% of the patients. Conclusion.– Oral symptoms and xerostomia occur frequently, but are not often recognised. There is a significant correlation between the use of benzodiazepines and antidepressants and the risk of xerostomia. We did not find any relationship between xerostomia and underlying diseases or between xerostomia and malnutrition. We recommend that geriatric patients should be asked whether they have oral symptoms, such as xerostomia and other oral symptoms. Medication, particularly antidepressants and benzodiazepines, should be reviewed and a thorough oral examination should be performed. http://dx.doi.org/10.1016/j.eurger.2013.07.608 P541

Optimizing drug treatment among older people in residential care facilities in Helsinki – A randomized, controlled trial A.L. Juola a,b,c , M. Bjorkman a,b,c , S. Pylkkanen a,b,c , H. Finne-Soveri a,b,c , K.H. Pitkala a,b,c a Kouvola Health Center, Helsinki University, Kouvola, Finland b Helsinki University, Helsinki, Finland c National Institute for Health and Welfare, Helsinki, Finland Introduction.– Use of inappropriate, anticholinergic and psychotropic drugs is common among institutionalized older people. There are only few randomized trials exploring effectiveness of staff training on optimizing drug treatment in institutionalized settings. The aim is to investigate effectiveness of staff education on the use of drugs, quality-of-life and hospitalizations among older residents in residential care. Methods.– Participants (n = 227) were recruited from residential care facilities. The wards were randomized in two arms: – in intervention wards staff received training (2 × 4 hours) to identify harmful and evidence-based drugs;

–control wards. The study nurses assessed all participants at baseline, 6 and 12 months. Main outcome measure were the changes in the inappropriate drugs (Beers’, anticholinergics, psychotropics, polypharmacy), quality of life (QOL) by15D and number of hospitalizations and health care costs during 12 months’ follow-up. Results.– The participants’ mean age was 83 y, MMSE 9.4 and number of drugs 7.6. During the follow-up there were no differences between the groups in the changes in the mean number of drugs. The intervention group decreased significantly their use of psychotropics, and there was a similar trend in the use of anticholinergics and Beers’ drugs compared with controls. There was a trend in improvement of QOL (0.080) in the intervention group compared with controls. The intervention group had significantly lower use and costs of hospital services than the controls (P = 0.042). Key conclusions.– Use of inappropriate drugs among institutionalized older people can be reduced by a light educational intervention. This was reflected in the hospitalizations. http://dx.doi.org/10.1016/j.eurger.2013.07.609 P542

The effect of pharmaceutical care on three-year mortality a follow-up study K. Buus , P. Harbigg , C. Olesen , E.M. Damsgaard Department of Geriatrics, Aarhus University Hospital, Aarhus, Denmark Introduction.– The elderly have often several diseases which need medical treatment. Medical regimes are often complicated. The consequences for the elderly can either lead to morbidity or be fatal. Pharmaceutical care could be a possibility to prevent these consequences. The aim of this study was to investigate the effect of pharmaceutical care on three-year mortality in elderly polypharmacy patients. Methods.– A randomised controlled trial with two arms (pharmaceutical care and control) was designed as a part of an adherence study. It comprised 630 participants aged 65+ years, living in Aarhus, Denmark, home-based and using > 5 drugs without caretaker assistance. The intervention group received pharmaceutical care consisting of one homevisit and three telephone calls by a pharmacist during one year. The pharmacists had no direct contact to the general practitioners. Mortality data were obtained from the electronic patient records and registered, within three years from inclusion. Results.– All 630 participants were included in the final analysis. Median age 75 (range 65–97) and 52% females. The number of deaths was 34 (11%) in pharmaceutical care versus 29 (9%) in the control group. Hazards Ratio 1.16; 95% CI 0.71; 1.91 for three-year mortality for the Pharmaceutical care group. Conclusion.– This study indicates that pharmaceutical care in this setting has no effect on three year mortality among home-based rather healthy participants with polypharmacy. We recommend that future research should focus on high risk groups and the pharmaceutical care should take place as a team work between the patient, the doctor, and the pharmacist. http://dx.doi.org/10.1016/j.eurger.2013.07.610 P543

Medication reviews in elderly patients: Substantial variation in daily practice K.P.G.M. Hurkens a , C. Mestres-Gonzalvo b , H.A.J.M. de Wit b , P.H.M. van der Kuy b , R. Janknegt b , F. Verhey a,b,c,d , J.M.G.A. Schols d , C.D.A. Stehouwer a,e , W. Mulder a a Department of Internal Medicine, Maastricht UMC, PO box 5800, Maastricht, The Netherlands

9th congress of the EUGMS / European Geriatric Medicine 4 (2013) S142–S216 b Department of Clinical Pharmacology, Orbis MC Sittard, PO box 5500, Sittard, The Netherlands c Alzheimer Centrum Limburg, School of Mental Health and Neuroscience, Maastricht MC, PO box 5800, Maastricht, The Netherlands d Department of General Practice, Maastricht UMC, PO box 616, 6200 MD Maastricht, The Netherlands e Cardiovasculair Research Institute Maastricht (CARIM), The Netherlands

Introduction.– The rising incidence of multi-morbidity in elderly makes polypharmacy a global challenge. Polypharmacy can lead to an increase in morbidity, hospital-admissions, and death. The aim of this study was to examine the way medication reviews are performed by general practitioners (GPs) and nursing home physicians (NHPs). Methods.– A questionnaire was sent to 134 NHPs and GPs working in the province of Limburg, the Netherlands. Results.– One hundred and thirty-four subjects received a questionnaire, 63 (47%) responded: 29% GPs and 71% NHPs. The frequency of performing the medication reviews ranged from daily (7.9%) to once a year (4.8%), but the majority of physicians performed a review monthly or four times a year. The reviews were mainly performed by the physician (84%) alone. In 91% of cases, regular meetings with a pharmacist took place, but the frequency varied from weekly to yearly. Median time spent on a review was 10 minutes for NHPs and 22.5 minutes for GPs. Fifty-nine percent of NHPs and 89% of GPs considered workload to be a limiting factor in performing a medication review. In case that medication was altered by another doctor, 46.7% of the NHPs and 44.4% the GPs often were informed. On the other hand13.3% of NHPs and 5.6% of GPs were never informed. Key conclusions.– There is substantial variation in the procedure of medication reviewing. Collaboration with the pharmacist and other colleagues requires improvement. Workload was a major limitation in reviewing. A different way of performing medication reviews should be developed to achieve a high standard. http://dx.doi.org/10.1016/j.eurger.2013.07.611 P544

The evidence for treating hypertension in older people with dementia L. Beishon , J.K. Harrison , R.H. Harwood , T.G. Robinson , J.R.F. Gladman , S.P. Conroy University of Leicester, Leicester, England Background.– Hypertension is a prevalent condition in older people (∼50%), the treatment of which significantly reduces cardio/cerebrovascular mortality. However, lowering blood pressure in the frail population with concomitant dementia could worsen cognitive outcomes, increase falls and even mortality. The aim of this review is to assess this evidence. Methods.– Four databases were screened (Medline, EMBASE, Cochrane Library, National research register archives) with individual search strategies. One thousand one hundred and seventy-eight abstracts were initially screened by one reviewer from which 24 papers were assessed by 2 reviewers using the Van Tulder Score. Seven studies were suitable for inclusion: inclusion Criteria: – randomised-controlled trials of hypertension treatment; – participants > 65 years; – diagnosis of dementia (global cognitive decline for more than six months affecting function); – cognitive outcomes assessed using validated tools Exclusion criteria; – poor quality (van Tulder < 9/19); – mild cognitive impairment; insufficient English language content.

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Results.– All 7 papers described RCTs, including patients with mild to moderate cognitive impairment; however, exclusion criteria were extensive with limited outcome measures. Four trials were placebo controlled; the remaining 3 comparative studies. All trials reported MMSE scores at baseline and follow-up; four reported blood pressure changes at follow-up; only three reported cardiovascular morbidity or mortality at follow-up. There was no clear evidence for benefit (or harm) from anti-hypertensives on cognition, physical function or other cardiovascular outcomes. Discussion.– This work highlights the need for further research in the frail population with multiple comorbidities, assessing the impact of antihypertensive use on multiple significant outcomes. http://dx.doi.org/10.1016/j.eurger.2013.07.612 P545

Reduction of polypharmacy in geriatric inpatients using the RASP list: A cluster-randomized controlled trial L. Van der Linden , L. Decoutere , J. Flamaing , I. Spriet , L. Willems , K. Milisen , S. Boonen , J. Tournoy University Hospitals Leuven, Leuven, Belgium Introduction.– Evidence concerning the relevance of screening tools to reduce polypharmacy is scarce. Hence, we developed and validated a novel instrument, the RASP list. We aimed to study the impact of these criteria on acute geriatric wards. Methods.– In a prospective cluster-randomized controlled trial, patients were randomly assigned to an intervention or a control arm. The intervention consisted of a pharmaceutical care plan, which was based on the RASP list. Co-primary endpoints were the number of stopped/reduced drugs and the actual number of drugs at discharge. Secondary endpoints included the acceptance rate, the number of fractures, readmissions (total and emergency department), and mortality during the 3 months follow-up. Results.– Hundred and seventy-two patients were included in the analysis (intervention: 91, control: 81). In the intervention group, 85% of the RASP-related recommendations were accepted by the geriatrician. At discharge, 47.4% and 34% of drugs were stopped/reduced in the intervention and control group, respectively (P < 0.0001). The absolute number of drugs at discharge decreased with 14.6%, after correction for new Ca/vit D treatment, which was started more in the intervention group. The number of drug intakes was decreased by 18% in the intervention group. There was no difference in the rate of fractures, readmission and mortality, although less emergency department readmissions were noted in the intervention group. Conclusion.– The RASP list reduced polypharmacy in geriatric inpatients, without increasing harm. More drugs were stopped or reduced in the intervention arm, resulting in a lower number of drugs and drug intakes at discharge. http://dx.doi.org/10.1016/j.eurger.2013.07.613 P546

In patients over 75 years, appreciation of adherence to the anticoagulation guidelines in atrial fibrillation L.A. Bertholon , G. Marques , C. Vanhaecke-Collard , R. Mahmoudi , P. Nazeyrollas , J.-L. Novella CHU de Reims, UMG2-3, Reims, France Introduction.– The European Society of Cardiology (ESC) provided in 2010 then in 2012 antithrombotic guidelines for the management of patients with AF. The aim of this study was to evaluate