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Sharma, R.; Mahajan, N.; Fadaleh, S.A.; Patel, H.; Ivo, J.; Faisal, S.; Chang, F.; Lee, L.; Patel, T. Clinical Outcomes in Persons with Dementia. Encyclopedia. Available online: https://encyclopedia.pub/entry/51099 (accessed on 17 May 2024).
Sharma R, Mahajan N, Fadaleh SA, Patel H, Ivo J, Faisal S, et al. Clinical Outcomes in Persons with Dementia. Encyclopedia. Available at: https://encyclopedia.pub/entry/51099. Accessed May 17, 2024.
Sharma, Rishabh, Neil Mahajan, Sarah Abu Fadaleh, Hawa Patel, Jessica Ivo, Sadaf Faisal, Feng Chang, Linda Lee, Tejal Patel. "Clinical Outcomes in Persons with Dementia" Encyclopedia, https://encyclopedia.pub/entry/51099 (accessed May 17, 2024).
Sharma, R., Mahajan, N., Fadaleh, S.A., Patel, H., Ivo, J., Faisal, S., Chang, F., Lee, L., & Patel, T. (2023, November 02). Clinical Outcomes in Persons with Dementia. In Encyclopedia. https://encyclopedia.pub/entry/51099
Sharma, Rishabh, et al. "Clinical Outcomes in Persons with Dementia." Encyclopedia. Web. 02 November, 2023.
Clinical Outcomes in Persons with Dementia
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This entry is adapted from the peer-reviewed paper 10.3390/pharmacy11050168

Dementia is an umbrella terms that encapsulated a number of neurodegenerative, irreversibly progressive disorders that are marked by cognitive decline and a steady reduction in everyday function, and it is typically accompanied by behavioral issues. 

older adults dementia medication review drug-related problems

1. Introduction

Dementia is an umbrella terms that encapsulated a number of neurodegenerative, irreversibly progressive disorders that are marked by cognitive decline and a steady reduction in everyday function, and it is typically accompanied by behavioral issues [1]. Cognitive impairment (CI) or dementia affects the ability to learn, memory, reasoning, focus, understanding, language, and judgment. Given that the risk of being diagnosed with dementia increases with age, the global prevalence of dementia is expected to increase from 50 to 150 million by 2050, with the aging of the world population [2][3][4]. Dementia is presently the seventh leading cause of death, and it is one of the primary causes of impairment and dependency in older people worldwide [2]. People with dementia and their caregivers, family, and society at large all experience social, psychological, physical, and financial repercussions. In Canada, the annual healthcare cost of dementia, including the out-of-pocket cost of caring for people with dementia, was CAD 10.4 billion in 2016 [5][6]. Older adults who have dementia commonly experience coexisting medical conditions, including hypertension, diabetes mellitus, coronary artery disease, stroke, and heart failure. These comorbidities are highly prevalent among this population [7]. Older adults who have CI or dementia are particularly at risk for drug-related problems (DRPs), with 41% of hospital admissions in older adults with dementia thought to be partially or entirely related to DRPs, which is higher than older adults without dementia [8]. Older adults with dementia have more comorbid conditions and are often prescribed multiple medications, which further increases the risk of DRPs [9]. Studies have reported that more than half of older adults with dementia are prescribed five or more medications per day [8]. The use of multiple medications, or polypharmacy, in older adults with dementia was found to be associated with the use of potentially inappropriate medications (PIMs), which are medications that increase the risk of adverse events. The literature reports the higher prevalence of PIMs among older adults with dementia, ranging between 10.2 and 63.4% [10][11][12][13]. Additionally, managing medications in people with dementia may lead to drug-related hospital admissions, medication mistakes, and dependency on others to help with medication management responsibilities [14]. Adherence to a prescribed regimen can be very difficult for older adults with dementia due to complex medication regimens, memory loss, and other cognitive deficits [15]. Polypharmacy, complex medication regimens, and the use of PIMs in older adults with dementia are associated with an increased risk of adverse events and drug interactions, medication nonadherence, an increased risk of hospitalization or prolonged hospitalization, and economic burden on patients and the healthcare system [16][17]. Moreover, prescribing decisions made for older adults with dementia lack unbiased scientific evidence, as this population has been excluded from 85% of the clinical trials [18].

2. Study Characteristics

The study designs included observational pre–post studies (n = 4) [14][19][20][21], retrospective studies (n = 7) [22][23][24][25][26][27][28], prospective studies (n = 5) [29][30][31][32][33], an audit (n = 1) [34], feasibility studies (n = 2) [35][36], and randomized controlled trials (n = 3) [37][38][39].
A total of 133,024 patients were included in 22 studies. The minimum–maximum mean ages of the participants ranged from 78.33 to 87.9 years old (not reported in three studies). Out of 22 studies, 17 studies included both women and men. About 65.7% (n = 86,645) of the population in the studies were females, which is 1.9 times more than the male population in the studies (not reported in five studies).
Of the included 22 studies, 1 study each was conducted in Canada [20], the Netherlands [39], Slovenia [19], France [26], Taiwan [31], Australia [36], northern Sweden [17], Germany [28], Denmark [32], and Hong Kong [33], 5 studies were conducted in the USA [22][23][24][25][29], 3 studies were conducted in the UK [34][35][38], and 4 studies were conducted in Spain [14][21][27][30]. All the studies were published within the previous ten years.
Nine studies were conducted in long-term care facilities [20][21][27][29][30][32][35][38][39], six studies in community settings [19][23][24][25][28][36], five studies in hospital settings [14][17][21][26][33][34], and one study in all three settings and one study in both a long-term care facility and community setting [22][31].

3. Information about Interventions

In terms of cognitive pharmacy services and specifically for clinical assessment, medication reviews were conducted by the pharmacists independently in 15 studies [17][20][21][23][24][25][26][27][29][32][33][34][35][36][40] and in collaboration with multidisciplinary teams in 6 studies [14][28][30][31][39]. One study reported a medication review conducted by a therapist [38]. The multidisciplinary teams in the six studies included a combination of a variety of healthcare professionals, such as “elderly care physicians”, nurse assistants, geriatric clinical pharmacists, physical and leisure therapists, administrators, neurologists, psychiatrists, geriatricians, primary care general practitioners, dementia specialists, nurses with expertise in dementia care, dieticians, physical therapists, occupational therapists, clinical psychologists, and social workers. Pharmacists or multidisciplinary teams identified and reported DRPs in 10 studies as part of clinical assessments in comprehensive medication management [24][25][26][27][29][30][33][34][36][37]. In eight studies, pharmacists or multidisciplinary teams also recommended appropriate interventions for DRPs identified during the medication reviews [23][24][26][27][30][32][36]. There were eight instances of pharmacists actively monitoring the outcomes of interventions and completing the essential follow-up tasks concerning the assessment part of complicated medication management [20][21][23][26][28][30][36][37][39].
Only one research study identified pharmacists as a source of drug information and counseling to people with dementia, family members, and carers [33]. In four reports for educational and advisory services to healthcare professionals, pharmacists served as a source of drug information and conducted educational sessions for other healthcare professionals [21][34][35][36].

3.1. Type of Outcomes Reported

Fifty-four outcomes relating to medication reviews have been reported in 22 studies. About one-fifth (10/54) of the studies have reported outcomes related to DRPs [24][25][26][27][29][31][33][34][36][37], followed by drug-related interventions (n = 11) [11][23][24][25][26][27][30][32][36][37], evaluations of medication use (n = 16) [9][19][24][25][26][27][28][29][30][31][32][34][38][39][40][41], cost-effectiveness (n = 2) [27][35], and drug-related admissions (n = 1) [30].

Effect of Medication Review

(A)
Evaluation of medication use
The impact of medication reviews on important clinical outcomes is outlined. Sixteen studies reported medication usage in older adults with dementia [11][20][21][24][25][26][27][28][34][37][38][39][40][42][43][44][45]. Hernandez et al. reported that 87.7% (57/65) of the population in the study was taking ≥ 5 drugs per day, and 38.5% (25/65) were on hyper-polypharmacy (taking ≥ 10 drugs per day) [30]. Almost two-thirds of the study population were prescribed antipsychotics (78.5%), followed by analgesics in 66.2%, and antidepressants in 53.9%. Nine out of ten studies reported the average number of medications per patient as ≥ 5, ranging from 6.4 to 13.3 per patient [11][20][21][25][29][30][34][36][37]. Results reported in six studies indicated a significant decrease in the average number of drugs per patient after medication reviews conducted by pharmacists independently or with multidisciplinary teams [11][20][21][34][37][38][42][43][44][45]. The intervention for one study involved a medication review conducted by a pharmacist using the medication review guidance (MRG) tool. The study was conducted among nursing home residents in Quebec. At the end of a 104-day follow-up, Wilchesky et al. found a substantial reduction in the overall number of regular drugs by 12.1% [20]. Another study reported an overall 28% decrease in the number of psychotropic drugs prescribed, with the largest decrease reported in antipsychotic use (49.66%) [21]. The intervention consisted of a review of the drugs used by the participating patients, carried out by a multidisciplinary team that involved one primary care physician and one pharmacist, as well as the nursing home doctors and nurses. At baseline, the average number of psychotropic medications administered per patient was 2.71; at one-month post-intervention, it was 1.95; and at six months, it was 2.01 (p ≤ 0.001 at both time points). A study conducted by Dong et al. reported the implications of Medicare Part D’s Comprehensive Medication Review (CMR) on Alzheimer’s patients’ adherence to medication [22]. The proportions of nonadherent Medicare beneficiaries in the intervention group for each prescription category decreased after they obtained a CMR, but the proportions in the comparison group grew over time. For instance, the proportion of beneficiaries in the intervention group who did not take their diabetic medications decreased from 13.1% to 9.8% in 2017. However, the percentage of nonadherent beneficiaries in the comparison group increased by 1.2%.
(B)
Drug-related problems
Ten studies reported on DRP outcomes [24][25][26][27][29][31][33][34][36][37]. Four studies defined DRPs based on established systems. For example, one study each used the Westerlund system [46], ASHP classification 1996 [47], Cipolle/Morley/Strand classification [48], and PCNE Classification V 6.2 [49], and two studies did not use any standard classification system, as shown in Table 1. The numbers of DRPs identified during medication reviews ranged from 11 to 1077. Wucherer et al. reported 1077 DRPs in 92.8% (414/446) of patients. Furthermore, the authors reported that the total number of DRPs was associated with the number of drugs taken (b = 0.07; 95% CI: 0.05–0.09; p < 0.001) based on a multivariate Poisson regression analysis [28]. Similar results have also been reported by another study. In one study, a multiple Cox regression model was employed to analyze the data. The results indicated that drug-related problems (DRPs) were more prevalent in certain populations. Specifically, a higher number of drugs used by individuals was associated with a greater likelihood of DRPs (odds ratio (OR): 1.255; 95% confidence interval (CI): 1.137–1.385). Additionally, populations with histories of strokes, and particularly earlier strokes, exhibited a significantly higher risk of DRPs (OR: 5.042; 95% CI: 2.032–12.509). Similarly, individuals with heart failure (OR: 2.66; 95% CI: 1.64–4.30) and diabetes mellitus (OR: 2.32; 95% CI: 1.41–3.81) were also more likely to experience DRPs [17][37][42][43].
Table 1. Types of drug-related problems reported.
Study Types of Drug-Related Problems Reported
Pearson et al., 2021 [23] 2019 Beers Criteria
  • Total of 59 PIMs identified in the 40 patients (average 1.5 PIMs/patient)
Levine et al., 2021 [24]
  • Unnecessary drug therapy = 1 DRP
  • Overuse a = 6 DRPs
  • Underuse b = 28 DRPs
Aziz et al., 2018 [34] 2015 STOPP Criteria
  • 164 drugs prescribed
Melville et al., 2020 [25] 2012 Beers Criteria
  • 62 (59%) patients received at least one PIM
Novais et al., 2021 [26] Westerlund System [46]
  • Total of 543 DRPs
  • Non-conformity to guidelines/contra-indication = 156 (28.7%) DRPs
  • Drug without indication = 118 DRPs
  • Improper administration = 82 DRPs
  • Supratherapeutic dosage = 51 DRPs
  • Untreated indication = 40 DRPs
  • Subtherapeutic dosage = 35 DRPs
  • Drug monitoring = 26 DRPs
  • Drug interaction = 17 DRPs
  • Adverse drug reaction = 17 DRPs
  • Failure to receive drug = 1 DRP
Hernandez et al., 2020 [30]
  • ASHP classification 1996 [47]
  • Total 175 DRPs (2.97 per patient) in 90.8% of patients
  • Actual and potential adverse drug events = 33 DRPs
  • Medication prescribed inappropriately for a particular condition = 29 DRPs
  • Therapeutic duplication = 18 DRPs
  • Inappropriate dose = 17 DRPs
  • Medication with no indication = 15 DRPs
  • Condition for which no drug is prescribed = 14 DRPs
  • Length = 14 DRPs
  • Schedule = 13 DRPs
  • Failure to receive the full benefit of prescribed therapy = 8 DRPs
  • Actual and potential drug–drug interactions that are clinically significant = 6 DRPs
  • Drug diseases that are clinically significant = 4 DRPs
  • Lack of understanding of the medication = 2 DRPs
  • Inappropriate-dose renal impairment = 1 DRPs
  • Dosage form = 1 DRP
Cross et al., 2020 [36] Beer’s 2015 Criteria or 2015 STOPP Criteria
  • 25 (54.3%) patients using ≥ 1 PIM cog
Gustafsson et al., 2017 [17][37][42][43] 2015 STOPP/START Criteria
  • 326 DRPs were identified in 153 (72.2%) patients
  • Cipolle/Morley/Strand classification [48]
  • Total of 310 DRPs reported in 140 (66%) patients
  • Unnecessary drug therapy = 54 DRPs
  • Needs additional therapy = 37 DRPs
  • Ineffective/inappropriate drug = 54 DRPs
  • Adverse drug reaction = 14 DRPs
  • Too-high dosage = 44 DRPs
  • Drug use process errors = 26 DRPs
  • Adherence = 4 DRPs
  • Monitoring = 13 DRPs
  • Drug interaction = 23 DRPs
Wucherer et al., 2017 [28] Inappropriate drugs according to the PRISCUS list reported in 105 (22.9%) patients.
PCNE Classification V 6.2 [49]
  • Total of 1077 DRPs in 414 (92.8%) patients
  • Ineffective/inappropriate drug = 158 DRPs
  • Adverse drug reaction = 27 DRPs
  • Administration and compliance = 645 DRPs
  • Drug interaction = 180 DRPs
  • Dosage = 67 DRPs
Wong et al., 2016 [33]
  • Total of 11 DRPs reported
Six studies reported outcomes on medication appropriateness [24][26][29][34][36][37]. Pharmacists’ interventions have been shown to decrease the number of PIMs used in patients after medication reviews. Pearson et al. reported a change in the mean number of PIMs in patients living with dementia from 1.5 PIMs per patient at baseline to 0.9 PIMs per patient at the 180-day follow-up after medication review [23]. In another study, the use of PIMs decreased significantly in the intervention group between admission and after medication review, from 20.3% to 14.2% (p = 0.002), particularly in the use of anticholinergic drugs (from 7.1% to 3.3%; p = 0.005) and NSAIDs, (from 3.3% to 0.9%; p = 0.025) [17][37][42][43]. Hernandez et al. reported a significant difference (p < 0.001) between the mean (SD) Medication Appropriateness Index (MAI) scores at admission and post-intervention (4 (4.6) vs. 0.5 (2.6)) [30].
PIMcog: potentially inappropriate medication for a person with cognitive impairment.
(C)
Drug-related interventions
Eight studies reported the total number of proposed recommendations to the prescriber by the pharmacist or multidisciplinary team after the medication review [23][24][26][27][29][30][32][36]. In their retrospective chart review, Melville et al. present data on the identification of the number and categories of medication-related recommendations made by a geriatric clinical pharmacist in their Caring for Older adults and Caregivers at Home (COACH) Program. The geriatric clinical pharmacist proposed a total of 248 recommendations to the prescribers after the medication review [25]. The three most frequent recommendations were stopping a drug, reducing the dose, and changing to a potentially safer alternative [25]. Providers accepted 110 (44%) of the drug-related recommendations given by the pharmacist within six months of the medication review. In the Cross et al. study, pharmacy professionals made 121 deprescribing recommendations, followed by 52 on adherence and medication management, and another 88 on care-related activities, such as monitoring/investigative testing [36]. At six months, 136 of the 209 suggestions (52.1%) had either been fully or partially carried out.

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Subjects: Geriatrics & Gerontology
Contributors MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to https://encyclopedia.pub/register :
Rishabh Sharma
,
Neil Mahajan
,
Sarah Abu Fadaleh
,
Hawa Patel
,
Jessica Ivo
,
Sadaf Faisal
,
Feng Chang
,
Linda Lee
,
Tejal Patel
View Times: 161
Revisions: 3 times (View History)
Update Date: 13 Nov 2023
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