Improving Quality Use of Medicines for People with Advanced Dementia in Long-term Care

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Background: Quality use of medicines is a phrase that is used to describe best possible medicines use that maximises the benefits of treatment while minimising medication-related harm. It includes selecting management options wisely, choosing appropriate medicines if a medicine is considered necessary, and using medicines safely and effectively. Best practice prescribing for frail older adults in long-term care should carefully balance benefits and harms. In the context of advanced dementia, this means aligning use of medications with a palliative approach. Potentially inappropriate prescribing is a term used to describe prescribing practices that are likely to be suboptimal and include overprescribing, under-prescribing, or poor choice of medications. Much research has focused on reducing use of potentially inappropriate prescribing of psychotropic agents but less so on other medications where risk of harm may similarly outweigh benefits. Medications of concern include not only those prescribed for non-palliative purposes but also those intended to manage symptoms that have risks arising from the pathophysiological changes associated with dementia. Aim and objectives: The aim of this PhD programme was to explore current practice regarding quality use of medicines (QUM) for long-term care (LTC) residents with advanced dementia and identify ways in which it might be improved. Three research questions were posed: 1) what systems exist for identifying potentially inappropriate prescribing (PIP) in the context of advanced dementia? 2) what is the prevalence of potentially inappropriate medications (PIMs) in Australian LTC residents with advanced dementia? and, 3) how can QUM be improved for people in this group? Methods: This PhD programme used a multiple methods approach to answer these individual questions. To answer research question one, a systematic review was conducted to identify and synthesise published systems for identifying PIP in the context of advanced dementia. To answer research question two, a retrospective chart audit was conducted of medication charts from 20 LTC facilities in Sydney and Brisbane, Australia to estimate the proportion of residents with advanced dementia receiving PIMs, identify those most commonly prescribed, and explore LTC facility and resident characteristics associated with their use. To answer research question three, two qualitative methods were used. First, in-depth interviews with pharmacists were conducted to explore barriers and facilitators to the national Residential Medication Management Review (RMMR) programme for improving QUM for LTC residents with advanced dementia. A model of interdisciplinary collaboration was used to inform the interpretative stage of analysis. Secondly, focus groups were used to explore medication-related decision-making by health professionals from different disciplines and specialties relevant to care for LTC residents with advanced dementia, with a special focus on dilemmas associated with medications commonly regarded as potentially inappropriate (acetylcholinesterase inhibitors, lipid-lowering agents, antibiotics and opioid analgesics). Findings: The systematic review identified only one system for identifying PIP in the context of advanced dementia - criteria developed by the Palliative Excellence in Alzheimer Care Efforts (PEACE) Program. The chart review (N=218) found that nearly a third (n=65, 30%) of residents were receiving at least one medication classed as ‘never appropriate’ by the PEACE criteria, the most common being lipid-lowering agents (n=38, 17.4%), antiplatelet agents (n=18, 8.3%) and acetylcholinesterase inhibitors (n=16, 7.3%). Residents who had been at the LTC facility for =10 months (odds ratio [OR] 5.60, 95% confidence intervals [CI] 1.74-18.06), and 11 to 21 months (OR 5.41, CI 1.67-17.75) had a significantly greater likelihood of receiving a 'never' appropriate medication compared to those with a residence of >5 years. Findings from in-depth interviews with pharmacists (N=15) suggested that motivation, trust and effective communication between pharmacists, GPs, LTC facilities and families can increase RMMR’s capacity to improve QUM for LTC residents with advanced dementia. A lack of formal processes and limited remuneration for interdisciplinary collaboration were identified as key barriers. Findings from four focus groups with health professionals (N=16) highlighted the need to individualise medication-related decisions, taking into account each resident’s history, clinical status and resident/family preferences and values. Informants identified a large range of competing considerations that may need to be weighed in deciding the appropriateness of starting, continuing or deprescribing medications. A dialectical approach to decision-making and regular review were identified as important in ensuring high-quality therapeutic decisions. Conclusion: QUM for LTC residents with advanced dementia requires an interdisciplinary team to work in collaboration with residents/families to regularly review medications in line with each individual’s changing context and goals of care. Systems level initiatives should recognise and support an environment that enables optimal assessment and partnerships between interdisciplinary health professionals, residents and families in order to reach appropriate medication-related decisions.
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