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Personalised, patient-inclusive clinical medication reviews can reduce drug-related problems in older patients

Por: Acorn · M.

Commentary on: Verdoorn S, Kwint HF, Blom JW, et al. Effects of a clinical medication review focused on personal goals, quality of life, and health problems in older persons with polypharmacy: a randomised controlled trial (DREAMeR-study). PLoS Med 2019;16:e1002798. doi: 10.1371/journal.pmed.1002798.

Implications for practice and research

  • Optimising personalised and tailored clinical medication reviews (CMRs) for older patients can reduce drug-related problems (DRPs) due to multimorbidity and polypharmacy.

  • An approach to the CMR guided by patient goals and preferences are beneficial to quality of life and well-being.

  • Context

    A CMR is a structured, critical examination of a patient’s medications with the objective of reaching an agreement about treatment, optimising medicine impact, minimising medication-related issues and reducing waste. Limited evidence exists on the CMR intervention ability to improve patient outcomes. The DREAMeR study looks at polypharmacy in older persons who can benefit from a patient-centred CMR...

    Frailty leads to higher mortality and hospital use

    Commentary on: Keeble, E, Parker, SG, Arora, S, et al. Frailty, hospital use and mortality in the older population: findings from the Newcastle 85+ study. Age Ageing 2019;48:797–802.

    Implications for practice and research

  • Frailty leads to higher mortality and hospital use.

  • Information about frailty should inform the development of services to meet patient need.

  • Research in the community setting is required to better understand proactive and preventative approaches in frailty management.

  • Context

    Frailty is a common clinical syndrome in older adults that carries an increased risk for poor health outcomes including falls, incident disability, hospitalisation and mortality. Frailty is a significant determinant of healthcare use and associated costs, both of which also increase as a person nears death. In the UK, and internationally, those aged over 85 years are the fastest growing demographic group. By 2050, the number of people...

    Combining physical and cognitive interventions positively affects gait in older adults with cognitive impairment

    Por: Mitchell · G. · McTurk · V.

    Commentary on: Zhang W, Low LF, Gwynn JD, et al. Interventions to improve gait in older adults with cognitive impairment: a systematic review. J Am Geriatr Soc 2019;67;381–91.

    Implications for practice and research

  • Gait is not solely a biomechanical process. Cognitive factors need to be considered when employing interventions to improve gait in older people.

  • Physical and cognitive factors affect gait performance, and both should be addressed in intervention programs.

  • To improve gait in older people living with mild cognitive impairment, or the early stages of dementia, gait interventions should include strength, balance and functional mobility training in combination with cognitive control training.

  • Context

    The prevalence of gait and balance disorders significantly increases as a person grows older. These disorders affect around 10% people in their 60s and >60% of people in their 80s.1 Recent studies have found a strong link...

    Healthcare professionals must communicate with patients and relatives. They must enable informed, realistic and appropriate decisions in end-of-life pharmacotherapy

    Por: Lee · A. J.

    Commentary on: Morin L, Wastesson JW, Laroche ML, et al. How many older adults receive drugs of questionable clinical benefit near the end of life? A cohort study. Palliat Med 2019;33:1080–90. doi: 10.1177/0269216319854013.

    Implications for practice and research

  • Healthcare professionals must review medications for appropriateness, efficacy and benefits to their patients and must communicate effectively with patients and relatives.

  • We need to re-examine and review drug use and prescribing practices to assert clinically and contextually appropriate care. However, qualitative research is needed to evaluate clinician prescribing with patients.

  • Context

    Use of a variety of drugs (polypharmacy) is required to manage complex disease processes. At the end of life, the focus of ‘treatment’ changes from extending survival to symptom management—therefore, aims of treatments change, requiring different pharmaceutical approaches.1 A recent Delphi study used consensus opinion of 40 experts to label drugs as ‘often...

    Repeated hospital admissions are missed opportunities to offer better end-of-life care for people with dementia

    Por: Anderson · C.

    Commentary on: Leniz J, Higginson IJ, Stewart R, et al. Understanding which people with dementia are at risk of inappropriate care and avoidable transitions to hospital near the end-of-life: a retrospective cohort study. Age and Ageing 2019:afz052. doi: 10.1093/ageing/afz052

    Implications for practice and research

  • Research: explorative study with healthcare professionals to identify their clinical reasoning when admitting to hospital people with dementia for end-of-life care.

  • Practice: ensure advanced directives are identified for people admitted to hospital with dementia.

  • Context

    Around 46 million people worldwide have a diagnosis of dementia. Caring for people with dementia at the end of life has significant economic implications.1 Hospital admission is not always the preferred option for people with dementia for end-of-life care. This study explores the number of transitions to hospital that people with dementia who need end-of-life care undergo. They consider, in particular, multiple admissions in...

    Comorbidity is a risk factor for poor quality of life in people with dementia

    Por: Zhang · N.

    Commentary on: Nelis SM, Wu YT, Matthews FE, et al. The impact of co-morbidity on the quality of life of people with dementia: findings from the IDEAL study. Age Ageing 2019;48:361–7. doi: 10.1093/ageing/afy155.

    Implications for practice and research

  • In practice, nurses should begin to recognise comorbidity as a risk factor for decreased global wellness in people with dementia.

  • Further research could explore interventions to help to improve the quality of life (QoL) for people with dementia who have multimorbidity.

  • Context

    Dementia is an increasingly common health problem.1 Many individuals live with comorbidities and this is also true of those individuals with dementia. A recent editorial summarised the landscape of dementia and comorbidities through the following points: (1) comorbidities negatively influence QoL; (2) dementia overshadows recognition of comorbidities and (3) interactions between these comorbidities and dementia can lead to poorer outcomes.2...

    Place of death preference among people with dementia: an important conversation

    Por: Reed · J.

    Commentary on: Wiggins N, Droney J, Mohammed K, et al. Understanding the factors associated with patients with dementia achieving their preferred place of death: a retrospective cohort study. Age Ageing 2019;48:433–439.

    plications for practice and research

  • Quality end-of-life care planning is of high importance for patients with dementia.

  • Numbers of people with dementia are projected to increase markedly over coming decades, investment in care homes is a necessity.

  • Further research necessary to examine other aspects of end-of-life care for this population and evaluate ‘Coordinate My Care’s role in improving end-of-life care.

  • Context

    As life expectancy increases, more and more people are suffering with dementia,1 with numbers anticipated to continue to rise into the foreseeable future.2 Despite this, little is known about the preferred place of death (a quality marker for end-of-life care) for patients suffering with...

    'Use it or lose it: the relationship between the frequency of word puzzle use and cognitive function

    Commentary on: Brooker H, Wesnes KA, Ballard C, et al. An online investigation of the relationship between the frequency of word puzzle use and cognitive function in a large sample of older adults. Int J Geriatr Psychiatry 2019;34:921–31. doi: 10.1002/gps.5033.

    Implications for practice and research

  • Psychosocial approaches to enhancing and reableing cognitive function are becoming increasingly useful in the everyday practice of nurses working with people with dementia.

  • There is a great benefit in conducting such longitudinal cohort studies, such as PROTECT (Platform for Research Online to investigate Genetics and Cognition in Ageing) and others, that allows for important subanalysis of data such as this, which add to the body of evidence in preventing or delaying dementia.

  • Context

    A degree of cognitive decline is common in ageing; however, it can also be a precursor to mild cognitive impairment and dementia, such as Alzheimer’s disease...

    The evidence base for pain management of people with dementia in the community is weak and needs to be improved

    Por: Parsons · G.

    Commentary on: Bullock L, Bedson J, Jordan JL, et al. Pain assessment and pain treatment for community-dwelling people with dementia: a systematic review and narrative synthesis. Int J Geriatr Psychiatry 2019;346:807–21. doi: 10.1002/gps.5078.

    Implications for practice and research

  • Currently knowledge and care rely upon evidence from hospital and nursing home settings and this review suggests that this knowledge is not transferable.

  • There is a strong requirement for comparative studies to evaluate the effectiveness of different approaches to pain assessment and treatment among people with dementia in the community.

  • Context

    There is an ageing population with a related increase in dementia many of whom are likely to experience pain.1 Many more people with dementia are likely to be cared for in the community than in a formal care setting. We know that people with dementia cared for in hospital and nursing home settings...

    Being non-frail and having an elective procedure are the strongest predictors associated with functional recovery among older survivors of major surgery

    Por: Rolls · K. · Mc Evoy · L. · Ritcher · M. · Frost · S. A.

    Commentary on: Becher RD, Murphy TE, Gahbauer, EA. et al. Factors associated with functional recovery among older survivors of major surgery. Ann Surg 2019; Feb 6. doi:10.1097/SLA.0000000000003233. [Epub ahead of print].

    Implications for practice and research

  • Presurgical frailty status needs to be routinely assessed among the elderly.

  • Comprehensive presurgical and postsurgical care needs to be planned for the frail.

  • Context

    Worldwide, the population is ageing and in the context of hospital care, the most problematic consequence of this is the clinical condition of frailty.1 Frailty develops as a result of age and or chronic disease-related decline in several physiological systems, leaving the individual vulnerable to minor stressor events (eg, change in medications, illness and surgery), leading to an acute deterioration in health and increasing the risk of adverse outcomes, in the hospital setting.1 2 Current data suggest that...

    Quality of life among older adults with Alzheimers disease in residential care: who knows best?

    Por: Kean · T.

    Commentary on: Dewitte L, Vandenbulcke M, Dezutter J. Cognitive functioning and quality of life: diverging views of older adults with Alzheimer and professional care staff. Int J Geriatr Psychiatry 2018;33:1074–1081. doi: 10.1002/gps.4895.

    Implications for practice and research

  • Older adults living with Alzheimer’s disease (AD) respond best to patient-centred care that values and affirms personhood and maintains the ‘self’.

  • Research to examine perceptions and attitudes of professional care staff towards AD in older adults may provide insight into pre-existing quality of life (QOL) biases.

  • Context

    As the prevalence of AD grows across the globe, individuals, caregivers and health organisations struggle to cope with the overwhelming personal, economic, and healthcare system challenges that often accompany the condition. With a growing need for residential care facilities to assume care, QOL has become an important measure to families and staff. The study by Dewitte et al1 examines the...

    Hospital admission may increase the risk of potentially inappropriate prescribing among older primary care patients

    Por: Schwanda · BSc · MScN · RN · M. · Gruber · BScN · MSc · RN · R.

    Commentary on: Pérez T, Moriarty F, Wallace E, et al. Prevalence of potentially inappropriate prescribing in older people in primary care and its association with hospital admission: longitudinal study. BMJ 2018;363:k4524. doi: 10.1136/bmj.k4524.

    Implications for practice and research

  • The process of medication reconciliation could be a strategy to reduce the risk of potentially inappropriate prescribing among older primary care patients.

  • There exists a significant association between hospital admission and potentially inappropriate prescribing, but further research regarding medication management across all involved healthcare professions is needed.

  • Context

    A crucial approach of the WHO’s third global patient safety challenge is to identify potentially inappropriate prescribing, associated with adverse drug events, hospital admissions and reduced quality of life.1 The omission of beneficial drugs, the use of drugs with a drug–drug interaction, the use of incorrect drug dosages and/or prescribing durations and the prescribing of drugs primarily...

    Higher risk of physical frailty in older person is associated with increased levels of loneliness rather than social isolation

    Por: Ganesalingam · G.

    Commentary on: Gale CR, Westbury L, Cooper C. Social isolation and loneliness as risk factors for the progression of frailty: the English Longitudinal study of aging. Age Ageing 2018;47:392–7.

    Implications for practice and research

  • Health professionals need to have deeper knowledge and understanding to support and prevent older persons experiencing loneliness, social isolation and the increased risk of frailty.

  • Research needs to be carried out with diverse ethnic groups to identify, what they consider experiences of social isolation and loneliness and what support can be provided to prevent physical frailty.

  • Context

    Recently, research has focused on social isolation and loneliness in older person.1 Studies tend to focus on frailty, physical health, mental health, mortality and public health link to risk for social isolation and loneliness in older person. This study by Gale et al identified that social isolation and loneliness were associated with...

    Should aspirin be used for primary prevention in the healthy elderly?

    Por: Thompson · D.

    Commentary on: McNeil JJ, Wolfe R, Woods RL, et al. Effect of aspirin on cardiovascular events and bleeding in the healthy elderly. N Engl J Med 2018;379:1509–18.

    Implications for practice and research

  • Low-dose aspirin as a primary prevention measure in older adults results in a significantly higher risk of major haemorrhage and does not result in a significantly lower risk of cardiovascular disease (CVD) than placebo.

  • All patients taking aspirin for primary prevention should be informed of the risk of major bleeding and the minimal benefits in terms of CVD events.

  • More research related to low-dose aspirin for primary prevention in younger age groups is warranted.

  • Context

    Aspirin is a wonder drug—it is the most used drug worldwide and recently celebrated its 120th birthday—and has been regarded as a key antiplatelet agent that protects from cardiovascular events and saves lives.1 Although...

    International study reveals aged patients with dementia frequently receive 'inappropriate prescriptions

    Por: :Lee · A. J.

    Commentary on: Renom-Guiteras A, Thürmann PA, Miralles R, et al. Potentially inappropriate medication among people with dementia in eight European countries. Age Ageing 2018;47:68–74.1

    Implications for practice and research

  • Clinicians must routinely evaluate prescriptions in elderly people with dementia to prevent adverse effects from polypharmacy.

  • Use and application of tools which evaluate ‘inappropriate prescribing’ must also be country specific (to reflect healthcare systems) and individual specific (to reflect clinical appropriateness in patient groups).

  • Context

    Older people suffering dementia have a range of needs and pharmacological treatments to manage the array of comorbidities associated with ageing and ill health.1 Many countries have reviewed medicine regimens which are potentially harmful in older populations. However, because of differences in healthcare and pharmaceutical regulations across the globe, identifying the drugs which may be ‘potentially harmful’ has been difficult. The situation becomes even more complicated by the...

    Evidence that active pain treatment improves sleep quality and quantity in people with depression and dementia

    Por: Swift · A.

    Commentary on: Blytt KM, Bjorvatn B, Husebo B, et al. Effects of pain treatment on sleep in nursing home patients with dementia and depression: A multicenter placebo-controlled randomized clinical trial. Int J Geriatr Psychiatry 2018;33:663–70.

    Implications for research and practice

  • Active pain treatment improves sleep in people with dementia and depression.

  • This study paves the way for improved methods; these results should be used as the basis for further exploration of this important issue.

  • Future studies should include subjective evaluation of the benefits of pain treatment on sleep and explore improvements in related areas such as day-time functioning and falls.

  • Context

    It is recommended that we get approximately 8 hours of sleep per day, and poor-quality sleep causes decline in physical and psychological functioning including impacts on the metabolism, immunity and memory.1 People with dementia (PWD) often experience sleep problems, and...

    Better support and education is imperative to bolster informal at-home carers of people with cognitive impairment and reduce incidences of involuntary treatment of older adults in their homes

    Por: Heale · R.

    Commentary on: Moermans VRA, Bleijlevens MHC, Verbeek H, et al. The use of involuntary treatment among older adults with cognitive impairment receiving nursing care at home: a cross-sectional study. Int J Nurs Stud 2018;88:135–42. doi: 10.1016/j.ijnurstu.2018.09.004.

    Implications for practice and research

  • There is a need to develop better education and support for informal caregivers of people with cognitive impairment at home to reduce the use of involuntary treatment.

  • More research is needed about the effectiveness of programmes to reduce involuntary treatment of older adults in the home.

  • Context

    Consent for care is a foundational principle for healthcare professionals.1 Despite this, burgeoning research has shown that cognitively impaired older adults living and receiving care at home are at risk for ‘involuntary treatment’, or care without their consent. This includes things such as physical restraints, psychotropic medication andnon-consensual care (such as being bathed or receiving...