Potentially inappropriate medications among elderly people with neurocognitive disorders – A nationwide register-based study using 3 different explicit criteria

BackgroundThe use of potentially inappropriate medications (PIMs) is a problem since it might contribute significantly to adverse drug reactions and hospital admissions among elderly with major neurocognitive disorder (NCD). To assess the appropriateness of drug treatment, different explicit criteria have been developed.ObjectivesTo investigate and compare the prevalence of PIM users among elderly with major NCD on a nationwide basis using 3 different explicit criteria. Furthermore, the study aimed to investigate factors associated with the use of PIMs.MethodsThis nationwide register-based study included 35,212 people, 65 years or older, diagnosed with major NCD and registered in the Swedish registry for cognitive/dementia disorders up to June 30, 2017 and alive December 31, 2017. PIMs were identified using 3 different explicit criteria; the Swedish quality indicators, the EU(7)-PIM list and the AGS Beers Criteria. PIM use was defined as having collected a minimum of one PIM at least once between July 01 – December 31, 2017.ResultsThe numbers of people using one or more PIMs were 7629 (21.7%) according to the Swedish quality indicators, 11,838 (33.6%) according to the EU(7)-PIM list, and 12,002 (34.1%) according to AGS Beers Criteria. Antipsychotics, antithrombotic agents and anxiolytics were the most frequently used PIM class according to the different assessment tools, respectively. The use of PIMs was positively associated with vascular dementia and Lewy body dementia/Parkinson's disease dementia, regardless of the assessment tool used. However, the association between using at least one PIM and age, sex, MMT-value and frontotemporal dementia, differed depending on the criteria used.ConclusionsThe different results and included PIMs indicate the different perspectives on PIMs between criteria, which make it difficult to compare the results. However, psychotropic drug use requires further highlighting, as well as the association between PIM use and different types of major NCD.     

Pharmacist–patient communication in Swedish community pharmacies

BackgroundIt is important that pharmacists counsel patients about their prescribed medicines, as it leads to improved therapeutic outcome, increases compliance, and decreases confusion and insecurity. Studies have shown that the number of patients getting any pharmaceutical counseling varies greatly. Swedish pharmacists claim that the focus of the dialog with the patient has switched from pharmaceutical counseling to economy and regulations.ObjectiveThe aim of this study was to determine the content and time disposition of the patient–pharmacist communication during dispensing of prescribed medicines at Swedish community pharmacies.MethodNon-participant observations and audio recordings were used as data-collecting methods. The content of the dialog was categorized into 2 deductively decided main categories–medicinal and non-medicinal issues–and 12 inductively decided subcategories.ResultsA total of 282 pharmacy encounters were observed and recorded, of which 259 fully coincided with the inclusion criteria. After categorizing the content of each encounter the results showed that there was little or no dialog regarding medicinal issues during the pharmacy encounter in Swedish community pharmacies. Forty percent of the dialog concerns non-medical issues and almost half of the encounter was silent.ConclusionMedicines are an essential treatment method in healthcare, and pharmaceutical expertise is available to patients who enter a community pharmacy. The results of this study show that today's pharmacy encounter is not focused on improving the use of medication, possibly resulting in the patient not gaining the most benefit from his or her treatment.     

Consumers’ expectations and experiences with chain community pharmacies in Lahore,Pakistan: a qualitative exploratory study

International Journal of Clinical Pharmacy - Background The model of community pharmacy practice is changing remarkably not only in the West but also in developing countries, which has led retail...     

A characterization of the current communication patterns in Danish community pharmacies – An observational study

BackgroundCommunity pharmacies have been trying to expand their core function by counseling customers at the counter. This has been challenging given that customers' interest in receiving counseling may be limited.ObjectivesTo characterize the current pharmacist–customer communication patterns to inform future studies and models of communication.MethodsNon-participant structured observations based on the works of Stevenson et al. were conducted. A random selection of one hundred encounters in five pharmacies in Denmark was obtained. Type of encounter, type of medicine purchased and the age and gender of the customer were observed, and associations between the parameters identified.ResultsCustomers initiated 13% of the dialogs, whereas 60% were initiated by the staff (with 38% of the customers declining the offer). 26% of the encounters saw no communication about the medicine. The customers' level of interest in counseling varied significantly and more with the type of medicine purchased than the level of encouragement from the staff to initiate a dialog. The customers' interest in dialog, in contrast with the staff behavior, depended significantly on age and gender.ConclusionsCustomers' interest in counseling varies significantly. Pharmacy staff should take this into consideration when trying to optimize communication.     

What influences the information exchange during self-medication consultations in community pharmacies? A non-participant observation study

BackgroundAlthough pharmaceutical staff consider guideline-compliant information exchange during self-medication consultations as crucial, they have not fully integrated it into practice. It is unclear what prevents pharmaceutical staff from implementing their positive intentions into their actual everyday practice. To improve the information exchange during the current consultation practice, a deeper understanding of its implementation is needed.ObjectivesThe aim was to evaluate the factors influencing information exchange during self-medication consultations in German community pharmacies.MethodsWe performed a non-participant observation of real-life consultations with post-consultation interviews of pharmaceutical staff in 10 pharmacies. The information exchanged during self-medication consultations was evaluated via 7 guideline-recommended information parameters in 2 stages of information exchange: (a) ‘information gathering’ and (b) ‘provision of information’. Directly after each observed consultation, pharmaceutical staff's opinion about the consultation, the customer's interest and their own performance was questioned. Factors associated with the observed extent of information exchange were analysed by Poisson regression analysis.ResultsIn the 379 self-medication consultations with 46 pharmaceutical staff members, 454 different customer enquiries were addressed, and 483 medications were dispensed. In median, 2 predefined information parameters (First-/Third quartile: 1/4) were fulfilled during an enquiry and 2 parameters (First-/Third quartile: 1/3) were fulfilled for a dispensed medication. Pharmaceutical staff were satisfied with 85% of their consultations and perceived 76% of them as easy to handle. In both information stages, information exchange increased when ‘customers were perceived to be interested in counselling’ (p < 0.001) and decreased when customers had a ‘specific medication request’ (p < 0.001).ConclusionsInformation exchange in pharmacies needs to be better integrated into daily practice. Strategies to encourage information exchange should also include pharmaceutical staffs’ perception of their own counselling technique. Ongoing patient-centred trainings should facilitate strategies to engage uninterested customers or costumers with specific medication requests in consultations.     

Existing arrangements for monitoring community pharmacies in England: Can they have a role in the revalidation of pharmacists?

BackgroundMaintaining and regulating professional competence in health care is a growing concern. Tasked with developing a system of revalidation for pharmacy professionals, the pharmacy regulator in Great Britain commissioned a series of studies to evaluate existing sources of evidence as potential contributors to the revalidation process.ObjectivesTo explore the utility of existing regulatory inspections and service commissioners' contract monitoring processes in the community pharmacy sector as sources of evidence of the fitness to practice of pharmacists in England.MethodsThirteen semistructured telephone interviews conducted with representatives of the regulatory Inspectorate and community pharmacy commissioners.ResultsInterviewees described current processes for inspecting and monitoring community pharmacy premises and the services they provided. Their focus was primarily on the pharmacy and not on the pharmacist. Views were given as to how the roles of the Inspectorate and service commissioners might be developed to incorporate aspects of revalidation. Particular issues were raised in relation to the revalidation of self-employed locum and independent owner pharmacists.ConclusionsExisting inspection and contract monitoring processes have little utility in providing evidence of the fitness to practice of individual community pharmacists in England. However, there may be potential for the Inspectorate and service commissioners to develop a role in revalidation, particularly for locum pharmacists and/or independent pharmacy owners. Moreover, they may take a role in providing the infrastructure required to support the process of revalidation for community pharmacists. Current financial pressures and restructuring in the National Health Service, however, are obstacles to the development of revalidation processes.     

Prescribing of psychotropics in the elderly: why is it so often inappropriate?

Psychotropic medications are an important treatment approach to mental health disorders; such disorders are common in the elderly population. Elderly patients are more likely to experience adverse effects from these agents than their younger counterparts due to age-related changes in pharmacodynamic and pharmacokinetic parameters. Because of these factors, inappropriate use of psychotropic medications in elderly patients has become a focus of concern. In general an agent is considered inappropriate if the risk associated with its use exceeds its benefit. Implicit and explicit criteria for inappropriate use of medications in the elderly have been created and include psychotropic agents. These criteria vary in their make-up but the explicit criteria tend to agree that amitriptyline, doxepin, and benzodiazepines that have long half-lives are not appropriate. Although explicit inappropriate medication criteria have been in existence since 1991, elderly patients continue to receive inappropriate psychotropic medications. A wide array of factors may be responsible for this practice. Provider-related causes include deficits in knowledge, confusion due to the lack of a consensus on the inappropriate psychotropic criteria, difficulties in addressing an inappropriate medication started by a previous provider, multiple prescribers and pharmacies involved in the care of a patient, negative perceptions regarding aging, and cost issues. Patients may contribute to the problem by demanding an inappropriate medication. Finally, the healthcare setting may inadvertently contribute to inappropriate prescribing by such policies as restrictive formularies or lack of reimbursement for pharmacists' clinical services. Successful approaches to optimising prescribing have been either educational or administrative. Educational approaches (e.g. one-on-one sessions, academic detailing) seek to influence decision making, while administrative approaches attempt to enforce policies to curtail the undesired practice. The US Omnibus Budget Reconciliation Act of 1987, which improved psychotropic medication use in long-term care, is an excellent example of administrative intervention. More research specifically focused on the causes of inappropriate psychotropic medication use and methods to avoid this practice is needed before targeted recommendations can be made.     

Can pharmacy assistants play a greater role in public health programs in community pharmacies? Lessons from a chlamydia screening study in Canberra,Australia

BackgroundLittle is known about the engagement of pharmacy assistants (PA) in public health service provision.ObjectiveTo explore the experiences of PA participating in a study to determine whether a cash reward, offered to consumers and pharmacy businesses, increased participation in community pharmacy-based chlamydia screening.MethodsPA experience of the study education and training package, participant recruitment and conducting screening (providing information about chlamydia, specimen collection and handling urine samples) were evaluated using knowledge assessment, a questionnaire and focus groups.ResultsTwenty PA participated in the study: 15 (75%) completed all education and training components, 20 (100%) completed the questionnaire and 10 (50%) attended a focus group. PA rated all education and training components as effective (mean visual analog scale scores >8.5). Most PA (13/18, 72.2%) did not support/were unsure about continuing the program, citing the 25% repeat testing rate (presumed to relate to the cash reward) and privacy/confidentiality issues as reasons. Qualitative analysis suggested that minimizing repeat testing, improved workload management and recognition of, and remuneration for, education and training would make this model more acceptable to PA.ConclusionFindings from this study support the assertion that PA can play a significant role in public health initiatives.     

Thalidomide in cancer treatment: a potential role in the elderly?

There is increased interest in the treatment of cancer with thalidomide because of its antiangiogenic, immunomodulating and sedative effects. In animal models, the antitumour activity of thalidomide is dependent on the species, route of administration and coadministration of other drugs. For example, thalidomide has shown antitumour effects as a single agent in rabbits, but not in mice. In addition, the antitumour effects of the conventional cytotoxic drug cyclophosphamide and the tumour necrosis factor inducer 5,6-dimethylxanthenone-4-acetic acid (DMXAA) were found to be potentiated by thalidomide in mice bearing colon 38 adenocarcinoma tumours. Further studies have revealed that thalidomide upregulates intratumoral production of tumour necrosis factor-alpha 10-fold over that induced by DMXAA alone. Coadministration of thalidomide also significantly reduced the plasma clearance of DMXAA and cyclophosphamide. All these effects of thalidomide may contribute to the enhanced antitumour activity. Recent clinical trials of thalidomide have indicated that it has minimal anticancer activity for most patients with solid tumours when used as a single agent, although it was well tolerated. However, improved responses have been reported in patients with multiple myeloma. Palliative effects of thalidomide on cancer-related symptoms have also been observed, especially for geriatric patients with prostate cancer. Thalidomide also eliminates the dose-limiting gastrointestinal toxic effects of irinotecan. There is preliminary evidence indicating that the clearance of thalidomide may be reduced in the elderly. The exact role of thalidomide in the treatment of cancer and cancer cachexia in the elderly remains to be elucidated. However, it may have some value as part of a multimodality anticancer therapy, rather than as a single agent.