Psychotropic medication in geriatric psychiatric patients: use and unreported use in relation to serum concentrations

Purpose

The aim of this observational study was to describe the type, number, and serum concentration levels of psychotropic drugs in elderly patients, on admission to a geriatric psychiatric inpatient unit. We further wanted to investigate the use and unreported use of psychotropic drugs by analyzing for a broad spectrum of drugs in the serum samples.

Methods

A total of 236 patients were included. Drug use, patient characteristics, and diagnoses were recorded, and serum analysis was performed for a total of 56 psychotropic drugs in 233 of the patients.

Results

Nine out of ten patients (88 %) used one or more psychotropic drugs on admission to hospital; the mean use was 2.8 (95 % confidence interval (CI) 2.6–2.9) drugs. In 25 patients (11 %), drugs reported used were not detected in serum. Unreported use of drugs (serum analysis revealing one or more drugs not reported) was found in 100 patients (43 %). This was more common in younger patients. Psychotropic polypharmacy (use of three or more psychotropic drugs) was found in 109 patients (47 %). Patients with a main diagnosis of affective disorder used the most psychotropic drugs.

Conclusions

Psychotropic drugs are commonly used among geriatric psychiatric patients on admission to hospital. Psychotropic polypharmacy is a major concern among these patients. There was considerable unreported use of drugs within this population, and a low threshold for a broader serum analysis for psychotropic drugs appears indicated.     

Polypharmacy, length of hospital stay, and in-hospital mortality among elderly patients in internal medicine wards. The REPOSI study

Purposes

We evaluated the prevalence and factors associated with polypharmacy and investigated the role of polypharmacy as a predictor of length of hospital stay and in-hospital mortality.

Methods

Thirty-eight internal medicine wards in Italy participated in the Registro Politerapie SIMI (REPOSI) study during 2008. One thousand three hundred and thirty-two in-patients aged ??65?years were enrolled. Polypharmacy was defined as the concomitant use of five or more medications. Linear regression analyses were used to evaluate predictors of length of hospital stay and logistic regression models for predictors of in-hospital mortality. Age, sex, Charlson comorbidity index, polypharmacy, and number of in-hospital clinical adverse events (AEs) were used as possible confounders.

Results

The prevalence of polypharmacy was 51.9% at hospital admission and 67.0% at discharge. Age, number of drugs at admission, hypertension, ischemic heart disease, heart failure, and chronic obstructive pulmonary disease were independently associated with polypharmacy at discharge. In multivariate analysis, the occurrence of at least one AE while in hospital was the only predictor of prolonged hospitalization (each new AE prolonged hospital stay by 3.57?days, p?p?=?0.02), comorbidities (OR 1.18; 95% CI 1.12?C1.24; p?p?Conclusions Although most elderly in-patients receive polypharmacy, in this study, it was not associated with any hospital outcome. However, AEs were strongly correlated with a longer hospital stay and higher mortality risk.     

In-hospital medication reviews reduce unidentified drug-related problems

Purpose

To examine the impact of a new model of care, in which a clinical pharmacist conducts structured medication reviews and a multi-professional team collates systematic medication care plans, on the number of unidentified DRPs in a hospital setting.

Methods

In a prospective two-period study, patients admitted to an internal medicine ward at the University Hospital of Lund, Sweden, were included if they were ≥ 65 years old, used ≥ 3 medications on a regular basis and had stayed on the ward for ≥ 5 weekdays. Intervention patients were given the new model of care and control patients received conventional care. DRPs were then retrospectively identified after study completion from blinded patient records for both intervention and control patients. Two pairs of evaluators independently evaluated and classified these DRPs as having been identified/unidentified during the hospital stay and according to type and clinical significance. The primary endpoint was the number of unidentified DRPs, and the secondary endpoints were the numbers of unidentified DRPs within each type and clinical significance category.

Results

The study included a total of 141 (70 intervention and 71 control) patients. The intervention group benefited from a reduction in the total number of unidentified DRPs per patient during the hospital stay: intervention group median 1 (1st–3rd quartile 0–2), control group 9 (6–13.5) (p < 0.001), and also in the number of medications associated with unidentified DRPs per patient: intervention group 1 (0–2), control group 8 (5–10) (p < 0.001). All sub-categories of DRPs that were frequent in the control group were significantly reduced in the intervention group. Similarly, the DRPs were less clinically significant in the intervention group.

Conclusions

A multi-professional team, including a clinical pharmacist, conducting structured medication reviews and collating systematic medication care plans proved very effective in reducing the number of unidentified DRPs for elderly in-patients.     

Pilot study to assess the influence of an enhanced medication plan on patient knowledge at hospital discharge

Purpose

This study assessed the effect of providing an enhanced medication plan (EMP) to patients during patient-physician conversation at hospital discharge and evaluated its immediate impact on patient knowledge on pharmacotherapy.

Methods

We observed patient-physician conversations at hospital discharge in three internal medicine wards of the University Hospital Heidelberg before and after the EMP was integrated into the discharge process, and documented how and to what extent physicians provided the patients with drug information. After the conversation, the patients’ knowledge was evaluated by three standardized questions about their pharmacotherapy.

Results

We observed 90 conversations (50 before EMP-implementation, 40 after). In both phases, the conversation duration was 5.6–6 min (p?=?0.56). However, the time spent on drug information increased significantly by 61.7 % after EMP-implementation (+63 s, p?=?0.02). Before implementation, physicians gave at least one drug administration recommendation for 75.1 % of all drugs, compared to 84.6 % after implementation (p?=?0.02). The EMP provided information for almost all drugs (98.9 %; p?p?Conclusion The provision of an EMP improves information transfer and therefore increases the patients’ knowledge of their individual drug treatment without prolonging the overall discharge process.     

Influence of Admission to a Tertiary Care Hospital after a Fall on Use of Potentially Inappropriate Medications among Older Patients

Background:

Each year, about one-third of individuals over the age of 65 years will experience a fall, and half of these will experience a subsequent fall in the following year. The use of potentially inappropriate medications (PIMs) is an important factor contributing to increased fall risk in geriatric patients.

Objective:

To determine the proportion of patients over the age of 65 admitted to orthopedics and general medicine services with diagnosis of a fall who experienced a change in the total number or dosage of PIMs, as defined by the Beers criteria, upon discharge from hospital.

Methods:

This retrospective observational study involved patients admitted to a tertiary care hospital with diagnosis of a fall between January 1 and December 31, 2011. Those aged 65 years or older with at least one PIM on admission were eligible for inclusion. Data analysis included χ² and Fisher testing, as well as multivariate analysis.

Results:

A total of 148 patients were included, of whom 63 (43%) had an overall change in the dosage or number of PIMs during their hospital stay. Forty patients (27%) had an overall reduction in the dosage or number of PIMs upon discharge from hospital, whereas 23 (16%) experienced an overall increase in the dosage or total number of PIMs. The mean number (± standard deviation) of PIMs decreased during the hospital stay, from 1.6 ± 0.8 on admission to 1.4 ± 0.9 on discharge (p = 0.03). Benzodiazepines were the class of PIMs most frequently discontinued or reduced in dosage.

Conclusion:

One-quarter of patients admitted with falls had de-escalation of PIMs upon hospital discharge. Although dosage reduction or drug discontinuation may not be appropriate for all patients, a standardized approach to medication review during the hospital stay and improved prescriber education and awareness of PIM use among elderly individuals are warranted.     

Increased use of second generation antipsychotic drugs in primary care: potential relevance for hospitalizations in schizophrenia patients

Aim

To analyze the changes in the prescribing pattern of antipsychotic drugs in primary care in Extremadura (Spain) from 1990 to 2005, and the potential association with schizophrenia hospitalization rate.

Methods

Data from 1990–2005 about the prescribing of antipsychotic drugs was drawn from all community pharmacy sales figures reimbursed by the Health System of Extremadura. Drug consumption figures were expressed as the number of defined daily doses per 1,000 inhabitants and per day of treatment (DDD/1,000/day). The total number of annual hospital discharges with the diagnosis of schizophrenia according to DSM-IV criteria from all hospitals in Extremadura from 1 January 1995 to 31 December 2000 was also determined.

Results

The use of second-generation antipsychotic drugs (SGAs) increased from 0% in 1990–1993 to 78% in 2005. Olanzapine was the most used SGA from 1999–2005. During 1995–2000 the sales of SGAs increased to 50% from 10%. In the same period, the hospitalization rate in schizophrenia patients fell by an average of 12%, which was significantly associated with SGA use (R?=??0.88; P?=?0.02).

Discussion

The increase in SGAs paralleled the decreased rate of hospitalization in schizophrenia patients. However, the influence of other factors such as SGA use for disorders other than schizophrenia can not be ruled out. Moreover changes in the health-care system, such as the increase in primary mental health care and social rehabilitation programs, may also have a relevant influence.

     

Comparative epidemiology of hospital-acquired adverse drug reactions in adults and children and their impact on cost and hospital stay – a systematic review

Purpose

To study and analyze the comparative impact of hospital-acquired adverse drug reactions (ADRs) in adult and pediatric patients in terms of the economic implications, (length of) hospital stay, and salient features in relation to the incidence rate, severity, morbidity, mortality, and preventability of the ADRs.

Methods

A systematic search to identify and retrieve relevant articles/studies in the PubMed, Medline, Scopus, MEDPAR, and Cochrane databases and by the Google search engine was performed for the study period 2000 to April 2013. In total, 51 studies were identified on patients hospitalized for ADRs, and these were included in the study. The incidence rate of ADRs, their severity, mortality, morbidity, preventability, cost, and association with extended hospital stay due to ADRs were extracted and scrutinized.

Results

Hospital-acquired ADRs are more widely studied in adults than in children, and the incidence rate is higher in the former. However, a wide variation in the incidence rate worldwide is observed in both groups. Irrespective of the ages of patients, ADRs are among the most frequent causes of morbidity and mortality. Interestingly, preventable ADRs are more frequently observed in patients at the younger and older ends of the age spectrum. Hospital-acquired ADRs place an immense economic burden on healthcare systems, with the overall cost for a hospitalized patient with an ADR reported to be $2,401 per patient, which is equivalent to a 19.86 % additional increase in the total cost of care and an increase in average length of hospital stay of 8.25 %.

Conclusion

Based on the findings of this review, we suggest that excellent assertive measures of pharmacovigilance with the aim to diminish the incidence rate of hospital-acquired ADRs and support the development of interventions are needed to promote vital facets of drug safety with an overall objective to avert potential ADRs.     

Objective assessment of nonadherence and unknown co-medication in hospitalized patients

Purpose

The intake of medications (drugs) without the knowledge of the treating physician (unknown co-medication) and nonadherence strongly influence drug safety. The aim of our study was to objectively assess unknown co-medication and nonadherence in hospitalized patients by screening urine for a large number of drugs using highly sensitive full scan gas chromatograpy/mass spectrometry (GC/MS). Secondary objectives were to determine the relationship of co-medication and nonadherence to the number of drugs prescribed and to compare history-taking by a pharmacist versus a physician.

Methods

In 152 patients, the drug histories taken by physicians, patients’ self-reported adherence, and information compiled during as many as three structured interviews conducted by a trained pharmacist on days 1–2, 3–4, and 7–11 of the hospital stay were compared with the GC/MS results from urine samples collected after each interview.

Results

In the interviews performed by the pharmacist, 235 additional drugs were identified that were not documented in the chart. Of all the drugs indicated in any interview, 16.9% were identified only by the physician, 24.1% only by the pharmacist, and 59% by both. Overall, in 78% of the patients at least one additional drug was identified by urine screening. The findings suggest overall nonadherence to at least one drug in 13.0% of patients on admission and in 23.3% of patients at any time during hospitalization. Nonadherence was less frequent for critical dose drugs and correlated with the number of prescribed drugs.

Conclusions

The drug history among hospitalized patients is often incomplete, and nonadherence and unknown co-medication are alarmingly frequent. This lack of knowledge might impact the overall success of drug therapies in the hospital setting.