Combined intervention programme reduces inappropriate prescribing in elderly patients exposed to polypharmacy in primary care

Purpose  To evaluate the effect of a combined or a single educational intervention on the prescribing behaviour of general practitioners (GPs). The primary endpoint was effect on inappropriate prescribing according to the Medication Appropriateness Index (MAI). Methods  General practitioners were randomised to either (1) a combined intervention consisting of an interactive educational meeting plus feedback on participating patients’ medication, (2) a single intervention with an interactive educational meeting or (3) a control group (no intervention). Elderly (>65 years) patients exposed to polypharmacy (≥5 medications) were identified and approached for inclusion. Data on medications prescribed over a 3-month period were collected, and the GPs provided detailed information on their patients before and after the intervention. A pre- and post-MAI were scored for all medications. Results  Of the 277 GPs invited to participate; 41 (14.8%) volunteered. Data were obtained from 166 patients before and after the intervention. Medication appropriateness improved in the combined intervention group but not in the single intervention group. The mean change in MAI and number of medications was −5 [95% confidence interval (CI) −7.3 to −2.6] and −1.03 (95% CI −1.7 to −0.30) in the combined intervention group compared with the group with the educational meeting only and the no intervention group. Conclusions  A combined intervention consisting of an interactive educational meeting plus recommendations given by clinical pharmacologists/pharmacists concerning specific patients can improve the appropriateness of prescribing among elderly patients exposed to polypharmacy. This study adds to the limited number of well-controlled, randomised studies on overall medication appropriateness among elderly patients in primary care. Important limitations to the study include variability in data provided by participating GPs and a low number of GPs volunteering for the study. The trial is not registered in a publicly available database of clinical trials. The trial was conducted in a period prior to June 1, 2007.     

唐山市住院精神分裂症患者抗精神病药物联合治疗调查

目的 分析住院精神分裂症患者抗精神病药物联合治疗率及影响因素.方法 调查1986,1996,2001和2006年4个年份在唐山市6所精神病院出院精神分裂症患者的住院病历,用专门设计的调查表记录患者的社会人口学资料、疾病特征以及患者出院时药物治疗信息.结果 4个年份住院精神分裂症患者出院时抗精神病药物联合治疗率分别为13.2%、18.1%、32.7%和28.9%,差异有显著性(x2=76.431,df=1,P＜0.01;趋势卡方检验x2=25.542,df=1,P＜0.01);多因素分析表明患者的病程(＜18月∶OR=0.686,95%CI∶0.528～0.893,ref:＞100月),住院次数(OR=1.117,95%CI∶1.037～1.203),就诊医院(市级A医院:OR=0.736,95%CI∶0.562～0.964;市级B医院∶OR=0.377,95%CI∶0.293～0.486;市级C医院:OR=1.803,95%CI∶1.279～2.540,ref:县级医院)、以及出院年份(1986∶OR=0.421,95%CI∶0.298～0.595;1996∶OR=0.590,95%CI∶0.456～0.764;2001∶OR=1.249,95%CI∶1.023～1.524,ref∶2006)与接受抗精神病药物联合治疗有关.结论 唐山地区住院精神分裂症患者联合抗精神病药物治疗的比例呈上升趋势,抗精神病药物联合治疗率存在医院差别,患者的发病年龄、病程、住院时间和住院次数与抗精神病药物联合治疗有关.     

Polypharmacy in elderly hospitalised patients in Slovakia

Objective The aims of the present study were to: analyse the prevalence of polypharmacy in a group of older patients; evaluate the influence of hospital stay on the number of drugs taken; assess the most frequently prescribed pharmacological classes; identify risk factors that predisposed the patient to polypharmacy. Setting The study was carried out in the Department of Internal Medicine of a non-university general hospital. Method In the retrospective study, 600 patients aged 65 years or more were enrolled. They were hospitalised in the period from 1st December 2003 to 31st March 2005. Each person taking six or more medications per day was considered to be a patient with polypharmacy. Particular sociodemographic and clinical characteristics, as well as comorbid conditions, were evaluated as factors potentially influencing the prevalence of polypharmacy. Main outcome measure The number and type of medications taken at the time of hospital admission and discharge were recorded and compared for each patient. Results Polypharmacy on admission and at discharge was observed in 362 (60.3%) and 374 (62.3%) patients, respectively. Hospitalisation led to a significant increase in the number of medications. The spectrum of medications used corresponded to the proportions of diagnoses in the evaluated group, in which cardiovascular diseases were most prevalent. According to the multivariate analysis using a logistic regression model, diabetes mellitus (odds ratio (OR) 2.40; 95% confidence interval (CI): 1.64–3.50), heart failure (OR 2.14; 95% CI: 1.46–3.14), dementia (OR 2.12; 95% CI: 1.26–3.57), living alone (OR 2.00; 95% CI: 1.28–3.10), arterial hypertension (OR 1.63; 95% CI: 1.08–2.44) and cerebrovascular disease (OR 1.58; 95% CI: 1.03–2.44) significantly increased the risk of the presence of polypharmacy. Conclusion Our study confirmed a relatively high prevalence of polypharmacy in Slovak elderly patients. Polypharmacy risk rose especially with the increased prevalence of diseases of advancing age (diabetes mellitus, heart failure, arterial hypertension, dementia and cerebrovascular diseases). The increasing numbers of medications in inpatients indicate the need for the careful re-evaluation of pharmacotherapy during the stay in hospital.     

Simplifying psychotropic medication regimen into a single night dosage and reducing the dose for patients with chronic schizophrenia

Rationale Taking psychotropic medications is frequently problematic from both consumers' and caregivers' perspective. Occasionally missed doses may lead to pervasive non-adherence with relapse a likely outcome. Objective To evaluate the simple medication regimen, all psychotropics were given at night for patients with chronic schizophrenia, who had been taking them at least twice a day for more than 12 weeks before the entry. Methods Switching of agents took place in two ways: converting only antipsychotic medications followed by other psychotropics, and changing all psychotropics simultaneously. Any psychotropics of little clinical significance were then cautiously minimized. Final evaluation was made 12 weeks after the competed dose consolidation. Patients finally rated their subjective impression on this intervention. Results Twenty-five patients were recruited in each treatment arm (50 in total). After switching, 11 got better, 29 remained stable whereas seven got worse, according to the Global Improvement. Three were not assessable. Overall, there were no relevant changes in clinical ratings including adverse effects. However, the chlorpromazine equivalent dose of antipsychotics and the number of total psychotropics were significantly reduced from 957 to 722 mg/day (p<0.0001) and from 4.0 to 3.2 (p<0.0001), respectively. Dose deflation of psychotropics was feasible in 35 subjects (74.5%). Twenty-six (of 40 successful) patients indicated that they favored the night-time regimen mainly because it was less complicated. Sedation in the morning was identified as an important adverse event, which should be addressed by reducing the dose. Conclusions The procedure may be of value to counteract a recent trend of psychotropic polypharmacy in schizophrenia.