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- Kindstedt, Jonas, 1986-
(author)
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Medication-related problems and psychotropic drug use in vulnerable older populations : a focus on acute hospital admissions and cognitive impairment
- 2023
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Doctoral thesis (other academic/artistic)abstract
- The ageing process involves several physiological changes that affect both pharmacodynamics and pharmacokinetics and that, in combination with a heavier disease burden and more extensive use of medicines, put older people at higher risk of medication-related problems and associated clinical outcomes. The older population is often treated as a homogenous group, when in fact there are factors that render certain individuals more vulnerable to adverse drug effects and other types of medication-related problems. Older people encountered in the acute medical care setting and/or individuals with varying degrees of cognitive impairment are especially vulnerable in that context. The overall aim of this thesis was to describe and understand medication use in certain vulnerable subgroups of older people, which in turn might identify suitable target populations in which medication-related problems can be prevented or managed through interventions or similar efforts.Paper I presented, in the form of a study protocol, a clinical pharmacist intervention intended to reduce the risk of medication-related readmission to hospital among people aged 75 years or older during transitions of care. Based on 300 participants from the intervention study, approximately 50% had been readmitted to hospital within 180 days of being discharged from the hospital. Both heart failure and cognitive impairment, the latter identified through a four-item test, were predictors of early readmission. Altogether, the study population seems relevant for the purpose of the intervention; whether the intervention model is effective remains to be determined.Based on the same sample of study participants, paper II found that approximately one third of the 300 index hospital admissions were possibly medication related. Moreover, possibly medication-related hospital admissions were negatively associated with the fewest positive/correct answers on the four-item screening tool for cognitive impairment, which suggests that those clinical events might be less prevalent among people with cognitive impairment when exploring the association cross-sectionally. Both papers III and IV were registry-based studies, and their overall objective can be summarized as to describe psychotropic drug use and associated factors among older people with major neurocognitive disorder (NCD). Paper III focused on differences between major NCD subtypes, whereas paper IV compared people with major NCD against matched references from the total older population. In brief, overall psychotropic drug use was notably higher among people with major NCD, although generally in line with national treatment guidelines in terms of individual drugs of choice. The use of hypnotic drugs was also extensive in the reference group, and deprescribing efforts seem warranted, although longitudinal studies that focus on long-term use could provide a better picture of the potential problem. Nursing home stay was also positively associated with psychotropic drug use for all classes of psychotropic drugs, and the difference was most prominent for antipsychotic drugs. In that context, over 1,200 people in the reference population, most of them nursing home residents, had filled prescriptions for antipsychotic drugs, a figure indicating that the management of neuropsychiatric symptoms might also be an issue among older people who, due to various circumstances, have not been examined and diagnosed with neurocognitive disorders. Regarding major NCD subtypes, individuals with Lewy body dementia had, except for antidementia drugs, higher odds of psychotropic drug use than did those with Alzheimer’s disease. For example, the odds of antipsychotic drug use were more than twice as high, which is a worrying figure given that people with Lewy body dementia are extremely sensitive to the adverse effects of those specific drugs.In conclusion, this thesis illustrates the heterogeneity of demographics and drug use among older people and indicates that certain types of medication-related problems may be more relevant in certain older subpopulations. Medicines appear to be involved in many hospital admissions of older people, and the acute medical setting and subsequent care transitions are likely an important focus of pharmaceutical interventions. However, psychotropic drugs are probably not a major issue in that specific context. Efforts to reduce psychotropic drug use are likely more relevant to people with major NCD, especially in the nursing home setting. Antipsychotic drug exposure among persons with Lewy body dementia could be one such focus, especially since there are other better-balanced pharmacological treatment options for these individuals in terms of efficacy and safety profile.
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| 2. |
- Sönnerstam, Eva, 1984-
(author)
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Potentially inappropriate drug treatment among older people with cognitive impairment
- 2022
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Doctoral thesis (other academic/artistic)abstract
- Background: The aging process contributes to alterations in organ systems, which lead to an increased risk for chronic conditions. Drug treatment is an important strategy in the management of chronic conditions; however, pharmacokinetic and pharmacodynamic alterations contribute to increased sensitivity to drug effects. This sensitivity is even more pronounced among older people with major neurocognitive disorder. Nevertheless, this group of people is often exposed to potentially inappropriate drug treatment associated with serious adverse drug reactions.Aim: To identify patterns of potentially inappropriate drug treatment and factors associated with this type of drug treatment among older people with cognitive impairment to enable further improvement of drug treatment and diminish the risk of adverse drug reactions among this vulnerable group of people.Method: Explicit criteria were utilized to identify inappropriate prescriptions based on renal function, potentially inappropriate medications according to age and clinically relevant drug-drug interactions among older people with cognitive impairment admitted to two hospitals in Northern Sweden. The first two studies included 428 people and the third study 458 people. Medical records were used as the data source. Moreover, explicit criteria were used to identify potentially inappropriate medications according to age among 1,881 and 1,305 nursing home residents in Västerbotten county in 2007 and 2013, respectively. The association between the length of nursing home stay and the use of potentially inappropriate medications were investigated based on information in questionnaires. Finally, the use of potentially inappropriate medications according to age were investigated three years pre- and post-diagnosis of major neurocognitive disorder among 67,226 older people registered in the Swedish registry for cognitive/dementia disorders.Results: Every tenth of the people admitted to hospital had at least one inappropriate prescription based on their estimated renal function. Moreover, 40.9% had at least one potentially inappropriate medication and 43.2% had at least one clinically relevant drug-drug interaction. Pharmacodynamic interactions were found to be the most common type. Increasing number of prescribed medications was significantly associated with having at least one potentially inappropriate medication according tovage and at least one clinically relevant drug-drug interaction, respectively. Moreover, potentially inappropriate medications were common among nursing home residents but had decreased 2013 compared to 2007 and were only to a lesser extent associated with the length of stay. In the nationwide study population, it was found that potentially inappropriate medications according to age were overall low and decreased continuously three years pre-diagnosis until three years post-diagnosis of major neurocognitive disorder. Consequently, the use of potentially inappropriate medications was found to be significantly lower post- diagnosis except when concerning antipsychotic drug treatment, which was significantly higher post-diagnosis when compared with the pre- diagnosis period.Conclusion: Potentially inappropriate drug treatment is common among older people with cognitive impairment admitted to the hospitals in Västerbotten regardless of their type of living. Increasing number of medications was significantly associated with potentially inappropriate medications and clinically relevant drug-drug interactions. The decreasing trend of potentially inappropriate medications among nursing home residents and among older people with a major neurocognitive disorder is positive and indicates an increased awareness of potentially inappropriate drug treatment in healthcare.
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| 3. |
- Lövheim, Hugo, 1981-
(author)
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Psychotropic and analgesic drug use among old people : with special focus on people living in institutional geriatric care
- 2008
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Doctoral thesis (other academic/artistic)abstract
- Old people in general, and those affected by dementia disorders in particular, are more sensitive to drug side effects than younger people. Despite this, the use of nervous system drugs and analgesics among old people is common, and has increased in recent years.Institutional geriatric care accommodates people who need round-the-clock supervision and care, due to somatic, psychiatric, cognitive or behavioral symptomatology. A majority of those living in institutional geriatric care suffers from dementia disorders.This thesis is based on three different data collections. Two large cross-sectional studies, the AC1982 and AC2000 data collections, including all those living in institutional geriatric care in the county of Västerbotten in May 1982 and 2000 respectively (n=3195 and n=3669) and one study, the GERDA/Umeå 85+ data collection, including a sample of very old people, living at home and in institutions (n=546), in the municipalities of Umeå, Sweden and Vaasa and Mustasaari, Finland, in 2005-2006.The use of psychotropic drugs and analgesics was common among old people living in geriatric care and among very old people in general. A higher proportion of people with dementia received certain nervous system drugs, such as antipsychotic drugs. The use of antipsychotic drugs among people with cognitive impairment living in geriatric care was found to be correlated to several behaviors and symptoms that are not proper indications for antipsychotic drug use, and also factors related more to the staff and the caring situation.Over the course of eighteen years, from 1982 to 2000, there has been a manifold increase in the use of antidepressants, anxiolytics and hypnotics in geriatric care, but the use of antipsychotics had decreased slightly. During the same time, the prevalence of several depressive symptoms decreased significantly, correcting for demographical changes. One analysis of calculated numbers needed to treat, however, indicated poor remission rates, suggesting that even better results might be achievable. The prevalence of depressive symptoms among people with moderate cognitive impairment remained unchanged between 1982 and 2000, despite the fact that about 50% were receiving treatment with antidepressants in 2000. One possible explanation might be that depressive symptoms have different etiologies in different stages of a dementia disorder.Approximately a quarter of the people experiencing pain in geriatric care were not receiving any regular analgesic treatment. One possible reason might be misconceptions among the caring staff regarding whether or not the residents were receiving analgesic treatment. Such misconceptions were found to be common.In conclusion, psychotropic and analgesic drug use among old people in geriatric care, and very old people in general, was found to be common and in many cases possibly inappropriate. The use of antipsychotics among people with dementia deserves particular concern, because of the high risk of severe adverse events and the limited evidence for positive effects. The use of antidepressants, on the other hand, might have contributed to a lower prevalence of depressive symptoms among old people.
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