First Author, Year | Country | Aim(s) | Design | N at baseline | Setting | Approach to identify inappropriate medications | Medication variables | Results |
---|---|---|---|---|---|---|---|---|
Studies which use number of medications as indication of potentially inappropriate prescribing i.e. polypharmacy | ||||||||
Blass et al. 2008 [15] | USA (Baltimore) | Identify how medication usage changed over time as resident with advanced dementia moves toward death, and identify correlates of increased medication usage. | Prospective cohort study (longitudinal) | 125 residents | 3 nursing homes | Number of medications prescribed i.e. polypharmacy. | Number of medications prescribed (regular + prn) at baseline, and factors associated with total number of medications. | Residents prescribed 14.6 medications each. Increase in palliative medicines i.e. opiates and a decrease in antibiotics, anti-dementia agents, cardiovascular agents and psychotropics as death approaches. No change in the number of medications given over time. |
Studies using explicit criteria to identify potentially inappropriate prescribing | ||||||||
Holmes et al. 2008 [16] | USA | Evaluate the feasibility of developing consensus recommendations for appropriate prescribing for patients with advanced dementia. | Modified Delphi consensus panel (and medication record audit) (cross-sectional) | 34 patients | 3 long term care facilities | Using modified Delphi process (12 geriatricians), medications categorised for use in palliative care patients with advanced dementia; never, rarely, sometimes and always appropriate. | Determine frequency of inappropriate medication prescribing, using in-house developed explicit criteria. | Patients taking 6.5 medications each. Six patients taking ten or more medications daily. 29 % of patients taking a medication considered never appropriate. |
Tjia et al. 2010 [17] | USA (Chicago) | Describe the pattern and factors associated with daily medication use in nursing home residents with advanced dementia. | Prospective cohort study (longitudinal) | 323 residents | 22 nursing homes | Drugs of questionable benefit i.e. ‘never appropriate’ according to medications classified by Holmes et al. 2008. | Resident characteristics associated with the use of daily medications and drugs deemed inappropriate. | Male, shorter length of stay at facility (<1 year), higher functional ability and diabetes independently associated with inappropriate drug use. Having a DNR order independently associated with a lower likelihood of inappropriate drug use. |
Colloca et al. 2012 [20] | 7 EU countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands) and Israel | Identify prevalence and factors associated with use of inappropriate drugs in older adult patients with severe cognitive impairment. | Medication chart audit (cross-sectional) | 1449 residents | 57 nursing homes | The use of drugs classified as rarely or never appropriate by criteria developed by Holmes et al. 2008. | Inappropriate drug use defined as rarely or never appropriate in patients with severe cognitive impairment based on the Holmes criteria published in 2008. | Inappropriate drug use in 643 (44.9 %) of residents. Most commonly prescribed inappropriate drugs were lipid-lowering agents (9.9 %), antiplatelet agents (9.9 %), Ach inhibitors (7.2 %) and antispasmodics (6.9 %). Inappropriate drug use associated with diabetes, HF, stroke, recent hospitalization. An inverse relationship between inappropriate drug use and geriatrician at facility. |
Toscani et al. 2013 [18] | Italy | Assess and compare treatments and prescriptions of patients with advanced dementia cared for in nursing homes and in home care and assess their appropriateness from a palliative care perspective. | Baseline data from multicentre prospective observational cohort study | 245 residents | Nursing homes | Used criteria developed by Holmes et al. 2008. | The appropriateness of each prescription assessed according to the Holmes et al. 2008 classification. | Patients received 4.1 medications on average (range 0–13). Laxatives, antipsychotics, and anxiolytics were the most frequently prescribed in the nursing homes. 8.1 % of residents receiving at least one analgesic. |
Tjia et al. 2014 [22] | USA | Estimate the prevalence of medications with questionable benefit used by nursing home residents with advanced dementia. | Medication record audit (cross-sectional) | 5406 residents | Nursing homes | Medications deemed never appropriate for use in advanced dementia according to criteria developed by Holmes et al. 2008. | Use of medication of questionable benefit in advanced dementia based on previously published criteria and mean 90-day expenditures due to these medications per resident. | 53.9 % of residents receiving at least one medication with questionable benefit. Anticholinesterase inhibitors (36.4 %), memantine (25.2 %) and lipid-lowering agents (22.4 %) most commonly prescribed medications with questionable benefit. |
Other approaches to identify inappropriate prescribing | ||||||||
Shega et al. 2009 [19] | USA | Describe hospice medical directors practice patterns and experiences in the use and discontinuation of anticholinesterase inhibitors and memantine in hospice patients with dementia. | Mail survey (cross-sectional) | 152 hospital medical directors | Hospice care | N/A | Associations between the likelihood of survey response and participant characteristics. Comparisons analysing whether or not a physician would recommend medication discontinuation based upon reported clinical benefit of anticholinesterase inhibitors and memantine use. | Of the respondents, 75 % and 33 % reported that at least 20 % of patients were taking anticholinesterase inhibitor or memantine at hospice admission. 80 % of respondents would recommend discontinuation of these agents, however, a subset believe they stabilize cognition (22 %), decrease challenging behaviours (28 %), maintain patient function (22 %,) reduce caregiver burden (20 %) and improve caregiver quality of life (20 %). |
Parsons et al. 2014 [21] | NI (Northern Ireland), RoI (Republic of Ireland) | Evaluate the extent to which patient-related factors and physicians’ country of practice influenced decision making regarding medication use in patients with end-stage dementia. | Factorial survey design | 662 health professionals | Community, nursing home, hospital | Medications selected due to contradictory evidence available to guide practice or because they have been identified in the limited literature as potentially inappropriate for individuals with advanced dementia: antibiotics, anticholinesterase inhibitors, memantine, lipid-lowering agents and antipsychotics. | Assess physician decision making regarding withholding or continuation/discontinuation of key medications in patients with end-stage dementia. | Considerable variability found regarding initiating/withholding antibiotics and continuing/discontinuing anticholinesterase inhibitors and memantine hydrochloride. Less variability found in decision making regarding lipid-lowering agents and antipsychotics. Patient place of residence and physician country of practice had the strongest and most consistent effects on decision making. |