SP - Pharmacology

Introduction Health affects older people’s quality of life (QoL). Those experiencing health decline often require multiple medications (polypharmacy). This narrative review aims to explore the effect polypharmacy has on QoL and health-related QoL (HRQoL). We also wished to determine the QoL/HRQoL measurement tools employed and polypharmacy definitions used in included studies. 

Method Searches were carried out primarily in MEDLINE and EMBASE. Publication databases for The Irish Longitudinal Study on Ageing (TILDA) and the English Longitudinal Study of Ageing (ELSA) were also searched. Search terms such as “polypharmacy”, “older person”, “health-related quality of life” and “quality of life” were used. Primary or secondary research articles investigating the association between polypharmacy and QoL/HRQoL, including qualitative studies, QoL/HRQOL tool development studies, and randomised controlled trials investigating the number of medications and QoL/HRQoL as outcomes were included. Screening and data extraction were undertaken by one reviewer and a narrative synthesis conducted. 

Results In total, 55 articles were included. The key finding of this review was the heterogeneity of the effect of polypharmacy on QoL/HRQoL, ranging from no association to a significant negative clinical association. Considerable variation was seen in the number of QoL/HRQoL measurement tools and polypharmacy definitions used. Qualitative studies highlighted factors which were perceived to impact QoL/HRQoL, including the relationship between patients and healthcare providers, clear benefit of medication and commitment to everyday medication management. These findings highlight the difficulty in interpreting the true impact of polypharmacy on QoL/HRQoL. 

Conclusion(s) In qualitative research, patients highlight the negative impact of polypharmacy on QoL; however, this isn’t always reflected in quantitative research. The range of differing associations could be due to the responsiveness of the tools used, populations studied, or the nature of the relationship between polypharmacy and QoL, which is likely intertwined bidirectionally with many contributing and confounding factors.

Background: Clinical pharmacists are increasingly working as part of primary care teams in UK. Many people living with dementia live at home with the support of primary care. Given the complexity of their health problems and their use of several medications, clinical pharmacists may potentially play a crucial role in their support Aims: To explore clinical pharmacists’ experiences of working in primary care with people living with dementia and identify any specific training needs to provide effective support for this patient group.

Methods: An online survey sent via email in 2023 through professional organisations, social media, and utilising research team contacts. The survey covered topics including clinical pharmacists’ background, experience of working with people with dementia, and training needs.

Results: 57 clinical pharmacists responded to the survey; the meantime working as a clinical pharmacist was 9.6 years (standard deviation 8.6) and within a primary care setting was 6.1 years (standard deviation 6.1). Just over three-quarters of respondents (n=31, 77%) work with people living with dementia. While almost two thirds (n=35, 61%) had undertaken training for dementia care, such training often lasted a few hours (less than a day) (n=17, 49%). Most respondents (n=39, 89%) wanted further information or training; including non-pharmacological interventions to improve quality of life in dementia and how to support carers and relatives. Practice challenges reported included a lack of face-to-face consultations and getting assurance that the patient could safely take medications.

Conclusions: These findings indicate an interest in dementia care, a willingness to undertake further training but practice uncertainties that suggest a system approach might be beneficial.

Introduction and Background- Bowel obstruction poses a considerable medical dilemma, demanding swift identification and intervention due to its propensity for severe complications. This challenge is exacerbated in elderly individuals who may be frail and less amenable to surgical interventions. Alvimopan, a peripherally acting μ-opioid receptor antagonist renowned for its pro-kinetic effects on the bowel, has shown promise in clinical trials. Nevertheless, despite its efficacy, it remains underutilised in many clinical hospital settings. Thus, our systemic review aims to underscore the potential benefits of Alvimopan, reintroducing its significance in managing bowel obstruction, particularly in elderly patients.

Methods- Four databases were searched to identify relevant studies investigating the use of Alvimopan for treating ileus. Included studies measured time for first bowel motion, and was compared with controls. Animal and non-original research articles were excluded.

Results- Ten randomised controlled trials (RCTs) were incorporated, each showcasing the significant reduction in both time to initial bowel movement and hospital stay attributed to Alvimopan. Findings indicated that Alvimopan can decrease the duration until the first bowel movement by an average of 14 hours compared to placebo, as well as abbreviate the time until discharge by an average of six hours.

Conclusion- Consistently, Alvimopan has demonstrated favourable results for patients experiencing bowel obstruction. Its utilisation could potentially circumvent the necessity for laparotomy in frail patients. Moreover, employing this medication contributes to shorter hospital stays, thus potentially mitigating associated complications. Consequently, we strongly advocate for its use and advocate for additional research to incorporate it into clinical guidelines.

Background and Objectives: Polypharmacy is common in frail older adults who often live with multiple co-morbidities. This polypharmacy can carry a significant anticholinergic burden. Frail older adults are particularly sensitive to the anticholinergic side effects of medications which can include constipation, urinary retention and dry mouth. Medications with a high anticholinergic burden scores have also been evidenced to contribute to an increased frequency of falls, cognitive decline and increased mortality. For frail older adults, a medication review, considering anticholinergic burden, is therefore an essential part of Comprehensive Geriatric Assessment. A local frailty census was completed for all medical inpatients over the age of 65 years old and as part of this anticholinergic burden scores were collated.

Materials and Methods: As part of this whole hospital frailty census, an anticholinergic burden score (ACB) was calculated for 77 inpatients. This was calculated using the Anticholinergic Cognitive Burden Scales and Anticholinergic Burden scores.

Results: The average age of the patients was 80.19 (± 9.35). 80.01% of patients were taking one or more medications with an anticholinergic burden. Of those, 40.25% had a significant ACB score of 3 or more (3-8). The patients with the highest ACB scores were those with multi-morbidity, an already established diagnosis of dementia and patients with recurrent falls.

Conclusions: The ACB score for patients included within this frailty census appeared to correlate with certain co-morbidities as would be expected from the known complications associated with these medications in frail older adults. The proportion of our inpatients with a significant ACB score informs us that we need to develop a more robust approach to delivering polypharmacy reviews as part of Comprehensive Geriatric Assessment within our hospital and will help us to inform future service planning and delivery.

Introduction

Medication-related harm (MRH) events are increasing among older adults especially in the 8-weeks after hospital discharge. The Discharge Medical Service (DMS), a UK initiative, aims to reduce post-discharge MRH. In this study, we will compare the clinical, economic, and service outcomes of the DMS.

Method

Using a randomized control trial design, 682 older adults ≥ 65years due for hospital-discharge will be recruited. Participants will be randomized to either intervention arm (medicine management plan (MMP) and DMS), or control arm (DMS only) using a 1:1 stratification. The MMP includes patient and carer education about MRH, copy of discharge medications, and MRH risk score calculated using a validated prediction tool (1). Data collection includes patient clinical and social demographics, and admission and discharge medications. At 8-weeks post discharge, study pharmacist will verify MRH through patient telephone interview, and review of patients’ GP records. Data Analysis Univariate analysis will be done for baseline variables comparing the intervention and control arms. Variables known to be associated with MRH will be described by the randomisation groups. Further multivariate logistic regression will be done incorporating these variables. Economic evaluation will compare the cost-of-service use among the two arms and modelled to provide national estimates. Qualitative data from focus group interviews at participating hospital sites will explore practitioners’ understanding and acceptance of the DMS and MMP.

Conclusion

This study will inform the use of a validated MRH risk prediction tool, and provide a clinical, and economic evaluation of the DMS and MMP in the NHS. The study has ethics approval and is adopted in the national ageing research portfolio. We are seeking additional sites. Reference 1. Parekh N, Ali K, Davies JG, et al. Medication-related harm in older adults following hospital discharge: development and validation of a prediction tool. BMJ Quality & Safety 2020; 29:142-153.