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BACKGROUND: Inadequate treatment of high blood pressure (BP) can lead to preventable adverse events in nursing home residents, while excessive treatment can lead to associated harms. METHODS: Data were extracted from the VA electronic health record and Bar Code Medication Administration system on 40,079 long-term care residents aged ≥65 years from October 2006 through September 2018 (FY2007-2018). Hypertension prevalence at admission was identified by ICD code(s) in the year prior, and antihypertensive medication use was defined as administration ≥50% of days. BP measures were averaged over 2-year epochs. RESULTS: The age-standardized prevalence of hypertension diagnosis at admission increased from 75.2% in FY2007-2008 to 85.1% in FY2017-2018 (p-value for trend 140/90 mmHg. Future research is needed to better understand the benefits and harms of BP control in nursing home residents.

ObjectivesEarly recognition of dementia would allow patients and their families to receive care earlier in the disease process, potentially improving care management and patient outcomes, yet nearly half of patients with dementia are undiagnosed. Our aim was to develop and validate an electronic health record (EHR)-based tool to help detect patients with unrecognized dementia (EHR Risk of Alzheimer's and Dementia Assessment Rule [eRADAR]).DesignRetrospective cohort study.SettingKaiser Permanente Washington (KPWA), an integrated healthcare delivery system.ParticipantsA total of 16 665 visits among 4330 participants in the Adult Changes in Thought (ACT) study, who undergo a comprehensive process to detect and diagnose dementia every 2 years and have linked KPWA EHR data, divided into development (70%) and validation (30%) samples.MeasurementsEHR predictors included demographics, medical diagnoses, vital signs, healthcare utilization, and medications within the previous 2 years. Unrecognized dementia was defined as detection in ACT before documentation in the KPWA EHR (ie, lack of dementia or memory loss diagnosis codes or dementia medication fills).ResultsOverall, 1015 ACT visits resulted in a diagnosis of incident dementia, of which 498 (49%) were unrecognized in the KPWA EHR. The final 31-predictor model included markers of dementia-related symptoms (eg, psychosis diagnoses, antidepressant fills), healthcare utilization pattern (eg, emergency department visits), and dementia risk factors (eg, cerebrovascular disease, diabetes). Discrimination was good in the development (C statistic = .78; 95% confidence interval [CI] = .76-.81) and validation (C statistic = .81; 95% CI = .78-.84) samples, and calibration was good based on plots of predicted vs observed risk. If patients with scores in the top 5% were flagged for additional evaluation, we estimate that 1 in 6 would have dementia.ConclusionThe eRADAR tool uses existing EHR data to detect patients with good accuracy who may have unrecognized dementia. J Am Geriatr Soc 68:103-111, 2019.

Background/objectivesGuideline-based management of cardiovascular disease often involves prescribing multiple medications, which contributes to polypharmacy and risk for adverse drug events in older adults. Deprescribing is a potential strategy to mitigate these risks. We sought to characterize and compare clinician perspectives regarding deprescribing cardiovascular medications across three specialties.DesignNational cross-sectional survey.SettingAmbulatory.ParticipantsRandom sample of geriatricians, general internists, and cardiologists from the American College of Physicians.MeasurementsElectronic survey assessing clinical practice of deprescribing cardiovascular medications, reasons and barriers to deprescribing, and choice of medications to deprescribe in hypothetical clinical cases.ResultsIn each specialty, 750 physicians were surveyed, with a response rate of 26% for geriatricians, 26% for general internists, and 12% for cardiologists. Over 80% of respondents within each specialty reported that they had recently considered deprescribing a cardiovascular medication. Adverse drug reactions were the most common reason for deprescribing for all specialties. Geriatricians also commonly reported deprescribing in the setting of limited life expectancy. Barriers to deprescribing were shared across specialties and included concerns about interfering with other physicians' treatment plans and patient reluctance. In hypothetical cases, over 90% of physicians in each specialty chose to deprescribe when patients experienced adverse drug reactions. Geriatricians were most likely and cardiologists were least likely to consider deprescribing cardiovascular medications in cases of limited life expectancy (all P

ObjectivesTo examine whether older adults taking nonsteroidal anti-inflammatory drugs (NSAIDs) decreased the underuse of gastroprotective agents over time.DesignBefore-and-after study.SettingHealth, Aging and Body Composition Study.ParticipantsDaily users of a NSAID (prescription and over the counter (OTC)) at visits in 2002-03 (preperiod; n = 404) and 2006-07 (postperiod; n = 172). The sample had a mean ± standard deviation age of 78.2 ± 2.7 at the preperiod visit and 81.9 ± 2.7 at the postperiod visit. The majority were white and female and had 12 or more years of education.MeasurementsUnderusers were defined as persons taking nonselective NSAIDs who were at risk of peptic ulcer disease (PUD; because of current warfarin or glucocorticoid use or history of PUD) and not using a proton pump inhibitor (PPI) or persons taking cyclooxygenase 2 (COX-2) selective NSAIDs and aspirin who were at risk of PUD (having at least one risk factor) and not using a PPI.ResultsDaily NSAID use decreased from 17.6% to 11.3% (P < .001), and gastroprotective agent underuse decreased from 23.5% to 15.1% (P = .008). Controlling for important covariates, having prescription insurance was somewhat protective against underuse in the preperiod (adjusted odds ratio (AOR) = 0.78, 95% confidence interval (CI) = 0.46-1.34; P = .37), but more so and significantly in the postperiod (AOR = 0.41, 95% CI = 0.18-0.93; P = .03). Having prescription insurance was more protective in the post- than in the preperiod (less gastroprotective agent underuse; adjusted ratio of OR = 0.53, 95% CI = 0.22-1.29; P = .16), but this increased protection was not statistically significant.ConclusionIn older daily NSAID users at high risk of PUD, having prescription insurance and adequate gastroprotective use was more common in the post- than in the preperiod.

Background: While many studies have assessed and measured patient attitudes toward deprescribing, less quantitative research has addressed the provider perspective. We thus sought to describe provider knowledge, beliefs, and self‐efficacy to deprescribe, with a focus on opioids and sedative‐hypnotics. Methods: An electronic anonymous survey was distributed to primary care providers at Kaiser Permanente Washington. Two reminder emails were sent. The survey included 10 questions on general deprescribing, and six questions each specific to opioid and sedative‐hypnotic deprescribing. Knowledge questions used a multiple‐choice response option format. Questions addressing beliefs and self‐efficacy (i.e., confidence) used a 0–10 Likert scale. Scales were dichotomized at ≥7 to define agreement (belief questions) or confidence (self‐efficacy questions). We calculated descriptive statistics to summarize the responses. Results: Of 370 eligible primary care providers, 95 (26%) completed the survey. For general deprescribing questions, a majority believed that lack of patient willingness, withdrawal symptoms and fear of symptom return, and time constraints impeded deprescribing. Approximately half chose the correct answers about opioid deprescribing, 21% were confident that they could alleviate patient concerns about opioid tapering, and 32% were confident managing chronic non‐cancer pain without opioids. For sedative‐hypnotics, 64%–87% of respondents correctly answered questions about risks and the relative effectiveness of alternatives, but only one‐third correctly answered a question about sedative‐hypnotic tapering. Roughly half were confident in their ability to successfully engage patients in sedative deprescribing conversations and select alternatives. Only 54% and 34% were confident in writing a tapering protocol for opioids and sedative‐hypnotics, respectively. Conclusion: Results suggest that raising provider awareness of patient willingness to deprescribe, addressing knowledge gaps, and increasing self‐efficacy for deprescribing are important targets for improving deprescribing. Support for writing tapering protocols and prescribing evidence‐based drug and non‐drug alternatives may be important to improve care. [ABSTRACT FROM AUTHOR]

The article discusses research which examined the prevalence and risk factors for falls and fall-related injuries in the 2018 National Post-acute and Long-term Care Study conducted by the U.S. National Center for Health Statistics. The study analyze the demographic or clinical characteristics of residential care community residents associated with falls and fall-related injuries. It attributes falls and injuries to functional and cognitive impairment, multimorbidity and antipsychotic drug use.

Improving the quality of medication use and medication safety are important priorities for prescribers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2020. We selected high‐quality studies that moved the field of research forward and were not merely replication studies. The chosen articles cover domains related to deprescribing, medication safety, and optimizing medication use. The first study, a noninferiority randomized clinical trial in England, evaluated whether antihypertensive medication reduction is possible without significant changes in systolic blood pressure control or adverse events over the 12‐week follow‐up (domain: deprescribing). The second study, a prospective cohort study of women at Kaiser Permanente Southern, California, examined the association between bisphosphonate use and atypical femur fracture (domain: medication safety). The third study examined the effectiveness and safety of a multifaceted antimicrobial stewardship and quality improvement initiative in reducing unnecessary antimicrobial use for unlikely cystitis cases in noncatheterized residents in 25 nursing homes across the United States (domain: optimizing medication use). Lastly, the fourth study, a population‐based cohort study in the United Kingdom, examined the association of tramadol use with risk of hip fracture (domain: medication safety). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens. [ABSTRACT FROM AUTHOR]

Background: Central nervous system (CNS)‐active medication use is an important modifiable risk factor for falls in older adults. A fall‐related injury should prompt providers to evaluate and reduce CNS‐active medications to prevent recurrent falls. We evaluated change in CNS‐active medications up to 12 months following a fall‐related injury in community‐dwelling older adults compared with a matched cohort without fall‐related injury. Methods: Participants were from the Adult Changes in Thought study conducted at Kaiser Permanente Washington. Fall‐related injury codes between 1994 and 2014 defined index encounters in participants with no evidence of such injuries in the preceding year. We matched each fall‐related injury index encounter with up to five randomly selected clinical encounters from participants without injury. Using automated pharmacy data, we estimated the average change in CNS‐active medication use at 3, 6, and 12 months post‐index according to the presence or absence of CNS‐active medication use before index. Results: One thousand five hundred sixteen participants with fall‐related injury index encounters (449 CNS‐active users, 1067 nonusers) were matched to 7014 index encounters from people without fall‐related injuries (1751 users, 5236 nonusers). Among CNS‐active users at the index encounter, those with fall‐related injury had an average decrease in standard daily doses (SDDs) at 12 months (−0.43; 95% CI: −0.63 to −0.23), and those without injury had a greater (p = 0.047) average decrease (−0.66; 95% CI: −0.78 to −0.55). Among nonusers at index, those with fall‐related injury had a smaller increase than those without injury (+0.17, 95% CI: +0.13 to +0.21, vs. +0.24, 95% CI: +0.20 to +0.28, p = 0.005). Conclusions: The differences in CNS‐active medication use change over 12 months between those with and without fall‐related injury were small and unlikely to be clinically significant. These results suggest that fall risk‐increasing drug use is not reduced following a fall‐related injury, thus opportunities exist to reduce CNS‐active medications, a potentially modifiable risk factor for falls. [ABSTRACT FROM AUTHOR]

Background/objective: As pharmacists work to ensure reimbursement for chronic disease management services on the national level, evidence of their impact on important health metrics, such as medication adherence, is needed. However, summative evidence is lacking on the effectiveness of pharmacists to improve medication adherence in older adults. The objective was to assess the effectiveness of pharmacist‐led interventions on medication adherence in older adults (65+ years). Design/setting/participants: Using a systematic review and meta‐analytic approach, a comprehensive search of publications in PubMed, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar was conducted through April 2, 2020 for randomized clinical trials of pharmacist‐led interventions to improve medication adherence in older adults. A standardized mean difference effect size (Cohen's d) was calculated for medication adherence in each study. Study effect sizes were pooled using a random‐effects model, with effect sizes weighted by inverse of its total variance. Measurements Medication adherence using any method of measurement. Results: Among 40 unique randomized trials of pharmacist‐led interventions with data from 8822 unique patients (mean age, range: 65–85 years), the mean effect size was 0.57 (k = 40; 95% Confidence Interval [CI]: 0.38–0.76). When two outlier studies were excluded from the analysis, the mean effect size reduced to 0.41 (k = 38; 95% CI: 0.27–0.54). A sensitivity analysis of medication adherence outcome by time point resulted in a mean effect size of 0.64 at 3 months (k = 12; 95% CI: 0.32–0.97), 0.30 at 6 months (k = 13; 95% CI: 0.11–0.48), 0.22 at 12 months (k = 12; 95% CI: 0.08–0.37), and 0.36 for outcome time points beyond 12 months (k = 5; 95% CI: 0.02–0.70). Conclusion: This meta‐analysis found a significant improvement in medication adherence among older adults receiving pharmacist‐led interventions. Implementation of pharmacist‐led interventions supported by Medicare reimbursement could ensure older adults' access to effective medication adherence support. [ABSTRACT FROM AUTHOR]

Objective: To describe and compare two age groups' knowledge of medications linked to falls and willingness to change these medications to reduce their fall risk. Method: We analyzed data from community‐dwelling adults age 55 and older (n = 1812): 855 adults aged 55 to 64 years and 957 older adults (65 and older) who participated in the 2016 summer wave of the ConsumerStyles survey, an annual Web‐based survey. The data are weighted to match the US Current Population Survey proportions on nine US Census Bureau demographic characteristics. Measurements: Survey respondents were asked about medication use, knowledge of side effects, their willingness to change their medications to reduce fall risk, communication in the previous year about fall risk with their healthcare provider, and their comfort in discussing fall risk with their healthcare provider. All data were weighted to match the 2016 population estimates. Descriptive statistics and χ2 (p ≤.05) were used to identify differences between the two age groups. Results: About one‐fifth of all respondents reported using at least one class of medication that increases fall risk. Older adults were less likely to report using medications for mood or sadness, less likely to report knowing the side effects of pain medications, and more willing to change their sleep medications compared with their younger counterparts. Among all respondents using these medication classes, less than one‐third knew the potential fall‐related side effects. However, most of them expressed willingness to change their medication if advised by their healthcare provider. Conclusion: Most older adults were unaware of potential fall risks associated with medications prescribed to address pain, difficulty sleeping, mood or sadness, and anxiety‐ or nervousness‐related health issues. However, most were willing to change their medication if recommended by a healthcare provider. J Am Geriatr Soc 67:527–533, 2019. [ABSTRACT FROM AUTHOR]