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We investigated how where a person lives may affect the use of medications required following a heart attack. Our research used dispensing information and hospital admission information for a population of 41 925 heart attack admissions. Our main findings were as follows: There were no clinically significant differences in initial dispensing or 12-month use of secondary prevention medications with respect to how remote a person may live in Victoria, Australia.Our research suggests that there is equal access to medications with respect to remoteness, and any differences in quality of life or life expectancy following a heart attack are unlikely to be driven by differences in access to medications.

Objective: To investigate symptomatic and preventive medication use according to age and frailty in Australian and Japanese nursing homes (NHs). Methods: Secondary cross-sectional analyses of two prospective cohort studies involving 12 Australian NHs and four Japanese NHs. Frailty was measured using the FRAIL-NH scale (non-frail 0–2; frail 3–6; most-frail 7–14). Regular medications were classified as symptomatic or preventive based on published lists and expert consensus. Descriptive statistics were used to compare the prevalence and ratio of symptomatic to preventive medications. Results: Overall, 550 Australian residents (87.7 ± 7.3 years; 73.3% females) and 333 Japanese residents (86.5 ± 7.0 years; 73.3% females) were included. Australian residents used a higher mean number of medications than Japanese residents (9.8 ± 4.0 vs 7.7 ± 3.7, p< 0.0001). Australian residents used more preventive than symptomatic medications (5.5 ± 2.5 vs 4.3 ± 2.6, p< 0.0001), while Japanese residents used more symptomatic than preventive medications (4.7 ± 2.6 vs 3.0 ± 2.2, p< 0.0001). In Australia, symptomatic medications were more prevalent with increasing frailty (non-frail 3.4 ± 2.6; frail 4.0 ± 2.6; most-frail 4.8 ± 2.6, p< 0.0001) but less prevalent with age (< 80 years 5.0 ± 2.9; 80–89 years 4.4 ± 2.6; ≥ 90 years 3.9 ± 2.5, p= 0.0042); while preventive medications remained similar across age and frailty groups. In Japan, there was no significant difference in the mean number of symptomatic and preventive medications irrespective of age and frailty. Conclusions: The ratio of symptomatic to preventive medications was higher with increasing frailty but lower with age in Australia; whereas in Japan, the ratio remained consistent across age and frailty groups. Preventive medications remained prevalent in most-frail residents in both cohorts, albeit at lower levels in Japan.

Clozapine is the most efficacious treatment for schizophrenia and is associated with lower overall mortality than are other antipsychotic drugs, despite the risk of agranulocytosis. Preliminary reports over the past 10 years suggest a possible risk of haematological malignancies, but the issue has remained unsettled. We aimed to study the risk of haematological malignancies associated with use of clozapine and other antipsychotics.

Tailored communication is necessary to address COVID‐19 vaccine hesitancy and increase uptake. We aimed to understand the information needs, perceived benefits and barriers to COVID‐19 vaccination of people prioritised, but hesitant to receive the vaccine.

AimsWe evaluated variation in treatment for, and outcomes following, myocardial infarction (MI) by diabetes status, sex and socioeconomic disadvantage.MethodsWe included all people aged ≥30 years who were discharged alive from hospital following MI between 1 July 2012 and 30 June 2017 in Victoria, Australia (n=43 272). We assessed receipt of inpatient procedures and discharge dispensing of cardioprotective medications for each admission, as well as 1-year all-cause, cardiovascular, and MI readmission rates and 1-year all-cause mortality.ResultsRisk of all-cause (HR: 1.22 (1.19–1.26)), cardiovascular (1.29 (1.25–1.34)), MI (1.52 (1.43–1.62)) and heart failure readmission (1.62 (1.50–1.75)) and mortality (1.18 (1.11–1.26)) were higher in people with diabetes. Males and people in more disadvantaged areas were at increased risk of readmission and mortality following MI. People with diabetes (vs without) were more likely to receive coronary artery bypass grafting (CABG) but less likely to receive percutaneous coronary intervention (PCI) during, or within 30 days of, their index admission. Females were less likely to receive either (eg, 87% of males with a STEMI received PCI or CABG vs 70% of females), and people in more disadvantaged areas were less likely to receive PCI. People with diabetes, males and people in more disadvantaged areas were more likely to be dispensed cardioprotective medications at or within 90 days of discharge.ConclusionsFollowing an MI, people with diabetes and males had poorer outcomes but received more intensive cardiovascular treatments. However, socioeconomic disadvantage was associated with both less intensive inpatient treatment and poorer outcomes.

Background: Fall-related hospitalisations from residential aged care services (RACS) are distressing for residents and costly to the healthcare system. Strategies to limit hospitalisations include preventing injurious falls and avoiding hospital transfers when falls occur. Aims: To undertake a root cause analysis (RCA) of fall-related hospitalisations from RACS and identify opportunities for fall prevention and hospital avoidance. Methods: An aggregated RCA of 47 consecutive fall-related hospitalisations for 40 residents over a 12-month period at six South Australian RACS was undertaken. Comprehensive data were extracted from RACS records including nursing progress notes, medical records, medication charts, hospital summaries and incident reports by a nurse clinical auditor and clinical pharmacist. Root cause identification was performed by the research team. A multidisciplinary expert panel recommended strategies for falls prevention and hospital avoidance. Results: Overall, 55.3% of fall-related hospitalisations were among residents with a history of falls. Among all fall-related hospitalisations, at least one high falls risk medication was administered regularly prior to hospitalisation. Potential root causes of falling included medication initiations and dose changes. Root causes for hospital transfers included need for timely access to subsidised medical services or radiology. Strategies identified for avoiding hospitalisations included pharmacy-generated alerts when medications associated with an increased risk of falls are initiated or changed, multidisciplinary audit and feedback of falls risk medication use and access to subsidised mobile imaging services. Conclusions: This aggregate RCA identified a range of strategies to address resident and system-level factors to minimise fall-related hospitalisations.

Aims: The objective of this study is to investigate the association between multiple antihypertensive use and mortality in residents with diagnosed hypertension, and whether dementia and frailty modify this association. Methods: This is a two-year prospective cohort study of 239 residents with diagnosed hypertension receiving antihypertensive therapy across six residential aged care services in South Australia. Data were obtained from electronic medical records, medication charts and validated assessments. The primary outcome was all-cause mortality and the secondary outcome was cardiovascular-related hospitalizations. Inverse probability weighted Cox models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause mortality. Covariates included age, sex, dementia severity, frailty status, Charlson’s comorbidity index and cardiovascular comorbidities. Results: The study sample (mean age of 88.1 ± 6.3 years; 79% female) included 70 (29.3%) residents using one antihypertensive and 169 (70.7%) residents using multiple antihypertensives. The crude incidence rates for death were higher in residents using multiple antihypertensives compared with residents using monotherapy (251 and 173/1000 person-years, respectively). After weighting, residents who used multiple antihypertensives had a greater risk of mortality compared with monotherapy (HR 1.40, 95%CI 1.03–1.92). After stratifying by dementia diagnosis and frailty status, the risk only remained significant in residents with diagnosed dementia (HR 1.91, 95%CI 1.20–3.04) and who were most frail (HR 2.52, 95%CI 1.13–5.64). Rate of cardiovascular-related hospitalizations did not differ among residents using multiple compared to monotherapy (rate ratio 0.73, 95%CI 0.32–1.67). Conclusions: Multiple antihypertensive use is associated with an increased risk of mortality in residents with diagnosed hypertension, particularly in residents with dementia and among those who are most frail.

•Does acetylcholinesterase inhibitor (AChEI) use prevent or delay initiation of psychotropics in people with dementia?•This cohort study found that AChEI use was associated with reduced risk of antipsychotic and anxiolytic initiation.•AChEIs may be of benefit for behavioural and psychological symptoms of dementia, thus reducing the need for psychotropics.

Background: The advent of hospital electronic medical records (EMRs) with electronic prescribing provides considerable opportunity for pharmacoepidemiological research. However, validity of EMR prescribing data for research purposes is not well established. Validity concerns the percentage of cases in which medications and characteristics (name, type, formulation, dose) are true when verified with an independent data source. This study evaluated the validity of EMR discharge prescription data within the Eastern Health hospital network in Melbourne, Australia.Methods: A random sample of patients were selected who had a diagnosis of atrial fibrillation (AF) and were prescribed at least five medications. Prescription records from 2012 to 2015 were compared with pharmacy dispensing and hospital medical records (reference standards). Medication name, dose, directions and route of administration were compared. Discrepancies between data sources were categorized as omissions, additions, discrepancies in dose, medication form or route of administration or discrepancies in reordering. Sensitivities and 95% confidence intervals (CIs) for intended medication exposure were estimated for therapeutic classes.Results: A total of 5724 prescription orders for 479 patients for whom reference standards were available were included. There were 163 discrepancies (2.8%) between prescription records and reference standards. Additions were the most common data discrepancy (n= 65; ~1.1% of total prescriptions evaluated), followed by discrepancies in reordering (n= 34; 0.59%). Sensitivities for intended patient exposure to a medication for each therapeutic class at the first level of the Anatomical Therapeutic Chemical (ATC) classification system were between 97% and 100%. The genitourinary system and sex hormone level of the ATC system demonstrated the lowest sensitivity, (97.3%; 95% CI 92.0%–100%) and the cardiovascular system level demonstrated the highest sensitivity (99.9%; 95% CI 99.7%–100%).Conclusion: EMR discharge prescription records for patients with AF are a valid information source for conducting pharmacoepidemiological research within Eastern Health in Melbourne, Australia. Further studies in different regions, countries and patient cohorts are required to establish validity of hospital EMR prescription records for pharmacoepidemiological research.

Background: The rapid increase in prescribing and use of opioids for noncancer pain has coincided with an increase in opioid-related adverse drug events (ADEs). The objective of our study was to describe ADEs related to tapentadol and oxycodone/naloxone spontaneously reported to the Australian Therapeutic Goods Administration (TGA).Methods: Public case detail reports for tapentadol (September 2013–March 2017) and oxycodone/naloxone (April 2011–March 2017) were sourced from the TGA. The total number of public case detail reports for tapentadol were 104 and 249 for oxycodone/naloxone. Demographic characteristics of patients, concomitant medications, causality assessment and outcome were described for each opioid according to the Medical Dictionary for Regulatory Activities (MedDRA) system organ class.Results: The most prevalent ADEs for tapentadol were nervous system disorders (n= 52, 50%), psychiatric (n= 34, 32.7%), gastrointestinal (n= 18, 17.3%), and general disorders and administration site conditions (n= 21, 20.2%). Sixteen (23.2%) of 69 nervous system disorders reaction terms were consistent with serotonin syndrome of which 14 (87.5%) involved documented coadministration with another serotonergic medication. The most prevalent ADEs for oxycodone/naloxone were psychiatric disorders (n= 78, 31.3%), gastrointestinal (n= 73, 29.3%), general disorders and administration site conditions (n= 87, 35%), and nervous system disorders (n= 62, 24.9%). There were 40 (16%) public case detail reports for oxycodone/naloxone with the MedDRA reaction terms ‘drug withdrawal syndrome’ and ‘withdrawal syndrome’.Conclusion: The profiles of spontaneous ADE reports for tapentadol and oxycodone/naloxone are largely consistent with their premarketing randomized controlled studies and profiles of opioids in general. Further research into the risk of serotonin syndrome with tapentadol use is warranted. The ADEs suggest clinicians should be cautious when switching patients to oxycodone/naloxone from other opioids.

Background Little is known about changes in prescribing practices in Australia since the introduction of the direct oral anticoagulants (DOACs). Our objective was to examine if the availability of DOACs has coincided with a change in prescribing of oral anticoagulants in older hospital inpatients with regard to risk factors for stroke and bleeding.Methods A prospective observational study was conducted between October 2012 and August 2015 of inpatients aged over 60 years initiated on an oral anticoagulant in a large metropolitan, tertiary referral, public teaching hospital in Australia. Treatment groups were patients who commenced an oral anticoagulant prior to inclusion of DOACs on the formulary and those who commenced after the introduction of DOACs. Subgroup analyses were conducted in patients with atrial fibrillation (AF). Differences in clinical characteristics and risk for stroke and bleeding were calculated using the CHADS2and HAS-BLED scores, respectively, were examined.Results A total of 289 patients were included. Inpatients prescribed an oral anticoagulant after the introduction of DOACs were significantly older, a greater proportion were female and more likely to have had a prior stroke. This was associated with a statistically higher CHADS2score in the post-DOAC group. Similar findings were observed when limiting the sample to patients with AF. Patients with AF who were at greatest likelihood of having a bleeding event were less likely to be treated with a DOAC.Conclusion Since the introduction of the DOACs, patients who may have previously received no therapy or suboptimal treatment were now more likely to be receiving anticoagulation, suggesting an appropriate change in prescribing practice.

Background Lifestyle and dietary advice typically precedes or accompanies the prescription of statin medications. However, evidence for adherence to this advice is sparse. The objective was to compare saturated fat intake, exercise, alcohol consumption and smoking between statin users and non-users in Australia.Methods Data were analysed for 4614 participants aged ≥37 years in the Australian Diabetes, Obesity and Lifestyle study in 2011–2012. Statin use, smoking status and physical activity were self-reported. Saturated fat and alcohol intake were measured via a food frequency questionnaire. Multinomial logistic regression was used to compute adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between statin use and the four lifestyle factors. All models were adjusted for age, sex, education, number of general practitioner visits, body mass index, hypertension, diabetes and prior cardiovascular diseases.Results In total 1108 (24%) participants used a statin. Statin users were 29% less likely to be within the highest quartile versus the lowest quartile of daily saturated fat intake compared to non-users (OR 0.71, 95% CI 0.54–0.94). There were no statistically significant associations between statin use and smoking, physical activity or alcohol consumption.Conclusions Smoking status, alcohol consumption and exercise level did not differ between users and non-users of statins. However, statin users were less likely to consume high levels of saturated fat than non-users. We found no evidence that people took statins to compensate for a poor diet or lifestyle.

Sodium glucose co-transporter-2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1RAs) reduce major adverse cardiovascular events (MACE) in people with type 2 diabetes (T2D). Despite known sex differences in diabetes-induced cardiovascular disease (CVD), pharmacological treatment recommendations are independent of sex. Our objective was to investigate possible sex differences in rates of MACE with SGLT2i vs. GLP-1RA use.

Objective: Depressive symptoms are highly prevalent in residential aged care facilities (RACFs). The prevalence of antidepressant use is increasing but the effectiveness of antidepressants in people with dementia is uncertain. The objective of the study was to investigate factors associated with antidepressant use in residents with and without dementia.Methods: This was a prospective cross-sectional study of 383 residents in six Australian RACFs. Data on health status, medications and demographics were collected by trained study nurses from April to August 2014. Logistic regression was used to compute adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for factors associated with antidepressant use. Analyses were stratified by dementia and depression.Results: Overall, 183 (47.8%) residents used antidepressants. The prevalence of antidepressant use was similar among residents with and without dementia. Clinician-observed pain was inversely associated with antidepressant use in the main analysis (AOR = 0.56, 95% CI = 0.32–0.99) and in subanalyses for residents with documented depression (AOR = 0.51, 95% CI = 0.27–0.96). In residents with dementia, moderate quality of life was associated with a lower odds of antidepressant use compared with poor quality of life (AOR = 0.35, 95% C I= 0.13–0.95). In residents without dementia, analgesic use was associated with antidepressant use (AOR = 2.34, 95% CI = 1.07–5.18).Conclusions: The prevalence of antidepressant use was similar in residents with and without dementia. Clinician-observed pain was inversely associated with antidepressant use but there was no association between self-reported pain and antidepressant use.

Objectives: The objective of our study was to describe spontaneously reported haemorrhagic adverse events associated with rivaroxaban and dabigatran in Australia.Methods: Data were sourced from the Australian Therapeutic Goods Administration (TGA) Database of Adverse Event Notifications between June 2009 and May 2014. Records of haemorrhagic adverse events in which rivaroxaban or dabigatran was considered as a potential cause were analysed.Results: There were 240 haemorrhagic adverse events associated with rivaroxaban and 504 associated with dabigatran. Age was specified for 164 (68%) haemorrhages associated with rivaroxaban, of which 101 occurred in people aged ⩾75 years. Age was specified for 437 (87%) haemorrhages associated with dabigatran, of which 300 occurred in people aged ⩾75 years. Time from treatment initiation to haemorrhage was specified for 122 (51%) haemorrhages associated with rivaroxaban, with 69 (57%) haemorrhages occurring within 30 days of rivaroxaban initiation. Time from treatment initiation to haemorrhage was specified for 253 (50%) haemorrhages associated with dabigatran, with 123 (49%) haemorrhages occurring within 30 days of dabigatran initiation. Gastrointestinal (GI) haemorrhages were the most frequent type of haemorrhages associated with both rivaroxaban (n= 105, 44%) and dabigatran (n= 302, 60%). Data were available on the severity of haemorrhage for 101 (42%) haemorrhages associated with rivaroxaban, with haemorrhage leading to death in 17 people. The severity of haemorrhage was specified for 384 (76%) haemorrhages associated with dabigatran, with haemorrhage leading to death in 61 people.Conclusions: Our study highlights the need for research on the haemorrhagic complications of anticoagulation in clinical care. A considerable proportion of reported haemorrhagic events occurred within 30 days of rivaroxaban and dabigatran initiation. This highlights the importance of considering bleeding risk at the time of treatment initiation.

Objectives:To investigate whether medication regimen complexity and/or polypharmacy are associated with all-cause mortality in older people. Methods:This was a population-based cohort study among community-dwelling and institutionalized people ≥60 years old (n = 3348). Medication regimen complexity was assessed using the 65-item Medication Regimen Complexity Index (MRCI) in 10-unit steps. Polypharmacy was assessed as a continuous variable (number of medications). Mortality data were obtained from the Swedish National Cause of Death Register. Cox proportional hazard models were used to compute unadjusted and adjusted hazard ratios (HRs) and 95% CIs for the association between regimen complexity and polypharmacy with all-cause mortality over a 3-year period. Subanalyses were performed stratifying by age (≤80 and>80 years), sex, and cognition (Mini-Mental State Examination [MMSE] <26 and ≥26). Results:During follow-up, 14% of the participants (n = 470) died. After adjusting for age, sex, comorbidity, educational level, activities of daily living, MMSE, and residential setting, a higher MRCI was associated with mortality (adjusted HR = 1.12; 95% CI = 1.01-1.25). Polypharmacy was not associated with mortality (adjusted HR = 1.03; 95% CI = 0.99-1.06). When stratifying by sex, both MRCI and polypharmacy were associated with mortality in men but not in women. MRCI was associated with mortality in participants ≤80 years old and in participants with MMSE ≥26 but not in participants >80 years old or with MMSE <26. Conclusion:Regimen complexity was a better overall predictor of mortality than polypharmacy. However, regimen complexity was not predictive of mortality in women, in participants >80 years old, or in those with MMSE<26. These different associations with mortality deserve further investigation.

ABSTRACTAustralia’s COVID-19 vaccine rollout included prioritizing older adults and those with underlying conditions. However, little was known around the factors impacting their decision to accept the vaccine. This study aimed to assess vaccine intentions, information needs, and preferences of people prioritized to receive the COVID-19 vaccine at the start of the Australian vaccine rollout. A cross-sectional online survey of people aged ≥70 years or 18–69 with chronic or underlying conditions was conducted between 12 February and 26 March 2021 in Victoria, Australia. The World Health Organization Behavioural and Social Drivers of COVID-19 vaccination framework and items informed the survey design and framing of results. Bivariate logistic regression was used to investigate the association between intention to accept a COVID-19 vaccine and demographic characteristics. In total, 1828 eligible people completed the survey. Intention to vaccinate was highest among those ≥70 years (89.6%, n = 824/920) versus those aged 18–69 years (83.8%, n = 761/908), with 91% (n = 1641/1803) of respondents agreeing that getting a COVID-19 vaccine was important to their health. Reported vaccine safety (aOR 1.4, 95% CI 1.1 to 1.8) and efficacy (aOR 1.9, 95% CI 1.5 to 2.3) were associated with intention to accept a COVID-19 vaccine. Concerns around serious illness, long-term effects, and insufficient vaccine testing were factors for not accepting a COVID-19 vaccine. Preferred communication methods included discussion with healthcare providers, with primary care providers identified as the most trusted information source. This study identified factors influencing the prioritized public’s COVID-19 vaccine decision-making, including information preferences. These details can support future vaccination rollouts.

Background:Medication-related problems and adverse drug events are leading causes of preventable hospitalizations. Few previous studies have investigated the possible association between medication regimen complexity and unplanned rehospitalization. Objective:To investigate the association between discharge medication regimen complexity and unplanned rehospitalization over a 12-month period. Method:The prospective study comprised patients aged ≥70 years old consecutively admitted to a Geriatrics Evaluation and Management (GEM) unit between October 2010 and December 2011. Medication regimen complexity at discharge was calculated using the 65-item validated Medication Regimen Complexity Index (MRCI). Cox proportional-hazards regression was used to compute unadjusted and adjusted hazard ratios (HRs) with 95% CIs for factors associated with rehospitalization over a 12-month follow-up period. Result:Of 163 eligible patients, 99 patients had one or more unplanned hospital readmissions. When adjusting for age, sex, activities of daily living, depression, comorbidity, cognitive status, and discharge destination, MRCI (HR = 1.01; 95% CI = 0.81-1.26), number of discharge medications (HR = 1.01; 95% CI = 0.94-1.08), and polypharmacy (≥9 medications; HR = 1.12; 95% CI = 0.69-1.80) were not associated with rehospitalization. In patients discharged to nonhome settings, there was an association between rehospitalization and the number of discharge medications (HR = 1.12; 95% CI = 1.01-1.25) and polypharmacy (HR = 2.24; 95% CI = 1.02-4.94) but not between rehospitalization and MRCI (HR = 1.32; 95% CI = 0.98-1.78). Conclusion:Medication regimen complexity was not associated with unplanned hospital readmission in older people. However, in patients discharged to nonhome settings, the number of discharge medications and polypharmacy predicted rehospitalization. A patient’s discharge destination is an important factor in unplanned medication-related readmissions.

Community treatment orders (CTOs) are a form of compulsory treatment of individuals with a mental illness in the community. The objectives of this study were to determine the demographic, clinical, and treatment plan factors associated with antipsychotic polypharmacy and high-dose antipsychotics among individuals issued with a CTO. This was a secondary analysis of all 377 individuals who were prescribed an antipsychotic, extracted from a retrospective study of 378 individuals issued with a CTO by the New South Wales Mental Health Review Tribunal in Australia in 2009. Deidentified information relating to individuals’ treatment plans, demographic, and clinical details were systematically extracted. Of the 377 individuals, 121 (32) were prescribed antipsychotic polypharmacy and 101 (27) high-dose antipsychotics. Unadjusted and adjusted odds ratios (ORs) and 95 confidence intervals (95 CIs) for factors associated with antipsychotic polypharmacy and high-dose antipsychotics were computed using binary logistic regression. There was a strong association between the use of antipsychotic polypharmacy and high-dose antipsychotics (P< 0.001). Only treatment plan factors were associated with antipsychotic polypharmacy and high-dose antipsychotics in adjusted models. Although first-generation long-acting injectable antipsychotics and clozapine were associated with antipsychotic polypharmacy (adjusted OR, 9.12; 95 CI, 4.21–19.74; adjusted OR, 7.97; 95 CI, 2.93–21.72), oral second-generation antipsychotics and risperidone long-acting injection were associated with high-dose antipsychotics (adjusted OR, 5.67; 95 CI, 2.89–11.12; adjusted OR, 8.14; 95 CI, 3.22–20.53). Therefore, the use of antipsychotic polypharmacy and high-dose antipsychotics among individuals issued with CTOs is associated only with the drugs prescribed in their treatment plans and not their individual demographic and clinical characteristics.

OBJECTIVE:To systematically review the prevalence of concomitant alcohol and sedative-hypnotic use among middle-aged and older persons.DATA SOURCES:A bibliographic search of English-language literature was performed using MEDLINE, EMBASE, and PsycINFO (January 1990-August 2012). The reference lists of all included articles were screened for additional relevant articles not identified by any of the bibliographic searches.STUDY SELECTION AND DATA EXTRACTION:Population-based studies in which the mean age of participants was 40 years or older were included. For a study to be included in the review, alcohol use had to be reported in terms of the quantity or frequency consumed. Data from included articles were extracted using a standardized data extraction tool.DATA SYNTHESIS:Five population-based studies conducted in North America, 10 in Europe, and 1 in Australia were included in the review. Up to 88% of men and 79% of women who used sedative-hypnotics also consumed alcohol. Up to 28% of those who consumed alcohol were concomitant users of sedative-hypnotics. Alcohol was consumed at higher levels among middle-aged than older persons. Risky drinking (eg, binge drinking, heavy drinking) was more prevalent among middle-aged than older persons. In contrast, sedative-hypnotic use was more prevalent among older persons.CONCLUSIONS:Our review identified a higher prevalence of alcohol consumption among middle-aged than older persons. However, middle-aged persons may experience harm from alcohol/sedative-hypnotic drug interactions due to risky drinking behavior. Despite lower levels of alcohol consumption, older persons may be more susceptible to addictive central nervous system effects than younger persons because of physiologic changes in psychotropic drug and alcohol metabolism. Clinicians should consider patients' alcohol consumption patterns before prescribing sedative-hypnotic drugs.

The aim of this study was to investigate the change in sedative load over time and the corresponding risk of death among community-dwelling older individuals. A random sample of 1000 individuals aged at least 75 years was invited to participate in 2004, of whom 700 were community dwelling. Demographic, diagnostic, and drug use data were obtained during annual nurse interviews. Sedative load was calculated according to a previously published model. The prevalence of sedative use increased from 29.3 to 36.1 from 2004 to 2007. In unadjusted analyses, sedative load was associated with an increased risk of death. After adjusting for clinically important covariates, sedative load was not associated with an increased risk of death sedative load 1–2; hazard ratio 1.12 (95 confidence interval 0.76–1.64), sedative load of at least 3; hazard ratio 0.92 (95 confidence interval 0.55–1.56). In conclusion, sedative use increased during the follow-up but was not associated with an increased risk of death.

Drugs with sedative properties are frequently used among older people. Sedative load is a measure of the cumulative effect of taking multiple drugs with sedative properties. The objective of this study was to investigate the association between sedative load and balance and mobility. A random sample of 1000 people 75 years or older was invited to participate. Seven hundred community-dwelling participants (mean age, 81.3 years; 69 women) were included in the present study. Demographic, diagnostic, and drug use data were elicited during nurse interviews in 2004. Balance and mobility were tested by physiotherapists. Sedative load was calculated using a previously published model for each participant by summing the sedative ratings of primary sedatives (rating 2) and drugs with sedation as a prominent adverse effect (rating 1). Analyses of covariance and logistic regression analyses were used to assess the association between sedative load and balance and mobility. Of the 700 participants, 21 (n = 147) had a sedative load of 1–2, and 8 (n = 58) had sedative load of 3 or greater. After adjusting for covariates, exposure to higher sedative load ranges was associated with slower walking speed (P= 0.0003), longer time to perform Timed Up and Go test (P= 0.005), and lower scores on Berg Balance Scale (P= 0.005), but not with self-reported ability to walk 400 m. In conclusion, having a higher sedative load was associated with impaired balance and mobility among community-dwelling older people. Clinicians should remain cognizant of this association and regularly reevaluate drug therapy prescribed to older people.

Since 2004, the Department of Veterans' Affairs (DVA) has funded the Veterans' Medicines Advice and Therapeutics Education Services (MATES) program. The main intervention of the program is quarterly targeted patient‐specific prescriber feedback. The feedback comprises a list of relevant medications dispensed to each patient and notes about potential medication‐related problems specific to the intervention. Supportive educational material is provided to assist general practitioners (GPs) resolve these medication‐related problems. Veterans identified in the GP mailing are sent an educational brochure highlighting medication issues and encouraging them to speak with their doctor. To enable pharmacists to support this practice change, educational material is also provided to all pharmacies and accredited pharmacists. The most recent of the 28 interventions implemented to date have addressed osteoporosis, opioid‐induced constipation and urinary incontinence. Overall, program materials have been mailed to 249 454 veterans, 34 527 GPs and around 8000 pharmacies and accredited pharmacists. Evaluation has demonstrated a doubling of home medicines review (HMR) rates in the veteran population. Analyses of the DVA data have reported a 45% reduction in hospitalisation for heart failure following HMR among veterans with heart failure (adjusted hazard ratio [HR] 0.6; 95% confidence interval [CI] 0.4–0.8), and a 79% reduction in hospitalisation for haemorrhage (HR 0.2; 95%CI 0.05–0.9) 2 to 6 months after an HMR in veterans dispensed warfarin. Veterans' MATES has resulted in clinically significant improvements in medication and health service use.

Background: Most studies on heavy drinking and sedative/anxiolytic drug use have been cross-sectional, and evidence for a possible temporal association is lacking.Objective: To prospectively investigate whether heavy drinking predicts initiation, continuation, or discontinuation of sedative/anxiolytic drugs at 4 arid 11 years and, conversely, whether sedative/anxiolytic drug use predicts heavy drinking.Method: This was a longitudinal population-based study conducted in Kuopio, Finland, An age-stratified random sample of 1516 men aged 42, 48, 54, and 60 years received a structured clinical examination at baseline (August 1986-December 1989). Follow-up clinical examinations were conducted at 4 (n − 1038) and 11 (n = 854) years. Multinomial logistic regression was used to compute odds ratios and 95% confidence intervals for the association between sedative/anxiolytic drug use and initiation, continuation, and discontinuation of heavy drinking (≥14 drinks/wk). The reverse association between heavy drinking and sedative/anxiolytic drug use was also investigated. Regression models were adjusted for age, working status, smoking, and depressive symptoms.Results: At baseline 12.9% (134/1038) of participants were heavy drinkers and 4.0% (41/1030) used sedative/anxiolytic drugs. In multivariate analyses, baseline heavy drinking predicted initiation of sedative/anxiolytic drug use at 4 years (OR 2.96; 95% CI 1.23 to 7.15). Conversely, baseline sedative/anxiolytic drug use predicted continuation of heavy drinking at 11 years in unadjusted analysis (OR 3.30; 95% CI 1.19 to 8.44). However, the association was not statistically significant in adjusted analyses (OR 2.69; 95% CI 0.86 to 8.44).Conclusions: The main finding of this study was the association between heavy drinking and subsequent initiation of sedative/anxiolytic drugs that was not fully explained by baseline depressive symptoms. This may inform strategies to optimize the use of sedative/anxiolytic drugs, and assist in the early identification of patients at risk of heavy drinking. Clinicians should consider a patent's alcohol consumption prior to prescribing or dispensing sedative/anxiolytic drugs. Clinicians should also monitor patients prescribed sedative/anxiolytic drugs for subsequent heavy drinking.

Objective: To investigate the association between the use of benzodiazepines (BDZs) and BDZ-related drugs and mortality among community-dwelling people aged 65 years and older in Finland.Method: This was a population-based retrospective cohort study. Records of all reimbursed drugs purchased by all 2224 residents of Leppävirta, Finland, aged 65 years and older in 2000 were extracted from the Finnish National Prescription Register. Diagnostic data were extracted from the Special Reimbursement Register. All-cause mortality was assessed after 9 years using national registers. Cox proportional hazards models were used to compute unadjusted and adjusted hazard ratios (HRs) and 95% confidence intervals for mortality among prevalent users of BDZs and BDZ-related drugs in 2000 (n= 325), compared with nonusers of BDZs and BDZ-related drugs between 2000 and 2008 (n= 1520).Results: BDZs and BDZ-related drugs were used by 325 out of the 2224 residents (14.6%) in 2000. The 9-year mortality was 50.2% among BDZ and BDZ-related drug users in 2000 and 36.3% among BDZ and BDZ-related drug nonusers between 2000 and 2008 (HR 1.53; 95% CI 1.28 to 1.82). After adjusting for baseline age, sex, antipsychotic drug use, and diagnostic confounders, the HR was 1.01 (95% CI 0.84 to 1.21).Conclusions: Use of BDZs and BDZ-related drugs was associated with an increased mortality hazard in unadjusted analyses. However, after adjusting for age, sex, antipsychotic drug use, and diagnostic confounders, the use of BDZs and BDZ-related drugs was not associated with excess mortality.

Background: The importance of email as a mode of communication between medication users and pharmacists is likely to increase. However, little is known about the email medication counseling practices of community pharmacies.Objective: To determine the prevalence of email medication counseling services in Finland and to assess the accuracy and comprehensiveness of responses by pharmacies providing the opportunity for email medication counseling to inquiries related to use of antidepressants.Methods: An inventory was made of all Finnish community pharmacies that provided the opportunity for email medication counseling. Data related to the accuracy and comprehensiveness of responses were collected, using a virtual pseudo-customer method with 3 scenarios related to common concerns of patients on antidepressants. Two inquiries were emailed to each pharmacy that provided the opportunity for email medication counseling in January and February 2005. The responses were content analyzed by 2 researchers, using a prestructured scoring system.Results: Almost one-third (30%, n = 182) of Finnish community pharmacies maintained a working Web site, and 94% of those provided the opportunity for email medication counseling. An online “ask-the-pharmacist” service was offered by 13% (n = 23) of the pharmacies with a Web site. Pharmacies responded to 54% of the email inquiries sent by the virtual pseudo-customers. The response rate and the content score ratio between mean and maximum scores varied among the scenarios. The content score ratio was highest for the scenarios concerning the adverse effects of fluoxetine (0.53, n = 55) and interactions with mirtazapine (0.52, n = 63) and lowest for the scenario related to sexual dysfunction and weight gain associated with citalopram (0.38, n = 52).Conclusions: Community pharmacies are potential providers of email medication counseling services. However, more attention should be directed to responding to consumer inquiries and to the content of these responses.

Objective: To describe practice and research related to pharmaceutical care In Estonia following the country's restoration of independence from Russia in 1991.Findings: The transition from a Soviet to a free market economy has Impacted the healthcare and pharmacy systems in Estonia. Following independence, ownership of community pharmacies was transferred from the Stale government to individual pharmacists. However, pharmacy ownership is no longer restricted to pharmacists and recent years have seen the emergence of large pharmacy chains. The number of community pharmacies in Estonia increased from 270 in 1992 to 523 in 2007. In addition to dispensing, Estonian pharmacies retain a focus on compounding of extemporaneous products and supply of herbal medications. Research into pharmaceutical care has addressed topics including pharmaceutical policy and the quality of pharmacy services provided at community pharmacies.Discussion: There has been limited pressure to date from the governmental Institutions and patient organizations to Introduce extended pharmaceutical services. However, the trend toward providing health services in primary care will create greater responsibilities and new opportunities for community pharmacists. Recent inclusion of clinical pharmacy and interprofessional learning In the undergraduate pharmacy curriculum will help ensure ongoing development of the profession and high-quality pharmacy services in the future.Conclusions: Pharmaceutical care services in Estonian community pharmacies have become more patient-oriented over the past 17 years. However, community pharmacies continue to retain a focus on traditional roles.

There is a well‐documented shortage of pharmacists in Australia and overseas. Mentoring has been proposed as a strategy to help bridge the gap between university and the workforce, and to maintain enthusiasm in young pharmacists and students for their profession. To develop, implement and evaluate a mentoring program, matching young pharmacists working in a range of pharmacy practice settings with pharmacy students. The mentoring program was divided into 3 phases: Phase 1—literature review and feasibility study; Phase 2—recruitment of young pharmacists (mentors) and pharmacy students (mentees), matching mentors and mentees by areas of pharmacy interest and encouraging them to discuss their individual needs, desires and work goals; Phase 3—program evaluation. 151 mentees and 56 mentors (n = 207) were recruited (April 2003 to October 2004). Of the 56 mentors, 13 were from a hospital pharmacy background. 42% of students selected hospital pharmacy as their first preference and 21% selected hospital pharmacy as their second preference. 58 students were recorded as having a hospital mentor. Due to poor response rates to the program evaluation survey, the data reported for phase 3 is for all participants and is not specific to hospital. No differences in qualitative results could be seen between the sectors. The mentoring program was flexible and appears transportable. Further studies are needed to determine whether mentoring impacts on the retention of young pharmacists and pharmacy students within the profession. We recommend that the profession support a national mentoring program where further outcomes of this model could be evaluated.

OBJECTIVE: To describe the provision of patient care in community pharmacies in Finland.FINDINGS: The network of 799 community pharmacies across Finland dispensed 42.1 million prescriptions in 2005. Medication counseling has been mandated by law since 1983 and only pharmacists are permitted to provide therapeutic advice in pharmacies. Measurable improvements in the rates of pharmacists' medication counseling have been observed since 2000. Long-term national pharmacy practice initiatives commenced with the World Health Organization EuroPharm Forum's Questions to Ask About Your Medicines campaign from 1993 to 1996. This was followed by the larger Customized Information for the Benefit of Community Pharmacy Patients project. Since the late 1990s, Finnish pharmacies have actively participated in ongoing national public health programs, initially in the areas of asthma and diabetes, and more recently in the treatment and prevention of heart disease. Automated dose dispensing and electronic prescribing are in the process of wider uptake and implementation. A nationwide multidisciplinary project to improve the use of drugs in older people has recently been announced and research in this area is underway.DISCUSSION: Research has focused on improving the quality of patient care as a strategic priority in community pharmacies. The development of community pharmacy services in Finland has been characterized by strong collaboration among the professional associations, university departments of social pharmacy, continuing education centers, and practicing pharmacists.CONCLUSIONS: Implementation of new patient care services has required long-term, systematic, and well coordinated actions at the local and national levels. Future services will seek to promote the quality use of medications and to ensure that rising costs do not limit uniform access to drugs by all Finnish residents.

Background: People with mental illness have been recognized as key stakeholders in the development of mental health education. However, few studies have evaluated the impact of people with mental illness as participants in education programs for students studying to become health professionals.Objective: To assess the impact of education provided by mental health consumer–educators on the attitudes of pharmacy students toward people with mental illness.Methods: The study used a 2 group, nonrandomized, clustered, comparative design, with 4 tutorial classes allocated to receive standard pharmacist-led instruction (comparison group), and 5 tutorial classes to receive standard pharmacist-led instruction plus additional input from mental health consumer–educators (intervention group). All pharmacy students (N = 229) enrolled in the third year of a 4 year pharmacy degree program were invited to participate. Consumer–educators receiving ongoing treatment for illnesses including schizophrenia, bipolar disorder, and major depression participated in small-group work, case-study discussions, and role plays with pharmacy students in the intervention group. Pharmacy students' attitudes were assessed using a 39 item survey instrument derived from previously published instruments evaluating social distance, attribution, provision of pharmaceutical services, and stigmatization of people with schizophrenia and severe depression.Results: Paired baseline and follow-up responses were obtained from 117 students in the intervention group and 94 students in the comparison group. Students who received the consumer intervention had decreased social distance scores (F(1209)= 5.30; p = 0.02). Students in the intervention group more strongly disagreed with 26 of 27 nonsocial distance statements that demonstrated a negative attitude toward people with mental illness (F(1209)= 13.58; p < 0.001) and more strongly agreed with all 4 nonsocial distance statements that demonstrated a positive attitude (F(1209)= 7.56; p = 0.014).Conclusions: Consumer participation in mental health education for pharmacy students improves students' attitudes toward people with mental illness.

Non‐medical use of prescription drugs (NMPD) is when prescription drugs are used in a manner other than for the reason or duration prescribed. To explore NMPD among clients admitted to an acute psychiatric unit. A prospective observational study was conducted of all clients aged ≥ 18 years admitted to an acute psychiatric unit from 2 July to 2 September 2012. NMPD definition was based on the United Nations Office on Drugs and Crime criteria. Clinical and demographic data were extracted from medical records. Descriptive statistics were used to compare the characteristics of clients with and without NMPD. Of the 76 eligible clients, 19 (25%) had evidence of NMPD. NMPD was associated with age < 65 years (p = 0.03), consumption of > 4 standard alcoholic drinks per day (p = 0.02), smoker (p = 0.02) and admission for a psychological reason with suicidal ideation (p = 0.03). There was no significant association between NMPD and gender or illicit drug use. Clients with NMPD had higher symptom severity scores at discharge (p = 0.01) and shorter durations of hospital stay than clients without NMPD (p < 0.001). NMPD was prevalent among clients admitted to an acute psychiatric unit. Clients with NMPD had a shorter hospital stay than those without NMPD. Clinicians and policy makers need to implement strategies to minimise NMPD.

Evaluation of: Berry SD, Lee Y, Cai S, Dore DD. Nonbenzodiazepine sleep medication use and hip fractures in nursing home residents. JAMA Intern. Med.173(9), 754–761 (2013).Sleep disturbances and complaints about poor sleep are common among residents of aged care facilities. Nonbenzodiazepine (non-BZD) hypnotics are often prescribed to older individuals in preference to benzodiazepines. To establish whether the use of non-BZD hypnotics is associated with an increased risk of hip fracture, Berry et al.conducted a case-crossover study among 15,528 long-stay US nursing home residents with a hip fracture. Medicare hospitalization and pharmacy claims data were used for determining hip fractures and medication use, and the minimum data set was used to ascertain resident characteristics. Odds ratios (ORs) for hip fracture were estimated by comparing the use of non-BZD hypnotics 0–29 days before hip fracture (hazard period) with use of non-BZD hypnotics 60–89 days and 120–149 days before hip fracture (control periods). During the 18-month study period, non-BZD hypnotics were dispensed to 11% (n = 1715) of the residents with hip fracture. There was an increased risk of hip fracture within 30 days of using a non-BZD hypnotic (OR: 1.66; 95% CI: 1.45–1.90). The risk of hip fracture was higher among new users of non-BZD hypnotics (OR: 2.20; 95% CI: 1.76– 2.74) and in those requiring supervision or limited assistance to transfer, compared with those requiring full assistance to transfer (OR: 2.02 vs 1.43; p = 0.02). The present study did not directly compare the risk of hip fracture associated with non-BZD hypnotics and benzodiazepines. However, the results suggest that clinicians should continue to exercise caution when prescribing non-BZD hypnotics to residents of aged care facilities.

Evaluation of: Butt DA, Mamdani M, Austin PC, Tu K, Gomes T, Glazier RH. The risk of hip fracture after initiating antihypertensive drugs in the elderly. Arch. Intern. Med.172(22), 1739–1744 (2012).Previous research has identified an association between antihypertensive drugs, falls and fractures. Nearly all hip fractures are fall-related. However, little is known about the risk of hip fracture immediately after initiating an antihypertensive. Butt et al.conducted a self-controlled case series of newly treated community-dwelling older people with hypertension. The authors linked data from the Ontario Drug Benefit Program database to a series of administrative healthcare registers. There were 1463 hip fractures among the 301,591 newly treated hypertensive older people over a 10-year period. There was a 43% increased risk of hip fracture in the 45 days immediately after initiating an antihypertensive compared with the six 45-day control periods before and after treatment initiation (incidence rate ratio: 1.43; 95% CI: 1.19–1.72). The within-person study design minimized the possibility of confounding by indication, which often occurs in cohort and case–control studies. Initiating an antihypertensive may be a risk factor for hip fracture in community-dwelling older people with hypertension.

Evaluation of: Billioti de Gage S, Bègaud B, Bazin F et al.Benzodiazepine use and risk of dementia: prospective population based study. 345, e6231 (2012).The use of benzodiazepines is highly prevalent in older people. It is well established that benzodiazepines can impair cognitive function. However, it is not clear whether benzodiazepines can cause dementia. Billioti de Gage et al.used three different epidemiological approaches to assess whether benzodiazepine use is associated with incident dementia in a population-based community-dwelling sample of people aged 65 years and older. In the main analysis, benzodiazepine use was associated with a hazard ratio of 1.60 (95% CI: 1.08–2.38) for the development of dementia over a 15-year follow-up period when compared with nonuse of benzodiazepines. The key strengths of the study included the new user design, long-term follow-up, and confirmation of dementia diagnoses by neurologists. The possibility of reverse causation arising from use of benzodiazepines for prodromal symptoms of dementia cannot be excluded. However, this study provides additional evidence about the risks of benzodiazepine use in older people.

Global Initiative for Asthma step 5 therapies (GINA-5), other than inhaled corticosteroids and long-acting β-agonists in fixed dose combinations (ICS/LABA FDC), often entail more expensive (eg, monoclonal biologics) or less safe (eg, maintenance oral corticosteroids [OCS]) treatments. It is therefore important to assess poor inhaler adherence as a possible cause of suboptimal response to ICS/LABA FDC before additional GINA-5.

Objective. To evaluate a consumer-led teaching intervention to reduce pharmacy students' stigma towards depression and schizophrenia, and improve attitudes toward providing pharmaceutical care for consumers with mental illness.

Objective. To determine Nepalese pharmacy students' perceptions of whether mental disorders impact performance in pharmacy school.