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Improving the quality of medication use and medication safety are important priorities for healthcare providers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2022. We selected high‐quality studies from an OVID search and hand searching of major high impact journals that advanced the field of research forward. The chosen articles cover domains related to deprescribing, medication safety, and optimizing medication use. The MedSafer Study, a cluster randomized clinical trial in Canada, evaluated whether patient specific deprescribing reports generated by electronic decision support software resulted in reduced adverse drug events in the 30 days post hospital discharge in older adults (domain: deprescribing). The second study, a retrospective cohort study using data from Premier Healthcare Database, examined in‐hospital adverse clinical events associated with perioperative gabapentin use among older adults undergoing major surgery (domain: medication safety). The third study used an open‐label parallel controlled trial in 39 Australian aged‐care facilities to examine the effectiveness of a pharmacist‐led intervention to reduce medication‐induced deterioration and adverse reactions (domain: optimizing medication use). Lastly, the fourth study engaged experts in a Delphi method process to develop a consensus list of clinically important prescribing cascades that adversely affect older persons' health to aid clinicians to identify, prevent, and manage prescribing cascades (domain: optimizing medication use). 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]

This article discusses the importance of empowering people living with dementia to be active partners in conversations about their medications. The authors describe their process of co-designing a conversation tool called the PRIME tool, which stands for "PReparing people living with dementia and their carers to Initiate deprescribing conversations about Medications." The tool is designed to provide subtle cues to healthcare professionals to review the ongoing need for medications during shared decision-making consultations. The authors reflect on their partnership with a stakeholder group consisting of consumers and healthcare professionals and provide recommendations for engaging stakeholders in the co-design process. They hope that their findings will inform the development of impactful deprescribing research resources alongside consumer groups. [Extracted from the article]

Background: Potentially inappropriate medications (PIMs) in older adults are medications in which risks often outweigh benefits and are suggested to be avoided. Worldwide, many distinct guidelines and tools classify PIMs in older adults. Collating these guidelines and tools, mapping them to a medication classification system, and creating a crosswalk will enhance the utility of PIM guidance for research and clinical practice. Methods: We used the Anatomical Therapeutic Chemical (ATC) Classification System, a hierarchical classification system, to map PIMs from eight distinct guidelines and tools (2019 Beers Criteria, Screening Tool for Older Person's Appropriate Prescriptions [STOPP], STOPP‐Japan, German PRISCUS, European Union‐7 Potentially Inappropriate Medication [PIM] list, Centers for Medicare & Medicaid Services [CMS] High‐Risk Medication, Anticholinergic Burden Scale, and Drug Burden Index). Each PIM was mapped to ATC Level 5 (drug) and to ATC Level 4 (drug class). We then used the crosswalk (1) to compare PIMs and PIM drug classes across guidelines and tools to determine the number of PIMs that were index (drug‐induced adverse event) or marker (treatment of drug‐induced adverse event) drug of prescribing cascades, and (2) estimate the prevalence of PIM use in older adults continuously enrolled with fee‐for‐service Medicare in 2018 as use cases. Data visualization and descriptive statistics were used to assess guidelines and tools for both use cases. Results: Out of 480 unique PIMs identified, only three medications—amitriptyline, clomipramine, and imipramine and two drug classes—N06AA (tricyclic antidepressants) and N06AB (selective serotonin reuptake inhibitors), were noted in all eight guidelines and tools. Using the crosswalk, 50% of classes of index drugs and 47% of classes of marker drugs of known prescribing cascades were PIMs. Additionally, 88% of Medicare beneficiaries were dispensed ≥1 PIM across the eight guidelines and tools. Conclusion: We created a crosswalk of eight PIM guidelines and tools to the ATC classification system and created two use cases. Our findings could be used to expand the ease of PIM identification and harmonization for research and clinical practice purposes. [ABSTRACT FROM AUTHOR]

Background: In July 2012, the Centers for Medicare & Medicaid services launched an antipsychotic reduction initiative (ARI) to improve care for nursing facility residents with Alzheimer's disease and related dementias (ADRD). We examined the impact of this policy on antipsychotic and psychotropic medication (PM) utilization and diagnosis patterns in long‐stay nursing facility residents with ADRD and other conditions in which antipsychotics are indicated. Methods: Using an 80% sample of fee‐for‐service Medicare beneficiaries with Part D, we conducted a retrospective cohort study of nursing facility residents with ADRD, bipolar disorder, psychosis, Parkinson's disease, and residents exempt from the policy due to diagnoses of schizophrenia, Tourette syndrome, and/or Huntington's disease. We used interrupted time‐series analyses to compare changes in diagnoses, antipsychotic use, and PM utilization before (January 1, 2011–June 30, 2012) and after (July 1, 2012–September 30, 2015) ARI implementation. Results: We identified 874,487 long‐stay nursing facility residents with a diagnosis of ADRD (n = 358,518), exempt (n = 92,859), bipolar (n = 128,298), psychosis (n = 93,402), and Parkinson's disease (n = 80,211). In all cohorts, antipsychotic use declined prior to the ARI; upon policy implementation, antipsychotic use reductions were sustained throughout the study period, including statistically significant ARI‐associated accelerated declines in all cohorts. PM changes varied by cohort, with ARI‐associated increases in non‐benzodiazepine sedatives and/or muscle relaxants noted in ADRD, psychosis, and Parkinson's cohorts. Although anticonvulsant use increased throughout the study period in all groups, with the exception of the bipolar cohort, these increases were not associated with ARI implementation. Findings are minimally explained by increased post‐ARI membership in the psychosis and Parkinson's cohorts. Conclusions: Our study documents antipsychotic use significantly declined in non‐ADRD clinical and exempt cohorts, where such reductions may not be clinically warranted. Furthermore, ARI‐associated compensatory increases in PMs do not offset these reductions. Changes in PM utilization and diagnostic make‐up of residents using PMs require further investigation to assess the potential for adverse clinical and economic outcomes. See related commentary by Reppas‐Rindlisbacher et al. in this issue. [ABSTRACT FROM AUTHOR]

Purpose: Psychotropic medications are used to manage behavioral symptoms of dementia in nursing homes despite limited efficacy and the risk of adverse effects, and may be considered an easier solution for the treatment of behavioral symptoms. However, non‐pharmacologic interventions are preferable but are most effective with consistent staffing. To address this, the Centers for Medicare and Medicaid Services implemented additional regulatory scrutiny through F‐tag for deficiencies of care, targeting inappropriate psychotropic medication use (F‐758 tag). The purpose of this study was to examine associations between nurse staffing levels and the occurrence of deficiency citations for inappropriate psychotropic medication use in residents with dementia symptoms. Design This was secondary data analysis of a cross‐sectional study using CASPER (Certification and Survey Provider Enhanced Reporting) and PBJ (Payroll‐Based Journal) data from 14,548 Medicare or Medicaid‐certified facilities surveyed between December 1, 2017 and December 31, 2018. Methods: Staffing measures included nursing hours per resident day and registered nurse skill‐mix. Generalized linear mixed models with facilities nested within states, were used to estimate the magnitude of the associations between the occurrence of inappropriate psychotropics use deficiency citations and nurse staffing levels. Covariates included facility location, size, ownership, the presence of dementia special care units, and the proportion of residents with dementia, depression, psychiatric disorders, mental behavioral symptoms, and residents with Medicare/Medicaid. Results: There were 1875 facilities with deficiency citations regarding inappropriate psychotropics use for residents with dementia. When controlling for covariates, facilities with greater hours per resident day for registered nurses (odds ratio [OR] = 0.54, 95% confidence interval [CI] = 0.44–0.67), certified nursing assistants (OR = 0.87, 95% CI = 0.77–0.99) and total nurse staff (OR = 0.87, 95% CI = 0.79–0.96) had significantly lower odds of inappropriate psychotropics use deficiency citations. Nursing homes with greater registered nurse skill‐mix had significantly lower odds of receiving the deficiency tags (OR = 0.10, 95% CI = 0.04–0.26). Conclusion: Citations for inappropriate psychotropic medication use among residents with dementia were less likely to occur in facilities with higher staffing levels for registered nurses, certified nursing assistants, total nurse staff, and greater registered nurse skill‐mix. Facilities need to be equipped with adequate nurse staffing levels to facilitate the use of non‐pharmacological interventions and reduce inappropriate psychotropic medication use. Clinical Relevance: Adequate nursing staffing is associated with fewer deficiencies related to the use of psychotropic medications to treat behavioral symptoms. Nursing home administrators and policymakers need to focus on assuring adequate nurse staffing levels to provide safe and high‐quality dementia care. [ABSTRACT FROM AUTHOR]

As a method of research, pragmatic trials are recommended so as to generate results that are applicable to real‐world care. This intent is especially important for the millions of older adults who receive long‐term care in thousands of nursing homes and assisted living communities across the country—and many millions more around the globe. This article presents key points raised by experts participating in a conference funded by the National Institute of Aging held at the 2021 conference of the Society for Post‐Acute and Long‐term Care Medicine. The purpose of the conference was to convene leading clinicians, researchers, and industry partners to address special considerations of pragmatic trials in long‐term care. Cross‐cutting and unique challenges and solutions to conducting pragmatic trials were discussed focusing on 3 areas of clinical relevance to long‐term care: (1) functional care and outcomes, (2) psychosocial care and quality of life, and (3) medical care and outcomes, with a special focus on persons with dementia. Challenges and innovative solutions were organized across the 9 domains of the revised Pragmatic‐Explanatory Continuum Indicator Summary (PRECIS) Tool, and future research recommendations for pragmatic trials in long‐term care were identified. See related editorial by Zimmerman et al. and Special Articles by Gurwitz et al. and Levy et al. in this issue. [ABSTRACT FROM AUTHOR]

We currently live in the age of medication overload. More than 40% of older adults (≥65 years old) are prescribed ≥5 medications a day and nearly 20% take ≥10. Although medications can provide a wide variety of benefits, the number of medications prescribed is the largest predictor of drug‐drug interactions, nonadherence, and most importantly adverse drug events. Increasingly, patients, caregivers, and health care providers are employing deprescribing efforts as a solution to medication overload. Clinical pharmacists are well positioned to lead and/or contribute to deprescribing efforts. Deprescribing, however, is not commonly and consistently taught within the United States health professional curriculums, and deprescribing infrastructure support is currently limited. The goal of this review is to present a pragmatic approach to pharmacist‐driven clinical practice deprescribing implementation. [ABSTRACT FROM AUTHOR]

An editorial on the development of a medication management guide for the COVID-19 pandemic is presented. It mentions the need for health care personnel to minimize the risk of transmitting COVID-19, presents examples of drug therapies that can be modified or stopped temporarily, and how to address unintended consequences.

Background: Engaging older adults, caregivers and family is necessary to produce relevant and meaningful evidence. Patient‐centered‐outcomes research (PCOR) engages these individuals as research partners. For instance, the process of shared decision‐making about deprescribing (reducing or stopping potentially inappropriate medications) between people living with dementia and their carers (consumers), and clinicians, is complex. Method: Various tactics were employed by the Elder Care Medicine Network (ECMN) and stakeholder steering groups from USA and Australia. These initiatives describes efforts to increase capacity of local communities – older adults, their caregivers, healthcare providers and researchers – to participate in medication related PCOR as well as the development of a tool (PRIME) to help with deprescribing medications for individuals with dementia. Result: There are over 120 active participants in the ECMN. After they shared their PCOR training needs, trainings were held as Discussion sessions where Council members and network participants shared their medication experiences and talked about participating on a PCOR research team. Network participants also identified what they felt were meaningful research questions on medication‐related PCOR (video). Additionally the PRIME tool was developed via an iterative process utilizing one‐to‐one semi‐structured interviews and a focus group session with 39 participants (people living with dementia, carers, and clinicians) to determine the usability and comprehensibility of the PRIME tool. Iterative changes were made to improve the content and layout of the tool. Conclusion: These two initiatives illustrate the importance of co‐design and incorporating the older adults and caregivers voice in medication optimization efforts in individuals with dementia. [ABSTRACT FROM AUTHOR]

The American Geriatrics Society (AGS) Beers Criteria® (AGS Beers Criteria®) for Potentially Inappropriate Medication (PIM) Use in Older Adults are widely used by clinicians, educators, researchers, healthcare administrators, and regulators. Since 2011, the AGS has been the steward of the criteria and has produced updates on a 3‐year cycle. The AGS Beers Criteria® is an explicit list of PIMs that are typically best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or conditions. For the 2019 update, an interdisciplinary expert panel reviewed the evidence published since the last update (2015) to determine if new criteria should be added or if existing criteria should be removed or undergo changes to their recommendation, rationale, level of evidence, or strength of recommendation. J Am Geriatr Soc 67:674–694, 2019. See related editorial by Steinman et al. in this issue. [ABSTRACT FROM AUTHOR]

Skilled nursing facilities and nursing homes are care settings that offer increasing opportunities for pharmacists to take the lead when addressing the new updated Centers for Medicare and Medicaid Services (CMS) requirements coupled with enhanced quality measures reporting. In addition, the complexity of the medication‐related needs and comorbidities of the patients served in long‐term care facilities promotes pharmacists practicing to the top of their license. Medication stewardship needs to be an interdisciplinary team activity led by the pharmacist. This article highlights areas of opportunity and innovation focusing on the four areas that reflect new regulations and enhanced scrutiny by CMS: psychotropic medications, transitions in care, antibiotic stewardship, and pain management. [ABSTRACT FROM AUTHOR]

Objective: To examine the determinants of potentially inappropriate medication (PIM) use.Data Sources/study Setting: U.S. nationally representative data on (n = 16,588) noninstitutionalized older adults (age ≥65) with drug use from the 2006-2010 Medical Expenditure Panel Survey.Study Design: We operationalized the 2012 Beers Criteria to identify PIM use during the year, and we examined associations with individual-level characteristics hypothesized to be quality enabling or related to need complexity.Principal Findings: Almost one-third (30.9 percent) of older adults used a PIM. Multivariate results suggest that poor health status and high-PIM-risk conditions were associated with increased PIM use, while increasing age and educational attainment were associated with lower PIM use. Contrary to expectations, lack of a usual care source of care or supplemental insurance was associated with lower PIM use. Medication intensity appears to be in the pathway between both quality-enabling and need-complexity characteristics and PIM use.Conclusion: Our results suggest that physicians attempt to avoid PIM use in the oldest old but have inadequate focus on the high-PIM-risk conditions. Educational programs targeted to physician practice regarding high-PIM-risk conditions and patient literacy regarding medication use are potential responses. [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of substance abuse claims redaction on Medicare spending estimates for beneficiaries with serious mental illness.Data Sources: The 2012 claims and unredacted beneficiary-level Medicare spending totals from CMS's Chronic Conditions Warehouse.Study Design: We identified beneficiaries with claims affected by the redaction by comparing claims-based spending estimates to unredacted spending totals. Differences in characteristics of beneficiaries with and without redacted claims were examined in bivariate analyses.Principal Findings: Claims-based spending totals differed from unredacted totals for 19.7 percent of the cohort. Part A spending for those with redacted claims was underreported by 57.0 percent. Characteristics of beneficiaries with and without redacted claims differed significantly.Conclusions: Researchers who rely on Medicare claims to analyze spending outcomes for beneficiaries with serious mental illness should be aware of the potential for bias due to nonrandom redaction of substance abuse data. [ABSTRACT FROM AUTHOR]

Objectives To examine disease-specific associations between antipsychotic dose and duration and all-cause mortality. Design Retrospective cohort study. Setting A 5% random sample of Medicare beneficiaries who had a Minimum Data Set 2.0 clinical assessment completed between 2007 and 2009. Participants Three mutually exclusive cohorts of new antipsychotic users with evidence of severe mental illness ( SMI, n = 5,621); dementia with behavioral symptoms (dementia + behavior) without SMI (n = 1,090); or delirium only without SMI or dementia + behavior (n = 2,100) were identified. Measurements Dose and duration of therapy with antipsychotics were assessed monthly with a 6-month look-back. Dose was measured as modified standardized daily dose ( mSDD), with a mSDD of 1 or less considered below or at recommended maximum geriatric dose. Duration was categorized as 30 or fewer, 31 to 60, 61 to 90, and 91 to 184 days for SMI and dementia + behavior and 7 or fewer, 8 to 30, 31 to 90, and 91 to 184 days for delirium. Complementary log-log models with mSDD and duration as time-dependent variables were used to estimate hazard ratios ( HRs) and 95% confidence intervals ( CIs) for mortality. Results In all three groups, new antipsychotic users with a mSDD of 1 or less had significantly lower mortality risk ( HRSMI = 0.77, 95% CI = 0.67-0.88; HRdementia+behavior = 0.52, 95% CI = 0.36-0.76; HRdelirium = 0.61, 95% CI = 0.44-0.85) than peers with a mSDD greater than 1. Individuals with longer duration of antipsychotic use (91-184 days for SMI and delirium) had significantly lower mortality than those with a short duration of use (≤30 days for SMI; ≤7 days for delirium). The interaction between dose and duration was statistically significant in the SMI cohort ( P < .001). Conclusion Lower mortality was observed with within-recommended dose ranges for dementia + behavior, SMI, and delirium and with long duration of antipsychotic use for the latter two disease groups. Prescribers should monitor antipsychotic dosage throughout the course of antipsychotic treatment and customize dose and duration regimens to an individual's indications. [ABSTRACT FROM AUTHOR]

The 2015 American Geriatrics Society (AGS) Beers Criteria are presented. Like the 2012 AGS Beers Criteria, they include lists of potentially inappropriate medications to be avoided in older adults. New to the criteria are lists of select drugs that should be avoided or have their dose adjusted based on the individual's kidney function and select drug-drug interactions documented to be associated with harms in older adults. The specific aim was to have a 13-member interdisciplinary panel of experts in geriatric care and pharmacotherapy update the 2012 AGS Beers Criteria using a modified Delphi method to systematically review and grade the evidence and reach a consensus on each existing and new criterion. The process followed an evidence-based approach using Institute of Medicine standards. The 2015 AGS Beers Criteria are applicable to all older adults with the exclusion of those in palliative and hospice care. Careful application of the criteria by health professionals, consumers, payors, and health systems should lead to closer monitoring of drug use in older adults. [ABSTRACT FROM AUTHOR]

Objectives To use the most recently available population-based data to estimate potentially inappropriate medication ( PIM) prevalence under the 2012 update of the Beers list of PIMs and to provide a benchmark from which to measure future changes. Design Retrospective cohort study using nationally representative data. Setting 2006-2010 Medical Expenditure Panel Survey ( MEPS). Participants Community-dwelling sample of U.S. older adults (N = 18,475). Measurements The updated Beers criteria were operationalized, generating a 'broad' PIM definition that incorporated form, route, or dose restrictions where clearly specified and a 'qualified' definition that applied specific exceptions where mentioned in the rationale associated with each drug category. Bivariate analyses described PIM prevalence, comparing the two operational definitions, and examined time trends. Results Of older adults with prescription medications, 42.6% had at least one medication fill that met the broad definition, with nonsteroidal anti-inflammatory drugs ( NSAIDs) having the highest prevalence (10.9%). The rate declined from 45.5% in 2006-2007 to 40.8% in 2009-2010. The categories with the largest absolute decline were NSAIDs, selected sulfonylureas, and estrogens. PIM prevalence was 30.9% using the qualified definition. Conclusion Despite the overall high use of PIMs, there has been a decline observed in recent years. Future studies should test the effect of educational and clinical interventions on changes in PIM use and outcomes. The current study results can aid in targeting these interventions. [ABSTRACT FROM AUTHOR]

Objectives To examine the influence of quality measures of psychopharmacological medication ( PPM) prescribing on all-cause mortality in a Medicare long-stay nursing home ( NH) population. Design Longitudinal. Setting 2007-09 Medicare data linked to Minimum Data Set 2.0 files. Participants Four new-user cohorts of residents initiating antipsychotic (n = 13,105), antidepressant (n = 14,251), anxiolytic and sedative-hypnotic (n = 10,789), and any PPM (n = 14,568) medication. Measurements Three measures of PPM prescribing quality were assessed monthly with a 6-month look-back: evidence of appropriate indication, dose (modified standardized daily dose ( mSDD); below (<1), at (1), and above (>1) recommended geriatric dose), and duration of therapy (DOT; ≤30, 31-60, 61-90, 91-180 days from medication initiation). Complementary log-log models with quality measures as time-dependent variables were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for mortality. Results Appropriate use of antidepressants, anxiolytics and sedative-hypnotics, and any PPMs, as evidenced by appropriate indications, was significantly associated with lower mortality risk (HRantidepressants = 0.81, 95% CI = 0.76-0.86; HRanxiolytics and sedative-hypnotics = 0.81, 0.75-0.88; HRPPM = 0.89, 0.83-0.95). Antipsychotic and anxiolytic and sedative-hypnotic users with a mSDD of less than 1 had lower mortality risk than those with a mSDD greater than 1, whereas a protective effect was observed in antidepressant users with a mSDD greater than 1. In all four cohorts, those with a DOT of 91 to 180 days had lower mortality than those with a DOT of 1 month or less; the lower risk of mortality was detected after antipsychotic use for 31 days or longer. Conclusion Optimal PPM prescribing quality, as measured by indication and duration, is associated with low mortality. The benefit related to drug dosage varied by therapeutic class. When prescribing PPMs to NH residents, providers should consider not only drug choice, but also dose and duration of prescribed regimens. [ABSTRACT FROM AUTHOR]