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Abstract Background and Aims Cooperation between practicing community pharmacists (PPs) and primary care physicians has traditionally been limited, with scarce communication on therapeutic issues. The aim of this study was to assess how PPs communicate in writing with physicians regarding (1) the clinically relevant problems they have identified in patients' medications and (2) recommendations to solve the problems to identify development needs in the communication process. Methods This retrospective validation study assessed medication reviews conducted by PPs in collaboration with home care nurses, practice nurses, and physicians for 46 older (≥65 years) home care clients in the Municipality of Lohja, Finland. The therapeutic and communicative appropriateness of clinically relevant drug‐related problems (DRPs) identified by PPs and reported in writing to physicians was blindly evaluated by (1) an accredited pharmacist (AP) and (2) two physicians specialized in geriatric pharmacotherapy. Descriptive statistical analysis was conducted to compare the assessments. Results The PPs (n = 13) identified 189 DRPs and made 4.1 recommendations per patient in 46 written reports to physicians. Of the PPs' written recommendations for medication changes, 46% (155/334) were the same as those by the AP. The two specialized physicians evaluated 69% and 67% of PPs' recommendations to be clinically relevant. The way the DRPs and recommendations to solve them were communicated was evaluated as appropriate in 38% and 38%, respectively, of the case reports written by the PPs. Conclusion The PPs were able identify DRPs quite well, particularly inappropriate medication use, according to current care guidelines and formularies. It was found that improvement was needed in the communication of DRPs in written reports with physicians. Interprofessional learning by working in care teams would be suitable for strengthening patient care–oriented competencies.

Malnutrition in older people has been considered as a health concern associated with a range of implications for health and functional ability. However, evidence of nutrition and health-related quality of life (HRQoL) among older people is limited. The aim of this study was to study the associations between nutritional status and HRQoL among home-dwelling older adults aged 75 years. In this cross-sectional study, we studied 75-year-old home-dwelling residents who participated in PORI75 preventive health screenings in 2020 and completed the full Mini Nutritional Assessment (MNA). The participants’ HRQoL was measured using the 15D instrument. Altogether, 462 participants (60% women) were included. Of these, 11% had decreased nutritional status (MNA score < 24); 12.7% were women and 8.6% were men, with no difference between the sexes (p = 0.17). A relationship was found between HRQoL and the MNA: a decreased MNA score was associated with decreased HRQoL (p < 0.001, r = 0.45, 95% CI: 0.38 to 0.53). All 15 HRQoL dimensions (except hearing) were associated with the MNA score. Among the men, the association was stronger compared to the women, especially when the MNA score was

AbstractBackground Patient safety strategies highlight patients’ own active involvement in ensuring medication safety. A prerequisite for involving patients in their medication therapy is having tools that can assist them in ensuring safe medicine use. Older home-dwelling adults with multiple medications are at high risk for medication-related problems, yet only a few age-specific patient self-administered medication risk screening tools exist. This study aimed to develop, validate, and assess the feasibility of a self-administered medication risk checklist for home-dwelling older adults ≥65 years.Materials and methods The draft checklist was formed based on a validated practical nurse-administered Drug Related Problem Risk Assessment Tool supplemented with findings from two systematic literature reviews. The content validity of the draft checklist was determined by a three-round Delphi survey with a panel of 19 experts in geriatric care and pharmacotherapy. An agreement of ≥80% was required. A feasibility assessment (i.e. understandability of the items, fill-out time of the checklist) of the content-validated checklist was conducted among older adults ≥65 years (n = 87) visiting community pharmacies (n = 4). Data were analysed using qualitative content analysis.Results The final validated and feasibility-tested Medication Risk Checklist (LOTTA) for home-dwelling older adults consists of eight items screening the highest priority systemic risks (three items), potentially drug-induced symptoms (one item), adherence, and self-management problems (four items). The checklist proved feasible for self-administration, the mean fill-out time being 6.1 min.Conclusions A wide range of potential medication risks related to the medication use process can be identified by patient self-assessment. Screening tools such as LOTTA can enhance early detection of potential medication risks and risk communication between older adults and their healthcare providers. A wider and more integrated use of the checklist could be facilitated by making it electronically available as part of the patient information systems.

BackgroundIn Finland, at least 1 in 4 residents will be >75 years of age in 2030. The national aging policy has emphasized the need to improve supportive services to enable older people to live in their own homes for as long as possible. ObjectiveThis study aimed to develop a preventive health screening procedure for home-dwelling older adults aged 75 years to enable the use of clinical patient data for purposes of strategic planning of supportive services in primary care. MethodsThe action research method was applied to develop the health screening procedure with selected validated health measures in cooperation with the local practicing interprofessional health care teams from 10 primary care centers in the Social Security Center of Pori, Western Finland (99,485 residents, n=11,938, 12% of them >75 years). The selection of evidence-based validated health measures was based on the national guide to screen factors increasing fall risk and the national functioning measures database. The cut-off points of the selected health measures and laboratory tests were determined in consecutive consensus meetings with the local primary care physicians, with decisions based on internationally validated measures, national current care guidelines, and local policies in clinical practice. ResultsThe health screening procedure for 75-year-old residents comprised 30 measures divided into three categories: (1) validated self-assessments (9 measures), (2) nurse-conducted screenings (14 measures), and (3) laboratory tests (7 measures). The procedure development process comprised the following steps: (1) inventory and selection of the validated health measures and laboratory tests, (2) training of practical nurses to perform screenings for the segment of 75-year-old residents and to guide them to possible further medical actions, (3) creation of research data from clinical patient data for secondary use purposes, (4) secondary data analysis, and (5) consensus meeting after the pilot test of the health screening procedure for 75-year-old residents procedure in 2019 based on the experiences of health care professionals and collected research data. ConclusionsThe developed preventive health screening procedure for 75-year-old residents enables the use of clinical patient data for purposes of strategic planning of supportive services in primary care if the potential bias by a low participation rate is controlled. International Registered Report Identifier (IRRID)DERR1-10.2196/48753

Abstract Background Poor medication management may negatively impact the health and functional capacity of older adults. This cross‐sectional study aimed to identify medication‐related risk factors in home‐dwelling residents using a validated self‐assessment as part of comprehensive health screening. Methods The data were derived from comprehensive health screening (PORI75) for older adults of 75 years living in Western Finland in 2020 and 2021. One of 30 validated measures in health screening focused on identifying medication‐related risk factors (LOTTA Checklist). The Checklist items were divided into (1) systemic risk factors (10 items) and (2) potentially drug‐induced symptoms (10 items). Polypharmacy was categorized according to the number of used drugs: (1) no polypharmacy (5 drugs, that is, having polypharmacy. Of the systemic risk factors most common was that the resident had more than one physician responsible for the treatment (48% of the residents), followed by missing drug list (43%), missing regular monitoring (35%), and unclear durations of the medication (35%). The most experienced potentially drug‐induced symptoms were self‐reported constipation (21%), urinating problems (20%), and unusual tiredness (17%). An increasing number of drugs in use, particularly excessive polypharmacy, was associated with various medication‐related risk factors. Conclusion As a part of comprehensive health screening the LOTTA Checklist provides useful information to prevent medication‐related risk factors in home‐dwelling older adults. The Checklist could be used to guide planning and implementing health services in the future.

Abstract Background As populations are aging, a growing number of home care clients are frail and use multiple, complex medications. Combined with the lack of coordination of care this may pose uncontrolled polypharmacy and potential patient safety risks. The aim of this study was to assess the impact of a care coordination intervention on medication risks identified in drug regimens of older home care clients over a one-year period. Methods Two-arm, parallel, cluster randomized controlled trial with baseline and follow-up assessment at 12 months. The study was conducted in Primary Care in Lohja, Finland: all 5 home care units, the public healthcare center, and a private community pharmacy. Participants: All consented home care clients aged > 65 years, using at least one prescription medicine who were assessed at baseline and at 12 months. Intervention: Practical nurses were trained to make the preliminary medication risk assessment during home visits and report findings to the coordinating pharmacist. The coordinating pharmacist prepared the cases for the triage meeting with the physician and home care nurse to decide on further actions. Each patient’s physician made the final decisions on medication changes needed. Outcomes were measured as changes in medication risks: use of potentially inappropriate medications and psychotropics; anticholinergic and serotonergic load; drug-drug interactions. Results Participants (n = 129) characteristics: mean age 82.8 years, female 69.8%, mean number of prescription medicines in use 13.1. The intervention did not show an impact on the medication risks between the original intervention group and the control group in the intention to treat analysis, but the per protocol analysis indicated tendency for effectiveness, particularly in optimizing central nervous system medication use. Half (50.0%) of the participants with a potential need for medication changes, agreed on in the triage meeting, had none of the medication changes actually implemented. Conclusion The care coordination intervention used in this study indicated tendency for effectiveness when implemented as planned. Even though the outcome of the intervention was not optimal, the value of this paper is in discussing the real world experiences and challenges of implementing new practices in home care. Trial registration ClinicalTrials.gov (NCT02545257). Registered September 9 2015.

Abstract Background and Aims Presence of sleep‐disordered breathing (SDB) and especially obstructive sleep apnea (OSA) is a known risk factor for ischemic stroke. Additionally, SDB effects negatively on recovery after stroke. Up to one fourth of strokes are present on awakening. The link between OSA and wake‐up stroke (WUS) has been suggested. We aim to determine the association between OSA and WUS in a Finnish stroke unit cohort. Material and Methods An observational prospective longitudinal study consisted of 95 TIA (transient ischemic attack) and mild to moderate stroke patients referred to a Stroke Unit in Finland. Respiratory polygraphy was performed within 72 h of hospital admission. Patients were classified into WUS and non‐WUS, and functional outcome measures (mRS, rehabilitation, hospitalization time) were collected. Functional outcomes and prevalence of OSA were compared between non‐WUS and WUS. Results OSA (AHI > 15/h) was more frequent among WUS than non‐WUS (71% and 36%, respectively, p = 0.009). Functional outcome measured with mRS was worse in patients with WUS than non‐WUS on registration day and at hospital discharge (p = 0.001). Need for rehabilitation in WUS was 43% of cases compared to 23% of non‐WUS (p = 0.067). Hospitalization time was longer (5–15days) in 55% of WUS and 41% of non‐WUS patients (p = 0.261). Conclusion Moderate‐to‐severe OSA is related to WUS compared to non‐WUS. In addition, WUS have worse short‐term outcomes measured in mRS. Further studies are needed to determine if OSA is causally linked to WUS.

Abstract Objectives Presence of sleep‐disordered breathing (SDB) affects negatively recovery from stroke. The aim of this study is to evaluate the relationships between sleep‐disordered breathing (SDB) and outcome measures in Finnish stroke unit cohort: mRS, need of rehabilitation and hospitalization time. Material and Methods An observational longitudinal study consisted of 95 patients referred to the Stroke Unit of Satakunta Hospital District over a period of November 2013 to March 2016. Patients were tested for SDB within 72 hr from the hospital admission because of ischemic stroke or TIA. The patients underwent polysomnography with NOX T3 wireless recorder. Results There are 37% (n = 35) non‐OSA patients, 20% (n = 19) of patients have mild obstructive sleep apnea (OSA) and 39% (n = 37) have moderate/severe OSA and 4% (n = 4) have CSA. Patients with OSA have higher proportion of disability scores of mRS 3–5 (38%) compared to non‐OSA (11%) and mild OSA (5%) patients on registration day (mRS0), and the same trend is seen at hospital discharge 35% versus 9% and 5%. (p = .009). Proportion of patients with OSA who needed rehabilitation is 65% (n = 19) versus non‐OSA patients 17.5% (n = 4) and mild OSA patients 17.5% (n = 4; p = .039). We observed longer duration of hospitalization (5–15 days) in 29% of OSA patients compared to mild OSA patients 47% and OSA patients 54%. (p = .045). Conclusion Ischemic stroke patients with OSA have higher disability, higher need of rehabilitation, and longer hospitalization length. Prescreening tools for recognizing these stroke patients in acute phase could be valuable. That could result in earlier initiation of treatment and might prevent worse recovery from stroke.

Parkinson's disease (PD) is a neurodegenerative disease inducing dystrophy of the motor system. Automatic movement analysis systems have potential in improving patient care by enabling personalized and more accurate adjust of treatment. These systems utilize machine learning to classify the movement properties based on the features derived from the signals. Smartphones can provide an inexpensive measurement platform with their built-in sensors for movement assessment. This study compared three feature selection and nine classification methods for identifying PD patients from control subjects based on accelerometer and gyroscope signals measured with a smartphone during a 20-step walking test. Minimum Redundancy Maximum Relevance (mRMR) and sequential feature selection with both forward (SFS) and backward (SBS) propagation directions were used in this study. The number of selected features was narrowed down from 201 to 4-15 features by applying SFS and mRMR methods. From the methods compared in this study, the highest accuracy for individual steps was achieved with SFS (7 features) and Naive Bayes classifier (accuracy 75.3%), and the second highest accuracy with SFS (4 features) and k Nearest neighbours (accuracy 75.1%). Leave-one-subject-out cross-validation was used in the analysis. For the overall classification of each subject, which was based on the majority vote of the classified steps, k Nearest Neighbors provided the most accurate result with an accuracy of 84.5% and an error rate of 15.5%. This study shows the differences in feature selection methods and classifiers and provides generalizations for optimizing methodologies for smartphone-based monitoring of PD patients. The results are promising for further developing the analysis system for longer measurements carried out in free-living conditions.

Abstract Background Studies on persistence of benzodiazepine agonist (BZDA) withdrawal in older outpatients are few, and few studies on long-term persistence over years have yet been published. To describe the persistence of temazepam, zolpidem, and zopiclone (BZDA) withdrawal among older outpatients at 3 years from the beginning of withdrawal, as well as any changes in use of other medications. Methods 92 outpatients (≥55 years) with primary insomnia, long-term BZDA use as hypnotics (mean duration of BZDA use 9.9 ± 6.2 years), and willingness to withdraw from BZDAs each received either melatonin or a placebo nightly for one month. During this period, BZDAs were meant to be gradually withdrawn. Sleep hygiene counselling and psychosocial support were provided. Three years later, use of BZDAs and other medications was determined by interview and confirmed from medical records. Results Of the original 92 outpatients, 83 (90%) participated in the 3-year survey (mean follow-up 3.3 ± 0.2 years). The number of BZDA-free participants decreased from 34 (37%) at 6 months to 26 (28%; intention-to-treat) at 3 years, that of irregular BZDA users decreased from 44 (48%) at 6 months to 27 (29%) at 3 years, while that of regular users increased from 11 (12%) at 6 months to 30 (33%) at 3 years (P = 0.001). Those who were regular BZDA users at 3 years had at baseline (before withdrawal) higher BMI (P = 0.001) than did other participants. At 3 years, the total number of medications remained unchanged for non-users (P = 0.432), but increased for the irregular (P = 0.011) and regular users (P = 0.026) compared to baseline. At 3 years, compared to baseline, use of antidepressants, dopamine agonists, melatonin, and NSAIDs/paracetamol was significantly more common in the whole cohort, but their use did not differ between the BZDA-user subgroups. Randomization to melatonin or placebo during BZDA withdrawal was unrelated to BZDA-withdrawal result. Conclusions At 3 years after withdrawal, the number of BZDA-free participants had decreased, but still one-third of the subjects remained BZDA-free, and one-third had reduced their use. Successful BZDA withdrawal did not lead to any increase in total number of medications; use of symptomatic medications in the whole cohort, however, did increase.

Abstract Background The magnitude of safety risks related to medications of the older adults has been evidenced by numerous studies, but less is known of how to manage and prevent these risks in different health care settings. The aim of this study was to coordinate resources for prospective medication risk management of home care clients ≥ 65 years in primary care and to develop a study design for demonstrating effectiveness of the procedure. Methods Health care units involved in the study are from primary care in Lohja, Southern Finland: home care (191 consented clients), the public healthcare center, and a private community pharmacy. System based risk management theory and action research method was applied to construct the collaborative procedure utilizing each profession’s existing resources in medication risk management of older home care clients. An inventory of clinical measures in usual clinical practice and systematic review of rigorous study designs was utilized in effectiveness study design. Discussion The new coordinated medication management model (CoMM) has the following 5 stages: 1) practical nurses are trained to identify clinically significant drug-related problems (DRPs) during home visits and report those to the clinical pharmacist. Clinical pharmacist prepares the cases for 2) an interprofessional triage meeting (50–70 cases/meeting of 2 h) where decisions are made on further action, e.g., more detailed medication reviews, 3) community pharmacists conduct necessary medication reviews and each patients’ physician makes final decisions on medication changes needed. The final stages concern 4) implementation and 5) follow-up of medication changes. Randomized controlled trial (RCT) was developed to demonstrate the effectiveness of the procedure. The developed procedure is feasible for screening and reviewing medications of a high number of older home care clients to identify clients with severe DRPs and provide interventions to solve them utilizing existing primary care resources. Trial registration The study is registered in the Clinical Trials.gov (NCT02545257). Registration date September 9 2015.

Potilaan sujuvan ja turvallisen kotiutumisen edistämiseksi tarvitaan kotiutuskäytäntöjen yhtenäistämistä ja sähköisen hoitotyön yhteenvedon tietosisällön parantamista. Kotiutuslistan käytöllä voidaan parantaa potilaan hoidon jatkuvuutta ja laatua. Se auttaa muistuttamaan hoidon jatkuvuuden kannalta oleellisista asioista hoitojakson aikana, ja sitä voidaan hyödyntää esimerkiksi sähköisen hoitotyön yhteenvedon laatimisessa. Kuvaamme tässä artikkelissa moniammatillisen kotiutuslistan tietosisällön kehittämistä hoitokertomukseen potilaan tulotilanteen ja hoitojakson aikaisen kirjaamisen yhtenäistämiseksi kirjallisuuden sekä erikoissairaanhoidossa, perusterveydenhuollossa ja sosiaalipalveluissa työskentelevien ammattilaisten (n = 82) yhteistyön tuloksena. Kotiutuslistaan sisällytettiin aikaisemman kirjallisuuden, käytössä olleiden paperisten kotiutuslistaesimerkkien ja moniammatillisten työryhmien tuotoksena syntyneitä potilaan turvallisen kotiutuksen kannalta keskeisiä tarkasteltavia asioita. Kotiutuslista pilotoitiin Satakunnan sairaanhoitopiirissä. Pilotointi toteutettiin kolmella keskussairaalan vuodeosastolla, keuhkosairauksilla, sisätaudeilla ja neurologialla, sekä vanhuspsykiatrian ja kuntoutuksen vuodeosastoilla paperimuodossa. Pilotoitu tietosisältö siirrettiin sähköiseen muotoon Effican hoitokertomukseen (hokeen) osaksi potilaan kliinistä hoitosuunnitelmaa. Moniammatillinen kotiutuslista otettiin pilotin jälkeen käyttöön Satakunnan erikoissairaanhoidon palveluissa. Kotiutuslistan keskeisimmät jatkokehittämistarpeet kohdistuvat asiakas- ja potilasnäkökulman esille saamiseen sekä sen tekniseen toimivuuteen potilastietojärjestelmässä.

Background: Recent epidemiologic studies have shown that the use of psychotropics is associated with many symptoms and may result in dependence and tolerance among elderly individuals. The aim of this study was to describe the symptoms related to withdrawal or dose reduction of long-term benzodiazepine (BZD) or BZD-related drugs (RDs) use and to compare them with nonuse of these drugs in community-dwelling individuals aged 65 and older. Methods: The study was a post hoc analysis embedded in a 12-month randomized, controlled fall-prevention trial that included withdrawal of BZDs and RDs. The participants (n = 248) in the intervention group were divided into the following four groups according to their use of BZDs/RDs at baseline and follow-up: (1) withdrawal (WG), (2) reduction (RG), (3) unchanged (UG), and (4) nonusers (NUG). Differences in symptom changes were compared between and within these four groups. Results: Using BZD/RD was associated with numerous symptoms at baseline and during the intervention. At follow-up, those symptoms reduced significantly among all participants. However, there were no significant differences between the groups in the changes of symptoms during the follow-up. Self-perceived health improved in only NUG (p

Background/Aims: Psychotropics and antiepileptics (AE) are medications commonly used among the aged with cognitive decline or dementia, although they may precipitate further cognitive decline. Our aim was to analyze the relationships between the use of (i) psychotropics (i.e. benzodiazepines or related drugs, BZD, antipsychotics, AP, or antidepressants, AD), opioids (Op), anticholinergics (ACh) or AEs or the concomitant use of two of these drugs, and (ii) the risk of precipitous cognitive decline in an older (≧65 years) cognitively disabled population. Methods: A longitudinal population-based study of general aged community-dwelling patients was executed in two phases (1990–1991 and 1998–1999) in Lieto, Finland. Fifty-two individuals cognitively disabled (MMSE score 0–23) at the 1990–1991 baseline form this study’s sample. Cognitive abilities were assessed in each phase with the Mini-Mental State Examination (MMSE) and medication utilization data were collected in both phases. The mean follow-up time was 7.6 years. Multivariate models were used to analyze the change in MMSE total score between medication users and non-users. Results: BZD or any psychotropic use was associated with greater cognitive decline in elders aged ≧75 years compared to non-users (change in MMSE sum score: –8.6 ± 7.0 vs. –3.3 ± 5.6 and –5.9 ± 7.0 vs. –2.7 ± 6.4, respectively). A greater decline was also associated specifically with the concomitant use of BZD and AP (–16 vs. –1.4 ± 7.8); as were BZD and any drug with CNS effects (–9.6 ± 9.9 vs. –1.3 ± 7.2) compared to non-users. The concomitant use of BZD and AD (–10.7 ± 4.7 vs. –3.2 ± 5.6) or ACh (–15.0 ± 8.5 vs. –3.3 ± 5.6) or any drug with CNS effects (–13.3 ± 6.5 vs. –3.3 ± 5.6) was associated with cognitive decline in patients ≧75 years compared to non-users of any drug with CNS effects. Conclusion: The use of a BZD or any psychotropic medication may be an independent risk factor for cognitive decline in the cognitively disabled aged, and patients co-prescribed psychotropic medications had greater cognitive decline. Studies with larger sample sizes and studies on possible pathophysiologic mechanisms are needed.