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

Purpose: Washington State's initiatives to increase the availability and quality of community residential care presented an opportunity to describe clients entering adult family homes, adult residential care, and assisted living and to identify outcomes of care. Design and Methods: We enrolled 349 residents, 243 informal caregivers, and 299 providers in 219 settings. We conducted interviews at enrollment and 12 months later, and we collected data from state databases. Results: The average resident was a 78-year-old woman reporting dependence in two of six activities of daily living. Residents in adult family homes demonstrated significantly more disability. Seventy-eight percent of residents survived at the 12-month follow-up. In analyses that controlled for differences at enrollment, residents in the three types of settings were very similar in health outcomes at follow-up. Implications: State policies should reflect the wide range of needs of residents seeking care in these settings. Choices among type of setting can be based on the match of needs to individual preferences.

This paper compares assisted living apartments (ALs), adult residential care facilities (ARCs), and small adult family homes (AFHs) for Medicaid residents in Washington State, with particular emphasis on the settings, staffing, services, and policies of AFHs. We targeted for enrollment all residents entering an AFH, ARC, or AL setting on Medicaid/state funding in a three-county area of Washington State. We obtained information on 199 settings, interviewing administrative and direct care providers. AFHs are smaller than ARCs and ALs and less likely to be part of a chain, with no significant difference in staffing ratios of registered nurses and licensed practical nurses. Sixty-four percent of AFH residents were receiving public funds compared to 32% of AL residents. AFHs report admitting residents with more activities of daily living needs, health conditions, and behavior problems. They are less likely to have autonomy-related policies, and they provide more services and fewer activities. While attention should continue to be paid to staff supports, policy and practice should support the continued role of AFHs, which are of special interest because of their potential to provide more homelike, less costly care but with possible trade-offs compared to larger facilities. KEYWORDS long-term care, residential care, assisted living, adult family homes

Byline: Peggy Soule Odegard, PharmD, BCPS, CDE (Geriatrics Program, School of Pharmacy, and the Department of Medicine, University of Washington, podegard@u.washington.edu); Shelly L. Gray, PharmD, MS (School of Pharmacy, University [...]

Purpose: Washington State's initiatives to increase the availability and quality of community residential care presented an opportunity to describe clients entering adult family homes, adult residential care, and assisted living and to identify outcomes of care. Design and Methods: We enrolled 349 residents, 243 informal caregivers, and 299 providers in 219 settings. We conducted interviews at enrollment and 12 months later, and we collected data from state databases. Results: The average resident was a 78-year-old woman reporting dependence in two of six activities of daily living. Residents in adult family homes demonstrated significantly more disability. Seventy-eight percent of residents survived at the 12-month follow-up. In analyses that controlled for differences at enrollment, residents in the three types of settings were very similar in health outcomes at follow-up. Implications: State policies should reflect the wide range of needs of residents seeking care in these settings. Choices among type of setting can be based on the match of needs to individual preferences. Key Words: Long-term care, Assisted living, Health status

One's experience with dementia may affect their perceptions about dementia preventability, which in turn could influence preventive health behaviors. We aimed to examine how having a family history of dementia and caregiving experience are associated with perceptions about and self-efficacy for dementia preventability. Cross-sectional, self-administered survey. Participants reported whether they have had a family member with dementia and, among those who reported having a family member with dementia, whether they served as a caregiver. Outcomes were perceptions about the likelihood of dementia preventability, self-efficacy for dementia prevention, and benefits of specific dementia prevention strategies. Associations were assessed via partial proportional odds model for ordinal outcome variables and logistic regression for binary outcome variables. Of 1,575 respondents, 71% had a family member with dementia, of which 42% served as a caregiver. People with a family member with dementia were less likely to believe that dementia is preventable (aOR = 0.75, 95% CI: 0.58, 0.96) and had lower self-efficacy for dementia prevention (aOR = 0.71, 95% CI: 0.56, 0.90). The subgroup analysis among those with caregiving experience was consistent with the primary findings, showing less belief in the likelihood of dementia preventability (aOR = 0.69, 95% CI: 0.46, 1.03) and self-efficacy (aOR = 0.75, 95% CI: 0.56, 1.00). Having a family member with dementia is associated with unfavorable perceptions about dementia preventability. Incorporating family history of dementia into communication efforts about dementia risk reduction may help address potential barriers to preventive health behaviors. [ABSTRACT FROM AUTHOR]

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

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

Informants' reports can be useful in screening patients for future risk of dementia. We aimed to determine whether informant-reported sleep disturbance is associated with incident dementia, whether this association varies by baseline cognitive level and whether the severity of informant-reported sleep disturbance is associated with incident dementia among those with sleep disturbance. A longitudinal retrospective cohort study was conducted using the uniform data set collected by the National Alzheimer's Coordinating Center. Older adults without dementia at baseline living with informants were included in analysis. Cox proportional hazards models showed that participants with an informant-reported sleep disturbance were more likely to develop dementia, although this association may be specific for older adults with normal cognition. In addition, older adults with more severe sleep disturbance had a higher risk of incident dementia than those with mild sleep disturbance. Informant-reported information on sleep quality may be useful for prompting cognitive screening. [ABSTRACT FROM AUTHOR]