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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]

Dysphagia is increasingly common in older adults; it is especially prevalent in long-term care settings. Patients with dysphagia likely require pharmacologic treatment for multiple comorbidities but may find it difficult or impossible to swallow oral medications. Administering crushed medications mixed with a soft food or liquid vehicle, or via a feeding tube, is a common strategy to circumvent swallowing difficulties in patients with dysphagia. However, inappropriate medication use and improper crushing technique can reduce the medication dose a patient receives, alter medication pharmacokinetics and pharmacodynamics, and compromise treatment efficacy and patient safety. Clinical judgment is needed to identify medications that can and cannot be crushed, select a crushing methodology and vehicle for administering crushed medications, and create a strategy for administering multiple medications. A coordinated effort from the entire care team—including physicians, pharmacists, nurses, advanced practice providers, speech therapists, patients, and caregivers—is necessary to develop and implement an individualized plan for administering medications to patients with dysphagia. This review details the current literature regarding the administration of medications that have been altered, such as by crushing tablets or opening capsules, for patients with dysphagia or who are receiving enteral feeding and provides recommendations on best practices. Plain Language Summary: Dysphagia, or difficulty swallowing, is common in hospitals and in places that provide long-term care. People who live at home may also have a hard time swallowing pills. In this review, we talk about how people who have a hard time swallowing pills can best take their medicines. A speech-language pathologist can help people with dysphagia find ways to eat and drink safely. Their healthcare provider and pharmacist should make sure all their medicines are needed and check if any of their medicines come in a form that does not need to be swallowed, like a patch. It is sometimes okay to take a medicine by crushing a pill and then mixing with food. However, some medicines may be dangerous or less effective if they are crushed or mixed with some foods. Mixing multiple crushed medicines may also be unsafe or make them less effective. People in hospitals and long-term care settings who have a hard time swallowing pills should have an individual plan in place for taking medicines. Physicians, pharmacists, speech-language pathologists, and front-line care staff should work with patients and caregivers to make the plan. The plan should be written down in their patient record. People who have a hard time swallowing medicines should talk to their doctor or pharmacist about how best to take their medicines. People should not alter their medicines without talking to a healthcare professional. [ABSTRACT FROM AUTHOR]

Despite the dynamic demands in the nursing home (NH), a definitive approach to managing chronic pain in older adults has yet to be established. Due to concerns for potential adverse pharmacologic effects, balancing appropriate pain management is a challenge among NH residents. The challenges encompass but are not limited to medical complexities, functional disabilities, and physical frailty. Barriers to the successful implementation of a comprehensive chronic pain management at the NH may include ambiguous directions on specific therapeutic interventions, insufficient guidance on treatment duration, and limited available treatment options. The Centers for Medicare and Medicaid Services' reporting requirement of adequate pain control among NH residents coupled with widely variable clinician-prescribing habits highlights the difficulties in overcoming the preceding challenges and barriers. The Coronavirus Disease 2019 (COVID-19) pandemic has further complicated pain management due to its negative consequences on well-being of residents of NHs. Associated symptoms of psychosocial stress, anxiety and depression, and chronic pain symptoms can exacerbate during the COVID-19 pandemic, leading to increased requirement for pain medications including but not limited to opioids. Pain is a multidimensional symptom and requires a strategic multimodal approach for its management. Nonpharmacologic modalities are underutilized in the NH setting and are the preferred first steps for mild pain, and nonopioid pharmacological agents can be added as a second step for a synergistic effect for moderate to severe pain. Opioids should be used as a last resort. Short-acting opioids are preferred over extended-release/long-acting opioids for chronic pain. Clinicians are encouraged to engage residents in proactive strategies in managing their pain, and to set realistic expectations toward improving their quality of life, as complete elimination of pain is not feasible in most cases. This review article provides the interdisciplinary team with a contemporary perspective of the multitude of changes and challenges influencing the prescribing as well as deprescribing of various pain medications. [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.

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]

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]

Prior research demonstrates substantial access problems associated with utilization management and formulary exclusions for antipsychotics in Medicaid, but the use and impact of coverage restrictions for these medications in Medicare Part D remains unknown. We assess the effect of coverage restrictions on antipsychotic utilization in Part D by exploiting a unique natural experiment in which low-income beneficiaries are randomly assigned to prescription drug plans with varying levels of formulary generosity. Despite considerable variation in use of coverage restrictions across Part D plans, we find no evidence that these restrictions significantly deter utilization or reduce access to antipsychotics for low-income beneficiaries. [ABSTRACT FROM AUTHOR]

This study examines the association between antipsychotic (AP) medication use and care transitions in the nursing home (NH) population. This cross-sectional study used data from a 5% random sample of Medicare beneficiaries between 2011 and 2015. Propensity score adjusted negative binomial regression was performed and conditional probabilities of having a first transition from the NH to specific locations were calculated. Among 150,284 eligible beneficiaries, the majority were female (67%), white (84%), and >75 years old (63%). Controlling for resident characteristics, the odds of having any transition was 5% lower among those with AP use [IRR (95% confidence interval (CI))=0.95(0.94–0.96)] relative to those with no AP use. Residents with AP use had higher proportions of transitions to hospital (22.7% vs. 19.5%, p < 0.01), emergency department (19.6% vs. 10.7%, p < 0.01), and different NH (1.5% vs. 0.4%, p < 0.01), and lower proportions of transition to non-healthcare locations compared to those without AP use. Findings demonstrate that residents with AP use had higher probabilities of transitions to more costly care settings such as the emergency department and hospital compared to those without AP use. Future longitudinal studies will help to inform clinical interventions aimed at improving the quality of care for this population. [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]

Engagement in children's mental health treatment is strikingly low. This might be due to differences in perspectives about what it means to be engaged in treatment as well as the strategies that are most effective at engaging families, as little is known about how well consumers' perspectives map onto current models of engagement and the empirical literature. This qualitative study examined family perspectives of (1) aspirational and actual engagement in treatment, (2) barriers that impeded engagement, and (3) engagement strategies they recommended their providers and agencies use. Four focus groups were conducted with 20 caregivers (ages 24-75), and 11 youth and young adults (ages 15-23). All participants were currently or formerly enrolled in children's mental health services. Data were analyzed through consensual qualitative research methods. Findings revealed that youth and caregivers' definitions of engagement included both attitudinal and behavioral components. Numerous barriers impeded components of aspirational engagement, and agency- and provider-related barriers were most pervasive. Youth reported more attitudinal barriers, whereas caregivers reported more behavioral barriers. Participants described advocacy (e.g., taking direct action to influence treatment) as a key engagement component; however, such advocacy often involved treatment non-adherence that could be interpreted by providers as disengagement. Families recommended strategies to strengthen the therapeutic relationship and build trust that are empirically supported. However, families described many experiences in which providers did not use these empirically supported strategies. Families also described some theoretically supported engagement strategies as having a negative impact on engagement. In sum, the findings suggest that providers should take an empowering family-centered treatment approach where they seek to understand and build upon clients' engagement perspectives. [ABSTRACT FROM AUTHOR]

We investigated whether symptoms of attention-deficit/hyperactivity disorder (ADHD) are pathways through which deficits in inhibition and working memory are associated with teacher- and parent-rated social impairment in children. Participants were 64 children (55 % males; 53 % with ADHD) in grades 3-6. Consistent with our hypotheses, the association between inhibition and social impairment was mediated by hyperactivity/impulsivity and the association between working memory and social impairment was mediated by inattention. Support was not obtained for alternative models wherein the association between inhibition and social impairment was mediated by inattention, and the association between working memory and social impairment was mediated by hyperactivity/impulsivity. Further, tests of hierarchical models suggest that neither inhibition nor working memory is primary but, rather, that these cognitive processes are related to one another and that they collectively (but not uniquely) contribute to hyperactivity/impulsivity and inattention. These findings have implications for conceptual models of ADHD, for understanding factors that influence and sustain social impairment among youth with symptoms of the disorder, and for interventions aimed to addressing such impairment. [ABSTRACT FROM AUTHOR]

Difficulty engaging families in mental health treatment is seen as an underlying reason for the disparity between child mental health need and service use. Interpretation of the literature on how best to engage families is complicated by a diversity of operational definitions of engagement outcomes and related interventions. Thus, we sought to review studies of engagement interventions using a structured methodology allowing for an aggregate summary of the most common practices associated with effective engagement interventions. We identified 344 articles through a combination of database search methods and recommendations from engagement research experts; 38 articles describing 40 studies met our inclusion criteria. Following coding methods described by Chorpita and Daleiden (J Consul Clin Psychol 77(3):566-579, , doi:), we identified 22 engagement practice elements from 89 study groups that examined or implemented family engagement strategies. Most frequently identified engagement practice elements included assessment, accessibility promotion, psychoeducation about services, homework assignment, and appointment reminders. Assessment and accessibility promotion were two practice elements present in at least 50 % of treatment groups that outperformed a control group in a randomized controlled trial. With the exception of appointment reminders, these frequently identified engagement practice elements had a high likelihood of being associated with winning treatments when they were used. This approach offers a novel way of summarizing the engagement literature and provides the foundation for enhancing clinical decision-making around treatment engagement. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to describe the Medication Management Instrument for Deficiencies in the Elderly (MedMalDE) and to provide results of reliability and validity testing. Design and Methods: Participants were 50 older adults, aged 65 and older, who lived in the community, took at least one prescription medication, and were then self-medicating. Non-medical study staff assessed participants in their homes at baseline and 1 week, and a study pharmacist conducted pill counts at baseline and 30 days. The MedMalDE covers three domains important for ensuring medication compliance (knowledge of medications, how to take medications, and procurement) and yields a total deficiency score. We assessed test-retest and interrater reliability. We assessed validity by comparing the MedMalDE deficiency scores to 30-day pill count compliance. Results: The sample was mostly female (72%) and White (56%), with a mean age of 78. Participants were taking an average of 7 prescription drugs, with an average pill count compliance of 70%. The MedMalDE had very good test-retest reliability (intraclass correlation coefficient [ICC] = 0.93) and good interrater reliability (ICC = 0.74). Internal consistency was also strong (Cronbach's alpha = .71). Comparing the MedMalDE to the pill count with those who were compliant (>80%) versus those that were not, the agreement was 75%. The MedMalDE was more highly specific and predictive of compliance compared to the pill count. Implications: The MedMalDE appears to be a reliable and valid instrument for determining if an older adult has deficiencies in managing medications. [ABSTRACT FROM AUTHOR]

Passage of the Medicare drug benefit legislation has renewed attention to the relationship between drug coverage and medication use. This study assesses the impact of drug coverage on COX-2 inhibitor use among elderly people with osteoarthritis, taking into account risk for adverse gastrointestinal events. COX-2 use among aged beneficiaries with the most generous coverage was twice that of those with no third-party coverage. COX-2 use also increased with increasing gastrointestinal risk. However, this risk differential in COX-2 use disappears among those with the most generous coverage. Potential overuse of costly medications should be addressed as the Medicare drug benefit is being phased in. [ABSTRACT FROM AUTHOR]

Provides information on several drugs for diseases and medical conditions common among the aged. Rivastigmine for Alzheimer's disease patients; Levodopa for Parkinson's disease patients; Effectiveness of risedronate and raloxifene in treating osteoporosis; Tolterodine and oxybutynin as treatment for urinary incontinence.

ObjectivesMethodsResultsConclusionsClinical ImplicationsTo describe nursing home (NH) characteristics associated with antipsychotic use and test whether associations changed after implementation of the National Partnership to Improve Dementia Care’s antipsychotic reduction initiative (ARI).Longitudinal quasi-experimental design using data from multiple sources and piecewise linear mixed models were used for statistical analyses.There was a significant decrease in monthly antipsychotic use across the study period (pre-ARI b = −0.0003, p <.001; post-ARI b = −0.0012, p <.001), which held after adjusting for NH characteristics. Registered nurse hours (b = −0.0026, p <.001), licensed practical nurse hours (b = −0.0019, p <.001), facility chain membership (b = −0.0013, p <.01), and health inspection ratings (b = −0.0003, p >.01) were associated with decreased antipsychotic use. Post-ARI changes in associations between NH characteristics and antipsychotic use were small and not statistically significant.Decreases in antipsychotic use were associated with most NH characteristics, and associations persisted post-ARI. Further research is warranted to examine the interactions between ARI policy and NH characteristics on antipsychotic prescribing, as well as other NH factors, such as facility prescribing cultures and clinical specialty of staff.Decreases in monthly antipsychotic use were observed following the ARI. The decreases in monthly antipsychotic use were associated with most NH characteristics, and these associations persisted during the post-ARI period. [ABSTRACT FROM AUTHOR]

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]

The Centers for Medicare and Medicaid (CMS) initiated the National Partnership to Improve Dementia Care in Nursing Homes in 2012, which helped decrease antipsychotics use. However, inappropriate use of antipsychotics and other psychotropic medications to control behavioral symptoms associated with dementia persists. Nursing homes (NHs) can be flagged for inappropriate psychotropics use as a deficiency of care citation (F-758 tag). The purpose of this study was to comprehensively explore inappropriate psychotropic medication use deficiency, F-758 citations, in caring for NH residents with dementia. A mixed-methods study was performed. During the first quarter of 2018 (January–March), 3526 NHs were surveyed, of which 642 received F-758 tags. Of the 642, the sample was confined to the 444 NHs that received the citation for the care of residents with dementia. Information on deficiencies was obtained from 2018 Certification and Survey Provider Enhanced Reporting data. Inspection reports for deficiencies were obtained from Centers for Medicare and Medicaid Nursing Home Compare and ProPublica. Quantitative analysis was used to examine the frequency of involved psychotropic medications, scope/severity of F-758 deficiency citations, and reasons for the citations. Reasons for F-758 citations by psychotropic medication categories and scope/severity of the citations were also examined using χ2 tests. Qualitative data analysis was conducted using content analysis with an inductive coding approach to summarize the inspection reports. Antipsychotics were the most involved drug category for F-758 tag citations. The 3 most common reasons for F-758 citations included failure to identify and/or monitor behavioral symptoms (178 NHs), attempt gradual drug reduction (131 NHs), and maintain 14-day limitations on Pro Re Nata (PRN) psychotropic orders (121 NHs). Compared with those with no involvement of antipsychotic drugs, facilities with antipsychotics-related F-758 tags had higher rates of failure to identify/monitor behavioral symptoms (P <.001), attempt gradual drug reduction (P <.001), and provide adequate indications for psychotropics use (P <.001). NHs with F-758 tags related to inappropriate antianxiety medication use had a higher prevalence of failure to maintain 14-day limitation on PRN orders (P <.001) and provide nonpharmacologic interventions (P <.001). This study suggests areas for improvement that could potentially reduce inappropriate psychotropics use. Supporting quality of dementia care workforce and improving cooperation within healthcare staff and professionals are recommended to ensure proper nonpharmacologic and pharmacologic interventions. [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]

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. [ABSTRACT FROM AUTHOR]

Low engagement is a significant problem in youth mental health services. In clinical practice, assessment of a problem is integral to its successful resolution, and yet little is known about what methods providers use to assess treatment engagement or what indicators they use to infer high or low engagement. Thirty-five providers serving youth and families primarily through school-based mental health services in an urban setting participated in a workshop training on engagement procedures. Prior to the training, providers responded to open-ended questions about their own clients demonstrating high and low treatment engagement. Behavioral observation was the method reported most by providers to assess client engagement (94.3%), followed by spontaneous self-report by the youth or caregiver (22.9%). No providers reported using psychometric instruments to assess engagement. Types of engagement indicators used also differed according to level of engagement. For low engagement, 74.3% of providers reported using their observations of attendance, whereas for high engagement, 68.6% of providers described relying on observations of in-session participation or out-of-session homework. Few providers described using indicators related to the therapeutic relationship, client expectancies related to treatment, or client comprehension of the treatment approach and related goals. These results highlight opportunities for improving resources to support the assessment of engagement. Such resources could help providers know not only which clients need support but also where to focus that support and how to do so early enough to create a larger window of opportunity for change. Highlights: Providers rely on behavioral observation to assess engagement. Low engagement is often inferred from youth and caregiver attendance. High engagement is often inferred from participation and homework completion. A method for assessing multiple dimensions of engagement would improve identification of engagement problems. [ABSTRACT FROM AUTHOR]

Interprofessional education (IPE) is critical for ensuring that students are prepared to collaborate with team members across disciplines once they enter clinical practice; particularly, in the complex care of the geriatric population. This qualitative study explored the experiences of interdisciplinary students in a clinical based IPE experience at a senior housing residence. Reflective journals were examined from students (n = 23) in nursing, social work, pharmacy, and medicine participating in an IPE program. Four core themes emerged in the analysis: exposure to geriatrics, IPE advantages for students, IPE advantages for older adults, and IPE challenges. Findings from this study confirmed advantages of IPE in a real-world clinical setting in terms of students learning the value and scope of practice of interdisciplinary team members. The exposure to geriatrics helped students to gain an in-depth understanding of issues affecting older adults in the community and increase professional confidence in their future clinical practice. [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]

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]

Background: Both antidepressants and antipsychotics are used in older adults with behavioral symptoms of Alzheimer's disease and related dementias. Despite the prevalent use of these agents, little is known about their comparative risks for falls and fractures.Methods: Using 2007-2009 Medicare claims data linked to Minimum Data Set 2.0, we identified new users of antidepressants and antipsychotics among nursing home residents with Alzheimer's disease and related dementias who had moderate-to-severe behavioral symptoms. Separate discrete-time survival models were used to estimate risks of falls, fractures, and a composite of both among antidepressant group versus antipsychotic group.Results: Compared to antipsychotic users, antidepressant users experienced significantly higher risk for fractures (adjusted hazard ratio = 1.35, 95% confidence interval = 1.10-1.66). The overall risk of falls or fractures remained significant in the antidepressant versus antipsychotic group (adjusted hazard ratio = 1.16, 95% confidence interval = 1.02-1.32).Conclusions: Antidepressants are associated with higher fall and fracture risk compared to antipsychotics in the management of older adults with Alzheimer's disease and related dementias who experience moderate-to-severe behavioral symptoms. Clinicians need to assess the ongoing risks/benefits of antidepressants for these symptoms especially in light of the increasingly prevalent use of these agents. [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]

Preventing unnecessary out-of-home placement for youth with behavioral and emotional needs is a goal of several public child-serving services, including child welfare, juvenile justice, and child mental health. Although a small number of manualized interventions have been created to promote family driven and community-based services and have empirical support, other less established programs have been initiated by local jurisdictions to prevent out-of-home placement. To synthesize what is known about efforts to prevent placement, this article describes the common program and practice elements of interventions described in 37 studies (published in 51 articles) that measured placement prevention outcomes for youth at risk for out-of-home care because of behavioral or mental health needs. The most common program elements across published interventions were program monitoring, case management, and accessibility promotion. The most common clinical practice elements for working with youth were assessment and individual therapy; for caregivers, problem solving skills were most frequently included; and family therapy was most common for the family unit. Effect size estimates for placement-related outcomes (decreased out-of-home placement, decreased hospitalization, decreased incarceration, and decreased costs) were calculated to estimate the treatment effectiveness of the interventions in which the program components and clinical practices are embedded. [ABSTRACT FROM AUTHOR]

This study examined impairment in multiple domains of functioning in children with and without ADHD who present with high or low levels of sluggish cognitive tempo (SCT) while taking into account the total symptom ratings of ADHD. Participants were 584 children in kindergarten through eighth grade (55.7 % male, 91.7 % Caucasian), drawn from five archival datasets. Two, 2 (SCT groups: high and low) x 3 (ADHD Status: ADHD-I, ADHD-C, and non-ADHD) MANCOVAs were conducted with the total ADHD symptom ratings and child age as covariates. One MANCOVA was conducted on scores on the teacher Impairment Rating Scale (IRS; Fabiano et al. Journal of Clinical Child and Adolescent Psychology 35:369-385, ) and the other on the 6 scores on the parent IRS. The results indicated that the presence of SCT symptoms was associated with greater functional impairment at home according to parent report while it was associated with less functional impairment at school according to teacher report. Thus, the relationship between SCT symptoms and impairment differs depending on the informant and the context in which impairment is evaluated. [ABSTRACT FROM AUTHOR]

The prescribing and dispensing of controlled substances within long-term care facilities is an important and complex issue from both the clinical and the public policy perspectives. This article reviews the regulatory background and clinical concerns regarding the enforcement of the Controlled Substances Act by the Drug Enforcement Administration within the institutional pharmacies serving long-term care facilities. The article argues that the processes implemented since 2009 in response to concerns about Drug Enforcement Administration enforcement are suboptimal at many levels. A robust solution that meets the needs of all parties involved will require multiple levels of collaboration and respect for several legitimate agendas pertinent to this issue. The comprehensive solution must address at least 4 concerns. It must ensure that (1) residents and patients of long-term care facilities receive appropriate and timely administration of controlled substances when they are part of their individualized plans of care; (2) long-term care facilities have rigorous processes in place to prevent diversion of controlled substances; (3) required processes for prescribing controlled substances are reasonable and not overly burdensome to the clinicians caring for this population; and (4) all parties are in compliance with statutory and regulatory requirements. The solution, however, will likely require legislative amendments to the Controlled Substances Act and regulatory revisions for optimal outcomes. The debate surrounding the enforcement of the Controlled Substances Act within long-term care facilities is ongoing and the parameters are in flux. This article provides a historical perspective and policy framework for understanding the topic, reviews various proposed solutions, and suggests a collaborative process for resolution. [Copyright &y& Elsevier]

Organic field-effect transistors were fabricated using offset printed source/drain structures. Interdigitated electrode structures were printed with a poly(3,4–ethylenedioxythiophene) (PEDOT) formulation. A polymeric semiconductor polytriarylamine and different insulator layers were deposited by spin coating. A field-effect mobility of 3×10-3 cm2 V-1 s-1 and on/off ratio of about 103 was achieved, making it possible to produce digital logic elements. [ABSTRACT FROM AUTHOR]