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A modified Delphi study was conducted to (1) identify intervention elements that are considered by geriatricians to be important in optimizing prescribing for older adults with multimorbidity, and (2) to select the accompanying behavior change techniques to be incorporated into a context-relevant intervention to support prescribing. Intervention elements such as medication review identified by the Delphi panel mirrored results from a previous scoping review. Statements involving roles of pharmacists selected by the panel validated findings in the literature that pharmacists play important collaborative roles to help reduce potentially inappropriate prescribing among older adults with multimorbidity. We identified relevant intervention elements and their accompanying behavior change techniques to aid in the development of a context-specific intervention. Potentially inappropriate prescribing among older adults is a rising concern, attributed mainly by polypharmacy and multimorbidity. We aimed to identify key components and strategies for construction of a context-relevant intervention to facilitate appropriate prescribing in outpatient clinics in Singapore. The modified Delphi study was conducted in two rounds with 20 geriatricians from seven public hospitals in Singapore. Round one survey presented 69 statements formulated from a scoping review, while round two presented 23 statements with some modifications based on round one comments. The statements were rated against a 7-point Likert scale on their importance and impact on prescribing for older adults with multimorbidty. Consensus were achieved for 90% of the statements. Seven intervention elements were identified as being important: medication review, training, medication therapy management, shared decision making, patient interview, medication reconciliation, comprehensive geriatric assessment. In addition, some commonly identified behavior change techniques included goal setting (behavior), goal setting (outcome) and problem solving. This study identified important intervention elements and their potential strategies that could be adopted in an intervention to optimize appropriate prescribing for older adults with multimorbidity.

Objectives We aimed to understand the barriers experienced by physicians when prescribing for older adults with multimorbidity in specialist outpatient clinics in Singapore. Methods A modified Delphi study was conducted via email with 20 panel experts in the field of geriatric medicine. Barriers identified from an earlier scoping review were presented as statements to the panel. Results Eleven barrier statements reached consensus with high importance according to the Delphi panel. Of these statements, seven (64%) belong to the domain of Environmental context and resources in the Theoretical Domains Framework (TDF), while the remaining barriers belong to the domains of skills, knowledge, intentions, and professional/social role and identity. The barriers are further linked to intervention functions in the Behaviour Change Wheel (BCW). Conclusion Linking the TDF domains to intervention functions revealed strategic directions for the development of an intervention to address the barriers and optimize prescribing., Eleven barrier statements reached consensus with high importance according to the Delphi panel. Linking the barriers to Theoretical Domains Framework and intervention functions revealed strategic directions for the development of an intervention to address the barriers and optimize prescribing.

Key Summary points Aim RCT to evaluate the efficacy of multi-component interventions for prevention of hospital-acquired pneumonia in hospitalized older patients. Findings The multi-component interventions did not reduce hospital-acquired pneumonia but increased the mean time to next hospitalisation due to respiratory infection (11.5 months vs. 9.5 months; P = 0.049), and reduced the risk of hospitalisation in 1 year (18.6% vs. 34.4%; P = 0.049). This was likely due to the increased recognition of oropharyngeal dysphagia (35.6% vs. 20.3%; P < 0.001) and improved influenza (54.5% vs 17.2%; P < 0.001) and pneumococcal vaccination rates (52.5% vs. 20.3%; P < 0.001). Message A multi-component intervention for nosocomial pneumonia may not significantly reduce the incidence of hospital-acquired pneumonia but significantly increases the frequency of diagnosis of oropharyngeal dysphagia, improves vaccination rates and can reduce future hospitalisations for respiratory infections in older adults., Aims To evaluate the efficacy of multi-component interventions for prevention of hospital-acquired pneumonia in older patients hospitalized in geriatric wards. Methods A randomized, parallel-group, controlled trial was undertaken in patients aged 65 and above who were admitted to a tertiary hospital geriatric unit from January 1, 2016 to June 30, 2018 for an acute non-respiratory illness. Participants were randomized by to receive either a multi-component intervention (consisting of reverse Trendelenburg position, dysphagia screening, oral care and vaccinations), or usual care. The outcome measures were the proportion of patients who developed hospital-acquired pneumonia during hospitalisation, and mean time from randomization to the next hospitalisation due to respiratory infections in 1 year. Results A total of 123 participants (median age, 85; 43.1% male) were randomized, (n = 59) to intervention group and (n = 64) to control group. The multi-component interventions did not significantly reduce the incidence of hospital-acquired pneumonia but did increase the mean time to next hospitalisation due to respiratory infection (11.5 months vs. 9.5 months; P = 0.049), and reduced the risk of hospitalisation in 1 year (18.6% vs. 34.4%; P = 0.049). Implementation of multi-component interventions increased diagnoses of oropharyngeal dysphagia (35.6% vs. 20.3%; P

Background As the population ages, potentially inappropriate prescribing (PIP) in the older adults may become increasingly prevalent. This undermines patient safety and creates a potential source of major morbidity and mortality. Understanding the factors that influence prescribing behaviour may allow development of interventions to reduce PIP. The aim of this study is to apply the Theoretical Domains Framework (TDF) to explore barriers to effective prescribing for older adults in the ambulatory setting. Methods A scoping review was performed based on the five-stage methodological framework developed by Arksey and O’Malley. From 30 Aug 2018 to 5 Sep 2018, we conducted our search on PubMed, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews, and Web of Science. We also searched five electronic journals, Google and Google Scholar to identify additional sources and grey literature. Two reviewers applied eligibility criteria to the title and abstract screening, followed by full text screening, before systematically charting the data. Results A total of 5731 articles were screened. Twenty-nine studies met the selection criteria for qualitative analysis. We mapped our results using the 14-domain TDF, eventually identifying 10 domains of interest for barriers to effective prescribing. Of these, significant domains include physician-related factors such as “Knowledge”, “Skills”, and “Social/Professional Role and Identity”; issues with “Environmental Context and Resources”; and the impact of “Social Influences” and “Emotion” on prescribing behaviour. Conclusion The TDF elicited multiple domains which both independently and collectively lead to barriers to effective prescribing for older adults in the ambulatory setting. Changing the prescribing climate will thus require interventions targeting multiple stakeholders, including physicians, patients and hospital/clinic systems. Further work is needed to explore individual domains and guide development of frameworks to aid guide prescribing for older adults in the ambulatory setting.

Introduction Polypharmacy and inappropriate prescribing are associated with negative health outcomes in the elderly. Several prescribing tools have been developed to assess medication appropriateness. Explicit (criteria-based) tools often do not take into account patients' preferences and comorbidities, and have little room for individualised clinical judgement. Methods A cross-sectional observational study was conducted in 243 elderly patients admitted to the Geriatric Medicine service in a Singapore tertiary hospital over one month. We incorporated an implicit (judgement-based) tool developed by Scott et al into a mnemonic, 'S-I-R-E', to assess medication appropriateness: S = symptoms ('Have symptoms resolved?'), I = indication ('Is there a valid indication?'), R = risks ('Do risks outweigh benefits?') and E = end of life ('Is there short life expectancy limiting clinical benefit?'). Results Inappropriate prescribing was present in 27.6% of patients. The most common reason for inappropriateness of medications was lack of valid indication (62.2%), followed by high risk-benefit ratio (20.7%). The most common medications that lacked valid indication were supplements and proton pump inhibitors. Polypharmacy was found in 93% of patients and was significantly associated with inappropriate prescribing (p = 0.047). Conclusion Inappropriate prescribing and polpharmacy are highly prevalent in the hospitalised elderly. The 'S-I-R-E' mnemonic can be used as a memory aid and practical framework to guide appropriate prescribing in the elderly.

Background: As the population ages, potentially inappropriate prescribing (PIP) in the older adults may become increasingly prevalent. This undermines patient safety and creates a potential source of major morbidity and mortality. Understanding the factors that influence prescribing behaviour may allow development of interventions to reduce PIP. The aim of this study is to apply the Theoretical Domains Framework (TDF) to explore barriers to effective prescribing for older adults in the ambulatory setting. Methods: A scoping review was performed based on the five-stage methodological framework developed by Arksey and O’Malley. From 30 Aug 2018 to 5 Sep 2018, we conducted our search on PubMed, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews, and Web of Science. We also searched five electronic journals, Google and Google Scholar to identify additional sources and grey literature. Two reviewers applied eligibility criteria to the title and abstract screening, followed by full text screening, before systematically charting the data. Results: A total of 5,731 articles were screened. 29 studies met the selection criteria for qualitative analysis. We mapped our results using the 14-domain TDF, eventually identifying 10 domains of interest for barriers to effective prescribing. Of these, significant domains include physician-related factors such as “Knowledge”, “Skills”, and “Social/Professional Role and Identity”; issues with “Environmental Context and Resources”; and the impact of “Social Influences” and “Emotion” on prescribing behaviour.Conclusion: The TDF elicited multiple domains which both independently and collectively lead to barriers to effective prescribing for older adults in the ambulatory setting. Changing the prescribing climate will thus require interventions targeting multiple stakeholders, including physicians, patients and hospital/clinic systems. Further work is needed to explore individual domains and guide development of frameworks to aid guide prescribing for older adults in the ambulatory setting.

Aims: As the population ages, potentially inappropriate prescribing (PIP) in the elderly may become increasingly prevalent. This undermines patient safety and creates a potential source of major morbidity and mortality. Understanding the factors that influence prescribing behaviour may allow development of interventions to reduce PIP. The aim of this study is to apply the Theoretical Domains Framework (TDF) to explore barriers to effective prescribing in the elderly in the ambulatory setting.Methods: A scoping review was performed based on the five-stage methodological framework developed by Arksey and O’Malley. Our search strategy included PubMed, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews, and Web of Science. We also searched five electronic journals, Google and Google Scholar to identify additional sources and grey literature. Two reviewers applied eligibility criteria to the title and abstract screening, followed by full text screening, before systematically charting the data. Results: 5,731 articles were screened. 29 studies met the selection criteria for qualitative analysis. Using TDF, 14 domains for barriers to effective prescribing were identified. Significant domains include physician-related factors such as “Knowledge”, “Skills”, and “Social/Professional Role and Identity”; issues with “Environmental Context and Resources”; and the impact of “Social Influences” and “Emotion” on prescribing behaviour.Conclusion: The TDF elicited multiple domains which both independently and collectively lead to barriers to effective prescribing in elderly patients in the ambulatory setting. Changing the prescribing climate will thus require interventions targeting multiple stakeholders, including physicians, patients and hospital/clinic systems. Moving forward, we will perform a Delphi study to explore individual domains and ultimately develop a physician-pharmacist collaborative care intervention to guide prescribing for the elderly in the ambulatory setting.

ObjectivePolypharmacy occurs in approximately 30% of older adults aged 65 years or more, particularly among those with multimorbidity. With polypharmacy, there is an associated risk of potentially inappropriate prescribing (PIP). The aims of this scoping review were to (1) identify the intervention elements that have been adopted to reduce PIP in the outpatient setting and (2) determine the behaviour change wheel (BCW) intervention functions performed by each of the identified intervention elements.DesignScoping reviewData sourcesPubMed, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Web of Science and Cochrane Library databases, grey literature sources, six key geriatrics journals and the reference lists of review papers.Study selectionAll studies reporting an intervention or strategy that addressed PIP in the older adult population (age ≥65) with multimorbidity in the outpatient setting and in which the primary prescriber is the physician.Data extractionData extracted from the included studies can be broadly categorised into (1) publication details, (2) intervention details and (3) results. This was followed by data synthesis and analysis based on the BCW framework.ResultsOf 8195 studies yielded, 80 studies were included in the final analysis and 14 intervention elements were identified. An average of two to three elements were adopted in each intervention. The three most frequently adopted intervention elements were medication review (70%), training (26.3%) and tool/instrument(s) (22.5%). Among medication reviews, 70% involved pharmacists. The 14 intervention elements were mapped onto five intervention functions: ‘education’, ‘persuasion’, ‘training’, ‘environmental restructuring’ and ‘enablement’.ConclusionPIP is a multifaceted problem that involves multiple stakeholders. As such, interventions that address PIP require multiple elements to target the behaviour of the various stakeholders. The intervention elements and their corresponding functions identified in this scoping review will serve to inform the design of complex interventions that aim to reduce PIP.

Aim: Admission to an acute care geriatric unit may lead to adverse outcomes. It is therefore important to identify high-risk patients early so that appropriate management can be instituted to prevent or delay onset of adverse events. The aim of this study is to evaluate one-year mortality and its associated risk factors among hospitalized patients. Methods: This is a retrospective cohort study on consecutive patients admitted to an acute geriatric ward in a Singapore hospital from March to April 2013.Demographic and clinical information was collected from patient medical records. Linkage with death records from a national registry was performed. Results: Of the 196 patients assessed, 4.6%, 20.9% and 35.7% died during admission, within six months post-admission and within one year post-admission respectively. Pneumonia and cardiovascular diseases accounted for most of the death cases. In the multivariable logistic regression adjusted by age and gender, abbreviated mental test (AMT) score, admission for falls and depression were found to be significantly associated with death within one year post-admission. In the analysis stratified by gender, AMT score and depression were found to be significantly associated with death in males whereas AMT score and admission for falls were significantly associated with death in females. Conclusions: This study offers significant insight into mortality trends and risk factors for clinicians, hence guiding them in individualizing their management plan for acutely ill geriatric patients. Predicting long-term prognosis will enhance rehabilitation goal-setting and advance care-planning.

As the newer oral anticoagulants (NOACs) are increasingly used in older patients, clinical scenarios when they may need to be discontinued temporarily or indefinitely, may be encountered. Similarly with increasing use of permanent pacemakers and other intra-cardiac devices, there is an increased risk of upper limb venous thrombosis even few years after their insertion. We report a case of a patient with a permanent pacemaker, on rivaroxaban (NOAC) for atrial fibrillation, who developed an upper extremity deep vein thrombosis after its temporary withdrawal following a traumatic acute subdural haematoma. Physicians should be aware of the possibility of rebound hypercoagulability and venous thrombosis soon after the withdrawal of NOACs.