https://escholarship.org/content/qt1r33f4p8/qt1r33f4p8.pdf?t=qho8bi

Dementia prevention, intervention, and care: 2020 report of the Lancet Commission.

i n c y h h i t i a R Last month, Alzheimer’s & Dementia: The Journal of the lzheimer’s Association received acceptance for inclusion n MEDLINE, the bibliographic database of the U.S. Naional Library of Medicine (NLM). Three years since the aunch, this achievement marks an important recognition of he Journal’s scientific merit and contribution to the field of lzheimer’s disease research. The editors, our publishing artners from Elsevier, and our sponsoring colleagues from he Alzheimer’s Association are extremely thankful to the uthors, reviewers, Editorial Board members, and readers or their many valuable contributions. As the official journal of the Alzheimer’s Association, lzheimer’s & Dementia will now be circulated to the active embers of the Association’s new International Society to dvance Alzheimer Research and Treatment (ISTAART) imonthly, as well as other subscribers and libraries. The ournal will continue to cover critical scientific, medical, ocial, and policy issues that investigators and clinicians ace every day, on matters concerning healthy brain aging to ll forms of dementia. Unlike other journals in the field, lzheimer’s & Dementia bridges new thinking across dierse areas of investigation. This interdisciplinary journal rovides the impetus for new scientific initiatives and offers

Alzheimer's & Dementia: the Journal of the Alzheimer's Association.

The aim of the study was to develop a European list of potentially inappropriate medications (PIM) for older people, which can be used for the analysis and comparison of prescribing patterns across European countries and for clinical practice. A preliminary PIM list was developed, based on the German PRISCUS list of potentially inappropriate medications and other PIM lists from the USA, Canada and France. Thirty experts on geriatric prescribing from Estonia, Finland, France, the Netherlands, Spain and Sweden participated; eight experts performed a structured expansion of the list, suggesting further medications; twenty-seven experts participated in a two-round Delphi survey assessing the appropriateness of drugs and suggesting dose adjustments and therapeutic alternatives. Finally, twelve experts completed a brief final survey to decide upon issues requiring further consensus. Experts reached a consensus that 282 chemical substances or drug classes from 34 therapeutic groups are PIM for older people; some PIM are restricted to a certain dose or duration of use. The PIM list contains suggestions for dose adjustments and therapeutic alternatives. The European Union (EU)(7)-PIM list is a screening tool, developed with participation of experts from seven European countries, that allows identification and comparison of PIM prescribing patterns for older people across European countries. It can also be used as a guide in clinical practice, although it does not substitute the decision-making process of individualised prescribing for older people. Further research is needed to investigate the feasibility and applicability and, finally, the clinical benefits of the newly developed list.

/pdf/the-eu-7-pim-list-a-list-of-potentially-inappropriate-4enktrzzud.pdf

The EU(7)-PIM list: a list of potentially inappropriate medications for older people consented by experts from seven European countries

End-of-life decisions in medical practice in Flanders, Belgium: a nationwide survey.

Prevalence of Potentially Inappropriate Medication Use in Older Adults Living in Nursing Homes: A Systematic Review.

Nursing students' pharmacological knowledge and calculation skills: ready for practice?

Background: Antipsychotic agents are often used to treat neuropsychiatric symptoms (NPS) in people with dementia although there is uncertainty about the effectiveness of their long-term use for this indication and concern that they may cause harm, including higher mortality. When behavioural strategies have failed and treatment with antipsychotic drugs is instituted, regular attempts to withdraw them have been recommended in guidelines. Physicians, nurses and families of older people with dementia may be reluctant to stop antipsychotics, fearing deterioration of NPS. This is an update of a Cochrane Review published in 2013. Objectives: To evaluate whether withdrawal of antipsychotic agents is successful in older people with dementia and NPS in primary care or nursing home settings, to list the different strategies for withdrawal of antipsychotic agents in older participants with dementia and NPS, and to measure the effects of withdrawal of antipsychotic agents on participants' behaviour and assess safety. Search methods: We searched the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (ALOIS), theCochrane Library, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, clinical trials registries and grey literature sources up to 11 January 2018. Selection criteria: We included all randomised, controlled trials comparing an antipsychotic withdrawal strategy to continuation of antipsychotics in people with dementia who had been treated with an antipsychotic drug for at least three months. Data collection and analysis: We used standard methodological procedures according to the Cochrane Handbook for Systematic Reviews of Interventions. We rated the quality of evidence for each outcome using the GRADE approach. Main results: We included 10 studies involving 632 participants. One new trial (19 participants) was added for this update. One trial was conducted in a community setting, eight in nursing homes and one in both settings. Different types of antipsychotics at varying doses were discontinued in the studies. Both abrupt and gradual withdrawal schedules were used. Reported data were predominantly from studies at low or unclear risk of bias. We included nine trials with 575 randomised participants that used a proxy outcome for overall success of antipsychotic withdrawal. Pooling data was not possible due to heterogeneity of outcome measures used. Based on assessment of seven studies, discontinuation may make little or no difference to whether or not participants complete the study (low-quality evidence). Two trials included only participants with psychosis, agitation or aggression who had responded to antipsychotic treatment. In these two trials, stopping antipsychotics was associated with a higher risk of leaving the study early due to symptomatic relapse or a shorter time to symptomatic relapse. We found low-quality evidence that discontinuation may make little or no difference to overall NPS, measured using various scales (7 trials, 519 participants). There was some evidence from subgroup analyses in two trials that discontinuation may reduce agitation for participants with less severe NPS at baseline, but may be associated with a worsening of NPS in participants with more severe NPS at baseline. None of the studies assessed withdrawal symptoms. Adverse effects of antipsychotics (such as falls) were not systematically assessed. Low-quality evidence showed that discontinuation may have little or no effect on adverse events (5 trials, 381 participants), quality of life (2 trials, 119 participants), or cognitive function (5 trials, 365 participants). There were insufficient data to determine whether discontinuation of antipsychotics has any effect on mortality (very low-quality evidence). Authors' conclusions: There is low-quality evidence that antipsychotics may be successfully discontinued in older people with dementia and NPS who have been taking antipsychotics for at least three months, and that discontinuation may have little or no important effect on behavioural and psychological symptoms. This is consistent with the observation that most behavioural complications of dementia are intermittent and often do not persist for longer than three months. Discontinuation may have little or no effect on overall cognitive function. Discontinuation may make no difference to adverse events and quality of life. Based on the trials in this review, we are uncertain whether discontinuation of antipsychotics leads to a decrease in mortality. People with psychosis, aggression or agitation who responded well to long-term antipsychotic drug use, or those with more severe NPS at baseline, may benefit behaviourally from continuation of antipsychotics. Discontinuation may reduce agitation for people with mild NPS at baseline. However, these conclusions are based on few studies or small subgroups and further evidence of benefits and harms associated with withdrawal of antipsychotic is required in people with dementia and mild and severe NPS. The overall conclusions of the review have not changed since 2013 and the number of available trials remains low.

/pdf/withdrawal-versus-continuation-of-long-term-antipsychotic-1su5a1xmev.pdf

Withdrawal versus continuation of long‐term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia

Purpose: This study aims to identify and compare the relevance of barriers that nurses in nursing homes experience in medication management in Belgium.

Design: The mixed-method study started with an expert meeting in November 2008 and was followed by a cross-sectional survey in February–March 2009, questioning 246 nurses and 270 nurse assistants in 20 nursing homes.

Methods: Twelve nurses represented nursing homes in an expert meeting and listed all barriers that might cause suboptimal medication management. Based on the results, a survey was developed in which respondents could indicate whether they were involved in a particular stage of the medication process and if yes, rate the relevance of the barriers in that stage on a continuous scale, varying from 1 =no barrier to 10 =strong barrier. Barriers scored 7 or more were defined as strong.

Findings: Nurses experienced a large number of barriers to safe medication management related to the nurse, organization, interdisciplinary cooperation, or to the patient and family. In preparing medication, medication administration and monitoring, being interrupted, not knowing enough on interactions, and barriers in interdisciplinary cooperation caused the most hindrance. In general, barriers in medication monitoring scored the strongest.

Conclusions: In order to improve safe medication management by tailored interventions in nursing homes, through the use of a standard questionnaire, nurses and nurse assistants can give an overview of barriers they experience and rate their relevance. Nurses and nurse assistants had different opinions on the relevance of barriers, especially in the stage of medication monitoring. Job expectations in medication management were not always clear, creating additional barriers in medication safety.

Clinical Relevance: This study provides an overview of potential barriers to safe medication management in nursing homes, which can be addressed in practice. The relevance scoring of the barriers enables prioritization.

Barriers for Nurses to Safe Medication Management in Nursing Homes

Purpose

This study aims to investigate drug utilization in Belgian nursing homes in relation to the characteristics of residents and the institution.



Methods

A cross-sectional study design was used. A total of 2510 residents were randomly selected from a stratified random sample of 76 Belgian nursing homes with at least 30 beds, including high-intensity care beds. Data collection was based on medical chart review supplemented with clinical information from general practitioners (GPs)



Results

The residents included had a mean age of 85 and 77% were female. They presented a median of 2 clinical problems (range 0–10), three care problems (range 0–10) and 48% had dementia. Their medical consumption amounted to a mean of 8.4 prescriptions including 7.1 for chronic treatment. Mean expenditure per month for chronic medication was 140 EUR (SD 125), including 53 EUR out-of-pocket payment.



This study confirmed that multiple comorbidity was associated with polypharmacy. After peaking in the seventh decade, medical consumption decreased in older age groups. In palliative care, the number of prescriptions decreased while expenditure increased. A marked decrease in prescriptions, particularly of pain-relieving medication, was observed with increasing dementia. Larger public institutions, with an active coordinating physician and served by hospital pharmacists, had lower consumption and expenditure.



Conclusion

A high level of drug utilization, influenced by the characteristics of residents and the institution, was observed in Belgian nursing homes. There is a need to develop a comprehensive monitoring system of prescribing quality for nursing home residents. Copyright © 2010 John Wiley & Sons, Ltd.

Drug utilization in Belgian nursing homes: impact of residents' and institutional characteristics

(1) To describe the prevalence of benzodiazepine use in Belgian nursing homes, with specific attention to indications and dosages. (2) To compare actual and recommended dosages of benzodiazepines for anxiety and insomnia. (3) To explore the risk profile for chronic benzodiazepine use in institutionalised older adults. Medication charts of 1,730 residents from 76 nursing homes in Belgium were collected and analysed, using the ATC classification. Drug name, indication and daily dosage were recorded. From authoritative international sources, we extracted for each drug and each indication a daily dosage recommended not to be exceeded in older adults for comparison with observed actual dosages. Among the chronic benzodiazepine or z-drug (BZD/Z) users (50% of the residents), the leading indication was ‘insomnia’ (59% of the users) followed by ‘anxiety’ (17%) and ‘unrest’ (10%). In the chronic prescriptions of BZD/Zs indicated for insomnia, the actual daily dose exceeded the geriatric upper limit in 95% of lormetazepam prescriptions, 82% of zolpidem, 78% of zopiclone and 35% of lorazepam prescriptions. For anxiety, daily doses also exceeded the limit but not to the same extent. Multivariate analysis showed BZD/Z use was positively associated with pain (OR 1.58, 95% CI 1.27–1.97), constipation (OR 1.43, 95% CI 1.16–1.76) and depression (OR 1.68, 95% CI 1.35–2.08). Residents with dementia were less likely to receive a BZD/Z (OR 0.60, 95% CI 0.48–0.74). Efforts to reduce the use of BZD/Zs in nursing homes should concentrate on insomnia, with interventions aimed at reducing too high prevalence of chronic use and too high daily dosages in this indication.

/pdf/benzodiazepine-use-in-belgian-nursing-homes-a-closer-look-5g0mq2lsrx.pdf

Robert Vander Stichele

Papers

Nursing students' pharmacological knowledge and calculation skills: ready for practice?

Withdrawal versus continuation of long‐term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia

Barriers for Nurses to Safe Medication Management in Nursing Homes

Drug utilization in Belgian nursing homes: impact of residents' and institutional characteristics

Benzodiazepine use in Belgian nursing homes: a closer look into indications and dosages