Feasibility study of medication review by a specialist ...



Feasibility study of medication review by a specialist pharmacist and guided by a prognostic indicator for older people entering Aged Residential Care Protocol Date: 28th March 2018Claire Heppenstall, Clinical Lecturer, Principal InvestigatorJasjot Maggo, Research AssistantTracey Borrie, Research pharmacistCarl Hanger, Senior lecturer and consultant geriatricianContact detailsDr Claire HeppenstallUniversity of Otago, Christchurch, Department of MedicinePortacom A, Burwood Hospital,Private Bag 4708,Christchurch 8140claire.heppenstall@otago.ac.nz+64 27 349 4703AbstractIntroduction: Older people in Aged Residential Care (ARC) usually have multiple complex, physical, mental and social needs. Most are on multiple medications (polypharmacy). This is associated with adverse outcomes including falls, fractures, cognitive decline, incontinence and hospital admissions. This study will examine the intervention of a pharmacist-led medication review, guided by a routinely collected prognostic scale, and a frailty score.Methods and analysis: This is a feasibility study. Study population: Participants will be new admissions to long-term residential care in Christchurch. There will be 8 intervention facilities and 4 control facilities. Participants will be approached in the first month after they enter ARC. Intervention: A specialist pharmacist will review medications, guided by patient’s treatment priorities, a prognostic scale (InterRAI CHESS scale) and a frailty index (Reported Edmonton Frailty Score, REFS). Recommendations will be made to GPs, who will make final decisions on any medication changes. Primary outcomes: Number of older people and GPs accepting a medication review. Number of pharmacist recommendation adopted by GPs (measured by number and classes of medications) after three and six months. Secondary outcomes: quality of life at baseline, three and six months. Hospital admissions after 3 and 6 months. Increased level of care after three and six months.Ethics and dissemination: Ethics approval has been granted by the Human Disability and Ethics Committee. Ethical approval number (TBC) Trial registration: Australian New Zealand Clinical Trial registry (TBC). Funding: This work is funded by a Health Research Council (HRC) emerging researcher grant. No other funding was requested or received for this study. The principal investigator is employed by the University of Otago.KeywordsFrailty, polypharmacy, appropriate prescribing, medication review, feasibility studyBackgroundPolypharmacy, or the prescription of multiple medications, is increasingly common in frail older people, and is a focus of national and international research interest ADDIN EN.CITE <EndNote><Cite><Author>Agostini</Author><Year>2004</Year><RecNum>147</RecNum><DisplayText>(1)</DisplayText><record><rec-number>147</rec-number><foreign-keys><key app="EN" db-id="00at2ree6xt9rie9re85vsxp5sx00festp22" timestamp="0">147</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Agostini, Joseph V.</author><author>Han, Ling</author><author>Tinetti, Mary E.</author></authors></contributors><titles><title>The Relationship Between Number of Medications and Weight Loss or Impaired Balance in Older Adults</title><secondary-title>Journal of the American Geriatrics Society</secondary-title></titles><periodical><full-title>Journal of the American Geriatrics Society</full-title></periodical><pages>1719-1723</pages><volume>52</volume><keywords><keyword>polypharmacy</keyword><keyword>Aged</keyword><keyword>adverse drug reactions</keyword><keyword>weight loss</keyword><keyword>balance</keyword><keyword>falls</keyword></keywords><dates><year>2004</year></dates><urls></urls></record></Cite></EndNote>(1). This is driven by older people having multiple comorbidities for which treatment is available, and the increasing use of guidelines, for example for cardiovascular disease, which recommend multiple medicines ADDIN EN.CITE <EndNote><Cite><Author>Richardson</Author><Year>2011</Year><RecNum>215</RecNum><DisplayText>(2)</DisplayText><record><rec-number>215</rec-number><foreign-keys><key app="EN" db-id="00at2ree6xt9rie9re85vsxp5sx00festp22" timestamp="1438750445">215</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Richardson, K.</author><author>Ananou, A.</author><author>Lafortune, L.</author><author>Brayne, C.</author><author>Matthews, F.E.</author></authors></contributors><titles><title>Variation over time in the association between polypharmacy and mortality in the older population</title><secondary-title>Drugs and Aging</secondary-title></titles><periodical><full-title>Drugs and Aging</full-title></periodical><pages>547-560</pages><volume>28</volume><dates><year>2011</year></dates><urls></urls></record></Cite></EndNote>(2). Many of these medicines are prescribed to reduce risk of future events rather than to treat symptoms. Polypharmacy increases the risk of adverse outcomes including adverse drug effects, drug-drug or drug-disease interactions, hospitalizations, falls and fractures, decreased mobility, delirium, weight loss and malnutrition ADDIN EN.CITE <EndNote><Cite><Author>Frazier</Author><Year>2005</Year><RecNum>76</RecNum><DisplayText>(3, 4)</DisplayText><record><rec-number>76</rec-number><foreign-keys><key app="EN" db-id="00at2ree6xt9rie9re85vsxp5sx00festp22" timestamp="0">76</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Frazier, Susan C.</author></authors></contributors><titles><title>Health Outcomes and Polypharmacy in Elderly Individuals</title><secondary-title>Journal of Gerontological Nursing</secondary-title></titles><periodical><full-title>Journal of Gerontological Nursing</full-title></periodical><pages>4-11</pages><volume>31</volume><number>9</number><keywords><keyword>polypharmacy</keyword><keyword>elderly</keyword><keyword>Medication use</keyword><keyword>adverse drug reactions</keyword></keywords><dates><year>2005</year></dates><urls></urls></record></Cite><Cite><Author>Tamura</Author><Year>2012</Year><RecNum>199</RecNum><record><rec-number>199</rec-number><foreign-keys><key app="EN" db-id="00at2ree6xt9rie9re85vsxp5sx00festp22" timestamp="1436931963">199</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tamura, Bruce K.</author><author>Bell, Christina L.</author><author>Inaba, Michiko</author><author>Masaki, Kamal H.</author></authors></contributors><titles><title>Outcomes of Polypharmacy in Nursing Home Residents</title><secondary-title>Clinics in Geriatric Medicine</secondary-title></titles><periodical><full-title>Clinics in Geriatric Medicine</full-title></periodical><pages>217-236</pages><volume>28</volume><number>2</number><dates><year>2012</year></dates><urls></urls></record></Cite></EndNote>(3, 4). In people with short life-expectancy the potential benefits are reduced and in frail people the potential harms are increased. Most drug trials are completed in younger, fitter community-dwelling populations. Frail elderly, Aged Residential care (ARC) residents are usually excluded from clinical trials and are a group for whom the potential harms of polypharmacy are high and the potential benefits uncertain.ARC residents are a particularly frail group, with a short life expectancy. One-third to one half of those admitted to higher level care die within one yearPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IZXBwZW5zdGFsbDwvQXV0aG9yPjxZZWFyPjIwMTU8L1ll

YXI+PFJlY051bT4yMDM8L1JlY051bT48RGlzcGxheVRleHQ+KDUsIDYpPC9EaXNwbGF5VGV4dD48

cmVjb3JkPjxyZWMtbnVtYmVyPjIwMzwvcmVjLW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBw

PSJFTiIgZGItaWQ9IjAwYXQycmVlNnh0OXJpZTlyZTg1dnN4cDVzeDAwZmVzdHAyMiIgdGltZXN0

YW1wPSIxNDM3MDMzOTI1Ij4yMDM8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0i

Sm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0

aG9yPkhlcHBlbnN0YWxsLCBDbGFpcmUgUC48L2F1dGhvcj48YXV0aG9yPkJyb2FkLCBKb2FubmEg

Qi48L2F1dGhvcj48YXV0aG9yPkJveWQsIE1pY2hhbDwvYXV0aG9yPjxhdXRob3I+R290dCwgTWVy

cnluPC9hdXRob3I+PGF1dGhvcj5Db25ub2xseSwgTWFydGluIEouPC9hdXRob3I+PC9hdXRob3Jz

PjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPlByb2dyZXNzIFRvd2FyZHMgUHJlZGljdGlu

ZyAxLXllYXIgTW9ydGFsaXR5IGluIE9sZGVyIFBlb3BsZSBMaXZpbmcgaW4gUmVzaWRlbnRpYWwg

TG9uZy10ZXJtIENhcmU8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+QWdlIGFuZCBBZ2Vpbmc8L3Nl

Y29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5BZ2UgYW5kIEFn

ZWluZzwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PGRhdGVzPjx5ZWFyPjIwMTU8L3llYXI+PC9k

YXRlcz48dXJscz48L3VybHM+PGVsZWN0cm9uaWMtcmVzb3VyY2UtbnVtPmRvaTogMTAuMTA5My9h

Z2VpbmcvYWZ1MjA2PC9lbGVjdHJvbmljLXJlc291cmNlLW51bT48L3JlY29yZD48L0NpdGU+PENp

dGU+PEF1dGhvcj5IZXBwZW5zdGFsbDwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+PFJlY051bT4x

ODU8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjE4NTwvcmVjLW51bWJlcj48Zm9yZWlnbi1r

ZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjAwYXQycmVlNnh0OXJpZTlyZTg1dnN4cDVzeDAwZmVz

dHAyMiIgdGltZXN0YW1wPSIxMzk4MTI0MTMyIj4xODU8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVm

LXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48

YXV0aG9ycz48YXV0aG9yPkhlcHBlbnN0YWxsLCBDLiBQLjwvYXV0aG9yPjxhdXRob3I+SGFuZ2Vy

LCBILiBDLjwvYXV0aG9yPjxhdXRob3I+V2lsa2luc29uLCBULiBKLjwvYXV0aG9yPjwvYXV0aG9y

cz48L2NvbnRyaWJ1dG9ycz48YXV0aC1hZGRyZXNzPlByaW5jZXNzIE1hcmdhcmV0IEhvc3BpdGFs

LCBVbml2ZXJzaXR5IG9mIE90YWdvLCBDaHJpc3RjaHVyY2gsIE5ldyBaZWFsYW5kLiBDbGFpcmVI

QGNkaGIuZ292dC5uejwvYXV0aC1hZGRyZXNzPjx0aXRsZXM+PHRpdGxlPlByZWRpY3RvcnMgb2Yg

ZGlzY2hhcmdlIHN0YWJpbGl0eSBpbiB0aGUgZmlyc3QgeWVhciBmb2xsb3dpbmcgaG9zcGl0YWwg

YWRtaXNzaW9uIGZvciBhIGZyYWlsIGVsZGVybHkgcG9wdWxhdGlvbjwvdGl0bGU+PHNlY29uZGFy

eS10aXRsZT5JbnRlcm4gTWVkIEo8L3NlY29uZGFyeS10aXRsZT48YWx0LXRpdGxlPkludGVybmFs

IG1lZGljaW5lIGpvdXJuYWw8L2FsdC10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10

aXRsZT5JbnRlcm4gTWVkIEo8L2Z1bGwtdGl0bGU+PGFiYnItMT5JbnRlcm5hbCBtZWRpY2luZSBq

b3VybmFsPC9hYmJyLTE+PC9wZXJpb2RpY2FsPjxhbHQtcGVyaW9kaWNhbD48ZnVsbC10aXRsZT5J

bnRlcm4gTWVkIEo8L2Z1bGwtdGl0bGU+PGFiYnItMT5JbnRlcm5hbCBtZWRpY2luZSBqb3VybmFs

PC9hYmJyLTE+PC9hbHQtcGVyaW9kaWNhbD48cGFnZXM+MTcwLTM8L3BhZ2VzPjx2b2x1bWU+Mzk8

L3ZvbHVtZT48bnVtYmVyPjM8L251bWJlcj48a2V5d29yZHM+PGtleXdvcmQ+KkFjdGl2aXRpZXMg

b2YgRGFpbHkgTGl2aW5nPC9rZXl3b3JkPjxrZXl3b3JkPkFnZWQ8L2tleXdvcmQ+PGtleXdvcmQ+

QWdlZCwgODAgYW5kIG92ZXI8L2tleXdvcmQ+PGtleXdvcmQ+Q29nbml0aW9uPC9rZXl3b3JkPjxr

ZXl3b3JkPkNvaG9ydCBTdHVkaWVzPC9rZXl3b3JkPjxrZXl3b3JkPkZlbWFsZTwva2V5d29yZD48

a2V5d29yZD4qRnJhaWwgRWxkZXJseS9zdGF0aXN0aWNzICZhbXA7IG51bWVyaWNhbCBkYXRhPC9r

ZXl3b3JkPjxrZXl3b3JkPkdlcmlhdHJpYyBBc3Nlc3NtZW50PC9rZXl3b3JkPjxrZXl3b3JkPkhv

c3BpdGFsaXphdGlvbi9zdGF0aXN0aWNzICZhbXA7IG51bWVyaWNhbCBkYXRhPC9rZXl3b3JkPjxr

ZXl3b3JkPkh1bWFuczwva2V5d29yZD48a2V5d29yZD5JbnN0aXR1dGlvbmFsaXphdGlvbi9zdGF0

aXN0aWNzICZhbXA7IG51bWVyaWNhbCBkYXRhPC9rZXl3b3JkPjxrZXl3b3JkPkxlbmd0aCBvZiBT

dGF5PC9rZXl3b3JkPjxrZXl3b3JkPk1hbGU8L2tleXdvcmQ+PGtleXdvcmQ+TWVudGFsIEhlYWx0

aDwva2V5d29yZD48a2V5d29yZD5QYXRpZW50IERpc2NoYXJnZS8qc3RhdGlzdGljcyAmYW1wOyBu

dW1lcmljYWwgZGF0YTwva2V5d29yZD48a2V5d29yZD5QcmVkaWN0aXZlIFZhbHVlIG9mIFRlc3Rz

PC9rZXl3b3JkPjxrZXl3b3JkPlJldHJvc3BlY3RpdmUgU3R1ZGllczwva2V5d29yZD48a2V5d29y

ZD5SaXNrIEFzc2Vzc21lbnQ8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHllYXI+MjAwOTwv

eWVhcj48cHViLWRhdGVzPjxkYXRlPk1hcjwvZGF0ZT48L3B1Yi1kYXRlcz48L2RhdGVzPjxpc2Ju

PjE0NDUtNTk5NCAoRWxlY3Ryb25pYykmI3hEOzE0NDQtMDkwMyAoTGlua2luZyk8L2lzYm4+PGFj

Y2Vzc2lvbi1udW0+MTg3NzE0Mzc8L2FjY2Vzc2lvbi1udW0+PHVybHM+PHJlbGF0ZWQtdXJscz48

dXJsPmh0dHA6Ly93d3cubmNiaS5ubG0ubmloLmdvdi9wdWJtZWQvMTg3NzE0Mzc8L3VybD48L3Jl

bGF0ZWQtdXJscz48L3VybHM+PGVsZWN0cm9uaWMtcmVzb3VyY2UtbnVtPjEwLjExMTEvai4xNDQ1

LTU5OTQuMjAwOC4wMTY5Ny54PC9lbGVjdHJvbmljLXJlc291cmNlLW51bT48L3JlY29yZD48L0Np

dGU+PC9FbmROb3RlPgB=

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IZXBwZW5zdGFsbDwvQXV0aG9yPjxZZWFyPjIwMTU8L1ll

YXI+PFJlY051bT4yMDM8L1JlY051bT48RGlzcGxheVRleHQ+KDUsIDYpPC9EaXNwbGF5VGV4dD48

cmVjb3JkPjxyZWMtbnVtYmVyPjIwMzwvcmVjLW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBw

PSJFTiIgZGItaWQ9IjAwYXQycmVlNnh0OXJpZTlyZTg1dnN4cDVzeDAwZmVzdHAyMiIgdGltZXN0

YW1wPSIxNDM3MDMzOTI1Ij4yMDM8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0i

Sm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0

aG9yPkhlcHBlbnN0YWxsLCBDbGFpcmUgUC48L2F1dGhvcj48YXV0aG9yPkJyb2FkLCBKb2FubmEg

Qi48L2F1dGhvcj48YXV0aG9yPkJveWQsIE1pY2hhbDwvYXV0aG9yPjxhdXRob3I+R290dCwgTWVy

cnluPC9hdXRob3I+PGF1dGhvcj5Db25ub2xseSwgTWFydGluIEouPC9hdXRob3I+PC9hdXRob3Jz

PjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPlByb2dyZXNzIFRvd2FyZHMgUHJlZGljdGlu

ZyAxLXllYXIgTW9ydGFsaXR5IGluIE9sZGVyIFBlb3BsZSBMaXZpbmcgaW4gUmVzaWRlbnRpYWwg

TG9uZy10ZXJtIENhcmU8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+QWdlIGFuZCBBZ2Vpbmc8L3Nl

Y29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5BZ2UgYW5kIEFn

ZWluZzwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PGRhdGVzPjx5ZWFyPjIwMTU8L3llYXI+PC9k

YXRlcz48dXJscz48L3VybHM+PGVsZWN0cm9uaWMtcmVzb3VyY2UtbnVtPmRvaTogMTAuMTA5My9h

Z2VpbmcvYWZ1MjA2PC9lbGVjdHJvbmljLXJlc291cmNlLW51bT48L3JlY29yZD48L0NpdGU+PENp

dGU+PEF1dGhvcj5IZXBwZW5zdGFsbDwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+PFJlY051bT4x

ODU8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjE4NTwvcmVjLW51bWJlcj48Zm9yZWlnbi1r

ZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjAwYXQycmVlNnh0OXJpZTlyZTg1dnN4cDVzeDAwZmVz

dHAyMiIgdGltZXN0YW1wPSIxMzk4MTI0MTMyIj4xODU8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVm

LXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48

YXV0aG9ycz48YXV0aG9yPkhlcHBlbnN0YWxsLCBDLiBQLjwvYXV0aG9yPjxhdXRob3I+SGFuZ2Vy

LCBILiBDLjwvYXV0aG9yPjxhdXRob3I+V2lsa2luc29uLCBULiBKLjwvYXV0aG9yPjwvYXV0aG9y

cz48L2NvbnRyaWJ1dG9ycz48YXV0aC1hZGRyZXNzPlByaW5jZXNzIE1hcmdhcmV0IEhvc3BpdGFs

LCBVbml2ZXJzaXR5IG9mIE90YWdvLCBDaHJpc3RjaHVyY2gsIE5ldyBaZWFsYW5kLiBDbGFpcmVI

QGNkaGIuZ292dC5uejwvYXV0aC1hZGRyZXNzPjx0aXRsZXM+PHRpdGxlPlByZWRpY3RvcnMgb2Yg

ZGlzY2hhcmdlIHN0YWJpbGl0eSBpbiB0aGUgZmlyc3QgeWVhciBmb2xsb3dpbmcgaG9zcGl0YWwg

YWRtaXNzaW9uIGZvciBhIGZyYWlsIGVsZGVybHkgcG9wdWxhdGlvbjwvdGl0bGU+PHNlY29uZGFy

eS10aXRsZT5JbnRlcm4gTWVkIEo8L3NlY29uZGFyeS10aXRsZT48YWx0LXRpdGxlPkludGVybmFs

IG1lZGljaW5lIGpvdXJuYWw8L2FsdC10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10

aXRsZT5JbnRlcm4gTWVkIEo8L2Z1bGwtdGl0bGU+PGFiYnItMT5JbnRlcm5hbCBtZWRpY2luZSBq

b3VybmFsPC9hYmJyLTE+PC9wZXJpb2RpY2FsPjxhbHQtcGVyaW9kaWNhbD48ZnVsbC10aXRsZT5J

bnRlcm4gTWVkIEo8L2Z1bGwtdGl0bGU+PGFiYnItMT5JbnRlcm5hbCBtZWRpY2luZSBqb3VybmFs

PC9hYmJyLTE+PC9hbHQtcGVyaW9kaWNhbD48cGFnZXM+MTcwLTM8L3BhZ2VzPjx2b2x1bWU+Mzk8

L3ZvbHVtZT48bnVtYmVyPjM8L251bWJlcj48a2V5d29yZHM+PGtleXdvcmQ+KkFjdGl2aXRpZXMg

b2YgRGFpbHkgTGl2aW5nPC9rZXl3b3JkPjxrZXl3b3JkPkFnZWQ8L2tleXdvcmQ+PGtleXdvcmQ+

QWdlZCwgODAgYW5kIG92ZXI8L2tleXdvcmQ+PGtleXdvcmQ+Q29nbml0aW9uPC9rZXl3b3JkPjxr

ZXl3b3JkPkNvaG9ydCBTdHVkaWVzPC9rZXl3b3JkPjxrZXl3b3JkPkZlbWFsZTwva2V5d29yZD48

a2V5d29yZD4qRnJhaWwgRWxkZXJseS9zdGF0aXN0aWNzICZhbXA7IG51bWVyaWNhbCBkYXRhPC9r

ZXl3b3JkPjxrZXl3b3JkPkdlcmlhdHJpYyBBc3Nlc3NtZW50PC9rZXl3b3JkPjxrZXl3b3JkPkhv

c3BpdGFsaXphdGlvbi9zdGF0aXN0aWNzICZhbXA7IG51bWVyaWNhbCBkYXRhPC9rZXl3b3JkPjxr

ZXl3b3JkPkh1bWFuczwva2V5d29yZD48a2V5d29yZD5JbnN0aXR1dGlvbmFsaXphdGlvbi9zdGF0

aXN0aWNzICZhbXA7IG51bWVyaWNhbCBkYXRhPC9rZXl3b3JkPjxrZXl3b3JkPkxlbmd0aCBvZiBT

dGF5PC9rZXl3b3JkPjxrZXl3b3JkPk1hbGU8L2tleXdvcmQ+PGtleXdvcmQ+TWVudGFsIEhlYWx0

aDwva2V5d29yZD48a2V5d29yZD5QYXRpZW50IERpc2NoYXJnZS8qc3RhdGlzdGljcyAmYW1wOyBu

dW1lcmljYWwgZGF0YTwva2V5d29yZD48a2V5d29yZD5QcmVkaWN0aXZlIFZhbHVlIG9mIFRlc3Rz

PC9rZXl3b3JkPjxrZXl3b3JkPlJldHJvc3BlY3RpdmUgU3R1ZGllczwva2V5d29yZD48a2V5d29y

ZD5SaXNrIEFzc2Vzc21lbnQ8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHllYXI+MjAwOTwv

eWVhcj48cHViLWRhdGVzPjxkYXRlPk1hcjwvZGF0ZT48L3B1Yi1kYXRlcz48L2RhdGVzPjxpc2Ju

PjE0NDUtNTk5NCAoRWxlY3Ryb25pYykmI3hEOzE0NDQtMDkwMyAoTGlua2luZyk8L2lzYm4+PGFj

Y2Vzc2lvbi1udW0+MTg3NzE0Mzc8L2FjY2Vzc2lvbi1udW0+PHVybHM+PHJlbGF0ZWQtdXJscz48

dXJsPmh0dHA6Ly93d3cubmNiaS5ubG0ubmloLmdvdi9wdWJtZWQvMTg3NzE0Mzc8L3VybD48L3Jl

bGF0ZWQtdXJscz48L3VybHM+PGVsZWN0cm9uaWMtcmVzb3VyY2UtbnVtPjEwLjExMTEvai4xNDQ1

LTU5OTQuMjAwOC4wMTY5Ny54PC9lbGVjdHJvbmljLXJlc291cmNlLW51bT48L3JlY29yZD48L0Np

dGU+PC9FbmROb3RlPgB=

ADDIN EN.CITE.DATA (5, 6). ARC residents have polypharmacy with the mean numbers of medicines 7 to 8 per person, and over a third on 9 or more medications ADDIN EN.CITE <EndNote><Cite><Author>Elseviers</Author><Year>2010</Year><RecNum>166</RecNum><DisplayText>(5, 7)</DisplayText><record><rec-number>166</rec-number><foreign-keys><key app="EN" db-id="00at2ree6xt9rie9re85vsxp5sx00festp22" timestamp="0">166</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Elseviers, Monique M.</author><author>Vander Stichele, Robert R.</author><author>Van Bortel, Luc</author></authors></contributors><titles><title>Drug utilization in Belgian nursing homes: impact of residents&apos; and institutional characteristics</title><secondary-title>Pharmacoepidemiology and Drug Safety</secondary-title></titles><periodical><full-title>Pharmacoepidemiology and Drug Safety</full-title></periodical><pages>1041-1048</pages><volume>19</volume><keywords><keyword>medication use</keyword><keyword>nursing homes</keyword></keywords><dates><year>2010</year></dates><urls></urls></record></Cite><Cite><Author>Heppenstall</Author><Year>2015</Year><RecNum>203</RecNum><record><rec-number>203</rec-number><foreign-keys><key app="EN" db-id="00at2ree6xt9rie9re85vsxp5sx00festp22" timestamp="1437033925">203</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Heppenstall, Claire P.</author><author>Broad, Joanna B.</author><author>Boyd, Michal</author><author>Gott, Merryn</author><author>Connolly, Martin J.</author></authors></contributors><titles><title>Progress Towards Predicting 1-year Mortality in Older People Living in Residential Long-term Care</title><secondary-title>Age and Ageing</secondary-title></titles><periodical><full-title>Age and Ageing</full-title></periodical><dates><year>2015</year></dates><urls></urls><electronic-resource-num>doi: 10.1093/ageing/afu206</electronic-resource-num></record></Cite></EndNote>(5, 7). In a recent New Zealand study(8) in those who died within 12 months 70% were on psychotropics, 60% were on antihypertensives, 50% on anti-platelet agents, and 25% on statins.Notable findings from recent studies include: Lower blood pressure and treatment with anti-hypertensives in nursing home residents was associated with higher mortality and no reduction in major cardiovascular events PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZW5ldG9zPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48

UmVjTnVtPjIwMDwvUmVjTnVtPjxEaXNwbGF5VGV4dD4oOCwgOSk8L0Rpc3BsYXlUZXh0PjxyZWNv

cmQ+PHJlYy1udW1iZXI+MjAwPC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVO

IiBkYi1pZD0iMDBhdDJyZWU2eHQ5cmllOXJlODV2c3hwNXN4MDBmZXN0cDIyIiB0aW1lc3RhbXA9

IjE0MzcwMzI3OTciPjIwMDwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3Vy

bmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+

QmVuZXRvcywgQXRoYW5hc2U8L2F1dGhvcj48YXV0aG9yPkdhdXRpZXIsIFN5bHZpZTwvYXV0aG9y

PjxhdXRob3I+TGFiYXQsIENhcmxvczwvYXV0aG9yPjxhdXRob3I+U2FsdmksIERhdmlkZTwvYXV0

aG9yPjxhdXRob3I+VmFsYnVzYSwgRmlsaXBwbzwvYXV0aG9yPjxhdXRob3I+TWFyaW5vLCBGcmFu

Y2VzY2E8L2F1dGhvcj48YXV0aG9yPlRvdWx6YSwgT2xpdmllcjwvYXV0aG9yPjxhdXRob3I+QWdu

b2xldHRpLCBEYXZpZGU8L2F1dGhvcj48YXV0aG9yPlphbWJvbmksIE1hdXJvPC9hdXRob3I+PGF1

dGhvcj5EdWJhaWwsIERlbHBoaW5lPC9hdXRob3I+PGF1dGhvcj5NYW5ja291bmRpYSwgUGF0cmlj

azwvYXV0aG9yPjxhdXRob3I+Um9sbGFuZCwgWXZlczwvYXV0aG9yPjxhdXRob3I+SGFub24sIE9s

aXZpZXI8L2F1dGhvcj48YXV0aG9yPlBlcnJldC1HdWlsbGF1bWUsIENocmlzdGluZTwvYXV0aG9y

PjxhdXRob3I+TGFjb2xsZXksIFBhdHJpY2s8L2F1dGhvcj48YXV0aG9yPlNhZmFyLCBNaWNoZWwg

RS48L2F1dGhvcj48YXV0aG9yPkd1aWxsZW1pbiwgRnJhbmNpczwvYXV0aG9yPjwvYXV0aG9ycz48

L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0aXRsZT5Nb3J0YWxpdHkgYW5kIENhcmRpb3Zhc2N1bGFy

IEV2ZW50cyBhcmUgQmVzdCBQcmVkaWN0ZWQgYnkgTG93IENlbnRyYWwvIFBlcmlwaGVyYWwgUHVs

c2UgUHJlc3N1cmUgQW1wbGlmaWNhdGlvbiBidXQgbm90IGJ5IEhpZ2ggQmxvb2QgUHJlc3N1cmUg

TGV2ZWxzIGluIEVsZGVybHkgTnVyc2luZyBIb21lIFN1YmplY3RzPC90aXRsZT48c2Vjb25kYXJ5

LXRpdGxlPkpvdXJuYWwgb2YgdGhlIEFtZXJpY2FuIENvbGxnZSBvZiBDYXJkaW9sb2d5PC9zZWNv

bmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+Sm91cm5hbCBvZiB0

aGUgQW1lcmljYW4gQ29sbGdlIG9mIENhcmRpb2xvZ3k8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2Fs

PjxwYWdlcz4xNTAzLTE1MTE8L3BhZ2VzPjx2b2x1bWU+NjA8L3ZvbHVtZT48bnVtYmVyPjE2PC9u

dW1iZXI+PGRhdGVzPjx5ZWFyPjIwMTI8L3llYXI+PC9kYXRlcz48dXJscz48L3VybHM+PC9yZWNv

cmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+QmVuZXRvczwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+

PFJlY051bT4yMDE8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjIwMTwvcmVjLW51bWJlcj48

Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjAwYXQycmVlNnh0OXJpZTlyZTg1dnN4

cDVzeDAwZmVzdHAyMiIgdGltZXN0YW1wPSIxNDM3MDMzMDExIj4yMDE8L2tleT48L2ZvcmVpZ24t

a2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRy

aWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPkJlbmV0b3MsIEF0aGFuYXNlPC9hdXRob3I+PGF1dGhv

cj5MYWJhdCwgQ2FybG9zPC9hdXRob3I+PGF1dGhvcj5Sb3NzaWdub2ksIFBhdHJpY2s8L2F1dGhv

cj48YXV0aG9yPkZheSwgUmVuYXVkPC9hdXRob3I+PGF1dGhvcj5Sb2xsYW5kLCBZdmVzPC9hdXRo

b3I+PGF1dGhvcj5WYWxidXNhLCBGaWxpcHBvPC9hdXRob3I+PGF1dGhvcj5TYWx2aSwgRGF2aWRl

PC9hdXRob3I+PGF1dGhvcj5aYW1ib25pLCBNYXVybzwvYXV0aG9yPjxhdXRob3I+TWFuY2tvdW5k

aWEsIFBhdHJpY2s8L2F1dGhvcj48YXV0aG9yPkhhbm9uLCBPbGl2aWVyPC9hdXRob3I+PGF1dGhv

cj5HYXV0aWVyLCBTeWx2aWU8L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PHRpdGxl

cz48dGl0bGU+VHJlYXRtZW50IFdpdGggTXVsdGlwbGUgQmxvb2QgUHJlc3N1cmUgTWVkaWNhdGlv

bnMsIEFjaGlldmVkIEJsb29kIFByZXNzdXJlLCBhbmQgTW9ydGFsaXR5IGluIE9sZGVyIE51cnNp

bmcgSG9tZSBSZXNpZGVudHMuIFRoZSBQQVJUQUdFIFN0dWR5PC90aXRsZT48c2Vjb25kYXJ5LXRp

dGxlPkpvdXJuYWwgb2YgdGhlIEFtZXJpY2FuIE1lZGljYWwgQXNzb2NpYXRpb24gSW50ZXJuYWwg

TWVkaWNpbmU8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRs

ZT5Kb3VybmFsIG9mIHRoZSBBbWVyaWNhbiBNZWRpY2FsIEFzc29jaWF0aW9uIEludGVybmFsIE1l

ZGljaW5lPC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+OTg5LTk5NTwvcGFnZXM+PHZv

bHVtZT4xNzU8L3ZvbHVtZT48bnVtYmVyPjY8L251bWJlcj48ZGF0ZXM+PHllYXI+MjAxNTwveWVh

cj48L2RhdGVzPjx1cmxzPjwvdXJscz48L3JlY29yZD48L0NpdGU+PC9FbmROb3RlPn==

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZW5ldG9zPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48

UmVjTnVtPjIwMDwvUmVjTnVtPjxEaXNwbGF5VGV4dD4oOCwgOSk8L0Rpc3BsYXlUZXh0PjxyZWNv

cmQ+PHJlYy1udW1iZXI+MjAwPC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVO

IiBkYi1pZD0iMDBhdDJyZWU2eHQ5cmllOXJlODV2c3hwNXN4MDBmZXN0cDIyIiB0aW1lc3RhbXA9

IjE0MzcwMzI3OTciPjIwMDwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3Vy

bmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+

QmVuZXRvcywgQXRoYW5hc2U8L2F1dGhvcj48YXV0aG9yPkdhdXRpZXIsIFN5bHZpZTwvYXV0aG9y

PjxhdXRob3I+TGFiYXQsIENhcmxvczwvYXV0aG9yPjxhdXRob3I+U2FsdmksIERhdmlkZTwvYXV0

aG9yPjxhdXRob3I+VmFsYnVzYSwgRmlsaXBwbzwvYXV0aG9yPjxhdXRob3I+TWFyaW5vLCBGcmFu

Y2VzY2E8L2F1dGhvcj48YXV0aG9yPlRvdWx6YSwgT2xpdmllcjwvYXV0aG9yPjxhdXRob3I+QWdu

b2xldHRpLCBEYXZpZGU8L2F1dGhvcj48YXV0aG9yPlphbWJvbmksIE1hdXJvPC9hdXRob3I+PGF1

dGhvcj5EdWJhaWwsIERlbHBoaW5lPC9hdXRob3I+PGF1dGhvcj5NYW5ja291bmRpYSwgUGF0cmlj

azwvYXV0aG9yPjxhdXRob3I+Um9sbGFuZCwgWXZlczwvYXV0aG9yPjxhdXRob3I+SGFub24sIE9s

aXZpZXI8L2F1dGhvcj48YXV0aG9yPlBlcnJldC1HdWlsbGF1bWUsIENocmlzdGluZTwvYXV0aG9y

PjxhdXRob3I+TGFjb2xsZXksIFBhdHJpY2s8L2F1dGhvcj48YXV0aG9yPlNhZmFyLCBNaWNoZWwg

RS48L2F1dGhvcj48YXV0aG9yPkd1aWxsZW1pbiwgRnJhbmNpczwvYXV0aG9yPjwvYXV0aG9ycz48

L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0aXRsZT5Nb3J0YWxpdHkgYW5kIENhcmRpb3Zhc2N1bGFy

IEV2ZW50cyBhcmUgQmVzdCBQcmVkaWN0ZWQgYnkgTG93IENlbnRyYWwvIFBlcmlwaGVyYWwgUHVs

c2UgUHJlc3N1cmUgQW1wbGlmaWNhdGlvbiBidXQgbm90IGJ5IEhpZ2ggQmxvb2QgUHJlc3N1cmUg

TGV2ZWxzIGluIEVsZGVybHkgTnVyc2luZyBIb21lIFN1YmplY3RzPC90aXRsZT48c2Vjb25kYXJ5

LXRpdGxlPkpvdXJuYWwgb2YgdGhlIEFtZXJpY2FuIENvbGxnZSBvZiBDYXJkaW9sb2d5PC9zZWNv

bmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+Sm91cm5hbCBvZiB0

aGUgQW1lcmljYW4gQ29sbGdlIG9mIENhcmRpb2xvZ3k8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2Fs

PjxwYWdlcz4xNTAzLTE1MTE8L3BhZ2VzPjx2b2x1bWU+NjA8L3ZvbHVtZT48bnVtYmVyPjE2PC9u

dW1iZXI+PGRhdGVzPjx5ZWFyPjIwMTI8L3llYXI+PC9kYXRlcz48dXJscz48L3VybHM+PC9yZWNv

cmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+QmVuZXRvczwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+

PFJlY051bT4yMDE8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjIwMTwvcmVjLW51bWJlcj48

Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9IjAwYXQycmVlNnh0OXJpZTlyZTg1dnN4

cDVzeDAwZmVzdHAyMiIgdGltZXN0YW1wPSIxNDM3MDMzMDExIj4yMDE8L2tleT48L2ZvcmVpZ24t

a2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRy

aWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPkJlbmV0b3MsIEF0aGFuYXNlPC9hdXRob3I+PGF1dGhv

cj5MYWJhdCwgQ2FybG9zPC9hdXRob3I+PGF1dGhvcj5Sb3NzaWdub2ksIFBhdHJpY2s8L2F1dGhv

cj48YXV0aG9yPkZheSwgUmVuYXVkPC9hdXRob3I+PGF1dGhvcj5Sb2xsYW5kLCBZdmVzPC9hdXRo

b3I+PGF1dGhvcj5WYWxidXNhLCBGaWxpcHBvPC9hdXRob3I+PGF1dGhvcj5TYWx2aSwgRGF2aWRl

PC9hdXRob3I+PGF1dGhvcj5aYW1ib25pLCBNYXVybzwvYXV0aG9yPjxhdXRob3I+TWFuY2tvdW5k

aWEsIFBhdHJpY2s8L2F1dGhvcj48YXV0aG9yPkhhbm9uLCBPbGl2aWVyPC9hdXRob3I+PGF1dGhv

cj5HYXV0aWVyLCBTeWx2aWU8L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PHRpdGxl

cz48dGl0bGU+VHJlYXRtZW50IFdpdGggTXVsdGlwbGUgQmxvb2QgUHJlc3N1cmUgTWVkaWNhdGlv

bnMsIEFjaGlldmVkIEJsb29kIFByZXNzdXJlLCBhbmQgTW9ydGFsaXR5IGluIE9sZGVyIE51cnNp

bmcgSG9tZSBSZXNpZGVudHMuIFRoZSBQQVJUQUdFIFN0dWR5PC90aXRsZT48c2Vjb25kYXJ5LXRp

dGxlPkpvdXJuYWwgb2YgdGhlIEFtZXJpY2FuIE1lZGljYWwgQXNzb2NpYXRpb24gSW50ZXJuYWwg

TWVkaWNpbmU8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRs

ZT5Kb3VybmFsIG9mIHRoZSBBbWVyaWNhbiBNZWRpY2FsIEFzc29jaWF0aW9uIEludGVybmFsIE1l

ZGljaW5lPC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+OTg5LTk5NTwvcGFnZXM+PHZv

bHVtZT4xNzU8L3ZvbHVtZT48bnVtYmVyPjY8L251bWJlcj48ZGF0ZXM+PHllYXI+MjAxNTwveWVh

cj48L2RhdGVzPjx1cmxzPjwvdXJscz48L3JlY29yZD48L0NpdGU+PC9FbmROb3RlPn==

ADDIN EN.CITE.DATA (9,10). In those with prognosis of less than 1 year stopping statins was not associated with any adverse outcomes, reduces drug burden and improves quality of life ADDIN EN.CITE <EndNote><Cite><Author>Kutner</Author><Year>2015</Year><RecNum>202</RecNum><DisplayText>(10)</DisplayText><record><rec-number>202</rec-number><foreign-keys><key app="EN" db-id="00at2ree6xt9rie9re85vsxp5sx00festp22" timestamp="1437033636">202</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kutner, Jean S.</author><author>Blatchford, Patrick J.</author><author>Taylor, Don H.</author><author>Ritchie, Christine S.</author><author>Bull, Janet H.</author><author>Fairclough, Diane L.</author><author>Hanson, Laura C.</author><author>LeBlanc Thomas W.</author><author>Samsa, Greg P.</author><author>Wolf, Steven</author><author>Aziz, Noreen M.</author><author>Currow, David C.</author><author>Ferrell, Betty</author><author>Wagner-Johnston, Nina</author><author>Zafar, Yousef</author><author>Cleary, James F.</author><author>Dev, Sandesh</author><author>Goode, Patricia S.</author><author>Kamal, Arif H.</author><author>Kassner, Cordt</author><author>Kvale, Elizabeth A.</author><author>McCallum, Janelle G.</author><author>Ogunseitan, Adeboye B.</author><author>Pantilat, Steven Z.</author><author>Portenoy, Russell K.</author><author>Prince-Paul, Maryjo</author><author>Sloan, Jeff A.</author><author>Swetz, Keith M.</author><author>Von Gunten, Charles F.</author><author>Abernethy, Amy P.</author></authors></contributors><titles><title>Safety and Benefit of Discontinuing Statin Therapy in the Setting of Advanced, Life-Limiting Illness. A Randomized Clinical Trial</title><secondary-title>Journal of the American Medical Association Internal Medicine</secondary-title></titles><periodical><full-title>Journal of the American Medical Association Internal Medicine</full-title></periodical><dates><year>2015</year></dates><urls></urls><electronic-resource-num>doi:10.1001/jamainternmed.2015.0289</electronic-resource-num></record></Cite></EndNote>(11). Studies of aspirin treatment for the primary prevention of cardiovascular events have been performed in younger populations (mean age 57 years) ADDIN EN.CITE <EndNote><Cite><Author>Seshasai</Author><Year>2012</Year><RecNum>206</RecNum><DisplayText>(11)</DisplayText><record><rec-number>206</rec-number><foreign-keys><key app="EN" db-id="00at2ree6xt9rie9re85vsxp5sx00festp22" timestamp="1438047942">206</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Seshasai, Sreenivasa R.K.</author><author>Wijesuriya, Shanelle</author><author>Sivakumaram, Rupa</author><author>Nethercott, Sarah</author><author>Erqou, Sebhat</author><author>Sattar, Naveed</author><author>Ray, Kausik K.</author></authors></contributors><titles><title>Effect of Aspirin on Vascular and Nonvascular Outcomes: Meta-analysis of Randomized Controlled Trials</title><secondary-title>Archives of Internal Medicine</secondary-title></titles><periodical><full-title>Archives of Internal Medicine</full-title></periodical><pages>209-216</pages><volume>172</volume><dates><year>2012</year></dates><urls></urls></record></Cite></EndNote>(12). Even in this younger group, they found a number needed to treat (NNT) of 120 for 6 years to prevent one adverse cardiovascular outcome and a number needed to harm (NNH) of 73. In those in ARC with limited prognosis it is unlikely they will survive to benefit, and will be at high risk of complications. While anticoagulation with warfarin has been shown to reduce the rate of thromboembolic stroke in those with atrial fibrillation, haemorrhagic complications are common and have been found at a rate of up to 25% in the frail and nursing home residents ADDIN EN.CITE <EndNote><Cite><Author>Gurwitz</Author><Year>2007</Year><RecNum>204</RecNum><DisplayText>(12, 13)</DisplayText><record><rec-number>204</rec-number><foreign-keys><key app="EN" db-id="00at2ree6xt9rie9re85vsxp5sx00festp22" timestamp="1438046570">204</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Gurwitz, Jerry H.</author><author>Field, Terry S.</author><author>Radford, Martha J.</author><author>Harrold, Leslie R.</author><author>Becker, Richard</author><author>Reed, George</author><author>DeBellis Kristin</author><author>Moldoff, Jason</author><author>Verzier, Nancy</author></authors></contributors><titles><title>The Safety of Warfarin Therapy in the Nursing Home Setting</title><secondary-title>The American Journal of Medicine</secondary-title></titles><periodical><full-title>The American Journal of Medicine</full-title></periodical><pages>539-544</pages><volume>120</volume><dates><year>2007</year></dates><urls></urls></record></Cite><Cite><Author>Perera</Author><Year>2009</Year><RecNum>205</RecNum><record><rec-number>205</rec-number><foreign-keys><key app="EN" db-id="00at2ree6xt9rie9re85vsxp5sx00festp22" timestamp="1438046769">205</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Perera, Vidya</author><author>Bajorek, Beata V.</author><author>Matthews, Slade</author><author>Hilmer, Sarah N.</author></authors></contributors><titles><title>The Impact of Frailty on the Utilisation of Antithrombotic Therapy in Older Patients with Atrial Fibrillation</title><secondary-title>Age and Ageing</secondary-title></titles><periodical><full-title>Age and Ageing</full-title></periodical><pages>156-162</pages><volume>38</volume><dates><year>2009</year></dates><urls></urls></record></Cite></EndNote>(13,14). Studies of glycaemic control in those treated for Type 2 Diabetes have shown a U-shaped curve, with lower HbA1c (tighter control) actually being associated with poorer outcomes in frail elderly ADDIN EN.CITE <EndNote><Cite><Author>Currie</Author><Year>2010</Year><RecNum>207</RecNum><DisplayText>(14)</DisplayText><record><rec-number>207</rec-number><foreign-keys><key app="EN" db-id="00at2ree6xt9rie9re85vsxp5sx00festp22" timestamp="1438126439">207</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Currie, Craig J.</author><author>Peters, John R.</author><author>Tynan, Aodan</author><author>Evans, Marc</author><author>Heine, Robert J.</author><author>Bracco, Oswalda L.</author><author>Zagar, Tony</author><author>Poole, Chris D.</author></authors></contributors><titles><title>Survival as a function of HbA1c in people with type 2 diabetes: a retrospective cohort study</title><secondary-title>Lancet</secondary-title></titles><periodical><full-title>Lancet</full-title></periodical><pages>481-489</pages><volume>375</volume><number>9713</number><dates><year>2010</year></dates><urls></urls></record></Cite></EndNote>(15). Another recent study found high rates of hypoglycaemia in ARC residents (up to 60%) ADDIN EN.CITE <EndNote><Cite><Author>Andreassen</Author><Year>2014</Year><RecNum>208</RecNum><DisplayText>(15)</DisplayText><record><rec-number>208</rec-number><foreign-keys><key app="EN" db-id="00at2ree6xt9rie9re85vsxp5sx00festp22" timestamp="1438126647">208</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Andreassen, Lillan M.</author><author>Sandberg, Sverre</author><author>Kristensen, Gunn B.B.</author><author>Solvik, Una O.</author><author>Kjome, Reidun L.S.</author></authors></contributors><titles><title>Nursing home patients with diabetes: Prevalence, drug treatment and glycaemic control</title><secondary-title>Diabetes Research and Clinical Practice</secondary-title></titles><periodical><full-title>Diabetes Research and Clinical Practice</full-title></periodical><pages>102-109</pages><volume>105</volume><dates><year>2014</year></dates><urls></urls></record></Cite></EndNote>(16). Guidelines call for the prevention of hypoglycaemia, rather than strict glycaemic control, to be one of the main priorities in the treatment of diabetes in ARC ADDIN EN.CITE <EndNote><Cite><Author>Sinclair</Author><Year>2012</Year><RecNum>209</RecNum><DisplayText>(16)</DisplayText><record><rec-number>209</rec-number><foreign-keys><key app="EN" db-id="00at2ree6xt9rie9re85vsxp5sx00festp22" timestamp="1438127017">209</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sinclair, Alan</author><author>Morley, John E.</author><author>Rodriguez-Manas, Leo</author><author>Paolisso, Giuseppe</author><author>Bayer, Tony </author><author>Zeyfang, Andrej</author><author>Bourdel- Marchasson, Isabelle</author><author>Vischer, Ulrich</author><author>Woo, Jean</author><author>Chapman, Ian</author><author>Dunning, Trisha</author><author>Meneilly, Graydon</author><author>Rodriguez-Saldana, Joel</author><author>Guitierrez Robledo, Luis M.</author><author>Cukierman-Yaffe, Tali</author><author>Gadsby, Roger</author><author>Schernthaner, Guntram</author><author>Lorig, Kate</author></authors></contributors><titles><title>Diabetes Mellitius in Older People: Position Statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party (EDWPOP), and the International Task Force of Experts in Diabetes</title><secondary-title>Journal of the American Medical Directors Association</secondary-title></titles><periodical><full-title>Journal of the American Medical Directors Association</full-title></periodical><pages>497-502</pages><volume>13</volume><number>6</number><dates><year>2012</year></dates><urls></urls></record></Cite></EndNote>(17). Deprescribing psychotropics has been shown to reduce falls and improve cognitive function ADDIN EN.CITE <EndNote><Cite><Author>Agostini</Author><Year>2004</Year><RecNum>147</RecNum><DisplayText>(1)</DisplayText><record><rec-number>147</rec-number><foreign-keys><key app="EN" db-id="00at2ree6xt9rie9re85vsxp5sx00festp22" timestamp="0">147</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Agostini, Joseph V.</author><author>Han, Ling</author><author>Tinetti, Mary E.</author></authors></contributors><titles><title>The Relationship Between Number of Medications and Weight Loss or Impaired Balance in Older Adults</title><secondary-title>Journal of the American Geriatrics Society</secondary-title></titles><periodical><full-title>Journal of the American Geriatrics Society</full-title></periodical><pages>1719-1723</pages><volume>52</volume><keywords><keyword>polypharmacy</keyword><keyword>Aged</keyword><keyword>adverse drug reactions</keyword><keyword>weight loss</keyword><keyword>balance</keyword><keyword>falls</keyword></keywords><dates><year>2004</year></dates><urls></urls></record></Cite></EndNote>(1).General Practitioners are the main prescribers in ARC, but there are a number of barriers to stopping medications. These include uncertainty about prognosis, not wanting to discuss poor prognosis with patients, the sense of having “given up” by withdrawing medications, not wanting to cause harm, and wanting to adhere to guidelines ADDIN EN.CITE <EndNote><Cite><Author>Sondergaard</Author><Year>2015</Year><RecNum>213</RecNum><DisplayText>(17, 18)</DisplayText><record><rec-number>213</rec-number><foreign-keys><key app="EN" db-id="00at2ree6xt9rie9re85vsxp5sx00festp22" timestamp="1438137022">213</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sondergaard, Elisabeth</author><author>Willadsen, Tora G.</author><author>Guassora, Ann D.</author><author>Vestergaard, Mogens</author><author>Tomasdottir, Margret O.</author><author>Borgquist, Lars</author><author>Holmberg-Marttila, Doris</author><author>Olivarus, Niels</author><author>Reventlow, Susanne</author></authors></contributors><titles><title>Problems and challenges in relation to the treatment of patients with multimorbidity: General practitioners&apos; views and attitudes</title><secondary-title>Scandinavian Journal of Primary Health Care</secondary-title></titles><periodical><full-title>Scandinavian Journal of Primary Health Care</full-title></periodical><pages>121-126</pages><volume>33</volume><dates><year>2015</year></dates><urls></urls></record></Cite><Cite><Author>Schuling</Author><Year>2012</Year><RecNum>212</RecNum><record><rec-number>212</rec-number><foreign-keys><key app="EN" db-id="00at2ree6xt9rie9re85vsxp5sx00festp22" timestamp="1438136801">212</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Schuling, Jan</author><author>Gebben, Henkjan</author><author>Veehof, Leonardus J.G.</author><author>Haaijer-Ruskamp, Flora M.</author></authors></contributors><titles><title>Deprescribing medication in very elderly patients with multimorbidity: the view of Dutch GPs. A qualitative study</title><secondary-title>BMC Family Practice</secondary-title></titles><periodical><full-title>BMC Family Practice</full-title></periodical><pages>56-62</pages><volume>13</volume><dates><year>2012</year></dates><urls></urls></record></Cite></EndNote>(18,19). In an ongoing New Zealand study of GPs working in residential care issues raised have included the need for evidence to inform practice, and the challenges of identifying poor prognosis and discussing this with patients and families (Ailabouni, 2015, Dunedin, personal communication). In a recent Australasian study of geriatricians, issues included limited life expectancy, cognitive impairment and pill burden as influencing the decision to stop medications ADDIN EN.CITE <EndNote><Cite><Author>Ni Chroinin</Author><Year>2015</Year><RecNum>214</RecNum><DisplayText>(19)</DisplayText><record><rec-number>214</rec-number><foreign-keys><key app="EN" db-id="00at2ree6xt9rie9re85vsxp5sx00festp22" timestamp="1438137856">214</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ni Chroinin, Danielle</author><author>Ni Chroinin, Chantelle</author><author>Beveridge, Alexander</author></authors></contributors><titles><title>Factors influencing deprescribing habits among geriatricians</title><secondary-title>Age and Ageing</secondary-title></titles><periodical><full-title>Age and Ageing</full-title></periodical><dates><year>2015</year></dates><urls></urls><electronic-resource-num>doi: 10.1093/ageing/afv028</electronic-resource-num></record></Cite></EndNote>(20).The International Residential Assessment Instrument (InterRAI) is a data-set developed by a multidisciplinary network of academics and clinicians. It includes 236 standardized questions and is designed to be a comprehensive assessment for older people. It is now widely used internationally and has been mandated by the NZ Government for use in older people requiring long-term care, and an assessment is required in those entering ARC. The InterRAI CHESS (changes in health, end-stage disease and signs and symptoms) scale is a 6 point scale which is extracted routinely from InterRAI data, and is therefore available for all those entering ARC. It has been shown to be predictive of 6 and 12 month mortality in those in ARC ADDIN EN.CITE <EndNote><Cite><Author>Hirdes</Author><Year>2003</Year><RecNum>210</RecNum><DisplayText>(20)</DisplayText><record><rec-number>210</rec-number><foreign-keys><key app="EN" db-id="00at2ree6xt9rie9re85vsxp5sx00festp22" timestamp="1438128036">210</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hirdes, John P.</author><author>Frijters, Dinnus H.</author><author>Teare, Gary F.</author></authors></contributors><titles><title>The MDS-CHESS Scale: A New Measure to Predict Mortality in Institutionalized Older People</title><secondary-title>Journal of the American Geriatrics Society</secondary-title></titles><periodical><full-title>Journal of the American Geriatrics Society</full-title></periodical><pages>96-100</pages><volume>51</volume><dates><year>2003</year></dates><urls></urls></record></Cite></EndNote>(21), and those with neurological conditions including dementia and stroke ADDIN EN.CITE <EndNote><Cite><Author>Hirdes</Author><Year>2014</Year><RecNum>211</RecNum><DisplayText>(21)</DisplayText><record><rec-number>211</rec-number><foreign-keys><key app="EN" db-id="00at2ree6xt9rie9re85vsxp5sx00festp22" timestamp="1438128508">211</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hirdes, John P.</author><author>Poss, Jeffrey W.</author><author>Mitchell, Lori</author><author>Kornngut, Lawrence</author><author>Heckman, George</author></authors></contributors><titles><title>Use of the Inter RAI CHESS Scale to Predict Mortality among Persons with Neurological Conditions in Three Care Settings</title><secondary-title>PLoS ONE</secondary-title></titles><periodical><full-title>PLoS ONE</full-title></periodical><pages>e99066</pages><volume>9</volume><number>6</number><dates><year>2014</year></dates><urls></urls><electronic-resource-num>doi: 10.1371/journal.pone.0099066</electronic-resource-num></record></Cite></EndNote>(22). Polypharmacy and appropriate prescribing in ARC are currently a focus of considerable interest worldwide, in both research and clinical practice. This study aims to investigate these issues in the context of New Zealand society and healthcare system. There is a background of local Canterbury interest in, and support for a medication review intervention, and an existing primary care education programme, on which this study aims to build. The proposed use of the InterRAI tool which is now mandated by the New Zealand government when older people enter ARC will allow us to target the intervention appropriately. It is the first time the InterRAI tool has been used to guide such an intervention, and if trials are successful will be an important clinical use of the tool. The InterRAI tool is now widely used internationally, so this study has the potential to influence research and clinical practice worldwide. The long term goal is to provide a stepping stone on the way to a large multicentre clinical trial of a medication review intervention in ARC, utilising data from InterRAI assessment.AimsTo evaluate the feasibility and acceptability of a pharmacist-led Medicines Therapy Assessment (MTA) to older people at the time of entry to Aged Residential Care (ARC).To evaluate the acceptability of a pharmacist-led MTA to General Practitioners (GPs) providing care for older people in ARC.To evaluate the uptake of recommendations from the MTA by older people and their General Practitioners.To assess whether there is any change in Quality-of-Life (QOL) following a medication review intervention.MethodsStudy settingAged Residential Care facilities in Canterbury District Health Board region8 intervention facilities4 control facilitiesParticipantsInclusion criteriaAged over 65 years (>55y for Maori)Admitted for the first time to long-term Aged Residential Care within the Canterbury District Health Board regionInterRAI Long Term Care Facility (LTCF) assessment available (consent given for data to be used for planning and research)On 3 or more medicationsExclusion criteriaRespite or short-term entry to ARC facilityPalliative or terminal careNo consent given for data to be used for planning and researchLess than 3 medicationsNon-English speakingRecruitment, consent and interventionParticipants: Older people entering long-term ARC in participating facilities for the first time.InterRAI assessment (performed as standard for all people entering ARC). The routinely collected scores of Changes in Health, End-stage Symptoms and Signs (CHESS) prognostic indicator, Activities of Daily Living (ADL) scale, and Cognitive Performance scale (CPS) will be extracted. Potential participants allocated to intervention and control groups by facility.Older people entering ARC are identified by manager or Registered Nurse (RN).RN approaches them to take part in study.RN makes a brief global assessment of cognition, based on observed day-to-day functioning, and aided by InterRAI CPS. From there are 2 pathways.Intervention Facilities (Flow chart one)Pathway one: Person has capacity to understand and consentThose who agree to meet research team identified by RN.Research assistant (RA) goes to ARC facility and meets older person. They explain study, provide information, answer questions and obtain consent. RA completes the validated and widely used EuroQOL quality-of-life and Reported Edmonton Frailty Score (REFS).RA identifies if the person wishes to have time to consult with family/ whanau members or gain other advice. They will encourage the involvement of family/ whanau.RA identifies if any family/ whanau should be involved in study. They then telephone these people and explain study. Information sheet is sent by post or email.If after time to consider and discuss, the older person is willing to take part in study:Research pharmacist visits and conducts MTA.Based on findings of MTA, REFS and CHESS scores pharmacist makes recommendations about medication changes, together with advice about how these changes should be actioned (for example gradual weaning off sleeping tablets or benzodiazepines), to GP.GP considers these recommendations and discusses with the older person, and (where appropriate) family/ whanau members.GP decides on any medication changes and actions these.RA records medications at baseline; 3 and 6 months after the initial consultation.RA repeats EuroQOL and REFS measures at 3 and 6 months.Repeat InterRAI assessment conducted routinely at 6 months- CHESS, CPS and ADL scores extracted.Pathway two: Person may not have full capacity to understand and consentRN contacts older person’s Enduring Power of Attorney (EPOA - welfare) or significant other (where no EPOA for welfare) and asks if willing for research team to contact them.RN informs research team. RA speaks to EPOA/significant other (ideally in person), explains study risks and benefits, and answers questions. Information sheet will be provided in person, by email or post, or at a visit to the facility.If EPOA considers that the study is in the person’s best interest to participate in this review to encourage appropriate prescribing and has potential benefit for the older person they will inform RA, and complete a declaration form supporting person’s participation.Independent consultant geriatrician will then consider the case and if he/she considers the study has potential benefits for the older person, he will give proxy consent to include the person in the study (This step would only proceed if EPOA or significant other supports participation in the study).Research pharmacist will arrange a time to visit with the EPOA available.Pharmacist will conduct MTA, and based on their findings and the CHESS score, make recommendations to GP.GP considers these recommendations, reviews older person and discusses with EPOA.GP decides on any medication changes and actions these.RA records medications at baseline; 3 and 6 months after the initial consultation.Repeat InterRAI assessment conducted routinely at 6 months- CHESS, CPS and ADL scores extracted.Control Facilities (Flow chart two)Pathway one: Person has capacity to understand and consentThose who agree to meet the research team identified by RN.RA goes to ARC facility and explains study (ie We are trialling a new medication review process, they are in the control/ comparison group, so there won’t be any changes for them, their GP will continue to provide best standard current care. We are simply asking to access their health data, particularly their medications at different time points, and complete two simple scales.)If they consentRA completes the EuroQOL quality-of-life score and Reported Edmonton Frailty Score (REFS).GPs continue standard care, which may include a medication review if they feel this is appropriate.RA records medications at baseline; 3 and 6 months after the initial consultation.RA repeats EuroQOL and REFS measures at 3 and 6 months.Repeat InterRAI assessment conducted routinely at 6 months- CHESS, CPS and ADL scores extracted.Pathway two: Person may not have full capacity to understand and consent RN contacts older person’s Enduring Power of Attorney (EPOA - welfare) or significant other (where no EPOA for welfare) and asks if willing for research team to contact them.RN informs research team.RA contacts EPOA/ significant other and explains study (ie that a new medication review process is being trialled, that the person is in a control facility and best standard care from GP will continue as normal) and asks for permission to access their health records.If EPOA/ significant other agrees to team accessing recordsGPs continue standard care, which may include a medication review (by either GP or pharmacy services) if they feel this is appropriate.RA records medications at baseline; 3 and 6 months after the initial consultation.Repeat InterRAI assessment conducted routinely at 6 months- CHESS, CPS and ADL scores extracted.OutcomesNumber of older people (able to consent) or EPOAs (unable to give consent) accepting the offer of a medication review.Number of GPs accepting the offer of a medication review.Uptake of pharmacist MTA recommendations by older people, EPOAs and GPs.Number and types of medications before and after intervention (as a marker of uptake of recommendations).Changes in EuroQOL scale from baseline to 3 and 6 months post-intervention.Changes in InterRAI CPS and ADL scores from baseline to 3 and 6 months post-intervention.AnalysisFor the statistical analysis participant characteristics (demographics, medication use, and clinical characteristics) will be summarised by group using simple descriptive statistics, numbers and percentages for categorical data and means and standard deviations or medians and interquartile ranges for descriptive statistics.Feasibility outcomes will be summarised descriptively. Specifically the number and percentage of those approached of older people/ caregivers who consent to take part in the study and the number of GPs who consent to take part in the study, and the level of missingness in the data collected. Participant outcomes (medication use at the different time points, clinical events and QoL) will be summarised descriptively by group. In particular the type of medications prescribed (ie preventative versus symptomatic treatments) will be described. Differences for those receiving the intervention and those who received usual care will be explored using regression models.SummaryPolypharmacy is common in frail older people in ARC, and is known to be associated with a number of serious adverse outcomes. While many medications were prescribed earlier in life to prevent disease, these medications may no longer be appropriate in this group of people. This feasibility study aims to trial a pharmacist-led medication review intervention. A specialist pharmacist will visit older people newly admitted to ARC. She will discuss their treatment priorities with them and conduct a Medicines Therapy Assessment (MTA). Recommendations will be made to GPs along with a prognostic indicator (the InterRAI CHESS score). GPs will make the final decisions on medication changes. Outcomes will be the acceptability of this intervention to older people, EPOAs/ family/ whanau and GPs; the number of pharmacist recommendations taken up by GPs and a quality of life measure.AbbreviationsARC Aged Residential Care; InterRAI International Resident Assessment Instrument; LTCF Long-term care facilities; CHESS Changes in Health, End stage disease and Symptoms and Signs; REFS Reported Edmonton Frail Scale; QOL Quality of Life; ADL Activities of Daily Living; MTA Medicines Therapy Assessment; EPOA Enduring Power of Attorney (welfare); GP General Practitioner; RN Registered nurse; NNT Number needed to treat; NNH Number needed to harm.Trial StatusWe aim to begin recruitment on 16/4/2018 and continue until the final date for data collection which is to be 30/11/2019.Funding statement This study is being funded by a Human Research Committee emerging researcher grant. Competing interestsThe author declares that they have no competing interests and are responsible for the content of this report. References ADDIN EN.REFLIST 1.Agostini JV, Han L, Tinetti ME. The Relationship Between Number of Medications and Weight Loss or Impaired Balance in Older Adults. Journal of the American Geriatrics Society. 2004;52:1719-23.2.Richardson K, Ananou A, Lafortune L, Brayne C, Matthews FE. Variation over time in the association between polypharmacy and mortality in the older population. Drugs and Aging. 2011;28:547-60.3.Frazier SC. Health Outcomes and Polypharmacy in Elderly Individuals. Journal of Gerontological Nursing. 2005;31(9):4-11.4.Tamura BK, Bell CL, Inaba M, Masaki KH. Outcomes of Polypharmacy in Nursing Home Residents. Clinics in Geriatric Medicine. 2012;28(2):217-36.*5.Heppenstall CP, Broad JB, Boyd M, Gott M, Connolly MJ. Progress Towards Predicting 1-year Mortality in Older People Living in Residential Long-term Care. Age and Ageing. 2015.*6.Heppenstall CP, Hanger HC, Wilkinson TJ. Predictors of discharge stability in the first year following hospital admission for a frail elderly population. Internal medicine journal. 2009;39(3):170-3.7.Elseviers MM, Vander Stichele RR, Van Bortel L. Drug utilization in Belgian nursing homes: impact of residents' and institutional characteristics. Pharmacoepidemiology and Drug Safety. 2010;19:1041-8.*8.Heppenstall CP, Broad JB, Boyd M, Hikaka J, Zhiang X, Kennedy J, Connolly MJ. Medication use and potentially inappropriate medications in those with limited prognosis living in residential aged care. Austalasian Journal on Ageing. 2015;In press.9.Benetos A, Gautier S, Labat C, Salvi D, Valbusa F, Marino F, Toulza O, Agnoletti D, Zamboni M, Dubail D, Manckoundia P, Rolland Y, Hanon O, Perret-Guillaume C, Lacolley P, Safar ME, Guillemin F. Mortality and Cardiovascular Events are Best Predicted by Low Central/ Peripheral Pulse Pressure Amplification but not by High Blood Pressure Levels in Elderly Nursing Home Subjects. Journal of the American Collge of Cardiology. 2012;60(16):1503-11.10.Benetos A, Labat C, Rossignoi P, Fay R, Rolland Y, Valbusa F, Salvi D, Zamboni M, Manckoundia P, Hanon O, Gautier S. Treatment With Multiple Blood Pressure Medications, Achieved Blood Pressure, and Mortality in Older Nursing Home Residents. The PARTAGE Study. Journal of the American Medical Association Internal Medicine. 2015;175(6):989-95.11.Kutner JS, Blatchford PJ, Taylor DH, Ritchie CS, Bull JH, Fairclough DL, Hanson LC, W. LT, Samsa GP, Wolf S, Aziz NM, Currow DC, Ferrell B, Wagner-Johnston N, Zafar Y, Cleary JF, Dev S, Goode PS, Kamal AH, Kassner C, Kvale EA, McCallum JG, Ogunseitan AB, Pantilat SZ, Portenoy RK, Prince-Paul M, Sloan JA, Swetz KM, Von Gunten CF, Abernethy AP. Safety and Benefit of Discontinuing Statin Therapy in the Setting of Advanced, Life-Limiting Illness. A Randomized Clinical Trial. Journal of the American Medical Association Internal Medicine. 2015.12.Seshasai SRK, Wijesuriya S, Sivakumaram R, Nethercott S, Erqou S, Sattar N, Ray KK. Effect of Aspirin on Vascular and Nonvascular Outcomes: Meta-analysis of Randomized Controlled Trials. Archives of Internal Medicine. 2012;172:209-16.13.Gurwitz JH, Field TS, Radford MJ, Harrold LR, Becker R, Reed G, Kristin D, Moldoff J, Verzier N. The Safety of Warfarin Therapy in the Nursing Home Setting. The American Journal of Medicine. 2007;120:539-44.14.Perera V, Bajorek BV, Matthews S, Hilmer SN. The Impact of Frailty on the Utilisation of Antithrombotic Therapy in Older Patients with Atrial Fibrillation. Age and Ageing. 2009;38:156-62.15.Currie CJ, Peters JR, Tynan A, Evans M, Heine RJ, Bracco OL, Zagar T, Poole CD. Survival as a function of HbA1c in people with type 2 diabetes: a retrospective cohort study. Lancet. 2010;375(9713):481-9.16.Andreassen LM, Sandberg S, Kristensen GBB, Solvik UO, Kjome RLS. Nursing home patients with diabetes: Prevalence, drug treatment and glycaemic control. Diabetes Research and Clinical Practice. 2014;105:102-9.17.Sinclair A, Morley JE, Rodriguez-Manas L, Paolisso G, Bayer T, Zeyfang A, Bourdel- Marchasson I, Vischer U, Woo J, Chapman I, Dunning T, Meneilly G, Rodriguez-Saldana J, Guitierrez Robledo LM, Cukierman-Yaffe T, Gadsby R, Schernthaner G, Lorig K. Diabetes Mellitius in Older People: Position Statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party (EDWPOP), and the International Task Force of Experts in Diabetes. Journal of the American Medical Directors Association. 2012;13(6):497-502.18.Sondergaard E, Willadsen TG, Guassora AD, Vestergaard M, Tomasdottir MO, Borgquist L, Holmberg-Marttila D, Olivarus N, Reventlow S. Problems and challenges in relation to the treatment of patients with multimorbidity: General practitioners' views and attitudes. Scandinavian Journal of Primary Health Care. 2015;33:121-6.19.Schuling J, Gebben H, Veehof LJG, Haaijer-Ruskamp FM. Deprescribing medication in very elderly patients with multimorbidity: the view of Dutch GPs. A qualitative study. BMC Family Practice. 2012;13:56-62.20.Ni Chroinin D, Ni Chroinin C, Beveridge A. Factors influencing deprescribing habits among geriatricians. Age and Ageing. 2015.21.Hirdes JP, Frijters DH, Teare GF. The MDS-CHESS Scale: A New Measure to Predict Mortality in Institutionalized Older People. Journal of the American Geriatrics Society. 2003;51:96-100.22.Hirdes JP, Poss JW, Mitchell L, Kornngut L, Heckman G. Use of the Inter RAI CHESS Scale to Predict Mortality among Persons with Neurological Conditions in Three Care Settings. PLoS ONE. 2014;9(6):e99066.-5810250Flow-chart one: Intervention facilities020000Flow-chart one: Intervention facilities206692556515Older Person enters ARC020000Older Person enters ARCcenter148590002000250167005InterRAI LTCF completed00InterRAI LTCF completed53435255220335065341505096510GP declines00GP declines447675047345600042195755076825RA contacts GP020000RA contacts GP54768754505961054197253515359053625752477135032385051917610436245138582600right2458085No00No12001504324985left3425825No00Noleft4415155No00No35147254338955Independent clinician consent020000Independent clinician consent-6381755077460GP declines00GP declines6858005062855RA contacts GP020000RA contacts GP22860005058410Pharmacist MTA020000Pharmacist MTA301942554584600022479005744210CHESS, EFS scores and recommendations to GP00CHESS, EFS scores and recommendations to GP6191251705610Cognition OK00Cognition OK1495425157670500left2376805No00No283845115767050040862251657985Cognition impaired00Cognition impairedcenter176530005334003300730RA meets participant Contacts EPOA/ family/ whanau if appropriateInformed consent process, EFS, QOL scale00RA meets participant Contacts EPOA/ family/ whanau if appropriateInformed consent process, EFS, QOL scaleright3496310No00No9620252953385Yes00Yes1600199285813505067302287905Manager/ RN asks their permission to meet research team4000020000Manager/ RN asks their permission to meet research team1724025252730ARC manager/ RN identifies new admissionCHESS score, CPS, ADL scoreBrief assessment of cognition400000ARC manager/ RN identifies new admissionCHESS score, CPS, ADL scoreBrief assessment of cognition3209925115570Manager/ RN contacts EPOAAsks their permission for research team to contact them00Manager/ RN contacts EPOAAsks their permission for research team to contact them1267970004610100134620Yes 00Yes 43529256794503209925134620RA speaks to EPOADeclaration form completed00RA speaks to EPOADeclaration form completed-19051154305004685665249555Yes00Yes714375244475Yes00Yes5048250212090Yes00Yes1790700692150038195258826500304800021209003095625125984000204787516262353 months: RA records medications, repeat EFS, QOL scores6 months: RA records medications, repeat EFS, QOL scores003 months: RA records medications, repeat EFS, QOL scores6 months: RA records medications, repeat EFS, QOL scores2314575535940GP reviews patient (EPOA/ significant other)Discuss medications00GP reviews patient (EPOA/ significant other)Discuss medications-5238759525Flow chart two:Control facilities020000Flow chart two:Control facilities206692556515Older Person enters ARC020000Older Person enters ARCcenter148590002000250167005InterRAI LTCF completed00InterRAI LTCF completed541972535153590536257524771350right2458085No00No-1255333500left358203500left3425825No00No6191251705610Cognition OK00Cognition OK1495425157670500left2376805No00No283845115767050040862251657985Cognition impaired00Cognition impaired1752600519430ARC manager/ RN identifies new admissionCHESS score, CPS, ADL scoreBrief assessment of cognition400000ARC manager/ RN identifies new admissionCHESS score, CPS, ADL scoreBrief assessment of cognitioncenter176530005334003300730RA meets participant Contacts EPOA/ family/ whanau if appropriateConsent to access clinical records REFS, QOL scales00RA meets participant Contacts EPOA/ family/ whanau if appropriateConsent to access clinical records REFS, QOL scalesright3496310No00No9620252953385Yes00Yes1600199285813505067302287905Manager/ RN asks their permission to meet research team4000020000Manager/ RN asks their permission to meet research team3209925115570Manager/ RN contacts EPOAAsks their permission to speak for research team to contact them00Manager/ RN contacts EPOAAsks their permission to speak for research team to contact them4610100134620Yes 00Yes 43529256794503143250135255RA speaks to EPOADeclaration form completed, agreement to access clinical records00RA speaks to EPOADeclaration form completed, agreement to access clinical records4629150173355Yes00Yes440055049529003524250273050Independent clinician consent020000Independent clinician consent16287744000500546734917399000left102235No00No335280097790004086225202565Yes00Yes156210016510Yes00Yes205740012065GP continues best standard care to participant(EPOA/ family/ whanau)Discuss medications as normal00GP continues best standard care to participant(EPOA/ family/ whanau)Discuss medications as normal308610098425020478751612903 months: RA records medications, repeat EFS, QOL scores6 months: RA records medications, repeat EFS, QOL scores003 months: RA records medications, repeat EFS, QOL scores6 months: RA records medications, repeat EFS, QOL scores ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download