Optimising drug therapy in older patients. Exploring different approaches across the patient pathway

Abstract

<p><i>Background -</i> Drug therapy contributes to healthy aging but has a key duality: It prolongs and can improve quality of life, but drugs can also cause serious harm. Harm from drugs include falls, cognitive decline, lowered quality of life, hospitalisation, and death. Older patients are especially at risk for harm from drug therapy, therefore optimising drug therapy is imperative for this group. <p><i>Aim -</i> To generate new knowledge of drug therapy optimisation for older patients by exploring the impact of drug burden and investigating different approaches to optimise drug therapy across the patient pathway. <p><i>Methods -</i> This thesis used data from The Norwegian patient registry, The Norwegian Prescription Database and data collected in a randomised controlled trial (RCT). Observational data of the delivery of the RCT-intervention was included. In Paper I the association between anticholinergic (AC) and sedative (SED) drug burden and post-discharge institutionalisation (PDI) was assessed using multiple regression. Paper II described an RCT investigating the effect of an in-hospital pharmacist intervention. Paper III presented the fidelity and process outcomes of the intervention (Paper II). In Paper IV, an observational tool was developed and time distribution for the pharmacists running the RCT examined. <p><i>Results -</i> Number of drugs used before hospitalisation was mean 7.11 (SD 4.09) and at hospitalisation median 6.0 (range 4-9). Prevalence of AC/SED drugs was 45.5%. All measures of AC/SED drug burden was significantly associated with PDI. The number of AC drugs were most sensitive (OR 1.13, per AC drug), and the DBI most challenging to apply. The clinical pharmacist contributed to identify and solve discrepancies for 72% of the patients (median 1) and DRPs for 94.6% of the patients (median 4), and the acceptance rate was 67%. Intervention fidelity at admission was 100%, and 57% overall. The pharmacists advanced communication of drug therapy across the patient pathway. About 41% of pharmacist time was spent on administrative RCT-tasks and the estimated intervention time was >3.5 hours/patient. <p><i>Conclusions -</i> The drug burden is high in older patients acutely admitted to hospital in Norway and assessing AC/SED drug use can reduce the risk of PDI. The in-hospital pharmacist intervention contributed to drug therapy optimisation and facilitated communication across the patient pathway. These measures can contribute to optimisation of drug therapy but are time consuming and costly. It is essential to establish models for drug therapy optimisation across the pathway, including primary care.