Eva Sönnerstam

Objectives: The aim of the present study was to describe the association between behavioral and psychological symptoms and psychotropic drug use among older Swedish nursing home residents with cognitive impairment. Methods: Data was collected from a questionnaire survey which was sent out between 4 and 12 February 2019 within the Swedish National Inventory of Care and Health in Residential Aged Care (SWENIS) II. Sixty municipalities in Sweden were randomly selected and invited. Of these, 49 municipalities accepted the invitation. Six withdrew resulting in 43 participating municipalities and 187 nursing homes. The final study population comprised 1,541 participants, 65 years or older, with cognitive impairment. The Swedish Prescribed drug register was utilized to identify psychotropic drug use. Backward eliminating binary logistic regression analyses were conducted. Results: At least one psychotropic drug was used of 80.8% of the study population, 20.5% used at least one antipsychotic drug, 32.0% used anxiolytic drugs, 21.3% used hypnotic and sedatives, 58.4% used antidepressants and 32.1% of the residents used antidementia drugs. Among residents with mild cognitive impairment, anxiolytics were significantly associated with anxiety. Also, anxiolytics and hypnotics and sedatives were significantly associated with sleep and nighttime behavior disorders. Antidepressants were significantly associated with depression/dysphoria. The same pattern was found among residents with moderate cognitive impairment. However, anxiolytics were also significantly associated with worsening depression/dysphoria. Hypnotics and sedatives were also associated with anxiety and hallucinations. Moreover, antipsychotic drug use was significantly associated with agitation/aggression and anxiety. Among residents with severe cognitive impairment, antipsychotics, anxiolytics and hypnotics and sedatives were significantly associated with aberrant motor behavior. Anxiolytics were also significantly associated with anxiety and apathy/indifference, and hypnotics and sedatives were significantly associated with agitation/aggression and depression/dysphoria. Conclusions: Psychotropic drug use is remarkably high among Swedish nursing home residents but the prevalence of antidementia drugs is somewhat low. Associations found, call for further studies examining the treatment of behavioral and psychological symptoms (BPS) in this vulnerable group of people.

Background: Medicines complement healthy lifestyles in cardiovascular disease (CVD) prevention, but knowledge is lacking on how behaviours in these domains are related. This study aimed at investigating associations between physical activity and diet, and time to initiation of preventive medicines. Method: A cohort study based on the “Visualization of Asymptomatic Atherosclerotic Disease for Optimal Cardiovascular Prevention” (VIPVIZA)-trial, including 60-year-olds of low/moderate CVD-risk who were treatment-naive to antihypertensives or lipid-lowering medicines six months prior trial-inclusion. Sex-specific Cox proportional hazards models were used to analyse impacts of diet and physical activity, each categorized in three levels (least healthy – moderately healthy – healthiest), on initiation of antihypertensives and lipid-lowering medicines. Results: Of 1891 individuals in the cohort, 1340 (58% women) were antihypertensive-naive and 1783 (57% women) were lipid-lowering naive. Significantly faster initiation of antihypertensives was seen in women with the healthiest diet (HR [95%CI] 2.46 [1.18–5.14], ref. least healthy) whereas higher levels of physical activity were significantly associated with slower initiation of antihypertensives in women (HR [95%CI], moderate; 0.51 [0.30–0.88]), high; 0.48 [0.30–0.77], ref. low). Neither diet nor physical activity levels affected initiation of lipid-lowering medicines in women, and lifestyle factors were not associated with initiation of antihypertensives or lipid-lowering medicines in men. Conclusions: Relationships between lifestyle and medicine initiation varies with health behavior, drug-class, and sex. Regarding diet, initiation of antihypertensives in women may agree with a healthy adherer effect, whereas for physical activity, the association appear inverse. Diet and physical activity levels are less influential for initiation in men, and for lipid-lowering medicines. As findings are uncertain, further studies are needed to clarify relationships between these factors. Trial registration: VIPVIZA-trial registration number: NCT01849575, registration date: 2013-05-08.

Objectives: To investigate if beliefs about medicines affect the time to the initiation of cardiovascular preventive medications during a 3 year follow-up period. Design: A questionnaire and register-based cohort study. Setting: Primary care in Sweden, in which people 40, 50 and 60 years old underwent risk factor screening and individual health promotion within the Västerbotten intervention programme (VIP). Participants: People at low/medium risk of cardiovascular disease (CVD) according to the risk factor screening were included in the VI suali Z ation of asymptomatic A therosclerotic disease for optimum cardiovascular prevention—a population-based Pragmatic Randomised Open Blinded End-point trial (PROBE) nested in the V ästerbotten I ntervention P rogramme (VIPVIZA), aiming at improved primary prevention of CVD. People participating in the VIPVIZA 3 year follow-up (n=3167 (89.7%)), receiving the Beliefs about medicines questionnaire (BMQ) (n=2314 (73.1%)) and with complete answers to at least one subscale in the BMQ general (n=2258 (97.6%)) were included. Moreover, only those 60 years old at baseline (n=2073 (58.7%)) and without antihypertensive and/or lipid-lowering drugs (n=1769 (50.1%)) 6 months prior to inclusion in the VIPVIZA trial were included. Accordingly, the final study population comprised 888 people without antihypertensive medicines and 1185 without lipid-lowering drugs, respectively. Measures: The primary outcome was time to the binary event of initiating antihypertensives or lipid-lowering agents, identified within the time frame from inclusion in the VIPVIZA study until the study participants’ 3 year follow-up visit. General beliefs about medicines were assessed according to the BMQ. Cox proportional hazards models, adjusted for sex, were conducted to investigate primary outcome. Results: Participants with stronger general beliefs about medicines being overused had significantly longer time to initiation of antihypertensive drugs in the control group (HR 0.91; 95% CI 0.84 to 0.996) but not in the intervention group (HR 1.05; 95% CI 0.95 to 1.16). No significant associations were found between beliefs about medicines and initiation of lipid-lowering treatment. Conclusions: A more negative perception of drugs being overused was significantly associated with delayed initiation of antihypertensive drug treatment. Our results suggest that the VIPVIZA intervention may overbridge negative perceptions and affect the initiation of antihypertensive medications in a positive manner. Trial registration number: NCT01849575 (date of registration: 8 May 2013).

Introduction Medication-related problems (MRPs) are common among older adults. The global population is ageing and there are health-related challenges linked to ageing in rural areas. Home-living rural older adults often face barriers to access healthcare, like long distances to healthcare services and poor continuity of care. Telepharmacy is the remote provision of pharmaceutical care, and telepharmacy could be of particular importance for rural older adults to improve their access to clinical pharmacy services and reduce the incidence of MRPs. The objective of this study is to develop and evaluate a novel telepharmacy service in primary care for home-living older adults in Northern Sweden’s rural areas. The primary objective is to evaluate the effect of the telepharmacy service regarding the identification, classification and resolution of MRPs. Methods and analysis This study will be conducted as a single-arm interventional study. A total of 100 people ≥65 years will receive the telepharmacy service for 12 weeks. The key principles of the telepharmacy service are to perform medication interviews and follow-up meetings with study participants, to conduct structured medication reviews, to conduct regular electronic medical record reviews and to have interprofessional collaboration with primary care physicians. All meetings will be conducted through video conferencing via a secure virtual care platform. Identified MRPs will be classified, and the acceptance rate of the pharmacists’ recommendations will be evaluated. The results will be presented with descriptive statistics. As secondary objectives, intra-individual changes in participants’ medication adherence, health-related quality of life and beliefs about medicines will be assessed through self-report questionnaires. Statistical analysis will be conducted using two-sided McNemar’s tests. Semi-structured interviews will also be conducted to explore participants’ and healthcare professionals’ experiences and attitudes towards this telepharmacy service. Ethics and dissemination This study has been granted ethical approval by the Swedish Ethical Review Authority (registration number 2022-03819-01 and 2024-08441-02). Participant informed consent is required. The results will be published in peer-reviewed journals and presented at scientific conferences. Trial registration number NCT05629936.

Background: People with intermediate CVD risk constitute most of the population. Within this group, the proportion of events is lower compared to the high-risk group, but they contribute with the largest absolute number of events. Atherosclerosis is a dynamic process and progression can be slowed or even reversed with medication and lifestyle changes, but adherence to prescribed treatment is crucial. Aim: To investigate the long-term effects of interventions with pictorial risk communication of cardiovascular (CVD) risk on average adherence in a group of statin users. Compare response in adherence over time between men and women after intervention. Methods: Participants on active statin treatment were followed up to 5 years after being randomly assigned to an intervention program aimed at raising CVD risk awareness among participants and their physicians. Merging prescribed medication databases with VIPVIZA study to study adherence over time. A moving average adherence was used to compare groups. Results: Generally, the average adherence to statins among the 512 participants was high. Men had a higher average adherence over time, while women had a sharper increase in adherence in conjuncture with the intervention program. Conclusions: Both men and women were receptive to pictorial information regarding CVD risk, but the intervention effect was more pronounced in women. Sex differences are important when considering risk communication strategies. Periodically repeating the intervention was beneficial for maintaining the intervention effect over time. Trial registration: The VIPVIZA study is registered with ClinicalTrials.gov, May 8, 2013, number NCT01849575.

Background: The increased risk of adverse drug reactions due to age-related altered pharmacokinetics and pharmacodynamics is a challenge when prescribing medications to older people, and especially among older people with major neurocognitive disorder who are particularly sensitive to drug effects. The aim of this study was to investigate the use of potential inappropriate medications (PIMs) in 2012 and 2017 among old people with major neurocognitive disorder. A secondary aim was to investigate factors associated with PIM use. Methods: This register-study was based on the Swedish registry for cognitive/dementia disorders and the Swedish prescribed drug register. Criteria from the National Board of Health and Welfare were used to identify PIMs between 1 July–31 December 2012 and 1 July-–31 December 2017 among people ≥ 65 years. Drug use was defined as one or more filled prescriptions during each timeframe. Results: The total use of PIMs declined significantly between 2012 (28.7%) and 2017 (21.7%). All PIMs and PIM groups declined between these years, except for antipsychotic drugs, which increased from 11.6% to 12.3%. The results from the multiple regression model found that PIM use was associated with younger age (OR: 0.97 CI: 0.96–0.97), a lower Mini Mental State Examination score (OR: 0.99 CI: 0.99–1.00), the use of multi-dispensed drugs (OR: 2.05 CI: 1.93–2.18), and compared to Alzheimer’s disease, with the subtypes dementia with Lewy bodies and Parkinson’s disease dementia (OR: 1.57 CI: 1.40–1.75), frontotemporal dementia (OR: 1.29 CI: 1.08–1.54) and vascular dementia (OR: 1.10 CI: 1.03–1.16). Conclusions: Overall, the use of PIMs decreased between the years 2012 and 2017. The increase of antipsychotic drugs and the association between PIM use and multi-dispensed drugs warrant concern.

Objective The aim of the present study was to investigate how potentially inappropriate medication usage and anti-dementia drug use change from 3 years prior to, up until 3 years post-diagnosis of major neurocognitive disorders among older people living in Sweden. Methods People registered in the Swedish registry for cognitive/dementia disorders from 1 July, 2008 to 31 December, 2017, and aged 68 years or older at diagnosis, were included (n = 67,226). Data were combined with the Swedish Prescribed Drug Registry to obtain information about drugs collected in 6-month periods at Swedish pharmacies from 3 years pre-diagnosis until 3 years post-diagnosis. Potentially inappropriate medications were identified according to Swedish national guidelines. A generalised estimating equation regression model and estimated marginal means were used. Results Of the 67,226 people included in the study population, 59.2% were women and the mean age ± standard deviation was 81.5 ± 6.4 years, 47.0% lived together with a spouse or partner, and 88.9% were living at home at the time of diagnosis. The proportions of people using potentially inappropriate medications continuously decreased pre- and post-diagnosis, except for antipsychotic drug use, which continuously increased both pre- and post-diagnosis. Moreover, anticholinergic drug use increased pre-diagnosis and declined post-diagnosis. When comparing the periods pre- and post-diagnosis date, the adjusted proportion of people using potentially inappropriate medications was significantly lower post-diagnosis compared with pre-diagnosis, except for the adjusted proportion using antipsychotics, which was significantly higher post-diagnosis, 10.6%, compared with the period before, 3.1% (adjusted odds ratio 3.71; 95% confidence interval 3.59–3.83). The adjusted proportion of people using anticholinergic drugs was significantly lower post-diagnosis, 7.2%, compared with the pre-diagnosis period, 8.9% (adjusted odds ratio 0.80; 95% confidence interval 0.78–0.82). Anti-dementia drug use was significantly higher post-diagnosis, 52.6%, when compared with the pre-diagnosis period, 3.5% (adjusted odds ratio 30.13; 95% confidence interval 29.19–31.10). Conclusions Overall, the prevalence of people using potentially inappropriate medications decreased and was significantly lower post-diagnosis of major neurocognitive disorders, except for antipsychotics. This indicates that potentially inappropriate medication use should be noticed and reviewed among all older people. The small decrease in the prevalence of anticholinergic drug users and the increasing proportions of people using antipsychotic drugs post-diagnosis are of special concern because of the adverse drug reactions associated with these types of potentially inappropriate medications. Consequently, it is important to identify and regularly question anticholinergic and antipsychotic drug treatment to prevent unnecessary and serious adverse drug reactions among a vulnerable group of people.

To investigate the use of potentially inappropriate medications and their relation to the length of nursing home stay among older adults. Questionnaire surveys using the Multi-Dimensional Dementia Assessment scale were sent out to all nursing homes in Västerbotten county in northern Sweden in 2007 and 2013. In total, 3186 adults (1881 from 2007 and 1305 from 2013) ≥65 years old were included and 71.8% of those had cognitive impairment. Potentially inappropriate medications were identified using drug-specific quality indicators according to Swedish National Board of Health and Welfare. Potentially inappropriate medications were used by 48.0% of the 2007 study sample and by 28.4% of the 2013 study sample. The prevalence of glibenclamide use 2007 and antipsychotic drug use 2013 increased linearly (β = 0.534E− 3, 95% CI: 0.040E− 3-0.103E− 2, p = 0.034 and β = 0.155E− 2, 95% CI: 0.229E− 3-0.288E− 2, p = 0.022, respectively) with the length of nursing home stay. No significant association was found between the prevalence of propiomazine, codeine, long-acting benzodiazepines, anticholinergics, NSAIDs, tramadol or the total use of potentially inappropriate medications and the length of stay in nursing homes in 2007 or 2013. Antipsychotics were the most commonly prescribed of the drug classes investigated and used by 22.6% of the residents 2007 and by 16.0% of the residents 2013. These results indicate that treatment with potentially inappropriate medications is common among older adults living in nursing homes, but it seems to be related to the length of nursing home stay only to a smaller extent. Drug treatment should regularly be reviewed and followed-up among nursing home residents regardless of their length of nursing home stay, in order to prevent unnecessary adverse events.

Purpose Increased numbers of drugs and changes in pharmacokinetic and pharmacodynamic parameters among elderly people contribute to increased prevalence of adverse drug reactions. Drug–drug interactions (DDIs) are an important reason for admission to hospital and elderly people with dementia are particularly vulnerable. The aims of the present study were to assess the occurrence and characteristics of clinically relevant DDIs and to investigate potential risk factors associated with DDIs among elderly people with dementia. Methods People ≥ 65 years with dementia, admitted to two hospitals in Northern Sweden, were included. The medical records of 458 patients were reviewed. Clinically relevant DDIs were identified using the Janusmed interactions database. Pharmacological classification was conducted using Stockley’s classification system. Results A total of 401 DDIs were identified among 43.2% of the study population, of which 98.5% had interactions that may require dose adjustment and 7.6% had drug combinations that should be avoided. Pharmacodynamic interactions were most common, of which furosemide–citalopram (n = 35) were most frequently observed. Omeprazol–citalopram (n = 25) was the most common drug combination among pharmacokinetic interactions. Citalopram and warfarin were the most commonly involved drug substances. An association was found between a higher number of medications being prescribed and having at least one DDI. Conclusion Clinically relevant drug–drug interactions are prevalent among elderly people with dementia living in Northern Sweden. Drug–drug interactions should be identified in order to manage and prevent adverse outcomes. This is particularly important among this group of people especially when multiple medications are being prescribed.