Justin P. Turner

Background: Insomnia is common in people living with dementia and older adults. While clinical guidelines recommend non-pharmacological treatment as first-line therapy, insomnia is often managed with benzodiazepine receptor agonists (BZRAs), which carry a significant risk of medication-related harm. Objective: To explore what influences decisions to engage with pharmacological and non-pharmacological insomnia treatments among older adults, people living with dementia and their carers. Methods: Semi-structured interviews were conducted with three participant groups (people living with dementia, their carers, and older adults). The interviews were conducted and transcribed in Zoom. Participants identified and prioritized factors that influence their treatment decisions. Thematic analysis was conducted in NVivo to generate themes that described how participants’ beliefs and experiences influenced their preferences. Results: From 19 interviews with 20 participants (Median age range = 65–74 years, 37% female), 14 factors were identified. Risk of side effects (n = 10) and effectiveness (n = 7) were most commonly prioritized and frequently reported across all participant groups. Medication side effects on cognition and daytime sedation were frequent concerns. Underpinning these factors were five main themes determined from thematic analysis, including: beliefs about sleep and insomnia, treatment expectations and experiences, external influences, treatment characteristics, and barriers to treatment. Conclusions: Decisions about insomnia treatments are influenced not only by expected and/or experienced treatment effectiveness, but also by perceived risks and health beliefs. Integrating these perspectives into clinical decision-making may help reduce medication-related harm and promote safer, acceptable alternatives.

Background: The use of behavior change models to conceptualize deprescribing provides an opportunity to explore the components of communication needed to overcome the many barriers to deprescribing. Methods: Consensus development working group composed of care partner stakeholders and international experts in geriatrics, nursing, pharmacology, communication, and community outreach. The goal of the working group was to create a framework for the communication required among patients, care partners, and clinicians in the ambulatory setting to achieve the behavior of shared decision making about medication appropriateness and deprescribing. The COM‐B (Capability, Opportunity, Motivation—Behavior) model provided an apt framework for characterizing deprescribing communication. Results: Each component of the model requires specific communication skills, modes, and/or content. Capability requires clinician skills including elicitation of patient/care partner concerns and patient/care partner skills including self‐efficacy for raising medication questions and concerns. This facilitates a shared understanding of constructs that inform communication content, including medication benefits and harms and the “how‐to” of deprescribing. Opportunity requires the allocation of time during usual care or the creation of designated visits for communication. Motivation requires communication, such as audit and feedback directed at clinicians, and testimonials directed at patients and care partners, that encourages evaluation of medication appropriateness, increases awareness of potential problems, and overcomes clinical inertia. Conclusions: The application of a behavioral health model to deprescribing communication highlights the importance of addressing capability, opportunity, and motivation in behavior change. Developing communication strategies that address these three components may enhance the effectiveness of deprescribing interventions.

Introduction: High‐risk medications are medications associated with significant patient harm or death if misused or used in error. This study aimed to develop a national consensus high‐risk medication list for use in Australian residential aged care. Methods: A 3‐round modified Delphi study involving Australian healthcare professionals was conducted. In Round 1, participants indicated their level of agreement, on a 9‐point Likert scale, whether 60 medications/medication classes were considered high‐risk and should be included in a high‐risk medication list for Australian residential aged care. Round 2 included medications/medication classes that did not reach consensus and new medications identified by participants. Consensus was defined as 70% or more of participants responding at 7 or higher on the Likert scale. In Round 3, participants were asked to prioritise medications/medication classes that reached consensus in Round 1 or 2. Results: In total, 42 participants completed Round 1, and 35 (83%) completed all three rounds. Participants included pharmacists ( n = 21), prescribers ( n = 15), nurses ( n = 5) and a paramedic ( n = 1), with representation from all Australian states and mainland territories. Overall, 26 medications reached consensus (21 in Round 1, five in Round 2) and were categorised into 15 medications/medication classes for prioritisation in Round 3. The final prioritisation list was opioids, insulin, benzodiazepines, anticoagulants, z‐drugs, antipsychotics, lithium, sulfonylureas with high risk of hypoglycaemia, chemotherapeutic agents, methotrexate, digoxin, narrow therapeutic range antiepileptics, tricyclic antidepressants, immunosuppressants for transplant and sedating antihistamines. Discussion: This is the first, national consensus list of high‐risk medications developed specifically for Australian residential aged care. It can be used to implement targeted strategies to minimise medication‐related harm.

Background: Polypharmacy is prevalent among older adults. Identifying informative medication thresholds could enhance clinical decision-making and healthcare planning. Objectives: To measure the predictive capacity of medication count and polypharmacy thresholds on (1) frequent emergency visits and (2) mortality, in community-dwelling older adults in Quebec, Canada; To measure the predictive capacity of inappropriateness criteria (potentially inappropriate medications, anticholinergic burden level, and drug–drug interactions) on these same outcomes. Methods: We conducted a population-based study using the Quebec Integrated Chronic Disease Surveillance System. Using multivariable logistic regression models, we assessed the predictive capacity [area under the curve (AUC)] of medication use (medication count, polypharmacy thresholds, number of inappropriateness criteria) on frequent emergency visits (≥3) and mortality from April 2, 2022, to March 31, 2023. Findings were interpreted from two perspectives: clinical (with models including individuals’ clinical characteristics, such as chronic diseases) and public health (with models excluding clinical characteristics to mimic polypharmacy measures usually used in surveillance). Results: Medication count remained the most informative predictor in the clinical perspective analyses, with AUC = 0.739 for frequent emergency visits and AUC = 0.804 for one-year mortality, while medication thresholds lacked discrimination. Public health perspective analyses resulted in a bell-shaped predictive pattern peaking at eight medications for both frequent emergency visits (AUC = 0.690) and one-year mortality (AUC = 0.764). Inappropriateness criteria did not outperform medication count or polypharmacy thresholds. Conclusion: From a clinical perspective, medication count is more informative than polypharmacy thresholds. From a public health perspective, a threshold of eight medications may serve as a useful polypharmacy measure.

Background: Benzodiazepine receptor agonists (BZRAs) (benzodiazepines and z‐drugs) may provide limited benefits in the management of insomnia when used short‐term. However, they increase the risk of harms including falls, fractures, hospitalizations, and cognitive impairment. Deprescribing (cessation) of BZRAs may be beneficial for older adults and people living with cognitive impairment as they are at heightened risk of adverse events. This review investigated the effects of patient‐directed, non‐pharmacological interventions to support deprescribing of BZRAs used for insomnia in older adults and people living with cognitive impairment.Methods: Embase, CENTRAL, Scopus, and Medline were searched in January 2024 with no publication date restrictions. Screening, data extraction, and risk of bias assessments (ROB2 for randomized studies, ROBINS‐I for non‐randomized studies) were conducted independently by two authors. Outcomes of interest included the proportion of participants who ceased BZRAs, reduction in BZRAs, switching to another medication, sleep outcomes, and clinical outcomes. Studies were included if they investigated BZRA deprescribing in older adults (≥ 65 years) or people living with cognitive impairment.Results: Seventeen reports analyzing 16 studies in hospital, community, and aged care settings were included. BZRA cessation rates ranged between 23% to 72% for written education (n = 6); 14% to 57% for combined written and verbal education (n = 5); and 9% to 100% for multi‐component interventions (n = 6). One report investigated a BZRA deprescribing educational intervention in people with cognitive impairment and found comparable effectiveness to participants without cognitive impairment. Most studies were at a high risk of bias.Conclusions: Patient‐directed interventions led to BZRA cessation, although there was significant variability between studies. It is unknown if all interventions examined are similarly effective for people living with cognitive impairment. Further research investigating approaches to deprescribing BZRAs in older adults or people with cognitive impairment is required.

Background: Potentially inappropriate medications (PIMs) are medications whereby the harms may outweigh the benefits for a given individual. Although overprescribed to older adults, their direct costs on the healthcare system are poorly described. Methods: This was a cross‐sectional study of the cost of PIMs for Canadians aged 65 and older, using adapted criteria from the American Geriatrics Society. We examined prescription claims information from the National Prescription Drug Utilization Information System in 2021 and compared these with 2013. The overall levels of inflation‐adjusted total annual expenditure on PIMs, average cost per quarterly exposure, and average quarterly exposures to PIMs were calculated in CAD$. Results: Exposure to most categories of PIMs decreased, aside from gabapentinoids, proton pump inhibitors, and antipsychotics, all of which increased. Canadians spent $1 billion on PIMs in 2021, a 33.6% reduction compared with 2013 ($1.5 billion). In 2021, the largest annual expenditures were on proton pump inhibitors ($211 million) and gabapentinoids ($126 million). The quarterly amount spent on PIMs per person exposed decreased from $95 to $57. In terms of mean cost per person, opioids and antipsychotics were highest ($138 and $118 per exposure). Some cost savings may have occurred secondary to an observed decline of 16.4% in the quarterly rate of exposure to PIMs (from 7301 per 10,000 in 2013 to 6106 per 10,000 in 2021). Conclusions: While expenditures on PIMs have declined in Canada, the overall cost remains high. Prescribing of some seriously harmful classes of PIMs has increased and so directed, scalable interventions are needed.

Older adults are at risk of adverse drug events during transition of care from hospital to community, thus optimal communication about medications at discharge is essential. Standardization of medication discharge plan (MDP) is lacking. This study aimed to (1) create a standardized MDP for older adults using consensus‐based principles, (2) create a short‐version MDP and (3) generate a practical guide. Modified Delphi was used to establish consensus on guiding principles for the MDP. Additionally, participants were asked about guiding principles deemed most essential, patient prioritization, the format and mode of transmission of the MDP. Twenty‐six guiding principles reached consensus, with 17 prioritized for a short‐version MDP. The practical guide includes explanations of the guiding principles, criteria for patient selection and recommendations on the format and mode of transmission. The results of this study will assist implementation of MDPs when older adults are discharged from hospital.