Use of Potentially Harmful Medications and Health-Related Quality of Life among People with Dementia Living in Residential Aged Care Facilities.

E X T R A Dement Geriatr Cogn Disord Extra 2012;2:361–371 DOI: 10.1159/000342172 Published online: September 7, 2012 © 2012 S. Karger AG, Basel www.karger.com/dee This is an Open Access article licensed under the terms of the Creative Commons AttributionNonCommercial-NoDerivs 3.0 License (www.karger.com/OA-license), applicable to the online version of the article only. Distribution for non-commercial purposes only. Original Research Article Use of Potentially Harmful Medications and Health-Related Quality of Life among People with Dementia Living in Residential Aged Care Facilities Pascalle R. Bosboom a, b Helman Alfonso a, b Osvaldo P. Almeida a, b, d Christopher Beer a–c a Western Australia Centre for Health and Ageing, Centre for Medical Research, b School of Psychiatry and Clinical Neurosciences, and c School of Medicine and Pharmacology, University of Western Australia, and d Department of Psychiatry, Royal Perth Hospital, Perth, W.A., Australia Key Words Quality of Life – Alzheimer’s disease questionnaire ⴢ Potentially harmful medication ⴢ Potentially inappropriate medication ⴢ Modified Beers criteria ⴢ Drug Burden Index ⴢ Polypharmacy Abstract Background: Use of potentially harmful medications (PHMs) is common in people with dementia living in Residential Aged Care Facilities (RACFs) and increases the risk of adverse health outcomes. Debate persists as to how PHM use and its association with quality of life should be measured. We designed this study to determine the association of exposure to PHM, operationalized by three different measures, with self-reported Health-Related Quality of Life among people with dementia residing in RACFs. Methods: Cross-sectional study of 351 people aged 165 years diagnosed with dementia residing in RACFs and with MMSE ^24. The primary outcome measure was the self-rated Quality of Life – Alzheimer’s disease questionnaire (QoL-AD). We collected data on patients’ medications, age, gender, MMSE total score, Neuropsychiatric Inventory total score, and comorbidities. Using regression analyses, we calculated crude and adjusted mean differences between groups exposed and not exposed to PHM according to potentially inappropriate medications (PIMs; identified by Modified Beers criteria), Drug Burden Index (DBI) 10 and polypharmacy (i.e. 65 medications). Results: Of 226 participants able to rate their QoL-AD, 56.41% were exposed to at least one PIM, 82.05% to medication contributing to DBI 10, and 91.74% to polypharmacy. Exposure to PIMs was not associated with self-reported Pascalle R. Bosboom, MA Western Australia Centre for Health and Ageing (M573) University of Western Australia 35 Stirling Highway, Crawley, Perth, WA 6009 (Australia) Tel. +61 8 9224 2855, E-Mail bosboomp @ meddent.uwa.edu.au 361 E X T R A Dement Geriatr Cogn Disord Extra 2012;2:361–371 DOI: 10.1159/000342172 Published online: September 7, 2012 © 2012 S. Karger AG, Basel www.karger.com/dee Bosboom et al.: Use of Potentially Harmful Medications and Health-Related Quality of Life among People with Dementia Living in Residential Aged Care Facilities QoL-AD ratings, while exposure to DBI 10 and polypharmacy were (also after adjustment); exposure to DBI 10 tripled the odds of lower QoL-AD ratings. Conclusion: Exposure to PHM, as identified by DBI 10 and by polypharmacy (i.e. 65 medications), but not by PIMs (Modified Beers criteria), is inversely associated with self-reported health-related quality of life for people Copyright © 2012 S. Karger AG, Basel with dementia living in RACFs. Introduction The use of potentially harmful medications (PHMs) is common in later life and is associated with an increased risk of unfavourable health outcomes, including adverse drug events, morbidity, mortality and increased healthcare use [1–6]. Use of medication in older age is complicated by several factors, including changes in pharmacokinetics and the presence of multiple comorbidities [7–9]. Consequently, use of PHM is a source of concern that is likely to become more prevalent in the future as the world’s population ages [10, 11]. Observational studies have found use of PHM among Australians, with a worryingly high prevalence of the use of antipsychotics, antidepressants, and sedative-hypnotic drugs [12]. In a recent study we also found evidence that people with dementia (PWD) living in Residential Aged Care Facilities (RACFs) in Western Australia continue to be frequently exposed to polypharmacy, prescription of contraindicated medications, antipsychotics, medications with high anticholinergic burden, and combinations of potentially inappropriate medications (PIMs) [13]. These patterns of prescribing are not always in agreement with existing evidence-based guidelines [12, 14, 15]. Thus, there is a pressing need to know more about the epidemiology and sociology of medication use by older adults in Australia that in many cases may be unnecessary, costly and potentially harmful. Despite its importance, there is still debate as how to identify the use of PHM and several methods or clinical tools have been proposed. A common approach is the use of the Beers criteria [16]. The Beers criteria comprise a list of PIMs that should be avoided altogether, as well as doses, frequencies and duration of other medications that should be avoided in older adults. Use of PIMs has been associated with higher medical costs, increased rates of adverse drug events and poorer health outcomes [16, 17]. A more recently developed tool is the Drug Burden Index (DBI), a measure of total exposure to anticholinergic and sedative medications that incorporates the principle of dose-response and maximal effect [18]. DBI has been independently associated with poorer performances in physical and cognitive function in a population of well-functioning community-dwelling older people in the USA [19]. Similar associations have been reported by Cao et al. [20]. Recently, Gnjidic et al. [21] compared the DBI with the Beers criteria in older adults in low-level residential aged care. They found that the Beers criteria did not predict functional outcome, but the DBI did. Another measure to identify the use of PHM, which could assist healthcare practitioners, is polypharmacy (e.g. quantified as 65 medications at one time). Polypharmacy per se also appears to be a risk factor for PIM use and adverse outcomes [22, 23]. However, this apparent relationship may be confounded by the burden of multiple chronic diseases in the older population [24]. Consequently, it is still unclear which of the proposed measures to identify use of PHM best predicts health outcomes of older people. The use of PHM has been associated with lower quality of life [25], but this area has been thus far neglected. Health-related quality of life (HRQoL) measures have been identified as important multidimensional outcome measures for the treatment of chronic conditions and are increasingly valued to assess the effect of any intervention on recip (...truncated)