Background
Methods
Design and context
Participants and randomization
Standard home care
Intervention
Triage meetings and collaborative medication reviews
Clients’ preferences in the intervention
Outcome measures
Outcome | Aspects assessed |
---|---|
Number of all medications | The total number of regular and pro re nata (when required) medications that have been prescribed (i.e. prescribed medication that is scheduled), over-the-counter and herbal products are not included |
Use of harmful medications | |
Use of Beers Criteria [23] medications | Potentially inappropriate medicines for older adults according to Beers Criteria [23]. |
Use of CNS medications | Opioids (ATC code N01AH, N02A, N02BE51, R05DA, R05FA); anticholinergic drugs according to Puustinen et al. 2012 [26], antiepileptics (ATC code N03A); BZDs and related drugs (ATC codes N05BA, N05CD, N03AE01, N05CF, A03CA, C01DA70, M05AA51, N06CA01, N02BA71); antidepressants (ATC codes N06A, N06CA); antipsychotics (ATC codes N05A, N06CA01). |
Use of Psychotropic medications Proportion of study participants using > 3 psychotropic medications, n (%) | BZDs and related drugs (ATC codes N05BA, N05CD, N03AE01, N05CF, A03CA, C01DA70, M05AA51, N06CA01, N02BA71); antidepressants (ATC codes N06A, N06CA); antipsychotics (ATC codes N05A, N06CA01) [26] |
Proportion of study participants using > 2 serotonergic medications, n (%) | Serotonergic medications according to Salko database [27]. |
Proportion of study participants using anticholinergic medications, n (%) | Anticholinergic medicines according to Puustinen et al. 2012 [26]. |
Proportion of study participants using antipsychotics, n (%) | ATC codes N05A, N06CA01 |
BZD users, n (%) | BZDs and related drugs (ATC codes N05BA, N05CD, N03AE01, N05CF, A03CA, C01DA70, M05AA51, N06CA01, N02BA71) [26] |
Opioid users, n (%) | ATC codes N01AH, N02A, N02BE51, R05DA, R05FA |
PPI user, n (%) | ATC A02BC |
Prevalence of clinically significant drug-drug interactions (SFINX class D) [24] | Interactions that should be avoided or used with caution [24]. |
N | Total | Intervention Group (N = 65) | Control Group (N = 64) | pc | |
---|---|---|---|---|---|
Female, n (%) | 129 | 90 (69.8) | 44 (67.7) | 46 (71.9) | 0.61 |
Mean age; years, (SD), range | 129 | 82.8 (7.1), 65–96 | 81.6 (7.1), 65–95 | 84.0 (6.8), 67–96 | 0.05 |
Age group, n (%) | 129 | 0.08 | |||
65–69 | 8 (6.2) | 5 (7.7) | 3 (4.7) | ||
70–74 | 9 (7.0) | 5 (7.7) | 4 (6.3) | ||
75–79 | 17 (13.2) | 13 (20.0) | 4 (6.3) | ||
80–84 | 41 (31.8) | 21 (32.3) | 20 (31.3) | ||
85- | 54 (41.9) | 21 (32.3) | 33 (51.6) | ||
Living alone, n (%) | 126 | 104 (80.6) | 53 (84.1) | 51 (81.0) | 0.64 |
Rava indexa,b [29], mean (SD) | 128 | 1.98 (0.61) | 2.19 (0.63) | 1.77 (0.51) | < 0.001 |
MD | 1.83 | 2.08 | 1.59 | ||
MNA Screeningb [30] | 127 | 0.14 | |||
Normal nutritional status (12–14 points), n (%) | 65 (51.2) | 30 (46.9) | 35 (55.6) | ||
At risk of malnutrition (8–11 points), n (%) | 54 (42.5) | 32 (50.0) | 22 (34.9) | ||
Malnourished (0–7 points), n (%) | 8 (6.3) | 2 (3.1) | 6 (9.5) | ||
MMSEb [31] | 126 | 0.44 | |||
25–30 (no cognitive impairment), n (%) | 44 (34.9) | 19 (30.7) | 25 (39.1) | ||
18–24 (mild cognitive impairment), n (%) | 70 (55.6) | 38 (61.3) | 32 (50.0) | ||
0–17 (severe cognitive impairment), n (%) | 12 (9.5) | 5 (8.1) | 7 (10.9) | ||
GDS-15b [32] > 6 (suggestive of depression), n (%) | 127 | 39 (30.7) | 21 (33.3) | 18 (28.1) | 0.52 |
Proportion with orthostatic hypotension [33], n (%) | 106 | 24 (22.6) | 14 (29.2) | 10 (17.2) | 0.14 |
UDI-6 [34], mean (SD) | 126 | 3.2 (4.0) | 3.3 (4.4) | 3.2 (3.6) | 0.92 |
MD | 2.0 | 2.0 | 2.0 | ||
AUDIT-C [35], mean (SD) | 128 | 0.9 (1.7) | 1.2 (1.9) | 0.7 (1.5) | 0.59 |
MD | 0.0 | 0.0 | 0.0 | ||
128 | 52 (40.6) | 32 (50.0) | 20 (31.3) | 0.03 | |
Medication use | 129 | ||||
Number of regular medications, mean (SD) | 10.1 (3.3) | 10.4 (3.3) | 9.8 (3.2) | 0.25 | |
Number of pro re nata medications, mean (SD) | 3.0 (1.8) | 3.1 (1.7) | 2.9 (1.8) | 0.54 | |
Number of all medications, mean (SD) | 13.1 (4.1) | 13.5 (3.9) | 12.7 (4.3) | 0.25 | |
Number of all medication, classified | 0.53 | ||||
1–6, n (%) | 5 (3.9) | 1 (1.5) | 4 (6.3) | ||
7–9, n (%) | 16 (12.4) | 7 (10.8) | 9 (14.1) | ||
10–15, n (%) | 76 (58.9) | 40 (61.5) | 36 (56.3) | ||
16+, n (%) | 32 (24.8) | 17 (26.2) | 15 (23.4) |
Statistical analyses
1 Baseline analyses
2 Intention to treat- and per protocol analyses
Results
Study participants and attrition rate
Use of PIMs at baseline
Medication in use | Intervention group (N = 65) | Control group (N = 64) | |||||||
---|---|---|---|---|---|---|---|---|---|
Baseline | At 12 months | Adjusted mean change [95% CI] or adjusted OR (95% CI) for change | p for change | Baseline | At 12 months | Adjusted mean change [95% CI] or adjusted OR (95% CI) for change | p for change | Ph for the difference in change between the groups | |
Number of all medications, mean (SD) | 13.5 (3.9) | 14.1 (3.8) | 0.77 [0.05–1.48] | 0.04 | 12.7 (4.30) | 12.95 (4.03) | 0.52 [−0.37–1.41] | 0.25 | 0.59 |
Harmful medicationa user, n (%) | 56 (86.2) | 57 (87.7) | 1.15 (0.63–2.10) | 0.66 | 51 (79.7) | 51 (79.7) | 1.00 (0.63–1.60) | 1.00 | 0.73 |
Beers Criteria [23] medication user, n (%) | 61 (93.9) | 63 (96.9) | 2.12 (0.34–13.2) | 0.42 | 58 (90.6) | 57 (89.1) | 0.84 (0.39–1.82) | 0.66 | 0.36 |
Psychotropic medicationb user, n (%) | 43 (66.2) | 45 (69.2) | 1.15 (0.78–1.72) | 0.48 | 32 (50.0) | 30 (46.9) | 0.88 (0.62–1.25) | 0.48 | 0.32 |
Anticholinergic medicationc user, n (%) | 18 (27.7) | 17 (26.2) | 0.92 (0.58–1.42) | 0.74 | 12 (18.8) | 12 (18.8) | 1.00 (0.75–1.33) | 1.00 | 0.77 |
CNS medicationd user, n (%) | 56 (86.2) | 53 (81.5) | 0.69 (0.34–1.41) | 0.31 | 45 (70.3) | 43 (67.2) | 0.86 (0.49–1.50) | 0.59 | 0.64 |
Therapeutic duplication | |||||||||
Proportion using > 3 psychotropic medicationsb, n (%) | 13 (20.0) | 12 (18.5) | 0.81 (0.53–1.22) | 0.31 | 6 (9.4) | 5 (7.8) | 0.82 (0.41–1.62) | 0.57 | 0.97 |
Proportion using > 2 serotonergic medications [27], n (%) | 13 (20.0) | 16 (24.6) | 1.35 (0.88–2.06) | 0.17 | 5 (7.8) | 7 (10.9) | 1.47 (0.69–3.16) | 0.32 | 0.84 |
Use of special ATC classes | |||||||||
Antipsychotics userse, n (%) | 13 (20.0) | 15 (23.1) | 1.20 (0.72–2.01) | 0.48 | 7 (10.9) | 7 (10.9) | 1.00 (0.64–1.57) | 1.00 | 0.59 |
BZDf users, n (%) | 32 (49.2) | 30 (46.2) | 0.88 (0.62–1.25) | 0.48 | 21 (32.8) | 20 (31.3) | 0.93 (0.64–1.35) | 0.70 | 0.83 |
Opioidg users, n (%) | 18 (27.7) | 17 (26.2) | 0.92 (0.55–1.55) | 0.76 | 22 (34.4) | 20 (31.3) | 0.87 (0.58–1.29) | 0.48 | 0.85 |
PPI (ATC A02BC) user, n (%) | 30 (46.2) | 30 (46.2) | 1.00 (0.78–1.29) | 1.00 | 30 (46.9) | 33 (51.6) | 1.21 (0.92–1.59) | 0.17 | 0.31 |
Drug-drug interactions (DDI) | |||||||||
Clinically significant DDI (class D) [24], n (%) | 7 (10.8) | 6 (9.2) | 0.84 (0.39–1.79) | 0.65 | 1 (1.6) | 0 (0) | NA | 0.32i | NA |
Effect of the intervention (CoMM) on the use of PIMs (ITT analyses)
Per protocol analyses
Medication in use | Intervention group (N = 27) | Control group (N = 64) | |||||||
---|---|---|---|---|---|---|---|---|---|
Baseline | At 12 months | Adjusted mean change [95% CI] or adjusted OR (95% CI) for change | p for change | Baseline | At 12 months | Adjusted mean change [95% CI] or adjusted OR (95% CI) for change | p for change | Pi for the difference in change between the groups | |
Number of all medications, mean (SD) | 14.0 (3.9) | 13.3 (3.3) | −0.02 [−1.24–1.20] | 0.97 | 12.7 (4.3) | 13.0 (4.0) | 0.38 [−0.59–1.36] | 0.44 | 0.46 |
Harmful medicationa user, n (%) | 23 (85.2) | 22 (81.5) | 0.61 (0.13–2.88) | 0.54 | 51 (79.7) | 51 (79.7) | 1.00 (0.50–2.02) | 1.00 | 0.58 |
Beers Criteria [23] medication user, n (%) | 26 (96.3) | 25 (92.6) | 0.42 (0.02–7.52) | 0.56 | 58 (90.6) | 57 (89.1) | 0.82 (0.34–1.95) | 0.65 | 0.67 |
Psychotropic medicationb user, n (%) | 21 (77.8) | 19 (70.4) | 0.47 (0.04–5.24) | 0.54 | 32 (50.0) | 30 (46.9) | 0.56 (0.11–2.72) | 0.47 | 0.90 |
Anticholinergic medicationc user, n (%) | 8 (29.6) | 5 (18.5) | 0.62 (0.25–1.56) | 0.31 | 12 (18.8) | 12 (18.8) | 1.00 (0.72–1.39) | 1.00 | 0.34 |
CNS medicationd user, n (%) | 25 (92.6) | 20 (74.1) | 0.15 (0.03–0.80) | 0.03 | 45 (70.3) | 43 (67.2) | 0.81 (0.37–1.77) | 0.59 | 0.08 |
Therapeutic duplication | |||||||||
Proportion using > 3 psychotropic medicationsb, n (%) | 5 (18.5) | 2 (7.4) | 0.35 (0.11–1.10) | 0.07 | 6 (9.4) | 5 (7.8) | 0.82 (0.42–1.62) | 0.56 | 0.21 |
Proportion using > 2 serotonergic medications [27], n (%) | 6 (22.2) | 7 (26.0) | 1.28 (0.56–2.92) | 0.56 | 5 (7.8) | 7 (10.9) | 1.49 (0.68–3.26) | 0.32 | 0.79 |
Use of special ATC classes | |||||||||
Antipsychotics userse, n (%) | 6 (22.2) | 4 (14.8) | 0.59 (0.20–1.69) | 0.32 | 7 (10.9) | 7 (10.9) | 1.00 (0.61–1.65) | 1.00 | 0.37 |
BZDf users, n (%) | 15 (55.6) | 10 (37.0) | 0.43 (0.21–0.91) | 0.03 | 21 (32.8) | 20 (31.3) | 0.89 (0.47–1.67) | 0.71 | 0.15 |
Opioidg users, n (%) | 11 (40.7) | 7 (26.0) | 0.49 (0.21–1.11) | 0.09 | 22 (34.4) | 20 (31.3) | 0.86 (0.57–1.30) | 0.47 | 0.23 |
PPI (ATC A02BC) user, n (%) | 13 (48.2) | 13 (48.2) | 1.00 (0.62–1.61) | 1.00 | 30 (46.9) | 33 (51.6) | 1.23 (0.91–1.66) | 0.18 | 0.47 |
Drug-drug interactions (DDI) | |||||||||
Clinically significant DDI (class D) [24], n (%) | 2 (7.4) | 2 (7.4) | 1.00 (0.21–4.67) | 1.00 | 1 (1.6) | 0 (0.0) | NA | 0.32h | NA |