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      Role of community pharmacists in the use of antipsychotics for behavioural and psychological symptoms of dementia (BPSD): a qualitative study

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          Abstract

          Objective

          This study aimed to use qualitative methodology to understand the current role of community pharmacists in limiting the use of antipsychotics prescribed inappropriately for behavioural and psychological symptoms of dementia.

          Design

          A qualitative study employing focus groups was conducted. Data were analysed using thematic analysis.

          Setting

          3 different geographical locations in the England.

          Participants

          Community pharmacists (n=22).

          Results

          The focus groups identified an array of factors and constraints, which affect the ability of community pharmacists to contribute to initiatives to limit the use of antipsychotics. 3 key themes were revealed: (1) politics and the medical hierarchy, which created communication barriers; (2) how resources and remit impact the effectiveness of community pharmacy; and (3) understanding the nature of the treatment of dementia.

          Conclusions

          Our findings suggest that an improvement in communication between community pharmacists and healthcare professionals, especially general practitioners (GPs) must occur in order for community pharmacists to assist in limiting the use of antipsychotics in people with dementia. Additionally, extra training in working with people with dementia is required. Thus, an intervention which involves appropriately trained pharmacists working in collaboration with GPs and other caregivers is required. Overall, within the current environment, community pharmacists question the extent to which they can contribute in helping to reduce the prescription of antipsychotics.

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          Most cited references22

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          Appropriate prescribing in elderly people: how well can it be measured and optimised?

          Prescription of medicines is a fundamental component of the care of elderly people, and optimisation of drug prescribing for this group of patients has become an important public-health issue worldwide. Several characteristics of ageing and geriatric medicine affect medication prescribing for elderly people and render the selection of appropriate pharmacotherapy a challenging and complex process. In the first paper in this series we aim to define and categorise appropriate prescribing in elderly people, critically review the instruments that are available to measure it and discuss their predictive validity, critically review recent randomised controlled intervention studies that assessed the effect of optimisation strategies on the appropriateness of prescribing in elderly people, and suggest directions for future research and practice.
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            Does pharmacist-led medication review help to reduce hospital admissions and deaths in older people? A systematic review and meta-analysis.

            We set out to determine the effects of pharmacist-led medication review in older people by means of a systematic review and meta-analysis covering 11 electronic databases. Randomized controlled trials in any setting, concerning older people (mean age > 60 years), were considered, aimed at optimizing drug regimens and improving patient outcomes. Our primary outcome was emergency hospital admission (all cause). Secondary outcomes were mortality and numbers of drugs prescribed. We also recorded data on drug knowledge, adherence and adverse drug reactions. We retrieved 32 studies which fitted the inclusion criteria. Meta-analysis of 17 trials revealed no significant effect on all-cause admission, relative risk (RR) of 0.99 [95% confidence interval (CI) 0.87, 1.14, P = 0.92], with moderate heterogeneity (I(2) = 49.5, P = 0.01). Meta-analysis of mortality data from 22 trials found no significant benefit, with a RR of mortality of 0.96 (95% CI 0.82, 1.13, P = 0.62), with no heterogeneity (I(2) = 0%). Pharmacist-led medication review may slightly decrease numbers of drugs prescribed (weighted mean difference = -0.48, 95% CI -0.89, -0.07), but significant heterogeneity was found (I(2) = 85.9%, P < 0.001). Results for additional outcomes could not be pooled, but suggested that interventions could improve knowledge and adherence. Pharmacist-led medication review interventions do not have any effect on reducing mortality or hospital admission in older people, and can not be assumed to provide substantial clinical benefit. Such interventions may improve drug knowledge and adherence, but there are insufficient data to know whether quality of life is improved.
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              Does home based medication review keep older people out of hospital? The HOMER randomised controlled trial.

              To determine whether home based medication review by pharmacists affects hospital readmission rates among older people. Randomised controlled trial. Home based medication review after discharge from acute or community hospitals in Norfolk and Suffolk. 872 patients aged over 80 recruited during an emergency admission (any cause) if returning to own home or warden controlled accommodation and taking two or more drugs daily on discharge. Two home visits by a pharmacist within two weeks and eight weeks of discharge to educate patients and carers about their drugs, remove out of date drugs, inform general practitioners of drug reactions or interactions, and inform the local pharmacist if a compliance aid is needed. Control arm received usual care. Total emergency readmissions to hospital at six months. Secondary outcomes included death and quality of life measured with the EQ-5D. By six months 178 readmissions had occurred in the control group and 234 in the intervention group (rate ratio = 1.30, 95% confidence interval 1.07 to 1.58; P = 0.009, Poisson model). 49 deaths occurred in the intervention group compared with 63 in the control group (hazard ratio = 0.75, 0.52 to 1.10; P = 0.14). EQ-5D scores decreased (worsened) by a mean of 0.14 in the control group and 0.13 in the intervention group (difference = 0.01, -0.05 to 0.06; P = 0.84, t test). The intervention was associated with a significantly higher rate of hospital admissions and did not significantly improve quality of life or reduce deaths. Further research is needed to explain this counterintuitive finding and to identify more effective methods of medication review.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2016
                16 March 2016
                : 6
                : 3
                : e010278
                Affiliations
                [1 ]School of Life and Health Sciences, Aston Research Centre for Healthy Ageing (ARCHA), Aston University , Birmingham, UK
                [2 ]School of Life and Health Sciences, Aston University , Birmingham, UK
                [3 ]Faculty of Health and Social Care, University of Hull , Hull, UK
                [4 ]Department of Pharmacy, School of Life and Health Sciences, Aston University , Birmingham, UK
                [5 ]Avante Care , Faversham, Kent, UK
                Author notes
                [Correspondence to ] Dr Ian D Maidment; i.maidment@ 123456aston.ac.uk
                Author information
                http://orcid.org/0000-0003-4152-9704
                Article
                bmjopen-2015-010278
                10.1136/bmjopen-2015-010278
                4800147
                26983947
                332af440-0410-4bb3-b393-255febceaa4e
                Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                : 16 October 2015
                : 20 November 2015
                : 6 January 2016
                Categories
                Mental Health
                Research
                1506
                1712
                1723
                1725
                1712
                1713

                Medicine
                qualitative research,clinical pharmacology
                Medicine
                qualitative research, clinical pharmacology

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