Hello, deprescribing world! It has been some time since our first interview blog post, so here is a new one: Today we have Dr. Karen Andersen-Ranberg, Consultant Geriatrician at Odense University Hospital and Professor of Geriatric Medicine at the University of Southern Denmark, telling us about her experiences related to deprescribing and conducting (deprescribing) research among care home residents.
Q: First off, we know that conducting research in care home residents is extremely important, something which has become abundantly clear recently. We also know that there are some unique challenges with conducting research in care homes. What has been your experience conducting research among care home residents, and what issues have you seen through these experiences?
Karen: I have done epidemiological research involving care home residents for more than 25 years and what I noticed back when I started was the use of high doses of strong sedatives and antipsychotics. We rarely use these medications today in Denmark, so that has changed for the better. But I have also seen that many residents continue to receive high doses of paracetamol after a hip fracture, although the incident took place years before. No one questioned the continued prescription of a painkiller for years. And even today I believe we still see too many of these examples and that we can do even better in terms of deprescribing. Basically, we need to take notice of how the residents feel.
Q: Are there any unique challenges when it comes to deprescribing and deprescribing research among care home residents in particular?
Karen: In Denmark, care home residents may be attended to by their usual primary care physician, or a care home physician, who is also trained in primary care. There is no requirement of having been trained in geriatric medicine or having finished a course in geriatric pharmacology. Older vulnerable adults generally suffer from multimorbidity and polypharmacy, putting them at particular risk of unwanted interactions and side effects, and adverse health outcomes. This poses a special demand on the care home staff to observe unwanted medication side effects. But as the symptoms in many cases mimic symptoms commonly observed in ageing at advanced ages, e.g. drowsiness, lower cognitive and physical capability, they may go unnoticed and being perceived as what would be expected towards the end of life. These conditions lower the awareness of the need for deprescribing. When it comes to research in prescribed medicines used by care home residents, their generally fragile status may impede obtaining informed consent and participation in, for example, deprescribing research projects. Such a simple thing as inviting care home residents by a letter of invitation can be challenging. Formal caregivers may ignore an invitation. Or family members delegated to receiving a digital post on behalf of the care resident may disregard such invitations under the pretext that the resident is too frail and should not be bothered. Also, given the residents’ fragile status, projects involving personal interview or clinical examination, e.g. ECG to monitor QTc interval, would have to take place at the resident’s dwelling in the care home. Otherwise, the participation rate would likely drop to a very low level leading to high selection bias.
Medication reviews in care home residents are done at least once a year but given their vulnerable life situation, they need more frequent reviews. All in all, I think the biggest challenge lies in increasing the geriatric knowledge to all those health professionals working with care home residents. Also, we need to combat ageism, i.e. the negative discrimination because of advanced age, as it leads to indifference towards or even negligence of adverse effects. It seems that few care about the well-being of the oldest people, in particular, those in care homes – just look at the recent care home scandals in many countries during Covid-19. Older people should be treated respectfully and with a holistic approach towards health. Had it been children in the same conditions there would most likely be a pediatrician in the staff. Alas, the general lack of geriatrician presence in nursing homes doesn’t support deprescribing.
Q: You were recently part of a fully-funded Danish research project that aimed to investigate the prevention of Covid-19 among care home residents. The project was ultimately cancelled as the research group could not get approval to actually visit the care homes. While this is a disappointing result, can you share any reflections on what you learned through this process and how you might address some of the issues you faced in future research projects?
Karen: This was very sad. We had taken all measures to avoid contamination with the SARS-CoV-2 virus by wearing personal protective equipment and only using a few, but very experienced health professionals to have personal contact with the care home resident. Also, we excluded demented persons. Yet, the individual competent older adult was not allowed to make his or her own decision regarding participation. We even offered to have an ambulatory clinic outside the care home, where we could receive the participants, but it was still not allowed by the health ministry. Also, it was very dissatisfactory knowing that attending primary care physicians would enter the care home with no limitations and no requirements of wearing protective garments. I really think it is time to start a public debate on the dignity and the right of self-determination in older adults, even the fragile ones.
Q: Shifting back to deprescribing in general, from your point of view as a geriatrician and researcher, what are some of the key areas of focus for deprescribing in care homes over the next few years?
Karen: First, we need support from older peoples’ organizations to address the need for doing more research in vulnerable populations. Second, we need to address how to collaborate best with the care home physician and care home nurses and other staff members. What works and what does not? In my opinion, there could be a greater presence of geriatricians in nursing homes, to work with pharmacists and primary care physicians towards deprescribing. To make ends meet, I suggest that a useful area to explore would be video conferences for regular medication reviews that include a geriatrician and all team members (e.g. nurses, staff, attending nursing home physician) Finally, I think it would be relevant to develop a systematic way to capture increasing use of as needed (PRN) medicine, as it may be a proxy for something going the wrong way, e.g. some kind of simple machine learning whenever a PRN medicine is dispensed.
Q: Last but not least: What is your most satisfying deprescribing target?
Karen: Medications with anticholinergic side effects, but also, dose-lowering or discontinuation, where possible, of all medication. Too many older people take prescription medicine when there is no longer a need. Even just lowering the medication doses may be extremely satisfying in terms of minimizing side effects.
Reach Karen on KARanberg@health.sdu.dk.