Use of potentially inappropriate medications in people with dementia in Vietnam and its associated factors

Transcription

1 Use of potentially inappropriate medications in people with dementia in Vietnam and its associated factors 33 rd International Conference of Alzheimer s Disease International July 2018, Chicago, USA Tuan A. Nguyen 1, Thang Pham 2,, Elizabeth E. Roughead 1 1, School of Pharmacy and Medical Sciences, University of South Australia 2 National Geriatric Hospital of Vietnam Corresponding author: Tuan Anh Nguyen, NHMRC-ARC Dementia Research Development Fellow (Grant identification number APP ) Tuan.Nguyen@unisa.edu.au

2 Disclosure: Nothing to declare

3 Outline Background Methods Results Discussion and conclusion

4 Background Dementia: 60% of the dementia cases are in LMICs 1 Health system in LMICs: Not well developed or funded 2 Vietnam: up to 2.4 million by Prince et al. World Alzheimer Report Price et al. World Alzheimer Report Nguyen et al. American Journal of Alzheimer s Disease & Other Dementias 2018

5 Multi-symptoms An umbrella term a syndrome: over 100 diseases Deterioration cognition (memory, thinking, etc.) behaviour and personality the ability to perform everyday activities Co-occurrence of multi-symptoms

6 Primarily a disease of old age Younger onset (<65 years) - up to 9% globally 1 In Australia 2 Age < Percent 8% 18.1% 32.7% 41.1% 92% Rate/100 population WHO Dementia Fact sheet 2. AIHW Dementia in Australia

7 Age-related changes Age-related changes in pharmacokinetics 1,2 in blood-brain-barrier (BBB) permeability: allows more meds to enter CNS at higher levels 3 P-glycoprotein activity at the BBB 4 (P-gp transport substances immediately out of the brain, restricting uptake) These changes risk of ADR 5 1 Mangoni AA, Jackson SHD. Br J Clin Pharmacol 2004;57(1): Reeve E, et al. Expert Opin. Drug Metab. Toxicol 2017;13(6): Farrall AJ, Wardlaw JM. Neurobiol Aging 2009;30: van Assema DME, et al. Brain 2012;135: Mehta DC, et al. Pharm. Res 2015;32:819-39

8 Age-related changes Age-related changes in pharmacodynamics 1 Altered sensitivity to several classes of meds due to changes in receptors and binding affinity of med Increased sensitivity to CNS effects of benzodiazepines 2 and antipsychotics 3,4 More susceptible to side effects of meds (e.g. Parkinsonism, disorders of movement, QT prolongation) More sensitive to effects of meds on cognition 1. Mangoni AA, Jackson SHD. Br J Clin Pharmacol 2004;57(1):6-14; 2. Kruse WH. Drug Saf 1990; 5: Gregory C, McKenna P. Drugs Aging 1994; 5: ; 4. Maixner SM et al. J Clin Psychiatry 1999; 60(Suppl 8): 29 41

9 Multi-morbidities Table: Average number of health conditions for those with dementia and all people, by sex, age and residency, 2009 AIHW Dementia in Australia

10 Polypharmacy >90% in RACFs use 5 meds 1,2 ~68% in memory clinics use 5 meds % in community use 5 meds 4,5 ; 85% use 4 meds 6 On average use 10 different meds 2 1 Bosboom P et al. Dement Geriatr Cogn Disord Extra 2012;2: ; 2 Somers M et al. Australian Family Physician 2010; 39(6): 413-6; 3 Cross et al. Drugs Aging 2016; 33:37 44; 4 Montastruc F et al. Eur J Clin Pharmacol 2013; 69: ; 5 Lau DT et al. Alzheimer Dis Assoc Disord 2010; 24: 56-63; 6 Barry, H. E et al. Journal of Alzheimer's Disease 2016; 52(4):

11 Risk of drug interaction Karas S. Ann Emerg Med 1981; 10:

12 Treatment conflict ~92% PWD in RACFs: BPSD % people with Alzheimer s disease: incontinence 2 Pharmacotherapy: Antidepressants, antipsychotics 3, antimuscarinics anticholinergic property CEIs and anticholinergics: potential to antagonise each other 1 Edvardsson D. International Psychogeriatrics 2008, 20(4), ; CDPC Clinical Practice Guidelines and Principles of Care for People with Dementia

13 Potentially inappropriate meds PIM: risk from med use outweighs clinical benefit, safer alternative is available 1 Prevalence of use of PIM in PWD: 10.2% to 64.4% 1, 2,3, depending on the tools, settings Little is known about QUM in people with dementia in Vietnam 1 O'Mahony D et al. Age and Ageing 2015;44(2):213-8; 2 Johnell K. Current Clinical Pharmacology 2015;10(3):178-84; 3 Renom-Guiteras A et al. Age and Ageing 2017:1-7. doi: /ageing/afx147

14 Objectives to examine the use of potentially inappropriate medicines that may affect cognition in people with dementia and its associated factors to examine the prevalence of concomitant use of CEIs and anticholinergics, as well as antipsychotic use

15 Data source and study design Database of patients with dementia in the national dementia care program at National Geriatric Hospital of Vietnam Med use: 1 st, Jan 2015 to 31 st, Dec 2016

16 Data source and study design Med use was assessed against: A list of med considered potentially inappropriate for patients with cognitive impairment (PIMcog) 1 according to the Beers and STOPP criteria 1 Cross AJ et al. Drugs Aging. 2016;33:37-44.

17 Statistical analyses Descriptive statistics: Demographics and medicine use Multiple logistic regressions: association of different variables and having a PIMcog Age, gender, dementia type, severity, number of comorbidities, number of medicines used other than PIMcog, number of hospital visits, and number of treating specialists. Missing data: imputed using the fully conditional method in a multiple imputation approach

18 Outline Background Methods Results Discussion and conclusion

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21 Logistic regression model for PIM use Number of hospital visits during the study period: adjusted OR 1.08 ( ) Number of treating specialists (adjusted OR 0.61; 95% CI ) Older age: adjusted OR 1.02 ( ) Female gender: adjusted OR 1.55 ( )

22 Discussion A high level use of medicines that can further impair cognition (41%) reduce the effectiveness of CEIs in people with dementia (39%) 18% on antipsychotics most common: sulpiride - extrapyramidal symptoms (# haloperidol) 95% on anti-dementia medicines 82% for longer than 6 months 27% were at severe stage of dementia

23 Small sample size Limitations Patients attending 1 tertiary teaching hospital They were in a national dementia care program Special insurance cap that limits the total cost of medicines per prescription this is likely to affect the prescribing practice.

24 Conclusions PIMcog use, anticholinergics and sedatives use, and concurrent use of CEIs with anticholinergics: prevalent Efforts to improve quality use of medicines for this population are warranted Raising awareness of medicines that further impair cognition Providing the alternative options

25 Acknowledgements China-Australia Centre for Health Sciences Research seed funding grant (T.A.N, S.Q, E.E.R, L.K.E, M.G, and H.W). Australian NHMRC-ARC Dementia Research Development Fellowship (T.A.N Grant identification number APP )

26 Thang Pham 2, Huyen Thi Thanh Vu 2, Thanh Xuan Nguyen 2, Trinh Thi Vu 2, Binh Thi Thanh Nguyen 2, Ngoc Quynh Nguyen 2, Binh Thanh Nguyen 2, Binh Thanh Nguyen 2, Tam Ngoc Nguyen 2, Sinh Viet Phan 2, Anh Trung Nguyen 2, Tuan Le Pham 3, Ha Thu Dang 1, Lisa Kalisch-Ellett 1, Marianne Gillam 1, Nicole Pratt 1, Sun Qiang 4, Haipeng Wang 4, Tipaporn Kanjanarach 5, Mohamed Azmi Ahmad Hassali 6, Zaheer-Ud-Din Babar 7, Asrenee Ab Razak 8, Dujrudee Chinwong 9, Elizabeth E. Roughead 1 1, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide SA, Australia 2 National Geriatric Hospital of Vietnam, 1A Phuong Mai Street, Dong Da District, Hanoi, Vietnam 3 Hanoi Medical University and Ministry of Health of Vietnam, Hanoi, Vietnam 4 Center for Health Management and Policy, School of Health Care Management, Shandong University, 128# Wenhua Xi Rd 44, Jinan, Shandong , China 5 Faculty of Pharmaceutical Sciences, Khon Kaen University, Khon Kaen, Thailand 6 School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia 7 Department of Pharmacy, University of Huddersfield, Queensgate, HD1 3DH Huddersfield, United Kingdom 8 Department of Psychiatry, School of Medical Sciences, Universiti Sains Malaysia,11800 Penang, Malaysia 9 Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand

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