Three initiatives improve prescribing practices, care planning for older adults

An intervention significantly decreased the rate of potentially inappropriate prescribing among older adults in an ED setting, according to findings from a recent study.

This study, along with two other studies concerning care given to older adults, was the focus of a plenary paper presentation at the American Geriatrics Society Annual Scientific Meeting.

“These three abstracts . . . were selected based on their quality, originality and methodology of research,” moderator G. Michael Harper, MD, AGSF, a professor of medicine and the associate director for Strategy for Tideswell at the University of California, San Francisco (UCSF), said during the presentation.

Improving prescribing practices

Elizabeth Goldberg, MD, ScM, the associate director of the advanced MPH program and associate professor of emergency medicine and health services, policy and practice at Brown University, and colleagues examined the effectiveness of the Enhancing the Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUiPPED) medication safety program. The program was implemented in three EDs in Rhode Island and involved 362 clinicians.

The researchers assessed prescribing patterns of the clinicians both before and after the implementation of the EQUiPPED program, which launched in August and September 2019. The intervention involved grand round lectures, medication order sets, academic detailing and feedback and geriatric education.

Overall, potentially inappropriate prescribing was 1.36 times (95% CI, 1.25-1.47) higher before the EQUiPPED program was implemented than postimplementation, Goldberg said during the presentation. This amounted to a reduction in potentially inappropriate prescribing from 8.93% to 6.59%. The greatest prescribing reduction occurred with antihistamines, skeletal muscle relaxants and benzodiazepines. Significant reductions also occurred with NSAIDs and antispasmodics, according to Goldberg.

However, an increase in potentially inappropriate prescribing was observed in March 2020, a reflection of the first wave of the pandemic, she said.

“Implementation of EQUiPPED through a payor-supported quality incentive program contributed to an improvement in [potentially inappropriate] prescribing among clinicians,” Goldberg added.

Mobility planning

The average hospital patient spends more than 95% of their time in bed, according to data referenced by Lynnae Edwards-Carolina, MD, a geriatrics fellow at the Emory University School of Medicine in Georgia, during her presentation.

In a prospective study, Edwards-Carolina and colleagues compared the effectiveness of a nurse-driven early mobility program, Get Up and Go (GuG), with usual care among 1,479 older adults hospitalized in the Acute Care for the Elderly Unit at Grady Hospital in Atlanta. From February 2021 to November 2021, the nursing staff evaluated patients’ mobility level daily and implemented a corresponding expected activity plan to improve mobility during the hospital stay. Mobility was evaluated with a GuG scoring system, ranging from a score of one, indicating full, independent mobility, to nine, indicating bed rest or activity refusal. Education materials were provided to patients in their rooms.

The mean age of patients who received an activity plan was 78 years; 58.3% were women; and 80% were African American. The mean age of patients in the control group was 76 years; 45.6% were women; and 84% were African American. Many patients were hospitalized for dementia or falls, Edwards-Carolina said.

Overall, the activity plan had no significant impact on length of stay, discharge disposition or incidence of delirium compared with usual care. However, there was a significant improvement in delirium scores (P = .005) and mobility among those who followed an exercise plan.

The pandemic was a key barrier to more significant improvements in mobility, Edwards-Carolina said.

Predicting mortality

In another study, W. James Deardorff, MD, a research fellow in geriatrics at the UCSF School of Medicine, and colleagues estimated the mortality risk for older adults with dementia. They developed and internally validated a prognostic model for mortality using 1998 to 2016 data on 4,267 community-dwelling older adults with probable dementia who were enrolled in the Health and Retirement study. The researchers also used 2010 to 2019 data from the National Health and Aging Trends study as an external validation cohort.

Mortality prediction models can assist with estimating prognosis, Deardorff said during the presentation. Their model accounted for candidate predictors like demographics, health and behavioral factors and participation in vigorous activity.

“BMI category had an interesting relationship in that low BMIs were associated with an increased rate of mortality and high BMIs were associated with a decreased rate,” Deardorff said. “This has been shown in previous studies with older adults.”

Deardorff also reported that increased age, former or current smoking, difficulty walking several blocks, diabetes, heart disease, non-skin cancer and lung disease were associated with an increased risk for mortality. Meanwhile, the female sex and vigorous physical activity were associated with a decreased risk for mortality.

“Our model was fairly well discriminated and well calibrated,” he said.

Overall, risk estimates can help inform conversations related to clinical decisions and advance care planning, according to Deardorff.

References:

Deardorff WJ, et al. Development and internal validation of a mortality prediction model in community-dwelling older adults with dementia. Presented at: American Geriatrics Society Annual Scientific Meeting; May 12-14, 2022; (hybrid meeting).

Edwards-Carolina LA, et al. Comparative effectiveness of a nurse driven early mobility protocol in preventing undesirable outcomes during hospitalizations. Presented at: American Geriatrics Society Annual Scientific Meeting; May 12-14, 2022; (hybrid meeting).

Goldberg EM, et al. EQUiPPED study: Enhancing the quality of prescribing practices for older adults discharged from the emergency department in the largest health system in Rhode Island. Presented at: American Geriatrics Society Annual Scientific Meeting; May 12-14, 2022; (hybrid meeting).