Management and prevention of Sepsis during hospitalization proposal

Significance of the Practice Problem

How has polypharmacy become in a significant practice problem? First, older adult population in US has been estimated in 49,509,315 inhabitants that represents sixth part of the total population (15.2%) by the end of 2017 (United States Census Bureau, 2018). Second, comorbidities are common in older adults (Sheikh, Dhingra-Kumar, Kelley, Kieny, & Donaldson, 2017). For example, hypertension, diabetes mellitus, heart failure are prevalent conditions in older people that requires several medications to control each condition (Agbonjinmi, 2017). Third, polypharmacy complicates the current situation by increasing the risk of drug interactions, adverse reactions, other medical errors and poor adherence of the elderly to treatment with multiple drugs (World Health Organization, 2017). Aging changes pharmacokinetic, for example: decreasing hepatic blood flow by 4%, chronic kidney diseases affect 50% of elderly, heart failure can exacerbate the previous conditions (Agbonjinmi, 2017). Finally, in order to reduce harm that poly-medication provokes, is needed a correct management of polypharmacy standardization of policies, procedures and protocols (World Health Organization, 2017); implies follow guidelines, pharmacists’ participation on conciliation, medication review and education of medical and nursing prescribers and patients, health providers commitment, people empowerment.

How polypharmacy affects to older adults in different settings, such as: hospital, skill nursing facility (nursing home) and community during 2014-2018?

Population: Studies that met the criteria inclusion.

Intervention: Systematic review.

Comparison: Polypharmacy in older adults with settings (hospital, skill nursing facility or community).

Outcome: Identified settings that are explored polypharmacy in older adults.

Time: 2014-2018

General Objective.

To summarize evidence from studies that have investigated polypharmacy in older adults considering the scenarios where polypharmacy was identified, from 2014 to 2018.

Specific Objectives.

1. To synthesize studies on polypharmacy in older adults considering the scenarios where polypharmacy was identified.

2. To summarize diseases (group of diseases, number of disease), relate to polypharmacy.

3. To synthesize which medications have been described in association with polypharmacy in the older adults.

Theoretical Framework

Effects of polypharmacy in older adults can be explaining by Maslow’s Hierarchy of Human Needs. According to Craven and collaborators (2013), Maslow’s Theory states that in all humans there are present instinctive needs, represented in five categories from physical needs to self-actualization needs. At the same time, each category is organized by importance (Craven, Hirnle, & Jensen, 2013) (p. 1402)

Polypharmacy may affect each level of the Maslow’s pyramid. Physiological needs can be affected by warfarin use, it can increase the risk of bleeding if the international normalized ratio (INR) is too high or add risk of thrombosis if INR is too low. Polypharmacy including regular antidepressants or benzodiazepines have been associated with the increased of fall risk (Richardson, Bennett, & Kenny, 2015), which is a negative outcome of the safety needs category. Compliance with the treatment could be included in the category of esteem needs. On the other hand, polypharmacy increases the risk of falls, adverse reactions and non-compliance all those effects can lead to hospitalization, admission to nursing facilities or increases the need of attention which affect esteem needs. According to Lai and collaborators (2018), medication knowledge is independently positively associated with compliance association lack of compliance (Lai, Zhu, Huo, & Li, 2018). Polypharmacy can also lead to cognitive deficits (Agbonjinmi, 2017), decreasing the ability to problem solving.

Synthesis of the Literature

One hundred nineteen titles included in the CINALH data base has been evaluated for eligibility. After assessing each one, 42 publications have been selected for this systematic review phase. In order to identified how polypharmacy affects the elderly in different settings, the next paragraphs present a preliminary evaluation of sixteen articles.

The sample contains sixteen studies distributed: six in 2017, four in 2016, three in 2018, two in 2014 and one in 2015. Distribution by region was: Europe six articles, followed by US with three, Australia and Asia with two, and America, Canada and Africa one reference each one. Fifteen researches were observational and one was interventional. Eleven studies were retrospective and five prospective. In relation to the setting, eight studies were conducted in community-dwelling individuals, eight were developed in hospital settings, but four of those had assessed information from previous settings (community and nursing facilities).

Polypharmacy Prevalence:

Polypharmacy was identified as a major subject in nine studies, but the variable was addressed in different ways. In 2014 Husson and collaborators published the results of factors associated to polypharmacy in adults ages 60 or greater. The authors estimated the prevalence of polypharmacy 29.9%. Besides, the researchers found that polypharmacy was more frequent in women 75-year-old and older (Husson, et al., 2014). Di Giorgio and collaborators (2016) on other hand, developed a study designed to assess the medication used and potential inappropriate medications and prescribing omission in elderly before and during hospitalization and relation with comorbidities. Scientists identified that 36% of elderly consumed (6-10 drugs) and 4% (>10 drugs). During hospitalization the investigators observed that prevalence decreased in the consume of 6-10 drugs with 25% meanwhile, the consume of more than 10 drugs increased its prevalence to 70% (Di Giorgio, Provenzani, & Polidori, 2016). The study presented by Krentz and Gill in 2016, assessed the impact of non-ART polypharmacy (≥5 daily non-ART medications) for all adults. They stated in their study that 32.2% of all subjects were experiencing polypharmacy. However, this prevalence increased to 55.1% among patients aged > 60 years (Krentz & & Gill, 2016). Other study published in 2016 (Pedrós, Formiga, Corbella, & Arnau, 2016). estimated prevalence of adverse drug reaction related to hospitalization in older adults, assessed mortality and polypharmacy. According to the authors Pedrós and collaborators, polypharmacy was prevalent in 86% at the moment of admission to the hospital with not significative statistical difference between decennial groups ≥ 65 year compared (Pedrós, Formiga, Corbella, & Arnau, 2016). Avelino-Silva and collaborators (2017) on other hand, conducted a prospective cohort study with the objective to determine the association between delirium superimposed on dementia and hospital mortality and the mortality in hospitalized older adults. The authors found that prevalence of polypharmacy in this study was estimated in 60% in ≥ 60 years (Avelino-Silva, Campora, Curiati, & Jacob-Filho, 2017). Bazargan and collaborators (2017), investigated the association between adherence to treatments and different factors, (one of them was polypharmacy). The researchers stated that 60% of older African-American people were under polypharmacy (Bazargan, et al., 2017). König and collaborators’ in 2017, aimed their study to determine prevalence of chronic kidney disease and explore risk factors. Polypharmacy was minor subjects explored in glomerular filtrate rate (eGFR) this study. The prevalence of polypharmacy in ≥ 60 years with eGFR <30 mL/min/1.73 m2 was estimated in 18.5% (König, Gollasch, Demuth, & Steinhagen-Thiessen, 2017). Machón and collaborators (2017), addressed their study to assess health-related quality of life (HRQL) in older adults. Even though, polypharmacy (defined ≥ 3 drugs) was not a subject in this research the authors found association between this variable and poor HRQL. Thus, prevalence of polypharmacy was estimated 60% of the subjects with poor HRQL (Machón, Larrañaga, Dorronsoro, Vrotsou, & Vergara, 2017). Vrettos and collaborators (2017), direct their investigation to identify factors associated with polypharmacy in older patients (≥65years) with unplanned admissions. These group of scientists calculated that polypharmacy was present in 53.5% patients at admission time. Polypharmacy group consume approximately 7 drugs (Vrettos, Voukelatou, Katsoras, Theotoka, & Kalliakmanis, 2017). Ssonko and collaborators recently published their study of polypharmacy among older adults living with HIV, and its association or not with adverse effects of antiretroviral therapy (ART). According to Ssonko et al. (2018), polypharmacy (≥ 4 drugs non-HIV therapy) was prevalent in 18% of individuals aged 60-64 years and in 34% of aged ≥ 65 years (Ssonko, et al., 2018).

Even though, polypharmacy was one of the key words included to develop the search, prevalence of polypharmacy was not assessed in the six studies. The first study was carried out by Bennett et al. in 2014, this prospective study was aimed to investigate the relationship between medication exposure and adverse outcomes in a cohort of robust and frail older hospitalized after fall risk increased drugs (FRIDs). These authors estimated medication exposure for both cohorts, but not prevalence of polypharmacy (Bennett, et al., 2014). The second research was conducted by Turner and collaborators in 2016. They studied outpatients aged ≥70 years with cancer, in order to detect sensitivities and specificities of a range of polypharmacy cut-points of adverse reactions. Polypharmacy was defined as ≥ 5 drugs, but the researchers did not state the prevalence of polypharmacy in the studied group (Turner, et al., 2016). You-Seon et al. (2016) on the other hand, identified polypharmacy as a major subject in their research. These authors aimed their studied to identify potential inappropriate medication (PIM), its prevalence and patterns. One of the patterns studied was polypharmacy, but they do not estimate its prevalence, neither is clear what was the condition related to polypharmacy of the subject included in the study (You-Seon, et al., 2016). In 2017, Maust et al. aimed their research to assess the time trends in central nervous system (CNS) polypharmacy and relevant prescribing practices in older adults ≥ 65 years old. The authors defined polypharmacy as ≥ 3 drugs of antipsychotics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonists, tricyclic antidepressants, selective serotonin reuptake inhibitors, and opioids. This investigation did not clearly estimate prevalence of polypharmacy, the data is mixed between visits at the doctor office and subject studied (Maust, et al., 2017). Recently McDonald et al. (2018), compared results of postsurgical outcomes in high risk older patients after intervened one group. One of the interventions was to reduce polypharmacy. However, the letter did not show in the result how was affecting polypharmacy to older adults before intervention or after (McDonald, et al., 2018). Lai and collaborators (2018) for instance, used as inclusion criteria that the patients were exposed to polypharmacy (≥5 prescribed medication in this study). For this reason, polypharmacy prevalence was not estimated in this study (Lai, Zhu, Huo, & Li, 2018).

Polypharmacy has been stated as a risk of producing damage to older adults by iatrogenic management of therapies, or by patient’s error (Agbonjinmi, 2017; (Husson, et al., 2014). For this reason, the quantification of polypharmacy and the study of variables potentially related this phenomenon have been widely explored. However, different outcomes have been observed. First, the studies’ results are not always similar between different settings (hospitalized, no hospitalized). Besides, findings could vary when polypharmacy is explored in similar settings. Finally, to express a conclusive statement regarding to polypharmacy may be irrelevant in relation with the study’s objectives.

Among the elderly, polypharmacy has been identified as a causative factor of negative outcomes. For example, polypharmacy together to other conditions has been related to CKD (König, Gollasch, Demuth, & Steinhagen-Thiessen, 2017). The association between polypharmacy and poor health related quality of life (HRQL) has been recognized (Machón, Larrañaga, Dorronsoro, Vrotsou, & Vergara, 2017), and poor self-perceived health status, history of falls, lack of a physical activity, metabolic syndrome and low or medium education level (Husson, et al., 2014), potentially inappropriate medication (PIM) (You-Seon, et al., 2016), and cardiovascular diseases (Turner, et al., 2016).

At the same time, it has been documented that polypharmacy leads to urgent admission with ADR (Pedrós, Formiga, Corbella, & Arnau, 2016), and increases during hospitalization (Di Giorgio, Provenzani, & Polidori, 2016). In addition, presence of polypharmacy is common among hospitalized fallers, mainly in frail fallers (Bennett, et al., 2014). Moreover, polypharmacy has been linked with poor adherence to treatment in the older general population (Bazargan, et al., 2017), and in elderly living with HIV (Krentz & & Gill, 2016). Additionally, polypharmacy of drugs that affect central nervous system is a trending phenomenon in rural areas nowadays (Maust, et al., 2017). Similarly, drug consumption of ten or more drugs has been identified as a common problem among people ages ≥ 80 years (Lai, Zhu, Huo, & Li, 2018). Finally, it has been predicted the number of drugs enough to predict adverse drug reactions for patients with cancer (Vrettos, Voukelatou, Katsoras, Theotoka, & Kalliakmanis, 2017).

Ssonko et al. (2018) found that polypharmacy was common in elderly living with VIH. However, these authors stated that they did not find evidence that polypharmacy results in any harm (was not associated with falls, adherence to ART or unsuppressed viral loads (Ssonko, et al., 2018). This atypical result, may be influenced by study design, sample size or setting. As the author stated, ability to afford medications could be a causative of this phenomenon. According to Avelino-Silva and collaborators (2017), found high prevalence of polypharmacy in their study however this variable was not associated with a worse prognostic in hospitalized older adults with delirium superimposed on dementia (Avelino-Silva, Campora, Curiati, & Jacob-Filho, 2017). This result may be determined by characteristics of these conditions.

Practice Recommendations

There is a need to increase interventional projects under randomized controlled trials in order to reduce unnecessary polypharmacy. Evaluate and publish the results. Revealing the results is a better way to engage health providers, patients and caregivers in decreasing of unnecessary medication. It is common problem that older people be expose to polypharmacy, for this reason is important to plan strategies that protect the elderly population against unnecessary polypharmacy. Finally, it could be convenient that systematic reviews be execute by a group of researchers in order to reduce the probability of bias, and loss of valuable information during the process of reviewing.

Project Setting

A systematic review is carried out in order to accomplish a requirement for the Master in Family Nurse Practitioner of Ana G. Mendez University System. The problem under study was determined by its magnitude and actuality. The results of this study will benefice advance register nurses in their routine practice, especially during management of pharmacotherapy in older adults. CINAHL database is revised through 2018, to identify studies that evaluate polypharmacy in older adults. The search is performed on full academic articles published through 2014-2018 that include key words: polypharmacy in older adults. The selection of studies is carried out by analyzing their titles, evaluated abstract and finally reading the publication. Since, the research is still in selection of articles process, it is intended to increase the search including elderly, multiple medication or multiple drugs as new key words.

Project Description

The purpose of this literature review is to summarize evidence from studies that have investigated polypharmacy in older adults considering the scenarios where polypharmacy was identified, from 2014 to 2018. First, the results of the project would be presented in the educational institution where the review was designed. During the presentation, the PI will invite nurses from healthcare facilities nearby. PI will present the information in a keynote lecture. PI will provide the Power Point presentations to people who would be interested in it. It is important to consider the feedback of stakeholders for assessing the implication in the nursing practice. Professional nurses might help indicate possible gaps and limitations of the review and directions for further researches.

Second, the PI has an intention to publish the systematic literature review in a professional peer-reviewed journal. After this, the community would get the access to project results at the regional, national, and international levels. Finally, PI is going to present the results of literature analysis in the scientific conferences..

The proposed literature review research follows specific inclusion criteria that allows considering the results of relevant and up-to-date academic investigations. Firstly, the literature review considers scholarly sources devoted to the problems of polypharmacy in older adults with articles that have the words polypharmacy and older adults. Exclusion criteria are those articles that do not have those words.. Finally, the proposal considers only sources published not later than 2014 in order to maintain the rigor of the research.

This study is presented in the form of a literature review including 16 sources of evidence that will provide information on Alzheimer Disease in Ethnic Groups, from online databases including Google Scholar, CINAHL, and PubMed/MEDLINE. Although this is a literature review, all the data will be stored in a USB for the sole purpose of this study for a maximum of five years, kept in a secure location at the investigator’s office, and then destroyed with a hammer. Only the PI and the advisor will have access to the information.

The possible benefits of the performed literature review provide greater insights into the effects of polypharmacy in the older adults. The research on polypharmacy explores pointers relating to the use and abuse of multiple prescriptions in the older population. The research also benefits society because it focuses on a vulnerable group, since these group is minority groups at greater a risk for polypharmacy.

The nursing field will benefit from the proposal because the awareness of polypharmacy in older adults can help nurses better deal with patients more intimately. The nursing world also benefit by creating awareness for the most vulnerable age ethnic in developing educational programs, providing better planning and organization to the patients’ care and improving the quality of care.

Methodology

Developing the proposal for the study of polypharmacy in older adults has allowed me to acquire knowledge on the subject, in addition to providing me with sufficient elements to be an agent of change in the management of polypharmacy in the skill nursing facility where I work. The data generated in this research will be kept for 5 years.

Organizational Change for Decrease Polypharmacy in older adults, using eight steps of Kotter model (Mair, et al., 2018).

Establishing a Sense of Urgency

Informing to participants the need the urgent to change the ways to control quantity and quality medication in order to improve safety in medication management for older adults.

Detect and evaluate others interventions that exist and how they can influence in the development of the change process.

Forming a Powerful Guiding Coalition

A project group will be form, including family doctors, clinicians, geriatricians, family nurse practitioners and pharmacists. Will be debate, next actions and how to manage working as a team. Then, inform to directors of local health institutions and pharmacies about the project.

Creating a Vision

A vision will be built, expressing that the golden objective has been achieved for patients and healthcare providers.

An outline will be form in order to meet the vision.

Communicating the Vision

The written Vision and plan will be discussed with local leaders.

Empowering others to act on the vision

Will be assessed the project in order to finding weakness, threats and unexpected problems. Feedback will be provided, and amendments will be performed to the protocol.

Planning for and creating short-term wins

Frequent feedback on the progress of the project will be provided. Therefore, it will be necessary to divide it into smaller tasks, which will allow to see small results on the way to the great result. Design tool for evaluation.

Consolidating improvements and producing still more change

It's time to interact with influencers and disclose the results and expectations of the project in order to receive momentum for change. It will be the time to extend the project to other institutions.

Institutionalizing new approaches

Divulge results, mainly that ones that positively impact the reduction of polypharmacy in older adults, reduction of admission, falls, adverse drug reactions, reduction of inappropriate prescriptions. Adoption the project in a next level of healthcare

Methodology

Design. Systematic review

Variable.

Polypharmacy (qualitative): Routine use of four or more over-the-counter, prescription and/or traditional medications at the same time (World Health Organization, 2017).

Age (qualitative): aged ≥ 60 years (U.S. Department of Health and Human Services, 2018).

Settings (qualitative): hospital (patient admitted), skill nursing facility (patient living in SNF or nursing home), community (other place different of SNF or nursing home or admitted in a hospital).

Medication: Therapeutic group base on the active(s) ingredients and their mechanism of action (Alexander, 2013). Qualitative variable.

Morbidity: as appears in each study. Qualitative variable

Operationalization: Relation polypharmacy with age, relation polypharmacy with disease, relation polypharmacy with setting.

Reliability.

According to Mark S. Litwin, “Reliability statistical measure of how reproducible the survey instrument’s data are”. In this study, reliability will be assessed by internal consistency. Correlation coefficient (r values) will be used, considering “good vales” ≥ 0.70 (Litwin, 1995). (P. 8-30)

Validity.

Validity will be evaluating content, criterion, concurrent, construct validity. Correlation coefficient (r values) will be used, considering “good vales” ≥ 0.70 (Litwin, 1995). (P 33-44)

Population. Investigations that studied polypharmacy in people aged ≥ 65 years (119 academic articles)

Sample. 42 academic articles (2014-2018)

Protection of rights of human according to IRB criteria.

This proposal has been using existing data from previous studies. Therefore, it is not necessary to record identifiable information. The proposal will be evaluated by IRB to be considered for exempt review.

Project Evaluation Results

The prevalence of polypharmacy in older adults will be summarized by assessing the references selected from CINAHL database. The systematic review will assess investigations available in full text that studied people ≥ 65 years exposed to polypharmacy and include information about: settings (hospital, nursing facility and home), morbidity and medication. Then, the relationship between polypharmacy will be assessed, considering the different scenarios with morbidity and medication.

This systematic review will include all articles from CINAHL database published from 2014 to 2018 that include polypharmacy in older adults, and elderly as key words.

Exclusion criteria: abstracts, articles for continue education, patient teaching, case study, articles of opinion, protocols, systematic reviews, are written in other language than English, duplicated, not provide information about polypharmacy in older adults.

Using secondary data, a database has been built in Excel. Data analysis will be executed using RStudio software, to be able to get results. Results will be present in tables and graphs that will summarize the results.

In this project, PI will obtain all data from different literature review, after that the information will be available in Appendix’s A and B.

Appendix A will be a summary of primary research evidence and includes a citation, the question of hypothesis, theoretical foundation, research design (include tools) and sample size, key findings recommendations/implications and level of evidence.

Appendix B will be a summary of systematic reviews and include a citation, question, search strategy, inclusion/exclusion criteria, data extraction and analysis, key findings, recommendation/implications and level of evidence.

I will process all the data obtained through dissertation literature review. This data will be reflected in tables to discuss and reach the conclusions of the project.

Plans for Dissemination

The results of the project should be shared at the school level, communities of interest, scientific communities and the community at large. First, the results of the project would be presented in the educational institution where the review was designed. During the presentation, the PI will invite nurses from healthcare facilities nearby. PI will present the information in a keynote lecture. PI will provide the Power Point presentations to people who would be interested in it. It is important to consider the feedback of stakeholders for assessing the implication in the nursing practice. Professional nurses might help indicate possible gaps and limitations of the review and directions for further researches.

Second, the PI has an intention to publish the systematic literature review in a professional peer-reviewed journal. After this, the community would get the access to project results at the regional, national, and international levels. Finally, PI is going to present the results of literature analysis in the scientific conferences.

Discussion and Implications for Nursing and Healthcare

Aging, comorbidities and polypharmacy are facts that challenge public health today. Polypharmacy in the elderly could be the result of the need of treat comorbid conditions in a person. On the other hand, polypharmacy can also lead to the acquisition of new diseases. In the worse scenario polypharmacy could be also, the result of inappropriate prescriptions. Therefore, polypharmacy can be avoided. This is where the nurse practitioner plays a crucial role. Consequently, this professional need: a strong body of knowledge in pharmacology, a great ability in the art of obtaining information from the patient and / or the caregiver, and enough skill to perform physical assessment in order obtain accurate information regarding possible adverse effects, medication interactions and drug effectiveness in the patient. The elderly is more predisposed to to adverse drug reactions and drug-drug interactions since physiological changes and multiple comorbidities occur. Therefore, nurses should be alert to these characteristics and apply the best scientific evidence on drug use in any patient and especially for the elderly. The result of this research will provide new evidences that can improve the medication management in older patients and impact positively the elderly’s quality of life.

Summary and Conclusion

This document pretends to summarize important aspects of polypharmacy in older adults. This text can divide in major subjects. First, why is important to study polypharmacy in older adults? This includes: actuality and signification of practice problem. Second, what is going to be study? Here is found the purpose and object of study, research question and objectives, theoretical framework a synthesis of literature review, practice recommendation, How the study will be performed? Setting and methodology describe the subject, the setting, operationalization of variables and treatment of the data and project evaluation results. The implications for nursing and healthcare are the expected impact of the result in the practice.

Appendixes

Appendix A

Summary of Primary Research Evidence

Legend:

Level I: systematic reviews or meta-analysis Level II:  well-designed Randomized Controlled Trial (RCT)  Level III:  well-designed controlled trials without randomization, quasi-experimental  Level IV:  well-designed case-control and cohort studies  Level V: systematic reviews of descriptive and qualitative studies  Level VI:  single descriptive or qualitative study  Level VII: opinion of authorities and/or reports of expert committees

Appendix B

Summary of Systematic Reviews (SR)

Legend:

Level I: systematic reviews or meta-analysis Level II:  well-designed Randomized Controlled Trial (RCT)  Level III:  well-designed controlled trials without randomization, quasi-experimental  Level IV:  well-designed case-control and cohort studies  Level V: systematic reviews of descriptive and qualitative studies  Level VI:  single descriptive or qualitative study  Level VII: opinion of authorities and/or reports of expert committees

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