428 CHAPTER 6 SUMMARY Background The prevalence of multimorbidity and polypharmacy is increasing in the ageing population, and both are important risk factors for drug-related harm, such as drugrelated hospital admissions. Previous studies have reported that 10%–30%of all hospital admissions in older people are drug-related, half of which are potentially preventable. Several tools, such as the Screening Tool of Older Person’s Prescriptions (STOPP) and the Screening Tool to Alert to the Right Treatment (START) criteria, have been developed to detect potentially inappropriate prescribing in multimorbid older people to improve medication appropriateness and prevent adverse outcomes. To incorporate such tools into daily clinical practice, the application of software assistance has gained attention in facilitating medication optimisation. However, previous studies investigating pharmacotherapy optimisation interventions in older people reported inconsistent results on improved clinical outcomes. In this thesis, we focus on strategies for medication optimisation in hospitalised, multimorbid older people with polypharmacy and evaluate the effectiveness of a software-assisted in-hospital medication review on clinical outcomes. Applicability of tools for medication optimisation in hospitalised older people In Chapter 2, the applicability of medication optimisation tools recommended by clinical practice guidelines was investigated. The performance of a trigger tool recommended by the Dutch geriatric guideline for detecting adverse drug reactions (ADRs) was evaluated in a cross-sectional study in Chapter 2.1. This trigger tool lists combinations of clinical events and drugs frequently associated with drugrelated hospital admissions in older people. In 73% (n = 253/345) of patients with polypharmacy acutely admitted to the geriatric ward, 941 trigger-drug combinations listed in the ADR trigger tool were present. The fall, delirium, renal insufficiency and hyponatraemia triggers covered 86% (n = 810/941) of all trigger-drug combinations. After causality assessment based on the WHO-UMC criteria, 393 of 941 trigger-drug combinations were considered ADRs with at least possible causality, resulting in an overall positive predictive value (PPV) of 42%. However, the PPV for individual triggers was highly variable, ranging from0% to 100%. Usual care at the geriatric ward recognised the majority of ADRs (84%), increasing to 97% when restricted to ADRs with a ‘probable’ or ‘certain’ causality score.
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