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Refereed/Peer-reviewed Introduction: Studies have shown that use of medicines with sedative or anticholinergic properties is associated with a decline in physical function; however, the effects have not been quantified, and it is not known how and which specific physical movements are affected. This prospective study quantified the impact of a change in sedative or anticholinergic load over time on 24-hour activity composition. Methods: This study used data collected from a randomised trial assessing an ongoing pharmacist service in residential aged care. The 24-hour activity composition of sleep, sedentary behaviour, light-intensity physical activity, and moderate to vigorous physical activity was derived from 24-hour accelerometry bands. Mixed effect linear models were used to regress the multivariate outcome of 24-hour activity composition on medication load at baseline and at 12 months. A fixed effect interaction between trial stage and medication load was included to test for differing sedative or anticholinergic load effects at the two trial stages. Results: Data for 183 and 85 participants were available at baseline and 12 months respectively. There was a statistically significant interaction between medication load and time point on the multivariate outcome of 24-hour activity composition (sedative F = 7.2, p < 0.001 and anticholinergic F = 3.2, p = 0.02). A sedative load increase from 2 to 4 over the 12-month period was associated with an average increase in daily sedentary behaviour by an estimated 24 min. Conclusion: As sedative or anticholinergic load increased, there was an increase in sedentary time. Our findings suggest wearable accelerometry bands are a possible tool for monitoring the effects on physical function of sedative and anticholinergic medicines. Trial registration: The ReMInDAR trial was registered on the Australian and New Zealand Trials Registry ACTRN12618000766213.

BackgroundHealth emergencies disproportionally affect vulnerable populations. Digital tools can help primary care providers find, and reach, the right patients.AimTo evaluate whether digital interventions delivered directly to GPs’ clinical software were more effective at promoting primary care appointments during the COVID-19 pandemic than interventions delivered by post.Design and settingReal-world, non-randomised, interventional study involving GP practices in all Australian states.MethodIntervention material was developed to promote care coordination for vulnerable older veterans during the COVID-19 pandemic, and sent to GPs either digitally to the clinical practice software system or in the post. The intervention material included patient-specific information sent to GPs to support care coordination, and education material sent via post to veterans identified in the administrative claims database. To evaluate the impact of intervention delivery modalities on outcomes, the time to first appointment with the primary GP was measured; a Cox proportional hazards model was used, adjusting for differences and accounting for pre-intervention appointment numbers.ResultsThe intervention took place in April 2020, during the first weeks of COVID-19 social distancing restrictions in Australia. GPs received digital messaging for 51 052 veterans and postal messaging for 26 859 veterans. The digital group was associated with earlier appointments (adjusted hazard ratio 1.38 [1.34 to 1.41]).ConclusionData-driven digital solutions can promote care coordination at scale during national emergencies, opening up new perspectives for precision public-health initiatives.

Background: Aged care residents are vulnerable to the harmful effects of medicines; however, data on the prevalence and preventability of adverse medicine events in aged care residents are scarce. Aim: To determine the prevalence and preventability of adverse medicine events in Australian aged care residents. Methods: A secondary analysis of data from the Reducing Medicine-Induced Deterioration and Adverse Reactions (ReMInDAR) trial was conducted. Potential adverse medicine events were identified and independently screened by two research pharmacists to produce a short-list of potential adverse medicine events. An expert clinical panel reviewed each potential adverse medicine to determine the likelihood that the event was medicine related (based on the Naranjo Probability Scale criteria). The clinical panel assessed preventability of medicine-related events using Schumock-Thornton criteria. Results: There were 583 adverse events due to medicines, involving 154 residents (62% of the 248 study participants). There was a median of three medication-related adverse events (interquartile range [IQR] 1–5) per resident over the 12-month follow-up period. The most common medication-related adverse events were falls (56%), bleeding (18%) and bruising (9%). There were 482 (83%) medication-related adverse events that were preventable, most commonly falls (66% of preventable adverse medicine events), bleeding (12%) and dizziness (8%). Of the 248 residents, 133 (54% of the cohort) had at least one preventable adverse medicine event, with a median of 2 (IQR 1–4) preventable adverse medicine events per resident. Conclusion: In total, 62% of aged care residents in our study had an adverse medicine event and 54% had a preventable adverse medicine event in a 12-month period. Refereed/Peer-reviewed

Introduction: Medicines acting on the central nervous system can increase the risk of postoperative delirium, but the specific medicines associated with greatest risk remain unclear. Objectives: We aimed to examine the risk of individual central nervous system-acting medicines used preoperatively on delirium after hip or knee surgery. Methods: A matched case-control study was conducted using data from the Australian Government Department of Veterans’ Affairs. We included people aged 65 years or older who had knee or hip surgery between 2000 and 2019. People with hip or knee surgery who developed postoperative delirium were cases and controls were people with hip or knee surgery but who did not develop postoperative delirium. Use of medicines including anxiolytics, sedatives, and hypnotics, opioid analgesics and antidepressants prior to surgery was compared between cases and controls. Results: A total of 2614 patient cases with postoperative delirium were matched by same sex, age (±2 years), and year of admission (±2 years) with 7842 controls without postoperative delirium. Cases were more likely to be exposed to nitrazepam (odds ratio [OR] = 1.81, 95% confidence interval [CI] 1.24–2.64), sertraline (OR = 1.50, 95% CI 1.20–1.87), mirtazapine (OR = 1.38, 95% CI 1.11–1.74), venlafaxine (OR = 1.42, 95% CI 1.02–1.98), citalopram (OR = 1.54, 95% CI 1.19–1.99), escitalopram (OR = 1.42, 95% CI 1.06–1.89) or fluvoxamine (OR = 5.01, 95% CI 2.15–11.68) prior to surgery than controls. At the class level, exposure to benzodiazepines (OR = 1.20, 95% CI 1.05–1.37) and antidepressants (OR = 1.64, 95% CI 1.47–1.83) prior to surgery was significantly higher in cases than in controls. The numbers needed to treat to harm for one additional delirium case were 43 for sertraline, 40 for citalopram, 57 for mirtazapine and 26 for nitrazepam. Whereas, the numbers needed to treat to harm were found to be 20 for sertraline, 17 for citalopram, 19 for mirtazapine and 10 for nitrazepam in the 85 years or older age group, indicating that the harmful effect of these medicines is pronounced as age advances. Conclusions: People who developed delirium following hip or knee surgery were more likely to be exposed to nitrazepam, sertraline, mirtazapine, venlafaxine, citalopram, escitalopram or fluvoxamine at the time of admission for surgery. Planning to reduce use of these medicines well prior to surgery may decrease the risk of postoperative delirium. Refereed/Peer-reviewed

Purpose: This study aimed to compare the utilization of Alzheimer’s disease (AD) treatments, donepezil, galantamine, rivastigmine, and memantine, in Korea with Australia and other countries with universal health coverage. Methods: Reimbursement criteria and the patent status of four AD treatments in Korea and Australia were reviewed.The monthly spending and utilization of the treatments were extracted from the national electronic database in Korea and Australia. The defined daily dose per 1000 elderly population per day (DDD/1000e/day) were calculated from July 2008 to June 2019. Annual cost trends of Norway and England were compared with Korea and Australia. Results: With the highest share of the use of donepezil in both countries, the cost and utilization of AD treatments in Korea increased more rapidly and remained higher than Australia. The cost of AD treatments in Korea increased by 15.5% every year during the study period, while the spending of the same drugs in Australia decreased by 10.5%annually. The utilization in DDD/1000e/day of AD treatments in Korea increased by 18.3% annually compared with 1.4% in Australia. When compared with Norway and England, countries with similar universal health coverage (UHC) system and elderly polupation, the cost of AD treatments in Korea was still higher with the opposite trendfrom other countries. Conclusions: Despite the similar UHC systems, there were considerable differences in the post-market utilization of AD treatments in Korea from Australia and other countries. This results can be attributed to differences in re-assessment system, pricing and reimbursement policies, and prescribing culture. This study provides a baseline to explore more comprehensive crosscountry studies on rational use of medicines. Refereed/Peer-reviewed

Background: Polypharmacy has been associated with increased mortality but the contribution of different medication-related factors to this is unknown. Aims: The aim of this study was to identify demographic and medication-related predictors of mortality in the older population. Given the intrinsic link between polypharmacy and multimorbidity, the secondary aim was to examine if the medicines or underlying diseases predicted mortality. Methods: Patients aged ≥ 65 years from an outpatient multimorbidity clinic were included. Medication-related factors included the medicines count, high-risk medicines, inappropriate medicines duplication, and potential drug–drug and drug–disease interactions. Logistic regression was used to identify mortality predictors within a year of clinic discharge from the outpatient clinic. Patients attend the clinic until medications and comorbidity management have been optimised, at which point they are discharged from the clinic, and their General Practitioner provides ongoing care. Results: A total of 584 patients were included (median age 80.0 years) and 9.9% (n = 58) died within a year of discharge. Demographics, namely age (adjusted odds ratio [aOR] 1.05; 95% CI 1.01–1.09; p = 0.018) and being male (aOR 5.10; 95% CI 2.63–9.88; p < 0.001); chronic disease, namely heart failure (aOR 3.36; 95% CI 1.78–6.35; p < 0.001); and medication-related factors, namely the number of sedative and anticholinergic medicines (aOR 1.66; 95% CI 1.19–2.33; p = 0.003) predicted mortality in the study population. Conclusion: Whilst polypharmacy has been defined using the number of medicines in the literature, a combination of demographics, chronic disease and medications predicted mortality in our study. This provides guidance for the development of future tools and guidelines regarding the inclusion of key factors for identifying high-risk patients at risk of adverse health outcomes such as mortality. Refereed/Peer-reviewed

AIMS: To determine the prevalence of potentially inappropriate medication (PIM) use at hospital admission and discharge, and the contribution to hospital admission among residential aged care facility (RACF) residents with and without dementia. METHODS: We conducted a secondary analysis using data from a multi‐hospital prospective cohort study involving consecutively admitted older adults, aged 75 years or older, who were taking five or more medications prior to hospital admission and discharged to a RACF in South Australia. PIM use was identified using the 2015 Screening Tool for Older Persons’ Prescription (STOPP) and 2019 Beers Criteria. An expert panel of clinicians with geriatric medicine expertise evaluated the contribution of PIM to hospital admission. RESULTS: In total, 181 participants were included, the median age was 87.5 years and 54.7% were female. Ninety‐one (50.3%) had a diagnosis of dementia. Participants with dementia had less PIMs, according to at least one of the two screening criteria, than those without dementia, at admission (dementia: 76 (83.5%) vs no dementia: 84 (93.3%), p=0.04) and discharge (78 (85.7%) vs 83(92.2%), p=0.16). PIM use was causal or contributory to the admission in 28.1% of study participants (n=45) who were taking at least one PIM at admission. CONCLUSIONS: Over 80% of acutely admitted older adults took PIMs at hospital admission and discharge and for over a quarter of these people the admissions were attributable to PIM use. Hospitalisation presents an opportunity for comprehensive medication reviews, and targeted interventions that enhance such a process could reduce PIM use and related harm. Refereed/Peer-reviewed

The COVID-19 (Coronavirus Disease-2019) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), poses a serious risk to older adults’ health worldwide. As of April 17th 2020, there are over 1.9 million confirmed cases with 131,037 deaths 1. Most deaths in China, the United States (US) and Europe (Italy, Spain, Germany) occurred among adults aged ≥ 60years2-4. Multimorbidity, the co-occurrence of two or more chronic conditions 5, and polypharmacy, the use of five or more medicines, are highly prevalent in older adults 6. Achieving optimal medication use in this population is complex and challenging under normal circumstances. Given the disproportionate effect of COVID-19 on older adults, particularly those with multimorbidity, this challenge only increases. In this article, we therefore aim to highlight considerations to support safe medication use in older adults during the current COVID-19 pandemic. Refereed/Peer-reviewed

Background There is increasing interest in the development and use of clinical prediction models, but a lack of evidence-supported guidance on the merits of different modelling approaches. This is especially true for time-to-event outcomes, where limited studies have compared the vast number of modelling approaches available. This study compares prediction accuracy and variable importance measures for four modelling approaches in prediction of time-to-revision surgery following total knee arthroplasty (TKA) and total hip arthroplasty (THA). Methods The study included 321,945 TKA and 151,113 THA procedures performed between 1 January 2003 and 31 December 2017. Accuracy of the Cox model, Weibull parametric model, flexible parametric model, and random survival forest were compared, with patient age, sex, comorbidities, and prosthesis characteristics considered as predictors. Prediction accuracy was assessed using the Index of Prediction Accuracy (IPA), c-index, and smoothed calibration curves. Variable importance rankings from the Cox model and random survival forest were also compared. Results Overall, the Cox and flexible parametric survival models performed best for prediction of both TKA (integrated IPA 0.056 (95% CI [0.054, 0.057]) compared to 0.054 (95% CI [0.053, 0.056]) for the Weibull parametric model), and THA revision. (0.029 95% CI [0.027, 0.030] compared to 0.027 (95% CI [0.025, 0.028]) for the random survival forest). The c-index showed broadly similar discrimination between all modelling approaches. Models were generally well calibrated, but random survival forest underfitted the predicted risk of TKA revision compared to regression approaches. The most important predictors of revision were similar in the Cox model and random survival forest for TKA (age, opioid use, and patella resurfacing) and THA (femoral cement, depression, and opioid use). Conclusion The Cox and flexible parametric models had superior overall performance, although all approaches performed similarly. Notably, this study showed no benefit of a tuned random survival forest over regression models in this setting.

Background Digital technologies can enable rapid targeted delivery of audit and feedback interventions at scale. Few studies have evaluated how mode of delivery affects clinical professional behavior change and none have assessed the feasibility of such an initiative at a national scale. Objective The aim of this study was to develop and evaluate the effect of audit and feedback by digital versus postal (letter) mode of delivery on primary care physician behavior. Methods This study was developed as part of the Veterans’ Medicines Advice and Therapeutics Education Services (MATES) program, an intervention funded by the Australian Government Department of Veterans’ Affairs that provides targeted education and patient-specific audit with feedback to Australian general practitioners, as well as educational material to veterans and other health professionals. We performed a cluster randomized controlled trial of a multifaceted intervention to reduce inappropriate gabapentinoid prescription, comparing digital and postal mode of delivery. All veteran patients targeted also received an educational intervention (postal delivery). Efficacy was measured using a linear mixed-effects model as the average number of gabapentinoid prescriptions standardized by defined daily dose (individual level), and number of veterans visiting a psychologist in the 6 and 12 months following the intervention. Results The trial involved 2552 general practitioners in Australia and took place in March 2020. Both intervention groups had a significant reduction in total gabapentinoid prescription by the end of the study period (digital: mean reduction of 11.2%, P=.004; postal: mean reduction of 11.2%, P=.001). We found no difference between digital and postal mode of delivery in reduction of gabapentinoid prescriptions at 12 months (digital: –0.058, postal: –0.058, P=.98). Digital delivery increased initiations to psychologists at 12 months (digital: 3.8%, postal: 2.0%, P=.02). Conclusions Our digitally delivered professional behavior change intervention was feasible, had comparable effectiveness to the postal intervention with regard to changes in medicine use, and had increased effectiveness with regard to referrals to a psychologist. Given the logistical benefits of digital delivery in nationwide programs, the results encourage exploration of this mode in future interventions.

Objective To assess the effectiveness of a pharmacist-led intervention using validated tools to reduce medicine-induced deterioration and adverse reactions. Design and setting Multicenter, open-label parallel randomised controlled trial involving 39 Australian aged-care facilities. Participants Residents on ≥4 medicines or ≥1 anticholinergic or sedative medicine. Intervention Pharmacist-led intervention using validated tools to detect signs and symptoms of medicine-induced deterioration which occurred every 8 weeks over 12 months. Comparator Usual care (Residential Medication Management Review) provided by accredited pharmacists. Outcomes Primary outcome was change in Frailty Index at 12 months. Secondary outcomes included changes in cognition, 24-hour movement behaviour by accelerometry, grip strength, weight, adverse events and quality of life. Results 248 persons (median age 87 years) completed the study; 120 in the interventionand, 128 in control arms. In total 575 pharmacist, sessions were undertaken in the intervention arm. There was no statistically significant difference for change in frailty between groups (mean difference: 0.009, 95% CI: −0.028, 0.009, P = 0.320). A significant difference for cognition was observed, with a mean difference of 1.36 point change at 12 months (95% CI: 0.01, 2.72, P = 0.048). Changes in 24-hour movement behaviour, grip strength, adverse events and quality of life were not significantly different between groups. Point estimates favoured the intervention arm at 12 months for frailty, 24-hour movement behaviour and grip strength. Conclusions The use of validated tools by pharmacists to detect signs of medicine-induced deterioration is a model of practice that requires further research, with promising results from this trial, particularly with regards to improved cognition.

Medication-related problems often lead to patient harm. This paper aims to review the Australian literature to determine the overall incidence, severity and preventability of medication-related hospital admissions, as well as providing a national estimate on their extent and cost.The first part of the paper includes a literature search to identify studies that provided estimates of medication-related problems that caused hospital admissions. Incidence of medication-related hospital admissions, type of medication-related problem contributing to admission (e.g. adverse medicine reaction) and method used to estimate incidence (e.g. chart review) were extracted. Data on severity and preventability of the admissions were extracted where available. The second part of the paper involves use of methodological triangulation to estimate the extent and cost of medication-related hospital admission. Median estimates used to assess medication-related hospital admissions and the 2019-2020 national hospital admissions data were used to calculate the national estimate on the extent of medication-related hospital admission. Costs were also estimated.Seventeen studies provided estimates on the extent of medication-related hospital admissions as assessed using medication chart review. The median incidence of 2.5% (interquartile range [IQR] 0.6%) as a proportion of all hospital admissions suggests 275,000 hospital admissions annually in Australia are medication related. The median incidence of 9% (IQR 3.9%) of emergency admissions suggests that 270,000 admissions annually are medication related. Eight studies provided estimates of the extent of medication-related hospital admissions identified from administrative health data; the median incidence of 1.7% with an under-reporting rate of 82% suggests 280,000 hospital admissions annually are medication related. Triangulation of results suggests that at least 250,000 hospital admissions annually in Australia are medication related, with an estimated cost of 1.4 billion Australian dollars (AUD$). Five studies assessed severity, and nine studies assessed preventability. Preventability estimates suggest two-thirds of medication-related hospital admissions are potentially preventable.We estimated that 250,000 hospital admissions in Australia are medication related, with an annual cost of AUD$1.4 billion to the healthcare system. Two-thirds of medication-related hospital admissions are potentially preventable.

Medicines acting on the central nervous system can increase the risk of postoperative delirium, but the specific medicines associated with greatest risk remain unclear.We aimed to examine the risk of individual central nervous system-acting medicines used preoperatively on delirium after hip or knee surgery.A matched case-control study was conducted using data from the Australian Government Department of Veterans' Affairs. We included people aged 65 years or older who had knee or hip surgery between 2000 and 2019. People with hip or knee surgery who developed postoperative delirium were cases and controls were people with hip or knee surgery but who did not develop postoperative delirium. Use of medicines including anxiolytics, sedatives, and hypnotics, opioid analgesics and antidepressants prior to surgery was compared between cases and controls.A total of 2614 patient cases with postoperative delirium were matched by same sex, age (±2 years), and year of admission (±2 years) with 7842 controls without postoperative delirium. Cases were more likely to be exposed to nitrazepam (odds ratio [OR] = 1.81, 95% confidence interval [CI] 1.24-2.64), sertraline (OR = 1.50, 95% CI 1.20-1.87), mirtazapine (OR = 1.38, 95% CI 1.11-1.74), venlafaxine (OR = 1.42, 95% CI 1.02-1.98), citalopram (OR = 1.54, 95% CI 1.19-1.99), escitalopram (OR = 1.42, 95% CI 1.06-1.89) or fluvoxamine (OR = 5.01, 95% CI 2.15-11.68) prior to surgery than controls. At the class level, exposure to benzodiazepines (OR = 1.20, 95% CI 1.05-1.37) and antidepressants (OR = 1.64, 95% CI 1.47-1.83) prior to surgery was significantly higher in cases than in controls. The numbers needed to treat to harm for one additional delirium case were 43 for sertraline, 40 for citalopram, 57 for mirtazapine and 26 for nitrazepam. Whereas, the numbers needed to treat to harm were found to be 20 for sertraline, 17 for citalopram, 19 for mirtazapine and 10 for nitrazepam in the 85 years or older age group, indicating that the harmful effect of these medicines is pronounced as age advances.People who developed delirium following hip or knee surgery were more likely to be exposed to nitrazepam, sertraline, mirtazapine, venlafaxine, citalopram, escitalopram or fluvoxamine at the time of admission for surgery. Planning to reduce use of these medicines well prior to surgery may decrease the risk of postoperative delirium.

Introduction and aims: Mental health disorders and substance abuse are risk factors that both precede and follow chronic opioid use. We predicted that incident opioid users would have lower rates of mental health comorbidities than chronic opioid users, but that incident chronic opioid users would have lower rates of mental health comorbidities than prevalent chronic users.Design and methods: We used administrative health claims data to evaluate differences in lifetime mental health and substance abuse comorbidity profiles of people who were prevalent and incident chronic opioid users, as well as those who used opioids acutely. Results were stratified by age.Results: Over 5,188 people were prevalent chronic opioid users at study entry. Of the 10,079 people who initiated opioids, 10.2 percent had a subsequent chronic episode (incident chronic) and the remainder stopped within 90 days (incident acute). In prevalent chronic users compared to incident chronic users, rates of depression and anxiety were higher across all age groups (odds ratio (OR) across age groups range from = 1.60, 95 percent confidence interval (CI) = 1.35,1.89, to OR = 6.66, 95 percent CI = 3.02, 14.69) and prevalence of alcohol abuse was higher in those aged 55 to 74 years (OR = 5.11, 95 percent CI = 1.83, 14.24, p = 0.002). Acute users were less likely than incident chronic users to have depression and anxiety in those aged over 74 years (depression OR = 0.82, 95 percent CI = 0.70, 0.95; anxiety OR = 0.82, 95% CI 0.70, 0.98).Conclusions: Mental health morbidities commonly associated with chronic opioid use increase in prevalence as chronic use continues. Refereed/Peer-reviewed

BACKGROUND Digital technologies can enable rapid targeted delivery of audit and feedback interventions at scale. Few studies have evaluated how mode of delivery affects clinical professional behavior change and none have assessed the feasibility of such an initiative at a national scale. OBJECTIVE The aim of this study was to develop and evaluate the effect of audit and feedback by digital versus postal (letter) mode of delivery on primary care physician behavior. METHODS This study was developed as part of the Veterans’ Medicines Advice and Therapeutics Education Services (MATES) program, an intervention funded by the Australian Government Department of Veterans’ Affairs that provides targeted education and patient-specific audit with feedback to Australian general practitioners, as well as educational material to veterans and other health professionals. We performed a cluster randomized controlled trial of a multifaceted intervention to reduce inappropriate gabapentinoid prescription, comparing digital and postal mode of delivery. All veteran patients targeted also received an educational intervention (postal delivery). Efficacy was measured using a linear mixed-effects model as the average number of gabapentinoid prescriptions standardized by defined daily dose (individual level), and number of veterans visiting a psychologist in the 6 and 12 months following the intervention. RESULTS The trial involved 2552 general practitioners in Australia and took place in March 2020. Both intervention groups had a significant reduction in total gabapentinoid prescription by the end of the study period (digital: mean reduction of 11.2%, P=.004; postal: mean reduction of 11.2%, P=.001). We found no difference between digital and postal mode of delivery in reduction of gabapentinoid prescriptions at 12 months (digital: –0.058, postal: –0.058, P=.98). Digital delivery increased initiations to psychologists at 12 months (digital: 3.8%, postal: 2.0%, P=.02). CONCLUSIONS Our digitally delivered professional behavior change intervention was feasible, had comparable effectiveness to the postal intervention with regard to changes in medicine use, and had increased effectiveness with regard to referrals to a psychologist. Given the logistical benefits of digital delivery in nationwide programs, the results encourage exploration of this mode in future interventions.

Renal function testing should be performed prior to initiating medicines that require dose adjustment in renal impairment, with ongoing monitoring in continued use, particularly in older people. There is little evidence regarding the extent to which renal function monitoring is performed in older Australians dispensed medicines requiring renal function monitoring.The aim of this study was to determine the extent of renal function testing in older people dispensed medicines requiring renal function monitoring.A retrospective analysis of administrative claims data from the Australian Government Department of Veterans' Affairs was conducted for people aged 65 years or older who were dispensed one or more medicines requiring renal function monitoring, from 1 June 2019 to 30 September 2019, to investigate the proportion of people with a claim for a pathology test that included creatinine levels in the 6-12 months before or after dispensing of a medicine requiring renal function monitoring.There were 100,113 people who were dispensed at least one medicine requiring renal function monitoring during the study period, of whom 15% had a history of renal impairment and 16% had diabetes mellitus. Sixty-one percent had a claim for a test in the prior 6 months; this increased to 80% of participants with a claim for a test in the prior 12 months. The rate of claims for testing was lower in aged care facility residents compared with people living in the community (54% vs 62% in the previous 6 months; p 0.001), and was higher in people with diabetes (75% vs 58%; p 0.001), history of renal impairment (91% vs 59%; p 0.001) or heart failure (77% vs 60%; p 0.001) compared with those without these conditions.Medicines that require renal function monitoring are commonly used in older Australians, and while the majority have claims for tests that include renal function, some are missing out.

Background: Little is known about how clinicians assess polypharmacy in real-world practice. Objectives: To identify which medication-related factors influence clinicians’ ratings of polypharmacy, harm from medicines and deprescribing of medicines when presented with a patient’s list of medications and comorbidities.Setting: A novel website called What Is Polypharmacy Exactly (WIPE) was created with 50 de-identified real-world cases with varying numbers of comorbidities and medicines.Methods: Participants, consisting of physicians and pharmacists were asked to rate each case from zero (lowest) to 10 (highest) on three questions: i) degree of polypharmacy, ii) potential for medication-related harm and iii) potential to deprescribe medicines. Medication-related factors including medicines count, high-risk medicines, inappropriate duplication, drug-drug and drug-disease interactions were assessed. Multiple linear regression was used to determine which medication-related factors influenced median ratings for the three questions. Main outcome measures: The primary outcome measure was the median rating for the degree of polypharmacy for each case. Secondary outcome measures were the median rating for the potential for harm from medicines for each case and median rating for the potential to deprescribe medicines for each case. Results: Ninety-two clinicians were included in the study, comprising of 76.1% pharmacists (n=70) and 23.9% physicians (n=22). The comorbidity count (P=0.001), medicines count (PP=0.017), high-risk medicines (P=0.049), use of NSAIDs (P=0.032) and antihypertensives (P=0.040) were predictive of the perceived degree of polypharmacy. The comorbidity count (PPP=0.016) and high-risk medicines (P=0.036) were predictive of the recognised potential for medication-related harm. The medicines count (PP=0.017), benzodiazepine use (P=0.003) and antipsychotic use (P=0.039) were predictive of the recognised potential to deprescribe medicines. Conclusion: Whilst polypharmacy has traditionally been defined using the medicines count, our findings suggest that clinicians also consider other factors such as high-risk medicines and inappropriate medicines duplication to identify patients at risk of adverse outcomes. Future polypharmacy assessment tools should additionally include these factors.

Objective: To determine the prevalence of medication- related hospitalisations pre-ceded by potentially suboptimal processes of care in aged care residents Method: We conducted a retrospective analysis of administrative claims data from the Australian Government Department of Veterans’ Affairs (DVA). We identified all hospital admissions for aged care residents between 1 July 2014 and 30 June 2019. The proportion of hospital admissions preceded by potentially suboptimal medication- related processes of care was determined Results: A total of 18874 hospitalisations were included, and 46% were preceded by potentially suboptimal medication- related care. One- quarter of fracture admissions occurred in residents at risk of fracture who were not using a medicine to prevent fracture, and 87% occurred in residents using falls- risk medicines. Thirty per cent of heart failure admissions occurred in patients who were not using an angiotensin- converting enzyme inhibitor or angiotensin receptor blocker Conclusion: Nearly half of hospital admissions were preceded by potentially sub-optimal medication- related processes of care. Interventions to improve use of medi-cines for aged care residents in these areas are warranted. Refereed/Peer-reviewed

The Veterans' Medicines Advice and Therapeutics Education Services (MATES) program is a national data driven, behaviorally informed, health intervention to improve the use of medicines among Australian veterans. The program, which has been operating since 2004, has led the way in the use of government held data assets to generate evidenced-based health information, which, when provided to clinicians alongside educational materials, can make demonstrable improvements in health and promote practice change.

Introduction: Renal function testing should be performed prior to initiating medicines that require dose adjustment in renal impairment, with ongoing monitoring in continued use, particularly in older people. There is little evidence regarding the extent to which renal function monitoring is performed in older Australians dispensed medicines requiring renal function monitoring. Objective: The aim of this study was to determine the extent of renal function testing in older people dispensed medicines requiring renal function monitoring. Methods: A retrospective analysis of administrative claims data from the Australian Government Department of Veterans’ Affairs was conducted for people aged 65 years or older who were dispensed one or more medicines requiring renal function monitoring, from 1 June 2019 to 30 September 2019, to investigate the proportion of people with a claim for a pathology test that included creatinine levels in the 6–12 months before or after dispensing of a medicine requiring renal function monitoring. Results: There were 100,113 people who were dispensed at least one medicine requiring renal function monitoring during the study period, of whom 15% had a history of renal impairment and 16% had diabetes mellitus. Sixty-one percent had a claim for a test in the prior 6 months; this increased to 80% of participants with a claim for a test in the prior 12 months. The rate of claims for testing was lower in aged care facility residents compared with people living in the community (54% vs 62% in the previous 6 months; p < 0.001), and was higher in people with diabetes (75% vs 58%; p < 0.001), history of renal impairment (91% vs 59%; p < 0.001) or heart failure (77% vs 60%; p < 0.001) compared with those without these conditions. Conclusion: Medicines that require renal function monitoring are commonly used in older Australians, and while the majority have claims for tests that include renal function, some are missing out. Refereed/Peer-reviewed

Refereed/Peer-reviewed Use of psychotropic medicines such as antipsychotics, antidepressants, and anxiolytics is common in children with autism spectrum disorder (ASD); however, very little is known about medicine use in adults with ASD. This pilot project aimed to describe medicines use in Australian adults with ASD. We conducted a retrospective analysis of mental health care plan records for adults with a confirmed diagnosis of ASD from a single metropolitan psychology practice. One hundred and twenty one of the 168 participants (72%) were taking at least one medicine. Fifty-nine of the 168 persons whose care plans were reviewed (35%) were taking an antidepressant, the most frequently prescribed psychotropic medicine. Twenty-three (14%) were prescribed a medicine for airways disease, most commonly salbutamol. Antipsychotics were used by 11% and anxiolytic/hypnotics by 10%. The most commonly used antidepressants were sertraline and escitalopram (21 and 19% of antidepressant users, respectively). The most commonly used antipsychotics were quetiapine and risperidone (32% and 27%, respectively). This pilot project has highlighted that use of psychotropic medicines is common in adults with ASD.

ObjectivesTo evaluate the impact of a patient-specific national programme targeting older Australians and health professionals that aimed to increase use of emollient moisturisers to reduce to the risk of skin tears.DesignA prospective cohort intervention.ParticipantsThe intervention targeted 52 778 Australian Government’s Department of Veterans’ Affairs patients aged over 64 years who had risk factors for wound development, and their general practitioners (GPs) (n=14 178).Outcome measuresAn interrupted time series model compared the rate of dispensing of emollients in the targeted cohort before and up to 23 months after the intervention. Commitment questions were included in self-report forms.ResultsIn the first month after the intervention, the rate of claims increased 6.3-fold (95% CI: 5.2 to 7.6, pConclusionsThe intervention had a sustained effect over 23 months. Veterans who responded positively to commitment questions had higher uptake of emollients than those who did not.

IntroductionMany medicines have adverse effects which are difficult to detect and frequently go unrecognised. Pharmacist monitoring of changes in signs and symptoms of these adverse effects, which we describe as medicine-induced deterioration, may reduce the risk of developing frailty. The aim of this trial is to determine the effectiveness of a 12-month pharmacist service compared with usual care in reducing medicine-induced deterioration, frailty and adverse reactions in older people living in aged-care facilities in Australia.Methods and analysisThe reducing medicine-induced deterioration and adverse reactions trial is a multicentre, open-label randomised controlled trial. Participants will be recruited from 39 facilities in South Australia and Tasmania. Residents will be included if they are using four or more medicines at the time of recruitment, or taking more than one medicine with anticholinergic or sedative properties. The intervention group will receive a pharmacist assessment which occurs every 8 weeks. The pharmacists will liaise with the participants’ general practitioners when medicine-induced deterioration is evident or adverse events are considered serious. The primary outcome is a reduction in medicine-induced deterioration from baseline to 6 and 12 months, as measured by change in frailty index. The secondary outcomes are changes in cognition scores, 24-hour movement behaviour, grip strength, weight, percentage robust, pre-frail and frail classification, rate of adverse medicine events, health-related quality of life and health resource use. The statistical analysis will use mixed-models adjusted for baseline to account for repeated outcome measures. A health economic evaluation will be conducted following trial completion using data collected during the trial.Ethics and disseminationEthics approvals have been obtained from the Human Research Ethics Committee of University of South Australia (ID:0000036440) and University of Tasmania (ID:H0017022). A copy of the final report will be provided to the Australian Government Department of Health.Trial registration numberAustralian and New Zealand Trials Registry ACTRN12618000766213.

Introduction: People with dementia may be particularly susceptible to medication-related problems for various reasons. They include progressive cognitive decline, high sensitivity to the effect of medications on cognition and memory, and increased likelihood of comorbidities. Areas covered: This paper aimed to review current literature on the frequency and the types of medication-related problems, and their contribution to hospital admission in people with dementia. Literature searches were conducted using key search terms of dementia and medication-related problems. Studies investigating any medication-related problems in people with dementia or cognitive impairment were included. Expert opinion: Previous research showed a high prevalence of medication-related problems in people with dementia. However, no single category of medication-related problems was reported consistently as the most frequent type across studies. The available studies also showed that medication-related hospitalization was common among people with dementia. These findings underline the need for effective medication management services to reduce the risk of these problems in people with dementia and cognitive impairment. Further work is required to characterize medication-related problems comprehensively in this vulnerable patient group across settings of care. Future research should take a holistic approach in the identification of medication-related problems. Refereed/Peer-reviewed

For permissions. Initial assessment Older people are at increased risk of medication-related potentially preventable hospitalizations (MR-PPH) due to the presence of multiple chronic conditions (multimorbidity) and subsequent polypharmacy. Choice of solution A pilot study was conducted, using evidence-based indicators to detect older patients in a chronic disease management program (CDMP) at risk of hospitalization due to sub-optimal medication use. Implementation Previously validated indicators for MR-PPH were applied to patients with multimorbidity, aged 65 years or older and who were enrolled in a national community-based CDMP. Nurse-led telephone interviews and case note abstraction were used as data sources. Evaluation Nineteen patients triggered the MR-PPH indicators 85 times with a median of four per patient. Sub-optimal medication management was identified 34 times (40%) with a median of two per patient. The most common reasons for sub-optimal medication management were exposure to medications associated with falls, underuse of angiotensin-converting enzyme inhibitor/angiotensin-2 receptor blocker medications for cardiovascular disease and low rates of hemoglobin A1c and renal monitoring in patients with diabetes. Lessons learned This study has shown the utility of MR-PPH indicators within a CDMP to identify and monitor sub-optimal medication-related care. Implementation and ongoing monitoring of these types of indicators can support the development of targeted programs to reduce the ongoing risk of adverse events in the older population and improve the overall quality of life. Refereed/Peer-reviewed

Background: Medicines are potentially modifiable risk factors for postoperative delirium. However, the extent to which preoperative medicines are included in risk prediction models (RPMs) is unknown. Objective: This systematic review aimed to assess the extent of inclusion of preoperative medications in RPMs for postoperative delirium. Methods: Articles were systematically searched from MEDLINE, EMBASE and CINAHL using Medical Subject Headings (MeSH) where possible and keywords for postoperative delirium and prediction model. Studies published until May 2017 with a primary outcome of postoperative delirium that developed an RPM containing preoperative patient information were considered. Where a study had two cohorts, a derivation and a validation cohort, findings from the derivation cohort were extracted and reported. Results: Eighteen prospective and one retrospective cohort studies were included for review. Of the 19 studies, only nine considered preoperative medication data, with medications appearing as predictor variables in five models. There was wide variability in the factors included in the final models, with the most frequent predictors being age and cognitive impairment, appearing in 13 (68%) and 11 (58%) RPMs, respectively. Conclusion: While medications are commonly cited risk factors for delirium, they are not adequately considered when developing RPMs. Future studies aiming to develop an RPM for postoperative delirium should include preoperative medication data as a potential predictor variable because of the modifiable nature of medication use and its impact on other factors commonly in models, such as cognition. Refereed/Peer-reviewed

Background: This systematic review aims to summarise available patient-reported questionnaires to detect adverse drug reactions (ADRs) that can be utilised by healthcare professionals in clinical practice and to summarise the psychometric properties (validity, reliability, and responsiveness) of the questionnaires. Methods: A systematic literature search was conducted using Medline, Pubmed, Embase, and Emcare databases to screen for articles published between January 2000 and July 2020. Data items regarding validity, reliability, and responsiveness were extracted independently by two authors. The methodological quality was assessed using the COSMIN (Consensus-Based Standards for the Selection of Health Measurement Instruments) checklist. Results: A total of 1563 unique article titles were identified after removing duplicates. Following shortlisting of relevant articles, 19 patient-reported ADR questionnaires were identified. Questionnaires most commonly focused on mental health medications (42.1%, n = 8), followed by general questionnaires applicable to any medication (21.1%, n = 4). Many questionnaires did not report assessing the validity and reliability of the measurement tool. For example, only 11 questionnaires (58%) mentioned assessing content validity, in addition to criterion or construct testing. Conclusion: This systematic review summarised the available patient-reported questionnaires that can be used in research and clinical practice to identify ADRs. Results of this systematic review highlight the need for more robust validity and reliability testing when developing patient-reported ADR questionnaires. Refereed/Peer-reviewed

Background: Delirium is a serious condition in which medications are just one of a number of potential predisposing or precipitating factors. Adequate knowledge of delirium among all healthcare professionals, including pharmacists, may assist in effective prevention and management. However, little is known about the knowledge of pharmacists regarding delirium. Aim: To assess Australian hospital pharmacists’ knowledge of risk factors, symptoms, prevention and treatment of delirium in elderly patients. Method: A cross-sectional survey was conducted via a web-based questionnaire to collect information on participants’ demographics, knowledge of delirium risk factors, symptoms, prevention and treatment. A link to the survey was included in the newsletters of The Society of Hospital Pharmacists of Australia, Australasian Delirium Association and New South Wales Therapeutic Advisory Group and distributed to hospital pharmacists in Australia via email. Results: One-hundred and six responses from hospital pharmacists were available for analysis. Nine of 11 questions assessing basic knowledge were correctly answered by more than half of respondents. Seven of the eight questions related to delirium prevention strategies were correctly answered by more than half of pharmacists. However, only three of the eight questions about risk factors for delirium were answered correctly by more than half of pharmacists. Conclusion: Pharmacists’ basic knowledge about delirium and prevention strategies was good; however, their knowledge of risk factors and symptoms of delirium needs to be improved. Delirium-specific educational programs for pharmacists should be considered for improving their knowledge and understanding regarding delirium. Refereed/Peer-reviewed

Refereed/Peer-reviewed

Objective: To identify demographic and medication-related predictors of unplanned hospitalisation and combine them into a hospitalisation risk score.Methods: Patients aged ≥65 years from an outpatient multimorbidity clinic were included. Hospitalisation predictors within a year of clinic discharge were identified using logistic regression. A risk score was developed. The area under the curve(AUC) was used to assess its predictive ability, compared to that of the medicines count (definition of polypharmacy). Results: A total of 598 patients were included (median age of 80.0 years). 58.0%(n = 347) were hospitalised within a year of clinic discharge. The AUC for the risk score incorporating age, medicines count, heart failure (HF), atherosclerotic disease and systemic steroids was 0.67 [95% CI 0.62-0.71], compared to 0.62 [95% CI 0.58-0.67] for the medicines count. Conclusion: A hospitalisation risk score incorporating demographics, medicines,namely steroids, and diseases such as HF had increased predictive ability compared to the medicines count, providing guidance for developing future polypharmacy tools. Refereed/Peer-reviewed

Background: In the literature, polypharmacy is commonly defined as using five or more medicines. Little is known about how physicians and pharmacists define and assess polypharmacy in practice.Aim: This study determined how expert physicians and pharmacists define and assess polypharmacy in practice.Methods: An online survey was sent to 25 expert physicians and pharmacists who were chosen if they had done significant work in the area of polypharmacy through major research, clinical practice or both, to identify how experts define and assess polypharmacyin practice. Results: Twenty-two participants completed the survey (88% response rate). There was strong agreement between experts, including which factors are important when assessing polypharmacy (intraclass correlation coefficient = 0.94). Respondents used the numberof medicines (n = 18 respondents; 56.3% of all definitions), such as five or more medicines, and brief descriptions (n = 4 respondents;43.7% of all definitions), such as assessing appropriateness given comorbidities, to define polypharmacy. Respondents commonly indicated patient factors such as functional status (n = 11 respondents; 50%) and medicine-related factors such as drug-drug interactions(n = 11; 50%) as important when assessing polypharmacy. Experts reported low use of externally validated polypharmacy tools during polypharmacy assessment, with 36.4% (n = 8) being unfamiliar with or never or rarely using these tools.Conclusion: Medication- and patient-related factors beyond a medicines count were deemed important in assessing polypharmacy. Given the low use of externally validated polypharmacy tools, strategies that include important medication- and patient-related factors are required to facilitate polypharmacy rationalisation. Refereed/Peer-reviewed

Objectives Medications with anticholinergic or sedative effects are frequently used by older people but can increase risk of falls and adverse events; however, less is known about their effect on movement behaviour. Here we examine the cross-sectional association between medication use and movement behaviour in older adults living in residential aged care. Materials and Methods Twenty-eight older adults living in residential aged care in metropolitan Australia participated. Medication data were collected from participants’ medical charts and sedative load and anticholinergic burden were determined. Seven-day movement behaviour was objectively assessed by a wrist-worn triaxial accelerometer. Raw accelerations were converted to sleep, sedentary time, and time in light, moderate, and moderate-to-vigorous physical activity. To explore the relationship between medication and movement behaviour, Spearman’s Rho correlations were conducted, as the data were not normally distributed. Results Analyses indicated that while anticholinergic burden was not associated with movement behaviour, sedative load was negatively correlated with a number of variables, accounting for 14% variance in moderate-to-vigorous physical activity (MVPA), and 17% in the bout length of MVPA (p Conclusion The findings of this study showed a negative association between sedative load, due to medicines, and an individual’s movement behaviour. The impact of this could be a reduction in the ability of this population to maintain or improve their functional mobility, which may overshadow any benefits of the medicine in some circumstances.

Objective To determine the access to and use of health‐care services by people with dementia in the community. Methods A retrospective cross‐sectional analysis of the Australian Government Department of Veterans' Affairs (DVA) administrative claims data was conducted. Veterans and their spouses with one or more dementia claims between 1 January 2000 and 30 June 2016, who were aged ≥45 years at the time of the claim and who were still alive and living in the community on 30 June 2017, were included. We assessed the proportions of people with dementia who received medical, pharmacy and medicines, allied health services, and home care supports from 1 July 2016 to 30 June 2017. Results A total of 10 171 people with dementia were included. They had a median age of 89 years, 60% were female, and 63% lived in a major city. Over the one‐year study period, 98% visited the GP and 99% had medicines dispensed at a pharmacy. Eighty‐two per cent saw a specialist, and 19% saw a geriatrician. Thirty‐one per cent received a DVA‐funded dose administration aid to support medication administration, and 19% received a home medicines review. Less than half had claims for occupational therapist services (48%), community nursing (48%), physiotherapists (41%) or dentist visits (33%). Fifty‐eight per cent received home care supports, for example domestic assistance. Conclusions Many people living with dementia in the community do not access all of the health‐care or support services available to them. Ensuring that people with dementia and their carers are supported to access the services available to assist them live in the community setting for as long as possible is important. Refereed/Peer-reviewed

Background: People with Alzheimer's disease (AD) often have multimorbidity and take multiple medicines. Yet few studies have examined medicine utilization for comorbidities comparing people with and without AD. Objective: The aim was to investigate the patterns of medication use for comorbidities in people with and without AD. Methods: An Australian population-based study was conducted using the Pharmaceutical Benefits Scheme 10% sample of pharmacy claims data.People with AD were defined as those dispensed medicines for dementia (cholinesterase inhibitors, memantine, or risperidone for behavioral and psychological symptoms of dementia) between January 1, 2005 and December 31, 2015, who were aged 65 years or older and alive at the end of 2016. An age- and gender-matched comparison cohort (5:1) of people without AD were identified.Medication use for comorbidities was identified using the validated comorbidity index, Rx-Risk-V. A χ2 test was used to compare differences in the pattern of medicine use between the two groups. Results: A total of 8280 people with AD and 41,400 comparisons without AD were included;63.4% were female and the median age was 82 years. The median number of comorbidities was greater in people with AD (median (interquartile range (IQR)): 5(3-7)) than the comparison group (median (IQR): 4(3 –6)), p

ObjectiveTo test the association between use of medicines with anticholinergic or sedative properties and physical function, cognitive function, appetite and frailty.Design, setting and participantsThis cross-sectional study analysed baseline data collected as part of the Australian Longitudinal Study of Ageing, a population-based cohort of 2087 participants aged 65 years or over living in South Australia.Main outcome measuresPhysical function was measured at baseline using measures including hand grip strength, walking speed, chair stands, activities of daily living and instrumental activities of daily living (IADL). Cognitive function was measured using Mini-Mental State Examination. Appetite was measured using Center for Epidemiologic Studies Depression question 2. Frailty was measured using frailty index. The association between use of anticholinergics or sedatives and physical or cognitive function, appetite, or frailty was assessed using analysis of covariance and ordinal or binary logistic regression.ResultsAlmost half of the population were using anticholinergics or sedatives (n=954, 45.7%). Use of anticholinergics was significantly associated with poorer grip strength, slower walking speed, poorer IADL and poorer appetite. Use of sedatives was significantly associated with poorer grip strength, slower walking speed and poorer IADL. We found no significant association between medicine use and cognitive function. Users of anticholinergics or sedatives were significantly more likely to be frail compared with non-users.ConclusionUse of medicines with anticholinergic or sedative properties is significantly associated with poorer physical function, poorer appetite and increased frailty. Early identification of signs and symptoms of deterioration associated with medicine use is particularly important in older people so that worsening frailty and subsequent adverse events are prevented.

Objectives: To examine the risk of dementia associated with posttraumatic stress disorder (PTSD) and the contribution of antipsychotic use to this risk. Design: Retrospective cohort study Setting: Australia. Administrative claims data from the Australian Government Department of Veterans' Affairs were used. Participants: Male Vietnam veterans aged 55 to 65 at baseline (2001-02) with no preexisting dementia diagnosis (N = 15,612). Measurements: The association between PTSD and dementia was assessed over 12 years of follow-up. Dementia was identified as a hospital diagnosis, dementia record in service disability data, or dispensing of medicines for dementia. Cox-proportional hazards models were used, with age as the time-scale. Results were stratified according to baseline antipsychotic use. Results: No greater risk of dementia was observed with PTSD. In veterans who received antipsychotics, dementia risk was significantly higher than in those who did not (hazard ratio (HR) = 2.1, 95% confidence interval (CI) = 1.4-3.3). Dementia risk was significantly greater in veterans hospitalized for PTSD who received antipsychotics (HR = 2.2, 95% CI = 1.1-4.6) and veterans without PTSD who received antipsychotics (HR = 4.3, 95% CI = 2.1-8.6) than in those without PTSD with no antipsychotic use. Conclusion: Antipsychotic use may be a contributor to dementia risk. These findings should be interpreted with caution because the study design was observational. Further research using prospective study designs in settings where diagnostic data, cognitive function, and disease severity are available are required. Refereed/Peer-reviewed

Background: Most studies assessing the effect of central nervous system (CNS)-acting medicines on cognitive disturbances have focused on the use of individual medicines. The impact on cognitive function when another CNS-acting medicine is added to a patient's treatment regimen is not well known. Objective: To determine risk of hospitalization for confusion, delirium, or dementia in older people associated with increasing numbers of CNS-acting medicines taken concurrently, as well as the number of standard doses taken each day (measured as defined daily doses). Design: Retrospective cohort study, from July 2011 to June 2012, using health claims data. Setting: Australian veteran population. Participants: A total of 74,321 community-dwelling individuals aged 65 years and over, who were dispensed at least 1 CNS-acting medicine in the year before study entry. Patients with prior hospitalization for confusion or delirium, and those with dementia or receiving palliative care, were excluded. Main outcome measure: Hospitalization for confusion, delirium, or dementia. Results: Over the 1-year study period, 401 participants were hospitalized with confusion, delirium, or dementia. Adjusted analyses showed the risk of hospitalization was 2.4 times greater with the use of 2 CNS-acting medicines compared with no use [incident rate ratio (IRR) 2.39, 95% confidence interval (CI) 1.79-3.19, P < .001], and more than 19 times greater when 5 or more CNS-acting medicines were taken concurrently (IRR 19.35, 95% CI 11.10-33.72, P < .001). Similarly, the risk of hospitalization was significantly increased among patients taking between 1.0 and 1.9 standard doses per day (IRR 2.64, 95% CI 1.99-3.50, P < .001) and between 2.0 and 2.9 standard doses per day (IRR 3.43, 95% CI 2.07-5.69, P < .001) compared with no use. Conclusions: Use of multiple CNS-acting medicines or higher doses is associated with an increased risk of hospitalization for confusion, delirium, or dementia. Health care professionals need to be alert to the contribution of CNS-acting medicines among patients presenting with confusion or delirium and consider strategies to reduce treatment burden where possible. Refereed/Peer-reviewed

Background: The Australian medicines regulator, the Therapeutic Goods Administration (TGA), rescheduled all codeine-containing medicines to be available only on prescription on 1 February 2018. This study was conducted to determine whether use of analgesics changed following codeine re-scheduling to prescription only status, and whether there was a change in the use of codeine preparations and a therapeutic shift to stronger opioids or other analgesics in the Australian veteran population following the change.Methods: Interrupted time series analysis using Repatriation Pharmaceutical Benefits Scheme (RPBS) claims data from the Australian Government Department of Veterans’ Affairs (DVA) for clients with dispensing of opioid and non-opioid analgesics between January 2015 and April 2019. Trends in the monthly rate of analgesic dispensings (opioid and non-opioid) were compared for the period between January 2015 and January 2018 with the period February 2018 to April 2019. Results: Paracetamol with codeine 8mg was the only analgesic with an increased rate of dispensing following the February 2018 codeine scheduling changes. Prior to codeine re-scheduling, the rate of dispensing of paracetamol with codeine 8mg was decreasing by 0.9% each month. Immediately after the scheduling changes, dispensing of paracetamol with codeine 8mg increased by 45% (95%CI=1.282-1.676, p

Objective: To investigate the prevalence of potentially inappropriate prescribing (PIP) using the Screening Tool of Older Person's Prescriptions (STOPP) criteria in people with dementia compared with people without dementia. Methods: A retrospective cohort study was conducted using the Pharmaceutical Benefits Scheme 10% sample of pharmacy claims. People with dementia were defined as those dispensed a medicine for dementia (cholinesterase inhibitors, memantine, or risperidone for behavioural and psychological symptoms of dementia) between 1 January 2005 and 31 December 2015, aged 65 years or older at 1 January 2016 and alive at the end of 2016. An age‐ and gender‐matched comparison cohort of people not dispensed medicines for dementia was identified. PIP prevalence was determined between 1 January 2016 and 31 December 2016. Results: In total, 8280 people dispensed medicines for dementia and 41 400 comparisons not dispensed medicines for dementia were included: 63% were female and the median age was 82 years. PIP prevalence was 79% among people with dementia compared with 70% among the comparison group (P < .0001). Use of anticholinergics, long‐term use of high‐dose proton pump inhibitors, and use of benzodiazepines were the most common instances of PIP in people with dementia. After adjustments for age, gender, comorbidity, and number of prescribers, people with dementia were more likely to be exposed to PIP than comparisons (adjusted OR 1.44, 95% CI, 1.35‐1.53, P < .0001). Conclusions: PIP was more common in people dispensed medicines for dementia than comparisons. These results highlight the need for effective interventions to optimize prescribing in people with dementia. Refereed/Peer-reviewed