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Use of Psychotropic Drugs and Drugs with Anticholinergic Properties

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Use of Psychotropic Drugs and Drugs with Anticholinergic Properties BMJ Open: first published as 10.1136/bmjopen-2020-045787 on 8 April 2021. Downloaded from PEER REVIEW HISTORY BMJ Open publishes all reviews undertaken for accepted manuscripts. Reviewers are asked to complete a checklist review form (http://bmjopen.bmj.com/site/about/resources/checklist.pdf) and are provided with free text boxes to elaborate on their assessment. These free text comments are reproduced below. ARTICLE DETAILS TITLE (PROVISIONAL) Use of psychotropic drugs and drugs with anticholinergic properties among residents with dementia in intermediate care facilities for older adults in Japan: a cohort study AUTHORS Hamada, Shota; Kojima, T; Hattori, Yukari; Maruoka, Hiroshi; Ishii, Shinya; Okochi, Jiro; Akishita, Masahiro VERSION 1 – REVIEW REVIEWER Hélène Verdoux University of Bordeaux France REVIEW RETURNED 18-Nov-2020 GENERAL COMMENTS It is of great interest to explore the prescribing practice of drugs with anticholinergic properties in elderly persons, considering the risks associated with exposure to high anticholinergic load, especially in persons presenting with dementia. It is also of interest to investigate this issue in different countries with different organizations of care for these persons. The present study as several strengths particularly regarding deprescribing of drugs with deleterious side effects in elderly persons after admission in the http://bmjopen.bmj.com/ Roken services. Unfortunately, this interesting point is not sufficiently developed. The present study is hampered by several methodological drawbacks that should be further addressed by the authors. In the highlights section: please give the spelled-out form of the acronym NH/LTCFs. on September 30, 2021 by guest. Protected copyright. The aims of the study are unclear and do not match with the analyses reported in the manuscript. The most interesting part of the study is related to change of prescription over the 1st two months after admission. This issue is not mentioned in the aim section. The organization of Roken has to be further explained for international readers : are they private or public structures ? Which proportion of elderly persons are managed in these structures in Japan ? What is the mean age at admission ? What is the organization of medical care i.e. who are the practitioners in charge of medication prescribing ? Are the drugs free of charge the patients ? It is also unclear for me whether the persons are living in the Roken as they are described as “resident” but it is also mentioned that the aim of the Roken is to improve functioning to live at home. Are persons leaving the Roken once included, and if yes, what is the mean duration of stay ? 1 BMJ Open: first published as 10.1136/bmjopen-2020-045787 on 8 April 2021. Downloaded from The rationale and method used to identify the sample of Roken under study is unclear. Why only 368 Roken were included ? How many Roken were existing in Japan in 2005 (3,598? ) i.e. which proportion of the total number of Roken is included in the present study ? The method used to collect information on prescribed drugs is not sufficiently detailed, especially for drugs prescribed at admission. How was obtained this information ? By whom ? From which source ? Which classification was used to categorize the psychotropic drugs ? The list provided is not sufficient, the categories have to be defined according to international classifications (ATC for instance). It is really difficult to understand why mood stabilizers were not included in a study on psychotrotric drugs. This issue is problematic considering the case definition of dementia, as persons presenting with severe mental illness such as bipolar disorder or schizophrenia may be diagnosed as presenting with dementia, and these persons are frequently treated by mood stabilizers (lithium or anticonvulsants). Regarding antipsychotics, please use the terms 1st and 2nd generation antipsychotics instead of typical and atypical, and also describe which drugs are included in these 2 categories as the list of marketed antipsychotics is highly variable from one country to another ; sulpiride is not considered as a 2nd generation antipsychotics in the literature, amisulpride is the only benzamide drug categorized as 2nd generation. The definition of psychotropic polypharmacy is also problematic regarding the issue explored in the present study. Polypharmacy may also be related to the co-prescription of several drugs from http://bmjopen.bmj.com/ the same pharmacological category for instance 2 antipsychotics or 2 antidepressants. The method used to asses anticholinergic activity is questionable. It is true that various scales are available, but some of them are more reliable than others. It is acknowledged that the most relevant are those assessing an anticholinergic score : see for instance Salahudeen, M. S., Duffull, S. B. & Nishtala, P. S. (2015). Anticholinergic burden quantified by anticholinergic risk scales and on September 30, 2021 by guest. Protected copyright. adverse outcomes in older people: a systematic review. BMC Geriatrics 15, 31 ; Duran, C. E., Azermai, M. & Vander Stichele, R. H. (2013). Systematic review of anticholinergic risk scales in older adults. Eur J Clin Pharmacol 69, 1485-96. Hence, the findings of the present study regarding this variable should be considered with cautious. The comparisons of the characteristics of patients according to the severity of dementia are of little interest in the present study as they are out of the scope of the objectives (which have to be better defined as already mentioned). These findings have to be suppressed. Also regarding the statistical analyses, the method used to explore the most interesting issue related to changes in prescription after admission has to be revised. This point has to be developed, and the authors should consider use of multivariate rather than univariate analyses to explore this issue. It is much more 2 BMJ Open: first published as 10.1136/bmjopen-2020-045787 on 8 April 2021. Downloaded from interesting to explore the factors associated with change in prescription (especially deprescribing of drugs with cognitive side effects) rather than with prescriptions at one point. The section results is poorly structured and poorly presented. Once again, the comparison of prescription according to the severity of dementia is of little interest considering the limited validity of these categories. Table 2 has hence to be drastically modified and focused on the temporal evolution of prescriptions, using multivariate analyses, with severity of dementia as an adjustment variable. More details should be given on the type of prescribed antipsychotics. It is useless to distinguish 1st and 2nd generation antipsychotics in the method if these categories are never used in the analyses and the results. Yokukansan, a traditional Japanese Kampo medicine, is presented in the result section, and should be presented first in the method section with further explanations on this treatment. The discussion mostly repeats the information already given in the result section. Once again, the most interesting issue of this study is related to deprescribing of drugs with deleterious side effects after admission in Roken i.e. in the health service specialized in geriatric care. This issue is much more interesting for the international readers than the description of prescribing practices in the elderly population. REVIEWER Gerlach, Lauren B University of Michigan REVIEW RETURNED 27-Jan-2021 http://bmjopen.bmj.com/ GENERAL COMMENTS In this study the authors evaluated the prevalence of psychotropic and anticholinergic medication prescribing to residents in long- term care facilities (Roken) in Japan. Use of potentially inappropriate medications among nursing home residents and residents with dementia is a major issue given the risk of medication related harms. This study provides useful information regarding psychotropic and anticholinergic medication prevalence within Roken as well as factors associated with prescribing. The on September 30, 2021 by guest. Protected copyright. manuscript could be strengthened through the following revisions. Major Issues: Introduction (Page 6, Lines 19-26): The Introduction overall would be strengthened by providing a little more information regarding Roken for International readers to best place this type of care facility in context. From the description provided, Roken may sound more similar to a subacute rehabilitation facility in the U.S., rather than a long-term care nursing home where the majority of previous work regarding psychotropic prescribing has been performed. Methods: Overall it would be helpful to provide more information about who are the respondents filling out the surveys and how they were selected. Are these families of patients with dementia, facility staff caring for the patient, or patients themselves in some cases? A description of how it was determined who would fill out 3 BMJ Open: first published as 10.1136/bmjopen-2020-045787 on 8 April 2021. Downloaded from the survey would be helpful as well as the breakdown of respondents for the information presented here (if available). Discussion: -It would be helpful to provide some information regarding potential regulatory pressures or initiatives to reduce antipsychotic prescribing in Japan. For instance, in the U.S. nursing home antipsychotic prescribing rates publicly reported and impact nursing facilities ratings through a Five Star Rating System. Is there similar public reporting or regulatory
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