Journal Highlights From the August Issue of JAMDA

        Graphical abstract

        Oral Medications

        Dimensions, palatability, and the appearance of the final drug product all help determine older individuals’ acceptance of and adherence to medication regimens, according to a mixed-methods systematic review conducted in Birmingham, United Kingdom.
        Led by Zakia B. Shariff, MPharm, of Aston University, researchers conducted a database search, supplemented by a gray literature and Google Scholar search, for studies that included individuals aged 60 and older or their caregivers and that investigated the formulation of oral solid dosage forms and patient adherence. The final analysis included 16 studies.
        “One of the key motivators towards undertaking this research was our experience in pharmacy practice,” Ms. Shariff said in an email. “Having worked with older people within the community, we encountered patients on a regular basis who were struggling to take their medication due to factors such as the size and shape of the dosage form.”
        In 29.6% of cases in which individuals had difficulty using medication, they attributed it to the dosage form being too large or small, the researchers found. However, older adults, especially those with dysphagia, generally preferred smaller dosage forms. Although 40% of individuals without dysphagia reported no difficulties swallowing any of the capsule sizes presented, only 6% of individuals with dysphagia reported no difficulties. Among individuals with dysphagia, slightly more than 40% began experiencing difficulties with an 11-mm arched, round tablet. Another 35% began experiencing difficulties with a 13-mm oblong tablet. In one study individuals with dysphagia preferred torpedo-shaped tablets or capsules.
        Additional factors that may affect adherence to medications include:
        • Surface texture. A “chalky” texture contributed to 18.5% of difficulties encountered with medications and was the second most commonly reported cause of swallowing difficulties in people with dysphagia.
        • Taste. In one study, 19% of participants used food or drink just before or after taking medication to mask the taste and make the medication easier to swallow.
        • Appearance. Clinical deterioration may occur when individuals cannot distinguish between different strengths of medications due to a similar appearance, the researchers found. Older individuals, especially those with visual impairment, had trouble seeing smaller tablets, including mini-tablets. However, taking large tablets is not a solution, as it may make individuals anxious.
        • Color. Studies have shown that individuals who use multiple medications are more likely to prefer brightly colored tablets or bichromatic (two-color) tablets — characteristics that help them identify the medication.
        The study emphasizes the need for communication between health care providers and patients. “Older people are sometimes reluctant to voice concerns about their medications, and often symptoms such as dysphagia are underreported and underrecognized,” Ms. Shariff said. “There is a need for health care providers to actively engage in discussion with patients about the acceptability of their medication.”
        Specifically, providers should ask about any problems relating to the dimensions and palatability, both of which can affect the appearance of the drug and the ability of the patient to swallow it. “We should work closely with patients to understand their attitudes and needs towards their treatment and share decision-making on formulation choice with older patients,” Ms. Shariff said. “By doing so, we can help ensure that age-appropriate designs are used by manufacturers of medicines, and the patients receive the most appropriate treatment. This will, in turn, prevent patients from modifying medicines themselves and lead to improved overall patient acceptance and adherence.”Source: Shariff ZB, et al. Does the Formulation of Oral Solid Dosage Forms Affect Acceptance and Adherence in Older Patients? A Mixed Methods Systematic Review [Published online: March 27, 2020]. J Am Med Dir Assoc. DOI:

        Palliative Care

        As the number of older adults grows, the number of individuals dying in long-term care facilities is increasing as well. To address variations in the quality of care across facilities, the European Palliative Care Association issued a white paper on improving palliative care in these facilities.
        An expert workshop and online survey refined the recommendations for implementing palliative care that were identified during the Palliative Care for Older People Study, which mapped palliative care in facilities in Europe and evaluated the quality of end-of-life care and dying.
        The recommendations for implementing palliative care in long-term care facilities include raising awareness of palliative care among residents, families, and staff; providing training and education to staff members; and making the interventions part of routine care. The white paper also recommended having appropriate equipment, sufficient staffing, and time to make changes.Source: Froggatt KA, et al. Palliative Care Implementation in Long-Term Care Facilities: European Association for Palliative Care White Paper [Published online: February 28, 2020]. J Am Med Dir Assoc. DOI:

        Oral Anticoagulants

        In individuals with atrial fibrillation and dementia, direct oral anticoagulants, or DOACs (also known as novel oral anticoagulants or NOACs), and warfarin each have similar and specific risks, according to a new-user retrospective cohort study in the United Kingdom.
        Led by Laura Fanning, MPH, of University College London, the researchers extracted data from The Health Improvement Network (THIN), a nationwide database of primary care records for 15 million individuals in the United Kingdom. Of 2,399 people with atrial fibrillation and dementia identified, 42% used DOACs (rivaroxaban, apixaban, dabigatran, or edoxaban), and 58% used warfarin.
        Overall, 12 patients developed intracranial bleeding, 43 developed gastrointestinal bleeding, and 57 developed other bleeding. The crude rates of all-cause mortality were 121.5 per 1,000 person-years for individuals using DOACs versus 49.9 per 1,000 person-years among individuals using warfarin.
        After adjusting for multiple comorbidities, individuals using DOACs demonstrated similar risks of ischemic stroke, ischemic stroke/transient ischemic attack/systemic embolism and ischemic stroke as individuals who used warfarin. Individuals who used DOACs had a reduced risk of intracranial bleeding but an increased risk of gastrointestinal bleeding and all-cause mortality compared with those who used warfarin.
        “More studies are urgently needed to understand safety and effectiveness of DOACs in people with dementia, including a large prospective trial of DOACs vs warfarin and direct head-to-head DOAC comparisons,” the researchers said.Source: Fanning L, et al. Safety and Effectiveness of Direct Oral Anticoagulants vs Warfarin in People With Atrial Fibrillation and Dementia [Published online: January 6, 2020]. J Am Med Dir Assoc. DOI: