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Title: Ageing of the population and specific aspects of prescribing of hypnotics in older adults (II.) Student: Karolína Puldová, Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Czech Republic Supervisor: Assoc. Prof. Daniela Fialová, PharmD, Ph.D., Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové and Department of Geriatrics and Gerontology, 1st Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic Introduction: World population is ageing and rational geriatric pharmacotherapy receives increasing attention. In seniors, rational pharmacotherapy is complicated by many risk factors, especially by physiological and pathological changes accompanying ageing, polymorbidity, polypharmacy, higher risk of adverse drug events, drug interactions and other risk factors. Particularly psychotropics belong to drug classes where rational prescribing in seniors often requires respecting of different rules. This diploma thesis focuses on specific aspects of irrational prescribing of hypnosedatives in ambulatory geriatric patients, particularly in the area of use of nongeriatric doses and nongeriatric lenght of therapy. Methodology: Data collection for this diploma thesis has been conducted between 2019-2020 years in the...

1 Abstract Crime relating to the abuse of addictive substances This thesis deals with the issue of substance abuse and criminality associated with this pathological phenomenon. Addiction and substance abuse can be considered a significant criminogenic factor, which is a common cause of traffic accidents, domestic violence, reduced self-control, increased aggression and other crime-related behaviors. Criminality related to the production, distribution and use of addictive substances covers a wide range of offenses, from trivial offenses bordering on offenses to the diverse activities of international organized crime, which can be consider a global issue. Subject matter of this thesis is to link this stated issue with fundamental knowledge about narcotic and psychotropic substances and its effects on individuals, along with their potential influence on the delinquent behavior of drug users, while providing a theoretical definition of crimes related to substance abuse and an effort to quantify this phenomenon. This thesis is devided into four parts. The introductory chapter focuses on interpreting concepts related to substance abuse, which is necessary for a comprehensive understanding of the stated issue. As a follow up to this, the second chapter deals with narcotic and psychotropic substances' fundamental...

Bakgrund: Varje år insjuknar 1500–2000 personer i psykos i Sverige, och cirka 30000–40 000 personer i Sverige har diagnosen schizofreni. Läkemedel är grunden i behandlingen av schizofreni, detta i kombination med olika psykosociala behandlingar samt åtgärder. Återhämtning beskrivs som en djupt personlig, unik förändringsprocess. Sjuksköterskor i Sverige arbetar enligt HSL, Hälso- och sjukvårdslagen och hälsa är ett av omvårdnadens centrala begrepp som sjuksköterskan skall jobba utifrån. Syfte: Syftet är att beskriva erfarenheter av återhämtning från psykos hos personer med schizofreni samt beskriva urvalsgrupperna i artiklarna.Metod: En deskriptiv litteraturstudie innefattande 11 vetenskapliga artiklar sökta i PubMed och PsychINFO. Huvudresultat: I föreliggande studie var syftet att beskriva erfarenheter från psykos hos personer med schizofreni. Det som framkom i resultatet visade att ett stort stöd från omgivning samt medicinering var nödvändigt för en god återhämtning. Att umgås med familj och vänner gav en känsla av acceptans samt minskade symtomen. Psykofarmaka visar sig dock påverka sömn samt livskvalitet på ett negativt sätt vilket hämmade följsamheten. Många beskrev att de förlorat sin självbild efter psykosen vilket gav en sämre självkänsla, det hämmade återhämtning samt återgång till arbete. När de hittat acceptans i sin sjukdom samt inte såg sig själva som en diagnos och lärde sig nå sina mål främjade det återhämtningsprocessen och personerna kunde se en ljus framtid.Slutsatser: Personer med schizofreni upplever idag svårigheter att komma tillbaka till det vanliga livet efter en psykos. Personerna berättar att de förlorat sin identitet, vänner, familj och arbete och till följd av detta förlorat hopp och framtids utsikter. Denna stigmatisering beror mycket på okunskap i samhälle och därför är det viktigt att soms juksköterska ha kunskap inom detta ämne för att kunna ge en god omvårdnad. / Background: Every year 1500-2000 people gets a psychosis in Sweden, and about 30000-40000 people in Sweden is diagnosed with schizophrenia. Medicines are the basis for the treatment of schizophrenia, this in combination with various psychosocial treatments as well as measures. Recovery is described as a deep personal, uniquechange process. Nurses in Sweden work according to the law “HSL”, the Swedish Health and Medical Service Act. Health is one of the nursing concepts that the nurse should work from outside.Aim: The aim of this study is to describe people diagnosed with schizophrenia experiences of recovery after psychosis, as well as describing the selection groups in thearticles. Methods: A descriptive literature study of 11 studies with a qualitative approach. Main results: In the present study, the purpose was to describe psychosocial experiencei n schizophrenia patients. What was found in the results showed that a strong support from the environment and medication was necessary for a good recovery. To spend time with family and friends gave a sense of acceptance and reduced the symptoms. Psychiatric drugs prove to affect sleep and quality of life in a negative way, which impeded compliance. Many described that they lost their self-esteem after psychosis, resulting in a worse self-esteem, inhibited recovery and return to work. When theyfound acceptance in their illness and did not see themselves as a diagnosis and learned to reach their goals, it promoted the recovery process and they could see a brighter future.Conclusion: People with schizophrenia experience difficulties in returning to normal life after a psychosis. The people tell that they lost their identity, friends, family and work and as a consequence they lost hope and prospects. This stigmatization depends largely on ignorance in society and therefore it is important as a nurse to have knowledge of this subject in order to provide good care.

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Introduction: The volume of antipsychotic medications prescribed to children and adolescents has risen sharply since second generation antipsychotics, also referred to as atypical antipsychotics, were introduced in the 1990’s. The concern surrounding the expanded use of antipsychotics was that the medications have significant adverse metabolic side effects and they were often prescribed to treat conditions in young children for which they have not been proven to be safe and effective. While it is not unlawful for health care providers to prescribe medications for uses beyond which they have been approved by the United States Food and Drug Administration, the lack of empirical evidence guiding much of the antipsychotic use in children had professional pediatric medical groups and policy makers concerned for the well-being of children receiving the medications. Several states, including Pennsylvania, enacted prior authorization policies in an attempt to restrict prescribing to children where a medical need has been established. However, the impact of the policies is largely unknown since published data on the topic is sparse. Methods: This retrospective, medical claims-based cohort study, used de-identified administrative Medicaid data from January 2008 to December 2010 to investigate the impact of Pennsylvania’s September 2008 antipsychotic prior authorization policy on antipsychotic prescribing prevalence in children targeted by the policy. Descriptive methods and segmented regression of the interrupted time series were used to assess the effects of the policy on monthly antipsychotic prescribing prevalence. A difference-in-difference analysis compared Pennsylvania’s prescribing to Ohio, a geographically proximate and demographically similar state without a prior authorization policy; and Delaware, a state that enacted a policy 3 years prior to Pennsylvania. The potential for compensatory prescribing was assessed by reporting the prevalence of other psychotropic medications over the study period. Results: An average of 99,074 Pennsylvania Medicaid enrollees ages 0-6 were identified as meeting the study criteria annually from 2008-10. Immediately following the policy intervention, an abrupt, significant reduction in monthly prescriptions of antipsychotics was observed (-51 prescriptions per 100,000; p=0.0052) and sustained over the observation period. The proportion of children filling prescriptions for antipsychotics dropped approximately 46% and the average number of antipsychotic prescriptions filled per month was reduced by 53% in 2010 compared to 2008. In Ohio, a state without such a policy, the proportion of children receiving an antipsychotic increased nearly 10% in 2010 compared to 2008 and the average number of monthly prescriptions increased 30%. Reductions in antipsychotic prescribing in Delaware, a state that had its antipsychotic policy in place since 2005, were comparable to Pennsylvania. There was no evidence that non-antipsychotic psychotropic medications were prescribed in place of the medications restricted by the policy. Conclusions: Pennsylvania’s 2008 prior authorization policy was associated with a significant decrease in annual and monthly antipsychotic prescribing prevalence in Medicaid-insured children targeted by the policy, those ages 0-6 years of age. Reductions in most other psychotropics was also observed, indicating changes in prescribing behavior may have extended beyond antipsychotics. While this analysis suggests the policy may have achieved its primary aim of reducing antipsychotic prescribing, more research is needed to better understand the complex array of factors influencing provider behavior and to explore potential unintended consequences of the policy. / Public Health

Background: Drugs are one of the cornerstones in the management of many diseases. In general, drugs are used for diagnosis, prevention, mitigation of symptoms, and, sometimes, to cure disease. However, drug treatment in elderly people, especially those with dementia and cognitive impairments, may involve significant risk of adverse drug events.  The aim of this thesis was to identify the extent of potentially inappropriate drug treatment among people with dementia and cognitive impairment and to assess the occurrence and character of drug-related problems that lead to acute hospital admissions. Another aim was to assess the potential impact of a comprehensive medication review conducted by clinical pharmacists as part of a health care team on quality of patients’ drug therapy and drug-related hospital readmission rates. Method: Long-term use of antipsychotic/psychotropic drugs and associated factors were investigated among 344 and 278 people respectively with dementia living in specialized care units. Trends in the prescribing of potentially inappropriate drugs between 2007 and 2013, comprising 2772 and 1902 people, living in nursing homes in the county of Västerbotten, were assessed using six national quality indicators. Data on drug use, function in the activities of daily living, cognitive function and behavioral and psychological symptoms were collected using the Multi-Dimensional Dementia Assessment Scale. Further, an investigation of a separate corresponding population from 2012 was done, where potentially inappropriate drug use was measured before and after a total of 895 medication reviews. Finally, a randomized, controlled trial was carried out among people 65 years or older with dementia or cognitive impairment in internal medicine and orthopedic wards at two hospitals in northern Sweden. The proportion of hospital admissions that were drug-related were estimated, and also whether comprehensive medication reviews conducted by clinical pharmacists as part of a health care team could affect the risk of drug-related hospital readmissions. Results: Antipsychotic and other psychotropic drugs were frequently prescribed to people with dementia living in specialized care units for prolonged periods. Associations were found between behavioral and psychological symptoms and different psychotropic drugs. The extent of potentially inappropriate drug use declined between 2007 and 2013. In the separate corresponding population from 2012, the frequency of potentially inappropriate drug use was significantly reduced among people who underwent medication reviews. Hospitalizations due to drug-related problems among old people with dementia or cognitive impairment were prevalent. We found that inclusion of a clinical pharmacist in the health care team significantly reduced the risk of drug-related 30-day and 180-day readmissions. However, in a subset of patients with concomitant heart failure no effect was seen. Conclusion: Among patients with dementia or cognitive impairment long-term treatment with antipsychotic and other psychotropic drugs is common. The results indicate that these drugs are prescribed to treat behavioral and psychological symptoms among cognitively impaired individuals, despite limited evidence of their efficacy and the high risk of adverse effects. Drug-related problems, such as adverse drug reactions, constituted a major cause of hospital admissions. By reducing potentially inappropriate drug use and optimizing overall drug therapy, inclusion of clinical pharmacists in a health care team might improve the quality of patient care and reduce the risk of hospital readmissions among people with dementia.

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