CHALLENGES FACED BY OLDER PERSONS IN USING PRESCRIPTION MEDICATION LABELS: WHAT NEEDS TO CHANGE?

Abstract In Singapore, while many older people cannot read English, prescription medication labels (PMLs) are predominantly dispensed in English. This qualitative study documented the challenges faced and solutions employed by users (i.e. older Singaporeans) and dispensers (i.e. pharmacy staff) of PMLs. In total, 30 in-depth interviews were conducted; 20 were equally divided between older Singaporeans (≥60 years) who could read English and those with limited/no English reading ability, and 10 were conducted with pharmacy staff across 6 polyclinics. The audio-taped interviews were transcribed verbatim and analysed thematically. The interviews with older Singaporeans and pharmacy staff revealed similar challenges in using PMLs. The first challenge related to reading and understanding PMLs by older people, mainly due to their limited English proficiency (LEP) or illiteracy. Consequently, older Singaporeans often relied on family members, domestic workers or pharmacy staff to help them interpret PMLs. Specifically, to address LEP, pharmacy staff reported translating PML instructions verbally and also handwriting them on PMLs. For illiterate patients, pharmacy staff reported drawing illustrations on PMLs to communicate key medication information. The second challenge related to PML readability, due to small font size. To address this, pharmacy staff routinely re-wrote medication information on PMLs in larger handwriting. Such improvised solutions by pharmacy staff to address the challenges faced by older Singaporeans in using PMLs indicate a pressing need for system-level improvements to PMLs. Improvements such as standardised and legible bilingual medication instructions and/or pictograms would appreciably facilitate medication counselling and allow for better understanding of PMLs by older Singaporeans.

(10 vs. 9.7) and anticholinergic medications (3.5 vs. 3.1) was reduced; this was not the case in the control group, where the mean number of overall medications remained the same (11.92) and the mean number of anticholinergic medications increased (3.83 vs. 3.92). More significantly, in comparing admit versus discharge scores, both the mean ACB and DBI scores were reduced in the intervention group, but in the control group both the ACB and DBI scores either remained the same or increased at the time of discharge. This clearly shows that a simple intervention (highlighting anticholinergic medications in the patient chart) can have a clinically beneficial outcome of reducing these harmful medications in patients. With approximately 50% of the older population taking at least one anticholinergic drug, the importance of reducing anticholinergic burden cannot be overemphasized.

THE OPIOID EPIDEMIC IN LONG-TERM CARE: A STAFF PERSPECTIVE
Rachael Hemmert, 1 Gabriella E. Dull, 1 and Linda S. Edelman 1 , 1. University of Utah, Salt Lake City, Utah, United States Opioid-based analgesic therapy is a common treatment for moderate to severe pain among long term care (LTC) residents. It has been estimated that 60% of LTC residents have an opioid prescription. Of these, 14% use opioids as part of a long term pain management strategy. LTC residents are particularly vulnerable to opioid misuse, exhibiting higher rates of adverse drug events. However, addressing pain, polypharmacological needs and resident well-being in the LTC setting is challenging. More research and education regarding opioid use in LTC is needed. The Utah Geriatric Education Consortium conducted interprofessional focus groups with LTC partners to 1) determine educational needs of staff regarding opioid use, and 2) gather qualitative data about the pain management experiences of staff when working with residents and families. Staff identified the following training needs: pain manifestation and assessment; certified nurse assistant education on opioid use; nonpharmacological options for pain management. Review of staff's perception of the intersection of opioids, family and staff in a LTC setting revealed that 1) family is concerned about opioid use; 2) conversely, staff may not see opioid use as a problem; and 3) non-pharmacological options for pain management are often costly and unavailable to those in LTC. Identifying educational needs of LTC staff will help guide the development of educational materials and provide baseline data for future assessments of the impact of opioid education on long-term care patient outcomes. Overall opioid use, prolonged opioid use (prescription supply 90+ days) and long-acting opioid use were identified from Medicare part D. Descriptive statistics were used to describe opioid use by cognitive impairment. Cochrane Armitage trends test was used to determine trends in opioid use. 114,622 (19%) patients had severe and 129,257 (22%) had moderate dementia. Overall opioid (none/mild=15.4%, moderate=13.9%, severe=9%), prolonged opioid (none/ mild=5.2%, moderate=4.5%, severe=3.2%) and long-acting opioid use (none/mild=1.1%, moderate=0.9%, severe=0.3% ) were lower in patients with advanced dementia. Opioid use was significantly higher in females and Whites and varied by states. Substantial increase was found in overall opioid and prolonged opioid use from 2011 to 2016, with greater increase in none/mild and moderate dementia patients. For example, prolonged opioid use increased by 69% in none/mild and 71% in moderate dementia patients compared to 52% in severe dementia patients (p<0.0001). Long-acting opioid use decreased, with a greater decline in none/mild (69%) and moderate (71%) dementia patients compared to severe dementia patients (58%) (p<0.0001). Contrary to decreasing opioid use in community setting, overall and prolonged opioid use increased in nursing home residents. Future studies should identify the reasons behind increased use.

CHALLENGES FACED BY OLDER PERSONS IN USING PRESCRIPTION MEDICATION LABELS: WHAT NEEDS TO CHANGE?
Rahul Malhotra, 1 Sumithra Suppiah, 1 Yi Wen Tan, 1 and PROMISE Study Group PROMISE Study Group 1 , 1. Duke-NUS Medical School, Singapore, Singapore In Singapore, while many older people cannot read English, prescription medication labels (PMLs) are predominantly dispensed in English. This qualitative study documented the challenges faced and solutions employed by users (i.e. older Singaporeans) and dispensers (i.e. pharmacy staff) of PMLs. In total, 30 in-depth interviews were conducted; 20 were equally divided between older Singaporeans (≥60 years) who could read English and those with limited/ no English reading ability, and 10 were conducted with pharmacy staff across 6 polyclinics. The audio-taped interviews were transcribed verbatim and analysed thematically. The interviews with older Singaporeans and pharmacy staff revealed similar challenges in using PMLs. The first challenge related to reading and understanding PMLs by older people, mainly due to their limited English proficiency (LEP) or illiteracy. Consequently, older Singaporeans often relied on family members, domestic workers or pharmacy staff to help them interpret PMLs. Specifically, to address LEP, pharmacy staff reported translating PML instructions verbally and also handwriting them on PMLs. For illiterate patients, pharmacy staff reported drawing illustrations on PMLs to communicate key medication information. The second challenge related to PML readability, due to small font size. To address this, pharmacy staff routinely re-wrote medication information on PMLs in larger handwriting. Such improvised solutions by pharmacy staff to address the challenges faced by older Singaporeans in using PMLs indicate a pressing need for system-level improvements to PMLs. Improvements such as standardised and legible bilingual medication instructions and/or pictograms would appreciably facilitate medication counselling and allow for better understanding of PMLs by older Singaporeans.

AN EXPLORATION OF HOME CARE NURSES' EXPERIENCES IN DEPRESCRIBING OF MEDICATIONS FOR OLDER ADULTS IN THE COMMUNITY Winnie Sun 1 , 1. University of Ontario Institute of Technology, Oshawa, Ontario, Canada
The aim of this study is to explore the barriers and enablers of deprescribing from the perspectives of home care nurses, as well as to conduct a scalability assessment of an educational plan to address the learning needs of home care nurses about deprescribing. This study employed an exploratory qualitative descriptive research design, using scalability assessment from two focus groups with a total of eleven home care nurses in Ontario, Canada. Thematic analysis was used to derive themes about home care nurse's perspectives about barriers and enablers of deprescribing, as well as learning needs in relation to deprescribing approaches. Home care nurse's identified challenges for managing polypharmacy in older adults in home care settings, including a lack of open communication and inconsistent medication reconciliation practices. Additionally, inadequate partnership and ineffective collaboration between inter-professional healthcare providers were identified as major barriers to safe deprescribing. Further, home care nurses highlighted the importance of raising awareness about deprescribing in the community, and they emphasized the need for a consistent and standardized approach in educating healthcare providers, informal caregivers, and older adults about the best practices of safe deprescribing. Nurses in home care play a vital role in medication management and, therefore, educational programs must be developed to support their awareness and understanding of deprescribing. Study findings highlighted the need for the future improvement of existing programs about safer medication management through the development of a supportive and collaborative relationship among the home care team, frail older adults and their informal caregivers.

PATTERNS OF PSYCHOACTIVE MEDICATION USE IN COMMUNITY-DWELLING OLDER ADULTS IN THE UNITED STATES IN 2015
Rashmita Bajracharya, 1 and Danya Qato 2 , 1. University of Maryland, Baltimore, Maryland, United States, 2. University of Maryland Baltimore, School of Medicine,

Maryland, United States
Per the 2015 Beer's Criteria, most psychoactive medications are identified as potentially inappropriate for use in older adults as this population is especially vulnerable to the potential adverse effects associated with psychoactive medications, including sedation, anticholinergic effects, and falls. Past studies found increasing use of psychoactive medications in community-dwelling older adults; however, patterns of use by other sociodemographic, socioeconomic, and clinical subgroups have not been explored. This is a cross-sectional analysis of 2015 Medical Expenditure Panel Survey in a sample of 6122 older adults (60-85 years). We utilized Andersen's Behavioral Model of Health Services Utilization to guide logistic regression model development and estimated odds ratios (OR) with 95% confidence intervals (CI) to quantify the association between psychoactive use and predisposing(sex and race); enabling(marital status, education, poverty, insurance); and need-based[multimorbidity and activities of daily living (ADL) limitations] factors. Over 30% of older adults in the U.S. reported taking a psychoactive medication in 2015. Prevalence of use was significantly higher in women (35.9%), the unmarried(34.1%), low-income(35.7%), white(34.0%), multimorbid (32.0%), and ADL limitation groups (45.9%) compared to men, married, high-income, other races, not multimorbid, and no ADL limitations groups, respectively. Female sex [OR=1.62(1.38-1.91)], low-income [OR=1.30(1.04-1.6)], multimorbidity [OR=3.2(2.6-3.9)], and ADL limitations [OR=2.2(1.7-2.8)] were identified as independent predictors of psychoactive use. There is differential use of psychoactive medications by sociodemographic, socioeconomic, and clinical factors. Given the increased complexity of pharmacotherapy regimens, especially in those with multimorbidity and ADL limitations, improved efforts aimed at prudent use of psychoactive medications should be intensified.

WHAT IS THE EVIDENCE BASE FOR NONPHARMACEUTICAL INTERVENTIONS TO DECREASE USE OF PSYCHOTROPIC MEDICATIONS?
German Alarcon Garavito, 1 and Kathleen Abrahamson 2 , 1. Universidad Nacional de Columbia, Bogata, Colombia,

Purdue University, West Lafayette, Indiana, United States
Psychotropic medications (anti-depressants, antianxiolytics, anti-psychotics, others), have been targeted as a class of medications that can be reduced among residential long-term care (LTC) residents with proper environmental intervention. Reduction of psychotropic medications has the potential to increase resident health/well-being and decrease costs. However, residential LTC facilities face numerous challenges in reducing psychotropic medications, including but not limited to behavior and communication difficulties in advanced dementia, lack of staff training/ awareness of needed environmental modifications, and use of medications to manage the cascade of side-effects that occur with polypharmacy and multi-morbidity in the LTC population. A developed literature exists surrounding nonpharmaceutical interventions to reduce psychotropic use in residential LTC. The goal of this current study was to synthesize that body of literature through a systematic review, and categorize findings in a way that is meaningful to directcare nursing staff. The search of 13 databases identified 14 studies published since 2007 that focused specifically upon residential care and nurse-led non-pharmaceutical interventions. Identified study designs were experimental (5), observational (3), and systematic reviews/meta-analyses from within 8 countries. Findings were categorized based upon type of intervention (educational, environmental, sensorial, care-approach, physiological, and social), as well the target population. Successful interventions were most commonly targeted toward staff and residents, less commonly toward family. The most common approach was education and change in care-approach, with physiological interventions being the least common. We will discuss the implications for nursing staff surrounding the available evidence, and pro/ cons of implementing interventions within different organizational settings based upon the study findings.