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CONTINUING PROFESSIONAL DEVELOPMENT
clinically significant.15 In consideration
of the relatively small benefit of
cholecalciferol supplementation, it too
was identified as a medicine that could
potentially be ceased.
Whilst the general HbA1c target for
people with diabetes is ≤53 mmol/
mol, there are a number of factors
that influence the appropriateness of
stringent blood glucose control and
treatment targets. The relatively limited
life expectancy of the patient discussed
in this case, in addition to the potentially
severe adverse outcomes resulting from
an episode of hypoglycaemia, indicate
that a target HbA1c of somewhat
greater than 53 mmol/mol would be
acceptable.16 As his most recent HbA1c
was <53 mmol/mol, it was likely that
adequate glucose control could be
achieved without glimepiride.
Urinary incontinence, particularly urge
incontinence, is very common in people
with dementia, and its prevalence
increases as dementia progresses.17
As with people who do not have
dementia, management strategies for
urinary incontinence are multi-factorial
and may involve behavioural, physical,
pharmacological, and occasionally
surgical techniques.18 Dementia
presents particular challenges with
urge incontinence management, as
several effective and frequently used
interventions either require the use of
cognitive abilities that are diminished
in dementia (e.g. bladder training),
or may exacerbate cognitive impairment
For the man reviewed in this HMR,
the lack of effectiveness of solifenacin,
coupled with administration difficulties
and potential adverse cognitive effects
provided good reasons to cease
it. However, as this would possibly
exacerbate his urinary incontinence,
an alternative management strategy
needed to be formulated. In terms
of pharmacological management,
mirabegron is considered to be less
likely to affect cognitive function
than antimuscarinics,19 although
currently there is no data regarding
its use in people with dementia. As its
effectiveness is approximately equivalent
to antimuscarinics, and minimising
medicines was a priority for the
review, it was not considered to be an
appropriate management option.
The most commonly used behavioural
approaches for continence management
for people with dementia involve
prompted and timed voiding.17
Both approaches generally rely on carer
assistance, and focus on preventing urine
loss rather than restoring normal bladder
function. In prompted voiding, the
person with dementia is regularly asked
whether they need to urinate, whereas
timed voiding involves presenting the
person to the toilet at regular intervals.
As both techniques require vigilance
on behalf of the carer, a number of
adaptations have been developed to
reduce this additional burden, such as the
use of programmable alarms and timers.18
To assist the wife with her husband's
regular refusal to take medicine, a referral
to the Dementia Behaviour Management
Advisory Service (DBMAS) was made.
A DBMAS team member promptly
reviewed the man and provided his wife
with a number of strategies to assist her
to manage his behaviour. Following this
positive interaction, it was suggested to
the GP that risperidone was unnecessary
at this time.
After a discussion with the man, his wife
and the GP, a number of options were
reviewed to minimise the man's medicine
burden. It was suggested that metoprolol
and glimepiride be ceased, and his
blood pressure and HbA1c monitored
after two weeks and three months,
respectively, to ensure that no adverse
outcomes resulted from these accepted
changes. Based on his recent lipid profile,
simvastatin was also ceased as it was felt
that it was not conferring substantial
The man's wife expressed a strong
preference to continue aspirin, and it
was recommended that a soluble
dosage form be trialled to see if the
man was more amenable to a solution
over a tablet. Whilst liquid preparations
of cholecalciferol are available, it was
decided to also cease cholecalciferol as
his recent vitamin D level was well above
the recommended minimum. The man's
wife was also instructed on how to
disperse esomeprazole tablets, should
the man be more receptive to liquids.
To assist with continence management,
the GP referred the man to a
continence advisory service. It was
also recommended that a withdrawal
of solifenacin be trialled, based on its
lack of effectiveness and potential to
exacerbate his cognitive impairment.
Medicine management is frequently
challenging for older people, and the
balance between the benefits and
risks associated with pharmacotherapy
changes as medical conditions progress.
HMRs provide an ideal opportunity
to ensure that all medicines taken are
aligned with a person's current goals of
therapy, and can substantially assist in
alleviating the burden associated with
medicine management for older people.
1. Kaasalainen S, Dolovich L, Papaioannou A, et al. The process
of medication management for older adults with dementia.
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2. Australian Government Department of Health and Ageing.
Dementia Behaviour Management Advisory Services.
ReBOC (Reducing behaviours of concern): a hands on
guide -- a resource to assist those caring for people living
with dementia. Adelaide, South Australia: Alzheimer's
Australia; 2012. At: dbmas.org.au/uploads/resources/
3. Criddle D. Dealing with dementia -- communication tips for
pharmacists who care. Aust J Pharm 2013;32(5):56--8.
4. Burns K, Eyers K, Brodaty H. Dealing with behaviours in
people with dementia: a guide for family carers. Sydney,
New South Wales: Dementia Collaborative Research
Centre--Assessment and Better Care (DCRC--ABC) at UNSW;
5. Arlt S, Lindner R, Rösler A, et al. Adherence to medication
in patients with dementia: predictors and strategies for
improvement. Drugs Aging 2008;25(12):1033--47.
6. Scott IA, Hilmer SN, Reeve S, et al. Reducing inappropriate
polypharmacy: the process of deprescribing. JAMA Intern
7. Kua EH, Ho E, Tan HH, et al. The natural history of dementia.
8. Acute Coronary Syndrome Guidelines Working Group.
Guidelines for the management of acute coronary
syndromes 2006. Med J Aust 2006;184(8 Suppl):S9--29.
9. Kezerashvili A, Marzo K, De Leon J. Beta blocker use after
acute myocardial infarction in the patient with normal
systolic function: when is it "ok" to discontinue? Curr Cardiol
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