Please select the eligibility criteria that correspond to the clinical trial below.
Title: Discontinuing Inappropriate Medication in Nursing Home Residents (the DIM NHR Study): a Cluster Randomized Controlled Trial
Brief Summary: Nursing home residents are among the frailest patient groups with a high number of co-morbidities and a high use of medicines. Inappropriate polypharmacy (i.e. often overprescribing) is one of the major problems in the nursing home population increasing the number of adverse drug reactions, falls, hospital admissions, mortality as well as having an impact on health care utilization. Multidisciplinary medication reviews have a great potential to reduce inappropriate medication use. The purpose of this study is to determine the efficacy of a multidisciplinary medication review model focussing on discontinuing inappropriate medication in a cluster randomized controlled trial in 600 nursing home residents. The primary outcome measure is the difference in proportion of residents who successfully discontinued medication between intervention and control group after four months. Secondary outcome measures will be the drug burden index, adverse drug withdrawal events related to the discontinued medication, death, referral to hospitals and quality of life.


Options:
A: Nursing Home Wards:

Inclusion criteria:

* Long stay ward
* Capability and commitment to perform a multidisciplinary multistep medication review.

Exclusion criteria:

* Short stay, revalidation or observation wards
* Specialized ward where patients with an atypical etiology are cared for.
* Elderly care physicians who have recently received or who are to receive recertification at short notice with regard to systematic medication review methodology.
* Participation in other studies aimed at improving the quality of drug prescription (in the past 12 months).

Nursing Home Residents:

Inclusion criteria:

* A life expectancy of \>4 weeks as judged by the treating elderly care physician.
* IC provided by patients themselves or provided by a legal representative for incapacitated patients.

Exclusion criteria:

* Refusal of treatment with medicines.
* Having received a multidisciplinary systematic medication review in the past 6 months.
* Being terminally ill and having a life expectancy ≤ 4 weeks as judged by the treating elderly care physician.
* Other reasons at the discretion of the elderly care physician / nursing staff
B: Inclusion Criteria assessed at Visit 1 (Screening):

* Subject is willing and able to complete the micturition diary and questionnaires correctly.
* Subject has symptoms of wet overactive bladder (OAB) (urinary frequency and urgency with incontinence) for greater than or equal to 3 months prior to Screening.
* Subject agrees not to participate in another interventional study from the time of screening until the final study visit.

Inclusion Criteria assessed after placebo run-in period at Visit 3 (Baseline):

* Subject continues to meet all inclusion criteria of Visit 1.
* Subjects must experience at least one incontinence episode in the placebo run-in period based on the 3-day micturition diary.
* Subject must experience at least 3 episodes of urgency (grade 3 or 4) based on the 3-day micturition diary.
* Subject must experience an average of greater than or equal to 8 micturitions/day based on the 3-day micturition diary.

Exclusion Criteria assessed at Visit 1 (Screening):

* Subject has ongoing symptoms suggestive of bladder outlet obstruction (BOO) or history of BOO that is currently not well controlled.
* Subject has Post-Void Residual Volume (PVR) greater than 150 mL.
* Subject has neurogenic bladder or neurological dysfunction or injury which could affect the lower urinary tract or nerve supply.
* Subject has significant stress incontinence or mixed stress/urgency incontinence where stress is the predominant factor as determined by the Investigator (for female subjects confirmed by a cough provocation test). Subjects with a history of stress incontinence that is currently treated (e.g. remote history of surgery for stress incontinence) may be included as long as they pass cough provocation test.
* Subject has an indwelling catheter or practices intermittent self-catheterization.
* Subject has evidence of Urinary Tract Infection (UTI). Urine culture and sensitivity will be performed for positive leukocytes, or nitrites, or turbidity, or at the investigator's discretion and will be confirmed with a culture greater than 100,000 cfu/mL. If a subject has a UTI at Screening (Visit 1), the subject can be rescreened after successful treatment of the UTI (confirmed by a laboratory result of negative urine culture).
* Subject has a chronic inflammatory condition such as interstitial cystitis, bladder stones, previous pelvic radiation therapy, or previous or current malignant disease of the pelvic organs (i.e., within the confines of the pelvis including the bladder and rectum in both sexes and the uterus, ovaries, and fallopian tubes in females; organs of the lower gastrointestinal tract are not necessarily considered pelvic organs as the distal ascending colon, the full transverse colon and proximal portion of the descending colon are in the abdomen).
* Subject resides in a nursing home.
* Subject is likely to enter a hospital or nursing home due to medical instability within the next 6 months in the opinion of the Investigator.
* Subject has received intravesical injection in the past 12 months with botulinum toxin, resiniferatoxin, or capsaicin.
* Subject has received electro-stimulation therapy for OAB (e.g. sacral nerve stimulation or Percutaneous Tibial Nerve Stimulation \[PTNS\]).
* Subject began or has changed a bladder training program or pelvic floor exercises less than 30 days prior to Screening.
* Subject has moderate or severe hepatic impairment defined as Child-Pugh Class B or C.
* Subject has severe renal impairment defined as estimated creatinine clearance less than 29 mL/min determined by Estimated Glomerular Filtration Rate (eGFR, Cockroft-Gault, or MDRD formulae). A subject with end stage renal disease or undergoing dialysis is also not a candidate for the study.
* Subject has severe uncontrolled hypertension, which is defined as a sitting systolic blood pressure greater than or equal to 180 mmHg and/or diastolic blood pressure greater than or equal to 110 mmHg.
* Subject has evidence of QT prolongation on electrocardiogram (ECG) defined as QTc greater than 450 msec for males, QTc greater than 470 msec for females or a known history of QT prolongation.
* Subject has a clinically significant ECG abnormality, as determined by the Investigator.
* Subject has aspartate aminotransferase (AST) or alanine aminotransferase (ALT) greater than 2x upper limit of normal (ULN), or γ-GT greater than 3x ULN and considered clinically significant by the Investigator.
* Subject has a hypersensitivity to any components of mirabegron, other β-AR agonists, or any of the inactive ingredients.
* Subject has any clinically significant condition, which in the opinion of the Investigator makes the subject unsuitable for study participation.
* Subject has been treated with an experimental device within 28 days or received an investigational agent within 28 days or 5 half-lives, whichever is longer, prior to Screening.
* Subject has a concurrent malignancy or history of any malignancy (within the past 5 years), except non-metastatic basal or squamous cell carcinoma of the skin that has been treated successfully.
* Subject with current history of alcohol and/or drug abuse.
* Subject is using prohibited medications which cannot be stopped safely during the period.
* Subject has stopped, started or changed the dose of a restricted medication within the last 30 days prior to Screening.
* Subject is involved in the conduct of the study as an employee of the Astellas group, third party associated with the study, or the study site team.
* Subject has previously received mirabegron.

Exclusion Criteria assessed after placebo run-in period at Visit 3 (Baseline):

* Subject fulfills any exclusion criteria of Visit 1 (subject does not need to repeat screening assessments \[PVR, cough provocation test, chemistry/hematology/urinalysis\]).
* Subject was non-compliant during 2-week placebo run-in period, defined as taking less than 80% or greater than 120% of study medication.
* Subject has any systolic blood pressure measurement \> 180 mmHg or diastolic blood pressure measurement \> 110 in the 3-day diary or during the baseline visit.
C: Inclusion Criteria:

* age ≥ 65,
* living independently,
* polypharmacy (≥ 5 medications),
* Drug Burden Index ≥ 1
* written informed consent

Exclusion Criteria:

* patients who have a limited life expectancy (\<3 months)
* patients who urgently need a medication review and for whom postponing a medication review is unethical
* insufficient command of the Dutch language
* patients with advanced dementia.
* patients who received a medication review \< 9 months before recruitment date
D: Inclusion Criteria:

* ≥ 1 primary care visit at Eskenazi Health or IU Health in past 12 months
* Age ≥ 60 years
* Written informed consent and HIPAA authorization for the release of personal health information.
* English-speaking
* At least one prescription for a strong anticholinergic medication with Anticholinergic Cognitive Burden (ACB) score 2 or 3 in prior 12 months, and currently using it
* Community-dwelling in Central Indiana
* Not cognitively impaired
* Not terminally ill
* Not sensory impaired (after correction)

Exclusion Criteria:

* Permanent resident of an extended care facility (nursing home); independent or assisted senior care living is allowed if managing own medications.
* Diagnosis of Alzheimer's disease or related dementia (ADRD), determined by International Classification of Diseases (ICD)-9/ICD-10 codes or current use of a medication for ADRD
* Diagnosis of schizophrenia, bipolar disorder, or schizoaffective disorder defined by ICD-9/ICD-10 codes
* Involvement in another clinical trial that would prevent or interfere with study objectives
* Sensory or other impairment prohibiting the use of a mobile touchscreen device or other study activity (after correction)
* Not currently using anticholinergic medication

Answer: A