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Abstract
BACKGROUND Polypharmacy can appropriately treat multiple chronic conditions, but it can also increase potential harm. Polypharmacy information for primary headaches is minimal, despite drugs being the main tools to manage headaches. OBJECTIVE The aim was to evaluate the prevalence, characteristics and risk factors of polypharmacy in patients with primary headaches and examine whether these variables differ between episodic and chronic headache patients. METHODS We analysed polypharmacy (simultaneous use of five or more medications), medication type, comorbidity, and risk factors in 300 patients (mean age 42.81 ± 13.21 years) with primary headaches, divided into episodic and chronic, afferent to a headache centre. RESULTS Patients took an average of 4.37 medications. Polypharmacy was common in 40.7% of patients, and among chronic patients, it reached 58.8%. Most patients used medications (mainly nonsteroidal anti-inflammatory drugs; 73.5%) to treat acute headaches, and 30.4% of episodic and 64.7% of chronic sufferers underwent prophylactic treatment (P < 0.0001), mostly using antidepressants (77.3%). Up to 76.7% of the cohort was taking other medications, primarily for acid-related disorders (21.7%). Comorbidities were present in 59.7% of the cohort. Variables significantly associated with polypharmacy were comorbidities, prophylactic treatment, and triptans (P < 0.001). CONCLUSIONS Patients with primary headaches, mainly young adults, are exposed to high polypharmacy, comparable to that of the elderly. Because increased numbers of drugs increase the risk of adverse reactions, the many medications concomitantly taken by primary headache sufferers should be frequently reviewed.
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552
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Linsky A, Simon SR, Stolzmann K, Meterko M. Patient attitudes and experiences that predict medication discontinuation in the Veterans Health Administration. J Am Pharm Assoc (2003) 2018; 58:13-20. [PMID: 29154017 PMCID: PMC6788281 DOI: 10.1016/j.japh.2017.10.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 10/16/2017] [Accepted: 10/20/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Polypharmacy is associated with adverse medication effects. One potential solution is deprescribing, which is the intentional, proactive, rational discontinuation of a medication that is no longer indicated or for which the potential harms outweigh the potential benefits. We identified patient characteristics, attitudes, and health care experiences associated with medication discontinuation. DESIGN, SETTING, AND PARTICIPANTS We conducted a national mail survey, with the use of the Patient Perceptions of Discontinuation (PPoD) instrument, of 1600 veterans receiving primary care at Veterans Affairs (VA) medical centers and prescribed 5 or more concurrent medications. MAIN OUTCOME MEASURES The primary outcome was the response to: "Have you ever stopped taking a medicine (with or without your doctor's knowledge)?" The primary predictors of interest were 8 validated attitudinal scales. Other predictors included demographics, health status, and health care experiences. RESULTS Respondents (n = 803; adjusted response rate 52%) were predominantly male (85%); non-Hispanic white (68%), 65 years of age or older (60%), and with poor (16%) or fair (45%) health. Participant attitudes toward medications and their providers were generally favorable. One in 3 patients (34%) reported having stopped a medicine in the past. In a multivariable logistic regression model (P < 0.001; pseudo-R2 = 0.31; c-statistic = 0.82), factors associated with discontinuation included being told or asking to stop a medicine, greater interest in deprescribing and shared decision making, and higher education. Factors associated with decreased discontinuation were more prescriptions, higher trust in provider, and seeing a VA clinical pharmacist. CONCLUSION More highly educated patients with interest in deprescribing and shared decision making may be more receptive to discontinuation discussions. Future research evaluating how to incorporate this survey and these findings into clinical workflow through the design of clinical interventions may help to promote safe and rational medication use.
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Affiliation(s)
- Amy Linsky
- General Internal Medicine (152G), VA Boston Healthcare System, 150 S. Huntington Ave., Boston, MA 02130
| | - Steven R. Simon
- General Internal Medicine (152G), VA Boston Healthcare System, 150 S. Huntington Ave., Boston, MA 02130
| | - Kelly Stolzmann
- General Internal Medicine (152G), VA Boston Healthcare System, 150 S. Huntington Ave., Boston, MA 02130
| | - Mark Meterko
- General Internal Medicine (152G), VA Boston Healthcare System, 150 S. Huntington Ave., Boston, MA 02130
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553
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Benson H, Lucas C, Benrimoj SI, Kmet W, Williams KA. Pharmacists in general practice: recommendations resulting from team-based collaborative care. Aust J Prim Health 2018; 24:448-454. [DOI: 10.1071/py18022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 07/19/2018] [Indexed: 11/23/2022]
Abstract
The Western Sydney Primary Health Network (PHN), WentWest, has been working to improve patient and health system outcomes by commissioning projects that enhance patient-focussed, team-based care. One such project is the WentWest General Practice Pharmacist Project, involving the integration of pharmacists within general practice sites. The aim of this study is to describe, classify and analyse recommendations made by pharmacists to GPs, resulting from patient consultations between pharmacists and patients in a general practice setting. This study was a multi-centre prospective observational study (April 2017–September 2017) investigating recommendations made by pharmacists integrated in a general practice setting. Thirteen general practice sites located in Western Sydney, NSW, Australia were involved in the study. The main outcome measures of this study include the classification of pharmacist recommendations and the percentage of those recommendations accepted by GPs. The pharmacists recorded the results from 618 patient consultations. These consultations resulted in 1601 recommendations of which 1404 (88%) were recorded as accepted. This study demonstrated that the recommendations made by pharmacists in general practice are well accepted by GPs and may lead to improvements in medication management and patient care.
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554
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Morris NF, Stewart S, Riley MD, Maguire GP. The burden and nature of malnutrition among patients in regional hospital settings: A cross-sectional survey. Clin Nutr ESPEN 2017; 23:1-9. [PMID: 29460781 DOI: 10.1016/j.clnesp.2017.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 10/18/2017] [Accepted: 12/13/2017] [Indexed: 01/24/2023]
Abstract
BACKGROUND/AIMS Indigenous people experience a higher burden of nutrition-related conditions and are more likely to experience food insecurity compared to non-Indigenous people. Consequently, they remain at increased risk of malnutrition; particularly when residing in regional or remote areas. This study aims to compare and characterise the burden and nature of malnutrition among a representative cohort of Indigenous and non-Indigenous Australians admitted to regional hospitals for medical inpatient care. METHODS This was a cross-sectional survey conducted in three regional hospitals in the Northern Territory and Far North Queensland of Australia from February 2015 to September 2015. A total of 1606 adult medical inpatients were screened for eligibility. Of these, 608 eligible patients were screened for malnutrition using the validated Malnutrition Screening Tool and assessed for malnutrition using the Subjective Global Assessment. Socio-economic and health-related variables and anthropometric measurements were collected to identify the correlates of malnutrition. RESULTS Of the 271 Indigenous patients and 337 non-Indigenous patients screened and assessed for malnutrition, 250/608 (41.7%, 95% CI 40.1-52.3%) were found to be malnourished. Significantly higher rates of malnutrition (46.1%, 95% CI 40.1-52.3% versus 37.1%, 95% CI 31.9-42.5%) were found in Indigenous patients compared to non-Indigenous patients (P = 0.024). Higher rates of malnutrition were observed in Indigenous patients residing in Central Australia (56.7%, 95% CI 46.7-66.4%) than in the Top End of the Northern Territory (40.7%, 95% CI 31.7-50.1%) and in Far North Queensland (36.7%, 95% CI 23.4-51.7%). Factors independently predictive of malnutrition for both Indigenous and non-Indigenous participants included residence in Central Australia (OR 4.31, 95% CI 2.63-7.90, P < 0.001); an increased Charlson Comorbidity Index prognostic score (OR 1.37 [per incremental score], 95% CI 1.19-1.59, P < 0.001); and an underweight Body Mass Index (OR 29.97, 95% CI 3.68-244.0, P < 0.001). Of the 250/608 patients who were malnourished, the positive predictor value (PPV) for malnourished patients who were underweight was 96.6% (95% CI 88.3-99.6%); for Indigenous Australians who were malnourished and underweight, the PPV was 100%. A mid-upper arm circumference of less than 23 cm demonstrated a strong PPV for all patients who were malnourished (96.1%, 95% CI 89.0-99.2%). CONCLUSION This is the first study to characterise malnutrition in adult Indigenous Australians in a hospital inpatient setting. Compared to non-Indigenous patients the burden and pattern of malnutrition was both higher and markedly different among Indigenous patients. These data highlight the critical importance for actively screening for and responding to malnutrition in this vulnerable patient population in regional and remote settings.
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Affiliation(s)
- Natasha F Morris
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3084, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; The University of Melbourne, Department of Nursing, Melbourne, Australia
| | - Simon Stewart
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3084, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Malcolm D Riley
- CSIRO Health and Biosecurity, PO Box 10041, Adelaide BC, SA 5000, Australia
| | - Graeme P Maguire
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3084, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
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555
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König M, Spira D, Demuth I, Steinhagen-Thiessen E, Norman K. Polypharmacy as a Risk Factor for Clinically Relevant Sarcopenia: Results From the Berlin Aging Study II. J Gerontol A Biol Sci Med Sci 2017; 73:117-122. [PMID: 28481965 DOI: 10.1093/gerona/glx074] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 04/18/2017] [Indexed: 01/01/2023] Open
Abstract
Background Sarcopenia affects more than 10% of older adults. Next to age-associated physiologic changes, diseases like diabetes or inflammatory, neurological, malignant and endocrine disorders may contribute to the development of sarcopenia. Likewise, polypharmacy, i.e., multiple drug use, is common among older adults. Although the two conditions frequently co-occur, the association of polypharmacy with sarcopenia has not yet been examined. We investigated the association of polypharmacy and sarcopenia in a large cohort of community-dwelling older adults (60-84 years). Methods Thousand five hundred and two participants from the Berlin Aging Study II were included. Polypharmacy was defined as concurrent use of 5 or more drugs (prescription and nonprescription). Body composition was assessed with dual-energy X-ray absorptiometry, and appendicular lean mass (ALM) was calculated as sum of the four limbs' lean mass. Sarcopenia was defined as low ALM-to-body mass index (BMI)-ratio using validated sex-specific cutoffs. Results Mean age was 68.7 ± 3.7 years, 50.7% were female. The median (interquartile range) number of drugs was 2 (1-4); 21.1% of subjects reported regular use of ≥5 drugs. Subjects with polypharmacy were more often sarcopenic according to the applied ALM/BMI-cutoffs (16.3% vs 6.9%, p < 0.001), with a higher BMI (p < 0.001) and lower ALM/BMI (p < 0.001), but no significant difference in mean ALM. Notably, polypharmacy was also associated with higher rates of reduced gait speed and exhaustion. Even after multivariable adjustment (sex, age, comorbid conditions and physical activity) polypharmacy was consistently associated with a significantly increased likelihood of sarcopenia (odds ratio = 2.24, 95% confidence interval [CI] = 1.33-3.75). Conclusion Polypharmacy is associated with clinically relevant sarcopenia, as assessed by a low ALM/BMI.
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Affiliation(s)
- Maximilian König
- Research Group on Geriatrics, Charité - Universitätsmedizin Berlin, Germany
| | - Dominik Spira
- Research Group on Geriatrics, Charité - Universitätsmedizin Berlin, Germany
| | - Ilja Demuth
- Research Group on Geriatrics, Charité - Universitätsmedizin Berlin, Germany.,Institute of Medical and Human Genetics, Charité - Universitätsmedizin Berlin, Germany
| | - Elisabeth Steinhagen-Thiessen
- Research Group on Geriatrics, Charité - Universitätsmedizin Berlin, Germany.,Lipid Clinic and Lipid Apheresis, Charité - Universitätsmedizin Berlin, Germany
| | - Kristina Norman
- Research Group on Geriatrics, Charité - Universitätsmedizin Berlin, Germany
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556
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Mañas A, Del Pozo-Cruz B, Guadalupe-Grau A, Marín-Puyalto J, Alfaro-Acha A, Rodríguez-Mañas L, García-García FJ, Ara I. Reallocating Accelerometer-Assessed Sedentary Time to Light or Moderate- to Vigorous-Intensity Physical Activity Reduces Frailty Levels in Older Adults: An Isotemporal Substitution Approach in the TSHA Study. J Am Med Dir Assoc 2017; 19:185.e1-185.e6. [PMID: 29269096 DOI: 10.1016/j.jamda.2017.11.003] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 11/01/2017] [Accepted: 11/01/2017] [Indexed: 12/25/2022]
Abstract
INTRODUCTION The effects of replacing sedentary time with light or moderate- to vigorous-intensity physical activity on frailty are not well known. AIM To examine the mutually independent associations of sedentary time (ST), light-intensity physical activity (LPA), and moderate- to vigorous-intensity physical activity (MVPA) with frailty status in older adults. METHODS A total of 628 people aged ≥65 years from the Toledo Study of Healthy Aging (TSHA) participated in this cross-sectional study. Frailty was measured using the Frailty Trait Scale. Hip-worn accelerometers were used to capture objective measurements of ST, LPA, and MVPA. Linear regression and isotemporal substitution analyses were used to examine associations of ST, LPA, and MVPA with frailty status. Analyses were also stratified by comorbidity. RESULTS In single and partition models, LPA and MVPA were negatively associated with frailty. Time in sedentary behavior was not associated with frailty in these models. In the isotemporal substitution models, replacing 30 minutes/d of ST with MVPA was associated with a decrease in frailty [β -2.460; 95% confidence interval (CI): -3.782, -1.139]. In contrast, replacing ST with LPA was not associated with favorable effects on this outcome. However, when the models were stratified by comorbidity, replacing ST with MVPA had the greatest effect on frailty in both the comorbidity (β -2.556; 95% CI: -4.451, -0.661) and the no comorbidity group (β -2.535; 95% CI: -4.343, -0.726). Moreover, the favorable effects of LPA in people with comorbidities was found when replacing 30 minutes/d of ST with LPA (β -0.568; 95% CI: -1.050, -0.086). CONCLUSIONS Substituting ST with MVPA is associated with theoretical positive effects on frailty. People with comorbidity may also benefit from replacing ST with LPA, which may have important clinical implications in order to decrease the levels of physical frailty.
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Affiliation(s)
- Asier Mañas
- GENUD Toledo Research Group, University of Castilla-La Mancha, Toledo, Castilla-La Mancha, Spain; CIBER of Frailty and Healthy Aging (CIBERFES), Madrid, Comunidad de Madrid, Spain
| | - Borja Del Pozo-Cruz
- Department of Exercise Sciences, University of Auckland, Auckland, New Zealand
| | - Amelia Guadalupe-Grau
- CIBER of Frailty and Healthy Aging (CIBERFES), Madrid, Comunidad de Madrid, Spain; ImFINE Research Group, Department of Health and Human Performance, Technical University of Madrid, Madrid, Spain
| | - Jorge Marín-Puyalto
- GENUD Research Group, Faculty of Health and Sport Sciences, University of Zaragoza, Huesca, Aragón, Spain
| | - Ana Alfaro-Acha
- CIBER of Frailty and Healthy Aging (CIBERFES), Madrid, Comunidad de Madrid, Spain; Geriatric Department, Hospital Virgen del Valle, Toledo, Castilla-La Mancha, Spain
| | - Leocadio Rodríguez-Mañas
- CIBER of Frailty and Healthy Aging (CIBERFES), Madrid, Comunidad de Madrid, Spain; Geriatric Department, Hospital Universitario de Getafe, Getafe, Comunidad de Madrid, Spain
| | - Francisco J García-García
- CIBER of Frailty and Healthy Aging (CIBERFES), Madrid, Comunidad de Madrid, Spain; Geriatric Department, Hospital Virgen del Valle, Toledo, Castilla-La Mancha, Spain
| | - Ignacio Ara
- GENUD Toledo Research Group, University of Castilla-La Mancha, Toledo, Castilla-La Mancha, Spain; CIBER of Frailty and Healthy Aging (CIBERFES), Madrid, Comunidad de Madrid, Spain.
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557
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Komagamine J, Hagane K. Intervention to improve the appropriate use of polypharmacy for older patients with hip fractures: an observational study. BMC Geriatr 2017; 17:288. [PMID: 29246247 PMCID: PMC5732518 DOI: 10.1186/s12877-017-0681-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 12/07/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Polypharmacy is frequently observed in hip fracture patients. Although it is associated with an increased risk of hip fracture, polypharmacy often continues after hip fracture recovery. This study aimed to evaluate the effectiveness of an intervention to improve appropriate polypharmacy for elderly patients admitted to the hospital for hip fractures. METHODS We conducted a retrospective observational study to compare the outcomes of patients receiving the intervention (n = 32) with those of patients who received usual care (n = 132). All hip fracture patients aged 65 years or older and prescribed 5 or more medications at admission from January 2015 to December 2016 were included in the study. The intervention consisted of an assessment by internal medicine physicians of the appropriateness of polypharmacy and the de-prescription of any unnecessary medications during the patients' hospital stay. The primary composite outcome was death or the first occurrence of any new fracture. Comparisons between the intervention and usual care groups were analyzed using binary logistic regression. RESULTS A total of 164 patients were included in the study. The mean patient age was 84.8 years, and the mean numbers of prescribed medications and potentially inappropriate medications at admission were 8.0 and 1.3, respectively. The mean follow-up period was 8.0 months. The primary composite outcome occurred in 35 (21.3%) patients. The total number of potentially inappropriate medications at discharge was significantly lower in the intervention group than in the usual care group (0.8 ± 0.8 for the intervention group vs 1.1 ± 1.0 for the usual care group; p = 0.03). However, no significant differences in the primary composite outcome were found between the intervention and usual care groups (7 in the intervention group and 28 in the usual care group, odds ratio 1.04, 95% CI 0.41-2.65; p = 1.00). CONCLUSIONS The intervention to improve appropriate polypharmacy was associated with a reduction in potentially inappropriate medications but not an improvement in clinical outcomes. This intervention, which focused only on polypharmacy, may not effectively improve outcomes for elderly patients with hip fractures. TRIAL REGISTRATION UMIN-CTR UMIN000025495 . Retrospectively registered 2 January 2017.
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Affiliation(s)
- Junpei Komagamine
- Department of Internal Medicine, National Hospital Organization Tochigi Medical Center, 1-10-37, Nakatomatsuri, Utsunomiya, Tochigi, 3208580 Japan
| | - Kazuhiko Hagane
- Department of Pediatric Surgery, National Hospital Organization Tochigi Medical Center, 1-10-37, Nakatomatsuri, Utsunomiya, Tochigi, 3208580 Japan
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558
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Hernández-Aceituno A, Pérez-Tasigchana RF, Guallar-Castillón P, López-García E, Rodríguez-Artalejo F, Banegas JR. Combined Healthy Behaviors and Healthcare Services Use in Older Adults. Am J Prev Med 2017; 53:872-881. [PMID: 28774549 DOI: 10.1016/j.amepre.2017.06.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 05/22/2017] [Accepted: 06/23/2017] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Data on the combined impact of healthy behaviors on healthcare use in older adults are limited. METHODS Study with community-dwelling individuals aged ≥60 years from the Spanish Seniors-ENRICA cohort, recruited in 2008-2010, followed through 2012-2013, and analyzed in 2016 (N=2,021). At baseline, the following healthy behaviors were self-reported: three traditional (never smoking, being physically active, having a healthy diet) and three emerging (sleeping 7-8 hours/day, sitting <8 hours/day, not living alone). Outcomes were self-reported polypharmacy (five or more drugs per day), primary care physician visits (one or more per month), medical specialist visits (more than one per year), and hospitalization (one or more in the last year). The associations between baseline healthy behaviors and healthcare services used in 2012-2013 were summarized with ORs and 95% CIs from multiple logistic regression, adjusting for demographics, lifestyles, comorbidities, and baseline health services used. RESULTS Most single healthy behaviors were associated with lower use of most health services. Compared with participants with zero or one healthy behavior, those with five or six healthy behaviors showed lower risk of polypharmacy (OR=0.46, 95% CI=0.24, 0.85, p-trend=0.001), visits to the primary care physician (OR=0.50, 95% CI=0.26, 0.96, p-trend=0.013), and hospitalization (OR=0.50, 95% CI=0.24, 1.01, p-trend=0.016). No association was found with visits to the medical specialist. CONCLUSIONS The combination of five to six healthy behaviors in older adults is associated with half the risk of polypharmacy and using several healthcare services. In an era of constrained resources in most countries, this information may help inform health policy to control healthcare spending in the future.
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Affiliation(s)
- Ana Hernández-Aceituno
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid/IdiPAZ and CIBER in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Raúl F Pérez-Tasigchana
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid/IdiPAZ and CIBER in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Pilar Guallar-Castillón
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid/IdiPAZ and CIBER in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Esther López-García
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid/IdiPAZ and CIBER in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Fernando Rodríguez-Artalejo
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid/IdiPAZ and CIBER in Epidemiology and Public Health (CIBERESP), Madrid, Spain; IMDEA-Food Institute, CEI UAM+CSIC, Madrid, Spain
| | - José R Banegas
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid/IdiPAZ and CIBER in Epidemiology and Public Health (CIBERESP), Madrid, Spain.
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559
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Yusupov E, Chen D, Krishnamachari B. Medication use and falls: Applying Beers criteria to medication review in Parkinson's disease. SAGE Open Med 2017; 5:2050312117743673. [PMID: 29201368 PMCID: PMC5700784 DOI: 10.1177/2050312117743673] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 10/29/2017] [Indexed: 11/23/2022] Open
Abstract
Objectives: Our goal was to assess the association between potentially inappropriate medication use and risk of falls in the Parkinson’s disease population. Methods: This was a retrospective cohort study conducted at an outpatient Parkinson’s Disease Treatment Center. Individuals 65 years of age or older, diagnosed with Parkinson’s disease who attended at least three visits in 2015 for physical, occupational therapy, or physician’s visits were included in the study. Electronic medical records were utilized to perform chart reviews, and medications were analyzed to identify prescription medications, combination preparations, over-the-counter medications, and dietary supplements. The goal of this study was to test the following hypothesis: elderly individuals with Parkinson’s disease who take multiple potentially inappropriate medications are more likely to experience a fall compared to elderly individuals with Parkinson’s disease who do not take multiple potentially inappropriate medications. Results: A higher mean number of prescription medications were associated with falls in elderly Parkinson’s disease patients (6.53 vs 5.21, p < 0.01). Polypharmacy (taking five or more prescription and nonprescription medications) was not significantly associated with falls. Patients taking potentially inappropriate medications specifically contraindicated for those with a history of falls and fractures were more likely to report falls (p < 0.04). Analysis of the specific therapeutic medication categories demonstrated no significant differences between those who did and did not report falls. Conclusion: A future prospective study at Parkinson’s disease center should include an electronic medical record–based intervention to reduce the total number of medications, as well as to minimize the use of high-risk medications.
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Affiliation(s)
- Eleanor Yusupov
- Department of Clinical Specialties, New York Institute of Technology College of Osteopathic Medicine (NYIT COM), Old Westbury, NY, USA
| | - Davina Chen
- New York Institute of Technology College of Osteopathic Medicine (NYIT COM), Old Westbury, NY, USA
| | - Bhuma Krishnamachari
- Department of Clinical Specialties, New York Institute of Technology College of Osteopathic Medicine (NYIT COM), Old Westbury, NY, USA
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560
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[Geriatric assessment and prognostic scores in older cancer patient: Additional support to the therapeutic decision?]. Bull Cancer 2017; 104:946-955. [PMID: 29150094 DOI: 10.1016/j.bulcan.2017.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 08/25/2017] [Accepted: 10/03/2017] [Indexed: 01/10/2023]
Abstract
Cancer is a disease of the elderly as demonstrated by the epidemiological evolution of Western countries. Indeed, two third of cancers newly diagnosed occur over 65 years. However, older cancer patients have been often excluded from clinical trials in oncology and the extrapolation of cancer treatments in this population remains difficult in practice. Scientific societies recommend that a comprehensive geriatric assessment (CGA) be performed in patients aged 70 and over and selected using screening tools for frailty such as the G8 index. The CGA allows to detect aging-related vulnerabilities in various domains (comorbidities, polypharmacy, autonomy, nutrition, mobility, cognition, mood, social) and associated with adverse outcomes during cancer treatment (reduced overall survival, perioperative complications, toxicity-related chemotherapy). The CGA is allow to elaborate a personalized treatment plan in geriatric oncology. However, to date, no algorithms based on CGA is validated to guide therapeutic decision in geriatric oncology. The collaboration between geriatrician and oncologist remains essential to elaborate an appropriate therapeutic strategy and limit the situations of over- and under-treatment. This article presents the set of tools and scores used in geriatric oncology to guide the therapeutic decision.
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561
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Leelakanok N, Holcombe AL, Lund BC, Gu X, Schweizer ML. Association between polypharmacy and death: A systematic review and meta-analysis. J Am Pharm Assoc (2003) 2017; 57:729-738.e10. [DOI: 10.1016/j.japh.2017.06.002] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/27/2017] [Accepted: 06/01/2017] [Indexed: 12/30/2022]
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562
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Anderson K, Foster M, Freeman C, Luetsch K, Scott I. Negotiating "Unmeasurable Harm and Benefit": Perspectives of General Practitioners and Consultant Pharmacists on Deprescribing in the Primary Care Setting. QUALITATIVE HEALTH RESEARCH 2017; 27:1936-1947. [PMID: 29088989 DOI: 10.1177/1049732316687732] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The use of multiple medicines, known as polypharmacy, poses a risk of harm that is greatest in older adults with multimorbidity. Deprescribing aims to improve health outcomes through ceasing medicines that are no longer necessary or appropriate due to changing clinical circumstances and patient priorities. General practitioners (GPs) and consultant pharmacists (CPs) are well positioned to facilitate deprescribing in primary care in partnership with older adults who present with inappropriate polypharmacy. In this article, we explore GPs' and CPs' views about inappropriate polypharmacy, the reasoning they apply to deprescribing in primary care, and identify factors that support or inhibit this process. Using focus group methodology and the Framework Method for thematic analysis, two major themes were discerned from the data-working through uncertainty and risk perception as a frame of reference. The findings provide important insights when devising methods for advancing and supporting deprescribing in primary care.
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Affiliation(s)
| | - Michele Foster
- 2 Griffith University, Brisbane, Queensland, Australia
- 3 Metro South Health, Brisbane, Queensland, Australia
| | | | - Karen Luetsch
- 1 University of Queensland, Brisbane, Queensland, Australia
| | - Ian Scott
- 1 University of Queensland, Brisbane, Queensland, Australia
- 4 Princess Alexandra Hospital, Brisbane, Queensland, Australia
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563
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Abrahamson K, Nazir A, Pressler K. A novel approach to deprescribing in long-term care settings: The SMART campaign. Res Social Adm Pharm 2017; 13:1202-1203. [DOI: 10.1016/j.sapharm.2016.11.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 11/27/2016] [Indexed: 11/16/2022]
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564
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Kim TW, Walley AY, Ventura AS, Patts GJ, Heeren TC, Lerner GB, Mauricio N, Saitz R. Polypharmacy and risk of falls and fractures for patients with HIV infection and substance dependence. AIDS Care 2017; 30:150-159. [PMID: 29034725 DOI: 10.1080/09540121.2017.1384532] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Although people with HIV infection (PLWH) are at higher risk of polypharmacy and substance use, there is limited knowledge about potential harms associated with polypharmacy such as falls and fractures in this population. The study objective was to determine whether polypharmacy, as measured by the number and type of medication, is associated with falls and fractures among PLWH and DSM-IV substance dependence in the past year or ever injection drug use (IDU). We identified the number of medications by electronic medical record review in the following categories: (i) systemically active, (ii) non-antiretroviral (non-ARV), (iii) sedating, (iv) non-sedating as well as any opioid medication and any non-opioid sedating medication. Outcomes were self-reported (1) fall/accident requiring medical attention and (2) fracture in the previous year. Separate logistic regression models were fitted for medications in each category and each outcome. Among 250 participants, the odds of a fall requiring medical attention were higher with each additional medication overall (odds ratio [OR] 1.12, 95% Confidence Interval [CI] = 1.05, 1.18), each additional non-ARV medication (OR 1.13, 95%CI = 1.06, 1.20), each additional sedating medication (OR 1.36, 95%CI = 1.14, 1.62), and a non-opioid sedating medication (OR 2.89, 95%CI = 1.06, 7.85) but not with an additional non-sedating medication or opioid medication. In receiver operating characteristic (ROC) curve analyses, optimal cutoffs for predicting falls were: ≥8 overall and ≥2 sedating medications. Odds ratios for fracture in the previous year were OR 1.05, 95%CI = 0.97, 1.13 for each additional medication overall and OR 1.11, 95%CI = 0.89, 1.38 for each additional sedating medication. In PLWH and substance dependence or ever IDU, a higher number of medications was associated with greater odds of having a fall requiring medical attention. The association appeared to be driven largely by sedating medications. Future studies should determine if reducing such polypharmacy, particularly sedating medications, lowers the risk of falls.
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Affiliation(s)
- Theresa W Kim
- a Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center , Boston University School of Medicine , Boston , MA , USA
| | - Alexander Y Walley
- a Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center , Boston University School of Medicine , Boston , MA , USA
| | - Alicia S Ventura
- a Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center , Boston University School of Medicine , Boston , MA , USA
| | - Gregory J Patts
- b Data Coordinating Center , Boston University School of Public Health , Boston , MA , USA
| | - Timothy C Heeren
- c Department of Biostatistics , Boston University School Public Health , Boston , MA , USA
| | | | | | - Richard Saitz
- a Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center , Boston University School of Medicine , Boston , MA , USA.,e Department of Community Health Sciences , Boston University School of Public Health , Boston , MA , USA
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565
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Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr 2017; 17:230. [PMID: 29017448 PMCID: PMC5635569 DOI: 10.1186/s12877-017-0621-2] [Citation(s) in RCA: 1578] [Impact Index Per Article: 225.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 10/02/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Multimorbidity and the associated use of multiple medicines (polypharmacy), is common in the older population. Despite this, there is no consensus definition for polypharmacy. A systematic review was conducted to identify and summarise polypharmacy definitions in existing literature. METHODS The reporting of this systematic review conforms to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist. MEDLINE (Ovid), EMBASE and Cochrane were systematically searched, as well as grey literature, to identify articles which defined the term polypharmacy (without any limits on the types of definitions) and were in English, published between 1st January 2000 and 30th May 2016. Definitions were categorised as i. numerical only (using the number of medications to define polypharmacy), ii. numerical with an associated duration of therapy or healthcare setting (such as during hospital stay) or iii. Descriptive (using a brief description to define polypharmacy). RESULTS A total of 1156 articles were identified and 110 articles met the inclusion criteria. Articles not only defined polypharmacy but associated terms such as minor and major polypharmacy. As a result, a total of 138 definitions of polypharmacy and associated terms were obtained. There were 111 numerical only definitions (80.4% of all definitions), 15 numerical definitions which incorporated a duration of therapy or healthcare setting (10.9%) and 12 descriptive definitions (8.7%). The most commonly reported definition of polypharmacy was the numerical definition of five or more medications daily (n = 51, 46.4% of articles), with definitions ranging from two or more to 11 or more medicines. Only 6.4% of articles classified the distinction between appropriate and inappropriate polypharmacy, using descriptive definitions to make this distinction. CONCLUSIONS Polypharmacy definitions were variable. Numerical definitions of polypharmacy did not account for specific comorbidities present and make it difficult to assess safety and appropriateness of therapy in the clinical setting.
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Affiliation(s)
- Nashwa Masnoon
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Frome Road, Adelaide, South Australia Australia
- Department of Pharmacy, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia Australia
| | - Sepehr Shakib
- Department of Clinical Pharmacology, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia Australia
- Discipline of Pharmacology, School of Medicine, University of Adelaide, North Terrace, Adelaide, South Australia Australia
| | - Lisa Kalisch-Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Frome Road, Adelaide, South Australia Australia
| | - Gillian E. Caughey
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Frome Road, Adelaide, South Australia Australia
- Department of Clinical Pharmacology, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia Australia
- Discipline of Pharmacology, School of Medicine, University of Adelaide, North Terrace, Adelaide, South Australia Australia
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566
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Pelavski AD, De Miguel M, Alcaraz Garcia-Tejedor G, Villarino L, Lacasta A, Señas L, Rochera MI. Mortality, Geriatric, and Nongeriatric Surgical Risk Factors Among the Eldest Old. Anesth Analg 2017; 125:1329-1336. [DOI: 10.1213/ane.0000000000002389] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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567
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Retraction statement: ‘Psychotropic drug usage characteristics amongst people with severe and profound disability undergoing home medicines review’ by Fares Al-Sarawi and Chris Alderman. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2017. [DOI: 10.1002/jppr.1220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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568
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Gorup EC, Šter MP. Number of medications or number of diseases: what influences underprescribing? Eur J Clin Pharmacol 2017; 73:1673-1679. [PMID: 28920183 DOI: 10.1007/s00228-017-2336-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 09/11/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE An increasing number of older adults suffer from multimorbidity and receive multiple medications. Despite that, underprescribing of potentially beneficial medications is widespread in this population. Our aim was to examine influence of polypharmacy and multimorbidity on the presence of prescribing omissions (PO) in general practice attenders. METHODS We conducted a cross-sectional study of older adults attending general practices in Slovenia who were regularly prescribed at least one medication. Patients' data was entered into a computer application evaluating the presence of START (Screening Tool to Alert doctors to Right Treatment) criteria for PO. Demographic data, CIRS-G (Cumulative Illness Rating Scale for geriatric patients) questionnaire, number of medications, and healthcare utilization data were also collected. We defined polypharmacy as five or more concurrent medications. RESULTS Five hundred three patients were enrolled, 258 (56.7%) female. The average age was 74.9 and average value of CIRS-G index 1.48 (± 0.6). Patients took on average 5.6 medications and 216 (42.9%) patients had at least one PO according to START criteria. In bivariate analysis, there was a significant association between age, number of medications, polypharmacy and CIRS-G index measures, and presence of PO. In multivariate analysis, only age and number of affected CIRS-G categories significantly predicted PO (p < 0.05). CONCLUSIONS Older patients with more affected CIRS-G categories were at higher risk for PO. Polypharmacy was not an independent risk factor for the presence of PO. A possible reason is that in multimorbid older people, physicians and patients set individual priorities to treatment instead of treating all diseases and conditions.
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Affiliation(s)
- Eva Cedilnik Gorup
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, Poljanski nasip 58, 1000, Ljubljana, Slovenia.
| | - Marija Petek Šter
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, Poljanski nasip 58, 1000, Ljubljana, Slovenia
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569
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Quality of prescribing in community-dwelling elderly patients in France: an observational study in community pharmacies. Int J Clin Pharm 2017; 39:1220-1227. [PMID: 28905162 DOI: 10.1007/s11096-017-0531-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 09/05/2017] [Indexed: 12/28/2022]
Abstract
Background In order to ensure safer prescriptions in the elderly, lists of potentially inappropriate medications (PIMs) and guidelines have been introduced. Whereas the effectiveness of these measures has been well studied in hospitals, data are sparse for the community-dwelling patients. Objective To assess the quality of prescriptions among community-dwelling elderly patients, and potential associations between prescription patterns, patient characteristics and medication adherence. Setting Community pharmacies in France. Method We conducted a prospective observational study between January and June 2013. Patients aged 75 and over coming to the community pharmacy with a prescription from a general practitioner were invited to participate to the study. The compliance of the prescription was assessed with regards to Beers Criteria and French Health Authority guidelines (FHA) for prescription in the elderly, the degree of adherence was assessed with the Girerd score. Main outcome measure Percentage of prescriptions compliant with Beers Criteria and FHA guidelines. Results Among the 1206 prescriptions analysed, 67.49% (n = 814) contained a PIM. Only 12.77% (n = 154) complied with mandatory requirements of the FHA. Prescriptions were ordered by therapeutic field in 51.24% (n = 618) of cases. Dosing regimen was incomplete in 57.21% (n = 690) of prescriptions. Only 29.19% (n = 352) of patients reported no difficulty with regard to adherence (Girerd score = 0). The use of International Non-proprietary Name was associated with an increased risk of nonadherence (adjusted OR = 1.59 [95% CI = 1.13-2.23] and 1.68 [95% CI = 1.12-2.49] respectively). Patient satisfaction with formulation was associated with a lower risk of non-adherence (adjusted OR = 0.63 [95% CI = 0.45-0.90]). Conclusion A substantial proportion of patients are exposed to PIMs and prescriptions that do not comply with the FHA Guidelines. This issue, as well as identified risk factors for non-adherence, should be taken into consideration by general practitioners and community pharmacists when prescribing/dispensing medications to the elderly.
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570
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Ticinesi A, Milani C, Lauretani F, Nouvenne A, Mancabelli L, Lugli GA, Turroni F, Duranti S, Mangifesta M, Viappiani A, Ferrario C, Maggio M, Ventura M, Meschi T. Gut microbiota composition is associated with polypharmacy in elderly hospitalized patients. Sci Rep 2017; 7:11102. [PMID: 28894183 PMCID: PMC5593887 DOI: 10.1038/s41598-017-10734-y] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 08/14/2017] [Indexed: 02/07/2023] Open
Abstract
Reduced biodiversity and increased representation of opportunistic pathogens are typical features of gut microbiota composition in aging. Few studies have investigated their correlation with polypharmacy, multimorbidity and frailty. To assess it, we analyzed the fecal microbiota from 76 inpatients, aged 83 ± 8. Microbiome biodiversity (Chao1 index) and relative abundance of individual bacterial taxa were determined by next-generation 16S rRNA microbial profiling. Their correlation with number of drugs, and indexes of multimorbidity and frailty were verified using multivariate linear regression models. The impact of gut microbiota biodiversity on mortality, rehospitalizations and incident sepsis was also assessed after a 2-year follow-up, using Cox regression analysis. We found a significant negative correlation between the number of drugs and Chao1 Index at multivariate analysis. The number of drugs was associated with the average relative abundance of 15 taxa. The drug classes exhibiting the strongest association with single taxa abundance were proton pump inhibitors, antidepressants and antipsychotics. Conversely, frailty and multimorbidity were not significantly associated with gut microbiota biodiversity. Very low Chao1 index was also a significant predictor of mortality, but not of rehospitalizations and sepsis, at follow-up. In aging, polypharmacy may thus represent a determinant of gut microbiota composition, with detrimental clinical consequences.
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Affiliation(s)
- Andrea Ticinesi
- Department of Medicine and Surgery, University of Parma, Parma, Italy. .,Dipartimento Medico-Geriatrico-Riabilitativo, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy.
| | - Christian Milani
- Laboratory of Probiogenomics, Department of Chemistry, Life Sciences and Environmental Sustainability, University of Parma, Parma, Italy
| | - Fulvio Lauretani
- Department of Medicine and Surgery, University of Parma, Parma, Italy.,Dipartimento Medico-Geriatrico-Riabilitativo, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Antonio Nouvenne
- Department of Medicine and Surgery, University of Parma, Parma, Italy.,Dipartimento Medico-Geriatrico-Riabilitativo, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Leonardo Mancabelli
- Laboratory of Probiogenomics, Department of Chemistry, Life Sciences and Environmental Sustainability, University of Parma, Parma, Italy
| | - Gabriele Andrea Lugli
- Laboratory of Probiogenomics, Department of Chemistry, Life Sciences and Environmental Sustainability, University of Parma, Parma, Italy
| | - Francesca Turroni
- Laboratory of Probiogenomics, Department of Chemistry, Life Sciences and Environmental Sustainability, University of Parma, Parma, Italy
| | - Sabrina Duranti
- Laboratory of Probiogenomics, Department of Chemistry, Life Sciences and Environmental Sustainability, University of Parma, Parma, Italy
| | - Marta Mangifesta
- Laboratory of Probiogenomics, Department of Chemistry, Life Sciences and Environmental Sustainability, University of Parma, Parma, Italy
| | | | - Chiara Ferrario
- Laboratory of Probiogenomics, Department of Chemistry, Life Sciences and Environmental Sustainability, University of Parma, Parma, Italy
| | - Marcello Maggio
- Department of Medicine and Surgery, University of Parma, Parma, Italy.,Dipartimento Medico-Geriatrico-Riabilitativo, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Marco Ventura
- Laboratory of Probiogenomics, Department of Chemistry, Life Sciences and Environmental Sustainability, University of Parma, Parma, Italy
| | - Tiziana Meschi
- Department of Medicine and Surgery, University of Parma, Parma, Italy.,Dipartimento Medico-Geriatrico-Riabilitativo, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
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571
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Bonaga B, Sánchez-Jurado PM, Martínez-Reig M, Ariza G, Rodríguez-Mañas L, Gnjidic D, Salvador T, Abizanda P. Frailty, Polypharmacy, and Health Outcomes in Older Adults: The Frailty and Dependence in Albacete Study. J Am Med Dir Assoc 2017; 19:46-52. [PMID: 28899661 DOI: 10.1016/j.jamda.2017.07.008] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 07/10/2017] [Accepted: 07/11/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVES To investigate if polypharmacy modifies the association between frailty and health outcomes in older adults. DESIGN Ongoing cohort study. SETTING Albacete City, Spain. PARTICIPANTS A total for 773 participants, 457 women (59.1%), over age 70 years from the FRADEA Study. MEASUREMENTS Frailty phenotype, polypharmacy considered as the chronic use of 5 or more drugs, and comorbidity were collected at the baseline visit. Participants were categorized in 6 groups according to frailty and polypharmacy, and were followed up for 5.5 years (mean 1057 days, range 1-2007). Mortality or incident disability in basic activities of daily living was considered the main outcome variable. Hospitalization and visits to the emergency department were also recorded. The adjusted association between combined frailty status and polypharmacy with outcome variables was analyzed. RESULTS The mean age of study population was 78.5 years. In this population, we identified a 15.3% (n = 118) of frail with polypharmacy, 3.4% (n = 26) of frail without polypharmacy, 35.3% (n = 273) of prefrail with polypharmacy, 20.3% (n = 157) of prefrail without polypharmacy, 10.3% (n = 80) of nonfrail with polypharmacy, and 15.4% (n = 119) of nonfrail participants without polypharmacy. Participants with frailty and polypharmacy had a higher adjusted risk of mortality or incident disability [odds ratio (OR) 5.3; 95% confidence interval (CI) 2.3-12.5] and hospitalization (OR 2.3; 95% CI 1.2-4.4), compared with those without frailty and polypharmacy. Frail and prefrail participants with polypharmacy had a higher adjusted mortality risk compared with the nonfrail without polypharmacy, hazard ratio 5.8 (95% CI 1.9-17.5) and hazard ratio 3.1 (95% CI 1.1-9.1), respectively. CONCLUSIONS Polypharmacy is associated with mortality, incident disability, hospitalization, and emergency department visits in frail and prefrail older adults, but not in nonfrail adults. Polypharmacy should be monitored in these patient subgroups to optimize health outcomes.
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Affiliation(s)
- Beatriz Bonaga
- Pharmacy Department, Hospital Clínico Universitario Lozano Blesa de Zaragoza, Zaragoza, Spain
| | - Pedro M Sánchez-Jurado
- Geriatrics Department, Complejo Hospitalario Universitario de Albacete, Albacete, Spain; CIBERFES, Instituto de Salud Carlos III, Madrid, Spain
| | - Marta Martínez-Reig
- Geriatrics Department, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Gabriel Ariza
- Geriatrics Department, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Leocadio Rodríguez-Mañas
- CIBERFES, Instituto de Salud Carlos III, Madrid, Spain; Geriatrics Department, Hospital Universitario de Getafe, Madrid, Spain
| | - Danijela Gnjidic
- Faculty of Pharmacy and Charles Perkins Center, University of Sydney, Sydney, New South Wales, Australia
| | - Tránsito Salvador
- Pharmacy Department, Hospital Clínico Universitario Lozano Blesa de Zaragoza, Zaragoza, Spain
| | - Pedro Abizanda
- Geriatrics Department, Complejo Hospitalario Universitario de Albacete, Albacete, Spain; CIBERFES, Instituto de Salud Carlos III, Madrid, Spain.
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572
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Peklar J, Kos M, O’Dwyer M, McCarron M, McCallion P, Kenny RA, Henman MC. Medication and supplement use in older people with and without intellectual disability: An observational, cross-sectional study. PLoS One 2017; 12:e0184390. [PMID: 28877256 PMCID: PMC5587307 DOI: 10.1371/journal.pone.0184390] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Accepted: 08/23/2017] [Indexed: 11/25/2022] Open
Abstract
Introduction Understanding the medication and supplement use of aging people is critical to ensuring that health service providers in primary care can optimise use of these agents. An increasing number of people with different levels of intellectual disability (ID) are living in the community and becoming for the first time substantial users of primary health care services. This, however, brings new challenges that need to be addressed at the primary health care level. We quantified the use of medicines and food supplements and described the associated patterns of morbidity in the two comparable cohorts of aging population with and without intellectual disability. Method This research aligned participants of 50 years and over who lived in the community from two nationally representative cohorts of older people; those with ID from the Intellectual Disability Supplement (n = 238) and those without ID (n = 8,081) from the Irish Longitudinal Study on Ageing. Results Data showed that both medication and supplement use in the two groups was prevalent but that those with ID received more of both medications and supplements (e.g. polypharmacy was 39.0% in ID vs. 18.1% in non-ID cohort). Moreover, based on an analysis of the therapeutic groups and medications used that treatment was more intense in the ID cohort (95.8 vs. 7.0 International Non-proprietary Names per 100 participants). Supplement use was almost twice as prevalent in the ID group but substantially less diverse with only 10 types of supplements reported. Morbidity was higher in the ID group and showed a higher prevalence of neurological and mental health disorders. Conclusion The results highlight that the burden of therapy management and the potential risks in those ageing with ID differs substantially from those ageing without ID. Understanding the medication and supplement use of people aging with intellectual disability (ID) is critical to ensuring that health service providers in primary/ambulatory care can optimise use of these agents.
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Affiliation(s)
- Jure Peklar
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
- * E-mail:
| | - Mitja Kos
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Máire O’Dwyer
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
- IDS-TILDA School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Mary McCarron
- IDS-TILDA School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
- Dean of the Faculty of Health Sciences, Trinity College Dublin, Dublin, Ireland
| | - Philip McCallion
- School of Social Work, Temple University, Philadelphia, Pennsylvania, United States of America
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Dublin, Ireland
- Trinity College Institute of Neuroscience (TCIN), Trinity College Dublin, Dublin, Ireland
| | - Martin C. Henman
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
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573
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Gallego González E, Ortiz Alonso FJ, Vidán Astiz MT, Soria Felix S, García Cárdenas V, Omonte Guzmán J, Abizanda P, Valadés Malagón MI, Oreja Sevilla S, Serra Rexach JA. Development and validation of a prognostic index for 6- and 12-month mortality in hospitalized older adults. Arch Gerontol Geriatr 2017; 73:269-278. [PMID: 28869885 DOI: 10.1016/j.archger.2017.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/16/2017] [Accepted: 07/17/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND/AIM Estimation of mortality in elderly patients is difficult yet very important when planning care. Previous tools are complicated or do no take into account some major determinants of mortality (i.e., frailty). We designed a simple, accurate, and non-disease-specific tool to predict individual mortality risk after hospital discharge in older adults. METHODS Patients admitted to the Acute Geriatric Unit were assessed at adission and at discharge and contacted 6 and 12 months later. Determinants of mortality were obtained. Using multivariable analysis, beta coeffcicients were calculated to build 2 scores able to predict mortality at 6 and 12 months after discharge. The scores were tested on a sample comprising 75% of the patients, who were randomly selected; they were validated using the remaining 25%. Discrimination was assessed using ROC curves. Scores were calculated for each patient and divided into tertiles. Survival analysis was performed. RESULTS Determinants of mortality at 6 months were dependent ambulation at baseline, full dependence at discharge, length of stay, pluripatology, pressure ulcers, low grip strength, malignacy, and male gender. At 12 months the determinants were: dependent amblation at baseline, full dependence at discharge, pluripatology, low BMI, low grip strength, heart failure, malignacy, and male gender. Discrimination and calibration were excellent. Survival analysis demonstrated different survival trajectories (p<0.001) for each tertile in both scores. CONCLUSIONS Our incices provide accurate prognostic information in elderly patients after discharge. They can be calculated easily, quickly and do not require technical or laboratory support, thus endorsing their value in dalily clinical practice.
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Affiliation(s)
- Eva Gallego González
- Hospital Universitario de Canarias, Geriatric Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, CIBERFES, Madrid, Spain.
| | - Francisco Javier Ortiz Alonso
- Instituto de Investigación Sanitaria Gregorio Marañón, CIBERFES, Madrid, Spain; Geriatrics Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Maria Teresa Vidán Astiz
- Instituto de Investigación Sanitaria Gregorio Marañón, CIBERFES, Madrid, Spain; Geriatrics Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, CIBERFES, Spain.
| | - Selene Soria Felix
- Geriatrics Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | | | - John Omonte Guzmán
- Geriatrics Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Pedro Abizanda
- Geriatrics Department, Complejo Hospitalario Universitario de Albacete, CIBERFES, Albacete, Spain.
| | | | - Silvia Oreja Sevilla
- Geriatrics Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - José Antonio Serra Rexach
- Instituto de Investigación Sanitaria Gregorio Marañón, CIBERFES, Madrid, Spain; Geriatrics Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, CIBERFES, Spain.
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574
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Mahmoudi R, Novella JL, Manckoundia P, Ahssaini F, Lang PO, Blanchard F, Jolly D, Dramé M. Is functional mobility an independent mortality risk factor in subjects with dementia? Maturitas 2017; 103:65-70. [DOI: 10.1016/j.maturitas.2017.06.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 05/11/2017] [Accepted: 06/29/2017] [Indexed: 10/19/2022]
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575
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Espaulella-Panicot J, Molist-Brunet N, Sevilla-Sánchez D, González-Bueno J, Amblàs-Novellas J, Solà-Bonada N, Codina-Jané C. [Patient-centred prescription model to improve adequate prescription and therapeutic adherence in patients with multiple disorders]. Rev Esp Geriatr Gerontol 2017; 52:278-281. [PMID: 28476211 DOI: 10.1016/j.regg.2017.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/16/2017] [Accepted: 03/20/2017] [Indexed: 06/07/2023]
Abstract
Patients with multiple disorders and on multiple medication are often associated with clinical complexity, defined as a situation of uncertainty conditioned by difficulties in establishing a situational diagnosis and decision-making. The patient-centred care approach in this population group seems to be one of the best therapeutic options. In this context, the preparation of an individualised therapeutic plan is the most relevant practical element, where the pharmacological plan maintains an important role. There has recently been a significant increase in knowledge in the area of adequacy of prescription and adherence. In this context, we must find a model must be found that incorporates this knowledge into clinical practice by the professionals. Person-centred prescription is a medication review model that includes different strategies in a single intervention. It is performed by a multidisciplinary team, and allows them to adapt the pharmacological plan of patients with clinical complexity.
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Affiliation(s)
- Joan Espaulella-Panicot
- Hospital Universitari de la Santa Creu, Vic, Barcelona, España; Hospital Universitari de Vic, Vic, Barcelona, España.
| | - Núria Molist-Brunet
- Hospital Universitari de la Santa Creu, Vic, Barcelona, España; Hospital Universitari de Vic, Vic, Barcelona, España
| | - Daniel Sevilla-Sánchez
- Hospital Universitari de la Santa Creu, Vic, Barcelona, España; Hospital Universitari de Vic, Vic, Barcelona, España
| | | | - Jordi Amblàs-Novellas
- Hospital Universitari de la Santa Creu, Vic, Barcelona, España; Hospital Universitari de Vic, Vic, Barcelona, España
| | | | - Carles Codina-Jané
- Hospital Universitari de Vic, Vic, Barcelona, España; Hospital Clínic de Barcelona, Barcelona, España
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576
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Diet quality and its implications on the cardio-metabolic, physical and general health of older men: the Concord Health and Ageing in Men Project (CHAMP). Br J Nutr 2017; 118:130-143. [PMID: 28820080 DOI: 10.1017/s0007114517001738] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The revised Dietary Guideline Index (DGI-2013) scores individuals' diets according to their compliance with the Australian Dietary Guideline (ADG). This cross-sectional study assesses the diet quality of 794 community-dwelling men aged 74 years and older, living in Sydney, Australia participating in the Concord Health and Ageing in Men Project; it also examines sociodemographic and lifestyle factors associated with DGI-2013 scores; it studies associations between DGI-2103 scores and the following measures: homoeostasis model assessment - insulin resistance, LDL-cholesterol, HDL-cholesterol, TAG, blood pressure, waist:hip ratio, BMI, number of co-morbidities and medications and frailty status while also accounting for the effect of ethnicity in these relationships. Median DGI-2013 score was 93·7 (54·4, 121·2); most individuals failed to meet recommendations for vegetables, dairy products and alternatives, added sugar, unsaturated fat and SFA, fluid and discretionary foods. Lower education, income, physical activity levels and smoking were associated with low scores. After adjustments for confounders, high DGI-2013 scores were associated with lower HDL-cholesterol, lower waist:hip ratios and lower probability of being frail. Proxies of good health (fewer co-morbidities and medications) were not associated with better compliance to the ADG. However, in participants with a Mediterranean background, low DGI-2013 scores were not generally associated with poorer health. Older men demonstrated poor diet quality as assessed by the DGI-2013, and the association between dietary guidelines and health measures and indices may be influenced by ethnic background.
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577
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Abstract
PURPOSE OF REVIEW Evidence-based strategies are needed to address the growing complexity of care of those ageing with HIV so that as life expectancy is extended, quality of life is also enhanced. RECENT FINDINGS Modifiable contributing factors to the quantity and quality of life in adults ageing with HIV include: burden of harmful health behaviours, injury from HIV infection, HIV treatment toxicity and general burden of age-associated comorbidities. In turn, these factors contribute to geriatric syndromes including multimorbidity and polypharmacy, physiologic frailty, falls and fragility fractures and cognitive dysfunction, which further compromise the quality of life long before they lead to mortality. SUMMARY Viral suppression of HIV with combination antiviral therapy has led to increasing longevity but has not enabled a complete return to health among ageing HIV-infected individuals (HIV+). As adults age with HIV, the role of HIV itself and associated inflammation, effects of exposure to antiretroviral agents, the high prevalence of modifiable risk factors for age-associated conditions (e.g. smoking), and the effects of other viral coinfections are all influencing the health trajectory of persons ageing with HIV. We must move from the simplistic notion of HIV becoming a 'chronic controllable illness' to understanding the continually evolving 'treated' history of HIV infection with the burden of age-associated conditions and geriatric syndromes in the context of an altered and ageing immune system.
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578
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Abstract
Sciatica is a debilitating condition affecting approximately 25 % of the population. Typically, the patient will complain of lower limb pain that is more severe than pain in the lower back, usually accompanied by numbness and motor weakness. Most international guidelines recommend pharmacological management for the pain relief of sciatica, including paracetamol, non-steroidal anti-inflammatory drugs, opioid analgesics, anticonvulsants, and corticosteroids, among others. However, the evidence for most of these pharmacological options is scarce, and the majority of clinical trials exclude older patients. There is overall very limited information on the efficacy, safety, and tolerability of these medicines in older patients with sciatica. This review presents a critical appraisal of the existing evidence for the pharmacological treatment of sciatica, with a special focus on the older adult. The age-related changes in the health of older patients, as well as their impact on the response to pharmacological treatment, including polypharmacy, drug interactions, and drug-disease interactions, is also discussed.
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Affiliation(s)
- Manuela L Ferreira
- The George Institute for Global Health, Sydney Medical School, The University of Sydney, PO Box M201, Missenden Rd, Sydney, NSW, 2050, Australia. .,Institute of Bone and Joint Research, The Kolling Institute, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.
| | - Andrew McLachlan
- Faculty of Pharmacy and Centre for Education and Research in Ageing, The University of Sydney and Concord Hospital, Sydney, NSW, Australia
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579
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Sociodemographic and Clinical Characteristics of Centenarians in Mexico City. BIOMED RESEARCH INTERNATIONAL 2017; 2017:7195801. [PMID: 28904969 PMCID: PMC5585632 DOI: 10.1155/2017/7195801] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 06/11/2017] [Accepted: 07/06/2017] [Indexed: 11/17/2022]
Abstract
Background There is little evidence about the demography and health status of adults aged 100 years and over in Latin America and there are no studies in Mexico. Objectives To describe the demographic characteristics and health status of centenarians residing in Mexico City. Methods This is a cross-sectional study using a population base of 393 community-dwelling centenarians in Mexico City. A comprehensive geriatric assessment was performed, including demographic information and health status. Results The mean age of centenarians was 101.82 ± 2.02 years, of whom 44 (9.1%) were semisupercentenarians (105–109 years old) and 5 (0.2%) were supercentenarians (≥110 years old). The female/male ratio was 3.2 : 1. Twelve (4.5%) reside in nursing homes. Women versus men have unfavorable conditions given their criteria: being without a partner, dependence in 1 or more basic activities, dependence in 1 or more instrumental activities, hypertension, cancer, and Parkinson's disease. Nevertheless, as compared to other populations, Mexican centenarians report having good self-perception of health (78.9%), polypharmacy (17.8%), low rate of pain (11.4%), diabetes (4.8%), and dyslipidemia (1.8%). Conclusions This is the first study in Latin America that describes the social and clinical characteristics of centenarians in Mexico City. This population has a high percentage of malnutrition and osteoarthrosis, a high self-perception of health, low frequency of diabetes, dyslipidemia, cardiovascular disease, and a high frequency of “escapers” (24%).
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580
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Choosing Wisely? Measuring the Burden of Medications in Older Adults near the End of Life: Nationwide, Longitudinal Cohort Study. Am J Med 2017; 130:927-936.e9. [PMID: 28454668 DOI: 10.1016/j.amjmed.2017.02.028] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 02/01/2017] [Accepted: 02/01/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND The burden of medications near the end of life has recently come under scrutiny, because several studies suggested that people with life-limiting illness receive potentially futile treatments. METHODS We identified 511,843 older adults (>65 years) who died in Sweden between 2007 and 2013 and reconstructed their drug prescription history for each of the last 12 months of life through the Swedish Prescribed Drug Register. Decedents' characteristics at time of death were assessed through record linkage with the National Patient Register, the Social Services Register, and the Swedish Education Register. RESULTS Over the course of the final year before death, the proportion of individuals exposed to ≥10 different drugs rose from 30.3% to 47.2% (P <.001 for trend). Although older adults who died from cancer had the largest increase in the number of drugs (mean difference, 3.37; 95% confidence interval, 3.35 to 3.40), living in an institution was independently associated with a slower escalation (β = -0.90, 95% confidence interval, -0.92 to -0.87). During the final month before death, analgesics (60.8%), anti-throm-botic agents (53.8%), diuretics (53.1%), psycholeptics (51.2%), and β-blocking agents (41.1%) were the 5 most commonly used drug classes. Angiotensin-converting enzyme inhibitors and statins were used by, respectively, 21.4% and 15.8% of all individuals during their final month of life. CONCLUSION Polypharmacy increases throughout the last year of life of older adults, fueled not only by symptomatic medications but also by long-term preventive treatments of questionable benefit. Clinical guidelines are needed to support physicians in their decision to continue or discontinue medications near the end of life.
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581
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Alvim MM, Cruz DTD, Vieira MDT, Bastos RR, Leite ICG. Prevalence of and factors associated with benzodiazepine use in community-resident elderly persons. REVISTA BRASILEIRA DE GERIATRIA E GERONTOLOGIA 2017. [DOI: 10.1590/1981-22562017020.170042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract Objective: to assess the prevalence of and factors associated with the use of benzodiazepines in elderly persons living in the community. Method: a cross-sectional study was conducted through a household survey of 423 elderly persons from Juiz de Fora, Minas Gerais, Brazil. To analyze the factors associated with the outcome, the Poisson regression model was used, based on the theoretical model of determination with hierarchical blocks. The variables were adjusted within each block, with those with a 5% significance level remaining in the final model. Result: The prevalence of benzodiazepine use was 18.3% (95% CI 15.2 to 21.6). Most benzodiazepines used had a long-elimination half-life (59.2%) and use was considered long in 85.5% of users. Among benzodiazepine users 38.4% also used antidepressants. The use of these drugs was associated with the presence of self-reported mental and behavioral disorders, polypharmacy and medical visits in the last three months. Conclusion: The use of benzodiazepines was considered high among the elderly. The reduction in the prescription of these drugs should be assessed individually, considering the physiological alterations of the elderly and the adverse effects of drugs, in order to minimize incorrect prescriptions.
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582
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Maclagan LC, Maxwell CJ, Gandhi S, Guan J, Bell CM, Hogan DB, Daneman N, Gill SS, Morris AM, Jeffs L, Campitelli MA, Seitz DP, Bronskill SE. Frailty and Potentially Inappropriate Medication Use at Nursing Home Transition. J Am Geriatr Soc 2017; 65:2205-2212. [PMID: 28752589 DOI: 10.1111/jgs.15016] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES To estimate the prevalence of potentially inappropriate medication (PIM) use among older adults with cognitive impairment or dementia prior to and following admission to nursing homes and in relation to frailty. DESIGN Retrospective cohort study using health administrative databases. SETTING Ontario, Canada. PARTICIPANTS 41,351 individuals with cognitive impairment or dementia, aged 66+ years newly admitted to nursing home between 2011 and 2014. MEASUREMENTS PIMs were defined with 2015 Beers Criteria and included antipsychotics, H2 -receptor antagonists, benzodiazepines, and drugs with strong anticholinergic properties. Medication information was obtained at nursing home admission and in the subsequent 180 days. Multivariable Cox proportional-hazards models were used to assess the impact of frailty status (determined by a 72-item frailty index) on the hazard of starting and discontinuing PIMs. RESULTS At admission, 44% of residents with cognitive impairment or dementia were on a PIM and prevalence varied by frailty (38.7% non-frail, 42.8% pre-frail, and 48.1% frail, P < .001). Following admission, many residents discontinued PIMs (23.5% for antipsychotics, 49.3% benzodiazepines, 32.2% anticholinergics, and 30.9% H2 -receptor antagonists). However, PIMs were also introduced with 10.9% newly started on antipsychotics, benzodiazepines (10.1%), anticholinergics (6.6%), and H2 -receptor antagonists (1.2%). After adjustment for other characteristics, frail residents had a similar risk of PIM discontinuation as non-frail residents except for anticholinergics (HR = 1.21, 95% CI 1.06-1.39) but were more likely to be newly prescribed benzodiazepines (HR = 1.32, 95% CI 1.20-1.44), antipsychotics (HR = 1.36, 1.23-1.49), and anticholinergics (HR = 1.34, 95% CI 1.20-1.50). CONCLUSION Many residents with cognitive impairment or dementia enter nursing homes on PIMs. PIMs are more likely to be started in frail individuals following admission. Interventions to support deprescribing of PIMs should be implemented targeting frail individuals during the transition to nursing home.
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Affiliation(s)
- Laura C Maclagan
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Colleen J Maxwell
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Sima Gandhi
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Jun Guan
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Chaim M Bell
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of General Internal Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - David B Hogan
- Divison of Geriatric Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nick Daneman
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sudeep S Gill
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Division of Geriatric Medicine, Queen's University, Kingston, Ontario, Canada.,Providence Care Hospital, Kingston, Ontario, Canada
| | - Andrew M Morris
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of General Internal Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Lianne Jeffs
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | | | - Dallas P Seitz
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Division of Geriatric Psychiatry, Queen's University, Kingston, Ontario, Canada
| | - Susan E Bronskill
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
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583
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Kim TW, Walley AY, Heeren TC, Patts GJ, Ventura AS, Lerner GB, Mauricio N, Saitz R. Polypharmacy and risk of non-fatal overdose for patients with HIV infection and substance dependence. J Subst Abuse Treat 2017; 81:1-10. [PMID: 28847449 DOI: 10.1016/j.jsat.2017.07.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 07/06/2017] [Accepted: 07/13/2017] [Indexed: 12/21/2022]
Abstract
INTRODUCTION People living with HIV (PLWH) are at risk of both polypharmacy and unintentional overdose yet there are few data on whether polypharmacy increases risk of overdose. The study objective was to determine if the number and type of medication (e.g., sedating) were associated with non-fatal overdose (OD) among PLWH with past-year substance dependence or a lifetime history of injection drug use. MATERIALS AND METHODS This was a longitudinal study of adults recruited from two urban, safety-net HIV clinics. Outcomes were i) lifetime and ii) past-year non-fatal OD assessed at baseline and a 12-month follow-up. We used logistic regression to examine the association between each outcome and the number of medications (identified from the electronic medical record) in the following categories: i) overall medications, ii) non-antiretroviral (non-ARV), iii) sedating, iv) non-sedating, as well as any vs no opioid medication and any vs no non-opioid sedating medication. Covariates included demographics, medical comorbidities, depressive and anxiety symptoms, and substance use. RESULTS Among 250 participants, 80% were prescribed a sedating medication, 50% were prescribed an opioid; 51% exceeded risky drinking limits. In the past month, 23% reported illicit opioid use and 9% illicit opioid sedative use; 37% reported lifetime non-fatal OD and 7% past-year non-fatal OD. The median number (interquartile range) of total medications was 10 (7, 14) and 2 (1, 3) sedating. The odds of lifetime non-fatal OD were significantly higher with each additional sedating medication (OR 1.26, 95% CI 1.08, 1.46) and any opioid medication (OR 2.31; 95% CI 1.37, 3.90), but not with each overall, non-ARV, or non-sedating medication. The odds of past year non-fatal OD were greater with each additional sedating medication (OR 1.18; 95% CI 1.00, 1.39, p=0.049), each additional non-ARV medication (OR 1.07; 95% CI 1.00, 1.15, p=0.048), and non-significantly for any opioid medication (OR 2.23; 95% CI 0.93, 5.35). CONCLUSIONS In this sample of PLWH with substance dependence and/or injection drug use, number of sedating medications and any opioid were associated with non-fatal overdose; sedating medications were prescribed to the majority of patients. Polypharmacy among PLWH and substance dependence warrants further research to determine whether reducing sedating medications, including opioids, lowers overdose risk.
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Affiliation(s)
- Theresa W Kim
- Clinical Addiction Research and Education (CARE) Unit (TWK, AYW, ASV, RS), Section of General Internal Medicine, Boston University School of Medicine (GBL, NM), Boston Medical Center, Boston, MA, United States.
| | - Alexander Y Walley
- Clinical Addiction Research and Education (CARE) Unit (TWK, AYW, ASV, RS), Section of General Internal Medicine, Boston University School of Medicine (GBL, NM), Boston Medical Center, Boston, MA, United States.
| | - Timothy C Heeren
- Department of Biostatistics (TH), Data Coordinating Center (GJP), Department of Community Health Sciences (RS), Boston University School Public Health, Boston, MA, United States.
| | - Gregory J Patts
- Department of Biostatistics (TH), Data Coordinating Center (GJP), Department of Community Health Sciences (RS), Boston University School Public Health, Boston, MA, United States.
| | - Alicia S Ventura
- Department of Biostatistics (TH), Data Coordinating Center (GJP), Department of Community Health Sciences (RS), Boston University School Public Health, Boston, MA, United States.
| | - Gabriel B Lerner
- Clinical Addiction Research and Education (CARE) Unit (TWK, AYW, ASV, RS), Section of General Internal Medicine, Boston University School of Medicine (GBL, NM), Boston Medical Center, Boston, MA, United States.
| | - Nicholas Mauricio
- Clinical Addiction Research and Education (CARE) Unit (TWK, AYW, ASV, RS), Section of General Internal Medicine, Boston University School of Medicine (GBL, NM), Boston Medical Center, Boston, MA, United States.
| | - Richard Saitz
- Clinical Addiction Research and Education (CARE) Unit (TWK, AYW, ASV, RS), Section of General Internal Medicine, Boston University School of Medicine (GBL, NM), Boston Medical Center, Boston, MA, United States; Department of Biostatistics (TH), Data Coordinating Center (GJP), Department of Community Health Sciences (RS), Boston University School Public Health, Boston, MA, United States.
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584
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Abstract
In the modern world, there is a rapid advance in the design and clinical introduction of a huge number of drugs that are able to cure a patient or to improve his/her health status on the one hand and to cause significant harm to his/her health on the other. Polypragmasy is the desire to enhance the efficiency of treatment and to help the patient recover from all developed diseases inevitably leads to the use of a large number of medications. At the present time, polypragmasy as a result of iatrogenia is a serious public health problem, as it is clinically manifested by a reduction in the effectiveness of pharmacotherapy, by the development of severe adverse drug reactions, and by a considerable increase in healthcare expenditures. The reason for the simultaneous prescription of multiple drugs may be comorbidity (multimorbidity), the availability of drugs, as well as clinical guidelines, manuals of professional medical associations, treatment standards that contain recommendations for using combination therapy with more than 5 drugs for only one disease in some cases, the efficiency of which corresponds to a high level of evidence. Currently, the fight against polypragmasy is one of the important tasks in rendering medical care to elderly and senile patients since it is a major risk factor of adverse drug reactions in this category of people. To minimize polypragmasy in elderly patients, it is necessary to use current methods for analyzing each prescription of a drug (the index of rational drug prescribing; an anticholinergic burden scale) and those for optimizing pharmacotherapy with the use of restrictive lists (Beers criteria, STOPP/START criteria) that will be able to reduce the number of errors in the administration of drugs and to maximize the efficiency and safety of pharmacotherapy.
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Affiliation(s)
- D A Sychev
- Russian Medical Academy of Postgraduate Education, Ministry of Health of Russia, Moscow, Russia
| | - V A Otdelеnov
- Multiprofile Medical Center, Bank of Russia, Moscow, Russia
| | - N M Krasnova
- Medical Institute, M.K. Ammosov North-Eastern Federal University, Yakutsk, Russia
| | - E S Ilyina
- Russian Medical Academy of Postgraduate Education, Ministry of Health of Russia, Moscow, Russia
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585
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Ritt M, Jäger J, Ritt JI, Sieber CC, Gaßmann KG. Operationalizing a frailty index using routine blood and urine tests. Clin Interv Aging 2017; 12:1029-1040. [PMID: 28721031 PMCID: PMC5500540 DOI: 10.2147/cia.s131987] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background Uncomplicated frailty instruments are desirable for use in a busy clinical setting. The aim of this study was to operationalize a frailty index (FI) from routine blood and urine tests, and to evaluate the properties of this FI compared to other frailty instruments. Materials and methods We conducted a secondary analysis of a prospective cohort study on 306 patients aged ≥65 years hospitalized on geriatric wards. An FI comprising 22 routine blood parameters and one standard urine parameter (FI-Lab), a 50-item FI based on a comprehensive geriatric assessment (FI-CGA), a combined FI (FI-combined [items from the FI-Lab + others from the FI-CGA]), the Clinical Frailty Scale, rule-based frailty definition, and frailty phenotype were operationalized from data obtained during patients’ hospital stays (ie, before discharge [baseline examination]). Follow-up data were obtained up to 1 year after the baseline examination. Results The mean FI-Lab score was 0.34±15, with an upper limit of 0.74. The FI-Lab was correlated with all the other frailty instruments (all P<0.001). The FI-Lab revealed an area under the receiver-operating characteristic curve (AUC) for 6-month and 1-year mortality of 0.765 (0.694–0.836) and 0.769 (0.706–0.833), respectively (all P<0.001). Each 0.01 increment in FI-Lab increased the risk (adjusted for age and sex) for 6-month and 1-year mortality by 7.2% and 7.1%, respectively (all adjusted P<0.001). When any of the other FIs (except the FI-combined) were also included in the models, each 0.01 increment in FI-Lab score was associated with an increase in the risk of 6-month and 1-year mortality by 4.1%–5.4% (all adjusted P<0.001). Conclusion The FI-Lab showed key characteristics of an FI. The FI-Lab can be applied as a single frailty measure or in combination with/in addition to other frailty instruments.
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Affiliation(s)
- Martin Ritt
- Institute for Biomedicine of Ageing (IBA), Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Nuremberg, Germany.,Department of Internal Medicine III (Medicine of Ageing), Geriatrics Center Erlangen, Hospital of the Congregation of St Francis Sisters of Vierzehnheiligen, Erlangen, Germany
| | - Jakob Jäger
- Department of Internal Medicine III (Medicine of Ageing), Geriatrics Center Erlangen, Hospital of the Congregation of St Francis Sisters of Vierzehnheiligen, Erlangen, Germany
| | - Julia Isabel Ritt
- Department of Internal Medicine III (Medicine of Ageing), Geriatrics Center Erlangen, Hospital of the Congregation of St Francis Sisters of Vierzehnheiligen, Erlangen, Germany
| | - Cornel Christian Sieber
- Institute for Biomedicine of Ageing (IBA), Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Nuremberg, Germany.,Department of General Internal Medicine and Geriatrics, Hospital of the Order of St John of God, Regensburg, Germany
| | - Karl-Günter Gaßmann
- Institute for Biomedicine of Ageing (IBA), Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Nuremberg, Germany.,Department of Internal Medicine III (Medicine of Ageing), Geriatrics Center Erlangen, Hospital of the Congregation of St Francis Sisters of Vierzehnheiligen, Erlangen, Germany
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586
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Abstract
OBJECTIVES To examine the relationship between polypharmacy and gait performance during simple (normal walk (NW)) and complex (walking while talking (WWT)) locomotion. DESIGN Cross-sectional. SETTING Community. PARTICIPANTS Community-dwelling older adults (N = 482). MEASUREMENTS Polypharmacy, defined as use of five or more medications and a cohort-specific alternate definition of eight or more medications, was examined. Velocity (cm/s) measured quantitatively during NW and WWT conditions. RESULTS The 164 participants (34%) with polypharmacy of five or more medications were older (77.0 ± 6.6 vs 76.0 ± 6.4) and more likely to have hypertension, congestive heart failure, diabetes mellitus, myocardial infarction, and higher body mass index (BMI) and to have fallen within the last year than the remaining 318 without polypharmacy and walked 6 cm/s slower (P = .004) during NW and 4 cm/s slower during WWT (P = .07), adjusting for age, sex, and education. Group differences were not statistically significant after adjusting for comorbidities. Prevalence of polypharmacy of eight or more medications was 10%. This group walked 11 cm/s slower during NW (P < .001) and 8.6 cm/s slower during WWT (P = .01) than those without polypharmacy, adjusted for age, sex, and education. Participants taking eight or more medications had slower NW (8.5 cm/s; P = .01), and WWT (6.9 cm/s; P = .07), compared to those without polypharmacy, adjusting for comorbidities. Adjustments for BMI, high-risk drugs, falls, and comorbidities yielded slower NW (9.4 cm/s, P = .005) and WWT (7.9 cm/s, P = .04 among those with polypharmacy compared to those without polypharmacy). CONCLUSION These results suggest an association between polypharmacy and locomotion that medical comorbidities only partly explained.
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Affiliation(s)
- Claudene George
- Division of Geriatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Joe Verghese
- Division of Cognitive and Motor Aging and Geriatrics, Albert Einstein College of Medicine, Bronx, New York
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587
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Abolhassani N, Castioni J, Marques-Vidal P, Vollenweider P, Waeber G. Determinants of change in polypharmacy status in Switzerland: the population-based CoLaus study. Eur J Clin Pharmacol 2017. [DOI: 10.1007/s00228-017-2288-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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588
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Ilango S, Pillans P, Peel NM, Scott I, Gray LC, Hubbard RE. Prescribing in the oldest old inpatients: a retrospective analysis of patients referred for specialist geriatric consultation. Intern Med J 2017. [PMID: 28632340 DOI: 10.1111/imj.13526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND While medications may prolong life and prevent morbidity in older people, adverse effects of polypharmacy are increasingly recognised. As patients age and become frail, prescribing may be expected to focus more on symptom control and minimise potentially harmful preventive medication use that confer little benefit within a short lifespan. Whether prescribing practice shifts to one of symptom controls among the oldest old admitted to hospital remains unclear. AIM To determine, in the oldest old inpatients, whether preventive versus symptom control medication prescribing was associated with age or level of frailty. METHODS Retrospective analysis of all patients aged ≥85 years referred for comprehensive geriatric assessment at a tertiary care hospital between May 2006 and December 2014 for whom all prescribed medications were documented. Medication use was assessed according to age group (85-89, 90-94, ≥95) and categories of frailty index calculated for patients based on 52 deficits (fitter, moderately frail, frail and severely frail). RESULTS Seven hundred and eighty-three inpatients were assessed of mean (SD) age 89.0 (3.4) and mean frailty index 0.45 (SD 0.14) with a median of eight co-morbidities (IQR 6-10) and who were prescribed a mean of 8.3 (SD 3.8) regular medications per day. Polypharmacy (5-9 medications per day) was observed in 406 patients (51.9%) and hyper-polypharmacy (≥10 medications per day) in 268 patients (34.2%). While there was a significant decrease in number of prescribed medications as age increased, there were no differences across age groups or frailty categories in proportions of medications used for prevention versus symptom control. CONCLUSION Polypharmacy is prevalent in oldest old inpatients and prescribing patterns according to prevention versus symptom control appear unaffected by age and frailty status.
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Affiliation(s)
- Sivarajah Ilango
- Department of Clinical Pharmacology, The Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Department of Internal Medicine, The Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Peter Pillans
- Department of Clinical Pharmacology, The Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Department of Internal Medicine, The Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Nancye M Peel
- Centre for Research in Geriatric Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Ian Scott
- Department of Internal Medicine, The Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Department of Clinical Epidemiology, The Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Leonard C Gray
- Centre for Research in Geriatric Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Ruth E Hubbard
- Centre for Research in Geriatric Medicine, The University of Queensland, Brisbane, Queensland, Australia
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589
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Bleijenberg N, Imhof L, Mahrer-Imhof R, Wallhagen MI, de Wit NJ, Schuurmans MJ. Patient Characteristics Associated With a Successful Response to Nurse-Led Care Programs Targeting the Oldest-Old: A Comparison of Two RCTs. Worldviews Evid Based Nurs 2017. [PMID: 28632933 DOI: 10.1111/wvn.12235] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND To improve the effectiveness of community-based care programs, especially those targeting the oldest-old population (80+), data are needed that elucidate those factors associated with a successful response to the intervention. Two comparable nurse-led care programs have been evaluated in two large randomized controlled trials (RCTs), one in Switzerland and one in the Netherlands. AIMS To identify common patient characteristics that are related to a successful response to proactive nurse-led care, we explored if and to what extent, identical factors were present in both study populations. METHODS A secondary data analysis using trial data from the intervention group of both RCTs was conducted. The study sample consisted 461 older adults, 230 from the U-PROFIT trial (the Netherlands) and 231 from the HPC trial (Switzerland). The mean age of the total sample was 85.1 years (SD 3.7). The UPROFIT intervention, delivered by registered nurses, included a frailty assessment and a comprehensive geriatric assessment (CGA) at home followed by an individualized evidence-based care plan, care coordination, and follow-up. The HCP intervention was delivered by advanced practice nurses consisting of four home visits and three phone calls, and was guided by the principles of health promotion, empowerment, partnership, and family-centeredness. A successful response was defined as "stable" or "no decline" in daily functioning at follow-up. Daily functioning was measured with 13 items of activities of daily living and instrumental activities of daily living. Multivariate logistic regression models were applied to calculate the association between individual characteristics and a successful response. RESULTS Almost half of the participants in the U-PROFIT trial (50.9%), and two-thirds (65.7%) of the participants in the HCP trial had a successful response at follow-up. Fewer comorbidities and a better self-rated health had the strongest predictive value for benefiting from the intervention (OR = 0.83 [95% CI 0.66-1.03], and OR = 1.5 [95% CI 0.92-2.45]), respectively. LINKING EVIDENCE TO ACTION Two large RCTs demonstrated that a preventive nurse-led care program can preserve daily functioning in the oldest-old population. Older people with few comorbidities and higher self-rated health had a higher likelihood of a positive outcome. Unraveling the characteristics associated with a successful response provides important information for further refining and targeting an intervention to obtain maximum effectiveness. More effort is needed to modify interventions for the oldest-old with multiple morbidities and low levels of education.
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Affiliation(s)
- Nienke Bleijenberg
- Assistant Professor, Julius Center for Health Sciences and Primary Care, Department of General Practice, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lorenz Imhof
- Head of Research Institute of Nursing, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Romy Mahrer-Imhof
- Professor, Research Institute of Nursing Zurich University of Applied Sciences (ZHAW), Winterthur, Switzerland
| | - Margaret I Wallhagen
- Director, John A. Hartford Center of Gerontological Nursing Excellence, University of California San Francisco, School of Nursing, Department of Physiological Nursing, San Francisco, CA, USA
| | - Niek J de Wit
- Professor, Julius Center for Health Sciences and Primary Care, Department of General Practice, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marieke J Schuurmans
- Professor, Department of Rehabilitation, Nursing Science and Sports Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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590
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Frailty, polypharmacy, and potentially inappropriate medications in old people: findings in a representative sample of the French population. Eur J Clin Pharmacol 2017; 73:1165-1172. [DOI: 10.1007/s00228-017-2276-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 05/31/2017] [Indexed: 12/20/2022]
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591
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Can Sarcopenia Quantified by Ultrasound of the Rectus Femoris Muscle Predict Adverse Outcome of Surgical Intensive Care Unit Patients as well as Frailty? A Prospective, Observational Cohort Study. Ann Surg 2017; 264:1116-1124. [PMID: 26655919 DOI: 10.1097/sla.0000000000001546] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To compare sarcopenia and frailty for outcome prediction in surgical intensive care unit (SICU) patients. BACKGROUND Frailty has been associated with adverse outcomes and describes a status of muscle weakness and decreased physiological reserve leading to increased vulnerability to stressors. However, frailty assessment depends on patient cooperation. Sarcopenia can be quantified by ultrasound and the predictive value of sarcopenia at SICU admission for adverse outcome has not been defined. METHODS We conducted a prospective, observational study of SICU patients. Sarcopenia was diagnosed by ultrasound measurement of rectus femoris cross-sectional area. Frailty was diagnosed by the Frailty Index Questionnaire based on 50 variables. Relationship between variables and outcomes was assessed by multivariable regression analysis NCT02270502. RESULTS Sarcopenia and frailty were quantified in 102 patients and observed in 43.1% and 38.2%, respectively. Sarcopenia predicted adverse discharge disposition (discharge to nursing facility or in-hospital mortality, odds ratio 7.49; 95% confidence interval 1.47-38.24; P = 0.015) independent of important clinical covariates, as did frailty (odds ratio 8.01; 95% confidence interval 1.82-35.27; P = 0.006); predictive ability did not differ between sarcopenia and frailty prediction model, reflected by χ values of 21.74 versus 23.44, respectively, and a net reclassification improvement (NRI) of -0.02 (P = 0.87). Sarcopenia and frailty predicted hospital length of stay and the frailty model had a moderately better predictive accuracy for this outcome. CONCLUSIONS Bedside diagnosis of sarcopenia by ultrasound predicts adverse discharge disposition in SICU patients equally well as frailty. Sarcopenia assessed by ultrasound may be utilized as rapid beside modality for risk stratification of critically ill patients.
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592
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Mihailovic A, Swenor BK, Friedman DS, West SK, Gitlin LN, Ramulu PY. Gait Implications of Visual Field Damage from Glaucoma. Transl Vis Sci Technol 2017; 6:23. [PMID: 28660098 PMCID: PMC5484170 DOI: 10.1167/tvst.6.3.23] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 04/01/2017] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To evaluate fall-relevant gait features in older glaucoma patients. METHODS The GAITRite Electronic Walkway was used to define fall-related gait parameters in 239 patients with suspected or manifest glaucoma under normal usual-pace walking conditions and while carrying a cup or tray. Multiple linear regression models assessed the association between gait parameters and integrated visual field (IVF) sensitivity after controlling for age, race, sex, medications, and comorbid illness. RESULTS Under normal walking conditions, worse IVF sensitivity was associated with a wider base of support (β = 0.60 cm/5 dB IVF sensitivity decrement, 95% confidence interval [CI] = 0.12-1.09, P = 0.016). Worse IVF sensitivity was not associated with slower gait speed, shorter step or stride length, or greater left-right drift under normal walking conditions (P > 0.05 for all), but was during cup and/or tray carrying conditions (P < 0.05 for all). Worse IVF sensitivity was positively associated with greater stride-to-stride variability in step length, stride length, and stride velocity (P < 0.005 for all). Inferior and superior IVF sensitivity demonstrated associations with each of the above gait parameters as well, though these associations were consistently similar to, or weaker than, the associations noted for overall IVF sensitivity. CONCLUSION Glaucoma severity was associated with several gait parameters predictive of higher fall risk in prior studies, particularly measures of stride-to-stride variability. Gait may be useful in identifying glaucoma patients at higher risk of falls, and in designing and testing interventions to prevent falls in this high-risk group. TRANSLATIONAL RELEVANCE These findings could serve to inform the development of the interventions for falls prevention in glaucoma patients.
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Affiliation(s)
| | | | | | - Sheila K. West
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
| | - Laura N. Gitlin
- Center for Innovative Care in Aging, School of Nursing, Johns Hopkins University, Baltimore, MD, USA
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593
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Smith JM, Flexner C. The challenge of polypharmacy in an aging population and implications for future antiretroviral therapy development. AIDS 2017; 31 Suppl 2:S173-S184. [PMID: 28471948 DOI: 10.1097/qad.0000000000001401] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
: It is estimated that by 2030 nearly three-quarters of persons living with HIV will be 50 years and older. The aging HIV population presents a new clinical concern for HIV providers: adverse effects from polypharmacy. An aging population means more comorbidities and potentially more drug-drug interactions for providers to manage. This review discusses major comorbidities including cardiovascular disease, anticoagulation, hypertension, diabetes mellitus and malignancy and considerations for drug-interactions with antiretrovirals.
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594
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Shah S, Galdo J, Cox ED, Moreno MA, Young HN. Impact of Bubble Packaging on Adherence to Long-Term Oral Medications
Used to Prevent Cardiovascular Disease. J Pharm Technol 2017; 33:114-120. [PMCID: PMC5998413 DOI: 10.1177/8755122517702171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023] Open
Abstract
Background: Adherence to long-term pharmacotherapy is problematic in the United States. Bubble packaging of medications has been touted to improve patients’ use of medications. Scant research has assessed bubble packaging’s impact on adherence to multiple medications. Objective: To compare medication adherence between patients receiving medications to address cardiovascular disease risk factors in bubble packages to those receiving medications in pill bottles. Methods: This retrospective cohort study utilized prescription dispensing records from an independent pharmacy. Patients receiving statins, β-blockers, angiotensin-converting enzyme inhibitors, or oral hypoglycemic agents were identified and grouped into those who received medications in bubble packages and those received medications in pill bottles. Adherence was assessed with medication possession ratios. Patients were classified as adherent if their medication possession ratio was 80% or more. Results: Receiving medications in bubble packaging was significantly associated with greater adherence compared to pill bottles (P < .001). In adjusted models, greater numbers of medications filled (P = .024) and increasing patient age (P = .018) were significantly associated with low adherence, while bubble packaging was not (P = .13). Stratified analyses revealed that bubble packaging was significantly associated with greater adherence when 4 or fewer medications are filled (P = .012) and for patients between 18 and 44 years of age (P = .023). Conclusion: Bubble packages can improve medication adherence. However, they may not resolve complex issues contributing to the problem of nonadherence, especially for older patients and those prescribed multiple medications.
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595
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Ong GJ, Page A, Caughey G, Johns S, Reeve E, Shakib S. Clinician agreement and influence of medication-related characteristics on assessment of polypharmacy. Pharmacol Res Perspect 2017; 5:e00321. [PMID: 28603638 PMCID: PMC5464348 DOI: 10.1002/prp2.321] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 04/05/2017] [Indexed: 12/31/2022] Open
Abstract
It is not known how clinicians assess polypharmacy or the medication‐related characteristics that influence their assessment. The aim of this study was to examine the level of agreement between clinicians when assessing polypharmacy and to identify medication‐related characteristics that influence their assessment. Twenty cases of patients with varying levels of comorbidity and polypharmacy were used to examine clinician assessment of polypharmacy. Medicine‐related factors within the cases included Beers and STOPP Criteria medicines, falls‐risk medicines, drug burden index (DBI) medicines, medicines causing postural hypotension, and pharmacokinetic drug–drug interactions. Clinicians were asked to rate cases on the degree of polypharmacy, likelihood of harm, and potential for the medication list to be simplified. Inter‐rater reliability analysis, correlations, and multivariate logistic regression analyses were conducted to identify medicine factors associated with clinicians' assessment. Eighteen expert clinicians were recruited (69.2% response rate). Strong agreement was observed in clinicians' assessment of polypharmacy (intraclass correlation coefficients [ICC] = 0.94), likelihood to cause harm (ICC = 0.89), and ability to simplify medication list (ICC = 0.90). Multivariate analyses demonstrated number of medicines (P < 0.0001) and DBI scores (P = 0.047) were significantly associated with assessment of polypharmacy. Medicines associated with harm were significantly associated with the number of medicines (P = 0.01) and Beers criteria medicines (P = 0.003). Ability to simplify the medication regimen was significantly associated with number of medicines (P = 0.03) and medicines from the STOPP criteria (P = 0.018). Among clinicians, strong consensus exists with regard to assessment of polypharmacy, medication harm, and ability to simplify medications. Definitions of polypharmacy need to take into account not only the numbers of medicines but also potential for medicines to cause harm or be inappropriate, and validate them against clinical outcomes.
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Affiliation(s)
- Gao-Jing Ong
- Department of Clinical Pharmacology Royal Adelaide Hospital North Terrace Adelaide South Australia Australia
| | - Amy Page
- School of Medicine and Pharmacology University of Western Australia Perth Australia
| | - Gillian Caughey
- Department of Clinical Pharmacology Royal Adelaide Hospital North Terrace Adelaide South Australia Australia.,School of Pharmacy and Medical Sciences University of South Australia Adelaide South Australia Australia
| | - Sally Johns
- Department of Clinical Pharmacology Royal Adelaide Hospital North Terrace Adelaide South Australia Australia
| | - Emily Reeve
- Cognitive Decline Partnership Centre Kolling Institute of Medical Research Sydney Medical School The University of Sydney New South Wales Australia.,Geriatric Medicine Research Unit Dalhousie University and Nova Scotia Health Authority 5955 Veterans' Memorial Lane Halifax Nova Scotia Canada
| | - Sepehr Shakib
- Department of Clinical Pharmacology Royal Adelaide Hospital North Terrace Adelaide South Australia Australia.,Discipline of Pharmacology School of Medicine University of Adelaide North Terrace Adelaide South Australia Australia
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596
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Schöttker B, Saum KU, Muhlack DC, Hoppe LK, Holleczek B, Brenner H. Polypharmacy and mortality: new insights from a large cohort of older adults by detection of effect modification by multi-morbidity and comprehensive correction of confounding by indication. Eur J Clin Pharmacol 2017; 73:1041-1048. [DOI: 10.1007/s00228-017-2266-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 05/11/2017] [Indexed: 01/10/2023]
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597
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Prasert V, Akazawa M, Shono A, Chanjaruporn F, Ploylearmsang C, Muangyim K, Wattanapongsatit T, Sutin U. Applying the Lists of Risk Drugs for Thai Elderly (LRDTE) as a mechanism to account for patient age and medicine severity in assessing potentially inappropriate medication use. Res Social Adm Pharm 2017; 14:451-458. [PMID: 28571945 DOI: 10.1016/j.sapharm.2017.05.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 05/22/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Potential inappropriate medication (PIM) prescribing is a medication that puts patients at risk rather than having benefits. PIM use has been associated with hospitalization, morbidity, and mortality resulting from ADRs in elderly patients. The Lists of Risk Drugs for Thai Elderly (LRDTE) was developed as the new screening tool to identify PIMs use. The prevalence of PIM use using the LRDTE has not been determined in Thailand. PURPOSE The main purpose of this study was to examine the prevalence of PIM use based on the LRDTE. In addition, this aimed to address the PIM problem by identifying factors that influenced PIM use among elderly patients in Thailand. METHODS A retrospective cross-sectional descriptive study was conducted using the computerized database at four community hospitals in Thailand during fiscal year 2014. The LRDTE criteria were used as a screening tool for identifying the medicine items of PIM use. Descriptive statistics and multivariate logistic regression were used to identify common and Thai region-specific predictors of PIM use. RESULTS Of a total of 13274 elderly patients, 79% were prescribed at least one PIM, as indicated by the LRDTE criteria. Amlodipine (32%), omeprazole (30%), and tramadol (18%) were the most commonly prescribed PIMs in elderly patients aged 60 years and older. Hospital and physician characteristics were identified as independent predictors after adjustment for patient and utilization factors. CONCLUSION PIM use in Thai elderly patients was highly prevalent in community hospitals because the LRDTE criteria reflected clinical practice in Thailand. Hospital and physician factors were identified as region-specific factors that were highly associated with PIM use. Revision of hospital formularies and educational programs for physicians are needed to improve prescribing and avoid PIM use.
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Affiliation(s)
- Vanida Prasert
- Department of Pharmacy, Sirindhorn College of Public Health, 20000, Thailand.
| | - Manabu Akazawa
- Department of Public Health and Epidemiology, Meiji Pharmaceutical University, 204-8588, Japan
| | - Aiko Shono
- Department of Public Health and Epidemiology, Meiji Pharmaceutical University, 204-8588, Japan
| | - Farsai Chanjaruporn
- Social and Administrative Pharmacy Excellence Research Unit, Faculty of Pharmacy, Mahidol University, 10400, Thailand
| | - Chanuttha Ploylearmsang
- Social Pharmacy Research Unit, Faculty of Pharmacy, Mahasarakham University, 44150, Thailand
| | - Kamolnut Muangyim
- Department of Pharmacy, Sirindhorn College of Public Health, 20000, Thailand
| | | | - Uthen Sutin
- Community and Family Medicine Unit, Bothong Hospital, 20270, Thailand
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598
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de Luna RA, Mihailovic A, Nguyen AM, Friedman DS, Gitlin LN, Ramulu PY. The Association of Glaucomatous Visual Field Loss and Balance. Transl Vis Sci Technol 2017; 6:8. [PMID: 28553562 PMCID: PMC5444495 DOI: 10.1167/tvst.6.3.8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 04/04/2017] [Indexed: 12/23/2022] Open
Abstract
Purpose To relate balance measures to visual field (VF) damage from glaucoma. Methods The OPAL kinematic system measured balance, as root mean square (RMS) sway, on 236 patients with suspect/diagnosed glaucoma. Balance was measured with feet shoulder width apart while standing on a firm/foam surface with eyes opened/closed (Instrumental Clinical Test of Sensory Integration and Balance [ICTSIB] conditions), and eyes open on a firm surface under feet together, semi-tandem, or tandem positions (standing balance conditions). Integrated VF (IVF) sensitivities were calculated by merging right and left eye 24-2 VF data. Results Mean age was 71 years (range, 57–93) and mean IVF sensitivity was 27.1 dB (normal = 31 dB). Lower IVF sensitivity was associated with greater RMS sway during eyes-open foam-surface testing (β = 0.23 z-score units/5 dB IVF sensitivity decrement, P = 0.001), but not during other ICTSIB conditions. Lower IVF sensitivity also was associated with greater RMS sway during feet together standing balance testing (0.10 z-score units/5 dB IVF sensitivity decrement, P = 0.049), but not during other standing balance conditions. Visual dependence of balance was lower in patients with worse IVF sensitivity (β = −21%/5 dB IVF sensitivity decrement, P < 0.001). Neither superior nor inferior IVF sensitivity consistently predicted balance measures better than measures of overall VF sensitivity. Conclusions Balance was worse in glaucoma patients with greater VF damage under foam surface testing (designed to inhibit proprioceptive contributions to balance) as well as feet-together firm-surface conditions when somatosensory inputs were available. Translational Relevance Good balance is essential to avoid unnecessary falls and patients with VF loss from glaucoma may be at higher risk of falls because of poor balance.
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Affiliation(s)
- Regina A de Luna
- Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | | | - Angeline M Nguyen
- Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - David S Friedman
- Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Laura N Gitlin
- Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Pradeep Y Ramulu
- Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland, USA
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599
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Valdiglesias V, Sánchez-Flores M, Maseda A, Lorenzo-López L, Marcos-Pérez D, López-Cortón A, Strasser B, Fuchs D, Laffon B, Millán-Calenti JC, Pásaro E. Immune biomarkers in older adults: Role of physical activity. JOURNAL OF TOXICOLOGY AND ENVIRONMENTAL HEALTH. PART A 2017; 80:605-620. [PMID: 28524767 DOI: 10.1080/15287394.2017.1286898] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Aging is associated with a decline in the normal functioning of the immune system. Several studies described the relationship between immunological alterations, including immunosenescence and inflammation, and aging or age-related outcomes, such as sarcopenia, depression, and neurodegenerative disorders. Physical activity is known to improve muscle function and to exert a number of benefits on older adult health, including reduced risk for heart and metabolic system chronic diseases. However, the positive influence of physical activity on the immune system has not been elucidated. In order to shed light on the role of physical activity in immune responses of older individuals, a number of immunological parameters comprising % lymphocyte subsets (CD3+, CD4+, CD8+, CD19+, and CD16+56+) and serum levels of neopterin and tryptophan metabolism products were evaluated in peripheral blood samples of older adults performing normal (N = 170) or reduced (N = 89) physical activity. In addition, the potential influence of other clinical and epidemiological factors was also considered. Results showed that subjects with reduced physical activity displayed significantly higher levels of CD4+/CD8+ ratio, kynurenine/tryptophan ratio, and serum neopterin, along with lower %CD19+ cells and tryptophan concentrations. Further, some immunological biomarkers were associated with cognitive impairment and functional status. These data contribute to reinforce the postulation that physical activity supports healthy aging, particularly by helping to protect the immunological system from aging-related changes.
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Affiliation(s)
- Vanessa Valdiglesias
- a Universidade da Coruña, DICOMOSA Group , Department of Psychology, Area of Psychobiology , A Coruña , Spain
| | - María Sánchez-Flores
- a Universidade da Coruña, DICOMOSA Group , Department of Psychology, Area of Psychobiology , A Coruña , Spain
- b Universidade da Coruña , Department of Cell and Molecular Biology , A Coruña , Spain
| | - Ana Maseda
- c Universidade da Coruña, Gerontology Research Group, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS , A Coruña , Spain
| | - Laura Lorenzo-López
- c Universidade da Coruña, Gerontology Research Group, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS , A Coruña , Spain
| | - Diego Marcos-Pérez
- a Universidade da Coruña, DICOMOSA Group , Department of Psychology, Area of Psychobiology , A Coruña , Spain
- b Universidade da Coruña , Department of Cell and Molecular Biology , A Coruña , Spain
| | - Ana López-Cortón
- a Universidade da Coruña, DICOMOSA Group , Department of Psychology, Area of Psychobiology , A Coruña , Spain
| | | | - Dietmar Fuchs
- d Biocenter, Innsbruck Medical University , Innsbruck , Austria
| | - Blanca Laffon
- a Universidade da Coruña, DICOMOSA Group , Department of Psychology, Area of Psychobiology , A Coruña , Spain
| | - José C Millán-Calenti
- c Universidade da Coruña, Gerontology Research Group, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS , A Coruña , Spain
| | - Eduardo Pásaro
- a Universidade da Coruña, DICOMOSA Group , Department of Psychology, Area of Psychobiology , A Coruña , Spain
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600
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Sirois C, Laroche ML, Guénette L, Kröger E, Cooper D, Émond V. Polypharmacy in multimorbid older adults: protocol for a systematic review. Syst Rev 2017; 6:104. [PMID: 28526062 PMCID: PMC5438541 DOI: 10.1186/s13643-017-0492-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 05/02/2017] [Indexed: 03/20/2023] Open
Abstract
BACKGROUND Polypharmacy, the concurrent use of multiple medications, consistently evokes a negative connotation, notably because it is associated with a plethora of adverse events. Nonetheless, the number of individuals exposed to polypharmacy is increasing steeply, especially for older people with multiple diseases. There is a need to carefully study the phenomenon at the population scale to full assess the associated health outcomes. Yet, this reveals a complex task because there exists no consensus indicator of polypharmacy. In fact, the definitions of polypharmacy are heterogeneous and its predisposing factors and associated outcomes are not well defined. The goal of this systematic review is to summarize the literature on polypharmacy in multimorbid individuals aged 65 years and over, targeting three objectives: (1) to identify the definitions of polypharmacy that are used in the context of multimorbidity among older individuals (≥65 years); (2) to ascertain predisposing and concurrent factors associated with polypharmacy; and (3) to describe positive and negative outcomes of polypharmacy among older individuals, including hospitalizations, mortality and costs. METHODS We will include publications from 2004 to 2016 that target four concepts: polypharmacy, older individuals, multimorbidity and positive/negative outcomes. The search will be performed using EBM Reviews, Embase, Global Health, MEDLINE, AgeLine, CINAHL, Health Policy Reference Center, Public Affairs Index, SocINDEX and Google Scholar. Two independent reviewers will screen the articles, extract the information and evaluate the methodological quality of included studies. The results will be presented in tables and narrative summaries will be performed. We will perform meta-analyses (objective 3) if the heterogeneity is not important. DISCUSSION This review will help describe the various ways of conceptualizing polypharmacy and how it is associated with health outcomes. We have selected outcomes most relevant for public surveillance performed with administrative databases. Other positive and negative outcomes have been associated with polypharmacy but may not be included in the review. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42014014989.
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Affiliation(s)
- Caroline Sirois
- Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Québec, Canada. .,Centre d'excellence sur le vieillissement de Québec, Centre de recherche du CHU de Québec, Québec, Canada. .,Institut national de santé publique du Québec, Québec, Canada. .,Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec, Québec, Canada. .,Centre d'excellence sur le vieillissement de Québec, Hôpital du St-Sacrement, 1050 Chemin Ste-Foy, Local L2-28, Québec, (Qc) G1S 4L8, Canada.
| | - Marie-Laure Laroche
- Service de Pharmacologie, Toxicologie et Pharmacovigilance, Centre Régional de Pharmacovigilance, de Pharmacoépidémiologie et d'information sur les médicaments, Centre Hospitalier Universitaire de Limoges, Limoges, France.,Faculté de Médecine, Université de Limoges, Limoges, France
| | - Line Guénette
- Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec, Québec, Canada.,Faculté de pharmacie, Université Laval, Québec, Canada
| | - Edeltraut Kröger
- Centre d'excellence sur le vieillissement de Québec, Centre de recherche du CHU de Québec, Québec, Canada.,Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec, Québec, Canada.,Faculté de pharmacie, Université Laval, Québec, Canada
| | - Dan Cooper
- Department of Social and Preventive Medicine, Faculty of Medicine, Laval University, Québec, Canada.,Faculté de pharmacie, Université Laval, Québec, Canada
| | - Valérie Émond
- Institut national de santé publique du Québec, Québec, Canada
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