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Liu X, Jing B, Graham LA, Liu CK, Lee SJ, Steinman MA, Dave CV, Manja V, Li Y, Fung K, Odden MC. Complex Patterns of Antihypertensive Treatment Changes in Long-Term Care Residents. J Am Med Dir Assoc 2024; 25:105119. [PMID: 38950584 PMCID: PMC11368635 DOI: 10.1016/j.jamda.2024.105119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 04/19/2024] [Accepted: 05/22/2024] [Indexed: 07/03/2024]
Abstract
OBJECTIVES Antihypertensive treatment changes are common in long-term care residents, yet data on the frequency and predictors of changes are lacking. We described the patterns of antihypertensive changes and examined the triggering factors. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS A total of 24,870 Department of Veterans Affairs (VA) nursing home residents aged ≥65 years with long-term stays (≥180 days) from 2006 to 2019. METHODS We obtained data from the VA Corporate Data Warehouse. Based on Bar Code Medication Administration medication data, we defined 2 types of change events in 180 days of admission: deprescribing (reduced number of antihypertensives or dose reduction of ≥30% compared with the previous week and maintained for at least 2 weeks) and intensification (opposite of deprescribing). Mortality was identified within 2 years after admission. RESULTS More than 85% of residents were prescribed antihypertensives and 68% of them experienced ≥1 change event during the first 6 months of the nursing home stay. We categorized residents into 10 distinct patterns: no change (27%), 1 deprescribing (11%), multiple deprescribing (5%), 1 intensification (10%), multiple intensification (7%), 1 deprescribing followed by 1 intensification (3%), 1 intensification followed by 1 deprescribing (4%), 3 changes with mixed events (7%), >3 changes with mixed events (10%), and no antihypertensive use (15%). Treatment changes were more frequent in residents with better physical function and/or cognitive function. Potentially triggering factors differed by the type of antihypertensive change: incident high blood pressure and cardiovascular events were associated with intensification, and low blood pressure, weight loss, and falls were associated with deprescribing. Death occurred in 7881 (32%) residents over 2 years. The highest mortality was for those without antihypertensive medication (incidence = 344/1000 person-years). CONCLUSIONS AND IMPLICATIONS Patterns of medication changes existing in long-term care residents are complex. Future studies should explore the benefits and harms of these antihypertensive treatment changes.
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Affiliation(s)
- Xiaojuan Liu
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA; Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA, USA.
| | - Bocheng Jing
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA, USA; Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Laura A Graham
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA; Stanford-Surgery Policy Improvement Research Education Center, Department of Surgery, Stanford University, Stanford, CA, USA
| | - Christine Kee Liu
- Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA, USA; Section of Geriatrics, Division of Primary Care and Population Health, Stanford University, School of Medicine, Stanford, CA, USA
| | - Sei J Lee
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA, USA; Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Michael A Steinman
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA, USA; Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Chintan V Dave
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA; Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, USA
| | - Veena Manja
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA; Department of Health Policy, Stanford University, Stanford, CA, USA
| | - Yongmei Li
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
| | - Kathy Fung
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA, USA; Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Michelle C Odden
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA; Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
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Japelj N, Kerec Kos M, Jošt M, Knez L. Impact of changes in antihypertensive medication on treatment intensity at hospital discharge and 30 days afterwards. Front Pharmacol 2024; 15:1376002. [PMID: 39185310 PMCID: PMC11341450 DOI: 10.3389/fphar.2024.1376002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 07/12/2024] [Indexed: 08/27/2024] Open
Abstract
Introduction Little is known about the cumulative effect of changes in antihypertensive medications on treatment intensity. This study analyzed how changes in antihypertensive medications affect the intensity of antihypertensive treatment at hospital discharge and 30 days afterwards. Methods A prospective observational study of 299 hospitalized adult medical patients with antihypertensive therapy was conducted. The effect of medication changes on treatment intensity was evaluated by the Total Antihypertensive Therapeutic Intensity Score (TIS). Results At discharge, antihypertensive medications were changed in 62% of patients (184/299), resulting in a very small median reduction in TIS of -0.16. Treatment intensity was reduced more with increasing number of antihypertensive medications at admission, whereas it increased with elevated inpatient systolic blood pressure. Thirty days after discharge, antihypertensive medications were changed in 37% of patients (88/239) resulting in a median change in TIS of -0.02. Among them, 90% (79/88) had already undergone a change at discharge. The change in treatment intensity after discharge was inversely correlated with a change at discharge. Discussion Changes in antihypertensive medication frequently occurred at discharge but had a minimal impact on the intensity of antihypertensive treatment. However, these adjustments exposed patients to further medication changes after discharge, evidencing the need for treatment reassessment in the first month post-discharge.
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Affiliation(s)
- Nuša Japelj
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Mojca Kerec Kos
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Maja Jošt
- Department of Pharmacy, University Clinic Golnik, Golnik, Slovenia
| | - Lea Knez
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
- Department of Pharmacy, University Clinic Golnik, Golnik, Slovenia
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Denig P, Stuijt PJC. Perspectives on deprescribing in older people with type 2 diabetes and/or cardiovascular conditions: challenges from healthcare provider, patient and caregiver perspective, and interventions to support a proactive approach. Expert Rev Clin Pharmacol 2024; 17:637-654. [PMID: 39119644 DOI: 10.1080/17512433.2024.2378765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/24/2024] [Accepted: 07/08/2024] [Indexed: 08/10/2024]
Abstract
INTRODUCTION For people with type 2 diabetes and/or cardiovascular conditions, deprescribing of glucose-lowering, blood pressure-lowering and/or lipid-lowering medication is recommended when they age, and their health status deteriorates. So far, deprescribing rates of these so-called cardiometabolic medications are low. A review of challenges and interventions addressing these challenges in this population is pertinent. AREAS COVERED We first provide an overview of relevant deprescribing recommendations. Next, we review challenges for healthcare providers (HCPs) to deprescribe cardiometabolic medication and provide insight in the patient and caregiver perspective on deprescribing. We summarize findings from research on implementing deprescribing of cardiometabolic medication and reflect on strategies to enhance deprescribing. We have used a combination of methods to search for relevant articles. EXPERT OPINION There is a need for rigorous development and evaluation of intervention strategies aimed at proactive deprescribing of cardiometabolic medication. To address challenges at different levels, these should be multifaceted interventions. All stakeholders must become aware of the relevance of deintensifying medication in this population. Education and training for HCPs and patients should support patient-centered communication and shared decision-making. Development of procedures and tools to select eligible patients and conduct targeted medication reviews are important for implementation of deprescribing in routine care.
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Affiliation(s)
- Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter J C Stuijt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
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Pajewski NM, Supiano MA. Deprescribing for older adults with hypertension at high risk for adverse events: not so fast. THE LANCET. HEALTHY LONGEVITY 2024; 5:e512-e513. [PMID: 39094593 DOI: 10.1016/j.lanhl.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Accepted: 07/09/2024] [Indexed: 08/04/2024] Open
Affiliation(s)
- Nicholas M Pajewski
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
| | - Mark A Supiano
- Center on Aging and Department of Internal Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, USA
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Sheppard JP, Temple E, Wang A, Smith A, Pollock S, Ford GA, Hobbs FDR, Kenealy N, Little P, Lown M, de Lusignan S, Mant J, McCartney D, Payne RA, Williams M, Yu LM, McManus RJ. Effect of antihypertensive deprescribing on hospitalisation and mortality: long-term follow-up of the OPTiMISE randomised controlled trial. THE LANCET. HEALTHY LONGEVITY 2024; 5:e563-e573. [PMID: 39094592 PMCID: PMC11327766 DOI: 10.1016/s2666-7568(24)00131-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 06/19/2024] [Accepted: 06/24/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND Deprescribing of antihypertensive medications is recommended for some older patients with low blood pressure and frailty. The OPTiMISE trial showed that this deprescribing can be achieved with no differences in blood pressure control at 3 months compared with usual care. We aimed to examine effects of deprescribing on longer-term hospitalisation and mortality. METHODS This randomised controlled trial enrolled participants from 69 general practices across central and southern England. Participants aged 80 years or older, with systolic blood pressure less than 150 mm Hg and who were receiving two or more antihypertensive medications, were randomly assigned (1:1) to antihypertensive medication reduction (removal of one antihypertensive) or usual care. General practitioners and participants were aware of the treatment allocation following randomisation but individuals responsible for analysing the data were masked to the treatment allocation throughout the study. Participants were followed up via their primary and secondary care electronic health records at least 3 years after randomisation. The primary outcome was time to all-cause hospitalisation or mortality. Intention-to-treat analyses were done using Cox regression modelling. A per-protocol analysis of the primary outcome was also done, excluding participants from the intervention group who did not reduce treatment or who had medication reinstated during the initial trial 12-week follow-up period. This study is registered with the European Union Drug Regulating Authorities Clinical Trials Database (EudraCT2016-004236-38) and the ISRCTN Registry (ISRCTN97503221). FINDINGS Between March 20, 2017, and Sept 30, 2018, a total of 569 participants were randomly assigned. Of these, 564 (99%; intervention=280; control=284) were followed up for a median of 4·0 years (IQR 3·7-4·3). Participants had a mean age of 84·8 years (SD 3·4) at baseline and 273 (48%) were women. Medication reduction was sustained in 109 participants at follow-up (51% of the 213 participants alive in the intervention group). Participants in the intervention group had a larger reduction in antihypertensives than the control group (adjusted mean difference -0·35 drugs [95% CI -0·52 to -0·18]). Overall, 202 (72%) participants in the intervention group and 218 (77%) participants in the control group experienced hospitalisation or mortality during follow-up (adjusted hazard ratio [aHR] 0·93 [95% CI 0·76 to 1·12]). There was some evidence that the proportion of participants experiencing the primary outcome in the per-protocol population was lower in the intervention group (aHR 0·80 [0·64 to 1·00]). INTERPRETATION Half of participants sustained medication reduction with no evidence of an increase in all-cause hospitalisation or mortality. These findings suggest that an antihypertensive deprescribing intervention might be safe for people aged 80 years or older with controlled blood pressure taking two or more antihypertensives. FUNDING British Heart Foundation and National Institute for Health and Care Research.
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Affiliation(s)
- James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - Eleanor Temple
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ariel Wang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Anne Smith
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Stephanie Pollock
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Gary A Ford
- Radcliffe Department of Medicine, University of Oxford, UK and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nicola Kenealy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Paul Little
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Mark Lown
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - David McCartney
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rupert A Payne
- Health and Community Sciences, University of Exeter, Exeter, UK
| | | | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Pozarickij A, Gan W, Lin K, Clarke R, Fairhurst-Hunter Z, Koido M, Kanai M, Okada Y, Kamatani Y, Bennett D, Du H, Chen Y, Yang L, Avery D, Guo Y, Yu M, Yu C, Schmidt Valle D, Lv J, Chen J, Peto R, Collins R, Li L, Chen Z, Millwood IY, Walters RG. Causal relevance of different blood pressure traits on risk of cardiovascular diseases: GWAS and Mendelian randomisation in 100,000 Chinese adults. Nat Commun 2024; 15:6265. [PMID: 39048560 PMCID: PMC11269703 DOI: 10.1038/s41467-024-50297-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 07/04/2024] [Indexed: 07/27/2024] Open
Abstract
Elevated blood pressure (BP) is major risk factor for cardiovascular diseases (CVD). Genome-wide association studies (GWAS) conducted predominantly in populations of European ancestry have identified >2,000 BP-associated loci, but other ancestries have been less well-studied. We conducted GWAS of systolic, diastolic, pulse, and mean arterial BP in 100,453 Chinese adults. We identified 128 non-overlapping loci associated with one or more BP traits, including 74 newly-reported associations. Despite strong genetic correlations between populations, we identified appreciably higher heritability and larger variant effect sizes in Chinese compared with European or Japanese ancestry populations. Using instruments derived from these GWAS, multivariable Mendelian randomisation demonstrated that BP traits contribute differently to the causal associations of BP with CVD. In particular, only pulse pressure was independently causally associated with carotid plaque. These findings reinforce the need for studies in diverse populations to understand the genetic determinants of BP traits and their roles in disease risk.
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Affiliation(s)
- Alfred Pozarickij
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Wei Gan
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Human Genetics Centre of Excellence, Novo Nordisk Research Centre Oxford, Innovation Building, Old Road Campus, Oxford, UK
| | - Kuang Lin
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Robert Clarke
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Zammy Fairhurst-Hunter
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Masaru Koido
- Department of Computational Biology and Medical Sciences, Graduate School of Frontier Sciences, The University of Tokyo, Tokyo, Japan
| | - Masahiro Kanai
- Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, MA, 02114, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, 02142, USA
| | - Yukinori Okada
- Department of Statistical Genetics, Osaka University Graduate School of Medicine, Suita, 565-0871, Japan
- Department of Genome Informatics, Graduate School of Medicine, University of Tokyo, Tokyo, 113-0033, Japan
- Laboratory for Systems Genetics, RIKEN Center for Integrative Medical Sciences, Kanagawa, 230- 0045, Japan
- Laboratory of Statistical Immunology, Immunology Frontier Research Center (WPI-IFReC), Osaka University, Suita, 565-0871, Japan
| | - Yoichiro Kamatani
- Department of Computational Biology and Medical Sciences, Graduate School of Frontier Sciences, The University of Tokyo, Tokyo, Japan
| | - Derrick Bennett
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Huaidong Du
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Yiping Chen
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ling Yang
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Daniel Avery
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Yu Guo
- National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences, 100037, Beijing, China
| | - Min Yu
- Zhejiang CDC, Zhejiang, China
| | - Canqing Yu
- Department of Epidemiology & Biostatistics, School of Public Health, Peking University, Xueyuan Road, Haidian District, 100191, Beijing, China
- Peking University Center for Public Health and Epidemic Preparedness and Response, 100191, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, 100191, Beijing, China
| | - Dan Schmidt Valle
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jun Lv
- Department of Epidemiology & Biostatistics, School of Public Health, Peking University, Xueyuan Road, Haidian District, 100191, Beijing, China
- Peking University Center for Public Health and Epidemic Preparedness and Response, 100191, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, 100191, Beijing, China
| | - Junshi Chen
- China National Center For Food Safety Risk Assessment, Beijing, China
| | - Richard Peto
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rory Collins
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Liming Li
- Department of Epidemiology & Biostatistics, School of Public Health, Peking University, Xueyuan Road, Haidian District, 100191, Beijing, China.
- Peking University Center for Public Health and Epidemic Preparedness and Response, 100191, Beijing, China.
- Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, 100191, Beijing, China.
| | - Zhengming Chen
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Iona Y Millwood
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Robin G Walters
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK.
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Bogaerts JMK, Gussekloo J, de Jong-Schmit BEM, Le Cessie S, Mooijaart SP, van der Mast RC, Achterberg WP, Poortvliet RKE. Effects of the discontinuation of antihypertensive treatment on neuropsychiatric symptoms and quality of life in nursing home residents with dementia (DANTON): a multicentre, open-label, blinded-outcome, randomised controlled trial. Age Ageing 2024; 53:afae133. [PMID: 38970547 PMCID: PMC11227112 DOI: 10.1093/ageing/afae133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Indexed: 07/08/2024] Open
Abstract
BACKGROUND Based on observational studies and randomised controlled trials (RCTs), the benefit-harm balance of antihypertensive treatment in older adults with dementia is unclear. OBJECTIVE To assess whether discontinuing antihypertensive treatment reduces neuropsychiatric symptoms (NPSs) and maintains quality of life (QoL) in nursing home residents with dementia. DESIGN Open-label, blinded-outcome RCT. Randomisation 1:1, stratified by nursing home organisation and baseline NPS. Trial registration: NL7365. SUBJECTS Dutch long-term care residents with moderate-to-severe dementia and systolic blood pressure (SBP) ≤160 mmHg during antihypertensive treatment. Exclusion criteria included heart failure NYHA-class-III/IV, recent cardiovascular events/procedures or life expectancy <4 months (planned sample size n = 492). MEASUREMENTS Co-primary outcomes NPS (Neuropsychiatric Inventory-Nursing Home [NPI-NH]) and QoL (Qualidem) at 16 weeks. RESULTS From 9 November 2018 to 4 May 2021, 205 participants (median age 85.8 [IQR 79.6-89.5] years; 79.5% female; median SBP 134 [IQR 123-146] mmHg) were randomised to either antihypertensive treatment discontinuation (n = 101) or usual care (n = 104). Safety concerns, combined with lacking benefits, prompted the data safety and monitoring board to advice a premature cessation of randomisation. At 16-week follow-up, no significant differences were found between groups for NPI-NH (adjusted mean difference 1.6 [95% CI -2.3 to 5.6]; P = 0.42) or Qualidem (adjusted mean difference - 2.5 [95% CI -6.0 to 1.0]; P = 0.15). Serious adverse events (SAEs) occurred in 36% (discontinuation) and 24% (usual care) of the participants (adjusted hazard ratio 1.65 [95% CI 0.98-2.79]). All 32-week outcomes favoured usual care. CONCLUSION Halfway through this study, a non-significant increased SAE risk associated with discontinuing antihypertensive treatment was observed, and an associated interim analysis showed that significant worthwhile health gain for discontinuation of antihypertensive treatment was unlikely. This unbeneficial benefit-harm balance shows that discontinuation of antihypertensive treatment in this context does not appear to be either safe or beneficial enough to be recommended in older adults with dementia.
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Affiliation(s)
- Jonathan M K Bogaerts
- Department of Public Health and Primary Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
- Department of Internal Medicine, Section Gerontology and Geriatrics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Bianca E M de Jong-Schmit
- Department of Public Health and Primary Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Saskia Le Cessie
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
- Department of Biomedical Datasciences, Section Medical Statistics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Simon P Mooijaart
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
- Department of Internal Medicine, Section Gerontology and Geriatrics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Roos C van der Mast
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
- Department of Psychiatry, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
- Department of Psychiatry, The Collaborative Antwerp Psychiatric Research Institute (CAPRI), Faculty of Medicine and Health Sciences, University of Antwerp, Campus Drie Eiken, S.033, Universiteitsplein 1, 2610 Wilrijk, Belgium
| | - Wilco P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
- University Network for the Care sector South Holland, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Rosalinde K E Poortvliet
- Department of Public Health and Primary Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
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Pan S, Li S, Jiang S, Shin JI, Liu GG, Wu H, Lyu B. Trends in Number and Appropriateness of Prescription Medication Utilization Among Community-Dwelling Older Adults in the United States: 2011-2020. J Gerontol A Biol Sci Med Sci 2024; 79:glae108. [PMID: 38644631 DOI: 10.1093/gerona/glae108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Indexed: 04/23/2024] Open
Abstract
BACKGROUND Contemporary data on the quantity and quality of medication use among older adults are lacking. This study examined recent trends in the number and appropriateness of prescription medication use among older adults in the United States. METHODS Data from the National Health and Nutrition Examination Survey (NHANES) between 2011 and March 2020 were used, and 6 336 adult participants aged 65 and older were included. We examined the number of prescription medication, prevalence of polypharmacy (≥5 prescription drugs), use of potentially inappropriate medication (PIM), and use of recommended medications (angiotensin-converting enzyme inhibitor [ACEI]/angiotensin receptor blockers [ARBs] plus beta-blockers among patients with heart failure and ACEI/ARBs among patients with albuminuria). RESULTS There has been a slight increase in the prevalence of polypharmacy (39.3% in 2011-2012 to 43.8% in 2017-2020, p for trend = .32). Antihypertensive, antihyperlipidemic, antidiabetic medications, and antidepressants are the most commonly used medications. There was no substantial change in the use of PIM (17.0% to 14.7%). Less than 50% of older adults with heart failure received ACEI/ARBs plus beta-blockers (44.3% in 2017-2020) and approximately 50% of patients with albuminuria received ACEI/ARBs (54.0% in 2017-2020), with no improvement over the study period. Polypharmacy, older age, female, and lower socioeconomic status were generally associated with greater use of PIM but lower use of recommended medications. CONCLUSIONS The medication burden remained high among older adults in the United States and the appropriate utilization of medications did not improve in the recent decade. Our results underscore the need for greater attentions and interventions to the quality of medication use among older adults.
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Affiliation(s)
- Shaoxi Pan
- School of Public Health, The Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang 561113, China
- China Center for Health Economic Research, Peking University, Beijing, China
| | - Shanshan Li
- China Center for Health Economic Research, Peking University, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Shaoxiang Jiang
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Jung-Im Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
| | - Gordon G Liu
- Institute for Global Health and Development, Peking University, Beijing, China
- National School of Development, Peking University, Beijing, China
| | - Hongyan Wu
- School of Public Health, The Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang 561113, China
| | - Beini Lyu
- Institute for Global Health and Development, Peking University, Beijing, China
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9
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Reeve E, Gnjidic D, Langford AV, Hilmer SN. Deprescribing antihypertensive drugs in frail older adults. Aust Prescr 2024; 47:85-90. [PMID: 38962389 PMCID: PMC11216913 DOI: 10.18773/austprescr.2024.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024] Open
Abstract
Antihypertensive drugs are commonly used by older adults because of the high prevalence of cardiovascular disease and its risk factors, and the increased absolute benefit of blood pressure reduction with increasing age. Clinical trials of blood pressure reduction in older adults have generally excluded older adults with multimorbidity, frailty and limited life expectancy. In this population, the benefit-harm ratio of aggressive blood pressure lowering may become unfavourable; a more relaxed blood pressure target may be appropriate; and deprescribing (cessation or dose reduction) of one or more antihypertensive drugs can be considered. Before deprescribing an antihypertensive drug, it is important to consider other indications for which it may have been prescribed (e.g. heart failure with reduced ejection fraction, diabetic nephropathy, atrial fibrillation). Evidence from randomised controlled deprescribing trials indicates that it is possible to deprescribe antihypertensives in frail older people. However, some patients may experience an increase in blood pressure that warrants restarting the drug. There are limited data on long-term outcomes (follow-up in deprescribing trials ranged from 4 to 56 weeks). The risk of adverse outcomes associated with deprescribing, such as withdrawal effects, can be minimised through appropriate planning, patient engagement, dose tapering and monitoring.
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Affiliation(s)
- Emily Reeve
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne
- Clinical and Health Sciences, University of South Australia, Adelaide
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney
- Royal North Shore Hospital, Sydney
- Geriatric Pharmacology, Faculty of Medicine and Health, The University of Sydney and Kolling Institute, Sydney
| | - Danijela Gnjidic
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne
- Clinical and Health Sciences, University of South Australia, Adelaide
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney
- Royal North Shore Hospital, Sydney
- Geriatric Pharmacology, Faculty of Medicine and Health, The University of Sydney and Kolling Institute, Sydney
| | - Aili V Langford
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne
- Clinical and Health Sciences, University of South Australia, Adelaide
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney
- Royal North Shore Hospital, Sydney
- Geriatric Pharmacology, Faculty of Medicine and Health, The University of Sydney and Kolling Institute, Sydney
| | - Sarah N Hilmer
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne
- Clinical and Health Sciences, University of South Australia, Adelaide
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney
- Royal North Shore Hospital, Sydney
- Geriatric Pharmacology, Faculty of Medicine and Health, The University of Sydney and Kolling Institute, Sydney
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10
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Yao A, Gao L, Zhang J, Cheng JM, Kim DH. Frailty as an Effect Modifier in Randomized Controlled Trials: A Systematic Review. J Gen Intern Med 2024; 39:1452-1473. [PMID: 38592606 PMCID: PMC11169165 DOI: 10.1007/s11606-024-08732-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 03/15/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The effect of clinical interventions may vary by patients' frailty status. Understanding treatment effect heterogeneity by frailty could lead to frailty-guided treatment strategies and reduce overtreatment and undertreatment. This systematic review aimed to examine the effect modification by frailty in randomized controlled trials (RCTs) that evaluate pharmacological, non-pharmacological, and multicomponent interventions. METHODS We searched PubMed, Web of Science, EMBASE, and ClinicalTrial.gov, from their inception to 8 December 2023. Two reviewers independently extracted trial data and examined the study quality with senior authors. RESULTS Sixty-one RCTs that evaluated the interaction between frailty and treatment effects in older adults were included. Frailty was evaluated using different tools such as the deficit accumulation frailty index, frailty phenotype, and other methods. The effect of several pharmacological interventions (e.g., edoxaban, sacubitril/valsartan, prasugrel, and chemotherapy) varied according to the degree of frailty, whereas other treatments (e.g., antihypertensives, vaccinations, osteoporosis medications, and androgen medications) demonstrated consistent benefits across different frailty levels. Some non-pharmacological interventions had greater benefits in patients with higher (e.g., chair yoga, functional walking, physical rehabilitation, and higher dose exercise program) or lower (e.g., intensive lifestyle intervention, psychosocial intervention) levels of frailty, while others (e.g., resistance-type exercise training, moderate-intensive physical activity, walking and nutrition or walking) produced similar intervention effects. Specific combined interventions (e.g., hospital-based disease management programs) demonstrated inconsistent effects across different frailty levels. DISCUSSION The efficacy of clinical interventions often varied by frailty levels, suggesting that frailty is an important factor to consider in recommending clinical interventions in older adults. REGISTRATION PROSPERO registration number CRD42021283051.
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Affiliation(s)
- Aaron Yao
- VillageMD Research Institute, Chicago, IL, USA.
- Virginia Commonwealth University, Richmond, VA, USA.
| | | | - Jiajun Zhang
- Qingdao Municipal Hospital, Qingdao, Shandong, China
| | - Joyce M Cheng
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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11
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Sheppard JP, Benetos A, Bogaerts J, Gnjidic D, McManus RJ. Strategies for Identifying Patients for Deprescribing of Blood Pressure Medications in Routine Practice: An Evidence Review. Curr Hypertens Rep 2024; 26:225-236. [PMID: 38305846 PMCID: PMC11153298 DOI: 10.1007/s11906-024-01293-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 02/03/2024]
Abstract
PURPOSE OF REVIEW To summarise the evidence regarding which patients might benefit from deprescribing antihypertensive medications. RECENT FINDINGS Older patients with frailty, multi-morbidity and subsequent polypharmacy are at higher risk of adverse events from antihypertensive treatment, and therefore may benefit from antihypertensive deprescribing. It is possible to examine an individual's risk of these adverse events, and use this to identify those people where the benefits of treatment may be outweighed by the harms. While such patients might be considered for deprescribing, the long-term effects of this treatment strategy remain unclear. Evidence now exists to support identification of those who are at risk of adverse events from antihypertensive treatment. These patients could be targeted for deprescribing interventions, although the long-term benefits and harms of this approach are unclear. PERSPECTIVES Randomised controlled trials are still needed to examine the long-term effects of deprescribing in high-risk patients with frailty and multi-morbidity.
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Affiliation(s)
- James P Sheppard
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK.
| | - Athanase Benetos
- CHRU-Nancy, Pôle "Maladies du Vieillissement, Gérontologie Et Soins Palliatifs", and Inserm DCAC u1116, Université de Lorraine, 54000, Nancy, France
| | - Jonathan Bogaerts
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, the Netherlands
| | - Danijela Gnjidic
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, University of Oxford, Oxford, OX2 6GG, UK
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12
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Müller-Werdan U. [Drug therapy for arterial hypertension and atrial fibrillation in frail patients : Are there any new insights and recommendations?]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:517-523. [PMID: 38456903 DOI: 10.1007/s00108-024-01681-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/09/2024] [Indexed: 03/09/2024]
Abstract
The frail and elderly are considered to be at particular risk of suffering an adverse drug reaction. Empirical studies confirm the increased rate of adverse drug reactions. Whether frailty per se impairs drug metabolism or the underlying organ ageing processes and multimorbidity cannot be answered with certainty based on current data. Cardiovascular diseases exhibit a considerable interdependence with frailty. For example, there is a disproportionate syndromal interdependence between heart failure and frailty, and the typical ageing processes of the sinus node can be interpreted as heartbeat frailty. Multimorbidity in the elderly often includes a cluster of chronic cardiovascular diseases, often leading to the use of several cardiovascular medications as required. More recent definitions of polypharmacy assess the appropriateness of drugs rather than their number. The Fit-fOR-The-Aged (FORTA) list, the PRISCUS 2.0 list and the "Cochrane Library Special Collection on deprescribing", for example, offer a practice-oriented assessment aid. In the treatment of arterial hypertension, the target values for older people have also been set ever lower in recent years. In the case of frail elderly people, on the other hand, the guidelines do not specify a strict blood pressure target corridor; tolerability is the crucial factor here. When initiating antihypertensive therapy in frail individuals, one can consider monotherapy-in a departure from the standard case of dual combination therapy. The OPTIMISE study showed that discontinuation of one blood pressure medication did not lead to better tolerability of the drug therapy. Current studies come to differing conclusions regarding the risk-benefit assessment of new oral anticoagulants compared to vitamin K antagonists in the anticoagulation of frail elderly people with atrial fibrillation. Shared decision-making, which could improve adherence particularly in older people, is recommended.
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Affiliation(s)
- Ursula Müller-Werdan
- Medizinische Klinik für Geriatrie und Altersmedizin, Charité - Universitätsmedizin Berlin, Reinickendorfer Str. 61, 13347, Berlin, Deutschland.
- Evangelisches Geriatriezentrum Berlin, Reinickendorfer Str. 61, 13347, Berlin, Deutschland.
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13
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Kim BS, Lee Y, Shin JH, Heo R, Kim HJ, Shin J. Blood pressure and variability responses to the down-titration of antihypertensive drugs. J Hypertens 2024; 42:809-815. [PMID: 38230618 DOI: 10.1097/hjh.0000000000003668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
OBJECTIVES Several recent guidelines have proposed the gradual reduction of antihypertensive drugs for patients with well controlled blood pressure (BP). However, no studies have examined alterations in BP variability (BPV) during the down-titration of antihypertensives. This study aims to investigate changes in home BPV during the down-titration of antihypertensives. METHODS We analyzed 83 hypertensive patients who underwent down-titration of antihypertensives and had available home BP data during the down-titration. Down-titration was performed when home SBP was less than 120 mmHg, regardless of the clinic SBP. Primary exposure variable was the standard deviation (SD) of home BP. RESULTS Among 83 patients (mean age 66.3 ± 11.9 years; 45.8% men), down-titration led to increase home SBP (from 110.5 to 118.7 mmHg; P < 0.001), and home DBP (from 68.8 to 72.8 mmHg; P = 0.001) significantly. There were no significant differences in SDs of SBP [from 6.02 ± 3.79 to 5.76 ± 3.09 in morning, P = 0.570; from 6.13 ± 3.32 to 6.63 ± 3.70 in evening, P = 0.077; and from 6.54 (4.80, 8.31) to 6.37 (4.65, 8.76) in home SBP, P = 0.464] and SDs of DBP during the down-titration of antihypertensive drugs. CONCLUSION Down-titration of antihypertensive drugs did not have notable impact on clinic BP and home BPV, while significantly increasing home BP. These findings provide important insights indicating that the potential concern related to an increase in BPV in the planned strategy of reducing antihypertensive drugs is not substantial.
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Affiliation(s)
- Byung Sik Kim
- Division of Cardiology, Department of Internal Medicine, Hanyang University Guri Hospital, Guri
| | - Yonggu Lee
- Division of Cardiology, Department of Internal Medicine, Hanyang University Guri Hospital, Guri
| | - Jeong-Hun Shin
- Division of Cardiology, Department of Internal Medicine, Hanyang University Guri Hospital, Guri
| | - Ran Heo
- Division of Cardiology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, South Korea
| | - Hyun-Jin Kim
- Division of Cardiology, Department of Internal Medicine, Hanyang University Guri Hospital, Guri
| | - Jinho Shin
- Division of Cardiology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, South Korea
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14
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Niznik JD, Shmuel S, Pate V, Thorpe CT, Hanson LC, Rice C, Lund JL. Validating claims-based definitions for deprescribing: Bridging the gap between clinical and administrative data. Pharmacoepidemiol Drug Saf 2024; 33:e5784. [PMID: 38556843 PMCID: PMC11145562 DOI: 10.1002/pds.5784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 03/05/2024] [Accepted: 03/13/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Limited research has evaluated the validity of claims-based definitions for deprescribing. OBJECTIVES Evaluate the validity of claims-based definitions of deprescribing against electronic health records (EHRs) for deprescribing of benzodiazepines (BZDs) after a fall-related hospitalization. METHODS We used a novel data linkage between Medicare fee-for-service (FFS) and Part D with our health system's EHR. We identified patients aged ≥66 years with a fall-related hospitalization, continuous enrollment in Medicare FFS and Part D for 6 months pre- and post-hospitalization, and ≥2 BZD fills in the 6 months pre-hospitalization. Using a standardized EHR abstraction tool, we adjudicated deprescribing for a sub-sample with a fall-related hospitalization at UNC. We evaluated the validity of claims-based deprescribing definitions (e.g., gaps in supply, dosage reductions) versus chart review using sensitivity and specificity. RESULTS Among 257 patients in the overall sample, 44% were aged 66-74 years, 35% had Medicare low-income subsidy, 79% were female. Among claims-based definitions using gaps in supply, the prevalence of BZD deprescribing ranged from 8.2% (no refills) to 36.6% (30-day gap). When incorporating dosage, the prevalence ranged from 55.3% to 65.8%. Among the validation sub-sample (n = 47), approximately one-third had BZDs deprescribed in the EHR. Compared to EHR, gaps in supply from claims had good sensitivity, but poor specificity. Incorporating dosage increased sensitivity, but worsened specificity. CONCLUSIONS The sensitivity of claims-based definitions for deprescribing of BZDs was low; however, the specificity of a 90-day gap was >90%. Replication in other EHRs and for other low-value medications is needed to guide future deprescribing research.
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Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Shahar Shmuel
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Virginia Pate
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Carolyn T Thorpe
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
| | - Colleen Rice
- Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jennifer L Lund
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
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15
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O'Mahoney L, Highton P, Abdala R, Dallosso H, Gillies CL, Ragha S, Munday F, Robinson J, Marshall A, Sheppard JP, Khunti K, Seidu S. Deintensification of potentially inappropriate medications amongst older frail people with type 2 diabetes: Protocol for a cluster randomised controlled trial (D-MED study). Prim Care Diabetes 2024; 18:132-137. [PMID: 38220558 DOI: 10.1016/j.pcd.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/14/2023] [Accepted: 12/17/2023] [Indexed: 01/16/2024]
Abstract
AIMS Amongst elderly people with type 2 diabetes (T2D) over prescribing can result in emergency ambulance call-outs, falls and fractures and increased mortality, particularly in frail patients. Current clinical guidelines, however, remain focused on medication intensification rather than deintensification where appropriate. This study aims to evaluate the effectiveness of an electronic decision-support system and training for the deintensification of potentially inappropriate medications amongst older frail people with T2D, when compared to 'usual' care at 12-months. METHODS This study is an open-label, multi-site, two-armed pragmatic cluster-randomised trial. GP practices randomised to the 'enhanced care' group have an electronic decision support system installed and receive training on the tool and de-intensification of diabetes medications. The system flags eligible patients for possible deintensification of diabetes medications, linking the health care professional to a clinical algorithm. The primary outcome will be the number of patients at 12-months who have had potentially inappropriate diabetes medications de-intensified. RESULTS Study recruitment commenced in June 2022. Data collection commenced in January 2023. Baseline data have been extracted from 40 practices (3145 patients). CONCLUSIONS Digital technology, involving computer decision systems, may have the potential to reduce inappropriate medications and aid the process of de-intensification. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number: ISRCTN53221378. Available at: https://www.isrctn.com/ISRCTN53221378.
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Affiliation(s)
- Lauren O'Mahoney
- Diabetes Research Centre, University of Leicester, Leicester, UK; National Institute for Health Research Applied Research Collaboration East Midlands, Leicester, UK
| | - Patrick Highton
- Diabetes Research Centre, University of Leicester, Leicester, UK; National Institute for Health Research Applied Research Collaboration East Midlands, Leicester, UK.
| | - Ruksar Abdala
- Diabetes Research Centre, University of Leicester, Leicester, UK; National Institute for Health Research Applied Research Collaboration East Midlands, Leicester, UK
| | - Helen Dallosso
- University Hospitals of Leicester NHS Trust, Leicester Diabetes Centre, Leicester, UK
| | - Clare L Gillies
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Seema Ragha
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Fiona Munday
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - John Robinson
- Primary Care Information Service, University of Nottingham, Nottingham, UK
| | - Andrew Marshall
- Primary Care Information Service, University of Nottingham, Nottingham, UK
| | - James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK; National Institute for Health Research Applied Research Collaboration East Midlands, Leicester, UK
| | - Samuel Seidu
- Diabetes Research Centre, University of Leicester, Leicester, UK
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16
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Ioffe D, Bhatia-Patel SC, Gandhi S, Hamad EA, Dotan E. Cardiovascular Concerns, Cancer Treatment, and Biological and Chronological Aging in Cancer: JACC Family Series. JACC CardioOncol 2024; 6:143-158. [PMID: 38774000 PMCID: PMC11103051 DOI: 10.1016/j.jaccao.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 02/08/2024] [Accepted: 02/12/2024] [Indexed: 05/24/2024] Open
Abstract
Cardiovascular disease (CVD) and cancer are leading causes of death globally, particularly among the rapidly growing population of older adults (OAs). CVD is a leading cause of mortality among cancer survivors, often accelerated by cancer treatments associated with short- or long-term cardiotoxicity. Moreover, there is a dynamic relationship among CVD, cancer, and aging, characterized by shared risk factors and biological hallmarks, that plays an important role in caring for OAs, optimizing treatment approaches, and developing preventive strategies. Assessment of geriatric domains (eg, functional status, comorbidities, cognition, polypharmacy, nutritional status, social support, psychological well-being) is critical to individualizing treatment of OAs with cancer. The authors discuss considerations in caring for an aging population with cancer, including methods for the assessment of OAs with CVD and/or cardiovascular risk factors planned for cancer therapy. Multidisciplinary care is critical in optimizing patient outcomes and maintaining quality of life in this growing vulnerable population.
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Affiliation(s)
- Dina Ioffe
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | | | - Sakshi Gandhi
- Department of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Eman A. Hamad
- Department of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Efrat Dotan
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
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Wang J, Shen JY, Conwell Y, Podsiadly EJ, Caprio TV, Nathan K, Yu F, Ramsdale EE, Fick DM, Mixon AS, Simmons SF. Implementation considerations of deprescribing interventions: A scoping review. J Intern Med 2024; 295:436-507. [PMID: 36524602 DOI: 10.1111/joim.13599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Over half of older adults experience polypharmacy, including medications that may be inappropriate or unnecessary. Deprescribing, which is the process of discontinuing or reducing inappropriate and/or unnecessary medications, is an effective way to reduce polypharmacy. This review summarizes (1) the process of deprescribing and conceptual models and tools that have been developed to facilitate deprescribing, (2) barriers, enablers, and factors associated with deprescribing, and (3) characteristics of deprescribing interventions in completed trials, as well as (4) implementation considerations for deprescribing in routine practice. In conceptual models of deprescribing, multilevel factors of the patient, clinician, and health-care system are all related to the efficacy of deprescribing. Numerous tools have been developed for clinicians to facilitate deprescribing, yet most require substantial time and, thus, may be difficult to implement during routine health-care encounters. Multiple deprescribing interventions have been evaluated, which mostly include one or more of the following components: patient education, medication review, identification of deprescribing targets, and patient and/or provider communication about high-risk medications. Yet, there has been limited consideration of implementation factors in prior deprescribing interventions, especially with regard to the personnel and resources in existing health-care systems and the feasibility of incorporating components of deprescribing interventions into the routine care processes of clinicians. Future trials require a more balanced consideration of both effectiveness and implementation when designing deprescribing interventions.
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Affiliation(s)
- Jinjiao Wang
- Elaine, Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Eric J Podsiadly
- Harriet J. Kitzman Center for Research Support, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Thomas V Caprio
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- UR Medicine Home Care, University of Rochester Medical Center, Rochester, New York, USA
- University of Rochester Medical Center, Finger Lakes Geriatric Education Center, Rochester, New York, USA
| | - Kobi Nathan
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York, USA
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA
| | - Erika E Ramsdale
- Department of Medicine, Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Donna M Fick
- Ross and Carol Nese College of Nursing, Penn State University, University Park, Pennsylvania, USA
| | - Amanda S Mixon
- Department of Medicine, Division of General Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Sandra F Simmons
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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18
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Ciarleglio MM, Li J, Peduzzi P. Unresolved issues with noninferiority pragmatic trials: Results of a literature survey. Clin Trials 2024; 21:242-256. [PMID: 37927102 DOI: 10.1177/17407745231206371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
BACKGROUND Issues with specification of margins, adherence, and analytic population can potentially bias results toward the alternative in randomized noninferiority pragmatic trials. To investigate this potential for bias, we conducted a targeted search of the medical literature to examine how noninferiority pragmatic trials address these issues. METHODS An Ovid MEDLINE database search was performed identifying publications in New England Journal of Medicine, Journal of the American Medical Association, Lancet, or British Medical Journal published between 2015 and 2021 that included the words "pragmatic" or "comparative effectiveness" and "noninferiority" or "non-inferiority." Our search identified 14 potential trials, 12 meeting our inclusion criteria (11 individually randomized, 1 cluster-randomized). RESULTS Eleven trials had results that met the criteria established for noninferiority. Noninferiority margins were prespecified for all trials; all but two trials provided justification of the margin. Most trials did some monitoring of treatment adherence. All trials conducted intent-to-treat or modified intent-to-treat analyses along with per-protocol analyses and these analyses reached similar conclusions. Only two trials included all randomized participants in the primary analysis, one used multiple imputation for missing data. The percentage excluded from primary analyses ranged from ∼2% to 30%. Reasons for exclusion included randomization in error, nonadherence, not receiving assigned treatment, death, withdrawal, lost to follow-up, and incomplete data. CONCLUSION Specification of margins, adherence, and analytic population require careful consideration to prevent bias toward the alternative in noninferiority pragmatic trials. Although separate guidance has been developed for noninferiority and pragmatic trials, it is not compatible with conducting a noninferiority pragmatic trial. Hence, these trials should probably not be done in their current format without developing new guidelines.
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Affiliation(s)
- Maria M Ciarleglio
- Department of Biostatistics, Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Jiaxuan Li
- Department of Biostatistics, Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Peter Peduzzi
- Department of Biostatistics, Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
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19
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Pajewski NM, Cohen JB. ATEMPTing to navigate between "lower is better" and "less is more". THE LANCET. HEALTHY LONGEVITY 2024; 5:e164-e165. [PMID: 38342122 DOI: 10.1016/s2666-7568(24)00024-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 01/30/2024] [Indexed: 02/13/2024] Open
Affiliation(s)
- Nicholas M Pajewski
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, PA, USA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, PA, USA
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20
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Majert J, Nazarzadeh M, Ramakrishnan R, Bidel Z, Hedgecott D, Perez-Crespillo A, Turpie W, Akhtar N, Allison M, Rao S, Gudgin B, McAuley M, A'Court C, Billot L, Kotecha D, Potter J, Rahimi K. Efficacy of decentralised home-based antihypertensive treatment in older adults with multimorbidity and polypharmacy (ATEMPT): an open-label randomised controlled pilot trial. THE LANCET. HEALTHY LONGEVITY 2024; 5:e172-e181. [PMID: 38342123 DOI: 10.1016/s2666-7568(23)00259-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/22/2023] [Accepted: 11/24/2023] [Indexed: 02/13/2024] Open
Abstract
BACKGROUND Older patients with multimorbidity and polypharmacy have been under-represented in clinical trials. We aimed to assess the effect of different intensities of antihypertensive treatment on changes in blood pressure, major safety outcomes, and patient-reported outcomes in this population. METHODS ATEMPT was a decentralised, two-armed, parallel-group, open-label randomised controlled pilot trial conducted in the Thames Valley area, South East England. Individuals aged 65 years or older with multimorbidity (three or more chronic conditions) or polypharmacy (five or more types of medications) and a systolic blood pressure of 115-165 mm Hg were eligible for inclusion. Participants were identified through a search of national hospital discharge databases, identification of patients registered with an online pharmacy, and via targeted advertising on social media platforms. Participants were randomly assigned to receive up to two more classes versus up to two fewer classes of antihypertensive medications. Apart from routine home visits for conducting the baseline assessment, all communication, monitoring, and management of participants by the trial team was conducted remotely. The primary outcome was change in home-measured blood pressure. FINDINGS Between Dec 15, 2020, and Aug 31, 2022, 230 participants were randomly assigned (n=126 to more vs n=104 to fewer antihypertensive medications). The frequency of serious adverse events was similar across both groups; no cardiovascular events occurred in the more antihypertensive drugs group, compared with six in the fewer antihypertensive drugs group, of which two were fatal. Over a 13-month follow-up period, the mean systolic blood pressure in the group allocated to receive more antihypertensive medications decreased from 134·5 mm Hg (SD 10·7) at baseline to 122·1 mm Hg (10·5). By contrast, in the group allocated to receive fewer antihypertensive medications, it remained relatively unchanged, moving from 134·8 mm Hg (SD 11·2) at baseline to 132·9 mm Hg (15·3); this corresponded to a mean difference of -10·7 mm Hg (95% CI -17·5 to -4·0). INTERPRETATION Remotely delivered antihypertensive treatment substantially reduced systolic blood pressure in older adults who are often less represented in trials, with no increase in the risk of serious adverse events. The results of this trial will inform a larger clinical trial focusing on assessing major cardiovascular events, safety, physical functioning, and cognitive function that is currently in the planning stages. These results also underscore the efficiency of decentralised trial designs, which might be of broader interest in other settings. FUNDING National Institute for Health Research Oxford Biomedical Research Centre and the Oxford Martin School.
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Affiliation(s)
- Jeannette Majert
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Milad Nazarzadeh
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Rema Ramakrishnan
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Zeinab Bidel
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Deborah Hedgecott
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | | | - Wendy Turpie
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Naseem Akhtar
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Moira Allison
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Shishir Rao
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | | | | | - Christine A'Court
- Nuffield Department of Primary Health Sciences, University of Oxford, Oxford, UK
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Dipak Kotecha
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK; NIHR Birmingham Biomedical Research Centre & NHS West Midlands Secure Data Environment, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - John Potter
- Department of Medicine, University of East Anglia, Norwich, UK
| | - Kazem Rahimi
- Deep Medicine, Oxford Martin School, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK.
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21
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Cristina García-Ulloa A, Jaime-Casas S, Rosado-Lozoya J, Serrano-Pérez NH, Hernández-Juárez D, Luis Cárdenas-Fragoso J, Eduardo Briones-García L, Jiménez-Soto R, García-Padilla C, García-Lara J, Aguilar-Salinas CA, Hernández-Jiménez S. De-escalating treatment indications for patients who achieve metabolic goals. Diabetes Res Clin Pract 2024; 208:111096. [PMID: 38244782 DOI: 10.1016/j.diabres.2024.111096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/10/2024] [Accepted: 01/13/2024] [Indexed: 01/22/2024]
Abstract
INTRODUCTION Robust evidence exists regarding initiation, intensification or modification of treatments. Recommendations to de-escalate therapy are lacking, specifically in diabetes. A successful treatment de-intensification reduces overtreatment, polypharmacy, and risk of adverse effects. OBJECTIVE To encompass current recommendations for deprescribing common drugs and create a consensus among health professionals. METHODS We reviewed four databases for deprescribing approaches published between 2010 and 2022. Articles were divided into different groups of drugs (for uric-acid, hypoglycemic, lipid-lowering, and psychotropic drugs). RESULTS Hypoglycemic agents: strategies were limited to newer agents and insulin regimens for elderly individuals. Reducing insulin was associated with 1.1% reduction of A1c over time. SGLT2i and GLP-1RAs dose reduction depends on adverse events. Lipid-lowering agents: studies show that patients with very low cholesterol have fewer cardiovascular events without associated increased risk. Antihypertensive agents: Younger patients, lower systolic blood pressure, and few comorbidities are ideal characteristics for discontinuation. Uric acid therapy: we found no recommendation for dose de-escalation. Poor treatment adherence is associated with episodes of gout and deforming arthritis in the long term. CONCLUSION Deprescribing hypoglycemic, statins, antihypertensives, and urate-lowering agents may be feasible in selected patients, but periodic surveillance is important. More evidence is necessary to support this decision entirely.
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Affiliation(s)
- Ana Cristina García-Ulloa
- Centro de Atención Integral del Paciente con Diabetes (CAIPaDi), Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | - Nancy H Serrano-Pérez
- Centro de Atención Integral del Paciente con Diabetes (CAIPaDi), Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Diana Hernández-Juárez
- Centro de Atención Integral del Paciente con Diabetes (CAIPaDi), Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - José Luis Cárdenas-Fragoso
- Centro de Atención Integral del Paciente con Diabetes (CAIPaDi), Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Luis Eduardo Briones-García
- Departamento de Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Rodolfo Jiménez-Soto
- Departamento de Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Carlos García-Padilla
- Departamento de Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Juan García-Lara
- Departamento de Geriatría, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Carlos A Aguilar-Salinas
- Dirección de Investigación, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Sergio Hernández-Jiménez
- Centro de Atención Integral del Paciente con Diabetes (CAIPaDi), Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
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22
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Groppelli A, Rivasi G, Fedorowski A, de Lange FJ, Russo V, Maggi R, Capacci M, Nawaz S, Comune A, Bianchi L, Zambon A, Soranna D, Ungar A, Parati G, Brignole M. Interventions aimed to increase average 24-h systolic blood pressure reduce blood pressure drops in patients with reflex syncope and orthostatic intolerance. Europace 2024; 26:euae026. [PMID: 38262617 PMCID: PMC10849184 DOI: 10.1093/europace/euae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/05/2024] [Indexed: 01/25/2024] Open
Abstract
AIMS Systolic blood pressure (SBP) drops recorded by 24-h ambulatory blood pressure (BP) monitoring (ABPM) identify patients with susceptibility to reflex syncope and orthostatic intolerance. We tested the hypothesis that treatments aimed to increase BP (reassurance, education, and lifestyle measures plus pharmacological strategies) can reduce SBP drops. METHODS AND RESULTS This was a multicentre, observational proof-of-concept study performed in patients with reflex syncope and/or orthostatic intolerance and with SBP drops on a screening ABPM. Among 144 eligible patients, 111 underwent a second ABPM on average 2.5 months after start of treatment. Overall, mean 24-h SBP increased from 114.1 ± 12.1 to 121.4 ± 14.5 mmHg (P < 0.0001). The number of SBP drops <90 and <100 mmHg decreased by 61%, 46% during daytime, and by 48% and 37% during 24-h period, respectively (P < 0.0001 for all). The dose-response relationship between difference in 24-h average SBP increase and reduction in number of SBP drops reached a plateau around ∼15 mmHg increase of 24-h SBP. The reduction in SBP drop rate was consistent and significant in patients who underwent deprescription of hypotensive medications (n = 44) and in patients who received BP-rising drugs (n = 67). CONCLUSION In patients with reflex syncope and/or orthostatic intolerance, an increase in average 24-h SBP, regardless of the implemented strategy, significantly reduced the number of SBP drops and symptom burden. A 13 mmHg increase in 24-h SBP appears to represent the optimal goal for aborting the maximal number of SBP drops, representing a possible target for future interventions. ClincalTrials.gov identifier: NCT05729724.
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Affiliation(s)
- Antonella Groppelli
- Faint and Fall Research Centre, Department of Cardiology, IRCCS Istituto Auxologico Italiano, S. Luca Hospital, Piazzale Brescia 20, 20149 Milano, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Artur Fedorowski
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Frederik J de Lange
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Vincenzo Russo
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’—Monaldi Hospital, Naples, Italy
| | - Roberto Maggi
- Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
| | - Marco Capacci
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Sara Nawaz
- Department of Clinical and Experimental Cardiology, Amsterdam UMC, Heart Centre, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Angelo Comune
- Cardiology and Syncope Unit, Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’—Monaldi Hospital, Naples, Italy
| | - Lorenzo Bianchi
- Department of Cardiology, Ospedali del Tigullio, Lavagna, Italy
| | - Antonella Zambon
- Biostatistics Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Davide Soranna
- Biostatistics Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Andrea Ungar
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Gianfranco Parati
- Department of Cardiology, IRCCS Istituto Auxologico Italiano, San Luca Hospital, Piazzale Brescia 20, 20149 Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Piazza dei daini 2, 20126 Milan, Italy
| | - Michele Brignole
- Faint and Fall Research Centre, Department of Cardiology, IRCCS Istituto Auxologico Italiano, S. Luca Hospital, Piazzale Brescia 20, 20149 Milano, Italy
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23
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Thompson W, McDonald EG. Polypharmacy and Deprescribing in Older Adults. Annu Rev Med 2024; 75:113-127. [PMID: 37729029 DOI: 10.1146/annurev-med-070822-101947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Older adults commonly end up on many medications. Deprescribing is an important part of individualizing care for older adults. It is an opportunity to discuss treatment options and revisit medications that may not have been reassessed in many years. A large evidence base exists in the field, suggesting that deprescribing is feasible and safe, though questions remain about the potential clinical benefits. Deprescribing research faces a myriad of challenges, such as identifying and employing the optimal outcome measures. Further, there is uncertainty about which deprescribing approaches are likely to be most effective and in what contexts. Evidence on barriers and facilitators to deprescribing has underscored how deprescribing in routine clinical practice can be complex and challenging. Thus, finding practical, sustainable ways to implement deprescribing is a priority for future research in the field.
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Affiliation(s)
- Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada;
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada;
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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24
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ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 13. Older Adults: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S244-S257. [PMID: 38078580 PMCID: PMC10725804 DOI: 10.2337/dc24-s013] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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25
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Boyd CM, Shetterly SM, Powers JD, Weffald LA, Green AR, Sheehan OC, Reeve E, Drace ML, Norton JD, Maiyani M, Gleason KS, Sawyer JK, Maciejewski ML, Wolff JL, Kraus C, Bayliss EA. Evaluating the Safety of an Educational Deprescribing Intervention: Lessons from the Optimize Trial. Drugs Aging 2024; 41:45-54. [PMID: 37982982 PMCID: PMC11101016 DOI: 10.1007/s40266-023-01080-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Patients, family members, and clinicians express concerns about potential adverse drug withdrawal events (ADWEs) following medication discontinuation or fears of upsetting a stable medical equilibrium as key barriers to deprescribing. Currently, there are limited methods to pragmatically assess the safety of deprescribing and ascertain ADWEs. We report the methods and results of safety monitoring for the OPTIMIZE trial of deprescribing education for patients, family members, and clinicians. METHODS This was a pragmatic cluster randomized trial with multivariable Poisson regression comparing outcome rates between study arms. We conducted clinical record review and adjudication of sampled records to assess potential causal relationships between medication discontinuation and outcomes. This study included adults aged 65+ with dementia or mild cognitive impairment, one or more additional chronic conditions, and prescribed 5+ chronic medications. The intervention included an educational brochure on deprescribing that was mailed to patients prior to primary care visits, a clinician notification about individual brochure mailings, and an educational tip sheets was provided monthly to primary care clinicians. The outcomes of the safety monitoring were rates of hospitalizations and mortality during the 4 months following brochure mailings and results of record review and adjudication. The adjudication process was conducted throughout the trial and included classifications: likely, possibly, and unlikely. RESULTS There was a total of 3012 (1433 intervention and 1579 control) participants. There were 420 total hospitalizations involving 269 (18.8%) people in the intervention versus 517 total hospitalizations involving 317 (20.1%) people in the control groups. Adjusted risk ratios comparing intervention to control groups were 0.92 [95% confidence interval (CI) 0.72, 1.16] for hospitalization and 1.19 (95% CI 0.67, 2.11) for mortality. Both groups had zero deaths "likely" attributed to a medication change prior to the event. A total of 3 out of 30 (10%) intervention group hospitalizations and 7 out of 35 (20%) control group hospitalizations were considered "likely" due to a medication change. CONCLUSIONS Population-based deprescribing education is safe in the older adult population with cognitive impairment in our study. Pragmatic methods for safety monitoring are needed to further inform deprescribing interventions. TRIAL REGISTRATION NCT03984396. Registered on 13 June 2019.
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Affiliation(s)
- Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Veterans Affairs Medical Center, Durham, NC, USA.
| | - Susan M Shetterly
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - John D Powers
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Linda A Weffald
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Orla C Sheehan
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Emily Reeve
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Melbourne, VIC, Australia
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Science, University of South Australia, Adelaide, SA, Australia
| | - Melanie L Drace
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Jonathan D Norton
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mahesh Maiyani
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Kathy S Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Jennifer K Sawyer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Matthew L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Veterans Affairs Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - Jennifer L Wolff
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Courtney Kraus
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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26
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Hoffmann U. [Management of polypharmacy in older people with multimorbidity]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:9-16. [PMID: 38059997 DOI: 10.1007/s00108-023-01630-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/03/2023] [Indexed: 12/08/2023]
Abstract
If the individual diagnoses of older people with multimorbidity are treated according to guidelines and by different specialists, confusing medication plans are sometimes the consequence. Therefore, a regular and structured drug evaluation is essential. As the life goals of patients can be very different, especially in older age, certain preliminary considerations should be made when starting, prescribing or discontinuing medication, taking into account the individual situation, including geriatric aspects. Updated so-called positive and negative lists provide assistance as to which medications are suitable or unsuitable for older people. Discontinuing certain medications when the life expectancy is reduced certainly makes sense but undertreatment of symptoms that cause distress to people, such as pain, should definitely be avoided.
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Affiliation(s)
- Ute Hoffmann
- Klinik für Allgemeine Innere Medizin und Geriatrie, Krankenhaus Barmherzige Brüder, Prüfeninger Str. 86, 93049, Regensburg, Deutschland.
- Klinik für Alterstraumatologie, Krankenhaus Barmherzige Brüder, Regensburg, Deutschland.
- Zentrum für Ernährungsmedizin, Krankenhaus Barmherzige Brüder, Regensburg, Deutschland.
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27
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Kaye MG, Rutowski J, Aftab H, Pandey R, Khan R, Kalot MA, Anand R, Graham SP. Screening for orthostatic hypotension in the geriatric population in a real-world primary care setting reduces prescribed antihypertensive medications. Blood Press Monit 2023; 28:338-342. [PMID: 37661718 DOI: 10.1097/mbp.0000000000000673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
BACKGROUND To determine if outpatient screening for orthostatic hypotension (OH) in the geriatric population results in fewer prescribed antihypertensive medications and if a relationship exists between OH and specific pharmacologic classes of antihypertensive medications. MATERIALS AND METHODS Patients ≥ 65 years were screened for OH, defined as a decrease in systolic blood pressure (SBP) ≥ 20 mm Hg or a decrease in diastolic blood pressure (DBP) ≥ 10 mm Hg after standing for 3 minutes. Sitting blood pressure (BP) was measured after patients had been seated quietly in an exam room. Patients then stood for approximately 3 minutes at which time standing BP was recorded. RESULTS OH prevalence was 18%. Standing DBP was significantly different between the two groups (70 mmHg ± 18, 80 mmHg ± 13, P = 0.007). Compared to patients without OH, patients with OH were more likely to have been previously prescribed beta-blockers (56% vs. 32%, P = 0.056) and potassium-sparing diuretics (11% vs. 1%, P = 0.026). Physicians discontinued an antihypertensive medication more often in patients who screened positive for OH than in to those who did not (17% vs. 4%, P = 0.037). Calcium channel blockers were the most frequently discontinued class of medication. CONCLUSION Asymptomatic OH is prevalent in geriatric patients. Screening for OH may lead to de-escalation of antihypertensive regimen and a reduction in polypharmacy. Positive screening for OH was associated with de-prescribing of antihypertensive medications. Prior use of beta-blockers and potassium-sparing diuretics was most largely associated with OH.
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Affiliation(s)
- Matthew G Kaye
- Department of Medicine, University at Buffalo (State University of New York)
| | - James Rutowski
- Department of Medicine, University at Buffalo (State University of New York)
| | - Hamza Aftab
- Department of Medicine, University at Buffalo (State University of New York)
| | - Rohan Pandey
- Department of Medicine, University at Buffalo (State University of New York)
| | - Raheel Khan
- Department of Medicine, University at Buffalo (State University of New York)
| | - Mohamad A Kalot
- Department of Medicine, University at Buffalo (State University of New York)
| | - Renata Anand
- Department of Medicine, University at Buffalo (State University of New York)
| | - Susan P Graham
- Division of Cardiology, Department of Medicine, University at Buffalo (State University of New York), Buffalo General Medical Center, Buffalo, New York, USA
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28
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Thompson W, Reeve E, McDonald EG, Farrell B, Scott S, Steinman MA, Morin L, Lundby C. Ten deprescribing articles you should know about: A guide for newcomers to the field. Basic Clin Pharmacol Toxicol 2023; 133:661-664. [PMID: 37142559 PMCID: PMC10831497 DOI: 10.1111/bcpt.13877] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 05/06/2023]
Affiliation(s)
- Wade Thompson
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Emily Reeve
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, VIC, Australia
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, SA, Australia
| | - Emily G. McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Barbara Farrell
- Bruyere Research Institute, Ottawa, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Canada
- University of Waterloo School of Pharmacy, Waterloo, Canada
| | - Sion Scott
- School of Healthcare, University of Leicester, United Kingdom
| | - Michael A. Steinman
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, California, USA
| | - Lucas Morin
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Inserm CIC 1431, CHU Besançon, Besançon, France
- Inserm U1018, High-Dimensional Biostatistics for Drug Safety and Genomics, CESP, Villejuif, France
| | - Carina Lundby
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Hospital Pharmacy Funen, Odense University Hospital, Odense, Denmark
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van Poelgeest E, Seppala L, Bahat G, Ilhan B, Mair A, van Marum R, Onder G, Ryg J, Fernandes MA, Cherubini A, Denkinger M, Eidam A, Egberts A, Gudmundsson A, Koçak FÖK, Soulis G, Tournoy J, Masud T, Wehling M, van der Velde N. Optimizing pharmacotherapy and deprescribing strategies in older adults living with multimorbidity and polypharmacy: EuGMS SIG on pharmacology position paper. Eur Geriatr Med 2023; 14:1195-1209. [PMID: 37812379 PMCID: PMC10754739 DOI: 10.1007/s41999-023-00872-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 09/19/2023] [Indexed: 10/10/2023]
Abstract
Inappropriate polypharmacy is highly prevalent among older adults and presents a significant healthcare concern. Conducting medication reviews and implementing deprescribing strategies in multimorbid older adults with polypharmacy are an inherently complex and challenging task. Recognizing this, the Special Interest Group on Pharmacology of the European Geriatric Medicine Society has compiled evidence on medication review and deprescribing in older adults and has formulated recommendations to enhance appropriate prescribing practices. The current evidence supports the need for a comprehensive and widespread transformation in education, guidelines, research, advocacy, and policy to improve the management of polypharmacy in older individuals. Furthermore, incorporating deprescribing as a routine aspect of care for the ageing population is crucial. We emphasize the importance of involving geriatricians and experts in geriatric pharmacology in driving, and actively participating in this transformative process. By doing so, we can work towards achieving optimal medication use and enhancing the well-being of older adults in the generations to come.
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Affiliation(s)
- Eveline van Poelgeest
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Lotta Seppala
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Gülistan Bahat
- Division of Geriatrics, Department of Internal Medicine, Istanbul Medical School, Istanbul University, Capa, Istanbul, Turkey
| | - Birkan Ilhan
- Division of Geriatrics, Department of Internal Medicine, Liv Hospital Vadistanbul, Istanbul, Turkey
| | - Alpana Mair
- Effective Prescribing and Therapeutics, Health and Social Care Directorate, Scottish Government, Edinburgh, Scotland, UK
- Edinburgh Napier University, Edinburgh, UK
| | - Rob van Marum
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Department of Elderly Care Medicine, Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Graziano Onder
- Fondazione Policlinico Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Marília Andreia Fernandes
- Department of Internal Medicine, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Antonio Cherubini
- Geriatria Accettazione geriatrica e Centro di Ricerca per l'invecchiamento IRCCS INRCA, Ancona, Italy
| | - Michael Denkinger
- Agaplesion Bethesda Clinic Ulm, Institute for Geriatric Research, Ulm University, Geriatric Center Ulm, Ulm, Germany
| | - Annette Eidam
- Center for Geriatric Medicine, Heidelberg University Hospital, AGAPLESION Bethanien Hospital Heidelberg, Heidelberg, Germany
| | - Angelique Egberts
- Department of Hospital Pharmacy, Franciscus Gasthuis & Vlietland, Rotterdam, Schiedam, The Netherlands
| | - Aðalsteinn Gudmundsson
- Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Fatma Özge Kayhan Koçak
- Division of Geriatrics, Department of Internal Medicine, Faculty of Medicine, Ege University, Izmir, Turkey
| | - George Soulis
- Outpatient Geriatric Assessment Unit, Henry Dunant Hospital Center, Athens, Greece
- Hellenic Open University, Patras, Greece
| | - Jos Tournoy
- Department of Geriatric Medicine, KU Leuven University Hospitals Leuven Gasthuisberg Campus, Leuven, Belgium
- Department of Public Health and Primary Care, KU Leuven Biomedical Sciences Group, Leuven, Belgium
| | - Tahir Masud
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Martin Wehling
- Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nathalie van der Velde
- Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Aging and Later Life, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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30
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Steinman MA. The future of deprescribing research: Seizing opportunities and learning from the past. Basic Clin Pharmacol Toxicol 2023; 133:653-656. [PMID: 36916220 DOI: 10.1111/bcpt.13852] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/16/2023]
Affiliation(s)
- Michael A Steinman
- University of California, San Francisco and the San Francisco VA Medical Center, San Francisco, California, USA
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31
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Thomas NPB, Tonner E, Royal S, Evans P. Primary and secondary care collaboration in clinical research. Future Healthc J 2023; 10:259-262. [PMID: 38162215 PMCID: PMC10753210 DOI: 10.7861/fhj.2023-0106] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
More patients are seen in primary care than in any other part of the health system in the UK. Our NHS datasets are the envy of the world and provide us with huge opportunities to support our patients and populations. In this paper, we demonstrate the breadth of primary care research, recruitment and delivery options. We show how research can affect many different aspects of patient care and demonstrate, through the delivery and publication of game-changing research, the ability of recruitment in primary care to answer questions that are relevant to secondary care activity. Indeed, these complex and innovative study designs and their collaborative delivery across the multitude of diseases (acute and chronic) show the strength of primary care. Collaboration across boundaries, specialties and healthcare settings will provide increased opportunities for clinical research development and, most importantly, deliver the highest quality research to support our patients.
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Affiliation(s)
- Nicholas PB Thomas
- Oxford, UK, clinical lead for research, RCGP, London, UK, and GP, Windrush Medical Practice, Witney, UK
| | | | - Simon Royal
- Division of Primary Care, University of Nottingham Health Service, Nottingham, UK
| | - Philip Evans
- London, UK and professor of primary care research, University of Exeter, Exeter, UK
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32
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Hu K, Zhou G, Jiang M, Wei X, Yu J, Liu L, Wang Z, Feng L, Wu M, Li T, Ma B. Hypertension Treatment in Frail Older Adults: A Systematic Review and Appraisal of Guidelines. Drugs Aging 2023; 40:881-893. [PMID: 37594718 DOI: 10.1007/s40266-023-01053-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Managing hypertension in frail older patients is challenging. Several institutions and organizations have published up-to-date hypertension guidelines suggesting frailty screening among older hypertensive patients, with new recommendations for blood pressure-lowering treatment among the frail population. However, the quality of current hypertension guidelines and the consistency of antihypertension treatment recommendations for frail older patients and their supporting evidence remain unknown. OBJECTIVE In this review, we aimed to systematically collect guidelines with antihypertension treatment recommendations for frail older patients, examine and compare these recommendations, and critically assess reporting and methodology quality of these guidelines. METHODS A literature search was conducted on two databases and three major websites of guideline development organizations. The AGREE instrument and RIGHT checklist were used to evaluate the methodology and reporting quality of the guidelines, respectively. The consistency of recommendations within the guidelines were compared using descriptive analysis. RESULTS We identified 13 hypertension guidelines. The overall methodology quality scores (range 23.35-79.07%) and reporting rates (range 10/35-29/35) varied among these guidelines. Four guidelines provided an explicit definition of frailty. Considering treatment tolerability or increased likelihood of adverse effects while using pharmacotherapy in frail older patients was mentioned in all guidelines. Ten guidelines recommended adjusting blood pressure targets or specific pharmacotherapy programs. Four guidelines recommended using clinical judgment when prescribing. However, the specific recommendations lacked clarity and unity without sufficient evidence. CONCLUSIONS There were considerable variations in methodology and reporting quality across the 13 included hypertension guidelines. Furthermore, the depth and breadth of antihypertension treatment recommendations for frail older patients were varied and inconsistent. Further trials exploring optimal treatment are urgently required to promote the development of specific guidelines for managing frail older hypertensive patients.
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Affiliation(s)
- Kaiyan Hu
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
| | - Gang Zhou
- The First Clinical Medicine College, Lanzhou University, Lanzhou, 730000, China
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, 730000, China
| | - Mengyao Jiang
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xiaohong Wei
- Department of Neurology, China-Japan Friendship Hospital, Beijing, 100000, China
| | - Jing Yu
- Department of Critical Care Medicine, SunYat-sen University Cancer Center, Guangzhou, 510000, China
| | - Li Liu
- Department of Cardiology, Ningxia Medical University General Hospital, Yinchuan, 750000, China
| | - Zhe Wang
- Evidence-based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, 730000, China
| | - Liyuan Feng
- Evidence-based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, 730000, China
| | - Mei Wu
- Evidence-based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, 730000, China
| | - Tao Li
- Department of Cardiology, Gansu Gem Flower Hospital, Lanzhou, 730000, China.
| | - Bin Ma
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China.
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Anderson TS, Ayanian JZ, Curto VE, Politzer E, Souza J, Zaslavsky AM, Landon BE. Changes in the Use of Long-Term Medications Following Incident Dementia Diagnosis. JAMA Intern Med 2023; 183:1098-1108. [PMID: 37603340 PMCID: PMC10442785 DOI: 10.1001/jamainternmed.2023.3575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/09/2023] [Indexed: 08/22/2023]
Abstract
Importance Dementia is a life-altering diagnosis that may affect medication safety and goals for chronic disease management. Objective To examine changes in medication use following an incident dementia diagnosis among community-dwelling older adults. Design, Setting, and Participants In this cohort study of adults aged 67 years or older enrolled in traditional Medicare and Medicare Part D, patients with incident dementia diagnosed between January 2012 and December 2018 were matched to control patients based on demographics, geographic location, and baseline medication count. The index date was defined as the date of first dementia diagnosis or, for controls, the date of the closest office visit. Data were analyzed from August 2021 to June 2023. Exposure Incident dementia diagnosis. Main Outcomes and Measures The main outcomes were overall medication counts and use of cardiometabolic, central nervous system (CNS)-active, and anticholinergic medications. A comparative time-series analysis was conducted to examine quarterly changes in medication use in the year before through the year following the index date. Results The study included 266 675 adults with incident dementia and 266 675 control adults; in both groups, 65.1% were aged 80 years or older (mean [SD] age, 82.2 [7.1] years) and 67.8% were female. At baseline, patients with incident dementia were more likely than controls to use CNS-active medications (54.32% vs 48.39%) and anticholinergic medications (17.79% vs 15.96%) and less likely to use most cardiometabolic medications (eg, diabetes medications, 31.19% vs 36.45%). Immediately following the index date, the cohort with dementia had a greater increase in mean number of medications used (0.41 vs -0.06; difference, 0.46 [95% CI, 0.27-0.66]) and in the proportion of patients using CNS-active medications (absolute change, 3.44% vs 0.79%; difference, 2.65% [95% CI, 0.85%-4.45%]) owing to an increased use of antipsychotics, antidepressants, and antiepileptics. The cohort with dementia also had a modestly greater decline in use of anticholinergic medications (quarterly change in use, -0.53% vs -0.21%; difference, -0.32% [95% CI, -0.55% to -0.08%]) and most cardiometabolic medications (eg, quarterly change in antihypertensive use: -0.84% vs -0.40%; difference, -0.44% [95% CI, -0.64% to -0.25%]). One year after diagnosis, 75.2% of the cohort with dementia were using 5 or more medications (2.8% increase). Conclusions and Relevance In this cohort study of Medicare Part D beneficiaries, following an incident dementia diagnosis, patients were more likely to initiate CNS-active medications and modestly more likely to discontinue cardiometabolic and anticholinergic medications compared with the control group. These findings suggest missed opportunities to reduce burdensome polypharmacy by deprescribing long-term medications with high safety risks or limited likelihood of benefit or that may be associated with impaired cognition.
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Affiliation(s)
- Timothy S. Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - John Z. Ayanian
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Division of General Medicine, University of Michigan, Ann Arbor
| | - Vilsa E. Curto
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Eran Politzer
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey Souza
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Alan M. Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Bruce E. Landon
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Braithwaite E, Todd OM, Atkin A, Hulatt R, Tadrous R, Alldred DP, Pirmohamed M, Walker L, Lawton R, Clegg A. Interventions for reducing anticholinergic medication burden in older adults-a systematic review and meta-analysis. Age Ageing 2023; 52:afad176. [PMID: 37740900 PMCID: PMC10517713 DOI: 10.1093/ageing/afad176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Indexed: 09/25/2023] Open
Abstract
INTRODUCTION Anticholinergic medications block the neurotransmitter acetylcholine in the brain and peripheral nervous system. Many medications have anticholinergic properties, and the cumulative effect of these medications is termed anticholinergic burden. Increased anticholinergic burden can have short-term side effects such as dry mouth, blurred vision and urinary retention as well as long-term effects including dementia, worsening physical function and falls. METHODS We carried out a systematic review (SR) with meta-analysis (MA) looking at randomised controlled trials addressing interventions to reduce anticholinergic burden in older adults. RESULTS We identified seven papers suitable for inclusion in our SR and MA. Interventions included multi-disciplinary involvement in medication reviews and deprescribing of AC medications. Pooled data revealed no significant difference in outcomes between control and intervention group for falls (OR = 0.76, 95% CI: 0.52-1.11, n = 647), cognition (mean difference = 1.54, 95% CI: -0.04 to 3.13, n = 405), anticholinergic burden (mean difference = 0.04, 95% CI: -0.11 to 0.18, n = 710) or quality of life (mean difference = 0.04, 95% CI: -0.04 to 0.12, n = 461). DISCUSSION Overall, there was no significant difference with interventions to reduce anticholinergic burden. As we did not see a significant change in anticholinergic burden scores following interventions, it is likely other outcomes would not change. Short follow-up time and lack of training and support surrounding successful deprescribing may have contributed.
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Affiliation(s)
- Eve Braithwaite
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - Oliver M Todd
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - Abigail Atkin
- Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, UK
| | - Rachel Hulatt
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Ragy Tadrous
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
| | - David P Alldred
- School of Healthcare, University of Leeds, Leeds, UK
- NIHR Yorkshire & Humber Patient Safety Translational Research Centre, Bradford, UK
| | - Munir Pirmohamed
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Lauren Walker
- Department of Clinical Pharmacology, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L69 7DE, UK
| | - Rebecca Lawton
- Institute of Psychological Sciences, University of Leeds, Leeds, UK
- Department of Quality and Safety Research, Bradford Institute for Health Research, Bradford, UK
| | - Andrew Clegg
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds, UK
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Leal Rodríguez C, Haue AD, Mazzoni G, Eriksson R, Hernansanz Biel J, Cantwell L, Westergaard D, Belling KG, Brunak S. Drug dosage modifications in 24 million in-patient prescriptions covering eight years: A Danish population-wide study of polypharmacy. PLOS DIGITAL HEALTH 2023; 2:e0000336. [PMID: 37676853 PMCID: PMC10484442 DOI: 10.1371/journal.pdig.0000336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 07/20/2023] [Indexed: 09/09/2023]
Abstract
Polypharmacy has generally been assessed by raw counts of different drugs administered concomitantly to the same patients; not with respect to the likelihood of dosage-adjustments. To address this aspect of polypharmacy, the objective of the present study was to identify co-medications associated with more frequent dosage adjustments. The data foundation was electronic health records from 3.2 million inpatient admissions at Danish hospitals (2008-2016). The likelihood of dosage-adjustments when two drugs were administered concomitantly were computed using Bayesian logistic regressions. We identified 3,993 co-medication pairs that associate significantly with dosage changes when administered together. Of these pairs, 2,412 (60%) did associate with readmission, mortality or longer stays, while 308 (8%) associated with reduced kidney function. In comparison to co-medications pairs that were previously classified as drug-drug interactions, pairs not classified as drug-drug interactions had higher odds ratios of dosage modifications than drug pairs with an established interaction. Drug pairs not corresponding to known drug-drug interactions while still being associated significantly with dosage changes were prescribed to fewer patients and mentioned more rarely together in the literature. We hypothesize that some of these pairs could be associated with yet to be discovered interactions as they may be harder to identify in smaller-scale studies.
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Affiliation(s)
- Cristina Leal Rodríguez
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Amalie Dahl Haue
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, DK-2100 Copenhagen, Denmark
| | - Gianluca Mazzoni
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Robert Eriksson
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
- Department of Pulmonary and Infectious Diseases, Nordsjællands Hospital, DK-3400 Hillerød, Denmark
| | - Jorge Hernansanz Biel
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Lisa Cantwell
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - David Westergaard
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
- Department of Obstetrics and Gynaecology, Copenhagen University Hospital Hvidovre, DK-2650 Hvidovre, Denmark
| | - Kirstine G. Belling
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Søren Brunak
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
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Welsh TJ, Mitchell A. Centrally acting antihypertensives and alpha-blockers in people at risk of falls: therapeutic dilemmas-a clinical review. Eur Geriatr Med 2023; 14:675-682. [PMID: 37436689 PMCID: PMC10447259 DOI: 10.1007/s41999-023-00813-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/07/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE The aim of this clinical review was to summarise the existing knowledge on the adverse effects of alpha-blockers and centrally acting antihypertensives, the effect these may have on falls risk, and guide deprescribing of these medications. METHODS Literature searches were conducted using PubMed and Embase. Additional articles were identified by searching reference lists and reference to personal libraries. We discuss the place of alpha-blockers and centrally acting antihypertensives in the treatment of hypertension and methods for deprescribing. RESULTS Alpha-blockers and centrally acting antihypertensives are no longer recommended for the treatment of hypertension unless all other agents are contraindicated or not tolerated. These medications carry a significant falls risk and non-falls risk-associated side effects. Tools to aid and guide de-prescribing and monitoring of the withdrawal of these medication classes are available to assist the clinician including information on reducing the risk of withdrawal syndromes. CONCLUSIONS Centrally acting antihypertensives and alpha-blockers increase the risk of falls through a variety of mechanisms-principally by increasing the risk of hypotension, orthostatic hypotension, arrhythmias and sedation. These agents should be prioritised for de-prescribing in older frailer individuals. We identify a number of tools and a withdrawal protocol to aid the clinician in identifying and de-prescribing these medications.
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Affiliation(s)
- T J Welsh
- University of Bristol, Bristol, UK
- RICE-The Research Institute for the Care of Older People, The RICE Centre, Royal United Hospital, Bath, UK
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - A Mitchell
- RICE-The Research Institute for the Care of Older People, The RICE Centre, Royal United Hospital, Bath, UK.
- Pharmacy Department, University Hospitals Plymouth NHS Trust, Plymouth, UK.
- Department of Life Sciences, University of Bath, Bath, UK.
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Etherton-Beer C, Page A, Naganathan V, Potter K, Comans T, Hilmer SN, McLachlan AJ, Lindley RI, Mangin D. Deprescribing to optimise health outcomes for frail older people: a double-blind placebo-controlled randomised controlled trial-outcomes of the Opti-med study. Age Ageing 2023; 52:7181253. [PMID: 37247404 DOI: 10.1093/ageing/afad081] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND potentially harmful polypharmacy is very common in older people living in aged care facilities. To date, there have been no double-blind randomised controlled studies of deprescribing multiple medications. METHODS three-arm (open intervention, blinded intervention and blinded control) randomised controlled trial enrolling people aged over 65 years (n = 303, noting pre-specified recruitment target of n = 954) living in residential aged care facilities. The blinded groups had medications targeted for deprescribing encapsulated while the medicines were deprescribed (blind intervention) or continued (blind control). A third open intervention arm had unblinded deprescribing of targeted medications. RESULTS participants were 76% female with mean age 85.0 ± 7.5 years. Deprescribing was associated with a significant reduction in the total number of medicines used per participant over 12 months in both intervention groups (blind intervention group -2.7 medicines, 95% CI -3.5, -1.9, and open intervention group -2.3 medicines; 95% CI -3.1, -1.4) compared with the control group (-0.3, 95% CI -1.0, 0.4, P = 0.053). Deprescribing regular medicines was not associated with any significant increase in the number of 'when required' medicines administered. There were no significant differences in mortality in the blind intervention group (HR 0.93, 95% CI 0.50, 1.73, P = 0.83) or the open intervention group (HR 1.47, 95% CI 0.83, 2.61, P = 0.19) compared to the control group. CONCLUSIONS deprescribing of two to three medicines per person was achieved with protocol-based deprescribing during this study. Pre-specified recruitment targets were not met, so the impact of deprescribing on survival and other clinical outcomes remains uncertain.
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Affiliation(s)
- Christopher Etherton-Beer
- WA Centre for Health and Ageing, University of Western Australia, M577, 35 Stirling Hwy, Crawley WA 6009, Australia
| | - Amy Page
- WA Centre for Health and Ageing, University of Western Australia, M577, 35 Stirling Hwy, Crawley WA 6009, Australia
| | - Vasi Naganathan
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Kathleen Potter
- Operations, Ryman Healthcare, Christchurch, Canterbury, New Zealand
| | - Tracy Comans
- Centre for Health Services Research, University of Queensland, Brisbane, Australia
| | - Sarah N Hilmer
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Andrew J McLachlan
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Richard I Lindley
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Dee Mangin
- Family Medicine, McMaster University. Hamilton, Canada
- General Practice, University of Otago, Christchurch, New Zealand
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Russell P, Thompson C, Mangoni AA. Rational Prescribing and Deprescribing of Antihypertensive Medications in Older People, a Three-Part Narrative Review, Part 3. Sr Care Pharm 2023; 38:168-178. [PMID: 37185147 DOI: 10.4140/tcp.n.2023.168] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
What happens when you stop? This is the third of a three-part series on antihypertensive medication use in older people. In the first, we reviewed the importance of better blood pressure (BP) control, even in older people with hypertension. In the second, we discussed the limitations of the evidence favoring intensive therapy for some older people. For older people with advanced frailty or those with a limited life expectancy, medications taken for BP can actually be a source of morbidity. Guidelines encourage clinical judgment and rational prescribing. Sometimes the best action is to stop prescribing. De-prescribing of medical therapy is now considered good practice for a range of medications for suitable patients; should this include antihypertensives? In part three of this three-part series, we will review some of the evidence available thus far, demonstrating de-intensification of antihypertensive medications is not a new idea. We will offer a guide to identifying the most suitable patients for de-prescribing: cognitive impairment, frailty, when circumstances change, or when BP is (too) well-controlled. This is an area of equipoise and needs more research. There is a path forward that we hope to illuminate.
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Affiliation(s)
- Patrick Russell
- 1 Department of Internal Medicine, Royal Adelaide Hospital, Adelaide, South Australia
| | - Campbell Thompson
- 2 University of Adelaide, Department of Medicine, Royal Adelaide Hospital, Adelaide, South Australia
| | - Arduino A Mangoni
- 3 Department of Clinical Pharmacology, Flinders University and Flinders Medical Centre, Bedford Park, South Australia
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Wajngarten M. How to Improve Clinical Outcomes and Reduce Cardiovascular Risk in Older People with Cardiovascular Disease: Bridging Evidence Gaps. Eur Cardiol 2023; 18:e17. [PMID: 37405340 PMCID: PMC10316345 DOI: 10.15420/ecr.2022.59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/07/2023] [Indexed: 07/06/2023] Open
Abstract
The geriatric population is greatly impacted by cardiovascular disease. Thus, it becomes essential to 'geriatricise' the cardiologist through the dissemination of geriatric cardiology. In the early days of geriatric cardiology, it was discussed whether it was simply cardiology 'well done'. Today, 40 years later, it seems clear that this is indeed the case. Patients with cardiovascular disease usually have several chronic conditions. Clinical practice guidelines often address a single condition and do not provide sufficient guidance for patients with multimorbidity. There are several evidence gaps regarding these patients. Physicians and members ofthe care team need a multidimensional understanding ofthe patient to better promote the optimisation of care. It is important to understand that ageing is inevitable, heterogeneous and increases vulnerability. Caregivers must know how to assess elderly patients in a multidomain practical way and how to recognise the factors that may have implications on treatment.
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Affiliation(s)
- Mauricio Wajngarten
- Department of Cardiology, Hospital Israelita Albert Einstein São Paulo, Brazil
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da Silva Rodrigues G, Noronha NY, Almeida ML, Sobrinho ACDS, Watanabe LM, Pinhel MADS, de Lima JGR, Zhang R, Nonino CB, Alves CRR, Bueno Júnior CR. Exercise training modifies the whole blood DNA methylation profile in middle-aged and older women. J Appl Physiol (1985) 2023; 134:610-621. [PMID: 36701486 DOI: 10.1152/japplphysiol.00237.2022] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
This is a longitudinal single-arm clinical trial aimed to investigate whether exercise training would modify the whole blood methylation profile in healthy women. A total of 45 subjects were engaged in an exercise training protocol during a 14-wk follow up, consisting of aerobic cardiorespiratory and muscle strength exercises. Subjects were evaluated at baseline (PRE), after 7 wk of exercise training (POST 7), and after 14 wk of exercise training (POST 14). Functional primary outcomes included anthropometric, blood pressure, biochemical measurements, physical tests, and global health assessments. Blood samples were collected at each time point to determine the methylation profile using a DNA methylation array technique screening up to 850k different sites. Exercise training decreased blood pressure and triglyceride levels and enhanced physical performance, including upper- and lower-body maximum strength. Moreover, exercise training improved markers of quality of life. In the array analysis, 14 wk of exercise training changed the methylation of more than 800 sites. Across these differentially methylated sites, we found that differentially methylated sites in the promoter region were more hypermethylated after exercise training, suggesting that this hypermethylation process may affect the transcription process. When inputting the differentially methylated sites in pathway analysis, we found several metabolic pathways, including AMPK signaling, TGF-β signaling, and insulin signaling. This study demonstrates that exercise training promotes a robust change in the whole blood methylation profile and provides new insights into the key regulators of exercise-induced benefits.NEW & NOTEWORTHY We have shown that exercise training lowers blood pressure and triglyceride levels, improves physical performance, and improves quality of life in middle-aged and elderly women. Regarding epigenetic data, we noticed that more than 800 sites are differentially methylated in whole blood after physical training. We emphasize that the differentially methylated sites in the promoter region are more hypermethylated after physical training. In addition, this study shows that key members of metabolic pathways, including AMPK signaling, TGF-β signaling, and insulin signaling, are among the genes hypermethylated after physical exercise in older women.
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Affiliation(s)
| | - Natália Y Noronha
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Mariana L Almeida
- College of Nursing of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Andressa C da S Sobrinho
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Lígia M Watanabe
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Marcela A de S Pinhel
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - João G R de Lima
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Ren Zhang
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Carla B Nonino
- Health Sciences Department, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Christiano R R Alves
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Carlos R Bueno Júnior
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil.,College of Nursing of Ribeirão Preto, University of São Paulo, São Paulo, Brazil.,School of Physical Education and Sport of Ribeirão Preto, University of Sao Paulo, Sao Paulo, Brazil
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Hu Y, Huerta J, Cordella N, Mishuris RG, Paschalidis IC. Personalized hypertension treatment recommendations by a data-driven model. BMC Med Inform Decis Mak 2023; 23:44. [PMID: 36859187 PMCID: PMC9979505 DOI: 10.1186/s12911-023-02137-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 02/09/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Hypertension is a prevalent cardiovascular disease with severe longer-term implications. Conventional management based on clinical guidelines does not facilitate personalized treatment that accounts for a richer set of patient characteristics. METHODS Records from 1/1/2012 to 1/1/2020 at the Boston Medical Center were used, selecting patients with either a hypertension diagnosis or meeting diagnostic criteria (≥ 130 mmHg systolic or ≥ 90 mmHg diastolic, n = 42,752). Models were developed to recommend a class of antihypertensive medications for each patient based on their characteristics. Regression immunized against outliers was combined with a nearest neighbor approach to associate with each patient an affinity group of other patients. This group was then used to make predictions of future Systolic Blood Pressure (SBP) under each prescription type. For each patient, we leveraged these predictions to select the class of medication that minimized their future predicted SBP. RESULTS The proposed model, built with a distributionally robust learning procedure, leads to a reduction of 14.28 mmHg in SBP, on average. This reduction is 70.30% larger than the reduction achieved by the standard-of-care and 7.08% better than the corresponding reduction achieved by the 2nd best model which uses ordinary least squares regression. All derived models outperform following the previous prescription or the current ground truth prescription in the record. We randomly sampled and manually reviewed 350 patient records; 87.71% of these model-generated prescription recommendations passed a sanity check by clinicians. CONCLUSION Our data-driven approach for personalized hypertension treatment yielded significant improvement compared to the standard-of-care. The model implied potential benefits of computationally deprescribing and can support situations with clinical equipoise.
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Affiliation(s)
- Yang Hu
- Department of Electrical and Computer Engineering, Division of Systems Engineering, Boston University, 8 Saint Mary's St., Boston, MA, 02215, USA
| | - Jasmine Huerta
- Department of Medicine, Boston Medical Center, School of Medicine, Boston University, Boston, MA, USA
| | - Nicholas Cordella
- Department of Medicine, Boston Medical Center, School of Medicine, Boston University, Boston, MA, USA
| | - Rebecca G Mishuris
- Department of Medicine, Boston Medical Center, School of Medicine, Boston University, Boston, MA, USA
| | - Ioannis Ch Paschalidis
- Department of Electrical and Computer Engineering, Division of Systems Engineering, Boston University, 8 Saint Mary's St., Boston, MA, 02215, USA.
- Department of Biomedical Engineering, Faculty of Computing & Data Sciences, Hariri Institute for Computing and Computational Science & Engineering, Boston University, 8 Saint Mary's St., Boston, MA, 02215, USA.
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Wang J, Shen JY, Conwell Y, Podsiadly EJ, Caprio TV, Nathan K, Yu F, Ramsdale EE, Fick DM, Mixon AS, Simmons SF. How "age-friendly" are deprescribing interventions? A scoping review of deprescribing trials. Health Serv Res 2023; 58 Suppl 1:123-138. [PMID: 36221154 DOI: 10.1111/1475-6773.14083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To assess how age-friendly deprescribing trials are regarding intervention design and outcome assessment. Reduced use of potentially inappropriate medications (PIMs) can be addressed by deprescribing-a systematic process of discontinuing and/or reducing the use of PIMs. The 4Ms-"Medication", "Mentation", "Mobility", and "What Matters Most" to the person-can be used to guide assessment of age-friendliness of deprescribing trials. DATA SOURCE Published literature. STUDY DESIGN Scoping review. DATA EXTRACTION METHODS The literature was identified using keywords related to deprescribing and polypharmacy in PubMed, EMBASE, Web of Science, ProQuest, CINAHL, and Cochrane and snowballing. Study characteristics were extracted and evaluated for consideration of 4Ms. PRINCIPAL FINDINGS Thirty-seven of the 564 trials identified met the review eligibility criteria. Intervention design: "Medication" was considered in the intervention design of all trials; "Mentation" was considered in eight trials; "Mobility" (n = 2) and "What Matters Most" (n = 6) were less often considered in the design of intervention. Most trials targeted providers without specifying how matters important to older adults and their families were aligned with deprescribing decisions. OUTCOME ASSESSMENT "Medication" was the most commonly assessed outcome (n = 33), followed by "Mobility" (n = 13) and "Mentation" (n = 10) outcomes, with no study examining "What Matters Most" outcomes. CONCLUSIONS "Mentation" and "Mobility", and "What Matters Most" have been considered to varying degrees in deprescribing trials, limiting the potential of deprescribing evidence to contribute to improved clinical practice in building an age-friendly health care system.
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Affiliation(s)
- Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Eric J Podsiadly
- Elaine Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Thomas V Caprio
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Kobi Nathan
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York, USA
| | - Fang Yu
- Arizona State University, Edson College of Nursing and Health Innovation, Phoenix, Arizona, USA
| | - Erika E Ramsdale
- University of Rochester Medical Center, Department of Medicine, Division of Hematology/Oncology, Rochester, New York, USA
| | - Donna M Fick
- Penn State University, Ross and Carol Nese College of Nursing, University Park, Pennsylvania, USA
| | - Amanda S Mixon
- Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sandra F Simmons
- Division of Geriatrics & Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Fujiwara T, Sheppard JP, Hoshide S, Kario K, McManus RJ. Medical Telemonitoring for the Management of Hypertension in Older Patients in Japan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2227. [PMID: 36767594 PMCID: PMC9916269 DOI: 10.3390/ijerph20032227] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/13/2023] [Accepted: 01/24/2023] [Indexed: 06/18/2023]
Abstract
Hypertension is the most frequent modifiable risk factor associated with cardiovascular disease (CVD) morbidity and mortality. Even in older people, strict blood pressure (BP) control has been recommended to reduce CVD event risks. However, caution should be exercised since older hypertensive patients have increased physical vulnerability due to frailty and multimorbidity, and older patients eligible for clinical trials may not represent the general population. Medical telemonitoring systems, which enable us to monitor a patient's medical condition remotely through digital communication, have become much more prevalent since the coronavirus pandemic. Among various physiological parameters, BP monitoring is well-suited to the use of such systems, which enable healthcare providers to deliver accurate and safe BP management, even in the presence of frailty and/or living in geographically remote areas. Furthermore, medical telemonitoring systems could help reduce nonadherence to antihypertensive medications and clinical inertia, and also enable multi-professional team-based management of hypertension. However, the implementation of medical telemonitoring systems in clinical practice is not easy, and substantial barriers, including the development of user-friendly devices, integration with existing clinical systems, data security, and cost of implementation and maintenance, need to be overcome. In this review, we focus on the potential of medical telemonitoring for the management of hypertension in older people in Japan.
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Affiliation(s)
- Takeshi Fujiwara
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke 329-0498, Japan
| | - James P. Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
| | - Satoshi Hoshide
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke 329-0498, Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke 329-0498, Japan
| | - Richard J. McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK
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Mohammed SAD, Hanxing L, Fang L, Algradi AM, Alradhi M, Safi M, Shumin L. Integrated Chinese herbal medicine with Western Medicine versus Western Medicine in the effectiveness of primary hypertension treatment: A systematic review and meta-analysis of randomized controlled trials. JOURNAL OF ETHNOPHARMACOLOGY 2023; 300:115703. [PMID: 36096347 DOI: 10.1016/j.jep.2022.115703] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 07/30/2022] [Accepted: 09/05/2022] [Indexed: 06/15/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Integrated Chinese herbal medicine (CHM) and Western Medicine (WM) treatments have been used for primary hypertension (PHTN) patients in China. Currently, there are many randomized control trials (RCTs) published regarding the effect of CHM and WM on PHTN, which indicated that combining Chinese with WM was effective and safe for PHTN when compared with WM alone, but the quality of evidence was insufficient, and there is no clear information and summary are available for these RCTs assessing the effectiveness of CHM with WM versus WM in patients with PHTN. OBJECTIVES This systematic study and meta-analysis aimed to evaluate the effectiveness and safety of CHM combined with WM in comparison with WM in reducing systolic and diastolic blood pressure for patients with PHTN. METHODS The information of this study was searched from electronic databases (PubMed, COCHRANE, EMBASE, Ovid, CNKI, VIP, Wanfang, and CBM). The markedly effective and effective terms were according to Guiding Principles for Clinical Research of New Chinese Medicines. Two investigators independently reviewed each trial. The Cochrane risk of bias assessment tool was used for quality assessment, and RevMan 5.4 was used for meta-analysis. RESULTS In this study, a total of 29 studies that included 2623 patients were recorded. The study results displayed that the clinical effectiveness in the treatment of hypertension patients from the integrated medicines was considerably higher than that with WM alone, clinical effective (RR 1.23, 95% CI [1.17, 1.30], P < 0.00001), and markedly effective (ME) in the patients (RR 1.66, 95% CI [1.52, 1.80], and P < 0.00001). Random effect in SBP (MD 7.91 mmHg,[6.00, 983], P < 0.00001) and DBP (MD 5.46 mmHg, [3.88, 6.43], P < 0.00001), a subgroup analysis was carried out based on the type of intervention, duration of treatment, and CHM formulas that showed significance. Furthermore, no severe side effects were reported, and no patients stopped treatment or withdrawal due to any severe adverse events. CONCLUSION Compared to WM alone, the therapeutic effectiveness of CHM combined with WM is significantly improved in the treatment of hypertension. Additionally, CHM with WM may safely and efficiently lower systolic blood pressure (SBP) and diastolic blood pressure (DBP) in individuals with PHTN. However, rigorous randomized controlled trials with a large sample, high quality, long duration of treatment, and follow-up are recommended to strengthen this clinical evidence.
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Affiliation(s)
- Shadi A D Mohammed
- Heilongjiang University of Chinese Medicine, Harbin, 150040, Heilongjiang, China; School of Pharmacy, Lebanese International University, 18644, Sana'a, Yemen
| | - Liu Hanxing
- Heilongjiang University of Chinese Medicine, Harbin, 150040, Heilongjiang, China
| | - Lu Fang
- Heilongjiang University of Chinese Medicine, Harbin, 150040, Heilongjiang, China
| | - Adnan Mohammed Algradi
- Key Laboratory of Chinese Materia Medica, Ministry of Education of Heilongjiang University of Chinese Medicine, Harbin, 150040, Heilongjiang, China
| | - Mohammed Alradhi
- Department of Urology, Affiliated Hospital of Qingdao Binhai University, Qingdao, Shandong, China
| | - Mohammed Safi
- Department of Respiratory Diseases, Shandong Second Provincial General Hospital, Shandong University, Shandong, China
| | - Liu Shumin
- Heilongjiang University of Chinese Medicine, Harbin, 150040, Heilongjiang, China.
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Jeffrie Seley J, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 13. Older Adults: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S216-S229. [PMID: 36507638 PMCID: PMC9810468 DOI: 10.2337/dc23-s013] [Citation(s) in RCA: 72] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Rey-Rañal EM, Cordero A. Most Recent Trials and Advances in Hypertension. Eur Cardiol 2022; 17:e24. [PMID: 36845214 PMCID: PMC9947933 DOI: 10.15420/ecr.2022.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 07/14/2022] [Indexed: 12/14/2022] Open
Abstract
Hypertension is one of the most prevalent cardiovascular risk factors and blood pressure control remains a clinical challenge, especially for patients with established cardiovascular disease. Late-breaking clinical trials and other evidence in hypertension have evolved to assess the most accurate ways to measure blood pressure, the use of combination therapies, considerations in special populations and evaluation of new techniques. Recent evidence supports the superiority of ambulatory or 24-hour blood pressure measurements, rather than office blood pressure measurements, for the assessment of cardiovascular risk. The use of fixed-dose combinations and polypills has been demonstrated to be valid and to provide clinical benefits beyond blood pressure control. There have also been advances in new approaches such as telemedicine, devices and the use of algorithms. Clinical trials have provided valuable data on blood pressure control in primary prevention, during pregnancy and in the elderly. The role of renal denervation remains unsolved but innovative techniques using ultrasound or alcohol injections are being explored. Current evidence and results of latest trials are summarised in this review.
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Affiliation(s)
| | - Alberto Cordero
- Cardiology Department, Hospital Universitario de San JuanAlicante, Spain,Unidad de Investigación de Cardiología, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitad Valenciana (FISABIO)Valencia, Spain,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV)Madrid, Spain
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Xu YX, Zhou Y, Huang Y, Yu Y, Li JY, Huang WJ, Wan YH, Tao FB, Sun Y. Physical activity alleviates negative effects of bedroom light pollution on blood pressure and hypertension in Chinese young adults. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2022; 313:120117. [PMID: 36087897 DOI: 10.1016/j.envpol.2022.120117] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/08/2022] [Accepted: 09/02/2022] [Indexed: 06/15/2023]
Abstract
Excessive exposure to light at night (LAN) has become a serious public health concern. However, little is known about the impact of indoor LAN exposure on blood pressure, particularly among young adults. We aimed to investigate the effects of bedroom individual-level LAN exposure in real-world environment on blood pressure and hypertension among vulnerable young adults, and to evaluate the possible buffering effect of physical activity. In this cross-sectional study, a total of 400 healthy young adults aged 16-22 years were included. Bedroom LAN exposure was recorded at 1-min intervals for two consecutive nights using a TES-1339 R illuminance meter. Blood pressure was measured three times (8-11 a.m. in the physical examination day) in the seated position using an Omron HEM-7121 digital sphygmomanometer. A wrist-worn triaxial accelerometer (ActiGraph GT3X-BT) was used to assess physical activity for seven consecutive days. Each 1 lx increase of bedroom LAN intensity was associated with 0.55 mmHg-increase in SBP (95% CI: 0.15, 0.95), 0.30 mmHg-increase in DBP (95% CI: 0.06, 0.54), and 0.38 mmHg-increase in MAP (95% CI: 0.12, 0.65). Higher levels of LAN exposure were associated with increased risk of hypertension (LAN ≥ 3lx vs. LAN < 3lx: OR = 3.30, 95%CI = 1.19-9.19; LAN ≥ 5lx vs. LAN < 5lx: OR = 3.87, 95%CI = 1.37-10.98). However, these detrimental effects of bedroom LAN exposure on blood pressure and hypertension were not observed among young adults with high MVPA (≥2 h/day) level. MVPA can alleviate negative effects of bedroom LAN exposure on blood pressure and hypertension. Maintaining bedroom settings darkness at night may be an important strategy for reducing the risk of hypertension. Furthermore, for individuals living with high levels of indoor LAN exposure, regular physical activity may be a good option for preventing cardiovascular disease and hypertension.
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Affiliation(s)
- Yu-Xiang Xu
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China
| | - Yi Zhou
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China
| | - Yan Huang
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China
| | - Yang Yu
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China
| | - Jing-Ya Li
- School of Public Health, Anhui Medical University, Hefei, Anhui, China
| | - Wen-Juan Huang
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China
| | - Yu-Hui Wan
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China; Key Laboratory of Population Health Across Life Cycle (Anhui Medical University), Ministry of Education of the People's Republic of China, No 81 Meishan Road, Hefei, 230032, Anhui, China; Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Fang-Biao Tao
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China; Key Laboratory of Population Health Across Life Cycle (Anhui Medical University), Ministry of Education of the People's Republic of China, No 81 Meishan Road, Hefei, 230032, Anhui, China; Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Ying Sun
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, Anhui, China; Key Laboratory of Population Health Across Life Cycle (Anhui Medical University), Ministry of Education of the People's Republic of China, No 81 Meishan Road, Hefei, 230032, Anhui, China; Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China.
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Hassan D, Versmissen J, Hek K, van Dijk L, van den Bemt PMLA. Feasibility of a protocol for deprescribing antihypertensive medication in older patients in Dutch general practices. BMC PRIMARY CARE 2022; 23:280. [PMID: 36352363 PMCID: PMC9644553 DOI: 10.1186/s12875-022-01894-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 10/10/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Older patients using antihypertensive medication may experience Adverse Drug Events (ADEs), and thus benefit from deprescribing. The lack of a practical protocol may hamper deprescribing. Therefore, we aimed to develop a deprescribing protocol, based on a review of literature, combined with a feasibility test in a small number of patients. METHODS A deprescribing protocol for general practitioners was drafted and tested in older patients using multiple antihypertensive medication in a single arm intervention. Patients were included if they were 75 years or older, were using two or more antihypertensives, had at least one ADE linked to antihypertensive medication and deprescribing was considered to be safe by their general practitioner. The primary outcome was the percentage of patients for whom one or more antihypertensive drugs were stopped or reduced in dose after 12 months of follow up while maintaining safe blood pressures. Secondary outcomes were the proportion of patients reporting no ADEs after 12 months and the number of deprescribed antihypertensives. Patient's opinions on deprescribing and enablers and barriers for study participation were also collected. RESULTS Nine general practitioners included 14 patients to deprescribe antihypertensive medication using the deprescribing protocol. After 12 months antihypertensive drug use was lowered in 11 patients (79%). These patients had a mean systolic blood pressure increase of 16 mmHg and a mean diastolic blood pressure increase of 8 mmHg. Nine patients (64%) reported experiencing no ADEs anymore after twelve months. The mean number of deprescribed antihypertensives was 1.1 in all patients and 1.4 (range: 0.5 to 3.5) in patients who successfully lowered their medication. At baseline, being able to use less medication was the most frequently mentioned enabler to participate in this study. The most frequently mentioned positive experience at the end of the study was using less medication, which was in line with the most mentioned enabler to participate in this study. CONCLUSION A protocol for deprescribing antihypertensives in older patients was considered feasible, as it resulted in a substantial degree of safe deprescribing in this pilot study. Larger studies are needed to demonstrate the effect and safety of deprescribing antihypertensives in older patients.
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Affiliation(s)
- Dimokrat Hassan
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Jorie Versmissen
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Karin Hek
- Nivel, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
| | - Liset van Dijk
- Nivel, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
- Unit of PharmacoTherapy, Epidemiology & Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Patricia M L A van den Bemt
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
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Karayiannis CC. Hypertension in the older person: is age just a number? Intern Med J 2022; 52:1877-1883. [PMID: 36326489 PMCID: PMC9828098 DOI: 10.1111/imj.15949] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 09/25/2022] [Indexed: 11/06/2022]
Abstract
Older patients with hypertension are at a higher risk of cardiovascular events compared to younger adults but are also more vulnerable to the adverse effects of blood pressure (BP) lowering. Frailty is an important predictor of vulnerability to such adverse events, and age alone may not best reflect underlying risk. Therefore, an individualised approach to management of hypertension in the older person is required. Such an approach requires knowledge of frailty, the physiology of hypertension and ageing and a contextual understanding of best evidence. Management needs to be holistic and take account of the older person's care needs, wishes and priorities. This review describes physiological considerations and current guidelines and best practices regarding BP lowering in older people and highlights areas with paucity of evidence. A proposed and testable approach to managing hypertension in the older person (≥70 years) is discussed.
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Affiliation(s)
- Christopher C. Karayiannis
- Department of MedicinePeninsula HealthMelbourneVictoriaAustralia
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneVictoriaAustralia
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Sheppard JP, Benetos A, McManus RJ. Antihypertensive Deprescribing in Older Adults: a Practical Guide. Curr Hypertens Rep 2022; 24:571-580. [PMID: 35881225 PMCID: PMC9568439 DOI: 10.1007/s11906-022-01215-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW To summarise evidence on both appropriate and inappropriate antihypertensive drug withdrawal. RECENT FINDINGS Deprescribing should be attempted in the following steps: (1) identify patients with several comorbidities and significant functional decline, i.e. people at higher risk for negative outcomes related to polypharmacy and lower blood pressure; (2) check blood pressure; (3) identify candidate drugs for deprescribing; (4) withdraw medications at 4-week intervals; (5) monitor blood pressure and check for adverse events. Although evidence is accumulating regarding short-term outcomes of antihypertensive deprescribing, long-term effects remain unclear. The limited evidence for antihypertensive deprescribing means that it should not be routinely attempted, unless in response to specific adverse events or following discussions between physicians and patients about the uncertain benefits and harms of the treatment. PERSPECTIVES Clinical controlled trials are needed to examine the long-term effects of deprescribing in older subjects, especially in those with comorbidities, and significant functional decline.
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Affiliation(s)
- James P Sheppard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK.
| | - Athanase Benetos
- Maladies du Vieillissement, Gérontologie Et Soins Palliatifs", and Inserm DCAC u1116, CHRU-Nancy, Université de Lorraine, 54000, PôleNancy, France
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK
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