Adverse drug reactions in patients with Alzheimer's disease and related dementia in France: a national multicentre cross-sectional study

The Association of Dementia With Incident Adverse Drug Reactions in Hospitalized Older Adults

BACKGROUND

Older adults with dementia commonly receive multiple medications and have higher hospitalization rates, elevating the risk of potentially inappropriate prescribing and in-hospital adverse drug reactions (ADRs). There is limited evidence examining ADRs in older adults with dementia during hospitalization.

OBJECTIVES

Our aim was to assess the association between dementia and incidence of ADRs during hospitalization and to identify prevalent types of ADRs and medications linked to ADRs.

DESIGN

Secondary analysis of the SENATOR trial database, which was a randomized controlled trial of an intervention to reduce ADRs in older inpatients with multimorbidity.

SETTING AND PARTICIPANTS

A total of 1537 patients (47.2% females) with a mean age of 78.1 years were recruited from 6 European hospitals.

METHODS

Sociodemographic data, functional status, cognitive status, clinical information, and ADR-related outcomes were extracted from the SENATOR database. Inpatients with dementia were identified based on prior International Classification of Diseases, Tenth Revision (ICD-10), dementia diagnosis, receiving acetylcholinesterase inhibitors or memantine, or a Mini-Mental State Examination score ≤24 at admission without concurrent delirium.

RESULTS

Among participants, 392 (25.5%) were identified as having dementia. The proportion of patients with probable or certain incident in-hospital ADRs was similar between the groups with and without dementia (22.4% vs 25.4%, P > .05). However, in-hospital rates of probable or certain ADRs from 12 common categories were less frequently identified in patients with dementia compared to those without (19.4% vs 23%, P = .025). Major constipation (6.4% vs 9.9%, P = .03) and acute dyspepsia, nausea, or vomiting (2.8% vs 5%, P = .03) were less commonly observed ADRs in patients with dementia.

CONCLUSIONS AND IMPLICATIONS

We did not observe an increased risk of in-hospital ADRs among inpatients with dementia. However, ADRs related to the gastrointestinal tract and identified by subjective symptoms were less frequently identified in this group. This study lays the groundwork for developing new tools for ADR diagnosis for older patients with dementia.

Predictors of Adverse Drug Reaction-Related Hospitalisations Among People with Dementia: A Retrospective Case-Control Study

INTRODUCTION

Adverse drug reactions (ADRs) are common among people with dementia; however, little is known about the magnitude and predictors associated with ADR-related hospitalisation among these individuals. This study aimed to determine the magnitude, types, drugs implicated and predictors of ADRs associated with hospitalisation among people with dementia.

METHODS

This retrospective case-control study analysed medical records of individuals aged ≥ 65 years with dementia admitted to major public hospitals in Tasmania, Australia, from July 2010 to July 2021. Adverse drug reactions and implicated drugs were identified using administrative data and cross-checked with hospital medical records, with consensus reached among the research team.

RESULTS

Of the 7928 people admitted to hospital at least once within the study period, 1876 (23.7%) experienced at least one ADR-related hospitalisation. Of these, 300 case patients with 311 ADRs and 300 control patients were randomly selected. The most common types of ADRs were renal (acute kidney injury; AKI) (36.0%), followed by neuropsychiatric (17.6%), cardiovascular (16.0%) and haematological (13.1%). Diuretics, renin-angiotensin system (RAS) inhibitors and anti-thrombotics constituted the main implicated drug classes. The ADR-related hospitalisation was associated with: chronic kidney disease (CKD) (OR 8.00, 95% CI 2.63-24.28, p < 0.001), Australian-born (OR 1.62, 95% CI 1.08-2.43, p = 0.019), hypertension (OR 1.48, 95% CI 1.01-2.17, p = 0.044) and the number of medicines (OR 1.06, 95% CI 1.00-1.12, p = 0.022). Potentially inappropriate medication use and anticholinergic burden did not predict ADR-related hospitalisation.

CONCLUSIONS

These predictors could help identify the individuals at the highest risk and enable targeted interventions to be designed.

Longitudinal associations between the frequency of playing Mahjong and cognitive functioning among older people in China: evidence from CLHLS, 2008-2018

Background

Cognitive decline is prevalent among older adults, often resulting in decreased capabilities for self-care and a diminished quality of life. Mahjong, a culturally cherished and extensively played intellectual game in China, demands considerable cognitive function. While the cognitive benefits of playing Mahjong have been widely accepted, this study investigates an under explored aspect and aimed to ascertain the game's potential contributions toward bolstering self-care abilities, enhancing overall quality of life, and mitigating against rising societal healthcare costs.

Methods

The data analyzed in the study is collected from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) with cognitive functioning being assessed through the Mini-Mental State Examination (MMSE). The frequency of playing Mahjong was measured through a self-reported questionnaire. Multiple linear regression models, latent variable growth models, and cross-lagged models were used to investigate the longitudinal relationship between game frequency and cognitive function in older people.

Results

Of the 7,535 participants, the mean (SD) age was 81.96 (10.53) years. There were 7,308 (97%), 4,453 (59%), and 1,974 (26%) participants in 2011, 2014, and 2018, respectively. The results showed that Mahjong players had significantly higher MMSE scores compared to non-players from 2008 to 2018 (β = 0.893; p < 0.001), and non-players had significantly lower scores in 2011, 2014, and 2018 than in 2008 (β = -1.326, -0.912, -0.833; Ps > 0.05). Moreover, the frequency of playing Mahjong was associated with improved various cognitive domains. The declining frequency of playing Mahjong was substantially associated with the declining rate of MMSE scores (r = 0.336; p < 0.001). Mahjong frequency showed positive effects on MMSE scores, while the influence of Mahjong on MMSE scores were not significant.

Conclusion

Playing Mahjong has a positive influence on the cognitive functioning among older people. It can help buffer against the decline in cognitive function and maintain cognitive function levels. The higher frequency of playing Mahjong is associated with improved reaction, attention and calculation, and self-coordination. A decline in the frequency of playing Mahjong was associated with a declining rate of cognitive function. The higher frequency of playing Mahjong among older people unilaterally influenced the improvement of cognitive function levels in older people in China.

Adverse clinical outcomes associated with drug-related hospitalizations in people with dementia

BACKGROUND

This study aimed to determine the clinical impact associated with adverse drug reactions (ADRs) in patients with dementia.

RESEARCH DESIGN AND METHODS

This case-control, propensity score-matched study utilized administrative data of people with dementia admitted to major public hospitals in Tasmania, Australia, from July 2010 to December 2019.

RESULTS

Acute renal failure constituted the most common ADR. The length of hospital stay was greater for people with an ADR index admission, versus non-ADR index admission (median [IQR]: 9 [4-18] versus 6 [2-12]; p < 0.001). In-hospital mortality and combined in-hospital and post-hospital mortality within 30, 60 and 90 days were higher for those whose index admission was ADR-related (in-hospital: HR 1.40, 95% CI 1.11-1.77, p-value <0.001; 30 days: HR 1.25, 95% CI 1.05-1.49, p-value <0.001; 60 days: HR 1.27, 95% CI 1.08-1.49, p-value <0.001; 90 days: HR 1.29, 95% CI 1.10-1.50, p-value <0.001). Subsequent ADR admission within 30, 60 and 90 days of index discharge was 9 to 10 times greater for people with dementia (30 days: OR 10.0, 95% CI 6.04-16.8, p-value <0.001; 60 days: OR 8.96, 95% CI 5.57-14.4, p-value <0.001; 90 days: OR 9.31, 95% CI 5.79-14.9, p-value <0.001).

CONCLUSION

Safe prescribing and vigilant monitoring of ADRs is pivotal to mitigate adverse outcomes in people with dementia.

Understanding neuropsychiatric symptoms in Alzheimer's disease: challenges and advances in diagnosis and treatment

Neuropsychiatric symptoms (NPS) in Alzheimer's disease (AD) affect up to 97% of AD patients, with an estimated 80% of current AD patients experiencing these symptoms. Common AD-associated NPS include depression, anxiety, agitation, aggression, and apathy. The severity of NPS in AD is typically linked to the disease's progression and the extent of cognitive decline. Additionally, these symptoms are responsible for a significant increase in morbidity, mortality, caregiver burden, earlier nursing home placement, and greater healthcare expenditure. Despite their high prevalence and significant impact, there is a notable lack of clinical research on NPS in AD. In this article, we explore and analyze the prevalence, symptom manifestations, challenges in diagnosis, and treatment options of NPS associated with AD. Our literature review reveals that distinguishing and accurately diagnosing the NPS associated with AD remains a challenging task in clinical settings. It is often difficult to discern whether NPS are secondary to pathophysiological changes from AD or are comorbid psychiatric conditions. Furthermore, the availability of effective pharmaceutical interventions, as well as non-pharmacotherapies for NPS in AD, remains limited. By highlighting the advance and challenges in diagnosis and treatment of AD-associated NPS, we aspire to offer new insights into the complexity of identifying and treating these symptoms within the context of AD, and contribute to a deeper understanding of the multifaceted nature of NPS in AD.

Epidemiological investigation of emergency infusion adverse drug reactions in Nanjing, China: a prospective cross-sectional study

OBJECTIVE

Little is known about the morbidity and mortality of infusion Adverse drug reactions (ADRs) in the emergency department. We sought to evaluate the epidemiology of emergency infusion ADRs.

MATERIALS AND METHODS

This was a prospective study of infusion ADRs in the emergency infusion unit (EIU) of a tertiary hospital from 1 January 20201 January 2020, to 31 December 2021w31 December 2021. Emergency infusion ADRs were identified as intravenous drug-related ADRs that the causality was determined using the Naranjo algorithm. The incidence, severity and preventability of these ADRs were assessed using other standard criteria.

RESULTS

A total of 327 ADRs were recorded for 320 participants, antibiotics were the class of drugs most commonly involved, and 76.15% of ADRs occurred within the first hour. The most common symptoms observed were skin manifestations, accounting for 46.04% of ADRs. Mild reactions accounted for 85.32% based on the Hartwig and Siegel scale. In 89.30% of the reports, the ADRs were evaluated as not preventable based on the modified Schumock and Thornton scale. The causality and severity of ADRs were related to Charlson Comorbidity Index score and age (P < 0.05).

CONCLUSION

This epidemiological study described the pattern of emergency infusion ADRs in East China in detail. These findings may be useful to compare patterns among different centers.

Poisonings in Older People with Dementia: A Systematic Scoping Review and Meta-Analysis

BACKGROUND

Older people with dementia are at a particularly high risk of poisonings and their subsequent harms.

OBJECTIVE

This review aimed to describe the key agents, incidence, risk factors, and disposition of poisonings in people with dementia reported in the literature.

METHODS

Medline, Embase, CINAHL, and PsycINFO databases were searched from 1 September 2001 to 1 September 2021. Terms for dementia, poisonings, and older adults formed the search concepts. Quantitative studies published in English, describing poisonings in older people with dementia, including Alzheimer's disease, were included. Two investigators independently assessed articles for eligibility and extracted relevant data. A meta-analysis of the incidence of poisonings in people with dementia across studies was performed.

RESULTS

Of 4,579 articles, 18 were included for final synthesis. Nervous system medications were implicated in over half of all medicinal poisonings, with anti-dementia agents, benzodiazepines, and opioids the most common classes. The non-medicinal agents frequently associated with poisonings were personal care and household products. The yearly incidence of poisoning varied across definitions of poisoning from 3% for International Classification of Disease-defined poisonings to 43% for adverse drug event-defined poisonings. Several risk factors were identified, including multimorbidity, psychotropic medication use, and living in residential care. Where described, up to one in five poisonings resulted in hospitalisation and in death.

CONCLUSIONS

Poisonings are common in people with dementia, involving commonly prescribed medications or easily accessible substances. Given the significant outcomes associated, further research is required to better understand these poisonings and improve public health strategies to reduce the occurrence of this preventable harm.

Prevalence and Risk Factors for Drug-Related Problems in People With Dementia Living in the Community: A Systematic Review and Meta-Analysis

OBJECTIVES

The aims of this systematic review were to identify the prevalence and risk factors associated with of drug-related problems (DRPs) in people living with dementia in the community.

DESIGN

A systematic review and meta-analysis.

SETTING AND PARTICIPANTS

People with dementia living in the community.

METHODS

Six databases (Embase, Medline, PsycINFO, International Pharmaceutical Abstracts, Scopus, and CINAHL) were searched using a combination of keywords and Medical Subject Heading (MeSH) terms with 4 concepts: dementia, older adults, DRPs, and community-dwelling. Primary outcomes were adverse drug reactions (ADRs), adverse drug events (ADEs), and medication errors (MEs).

RESULTS

There were 22 studies included: 4 cross-sectional studies and 18 cohort studies. The number of participants in these studies ranged from 81 to 21,795. The pooled prevalence for any ADEs, including ADRs, in people living with dementia was 19.0% (95% CI 11.6%-27.7%), whereas the pooled prevalence for specific types of ADEs ranged from 2.6% to 10.2%. Furthermore, the prevalence of MEs ranged from 0.9% to 41.3%. Psychotropic medications, polypharmacy, and inappropriate medications contributed to an increased risk of experiencing DRPs, whereas support with medication management was a protective factor.

CONCLUSIONS AND IMPLICATIONS

The prevalence of overall DRPs experienced by people with dementia was highly variable in included studies. Awareness that certain medication, patient, and medication management factors are associated with the risk of people with dementia experiencing DRPs may guide clinicians to identify high-risk situations and implement suitable mitigation strategies.

"Drugs to avoid" to improve quality use of medicines: how is Australia faring?

BACKGROUND

Each year, the French independent bulletin Prescrire publishes a list of medicines, "Drugs to avoid", that should not be used in clinical practice as their risk-to-benefit ratio is unfavourable. This study assessed the market approval, reimbursement and use of these medicines in Australia.

METHODS

The approval status of the medicines included in 2019 Prescrire "Drugs to avoid" list was assessed by searching the Australian Register of Therapeutic Goods website. Funding status was assessed on the Pharmaceutical Benefits Scheme (PBS) website, the Australian public insurance system. Use levels were determined by examining governmental reports on prescribing rates including the Australian Statistics on Medicines (ASM) reports, drug use reports released by the Drug Utilisation Sub Committee (DUSC) and PBS statistics.

RESULTS

Of the 93 medicines included in the Prescrire 2019 "Drug to avoid" list included, 57 (61%) were approved in Australia in 2019 including 9 (16%) that were sold as over-the-counter medicines, 35 (38%) were listed on the PBS, 22 (24%) were registered but not listed on the PBS. Although most of these medicines were used infrequently, 16 (46%) had substantial use despite serious safety concerns. Dipeptidyl peptidase-4 (DPP-4) inhibitors were used by 22% of patients receiving a treatment for diabetes in 2016. More than 50,000 patients received an anti-dementia medicine in 2014, a 19% increase since 2009. Denosumab became the 8th medicine, in terms of total sales, funded by the Australian Government in 2017-2018.

CONCLUSIONS

Prescrire's assessments provide a reliable external benchmark to assess the current use of medicines in Australia. Sixteen "drugs to avoid", judged to be more harmful than beneficial based on systematic, independent evidence reviews, are in substantial use in Australia. These results raise serious concerns about the awareness of Australian clinicians of medicine safety and efficacy. Medicines safety has become an Australian National Health Priority. Regulatory and reimbursement agencies should review the marketing and funding status of medicines which have not been shown to provide an efficacy and safety at least similar to alternative therapeutic options.

Characteristics and Real-Life Outcomes of Dementia and Cognitive Impairment at a Geriatric Clinic

BACKGROUND

Various patterns of dementia care have been developed in different settings, depending on the availability of healthcare resources and facilities. The purpose of this study was to examine the epidemiology and characteristics of dementia care at a geriatric clinic, a field that has been subject to little prior evaluation.

METHODS

A retrospective chart review was undertaken of cohort patients with cognitive impairment who had received a diagnosis and were still on active follow-up at a geriatric clinic. A total of 892 patients were included. In addition, 203 geriatric patients with no cognitive impairment who attended the clinic during the study period were sampled as a control.

RESULTS

The main diagnoses of dementia were Alzheimer's disease (AD) (40.1%), vascular dementia (16.9%), unspecified dementia (16.3%), mixed dementia (9.0%), AD with cerebrovascular disease (8.7%), and Parkinson's disease dementia (6.1%). Atypical dementia was presented in 3.0% of cases. There were 178 patients with mild cognitive impairment, 20 with vascular cognitive impairment, and 18 with subjective cognitive decline. Other comorbidities were found in 97% of the subjects. Patients with cognitive impairment had a higher total number of other geriatric syndromes and higher percentages for delirium, falls, immobility, loss of appetite, and incontinence. Potentially reversible causes of dementia were found in 11.3% of the cases. Acetylcholinesterase inhibitors were administered to 61%, whereas 23.5% received an NMDA receptor antagonist. The need for a change in the antidementia medication was identified for 10.7% of the subjects; the major cause was adverse drug side effects. Nonpharmacological therapy only was administered to 52.4% of the people with dementia who had behavioral and psychological symptoms.

CONCLUSIONS

Mixed brain pathologies, comorbidities, and the coexistence of other geriatric syndromes are common at geriatric clinics. Holistic, integrated, and continuous care are needed to improve the outcomes of patients with more complicated comorbidities.

Using data linkage for national surveillance of clinical quality indicators for dementia care among Australian aged care users

Care quality has important implications for people with dementia. We examined trends and geographical variation of four clinical quality indicators (CQIs) in Australia. This retrospective cohort study included all people with dementia using Australian government-subsidised aged care in 2008-2016 (n = 373,695). Quality indicator data were derived from linked national aged care, health, and pharmaceutical datasets. Negative binomial regression modelling assessed trends in CQI performance over time (2011-2016) and funnel plots examined geographical variation in performance. The incidence rate of antipsychotic medicine dispensing decreased slightly from 1.17/1000 person-days to 1.07/1000 person-days (adjusted incidence rate ratio (aIRR) = 0.98, 95%CI 0.98-0.99). Cholinesterase inhibitors and memantine dispensing did not change (aIRR = 1.02, 95%CI 1.00-1.04), while exposure to high sedative load increased slightly from 1.39/1000 person-days to 1.44/1000 person-days (aIRR = 1.01, 95%CI 1.00-1.01). Dementia and delirium-related hospitalisations increased slightly from 0.17/1000 person-days to 0.18/1000 person-days (aIRR = 1.02, 95%CI 1.01-1.03). There was marked variation in cholinesterase inhibitor and memantine dispensing by geographical area (0-41%). There has been little change in four indicators of dementia care quality in Australian aged care users over time. Cholinesterase inhibitor and memantine dispensing varied substantially by geographical region. Existing strategies to improve national performance on these indicators appear to be insufficient, despite the significant impact of these indicators on outcomes for people with dementia.

Frequency and Severity of Adverse Drug Reactions to Medications Prescribed for Alzheimer's Disease in a Brazilian City: Cross-Sectional Study

Background: There is lack of national studies that assess the risks associated with the drugs provided under the Brazilian public health system for treating Alzheimer’s disease. Then, this study determined the prevalence and severity of self-reported adverse drug reactions (ADRs) prescribed to patients with Alzheimer’s disease in the Brazilian public health system.

Methods: A cross-sectional study was carried out based on public data from the MEDEX system (information on dispensing data, known as exceptional dispensing medications) and interviews with patients and/or caregivers who get access to Alzheimer’s drugs at a public pharmacy in a large Brazilian city, between July and September 2017, inquiring about ADRs and serious adverse events (SAEs).

Results: The subjects were asked about ADRs and SAEs related to the use of donepezil, galantamine, rivastigmine and memantine. Out of 285 patients enrolled on the database, 250 participated in the study (87.7%). Among the participants, approximately 63.0% were female, 70.3% aged ≥75 years and 70.3% had comorbidities. Overall, 209 patients (83.6%) reported at least one ADR (total 1,149 ADRs) and rivastigmine was associated with the largest number of ADRs per patient (7.9 ADRs/patient). The predominant adverse effects were psychiatric disorders with common frequency (57.1%) and mild severity (89.0%). Six patients (2.4%) had SAEs that required hospitalization. The use of antipsychotics was the variable associated with ADR (OR = 4.95; 95% CI: 1.45–16.93; p = 0.011).

Conclusion: There was a large number of reported ADRs and most of them were of common frequency and mild severity, being mainly related to psychiatric disorders. Considering the fragility of these patients, it is important to improve safety-related care in the use of drugs for treating this disease.

Benzodiazepine exposure in subjects with incident Alzheimer's disease and related syndromes in France: a longitudinal study 2011-2017

Benzodiazepines are commonly used for behavioral and psychiatric symptoms of dementia, despite their numerous adverse effects and the lack of evidence regarding their efficacy in this context. We studied longitudinal benzodiazepines exposure in incident cases of Alzheimer's disease and related syndromes (ADRS) in France. We used a cohort of incident ADRS patients identified in 2012 within the national health data system. Benzodiazepines exposure was measured 1 year before, to 5 years after ADRS identification. Quarterly benzodiazepines prevalence and incidence were computed. We identified factors associated with long half-life benzodiazepines initiation. A total of 106 508 subjects were included. Quarterly benzodiazepines prevalence was stable (around 25%) but we saw an important decrease in long half-life benzodiazepines compensated by an increase in short half-life benzodiazepines. In most benzodiazepine initiations, the first episode lasted less than 3 months. Factors associated with initiating a long half-life benzodiazepine were young age, male gender, no registration with ADRS as a long-term disease, having consulted an ADRS specialist, antipsychotic reimbursement before the index date, no admission in nursing home. Prevalence of benzodiazepines use remains high in subjects with ADRS despite guidelines for their avoidance. However, indicators regarding benzodiazepine initiations (duration, benzodiazepine type) suggest some caution in their use.

Prevalence of adverse drug events and adverse drug reactions in hospital among older patients with dementia: A systematic review

AIMS

This systematic review aimed to quantify the prevalence of adverse drug events (ADEs) and adverse drug reactions (ADRs) in older inpatients with dementia.

METHODS

A systematic search of observational studies was performed in Embase, Medline, PsycINFO, International Pharmaceutical Abstracts, Scopus and Informit. Articles published in English that reported the prevalence of ADEs or ADRs in hospital patients aged 65 years or older with dementia were included. Two authors reviewed titles and abstracts and all eligible full-text articles. Relevant information relating to ADEs, ADRs and dementia was obtained from each article.

RESULTS

In total, 5 articles were included. One study reported the prevalence of ADEs to be 81.5%, defined using the Naranjo algorithm. Four studies assessed the prevalence of ADRs, ranging from 12.7 to 24.0%, assessed using various methods. One study defined ADRs according to the World Health Organization-Uppsala Monitoring Centre criteria, 2 studies employed the World Health Organization definition and 1 study did not explicitly define ADRs. The most frequently reported drug classes implicated in ADEs and ADRs were psychotropic, antihypertensive and analgesic drugs.

CONCLUSION

Our findings suggest a high prevalence of ADEs and ADRs in older inpatients with dementia. However, only 1 study documented ADEs and there was variability in approaches to ADR assessment. A greater understanding of ADEs and ADRs, as well as tailored assessment tools, will promote prevention of ADEs and ADRs in people with dementia.

Prescribing medications of questionable benefit prior to death: a retrospective study on older nursing home residents with and without dementia in Germany

Purpose

We studied the prevalence of medications of questionable benefit in the last 6 months of life among older nursing home residents with and without dementia in Germany.

Methods

A retrospective cohort study was conducted on claims data from 67,328 deceased nursing home residents aged 65+ years who were admitted between 2010 and 2014. We analyzed prescription regimens of medications of questionable benefit in the 180–91-day period and the 90-day period prior to death for residents with dementia (n = 29,052) and without dementia (n = 38,276). Factors associated with new prescriptions of medications of questionable benefit prior to death were analyzed using logistic regression models among all nursing home residents and stratified by dementia.

Results

A higher proportion of nursing home residents with dementia were prescribed at least one medication of questionable benefit in the 180–91-day (29.6%) and 90-day (26.8%) periods prior to death, compared with residents without dementia (180–91 days, 22.8%; 90 days, 20.1%). Lipid-lowering agents were the most commonly prescribed medications. New prescriptions of medications of questionable benefit were more common among residents with dementia (9.8% vs. 8.7%). When excluding anti-dementia medication, new prescriptions of these medications were more common among residents without dementia (6.4% vs. 8.0%). The presence of dementia (odds ratio [OR] 1.40, 95% confidence interval [95%CI] 1.32–1.48) and excessive polypharmacy were associated with new prescriptions of medications of questionable benefit prior to death (OR 4.74, 95%CI 4.15–5.42).

Conclusion

Even when accounting for anti-dementia prescriptions, the prevalence of nursing home residents with dementia receiving medications of questionable benefit is considerable and may require further attention.

Electronic supplementary material

The online version of this article (10.1007/s00228-020-02859-3) contains supplementary material, which is available to authorized users.

CGA restrains the apoptosis of Aβ25-35-induced hippocampal neurons

Background: Chlorogenic acid (CGA) has anti-oxidant and anti-inflammatory effects, but the study on its role in Alzheimer's disease (AD) models remains rare. Here, the effects of CGA on β-amyloid protein (Aβ)-induced cell models were investigated, aiming to provide a direction for Aβ-induced AD.Material and methods: Hippocampal neurons were separated from newborn Sprague-Dawley (SD) rats and identified by immumofluorescence method. Hippocampal neurons were processed with Aβ_25-35 after pre-treatment CGA. MTT assay was used for detecting viability of treated cells. The activities of superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), malondialdehyde (MDA) and lactate dehydrogenase (LDH) of treated hippocampal neurons were determined by corresponding kits. Flow cytometry analysis assessed the apoptosis and mitochondrial membrane potential (MMP) in hippocampal neurons after treatment. The expressions of proteins related to apoptosis and endoplasmic reticulum stress (ERS) were measured by western blot (WB) analysis.Results: Immumofluorescence method showed that the Aβ_25-35 induction models were successfully constructed. CGA increased the viability and decreased the apoptosis rate of Aβ_25-35-induced hippocampal neurons. Decreasing activities of LDH and MDA, and raised contents of SOD and GSH-Px were appeared in Aβ_25-35-induced cells that pre-treated with CGA. Moreover, CGA also enhanced MMP intensity of hippocampal neurons induced by Aβ_25-35. In WB analysis, CGA reversed the promoting effect of Aβ_25-35 on the expressions of proteins related to pro-ERS and pro-apoptosis.Conclusion: CGA restrained the apoptosis of Aβ_25-35-induced hippocampal neurons via improving the anti-oxidant capacity, mitochondrial injury and ERS state of cells, which may provide a direction for AD.

MicroRNA-326 decreases tau phosphorylation and neuron apoptosis through inhibition of the JNK signaling pathway by targeting VAV1 in Alzheimer's disease

Alzheimer's disease (AD) is a progressive and age-related neurological dysfunction. Abundant data have profiled microRNA (miR) patterns in healthy, aging brain, and in the moderate and late-stages of AD. Herein, this study aimed to explore whether miR-326 could influence neuron apoptosis in AD mice and how miR-326 functions in this process. The candidate differentially expressed gene VAV1 was obtained by microarray analysis, and miRNAs that could regulate VAV1 candidate gene were predicted. Luciferase activity determination confirmed VAV1 as a target gene of miR-326. AD mice models were established for investigating the effect of miR-326 on AD mice. The overexpression of miR-326 contributed to decreased time of the mice to find the platform and the escape latency and increased residence time on the target area. Besides, elevation of miR-326 decreased Aβ deposition and contents of Aβ_1-40 and Aβ_1-42 . Moreover, miR-326 overexpression increased neuron cell ability, mediated cell entry, and inhibited neuron apoptosis via JNK signaling pathway. Of crucial importance, miR-326 negatively regulated the expression of VAV1, inhibited tau phosphorylation, and blocked the activation of the JNK signaling pathway. Taken together these observations, we demonstrate that miR-326 improves cognitive function of AD mice and inhibits neuron apoptosis in AD mice through inactivation of the JNK signaling pathway by targeting VAV1. Based on those findings, miR-326 might exert promise as target for the treatment of AD.

Incidence, causes, and consequences of preventable adverse drug reactions occurring in inpatients: A systematic review of systematic reviews

BACKGROUND

Preventable adverse drug reactions (PADRs) in inpatients are associated with harm, including increased length of stay and potential loss of life, and result in elevated costs of care. We conducted an overview of reviews (i.e., a systematic review of systematic reviews) to determine the incidence of PADRs experienced by inpatients. Secondary review objectives were related to assessment of the effects of patient age, setting, and clinical specialty on PADR incidence.

METHODS

The protocol was registered in PROSPERO (CRD42016043220). We performed a search of Medline, Embase, and the Cochrane Library, limiting languages of publication to English and French. We included published systematic reviews that reported quantitative data on the incidence of PADRs in patients receiving acute or ambulatory care in a hospital setting. The full texts of all primary studies for which PADR data were reported in the included reviews were obtained and data relevant to review objectives were extracted. Quality of the included reviews was assessed using the AMSTAR-2 tool. Both narrative summaries of findings and meta-analyses of primary study data were undertaken.

RESULTS

Thirteen systematic reviews encompassing 37 unique primary studies were included. Across primary studies, the PADR incidence was highly varied, ranging from 0.006 to 13.3 PADRs per 100 patients, with a pooled incidence estimate of 0.59 PADRs per 100 patients. Substantial heterogeneity was present across both reviews and primary studies with respect to review/study objectives, patient age, hospital setting, medical discipline, definitions and assessment tools used, event detection methods, endpoints of interest, and units of measure. Thirteen primary studies used prospective event detection methods and had a pooled PADR incidence of 3.13 (2.87-3.38) PADRs per 100 patients; however, extreme statistical heterogeneity (I2 = 97%) indicated this finding should be considered with caution. Subgroup meta-analyses demonstrated that PADR incidence varied significantly with event detection method (prospective > retrospective > voluntary reporting methods), hospital setting (ICU > wards), and medical discipline (medical > surgical). High statistical heterogeneity (I2 > 80%) was present across all analyses, indicating results should be interpreted with caution. Effects of patient age could not be assessed due to poor reporting of age groups used in primary studies.

DISCUSSION

The method of event detection appeared to significantly influence PADR incidence, with prospective methods having the highest reported PADR rate. This finding is in agreement with the background literature. High methodological and statistical heterogeneity across primary studies evaluating adverse drug events reduces the validity of the overall PADR incidence derived from the meta-analyses of the pooled data. Data pooled from studies using only prospective methods of event detection should provide an overall estimate closest to the true PADR incidence; however, our estimate should be considered with caution due to the statistical heterogeneity found in this group of studies. Future studies should employ prospective methods of detection. This review demonstrates that the true overall incidence of PADRs is likely much greater than the overall pooled incidence estimate of 0.59 PADRs per 100 patients obtained when event detection method was not taken into consideration.

Psychotropic drug use and mortality in old people with dementia: investigating sex differences

Background

Psychotropic drugs are common among old people with dementia, and have been associated with increased mortality. Previous studies have not investigated sex differences in this risk. This study was conducted to analyse associations between the use of antipsychotics, antidepressants, and benzodiazepines and 2-year mortality in old people with dementia, and to investigate sex differences therein.

Methods

In total, 1037 participants (74% women; mean age, 89 years) with dementia were included from four cohort studies and followed for 2 years. Data were collected through home visits and medical records. Cox proportional hazard regression models were used to analyse associations between ongoing baseline drug use and mortality. Multiple possible confounders were evaluated and adjusted for.

Results

In fully adjusted models including data from the whole population, no association between baseline psychotropic drug use and increased 2-year mortality was seen. Significant sex differences were found in mortality associated with antidepressant use, which was protective in men, but not in women (hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.40–0.92 and HR 1.09, 95% CI 0.87–1.38, respectively). The interaction term for sex was significant in analyses of benzodiazepine use, with a higher mortality risk among men than among women.

Conclusions

Among old people with dementia, ongoing psychotropic drug use at baseline was not associated with increased mortality in analyses adjusted for multiple confounders. Sex differences in mortality risk associated with antidepressant and benzodiazepine use were seen, highlighting the need for further investigation of the impact of sex.

Electronic supplementary material

The online version of this article (doi:10.1186/s40360-017-0142-9) contains supplementary material, which is available to authorized users.

Risk Factors for Adverse Drug Reactions in Older Subjects Hospitalized in a Dedicated Dementia Unit

OBJECTIVE

To identify risk factors for the occurrence of adverse drug reactions (ADRs) based on geriatric evaluation.

DESIGN

Longitudinal prospective study from May 2010 to November 2011.

SETTING

Dedicated acute geriatric care unit specializing in the management of patients with dementia syndrome (Alzheimer disease or related syndromes) at the University Hospital of Reims, France.

PARTICIPANTS

Older patients with dementia syndrome (Alzheimer disease or related syndromes).

MEASUREMENTS

Sociodemographic variables and comprehensive geriatric assessment were recorded. Occurrence of ADRs was noted. Risk factors for ADR were identified by multivariate logistic regression.

RESULTS

During the study period, 293 patients were included; average age was 82 ± 8 years; the majority were women (61.4%). Average Mini-Mental State Examination score was 13 ± 8; average activities of daily living (ADL) score was 3.6 ± 2.1. Independent risk factors for occurrence of at least one ADR were polypharmacy (≥5 drugs/day) (OR: 4.0, 95% CI: 1.1-14.1) and dependence on at least 1 ADL (OR: 2.6, 95% CI: 1.1-6.5).

CONCLUSIONS

Risk factors for ADRs were polypharmacy and dependence on at least one ADL. Our findings underline the importance of taking into consideration the characteristics of the patients when prescribing drugs in this specific population. Prescriptions should be re-evaluated at each follow-up.

Prediction of Hospitalization due to Adverse Drug Reactions in Elderly Community-Dwelling Patients (The PADR-EC Score)

BACKGROUND

Adverse drug reactions (ADRs) are the major cause of medication-related hospital admissions in older patients living in the community. This study aimed to develop and validate a score to predict ADR-related hospitalization in people aged ≥65 years.

METHODS

ADR-related hospitalization and its risk factors were determined using a prospective, cross-sectional study in patients aged ≥65 years admitted to two hospitals. A predictive model was developed in the derivation cohort (n = 768) and the model was applied in the validation cohort (n = 240). ADR-related hospital admission was determined through expert consensus from comprehensive reviews of medical records and patient interviews. The causality and preventability of the ADR were assessed based on the Naranjo algorithm and modified Schumock and Thornton criteria, respectively.

RESULTS

In the derivation sample (mean [±SD] age, 80.1±7.7 years), 115 (15%) patients were admitted due to a definite or probable ADR; 92.2% of these admissions were deemed preventable. The number of antihypertensives was the strongest predictor of an ADR followed by presence of dementia, renal failure, drug changes in the preceding 3 months and use of anticholinergic medications; these variables were used to derive the ADR prediction score. The predictive ability of the score, assessed from calculation of the area under the receiver operator characteristic (ROC) curve, was 0.70 (95% confidence interval (CI) 0.65-0.75). In the validation sample (mean [±SD] age, 79.6±7.6 years), 30 (12.5%) patients' admissions were related to definite or probable ADRs; 80% of these admissions were deemed preventable. The area under the ROC curve in this sample was 0.67 (95% CI 0.56-0.78).

CONCLUSIONS

This study proposes a practical and simple tool to identify elderly patients who are at an increased risk of preventable ADR-related hospital admission. Further refinement and testing of this tool is necessary to implement the score in clinical practice.

Toxicological Differences Between NMDA Receptor Antagonists and Cholinesterase Inhibitors

Cholinesterase inhibitors (ChEIs), represented by donepezil, rivastigmine, and galantamine, used to be the only approved class of drugs for the treatment of Alzheimer's disease. After the approval of memantine by the Food and Drug Administration (FDA), N-methyl-d-aspartic acid (NMDA) receptor antagonists have been recognized by authorities and broadly used in the treatment of Alzheimer's disease. Along with complementary mechanisms of action, NMDA antagonists and ChEIs differ not only in therapeutic effects but also in adverse reactions, which is an important consideration in clinical drug use. And the number of patients using NMDA antagonists and ChEIs concomitantly has increased, making the matter more complicated. Here we used the FDA Adverse Event Reporting System for statistical analysis , in order to compare the adverse events of memantine and ChEIs. In general, the clinical evidence confirmed the safety advantages of memantine over ChEIs, reiterating the precautions of clinical drug use and the future direction of antidementia drug development.

Severe potential drug-drug interactions in older adults with dementia and associated factors

OBJECTIVE

To identify the main severe potential drug-drug interactions in older adults with dementia and to examine the factors associated with these interactions.

METHOD

This was a cross-sectional study. The enrolled patients were selected from six geriatrics clinics of tertiary care hospitals across Mexico City. The patients had received a clinical diagnosis of dementia based on the current standards and were further divided into the following two groups: those with severe drug-drug interactions (contraindicated/severe) (n=64) and those with non-severe drug-drug interactions (moderate/minor/absent) (n=117). Additional socio-demographic, clinical and caregiver data were included. Potential drug-drug interactions were identified using Micromedex Drug Reax 2.0® database.

RESULTS

A total of 181 patients were enrolled, including 57 men (31.5%) and 124 women (68.5%) with a mean age of 80.11±8.28 years. One hundred and seven (59.1%) patients in our population had potential drug-drug interactions, of which 64 (59.81%) were severe/contraindicated. The main severe potential drug-drug interactions were caused by the combinations citalopram/anti-platelet (11.6%), clopidogrel/omeprazole (6.1%), and clopidogrel/aspirin (5.5%). Depression, the use of a higher number of medications, dementia severity and caregiver burden were the most significant factors associated with severe potential drug-drug interactions.

CONCLUSIONS

Older people with dementia experience many severe potential drug-drug interactions. Anti-depressants, antiplatelets, anti-psychotics and omeprazole were the drugs most commonly involved in these interactions. Despite their frequent use, anti-dementia drugs were not involved in severe potential drug-drug interactions. The number and type of medications taken, dementia severity and depression in patients in addition to caregiver burden should be considered to avoid possible drug interactions in this population.

Nurse-Led Medicines' Monitoring for Patients with Dementia in Care Homes: A Pragmatic Cohort Stepped Wedge Cluster Randomised Trial

BACKGROUND

People with dementia are susceptible to adverse drug reactions (ADRs). However, they are not always closely monitored for potential problems relating to their medicines: structured nurse-led ADR Profiles have the potential to address this care gap. We aimed to assess the number and nature of clinical problems identified and addressed and changes in prescribing following introduction of nurse-led medicines' monitoring.

DESIGN

Pragmatic cohort stepped-wedge cluster Randomised Controlled Trial (RCT) of structured nurse-led medicines' monitoring versus usual care.

SETTING

Five UK private sector care homes.

PARTICIPANTS

41 service users, taking at least one antipsychotic, antidepressant or anti-epileptic medicine.

INTERVENTION

Nurses completed the West Wales ADR (WWADR) Profile for Mental Health Medicines with each participant according to trial step.

OUTCOMES

Problems addressed and changes in medicines prescribed.

DATA COLLECTION AND ANALYSIS

Information was collected from participants' notes before randomisation and after each of five monthly trial steps. The impact of the Profile on problems found, actions taken and reduction in mental health medicines was explored in multivariate analyses, accounting for data collection step and site.

RESULTS

Five of 10 sites and 43 of 49 service users approached participated. Profile administration increased the number of problems addressed from a mean of 6.02 [SD 2.92] to 9.86 [4.48], effect size 3.84, 95% CI 2.57-4.11, P <0.001. For example, pain was more likely to be treated (adjusted Odds Ratio [aOR] 3.84, 1.78-8.30), and more patients attended dentists and opticians (aOR 52.76 [11.80-235.90] and 5.12 [1.45-18.03] respectively). Profile use was associated with reduction in mental health medicines (aOR 4.45, 1.15-17.22).

CONCLUSION

The WWADR Profile for Mental Health Medicines can improve the quality and safety of care, and warrants further investigation as a strategy to mitigate the known adverse effects of prescribed medicines.

TRIAL REGISTRATION

ISRCTN 48133332.

Adverse Drug Reactions Reported With Cholinesterase Inhibitors

Background: No worldwide pharmacovigilance study evaluating the spectrum of adverse drug reactions (ADRs) induced by cholinesterase inhibitors (ChEI) in Alzheimer’s disease has been conducted since their emergence on the market. Objective: To describe ChEI related ADRs in Alzheimer’s disease (donepezil, rivastigmine, and galantamine) and characterize their seriousness as reported by national pharmacovigilance systems to VigiBase, a World Health Organization International Drug Monitoring Program database, between 1998 and 2013. Methods: All ChEI related reports, submitted to VigiBase between 1998 and 2013 from the five continents were extracted. Analyses were carried out for general, serious, and nonserious ADRs. Results: A total of 18 955 reports (43 753 ADRs) from 58 countries were reported: 60.1% in women; mean age 77.4 ± 9.1 years. Most reports originated from Europe (47.6%) and North America (40.4%). Rivastigmine and donepezil were involved in most reports (41.4% each). The most frequently reported ADRs were neuropsychiatric (31.4%), gastrointestinal (15.9%), general (11.9%), and cardiovascular (11.7%) disorders. During the 2006-2013 period, serious ADRs remained more often reported than nonserious ones; the most serious were neuropsychiatric (34.0%), general (14.0%), cardiovascular (12.1%), and gastrointestinal (11.6%) disorders. Medication errors were reported in 2.0% of serious cases. Death occurred in 2.3% of the reports. Conclusions: This international pharmacovigilance study highlights the ADR pattern induced by ChEIs. Neuropsychiatric events were the most frequently reported ADRs. Serious cardiovascular events were frequently reported, suggesting that their significance has probably been previously underestimated. Given the frailty of the patients and the frequent comedications, caution is advised before introducing a ChEI.

Use of Benzodiazepines in Alzheimer's Disease: A Systematic Review of Literature

BACKGROUND

Benzodiazepines are frequently prescribed in patients with Alzheimer's disease. Unfortunately, studies evaluating their benefits and risks in these patients are limited.

METHODS

Clinical trials focusing on the effect of benzodiazepines on cognitive functions, disease progression, behavioral symptoms, sleep disturbances, and the general frequency of benzodiazepine use were included in this review. Published articles from January 1983 to January 2015 were identified using specific search terms in MEDLINE and PubMed Library according to the recommendations of The Strengthening the Reporting of Observational Studies in Epidemiology initiative.

RESULTS

Of the 657 articles found, 18 articles met predefined selection criteria and were included in this review (8 on frequency, 5 on cognitive functions, 5 on behavioral and sleep disturbances). The frequency of benzodiazepine use ranged from 8.5% to 20%. Five studies reported accelerated cognitive deterioration in association with benzodiazepine use. Two studies reported clinical efficacy for lorazepam and alprazolam to reduce agitation in Alzheimer's disease patients. No evidence was found for an improvement of sleep quality using benzodiazepines.

CONCLUSION

This systematic review shows a relatively high prevalence of benzodiazepine use but limited evidence for clinical efficacy in Alzheimer's disease patients. However, there is a paucity of methodologically high quality controlled clinical trials. Our results underscore a need for randomized controlled trials in this area.

Use of medications of questionable benefit in advanced dementia

IMPORTANCE

Advanced dementia is characterized by severe cognitive impairment and complete functional dependence. Patients' goals of care should guide the prescribing of medication during such terminal illness. Medications that do not promote the primary goal of care should be minimized.

OBJECTIVES

To estimate the prevalence of medications with questionable benefit used by nursing home residents with advanced dementia, identify resident- and facility-level characteristics associated with such use, and estimate associated medication expenditures.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of medication use by nursing home residents with advanced dementia using a nationwide long-term care pharmacy database linked to the Minimum Data Set (460 facilities) between October 1, 2009, and September 30, 2010.

MAIN OUTCOMES AND MEASURES

Use of medication deemed of questionable benefit in advanced dementia based on previously published criteria and mean 90-day expenditures attributable to these medications per resident. Generalized estimating equations using the logit link function were used to identify resident- and facility-related factors independently associated with the likelihood of receiving medications of questionable benefit after accounting for clustering within nursing homes.

RESULTS

Of 5406 nursing home residents with advanced dementia, 2911 (53.9%) received at least 1 medication with questionable benefit (range, 44.7% in the Mid-Atlantic census region to 65.0% in the West South Central census region). Cholinesterase inhibitors (36.4%), memantine hydrochloride (25.2%), and lipid-lowering agents (22.4%) were the most commonly prescribed. In adjusted analyses, having eating problems (adjusted odds ratio [AOR], 0.68; 95% CI, 0.59-0.78), a feeding tube (AOR, 0.58; 95% CI, 0.48-0.70), or a do-not-resuscitate order (AOR, 0.65; 95% CI, 0.57-0.75), and enrolling in hospice (AOR, 0.69; 95% CI, 0.58-0.82) lowered the likelihood of receiving these medications. High facility-level use of feeding tubes increased the likelihood of receiving these medications (AOR, 1.45; 95% CI, 1.12-1.87). The mean (SD) 90-day expenditure for medications with questionable benefit was $816 ($553), accounting for 35.2% of the total average 90-day medication expenditures for residents with advanced dementia who were prescribed these medications.

CONCLUSIONS AND RELEVANCE

Most nursing home residents with advanced dementia receive medications with questionable benefit that incur substantial associated costs.

Drug utilization pattern in patients with different types of dementia in Western India

Background. Dementia is one of the most frequent disorders among elderly patients, reaching to epidemic proportions with an estimated 4.6 million new cases globally annually. Partially effective treatments are available for dementia. Aims & Objectives. We aim to study drugs used in dementia and find out frequency of types of Dementia. Method. This was an observational study conducted at rurally based tertiary care hospital. Prospective data was collected from outpatient department, while retrospective data was collected from medical records. Descriptive statistics were used to analyze data. Result. Total 125 prescriptions of patients diagnosed with dementia were analyzed. Alzheimer's dementia was most common (65.6%), followed by vascular dementia (21.6%), and frontotemporal dementia (10.4%), with the rarest being Lewy body dementia in (2.4%) cases. 60.57% of patients were males. Mini Mental Score Examination mean score was 15.93 ± 1.37. Frontal Battery Assessment mean score was 4.75 ± 1.01. Prescribed drugs were Donepezil (68.49%), Rivastigmine (13.63%), Donepezil + Memantine (6.43%) and Galantamine (12.83%), Quetiapine (38.46%), Lorazepam (23.07%), Clozapine (11.53%), Escitalopram (10.25%), Haloperidol (3.84%), Zolpidem, Sertraline, Olanzepine (2.56%), Nitrazepine, Lamotrigine, Fluoxetine, Tianeptine (1.28%), Folic acid, and Vitamin B12, respectively. Conclusion. Alzheimer's is the most common type of dementia while Donepezil was the most frequent drug.