Geriatric Conditions and the Risk of Adverse Drug Reactions in Older Adults

Deprescribing interventions in older adults: An overview of systematic reviews

OBJECTIVE

The growing deprescribing field is challenged by a lack of consensus around evidence and knowledge gaps. The objective of this overview of systematic reviews was to summarize the review evidence for deprescribing interventions in older adults.

METHODS

11 databases were searched from 1st January 2005 to 16th March 2023 to identify systematic reviews. We summarized and synthesized the results in two steps. Step 1 summarized results reported by the included reviews (including meta-analyses). Step 2 involved a narrative synthesis of review results by outcome. Outcomes included medication-related outcomes (e.g., medication reduction, medication appropriateness) or twelve other outcomes (e.g., mortality, adverse events). We summarized outcomes according to subgroups (patient characteristics, intervention type and setting) when direct comparisons were available within the reviews. The quality of included reviews was assessed using A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2).

RESULTS

We retrieved 3,228 unique citations and assessed 135 full-text articles for eligibility. Forty-eight reviews (encompassing 17 meta-analyses) were included. Thirty-one of the 48 reviews had a general deprescribing focus, 16 focused on specific medication classes or therapeutic categories and one included both. Twelve of 17 reviews meta-analyzed medication-related outcomes (33 outcomes: 25 favored the intervention, 7 found no difference, 1 favored the comparison). The narrative synthesis indicated that most interventions resulted in some evidence of medication reduction while for other outcomes we found primarily no evidence of an effect. Results were mixed for adverse events and few reviews reported adverse drug withdrawal events. Limited information was available for people with dementia, frailty and multimorbidity. All but one review scored low or critically low on quality assessment.

CONCLUSION

Deprescribing interventions likely resulted in medication reduction but evidence on other outcomes, in particular relating to adverse events, or in vulnerable subgroups or settings was limited. Future research should focus on designing studies powered to examine harms, patient-reported outcomes, and effects on vulnerable subgroups.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020178860.

Patients' Characterization, Pattern of Medication Use, and Factors Associated with Polypharmacy: A Cross-Sectional Study Focused on Eight Units of the Portuguese National Network for Long-Term Integrated Care

The Portuguese National Network for Long-term Integrated Care (RNCCI) comprises several Units for Integrated Continuous Care (UCCIs) that provide medical, nursing, and rehabilitation care. This study aimed to evaluate the demographic and medical characteristics of patients admitted to the RNCCI, their patterns of medication use, and factors associated with polypharmacy. An observational, retrospective, cross-sectional, multicenter study was performed. This study population consisted of 180 patients. Polypharmacy status was divided into two groups: non-polypharmacy (taking ≤ 4 drugs) and polypharmacy (taking ≥ 5 drugs). Bivariate analysis and multivariate logistic regression analysis were used to determine the influence of predictor factors such as demographic and medical characteristics on the polypharmacy status during the UCCI stays. This study population (mean age of 78.4 ± 12.3 years, range 23-102 years, 59% female) was prescribed a median of 8 medications. Approximately 89.4% of the patients were taking ≥ 5 drugs, demonstrating that polypharmacy is highly prevalent in Portuguese RNCCI residents of the eight UCCIs studied. A subsequent analysis with multivariate logistic regression found that polypharmacy status was significantly associated with the unit of internment (facility) when compared to facility E with H and with the Charlson Comorbidity Index (CCI). The high prevalence of polypharmacy and the associated factors show that it is urgent to improve pharmacotherapy regimens through periodic monitoring and review of patients' therapeutic lists, an area in which pharmacists play a very important role.

Insight into Risk Factors, Pharmacogenetics/Genomics, and Management of Adverse Drug Reactions in Elderly: A Narrative Review

The European Medicine Agency (EMA) has defined Adverse Drug Reactions (ADRs) as "a noxious and unintended response to a medicine", not including poisoning, accidental, or intentional overdoses. The ADR occurrence differs based on the approach adopted for defining and detecting them, the characteristics of the population under study, and the research setting. ADRs have a significant impact on morbidity and mortality, particularly among older adults, and represent a financial burden for health services. Between 30% and 60% of ADRs might be predictable and preventable, emerging as a result of inappropriate prescription, drug chemistry inherent toxicity, cell-specific drug toxicity, age- and sex-related anomalies in drug absorption, distribution, metabolism, and elimination (ADME), and drug-drug interactions (DDIs) in combination therapies or when a patient is treated with different drugs for concomitant disorders. This is particularly important in chronic diseases which require long-term treatments. Rapid developments in pharmacogenetics/genomics have improved the understanding of ADRs accompanied by more accurate prescriptions and reduction in unnecessary costs. To alleviate the burden of ADRs, especially in the elderly, interventions focused on pharmaceutical principles, such as medication review and reconciliation, should be integrated into a broader assessment of patients' characteristics, needs, and health priorities. Digital health interventions could offer valuable solutions to assist healthcare professionals in identifying inappropriate prescriptions and promoting patient adherence to pharmacotherapies.

Assessing real-world safety concerns of Sacituzumab govitecan: a disproportionality analysis using spontaneous reports in the FDA adverse event reporting system

Aim

The aim of this study was to identify potential safety concerns associated with Sacituzumab Govitecan (SG), an antibody-drug conjugate targeting trophoblastic cell-surface antigen-2, by analyzing real-world safety data from the largest publicly available worldwide pharmacovigilance database.

Methods

All data obtained from the FDA Adverse Event Reporting System (FAERS) database from the second quarter of 2020 to the fourth quarter of 2022 underwent disproportionality analysis and Bayesian analysis to detect and assess the adverse event signals of SG, considering statistical significance when the lower limit of the 95% CI >1, based on at least 3 reports.

Results

Total of 1072 cases were included. The main safety signals were blood and lymphatic system disorders [ROR(95CI)=7.23 (6.43-8.14)], gastrointestinal disorders [ROR(95CI)=2.01 (1.81-2.22)], and relative infection adverse events, such as neutropenic sepsis [ROR(95CI)=46.02 (27.15-77.99)] and neutropenic colitis [ROR(95CI)=188.02 (120.09-294.37)]. We also noted unexpected serious safety signals, including large intestine perforation [ROR(95CI)=10.77 (3.47-33.45)] and hepatic failure [ROR(95CI)=3.87 (1.45-10.31)], as well as a high signal for pneumonitis [ROR(95CI)=9.93 (5.75-17.12)]. Additionally, age sub-group analysis revealed that geriatric patients (>65 years old) were at an increased risk of neutropenic colitis [ROR(95CI)=282.05 (116.36-683.66)], neutropenic sepsis [ROR(95CI)=101.11 (41.83-244.43)], acute kidney injury [ROR(95CI)=3.29 (1.36-7.94)], and atrial fibrillation [ROR(95CI)=6.91 (2.86-16.69)].

Conclusion

This study provides crucial real-world safety data on SG, complementing existing clinical trial information. Practitioners should identify contributing factors, employ monitoring and intervention strategies, and focus on adverse events like neutropenic sepsis, large intestine perforation, and hepatic failure. Further prospective studies are needed to address these safety concerns for a comprehensive understanding and effective management of associated risks.

Managing medical and psychiatric multimorbidity in older patients

Aging increases susceptibility both to psychiatric and medical disorders through a variety of processes ranging from biochemical to pharmacologic to societal. Interactions between aging-related brain changes, emotional and psychological symptoms, and social factors contribute to multimorbidity - the presence of two or more chronic conditions in an individual - which requires a more patient-centered, holistic approach than used in traditional single-disease treatment guidelines. Optimal treatment of older adults with psychiatric and medical multimorbidity necessitates an appreciation and understanding of the links between biological, psychological, and social factors - including trauma and racism - that underlie physical and psychiatric multimorbidity in older adults, all of which are the topic of this review.

Recent advances in dosage form design for the elderly: a review

INTRODUCTION

With the increase in the elderly population and the prevalence of multiple medical conditions, medication adherence, and efficacy have become crucial for the effective management of their health. The aging population faces unique challenges that need to be addressed through advancements in drug delivery systems and formulation technologies.

AREAS COVERED

The current review highlights the recent advances in dosage form design for older individuals, with consideration of their specific physiological and cognitive changes. Various dosage forms, such as modified-release tablets/capsules, chewable tablets, and transdermal patches, can be tailored to meet the specific needs of elderly patients. Advancements in drug delivery systems, such as nanotherapeutics, additive manufacturing (three-dimensional printing), and drug-food combinations, improve drug delivery and efficacy and overcome challenges, such as dysphagia and medication adherence.

EXPERT OPINION

Regulatory guidelines and considerations are crucial in ensuring the safe utilization of medications among older adults. Important factors to consider include geriatric-specific guidelines, safety considerations, labeling requirements, clinical trial considerations, and adherence and accessibility considerations.

Risk factors predictive of adverse drug events and drug-related falls in aged care residents: secondary analysis from the ReMInDAR trial

BACKGROUND

Residents of aged-care facilities have high rates of adverse drug events. This study aimed to identify risk factors for adverse drug events in aged-care residents.

METHOD

This was a secondary study using data from a multicentre randomised controlled trial. Data from 224 residents for whom there was 6 months of baseline information were analysed. We assessed the risk of adverse drug events and falls (post hoc) in the subsequent 6 months. Adverse events were identified via a key word search of the resident care record and adjudicated by a multidisciplinary panel using a modified version of the Naranjo criteria. Covariates identified through univariable logistic regression, including age, sex, medicines, physical activity, cognition (Montreal Cognitive Assessment), previous adverse events and health service use were included in multivariable models.

RESULTS

Overall, 224 residents were included, with a mean age of 86 years; 70% were female. 107 (48%) residents had an adverse drug event during the 6-month follow-up. Falls and bleeding were experienced by 73 (33%) and 28 (13%) residents, respectively. Age (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.01-1.10), weight (OR 1.02, 95% CI 1.002-1.04), previous fall (OR 2.58, 95% CI 1.34-4.98) and sedative or hypnotic medicine use (OR 1.98, 95% CI 1.52-2.60) were associated with increased risk of adverse drug events. Increased cognition (OR 0.89, 95% CI 0.83-0.95) was protective. Risk factors for falls were previous fall (OR 3.27, 95% CI 1.68-6.35) and sedative or hypnotic medicines (OR 3.05, 95% CI 1.14-8.16). Increased cognition (OR 0.88, 95% CI 0.83-0.95) was protective.

CONCLUSION

Our results suggest residents with a previous fall, reduced cognition, and prescription of sedative or hypnotic medicines were at higher risk of adverse drug events and should be considered for proactive prevention.

Adverse drug reactions in older adults: a narrative review of the literature

Aim

To summarize the classification and occurrence of ADRs and identify risk factors and strategies to reduce and prevent ADRs in older adults.

Findings

In frail, multimorbid older adults, who are often treated with polypharmacy, ADRs are frequently associated with health burden and hospitalization. Multiple age-related risk factors, including changes in pharmacokinetics, multimorbidity, polypharmacy, and frailty can increase the risk of ADRs, and different strategies have been suggested to prevent the onset of ADRs.

Message

A multidimensional and holistic approach combining pharmaceutical interventions with a global evaluation of health needs and priorities can reduce the burden of ADRs in older adults.

Purpose

Adverse drug reactions (ADRs) represent a common and potentially preventable cause of unplanned hospitalization, increasing morbidity, mortality, and healthcare costs. We aimed to review the classification and occurrence of ADRs in the older population, discuss the role of age as a risk factor, and identify interventions to prevent ADRs.

Methods

We performed a narrative scoping review of the literature to assess classification, occurrence, factors affecting ADRs, and possible strategies to identify and prevent ADRs.

Results

Adverse drug reactions (ADRs) are often classified as Type A and Type B reactions, based on dose and effect of the drugs and fatality of the reaction. More recently, other approaches have been proposed (i.e. Dose, Time and Susceptibility (DoTS) and EIDOS classifications). The frequency of ADRs varies depending on definitions, characteristics of the studied population, and settings. Their occurrence is often ascribed to commonly used drugs, including anticoagulants, antiplatelet agents, digoxin, insulin, and non-steroidal anti-inflammatory drugs. Age-related factors—changes in pharmacokinetics, multimorbidity, polypharmacy, and frailty—have been related to ADRs. Different approaches (i.e. medication review, software identifying potentially inappropriate prescription and drug interactions) have been suggested to prevent ADRs and proven to improve the quality of prescribing. However, consistent evidence on their effectiveness is still lacking. Few studies suggest that a comprehensive geriatric assessment, aimed at identifying individual risk factors, patients’ needs, treatment priorities, and strategies for therapy optimization, is key for reducing ADRs.

Conclusions

Adverse drug reactions (ADRs) are a relevant health burden. The medical complexity that characterizes older patients requires a holistic approach to reduce the burden of ADRs in this population.

Anti-Cholinergic Drug Burden Among Ambulatory Elderly Patients in a Nigerian Tertiary Healthcare Facility

Background: The use of drugs with anticholinergic effects among elderly patients is associated with adverse clinical outcomes. There is paucity of information about anticholinergic drug burden among Nigerian elderly population. Objectives: To determine the anticholinergic drug burden among elderly Nigerian patients. Methods: This was a retrospective cross-sectional study conducted among elderly patients (aged 65 and above) who visited the Family Medicine outpatients' clinics of the Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria between July 1 and October 31, 2018. Information extracted from the case files included patient's age, sex, diagnoses, and list of prescribed medications. Medicines with anticholinergic effects were identified and scored using the anticholinergic drug burden calculator (http://www.acbcalc.com). Results: The medical records of 400 patients were analyzed with females accounting for 60.5% of the study population. The mean age of participants was 73 ± 7.4 years with only 28 (7%) of patients having more than two co-morbid conditions. Polypharmacy was identified in 152 (38%) of the patients while 147 (36.7%) had drugs with anticholinergic effects prescribed. The anticholinergic burden was high in 60 (15%) patients. Polypharmacy was significantly associated with having more than two diagnosed conditions and high anticholinergic burden (p value of < 0 .001 and 0.013 respectively). There was significant correlation between total number of prescribed drugs and count of diagnoses (r = 0.598; p < 0 .000) and between total number of prescribed drugs and number of drugs with anticholinergic effects (r = 0 .196; p < 0 .000). Conclusion: The anticholinergic burden in this group of elderly Nigerian patients was low; majority (67%) had no exposure to drugs with anticholinergic effects with only 15% having high anticholinergic burden. Polypharmacy and multiple diagnosed conditions were positively associated with high anticholinergic burden. Based on the positive and significant correlations found in this study, a reduction in the number of prescribed medicines especially those with significant anticholinergic effects used for secondary indications may lessen the anticholinergic burden among the elderly.

An Algorithm for Comprehensive Medication Management in Nursing Homes: Results of the AMBER Project

INTRODUCTION

There are several barriers to conducting medication management in nursing homes. Our project aimed to develop an algorithm that guides and supports pharmacists to perform this clinical service.

METHODS

Phase I of the project examined the practitioner and patient perspectives on the medication process in nursing homes. The mixed methods approach consisted of interviews with qualitative content analysis and a quantitative questionnaire. Phase IIa scoped existing research and comprised a three-stepped systematic review. It was registered in the International Prospective Register of Systematic Reviews (CRD42017065002). Results of the first two steps were assessed for quality. Phase IIb was performed as a Delphi survey. The developed algorithm was tested in nursing homes. The primary endpoint was the number and type of detected drug-related problems. The study was conducted between June 2016 and December 2018 (Deutsches-Register-Klinischer-Studien-ID: DRKS00010995).

RESULTS

Interviews were held with 21 healthcare practitioners and six patients. Frequent and relevant aspects of the medication process in nursing homes were identified. The systematic reviews included 28 reviews, 12 interventional studies and 1450 non-interventional studies. As a result of the Delphi survey, two new aspects were added. Testing of the drafted algorithm was done in 73 nursing home residents. A mean of 6.3 drug-related problems were detected. Sample cases were executed in a mean time of 21 min by community pharmacists.

CONCLUSIONS

The developed and consented algorithm can guide pharmacists in conducting medication management in a timely and effective manner. It might serve as a facilitator to improve collaboration and quality of medication in nursing home residents.

Factors associated with adverse drug reaction occurrence and prognosis, and their economic impacts in older inpatients in Taiwan: a nested case-control study

OBJECTIVE

Older patients are likely to have higher disease complexity and more drug prescriptions of which are associated with a higher incidence of adverse drug reactions (ADR). This study aimed to investigate factors associated with ADR occurrence, prognosis and medical expenses in older inpatients.

DESIGN

A nested case-control study.

SETTING

A medical centre located in north Taiwan.

PARTICIPANTS

539 reported ADR cases from a patient cohort containing 108 548 older inpatients were collected from 2006 to 2012. There were 1854 non-ADR matched controls; a maximum of 1:5 matched by age, sex and principal diagnosis were collected.

EXPOSURE

Polypharmacy, the number of drugs prescribed, comorbidities and the admission department were factors associated with ADRs, as well as subsequent poor prognosis, length of stay and medical expenses.

PRIMARY AND SECONDARY OUTCOME MEASURES

ADR occurrence and poor prognosis (mortality, discharge against medical advice in critical conditions, or admitted to intensive care unit) were the primary outcomes. Additional medical expenses and the length of hospital stay were the secondary outcomes.

RESULTS

The admission department, number of comorbidities and number of drug prescriptions before ADRs were associated with ADR occurrence among older inpatients. ADR severity was a significant prognostic factor among ADR cases. The multivariate-adjusted OR of 1.63 (95% CI 1.36 to 1.95) for poor prognosis was found as the number of comorbidities increased. Patients prescribed ≥11 drugs including psychoactive drugs showed 2.45-fold (95% CI 1.40 to 4.28) poorer prognosis than other patients. ADRs caused the addition of US$1803.8, US$360.8 and 5.6 days in total medical expenses, drug expenses and length of stay among affected older inpatients, respectively.

CONCLUSIONS

The number of comorbidities and polypharmacy including the use of psychoactive drugs has significant impacts on ADR occurrence and prognosis among older inpatients. The findings provide clues for future prescription modification and patient's safety improvement in geriatric care.

Fluoroquinolone-Related Neuropsychiatric Events in Hospitalized Veterans

OBJECTIVE

To measure the incidence and risk factors for fluoroquinolone (ciprofloxacin, moxifloxacin, and levofloxacin)-associated psychosis or delirium in a veteran population.

METHODS

A retrospective study was conducted in the Western New York Veterans Affairs Health System (2005-2013). Participants were hospitalized veterans receiving a fluoroquinolone for at least 48 hours (n = 631). Cases of delirium or psychosis were defined by the Diagnostic and Statistical Manual of Mental Disorders-IV criteria, and the Naranjo scale (score ≥ 1) was used to determine the probability of the adverse drug reaction being related to fluoroquinolones. A bivariate analysis of covariates followed by a multivariate logistic regression was used to determine predisposing factors to the development of delirium/psychosis.

RESULTS

The mean age of the population was 71.5 years (range: 22-95). Fluoroquinolone-associated delirium/psychosis occurred in 3.7% of the inpatients studied (n = 23). The median Naranjo score was 3 indicating a possible association. Psychosis/delirium occurred in 3.6% of ciprofloxacin-treated patients (n = 14/391), 4.5% of patients-treated with moxifloxacin (n = 9/200), and 0% of those receiving levofloxacin (n = 0/40); p = 0.4. Significant risk factors for development of delirium/psychosis in patients receiving a fluoroquinolone in the multivariate logistical regression included typical antipsychotic use (OR, 5.4; 95% CI: 1.4-16.7) and age. A 10-year increase in age was associated with a 1.8-fold greater odds of a neuropsychiatric event.

CONCLUSIONS

Fluoroquinolones may be more commonly associated with delirium/psychosis than originally reported in this veteran population. Caution should be used when prescribing a fluoroquinolone for patients on typical antipsychotics and those of advanced age.

Characterization of adverse drug reactions causing admission to an intensive care unit

AIMS

This study aimed to determine the occurrence of adverse drug reactions (ADRs) that caused admission to the intensive care unit (ICU) of a university hospital.

METHODS

Clinical records were reviewed for patients meeting the inclusion criteria who were admitted to the ICU between September and December 2012. Suspected cases of ADRs were documented. Nine researchers later evaluated causality using the Naranjo Algorithm, preventability using the Schumock and Thornton criteria, and clinical classification based on the dose-time-susceptibility system.

RESULTS

In total, 96 patients presented 108 cases of ADR (13.8%, 95% confidence interval 11.2-16.4%) as the cause of admission. The most frequent ADRs were bradyarrhythmias and upper gastrointestinal bleeding (12%). Therapeutic failure accounted for 20%. The most commonly associated medications were acetylsalicylic acid (16%) and losartan (10%). Forty-six cases were categorized as possible, and only one as definite. According to the dose-time-susceptibility classification, in 82% of the cases, the dosage was collateral (within the therapeutic range), and 90% were independent of time; the factors most associated with susceptibility to ADRs were comorbidities (42%) and age (49%). Forty-four percent of the ADRs were considered possibly preventable.

CONCLUSIONS

ADRs contribute significantly to ICU admissions, and a significant number of ADRs are preventable. National studies are needed to assess their incidence and to establish classification standards to reduce their clinical impact.

Danish register-based study on the association between specific cardiovascular drugs and fragility fractures

OBJECTIVE

To determine whether drugs used in treatment of cardiovascular diseases (CVD-drugs), including hypertension, increase the risk of fragility fractures in individuals above the age of 65 years.

DESIGN

Retrospective nationwide cohort study.

SETTING

Danish nationwide national registers.

PARTICIPANTS

All individuals in Denmark ≥ 65 years who used specified CVD-drugs in the study period between 1999 and 2012.

MAIN OUTCOMES MEASURES

Time-dependent exposure to CVD-drugs (nitrates, digoxin, thiazides, furosemide, ACE inhibitors, angiotensin receptor antagonists, β-blockers, calcium antagonists and statins) was determined by prescription claims from pharmacies. The association between use of specific CVD-drugs and fragility fractures was assessed using multivariable Poisson regression models, and adjusted incidence rate ratios (IRRs) were calculated.

RESULTS

Overall, 1,586,554 persons were included, of these 16.1% experienced a fall-related fracture. The multivariable Poisson regression analysis showed positive associations between fracture and treatment with furosemide, thiazide and digoxin. IRRs during the first 14 days of treatment were for furosemide IRR 1.74 (95% CI 1.61 to 1.89) and for thiazides IRR 1.41 (1.28 to 1.55); IRR during the first 30 days of treatment with digoxin was 1.18 (1.02 to 1.37).

CONCLUSIONS

Use of furosemide, thiazides and digoxin was associated with elevated rates of fragility fractures among elderly individuals. This may warrant consideration when considering diuretic treatment of hypertension in elderly individuals.

CYP2D6 Metabolism in Frail Elderly Compared to Non-Frail Elderly: A Pilot Feasibility Study

BACKGROUND

Frailty is a clinical phenotype that is associated with adverse health outcomes. Since frail patients may be more prone for adverse drug events and about 15-20 % of commonly prescribed drugs are metabolized by CYP2D6, we hypothesized that CYP2D6 metabolism is decreased in frail patients compared with healthy subjects.

METHODS

The (13)C-dextromethorphan breath test (DM-BT) was used to determine CYP2D6 phenotype using (13)C-dextromethorphan ((13)C-DM) as a probe. Eleven frail and 22 non-frail (according to the Fried criteria) subjects aged 70-85 years were phenotyped for CYP2D6.

RESULTS

Despite inequalities in CYP2D6 genotype between frail and non-frail subjects, the CYP2D6 gene activity score was equally distributed between the two groups (1.33 ± 0.50 vs. 1.28 ± 0.752). In male patients, no difference in total and free serum testosterone levels was observed between frail and non-frail men. Serum dehydroepiandrostenedione sulfate (DHEAS) levels were lower in frail subjects (1.56 μmol/L) compared with non-frail subjects (2.36 μmol/L), but the difference was not significant (p = 0.15). Body mass index was significantly correlated to CYP2D6 phenotype, whereas frailty score and individual parameters of frailty, Karnofsky score, and activities of daily living score were not significantly correlated to CYP2D6 phenotype. Although there was no difference in CYP2D6 phenotype observed between frail mean ± standard deviation (mean ± SD) area under the curve for delta over baseline values (0-2 h) (AUCDOB2h) 319 ± 169 ‰ min] and non-frail subjects (mean ± SD AUCDOB2h 298 ± 159 ‰ min), the present sample size is considered too small to draw any firm conclusions regarding a potential phenoconversion of CYP2D6 in frail elderly as compared with healthy subjects.

CONCLUSION

Frail and non-frail subjects did not differ in CYP2D6 phenotype, taking into account that the precalculated sample size was not achieved. Further studies with more patients are needed in order to adequately understand a possible correlation.

Low Energy Trauma in Older Persons: Where to Next?

The global population is increasing rapidly with older persons accounting for the greatest proportion. Associated with this rise is an increased rate of injury, including polytrauma, for which low energy falls has become the main cause. The resultant growing impact on trauma resources represents a major burden to the health system. Frailty, with its related issues of cognitive dysfunction and sarcopenia, is emerging as the unifying concept that relates both to the initial event and subsequent outcomes. Strategies to better assess and manage frailty are key to both preventing injury and improving trauma outcomes in the older population and research that links measures of frailty to trauma outcomes will be critical to informing future directions and health policy. The introduction of "Geriatric Emergency Departments" and the development of "Fracture Units" for frail older people will facilitate increased involvement of Geriatricians in trauma care and aid in the education of other health disciplines in the core principles of geriatric assessment and management. Collectively these should lead to improved care and outcomes for both survivors and those requiring end of life decisions and palliation.