Managing hypertension among nursing-home residents and community-dwelling elderly in Germany: a comparative pharmacoepidemiological study

Influencing factors of medication literacy among community-dwelling older adult patients with hypertension: a study based on social learning theory

Objective: This study aimed to examine the factors affecting medication literacy in community-dwelling older adults with hypertension, guided by social learning theory. It sought to analyze the pathways these factors influenced and provide a theoretical foundation for designing targeted intervention programs. Study design: This is a cross-sectional study. Methods: From October 2022 to February 2023, a total of 432 community-dwelling older adults with hypertension from Linghe District, Guta District, and Taihe District, Jinzhou City, Liaoning Province, China, were selected using convenience sampling. Data were collected using a socio-demographic questionnaire, a medication literacy questionnaire, the Brief Illness Perception Questionnaire, the General Self-efficacy Scale, and the Perceived Social Support Scale. The collected data were analyzed with Kruskal-Wallis and Mann-Whitney tests, correlation analysis, multiple stepwise regression analysis, and structural equation modeling (SEM). Results: The medication literacy score among the participants was 3.83 ± 1.91. Multi-factor analysis revealed key factors affecting their medication literacy, including blood pressure-control status, utilization of community health education resources, receiving guidance for medication usage, marital status, number of annual visits, social support, self-efficacy, and disease perception. The SEM based on social learning theory showed that general self-efficacy mediated the relationship between social support, disease perception, and medication literacy. Conclusion: The present study developed a model and provided potential intervention strategies to improve medication literacy, knowledge, and safety among community-dwelling older adults with hypertension, considering the relationships between the identified variables.

Trends and concerns of potentially inappropriate medication use in patients with cardiovascular diseases

Introduction: The use of potentially inappropriate medications (PIM) is an alarming social risk factor in cardiovascular patients. PIM administration may result in iatrogenic disorders and adverse consequences may be attenuated by limiting PIM intake.Areas covered: The goal of this review article is to discuss the trends, risks, and concerns regarding PIM administration with focus on cardiovascular patients. To find data, we searched literature using electronic databases (Pubmed/Medline 1966-2021 and Web of Science 1975-2021). The data search terms were cardiovascular diseases, potentially inappropriate medication, potentially harmful drug-drug combination, potentially harmful drug-disease combination, drug interaction, deprescribing, and electronic health record.Expert opinion: Drugs for heart diseases are the most commonly prescribed medications in older individuals. Despite the availability of explicit and implicit PIM criteria, the incidence of PIM use in cardiovascular patients remains high ranging from 7 to 85% in different patient categories. Physician-induced disorders often occur when PIM is administered and adverse effects may be reduced by limiting PIM intake. Main strategies promising for addressing PIM use include deprescribing, implementation of systematic electronic records, pharmacist medication review, and collaboration among cardiologists, internists, geriatricians, clinical pharmacologists, pharmacists, and other healthcare professionals as basis of multidisciplinary assessment teams.

Drug interactions with oral anticoagulants in German nursing home residents: comparison between vitamin K antagonists and non-vitamin K antagonist oral anticoagulants based on two nested case-control studies

BACKGROUND

Vitamin K antagonists (VKAs) are susceptible to drug-drug interactions. Non-VKA oral anticoagulants (NOACs) have a decreased sensitivity to pharmacokinetic interactions and might be therefore considered superior in patients treated with multiple drugs. The objective of this study was to compare the risk of serious bleeding associated with interacting drugs in German nursing home residents treated with VKA or NOAC.

METHODS

Using claims data of new nursing home residents aged ≥ 65 years (2010-2014) we conducted separate nested case-control analyses within two cohorts of patients treated with VKA or NOAC, respectively. Cases were defined as patients hospitalized for serious bleeding. For each case, up to 20 controls were selected by risk-set sampling. Conditional logistic regression was used to obtain confounder-adjusted odds ratios (aORs) and 95% confidence intervals (CI) for the risk of bleeding associated with VKA or NOAC use and interacting drugs compared with the use of the respective oral anticoagulant alone.

RESULTS

Among 127,227 new nursing home residents, 16,804 patients received oral anticoagulation. Based on 372 cases and 7281 matched controls, the highest risk of bleeding in VKA users was observed for the concomitant use of antibiotics (aOR 3.00; CI 2.11-4.27) vs. VKA use alone, followed by non-steroidal anti-inflammatory drugs (1.66; 1.13-2.43). Among 243 NOAC cases and 4776 matched controls, elevated risks for bleeding were observed for the use of heparins (2.05; 1.25-3.36) and platelet inhibitors (1.92; 1.36-2.72).

CONCLUSIONS

Concomitant medication needs to be prescribed cautiously and monitored closely in nursing home residents treated with oral anticoagulants.

Prevalence, management and control of hypertension in older adults on admission to hospital

Introduction

The aim of this study was to explore the prevalence and management of hypertension among older adults on admission to hospital and to assess the choice of antihypertensive pharmacotherapy in light of relevant comorbid conditions using the national treatment guideline.

Materials and methods

A retrospective cross sectional study of 503 patients aged 65 years or older admitted to a large metropolitan teaching hospital in Sydney Australia was conducted. The main outcome measures were prevalence of hypertension, blood pressure (BP) control, antihypertensive medication use and the appropriateness of antihypertensive medications.

Results

Sixty-nine percent (n = 347) of the study population had a documented diagnosis of hypertension and of these, approximately one third were at target BP levels on admission to hospital. Some concerns regarding choice of antihypertensive noted with 51% of those with comorbid diabetes and 30% of those with comorbid heart failure receiving a potentially inappropriate antihypertensive agent.

Conclusions

Despite the use of antihypertensive pharmacotherapy, many older adults do not have optimal BP control and are not reaching target BP levels. New strategies to improve blood pressure control in older populations especially targeting women, those with a past history of myocardial infarction and those on multiple antihypertensive medications are needed.

Combined use of drugs inhibiting the renin-angiotensin system: prescribing patterns and risk of acute kidney injury in German nursing home residents

Background/aims

In 2012, the European Medicines Agency reviewed the safety of dual renin-angiotensin system (RAS) blockade because of potentially increased risks for inter alia acute kidney injury (AKI). Since residents of nursing homes are particularly vulnerable to adverse drug outcomes, the aims of our study were to describe RAS-inhibiting drug use in German nursing home residents and examine the risk of AKI associated with dual RAS blockade.

Methods

Based on claims data, a nested case-control study within a cohort of RAS-inhibiting drug users was conducted. Using conditional logistic regression, confounder-adjusted odds ratios (aORs) and 95% confidence intervals (CI) were obtained for the risk of AKI associated with dual RAS blockade. Subgroup analyses were performed in patients with diabetes or chronic kidney disease and both comorbidities.

Results

Of all 127,227 nursing home residents, the study cohort included 64,567 (50.7%) who were treated with at least one RAS-inhibiting drug. More than three quarters of the study population were female (77.1%). Mean age was 86.0 ± 6.8 years. Most residents were treated with angiotensin-converting enzyme inhibitors (77.8%), followed by angiotensin II receptor blockers (21.6%) and aliskiren (0.2%). Annual prevalence of dual RAS blockade declined from 9.6 (95% CI 7.8-11.8) in 2010 to 4.7 (95% CI 4.0-5.4) per 1,000 users in 2014. In the overall cohort, AKI was not significantly associated with dual RAS blockade (aOR 1.99; 0.77-5.17). However, significantly increased aORs were observed when considering patients with diabetes (3.47; 1.27-9.47), chronic kidney disease (4.74; 1.24-18.13) or both (11.17; 2.65-47.15).

Conclusions

Prescribing of drugs inhibiting the RAS is common in German nursing homes. Though the prevalence of dual RAS blockade declined, our study showed an increased risk of AKI in patients with diabetes and/or chronic kidney disease. Therefore, cautious use is warranted in these vulnerable patients.

Mortality by Timing of Hip Fracture Surgery: Factors and Relationships at Play

In hip fracture care, it is disputed whether mortality worsens when surgery is delayed. This knowledge gap matters when hospital managers seek to justify resource allocation for prioritizing access to one procedure over another. Uncertainty over the surgical timing-death association leads to either surgical prioritization without benefit or the underuse of expedited surgery when it could save lives. The discrepancy in previous findings results in part from differences between patients who happened to undergo surgery at different times. Such differences may produce the statistical association between surgical timing and death in the absence of a causal relationship. Previous observational studies attempted to adjust for structure, process, and patient factors that contribute to death, but not for relationships between structure and process factors, or between patient and process factors. In this article, we (1) summarize what is known about the factors that influence, directly or indirectly, both the timing of surgery and the occurrence of death; (2) construct a dependency graph of relationships among these factors based explicitly on the existing literature; (3) consider factors with a potential to induce covariation of time to surgery and the occurrence of death, directly or through the network of relationships, thereby explaining a putative surgical timing-death association; and (4) show how age, sex, dependent living, fracture type, hospital type, surgery type, and calendar period can influence both time to surgery and occurrence of death through chains of dependencies. We conclude by discussing how these results can inform the allocation of surgical capacity to prevent the avoidable adverse consequences of delaying hip fracture surgery.

Potentially inappropriate medication in the elderly in Germany: an economic appraisal of the PRISCUS list

BACKGROUND

Several lists of potentially inappropriate medication (PIM) for elderly patients have been developed worldwide in recent years. Those lists intend to reduce prescriptions of drugs that carry an unnecessarily high risk of adverse drug events in elderly patients. In 2010, an expert panel published the PRISCUS list for the German drug market. This study calculates the amount of drug reimbursement for PIM in Germany and potential cost effects from the perspective of statutory health insurance when these are replaced by the substitutes recommended by the PRISCUS list.

METHODS

Register-based data for the 30 top-selling drugs on the PRISCUS list in 2009 for patients greater than or equal to 65 years of age were provided by the Scientific Institute of the German Local Health Care Fund. We calculated the percentage of sales and defined daily doses for patients greater than or equal to 65 years of age compared with the total statutory health insurance population. Reimbursement costs for the recommended substitutions were estimated by considering different scenarios.

RESULTS

In 2009, drug reimbursement for the 30 top-selling PIM prescribed to patients greater than or equal to 65 years of age were calculated to be €305.7 million. Prescribing the recommended substitution medication instead of PIM would lead to an increased total reimbursement cost for the German health care system ranging between from €325.9 million to €810.0 million.

CONCLUSIONS

The results show that the substitution of PIM by medication deemed to be more appropriate for the elderly comes along with additional costs. Consequently, there is no short-term incentive for doing so from a payer perspective. Future studies have to consider the long-term effects and other sectors.

Drug-Related Problems Identified in a Sample of Portuguese Institutionalised Elderly Patients and Pharmacists' Interventions to Improve Safety and Effectiveness of Medicines

BACKGROUND

Currently, people live longer but often with poor quality of life. The decrease in healthy life-years is partly attributable to the institution of polypharmacy to treat various comorbidities.

OBJECTIVES

The objectives of the study were to determine the prevalence and nature of drug-related problems (DRPs) in polypharmacy elderly patients residing in nursing homes and to test the acceptability of a pharmacist's intervention.

METHODS

An exposure cohort was constituted in three Portuguese nursing homes, where all polypharmacy (five or more medicines) elderly patients (≥65 years of age) were analysed and then a random stratified sample was extracted to be subject to an intervention. Clinical and therapeutic data were collected and analysed for DRPs and classified according to the II Granada Consensus, by a pharmacist-led team. The intervention was the formulation of a pharmacist's recommendations to prescribers addressing clinically relevant DRPs, along with suggestions for therapy changes.

RESULTS

The initial sample included 126 elderly patients taking 1332 medicines, where 2109 DRPs were identified. The exposure cohort included 63 patients, with comparable baseline data (p > 0.005). Manifest DRPs occurred in 31.7 % of the intervention group (mainly quantitative ineffectiveness-DRP 4), whereas potential DRPs were identified in 100 % of patients (mainly non-quantitative unsafe-DRP 5). Amongst the DRPs identified, 584 (56.7 %) were reported to prescribers (all types of DRPs) and 113 (11 %) to nurses (only non-quantitative ineffectiveness-DRP 3). A total of 539 pharmacist recommendations were presented to physicians, corresponding to 62 letters sent by mail, each including an average of 8.7 recommendations to solve DRPs present in intervention group (IG) patients. There was a high non-response rate (n = 34 letters; 54.8 %; containing 367 pharmacist recommendations; 68.1 %) and amongst recommendations receiving feedback, only 8.7 % of pharmacist recommendations made were accepted (n = 15). Positive responses were significantly associated with a lower number of recommendations made, whereas a higher number of recommendations increased the odds of no response (p < 0.001).

CONCLUSION

A pharmacist-led medication review proved useful in identifying DRPs in elderly polypharmacy nursing home residents. Stronger bonds must be developed between healthcare professionals to increase patient safety in the vulnerable institutionalised elderly population.

Effect of self - care education on quality of life in patients with primary hypertension: comparing lecture and educational package

Background:

Hypertension is a dangerous risk factor for public health. It profoundly affects the patients’ quality of life. However, there is lack of agreement on the best method for self-care management in patients with hypertension.

Objectives:

This study was conducted to compare the effect of lecture and educational pamphlets on quality of life (QOL) in patients with primary hypertension.

Patients and Methods:

A quasi-experimental study was performed on 90 patients with chronic primary hypertension referred to two outpatient clinics in Kashan city. Patients were randomly divided into three groups including lecture group, educational package group, and control group. The participants’ quality of life was measured using the SF-36 questionnaire at the beginning of the study, and two months later. Data was analyzed using ANOVA and Chi-Square tests.

Results:

No significant differences were observed between the three groups for demographics characteristics and QOL before the intervention except for marital status. Mean scores of QOL dimensions of the intervention groups were increased at the end of the study, except for the dimension of bodily pain. Tukey post-Hoc test showed that except for general health, the two intervention groups were not significantly different in other dimensions, and significant differences were observed between the control group and the two intervention groups (P < 0.05). At start and the end of the study, the mean differences in the general health dimension in three groups were 2.25 ± 0.1, 0.07 ± 0.01, and -1.70 ± 0.01 respectively. There were significant differences among groups (P = 0.04).

Conclusions:

Lecture and educational package can both improve some dimensions of the QOL in patients with hypertension. However, as pamphlets are cheap and easy to use, this method may be used as an effective method for self-care education in health care settings in Iran, where the system is faced with nursing shortage.

The treatment of hypertension in care home residents: a systematic review of observational studies

AIM

To describe the prevalence of hypertension in care home residents, its treatment, change in treatment over time, and the achievement of blood pressure (BP) control.

METHOD

The PubMed, Cochrane, Embase, and PsychINFO databases were searched for observational studies involving care home residents with a diagnosis of hypertension. The search was limited to English language articles involving adults and humans published from 1990 onward. Abstracts and titles were reviewed with eligible articles read in full. Bibliographies were examined for further relevant studies. The final selection of studies was then analyzed and appraised.

RESULTS

Sixteen articles were identified for analysis, of which half were studies carried out in the United States. The prevalence of hypertension in care home residents was 35% (range 16%-71%); 72% of these were on at least 1 antihypertensive (mean 1.5 antihypertensives per individual), with diuretics being the most common. The prevalence of hypertension in study populations was greater in more recent studies (P = .004). ACEi/ARBs (P = .001) and β-blockers (P = .04) were prescribed more frequently in recent studies, whereas use of calcium-channel blockers and diuretics remained unchanged over time. The number of antihypertensives prescribed per patient was higher (correlation 0.332, P = .009), whereas fewer patients achieved target BP (correlation -0.671, P = .099) in more recent studies.

CONCLUSION

Hypertension is common in care home residents and is commonly treated with antihypertensive drugs, which were prescribed more frequently in more recent studies but with no better BP control. These studies indicate a tendency toward increasing polypharmacy over time, with associated risk of adverse events, without demonstrable benefit in terms of BP control.

Comparison of diagnosed, self-reported, and physically-measured hypertension in Canada

BACKGROUND

Hypertension is a substantial health concern because it poses significant risks for cardiovascular morbidity and mortality and is highly prevalent in the population. Tracking hypertension is important because it is a risk factor for other conditions, but prevalence estimates might vary depending on the data source used.

METHODS

This report describes 3 national population-based data sources for estimating hypertension prevalence in Canada and discusses their strengths and weaknesses to aid in their use for policy and program planning. They are compared based on: sample coverage, case identification, and prevalence estimates.

RESULTS

Each source produces a different measure of hypertension prevalence, as follows: (1) diagnosed hypertension from the Canadian Chronic Disease Surveillance System (CCDSS) (2007/2008); (2) self-reported diagnosed hypertension from the Canadian Community Health Survey (CCHS) (2007-2008); and, (3) physically-measured hypertension from the Canadian Health Measures Survey (CHMS) (2007-2009). Crude rates and counts of hypertension prevalence among individuals aged 20 to 79 years of age, excluding pregnant women, are compared, resulting in prevalence ranging from 18.2% in self-report data to 20.3% in diagnosed data. The data sources differ in terms of target population, case identification, and limitations, which affects the estimates.

CONCLUSIONS

Each source has unique strengths and is best suited for addressing particular research questions. For example, diagnosed hypertension can be used to determine health care utilization patterns, self-reported to examine health determinants, and measured high blood pressure to improve awareness, treatment, and control. Combined, they can address multiple issues and increase our knowledge of hypertension in Canada.

[Medication safety in nursing homes]

Multimorbidity, polymedication and functional impairment together with diminished everyday competence and communication ability predispose nursing home residents to adverse drug events (ADE). The high number of psychiatric drug prescriptions is a characteristic feature. The project "Medication Safety in Nursing Homes", funded by the Federal Ministry of Health, found an incidence of approximately 8 ADEs per 100 nursing home resident-months. About one third of the ADEs had clinical consequences, notably hospital admissions and additional visits of general practitioners. Many ADEs are due to errors in the medication process, coupled with the effects of poor communication among health care professionals. Thus, structured interventions are intended to not only sensitize to these problems, but also to support and foster a multidisciplinary way of thinking and acting.