Frailty, polypharmacy, and potentially inappropriate medications in old people: findings in a representative sample of the French population

'I think we could probably do more': an interview study to explore community pharmacists' experiences and perspectives of frailty and optimising medicines use in frail older adults

BACKGROUND

Community pharmacists potentially have an important role to play in identification of frailty and delivery of interventions to optimise medicines use for frail older adults. However, little is known about their knowledge or views about this role.

AIM

To explore community pharmacists' knowledge of frailty and assessment, experiences and contact with frail older adults, and perceptions of their role in optimising medicines use for this population.

METHODS

Semi-structured interviews conducted between March and December 2020 with 15 community pharmacists in Northern Ireland. Interviews were transcribed verbatim and analysed thematically.

RESULTS

Three broad themes were generated from the data. The first, 'awareness and understanding of frailty', highlighted gaps in community pharmacists' knowledge regarding presentation and identification of frailty and their reluctance to broach potentially challenging conversations with frail older patients. Within the second theme, 'problem-solving and supporting medication use', community pharmacists felt a large part of their role was to resolve medicines-related issues for frail older adults through collaboration with other primary healthcare professionals but feedback on the outcome was often not provided upon issue resolution. The third theme, 'seizing opportunities in primary care to enhance pharmaceutical care provision for frail older adults', identified areas for further development of the community pharmacist role.

CONCLUSIONS

This study has provided an understanding of the views and experiences of community pharmacists about frailty. Community pharmacists' knowledge deficits about frailty must be addressed and their communication skills enhanced so they may confidently initiate conversations about frailty and medicines use with older adults.

Factors Associated With PIM use in the Frail Elderly: A Cross-sectional Study

Background: The use of potentially inappropriate medications (PIM) by the elderly is commonly studied, but studies evaluating the use of PIM by frail elderly covered by prepaid health plans are still lacking. Objective: To identify the prevalence of use and the factors associated with the use of PIM by the elderly patients with high and moderate risk of clinical-functional vulnerability, according to the Beers criteria 2019. Methods: A cross-sectional study was developed with elderly people from a private health plan in Vitória-ES, Brazil. Socioeconomic, demographic and clinical data were collected through a digital platform and a structured questionnaire through an interview, from October 2018 to June 2019. The association between the use of PIM and independent variables was verified by univariate logistic regression with their respective confidence intervals (CI) 95%. The Multiple Model included the variables with P ≤ .20. Results: 332 elderly patients were interviewed (mean age 81.5 years, gender 237 female, 95 male). A 65% prevalence of PIM use was identified. In the multiple logistic regression model, the variables associated with the use of PIM were self-medication (P = .004), high risk of clinical-functional vulnerability (P = .022), use of psychotropic medications (P = .000001), musculoskeletal medications (P = .04) and alimentary tract medications (P = .03). Physical exercises were considered a protection factor (P = .02). Conclusion: The high prevalence of PIM use indicates the need for improvement in elderly private health care, to increase pharmacotherapy safety for this population.

The association between anticholinergic/sedative burden and physical frailty in people aging with HIV

OBJECTIVE

This study aimed to estimate the strength of the association between anticholinergic/sedative burden and concurrent physical frailty in people aging with HIV.

DESIGN

This cross-sectional analysis examined baseline data from 824 adults with a mean age of 53 enrolled in the Positive Brain Health Now study.

METHODS

Anticholinergic medications were identified using four methods: Anticholinergic Cognitive Burden (ACB) Scale, Anticholinergic Risk Scale (ARS), Anticholinergic Drug Scale (ADS), and the anticholinergic list of the Anticholinergic and Sedative Burden Catalog (ACSBC). Sedatives were identified using the Sedative Load Model (SLM) and the sedative list of the ACSBC. Physical frailty was assessed using a modified Fried Frailty Phenotype (FFP) based on self-report items. Multivariable logistic regression models, adjusted for sociodemographic factors, lifestyle considerations, HIV-related variables, comorbidities, and co-medication use, were used to estimate odds ratios (ORs).

RESULTS

Anticholinergic burden demonstrated associations with frailty across various methods: total anticholinergic burden (OR range: 1.22-1.32; 95% confidence interval (CI) range: 1.03-1.66), sedative burden (OR range: 1.18-1.24; 95% CI range: 1.02-1.45), high anticholinergic burden (OR range: 2.12-2.74; 95% CI range: 1.03-6.19), and high sedative burden (OR range: 1.94-2.18; 95% CI: 1.01-4.34).

CONCLUSION

The anticholinergic and sedative burdens may represent modifiable risk factors for frailty in people aging with HIV. Future studies should evaluate the effects of reducing anticholinergic and sedative burdens on frailty outcomes and explore the prognostic value of diverse scoring methods.

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.

Potentially inappropriate medication and frailty in older adults: A systematic review and meta-analysis

OBJECTIVES

The purpose of this study was to systematically assess existing studies to demonstrate the association between potentially inappropriate medication (PIM) and frailty.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched major electronic databases (PubMed, Web of Science, the Cochrane Library, Embase, CINHAL, PsycInfo, China National Knowledge Infrastructure, China Biology Medicine disk, Weipu, and Wanfang) from their inception until February 25, 2023 (data updated on May 4, 2023), for observational studies investigating PIM and frailty. I2 was used to measure the heterogeneity between studies quantitatively. A random effect model calculated pooled effect size owing to high heterogeneity. Subgroup analysis was conducted to explore sources of heterogeneity. Additionally, the studies' quality was evaluated using the Newcastle Ottawa Scale (a modified Newcastle Ottawa Scale was used to evaluate cross-sectional studies).

RESULTS

Twenty-four studies were included for systematic review, 14 of which were included in the meta-analysis. After pooling the effect size, the odds ratio with PIM as the dependent variable was 1.12 (95%CI: 1.01-1.25), and that with frailty as the dependent variable was 1.75 (95%CI: 1.25-2.43), indicating a bidirectional association between PIM and frailty.

CONCLUSIONS

PIM and frailty interact with each other and have a bidirectional association, thus providing additional information for early clinical identification and prevention of frailty, and medication safety management.

Potentially inappropriate medications and polypharmacy in the older population: A nationwide cross-sectional study in France in 2019

AIM OF THE STUDY

To assess the prevalence of potentially inappropriate medications (PIMs) and polypharmacy in adults aged 75 years and over in France in 2019 based on data from the French health insurance claims database, at the national level and by region.

METHODS

We conducted a cross-sectional study in French adults aged 75 years or over in 2019. We assessed the prevalence of seventeen PIM criteria adapted from the 2015 Beers and STOPP lists, as well as cumulative polypharmacy. Polypharmacy (5 to 9 drugs) and hyper-polypharmacy (≥10 drugs) were defined as the average number of drugs dispensed per quarter. The regional analysis used the age- and sex-standardized prevalence.

RESULTS

Of 6,707,897 older adults, 39.6% were exposed to at least one PIM in 2019, 46.7% were exposed to polypharmacy (5 to 9 drugs), and 25.2% to hyper-polypharmacy (≥10 drugs). Benzodiazepine PIMs were the most frequent (26.9%), followed by atropinic PIMs (8.3%), non-steroidal anti-inflammatory PIMs (7.8%), concomitant use of three or more central nervous system-active drugs (7.3%), and antihypertensive PIMs (6.0%). There was a gradient in the level of exposure to PIMs according to the level of polypharmacy for every PIM category. We observed regional variations in PIM prevalence, from 36.5% in Pays-de-la-Loire to 44.8% in Hauts-de-France in mainland France.

CONCLUSION

These results show that PIMs concerned more than one in three older adults after age 75 years in France in 2019 and support the need to secure medication use in this population. The reasons for geographic variations in PIM prevalence should be investigated in further studies.

A systematic review of randomised-controlled trials on deprescribing outcomes in older adults with polypharmacy

BACKGROUND

Mixed findings about deprescribing impact have emerged from varied study designs, interventions, outcome measures and targeting sub-categories of medications or morbidities. This systematic review controls for study design by reviewing randomised-controlled trials (RCTs) of deprescribing interventions using comprehensive medication profiles. The goal is to provide a synthesis of interventions and patient outcomes to inform healthcare providers and policy makers about deprescribing effectiveness.

OBJECTIVES

This systematic review aims to (1) review RCT deprescribing studies focusing on complete medication reviews of older adults with polypharmacy across all health settings, (2) map patients' clinical and economic outcomes against intervention and implementation strategies and (3) inform research agendas based on observed benefits and best practices.

METHODS

The PRISMA framework for systematic reviews was followed. Databases used were EBSCO Medline, PubMed, Cochrane Library, Scopus and Web of Science. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomised trials.

RESULTS

Fourteen articles were included. Interventions varied in setting, preparation, use of interdisciplinary teams, validated guidelines and tools, patient-centredness and implementation strategy. Thirteen studies (92.9%) found deprescribing interventions reduced the number of drugs and/or doses taken. No studies found threats to patient safety in terms of primary outcomes including morbidity, hospitalisations, emergency room use and falls. Four of five studies identifying health quality of life as a primary outcome found significant effects associated with deprescribing. Both studies with cost as their primary outcome found significant effects as did two with cost as a secondary outcome. Studies did not systematically study how intervention components influenced deprescribing impact. To explore this gap, this review mapped studies' primary outcomes to deprescribing intervention components using the Consolidated Framework for Implementation Research. Five studies had significant, positive primary outcomes related to health-related quality of life (HRQOL), cost and/or hospitalisation, with four reporting patient-centred elements in their intervention.

CONCLUSIONS

RCT primary outcomes found deprescribing is safe and reduces drug number or dose. Five RCTs found a significant deprescribing impact on HRQOL, cost or hospitalisation. Important future research agendas include analysing (1) understudied outcomes like cost, and (2) intervention and implementation components that enhance effectiveness, such as patient-centred elements.

Medication Assessment in an Older Population during Acute Care Hospitalization and Its Effect on the Anticholinergic Burden: A Prospective Cohort Study

(1) Background: Anticholinergic and sedative drugs (ASDs) contribute to negative health outcomes, especially in the frail population. In this study, we aimed to assess whether frailty increases with anticholinergic burden and to evaluate the effects of medication reviews (MRs) on ASD regimens among patients attending an acute care for the elderly (ACE) unit. (2) Methods: A cohort study was conducted between June 2019 and October 2020 with 150 consecutive patients admitted to our ACE unit. Demographic, clinical, and pharmacological data were assessed. Frailty score was determined using the Frail-VIG index (FI-VIG), and ASD burden was quantified using the drug burden index (DBI). In addition, the MR was performed using the patient-centered prescription (PCP) model. We used a paired T-test to compare the DBI pre- and post-MR and univariate and multivariate regression to identify the factors associated with frailty. (3) Results: Overall, 85.6% (n = 128) of participants showed some degree of frailty (FI-VIG > 0.20) and 84% (n = 126) of patients received treatment with ASDs upon admission (pre-MR). As the degree of frailty increased, so did the DBI (p < 0.001). After the implementation of the MR through the application of the PCP model, a reduction in the DBI was noted (1.06 ± 0.8 versus 0.95 ± 0.7) (p < 0.001). After adjusting for covariates, the association between frailty and the DBI was apparent (OR: 11.42, 95% (CI: 2.77-47.15)). (4) Conclusions: A higher DBI was positively associated with frailty. The DBI decreased significantly in frail patients after a personalized MR. Thus, MRs focusing on ASDs are crucial for frail older patients.

The MGPIDP-L project: Potentially inappropriate drug prescribing and its associated factors

OBJECTIVE

The aim of this study was to identify the prevalence of potentially inappropriate drug prescribing¹ (PIDP) using a combination of explicit and implicit criteria in a sample of Lebanese older adults taking 5 or more chronic medications per day in ambulatory care settings and to identify which factors were associated with PIDP. The explicit criteria included five different lists: Beers, Laroche, European Union (EU(7)-PIM list), STOPP/ START, STOPP Frail, and Alert and Mastering of Iatrogenesis issued by the French High Authority of Health. We also performed a sensitivity analysis to compare the potentially inappropriate medications according to each criterion.

METHODS

Data were collected from each patient via a face-to-face interview. Logistic regressions were conducted to evaluate both objectives.

RESULTS

Many factors were positively associated with PIDP. The risk of PIDP was positively associated with age (OR =4.692, 95% CI [1.889-11.655]). Treatment for insomnia doubled the odds of PIDP (P<0.05). Participants who picked their medications from the pharmacy and had excess stock of drugs were at higher risk of having PIDP by 2.042 (95% CI [1.199-3.478]) and 2.965(95% CI [1.133-7.762]) respectively. However, patients with a perception of being heavily medicated and patients with a missed dose in the last two weeks had lower odds of PIDP.

CONCLUSION

Our study showed a high prevalence of PIDP in Lebanon, which is associated with various correlates. Selecting the appropriate tools to assess PIDP and providing patient education regarding the risks associated with potentially inappropriate medications are issues to be addressed among older adults.

Polypharmacy and associated factors: a gender perspective in the elderly Spanish population (2011-2020)

Background: Few studies have examined the epidemiology of polypharmacy in non-institutionalized elderly adults with regard to sex differences. This study aimed to identify the prevalence of polypharmacy among people ≥65 years old residing in Spain, analyze trends in that prevalence from 2011/12 to 2020, describe the use of the medicines involved and study the possible relationship between polypharmacy and certain sociodemographic, health-related variables, as well as the use of care services by sex. Methods: A nationwide cross-sectional study with 21,841 non-institutionalized people ≥65 years old from the Spanish National Health Survey (2011/2012 and 2017) and the European Health Survey in Spain (2014 and 2020) was performed. We used descriptive statistics, performing two binary logistic regressions to determine the factors related to polypharmacy. Results: The prevalence of polypharmacy was 23.2% (women: 28.1%, men: 17.2%; p < 0.001). The most commonly consumed medicines were analgesics and tranquillizers, relaxants or sleeping pills in elderly women, compared with antihypertensives, antacids and antiulcer drugs and statins for elderly men. In both sexs, the positive predictors of polypharmacy included average, poor and very poor self-perceived states of health, people with overweight and obesity, being severely/non-severely limited due to a health problem, having ≥ three chronic conditions, visits to the family doctor and hospitalization. Among elderly women, negative predictors were alcohol intake, whereas in elderly men positive predictors were being 75-84 years old, being current smokers and having 1, 2 chronic conditions. Conclusion: Polypharmacy has a prevalence of 23.2%, with women accounting for 28.1% and men 17.2% of the total. Knowledge of positive and negative predictors of polypharmacy have important implications for public health efforts to develop or improve health guidelines and strategies for promoting the proper use of medication, particularly in the elderly population by sex.

Comparative analysis of potentially inappropriate medication use in long-term care facility residents and community-dwelling elders: A matched cohort study

As the population of the elderly in long-term care facilities has grown, the number of users of potentially inappropriate medication (PIM) is also increasing. With this study, we aimed to investigate the pattern of PIM usage and related factors among the elderly receiving long-term care services. Using the South Korean National Health Insurance Service Elderly Cohort Database, we conducted a retrospective matched cohort study. Elderly residents (n = 1980) in long-term care facilities in 2013 were selected and matched 1:1 with elderly persons living in the community applying propensity score method. The matching variables were sex, age, health insurance type, long-term care grade, Charlson's Comorbidity Index score, presence of dementia, cerebrovascular disease, or Parkinson's disease, and number of drugs prescribed. PIM use was assessed according to Beers criteria 2019. The prevalence of PIM was found to be higher among the elderly in long-term care facilities (86.77%) than among community-dwelling individuals (75.35%). Logistic regression showed that long-term care facility residents were 1.84 odds more likely to use PIM than community-dwelling older adults. We also confirmed that the average number of medications taken per day and the number of outpatient visits were the major influencing factors affecting PIM prescriptions. In addition, elders living in long-term care facilities were prescribed more PIM drugs acting on the central nervous system than community-dwelling older adults. The results of this study show that among those receiving long-term care services, older people in long-term care facilities use PIM more than do the elderly living at home. Medication management programs need to be developed to reduce the use of PIM in long-term care facilities.

Characteristics of Japanese Older Adults Whose Trunk Muscle Mass Decreased during the COVID-19 Pandemic

The coronavirus (COVID-19) pandemic significantly affected the physical and mental functions in older adults, resulting in "corona-frailty". This 2-year prospective study characterized changes in quantitative measures and corona-frailty among a cohort of community-dwelling older women. Changes were evaluated using face-to-face interactions with 39 Japanese women (mean age: 76.1 ± 5.9) in 2019 (pre-pandemic baseline) and 2021 (follow-up during the pandemic). Quantitative measurements of handgrip strength, walking speed, calf circumference, body composition, and background factors were evaluated. Body weight and trunk muscle mass significantly decreased at follow-up. Multiple regression analysis, using change in trunk muscle mass as the dependent variable and background factors as independent variables, identified that decrease in trunk muscle mass was associated with "being robust at baseline" and answering "Yes" to the question of "Do you go out less frequently compared with last year"? The 2-year trunk muscle mass change for each baseline frailty stage showed a significant decrease only in the robust group (-8.0%). The decrease in trunk muscle mass might be related to pandemic-induced lifestyle restraint, suggesting that robust older adults who are healthy and active should take measures that focus on trunk muscles to avoid "corona-frailty".

Probiotics Treatment Can Improve Cognition in Patients with Mild Cognitive Impairment: A Systematic Review

Background: In recent years, the existence of the gut-brain axis and the impact of intestinal microbiota on brain function has received much attention. Accumulated evidence has prompted the postulation of the infectious hypothesis underlying or facilitating neurodegenerative diseases, such as Alzheimer’s disease. Under this hypothesis, intervention with probiotics could be useful at a preventive and therapeutic level. Objective: The objective of this systematic review is to reveal a benefit of improved cognitive function following the use of probiotics in individuals with mild cognitive impairment. Methods: We searched bibliographic databases and analyzed in detail the evidence and methodological quality of five recent randomized, double-blind, placebo-controlled clinical trials using the Cochrane Tool and the SIGN checklist. Results: Overall, and with satisfactory methodological quality, the studies evaluated support the use of probiotics as a weapon to slow the progression of cognitive decline in subjects with mild cognitive impairment. The literature review also indicates that maximum benefit of probiotics is found in subjects with incipient cognitive dysfunction and has no effect in those with advanced disease or absence of disease. Conclusion: These results support the intervention with probiotics, especially as a preventive approach. However, caution is required in the interpretation of the results as microbiota has not been evaluated in all studies, and further large-scale research with a prolonged study period is necessary to ensure the translatability of the results into real practice.

Preventing frailty with the support of a home-monitoring and communication platform among older adults-a study protocol for a randomised-controlled pilot study in Sweden

Background

POSITIVE (i.e. maintaining and imPrOving the intrinSIc capaciTy Involving primary care and caregiVErs) is a new intervention program consisting of home-monitoring equipment and a communication platform to support treatment of frailty symptoms initially in primary care and prevent disability in older adults.

Methods

The primary objectives are to estimate the potential efficacy of the POSITIVE system on improving frailty in at least one point in Fried’s criteria and five points in Frailty Trait Scale. The secondary objectives are to (A) assess the recruitment, retention, drop-out rates, compliance with the intervention and the intervention mechanisms of impact; (B) evaluate the usability and acceptance of the POSITIVE system, and to get estimations on; (C) the potential efficacy of the intervention on improving the participants’ physical performance, cognitive functions, mood, independency level in activities in daily living, the impact on quality of life and number of falls during the follow-up period; (D) the impact on the caregiver quality of life and caregiver burden; and (E) on the consumption of health care resources, participants’ perception of health and level of care received, and healthcare professionals’ workload and satisfaction.

A randomised controlled, assessor-blinded pilot study design recruiting from a primary care centre in Stockholm Region will be conducted. Fifty older adults identified as pre-frail or frail will be randomised into a control or an intervention group. Both groups will receive a medical review, nutritional recommendations and Vivifrail physical exercise program. The intervention group will receive the POSITIVE-system including a tablet, the POSITIVE application and portable measurement devices. The participants receiving the POSITIVE program will be monitored remotely by a primary care nurse during a 6-month follow-up. Data will be collected at baseline, 3 and 6 months into the intervention though the platform, standardised assessments and surveys. A process evaluation as per Medical Research Council guidance will be conducted after the 6-month follow-up period.

Discussion

The implications of the study are to provide estimations on the potential efficacy of the POSITIVE system in improving frailty among older adults and to provide relevant data to inform powered studies of potential efficacy and effectiveness, as well as to inform about the feasibility of the current study design.

Trial registration

ClinicalTrials.gov. Registration number: NCT04592146. October 19, 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01147-4.

Comparisons in polypharmacy over a decade in community-dwelling older adults-findings from Israel national health and nutrition surveys

Background

Polypharmacy increases with age and is associated with serious health and economic costs. This study reports changes over a decade in medication-use patterns and polypharmacy, in Israeli community-dwelling older adults aged ≥ 65 years.

Methods

Demographic and health data from two representative national health cross-sectional surveys – MABAT ZAHAV 1 (MZ1) in 2005–2006, and MZ2 in 2014–2015 were analyzed. Polypharmacy was defined as use of ≥ 5 medications. Risk factors for polypharmacy were estimated by multivariable logistic regression with adjusted odds ratios (aOR) and their 95% confidence intervals (CI).

Results

Self-reported data on medications taken were available for 1647 participants (91.5%) in MZ1, and for 833 participants (80.2%) in MZ2, 55% women, and about 20% aged ≥ 80, in both surveys. The prevalence of polypharmacy was significantly lower in MZ2 than in MZ1: 64.2% versus 56.3%, p = .0001; with an aOR (95%CI) of 0.64 (0.52, 0.80). The most commonly taken drugs were for hypertension (27.0%, 25.3%), dyslipidemia (9.7%, 12.4%) and anticoagulation (9.2%, 9.8%). For approximately 10% of drugs, indications were either unknown or incorrect. Polypharmacy was significantly associated with poor self-health assessment 2.47 (1.99, 3.06), ≥ 4 versus 1–3 chronic illnesses 6.36 (3.85, 10.50), and age ≥ 80 versus younger 1.72 (1.32, 2.24). Similar associations were observed with major polypharmacy of ≥ 8 medications.

Conclusion

Polypharmacy, although reduced in the last decade, requires constant attention, especially concerning lack of knowledge of indications which leads to poor adherence and adverse side effects. Health-care teams should carry out regular medicine reconciliation in at-risk elderly patients.

Improving individualized prescription in patients with multimorbidity through medication review

Background

Older patients tend to have multimorbidity, represented by multiple chronic diseases or geriatric conditions, which leads to a growing number of prescribed medications. As a result, pharmacological prescription has become a major concern because of the increased difficulties to ensure appropriate prescription in older adults. The study’s main objectives were to characterize a cohort of older adults with multimorbidity, carry out a medication review and compare the pharmacological data before and after the medication review globally and according to the frailty index.

Methods

This was a quasi-experimental (uncontrolled pre-post) study with a cohort of patients ≥ 65 years old with multimorbidity. Data were collected from June 2019 to October 2020. Variables assessed included demographic, clinical, and pharmacological data, degree of frailty (Frail-VIG index), medication regimen complexity index, anticholinergic and or sedative burden index, and monthly drug expenditure. Finally, a medication review was carried out by an interdisciplinary team (primary care team and a consultant team with a geriatrician and a clinical pharmacist) by applying the Patient-Centered Prescription model to align the treatment with care goals.

Results

Four hundred twenty-eight patients were recruited [66.6% women; mean age 85.5 (SD 7.67)]. The mean frail index was 0.39 (SD 0.13), corresponding with moderate frailty. Up to 90% of patients presented at least one inappropriate prescription, and the mean of inappropriate prescriptions per patient was 3.14 (SD 2.27). At the three-month follow-up [mortality of 17.7% (n = 76)], the mean chronic medications per patient decreased by 17.96%, varying from 8.13 (SD 3.87) to 6.67 (SD 3.72) (p < 0.001). The medication regimen complexity index decreased by 19.03%, from 31.0 (SD 16.2) to 25.1 (SD 15.1), and the drug burden index mean decreased by 8.40%, from 1.19 (SD 0.82) to 1.09 (SD 0.82) (p < 0.001). A decrease in polypharmacy, medication regimen complexity index, and drug burden index was more frequent among frail patients, especially those with severe frailty (p < 0.001).

Conclusions

An individualized medication review in frail older patients, applying the Patient-Centered Prescription model, decreases pharmacological parameters related to adverse drug effects, such as polypharmacy, therapeutical complexity, and anticholinergic and, or sedative burden. The benefits are for patients with frailty.

Individualized Medication Review in Older People with Multimorbidity: A Comparative Analysis between Patients Living at Home and in a Nursing Home

(1) Background: aging is associated with complex and dynamic changes leading to multimorbidity and, therefore, polypharmacy. A periodic medication review (MR) in frail older people leads to optimizing medication use. The aims of the study were to perform a comparative analysis of the impact of place of residence (own home versus nursing home) in a cohort of older patients on the characteristics of the baseline therapeutic plan and characteristics of the therapeutic plan after an MR; (2) Methods: Study with paired pre- and post-MR data based on person-centred prescription, with a follow-up assessment at three months. Patients who lived either in their own home or in a nursing home were recruited. We selected patients of 65 years or more with multimorbidity whose General Practitioner identified difficulties with the prescription management and the need for an MR. Each patient’s treatment was analysed by applying the Patient-Centred Prescription (PCP) model; (3) Results: 428 patients. 90% presented at least one inappropriate prescription (IP) in both settings. In nursing homes, a higher number of implemented optimization proposals was detected (81.6% versus 65.7% (p < 0.001)). After the MR, nursing-home patients had a greater decrease in their mean number of medications, polypharmacy prevalence, therapeutic complexity, and monthly drug expenditure (p < 0.001); (4) Conclusions: PCP model detected a high number of IP in both settings. However, after an individualized MR, nursing-home patients presented a greater decrease in some pharmacological parameters related to adverse events, such as polypharmacy and therapeutic complexity, compared to those living at home. Nursing homes may be regarded as a highly suitable scenario to carry out a periodic MR, due to its high prevalence of frail people and its feasibility to apply the recommendations of an MR. Prospective studies with a robust design should be performed to demonstrate this quasi-experimental study along with a longitudinal follow-up on clinical outcomes.

What Is the Relationship between Lifestyle and Frailty Status? Data from the Portuguese Multicentre Descriptive Study

This observational and descriptive study attempted, within the scope of the ModulEn Research Project, to determine associations between lifestyle-related variables and frailty involving 160 community-dwelling older adults aged between 65 and 80 years living in the Central Region of Portugal. Forty-three percent of the study participants were pre-frail and 18% were frail. More than 50% of the frail people had slight cognitive decline, and the frailty condition was more frequently observed in women. As the literature highlights, there is potential for greater reversibility in the pre-frailty condition. To contribute to this reversibility, it is necessary to resort to interventions that promote physical activity and cognitive stimulation, apply adequate eating habits, and/or encourage the adoption of an active and socially integrated lifestyle. A healthy lifestyle implies good sleep and eating habits, and correct metabolic control that allows for effective surveillance of dyslipidemia, diabetes, and blood pressure.

Frailty and In-Hospital Mortality Risk Using EHR Nursing Data

PurposeThe purpose of this study was to evaluate four definitions of a Frailty Risk Score (FRS) derived from EHR data that includes combinations of biopsychosocial risk factors using nursing flowsheet data or International Classification of Disease, 10th revision (ICD-10) codes and blood biomarkers and its predictive properties for in-hospital mortality in adults ≥50 years admitted to medical-surgical units. Methods In this retrospective observational study and secondary analysis of an EHR dataset, survival analysis and Cox regression models were performed with sociodemographic and clinical covariates. Integrated area under the ROC curve (iAUC) across follow-up time based on Cox modeling was estimated. Results The 46,645 patients averaged 1.5 hospitalizations (SD = 1.1) over the study period and 63.3% were emergent admissions. The average age was 70.4 years (SD = 11.4), 55.3% were female, 73.0% were non-Hispanic White (73.0%), mean comorbidity score was 3.9 (SD = 2.9), 80.5% were taking 1.5 high risk medications, and 42% recorded polypharmacy. The best performing FRS-NF-26-LABS included nursing flowsheet data and blood biomarkers (Adj. HR = 1.30, 95% CI [1.28, 1.33]), with good accuracy (iAUC = .794); the reduced model with age, sex, and FRS only demonstrated similar accuracy. The poorest performance was the ICD-10 code-based FRS. Conclusion The FRS captures information about the patient that increases risk for in-hospital mortality not accounted for by other factors. Identification of frailty enables providers to enhance various aspects of care, including increased monitoring, applying more intensive, individualized resources, and initiating more informed discussions about treatments and discharge planning.

An evaluation of the appropriateness of prescribing and frailty in elderly patients using STOPP criteria and Frailty Index in tertiary care teaching hospital

People above 65 years of age would amount to 10.7% of total population of India by 2021. India has acquired the label of ‘an ageing nation’ with 7.7% of its population being more than 60 years old. Geriatric patients are exposed to potentially inappropriate medications (PIMs) thus strategies to improve quality of life and safety of prescribing is needed. One such explicit criteria tool is ‘Screening Tool of Older person’s Potentially inappropriate Prescriptions’ (STOPP) criteria. For older individuals, frailty plays a decisive role. Frailty assessment is useful for identification of risk stratifications to assist in clinical decision makings. Hence, this study is aimed to assess the percentage of PIM using STOPP criteria and correlation between PIMS and Frailty Index (FI) in elderly patients in our setting. An observational study was done in 60 patients in department of medicine at tertiary care teaching hospital. Demographic details, diagnosis and current medications were recorded in Microsoft excel 2016. PIMs based on STOPP criteria version 2 and FI suggested by Searle et al. was calculated and analyzed. Spearman rank correlation test was used to check the correlation between FI and PIM. Out of 60 prescriptions, 21 prescriptions with PIM were found. Most common drugs prescribed as PIM were Aspirin, calcium, ceftriaxone, multivitamin B complex and furosemide. FI was analyzed by using 34 variables. Value of FI was between 0.03 to 0.17. Spearman Rank correlation test showed direct low degree of significant correlation between FI and PIM with correlation (r) value of 0.1602 (P value=0.02). 35% of prescriptions were having at least one PIM in our study and we found that there was direct association between FI and PIM which will help us to reduce potential medication errors, drug interactions and adverse reactions.

Interventions to improve medicines optimisation in frail older patients in secondary and acute care settings: a systematic review of randomised controlled trials and non-randomised studies

Background: Frailty is a geriatric syndrome in which physiological systems have decreased reserve and resistance against stressors. Frailty is associated with polypharmacy, inappropriate prescribing and unfavourable clinical outcomes. Aim: To identify and evaluate randomised controlled trials (RCTs) and non-randomised studies of interventions designed to optimise the medications of frail older patients, aged 65 years and over, in secondary or acute care settings. Method: Literature searches were conducted across seven electronic databases and three trial registries from the date of inception to October 2021. All types of interventional studies were included. Study selection, data extraction, risk of bias and quality assessment were conducted by two independent reviewers. Results: Three RCTs were eligible for inclusion; two employed deprescribing as the intervention, and one used comprehensive geriatric assessment. All reported significant improvements in prescribing appropriateness. One study investigated the effect of the intervention on clinical outcomes including hospital presentations, falls, fracture, quality of life and mortality, and reported no significant differences in these outcomes, but did report a significant reduction in monthly medication cost. Two of the included studies were assessed as having ‘some concerns’ of bias, and one was judged to be at ‘high risk’ of bias. Conclusion: This systematic review demonstrates that medicines optimisation interventions may improve medication appropriateness in frail older inpatients. However, it highlights the paucity of high-quality evidence that examines the impact of medicines optimisation on quality of prescribing and clinical outcomes for frail older inpatients. High-quality studies are needed to address this gap.

Factors Associated with the Detection of Inappropriate Prescriptions in Older People: A Prospective Cohort

(1) Background: Ageing is associated with complex and dynamic changes leading to multimorbidity and, therefore, polypharmacy. The main objectives were to study an older community-dwelling cohort, to detect inappropriate prescriptions (IP) applying the Patient-Centred Prescription model, and to evaluate the most associated factors. (2) Methods: This was a prospective, descriptive, and observational study conducted from June 2019 to October 2020 on patients ≥ 65 years with multimorbidity who lived in the community. Demographic, clinical and pharmacological data were assessed. Variables assessed were: degree of frailty, using the Frail-VIG index; therapeutical complexity and anticholinergic and sedative burden; and the number of chronic drugs to determine polypharmacy or excessive polypharmacy. Finally, a medication review was carried out through the application of the Patient-Centred Prescription model. We used univariate and multivariate regression to identify the factors associated with IP. (3) Results: We recruited 428 patients (66.6% women; mean age 85.5, SD 7.67). A total of 50.9% of them lived in a nursing home; the mean Barthel Index was 49.93 (SD 32.14), and 73.8% of patients suffered some degree of cognitive impairment. The prevalence of frailty was 92.5%. Up to 90% of patients had at least one IP. An increase in IP prevalence was detected when the Frail-VIG index increased (p < 0.05). With the multivariate model, the relationship of polypharmacy with IP detection stands out above all. (4) Conclusions: 90% of patients presented one IP or more, and this situation can be detected through the PCP model. Factors with higher association with IP were frailty and polypharmacy.

Usability, User Experience, and Acceptance Evaluation of CAPACITY: A Technological Ecosystem for Remote Follow-Up of Frailty

Frailty predisposes older persons to adverse events, and information and communication technologies can play a crucial role to prevent them. CAPACITY provides a means to remotely monitor variables with high predictive power for adverse events, enabling preventative personalized early interventions. This study aims at evaluating the usability, user experience, and acceptance of a novel mobile system to prevent disability. Usability was assessed using the system usability scale (SUS); user experience using the user experience questionnaire (UEQ); and acceptance with the technology acceptance model (TAM) and a customized quantitative questionnaire. Data were collected at baseline (recruitment), and after three and six months of use. Forty-six participants used CAPACITY for six months; nine dropped out, leaving a final sample of 37 subjects. SUS reached a maximum averaged value of 83.68 after six months of use; no statistically significant values have been found to demonstrate that usability improves with use, probably because of a ceiling effect. UEQ, obtained averages scores higher or very close to 2 in all categories. TAM reached a maximum of 51.54 points, showing an improvement trend. Results indicate the success of the participatory methodology, and support user centered design as a key methodology to design technologies for frail older persons. Involving potential end users and giving them voice during the design stage maximizes usability and acceptance.

Polypharmacy Is Significantly and Positively Associated with the Frailty Status Assessed Using the 5-Item FRAIL Scale, Cardiovascular Health Phenotypic Classification of Frailty Index, and Study of Osteoporotic Fractures Scale

The aim of this study was to investigate the association between frailty and polypharmacy using three different frailty screening tools. This was a cross-sectional study of people aged ≥65 years. Participants were included and interviewed using questionnaires. Polypharmacy was defined as the daily use of eight or more pills. Frailty was assessed using a screening tool, including (1) the Fatigue, Resistance, Ambulation, Illness and Loss of Weight Index (5-item FRAIL scale), (2) the Cardiovascular Health Phenotypic Classification of Frailty (CHS_PCF) index (Fried’s Frailty Phenotype), and (3) the Study of Osteoporotic Fracture (SOF) scale. A total of 205 participants (mean age: 71.1 years; 53.7% female) fulfilled our inclusion criteria. The proportion of patients with polypharmacy was 14.1%. After adjustments were made for comorbidity or potential confounders, polypharmacy was associated with frailty on the 5-item FRAIL scale (adjusted odds ratio [aOR]: 9.12; 95% confidence interval [CI]: 3.6–23.16), CHS_PCF index (aOR: 8.98; 95% CI: 2.51–32.11), and SOF scale (aOR: 6.10; 95% CI: 1.47–25.3). Polypharmacy was associated with frailty using three frailty screening tools. Future research is required to further enhance our understanding of the risk of frailty among older adults.

Prevalence and direct costs of potentially inappropriate prescriptions in France: a population-based study

BACKGROUND

Potentially inappropriate prescriptions (PIPs) in the older population remain a growing public health concern due to the many associated adverse events increasing healthcare service use and health costs. This study aimed to assess the prevalence and direct costs of PIPs in older adults aged ≥65 years in France.

METHODS

A population-based cross-sectional study was conducted in 2017 using a representative sample of the French national healthcare reimbursement system database. PIPs were defined using the French REMEDI[e]S tool. Overall reimbursed direct costs and by PIP category were extrapolated to the French older population.

RESULTS

The overall PIP prevalence was estimated at 56.7% (95% CI: 56.4-57.0). Medications with an unfavorable benefit/risk ratio had the highest prevalence (34.0%, 95% CI: 33.7-34.3). Direct costs associated with PIPs represented 6.3% of the total reimbursed medication costs in 2017 (€507 million). Drug duplications were the main contributors to these costs (39.2% of the total reimbursed PIP costs, €199 million) and among all PIPs, proton pump inhibitors (>8 weeks) were the most expensive PIPs (€152 million).

CONCLUSIONS

PIP prevalence is still high among French older adults, with substantial direct costs. Large-scale interventions targeting the most prevalent and/or costly PIPs are needed to reduce their clinical and economic impacts.

Analysis of the regional difference in the number of multi-drug prescriptions and its predictors in Japan, 2015-2018

Objective

Polypharmacy and multi-drug prescription are major public health problems in Japan, but only a few studies have investigated the regional differences. By revealing regional differences in the multi-drug prescriptions, we can infer regions with high rates of multimorbidity or inappropriate prescribing. This study revealed regional differences in multi-drug prescriptions (the number of simultaneous prescriptions of seven or more internal medicines) and investigated the factors affecting the difference using the National Database of Health Insurance Claims and Specific Health Checkups of Japan data.

Results

The standardized claim ratio (SCR) of the number of multi-drug prescriptions, which corrected the difference in sex and age distribution of prefectures, varied depending on prefectures. A panel data analysis investigating the association between the SCR and explanatory variables (Medical institutions, socioeconomic factors, and physical characteristics of people in prefectures) revealed that the number of public assistance recipients per 1,000 persons was positively and significantly associated with the SCR (Standardized partial regression coefficient = 0.244, p-value = 0.038). In conclusion, regional differences in the number of the multi-drug prescriptions were revealed in Japan, suggesting that public assistance recipients tend to experience multi-drug prescriptions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-021-05787-2.

Assessing Prevalence and Factors Related to Frailty in Community-Dwelling Older Adults: A Multinomial Logistic Analysis

Frailty is an age-related clinical condition that typically involves a deterioration in the physiological capacity of various organ systems and heightens the patient’s susceptibility to stressors. For this reason, one of the main research goals currently being addressed is that of characterising the impact of frailty in different settings. The main aim of this study is to determine the prevalence of Fried’s frailty phenotype among community-dwelling older people and to analyse the factors associated with frailty. In this research study, 582 persons aged 65 years or more participated in this cross-sectional study that was conducted at primary healthcare centres in Málaga, Spain. Sociodemographic, clinical, functional and comprehensive drug therapy data were compiled. The relationship between the independent variables and the different states of frailty was analysed by using a multinomial logistic regression model. Frailty was present in 24.1% of the study sample (95% CI = 20.7–27.6) of whom 54.3% were found to be pre-frail and 21.6% were non-frail. The study variable most strongly associated with frailty was the female gender (OR = 20.54, 95% CI = 9.10–46.3). Other factors found to be associated with the state of frailty included age, dependence for the instrumental activities of daily living (IADL), polymedication, osteoarticular pathology and psychopathology. This study confirms the high prevalence of frailty among community-dwelling older people. Frailty may be associated with many factors. Some of these associated factors may be preventable or modifiable and, thus, provide clinically relevant targets for intervention. This is particularly the case for depressive symptoms, the clinical control of osteoarthritis and the use of polypharmacy.

The cross-sectional association of frailty with past and current exposure to strong anticholinergic drugs

BACKGROUND

Anticholinergic drugs may contribute to frailty by impairing cognitive and physical functions. Strong anticholinergic drugs in particular may have adverse effects among older adults.

OBJECTIVES

Determine the association between frailty and the use of strong anticholinergic drugs among older US Veterans.

METHODS

This is a cross-sectional study of community-dwelling Veterans 65 years and older who had determinations of frailty status. Prescription data for patients using strong anticholinergic medications (never/past/current) was obtained via electronic health records. A 31-item VA Frailty Index (VA-FI) was generated at the time of the assessment. We dichotomized the groups into non-frail (FI =  < 0.21) and frail (FI ≥ 0.21) patients. We used binomial logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (CIs). Frailty was the dependent variable and use of strong anticholinergic drugs was the independent variable. Multivariate adjustment was conducted for age, gender, race, ethnicity, marital status, and BMI.

RESULTS

Population sample consisted of 17,084 Veterans who were 71.05% Caucasian, 97.34% male, and with a mean age 75.60 (SD = 8.04) years. Among the population, 9940 (58.18%) patients had no previous use of strong anticholinergic drugs, whereas 5182 (30.33%) had past exposure and 1962 (11.49%) had current exposure. In binomial logistic regression, individuals with past (OR 3.27, 95% CI 3.03-3.54, p < 0.0005) or current (OR 4.78, 95% CI 4.30-5.31, p < 0.0005) exposure showed a higher association with frailty as compared to individuals who were never exposed.

CONCLUSIONS

Past and current use of strong anticholinergic drugs were associated with frailty in older Veterans. These results suggest that screening for frailty in patients with past or current exposure to strong anticholinergic medications may be necessary for proper management.

Polypharmacy in chronic neurological diseases: Multiple sclerosis, dementia and Parkinson's disease

Polypharmacy is an important aspect of medication management and particularly affects elderly and chronically ill people. Patients with dementia, Parkinson's disease (PD) or multiple sclerosis (MS) are at high risk for multimedication due to their complex symptomatology. Our aim was to provide an overview of different definitions of polypharmacy and to present the current state of research on polypharmacy in patients with dementia, PD or MS. The most common definition of polypharmacy in the literature is the concomitant use of ≥5 medications (quantitative definition approach). Polypharmacy rates of up to >50% have been reported for patients with dementia, PD or MS, although MS patients are on average significantly younger than those with dementia or PD. The main predictor of polypharmacy is the complex symptom profile of these neurological disorders. Potentially inappropriate medication (PIM), drug-drug interactions, poor treatment adherence, severe disease course, cognitive impairment, hospitalisation, poor quality of life, frailty and mortality have been associated with polypharmacy in patients with dementia, PD or MS. For patients with polypharmacy, either the avoidance of PIM (selective deprescribing) or the substitution of PIM with more suitable drugs (appropriate polypharmacy) is recommended to achieve a more effective therapeutic management.

'Fitting in the pharmacist' - a qualitative analysis of the perceived relationship between community pharmacists and older adults with complex care needs

OBJECTIVES

To explore the current perceived relationship between older adults with varying levels of frailty and healthcare needs and community pharmacists.

METHODS

This qualitative study conducted a thematic analysis of focus groups with older adults and older adult caregivers and community pharmacist participants. Participants were recruited following a maximum variation sampling technique. Verbatim transcripts were inductively coded using NVivo to develop key findings.

KEY FINDINGS

Four major themes emerged: (i) Pharmacy Landscape, (ii) Prescription and Non-Prescription Drug Safety, (iii) Patient-Pharmacist Relationship and (iv) Recommendations for Pharmacy Practice. Themes demonstrate three key findings: (1) older adults approach drug information with a key focus on safety and cost of both prescription and non-prescription drugs, (2) there is a demonstrated opportunity, recognized by older adults and practitioners, for community pharmacists to expand their role in the care of older adults, (3) community pharmacists are able, interested and/or have already incorporated frailty assessments into their practice to better support their care of the older adult population with varying levels of frailty.

CONCLUSIONS

The results demonstrate a reason for the community pharmacist role to shift. The unique knowledge and skills of community pharmacists, coupled with their accessibility and strong patient-clinician relationship, have the potential to better support older adults with varying levels of frailty.

No impact of a prescription booklet on medication consumption in nursing home residents from 2011 to 2014: a controlled before-after study

Background

Older persons are particularly exposed to adverse events from medication. Among the various strategies to reduce polypharmacy, educational approaches have shown promising results. We aimed to evaluate the impact on medication consumption, of a booklet designed to aid physicians with prescriptions for elderly nursing home residents.

Methods

Among 519 nursing homes using an electronic pill dispenser, we recorded the daily number of times that a drug was administered for each resident, over a period of 4 years. The intervention group comprised 113 nursing homes belonging to a for-profit geriatric care provider that implemented a booklet delivered to prescribers and pharmacists and specifically designed to aid with prescriptions for elderly nursing home residents. The remaining 406 nursing homes where no such booklet was introduced comprised the control group. Data were derived from electronic pill dispensers. The effect of the intervention on medication consumption was assessed with multilevel regression models, adjusted for nursing home status. The main outcomes were the average daily number of times that a medication was administered and the number of drugs with different presentation identifier codes per resident per month.

Results

96,216 residents from 519 nursing homes were included between 1 January 2011 and 31 December 2014. The intervention group and the control group both decreased their average daily use of medication (− 0.05 and − 0.06). The booklet did not have a statistically significant effect (exponentiated difference-in-differences coefficient 1.00, 95% confidence interval 0.99–1.02, P = .45).

Conclusion

We observed an overall decrease in medication consumption in both the control and intervention groups. Our analysis did not provide any evidence that this reduction was related to the use of the booklet. Other factors, such as national policy or increased physician awareness, may have contributed to our findings.

Electronic supplementary material

The online version of this article (10.1007/s40520-020-01670-5) contains supplementary material, which is available to authorized users.

Effect of number of medications and use of potentially inappropriate medications on frailty among early-stage older outpatients

Background

Frailty is an urgent concern among an aging population worldwide. However, the relationship between frailty and number and types of medications has not been studied in detail among early-stage older patients, and it is unclear what prescriptions may have a role in preventing frailty. This study aimed to clarify the effects of number of medications and use of potentially inappropriate medications (PIMs) on frailty among early-stage older outpatients in Japan.

Methods

A cross-sectional study was undertaken. Frailty scores and medications of outpatients aged 65–74 years who regularly visited community pharmacies were investigated. Frailty scores were classified as 0 (non-frailty), 1–2 (pre-frailty), and ≥ 3 (frailty). The association between frailty and number of medications was analyzed by age and compared between PIM use and non-use groups. The proportion of patients who used PIMs was also analyzed by frailty score.

Results

Of 923 older outpatients, 49 (5.3%) and 318 (34.5%) patients had frailty and pre-frailty scores, respectively. The numbers of medications among patients with pre-frailty and frailty were significantly higher than among those with non-frailty (p <  0.001 for both). A similar increase was shown for PIM use groups aged 69–71 and 72–74 years, but not for the PIM use group aged 65–68 years and all groups without PIM use. An increasing linear trend was observed for the relationship between the proportion of patients who used any PIM, as well as some subcategories of PIMs (such as NSAIDs, benzodiazepines, loop diuretics and antithrombotic drugs) and frailty score.

Conclusions

Unnecessary medication use among early-stage older outpatients, especially patients aged ≥69 years who use PIMs and many medications, seems to be associated with frailty, but further research is needed to confirm these findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40780-021-00195-x.

Prevalence and impact of potentially inappropriate medication on community-dwelling older adults

INTRODUCTION

Potentially inappropriate medication is associated with adverse health and functional outcomes, as well as increased health care costs.

OBJECTIVE

To estimate the prevalence and types of potentially inappropriate medication according to the Beers criteria in community-dwelling older persons and to identify the major clinical and functional consequences of potentially inappropriate medication during two years of following.

MATERIALS AND METHODS

We conducted a longitudinal, descriptive, and observational study that included 400 65-year or older community-dwelling people (48% women) selected by simple random sampling in 2012. In 2014, 372 people were re-evaluated and classified into two groups based on the presence or absence of potentially inappropriate medication through the follow-up period.

RESULTS

In total, 31% had polypharmacy (5-9 medications) and 1,8% had excessive polypharmacy (10 or more medications). The mean of the number of medications was higher in the potentially inappropriate medication group (3 vs. 5.78; p<0.001) and 21.9% still had the potentially inappropriate medication status during the follow-up; of them, 75% had one potentially inappropriate medication and 23% two. The presence of potentially inappropriate medication was more frequent among frail and depressed male individuals with a bad health self-assessment and comorbidities, especially diabetes mellitus and chronic obstructive pulmonary disease. In the group with sustained potentially inappropriate medication, we found a worsening health self-assessment, increased frailty, a higher incidence of recurrent falls and prevalence of depression, as well as a higher hospital admission rate, ambulatory medical consultation, and more prescribed medications. We did not find an impact on functional capacity.

CONCLUSIONS

We validated the negative effects of potentially inappropriate medication in the long run for the health of older people and, therefore, potentially inappropriate medications should be monitored in primary care services to avoid greater risks.

Polypharmacy among older Brazilians: prevalence, factors associated, and sociodemographic disparities (ELSI-Brazil)

Background:

Polypharmacy has become an increasingly public health issue as population age and novel drugs are developed. Yet, evidence on low- and middle-income countries (LMIC) is still scarce.

Objective:

This work aims to estimate the prevalence of polypharmacy among Brazilians aged 50 and over, and investigate associated factors.

Methods:

A cross-sectional study was conducted using data from the baseline assessment of the Brazilian Longitudinal Study of Aging (ELSI-Brazil), a nationally representative study of persons aged 50 years and older (n=9,412). Univariate and bivariate analyses described the sample. Robust Poisson regression was used to estimate prevalence ratios and predict probabilities of polypharmacy.

Results:

Prevalence of polypharmacy was estimated at 13.5% among older adults in Brazil. Important disparities were observed in regard to gender (16.1% among women and 10.5% among men), race (16.0% among whites and 10.1% among blacks) and geographic region (ranging from 5.1% in the North to 18.7% in the South). The multivariate analysis showed that polypharmacy is associated with various sociodemographic/individual factors (age, gender, race, education, region, health status, body mass index) as well as with several variables of healthcare access/utilization (number of visits, same physician, provider’s knowledge of patient’s medications, gate-keeper, and difficulty managing own medication). Overall, the more utilization of health services, the higher the probability of polypharmacy, after adjusting for all other model covariates.

Conclusions:

Polypharmacy prevalence is relatively low in Brazil, compared to European countries. After controlling for variables of healthcare need and demographic characteristics, there is still substantial residual variance in polypharmacy prevalence. Policies to identify inappropriate prescribing and reduce regional discrepancies are necessary.

Persistence of Effect of Medication Review on Potentially Inappropriate Prescriptions in Older Patients Following Hospital Discharge

BACKGROUND

Potentially inappropriate prescriptions (PIPs) can lead to adverse drug reactions and should be avoided whenever possible.

OBJECTIVE

Our objective was to assess the PIP resumption rate 6 months after discharge from our geriatric unit and to compare it with data in the literature.

METHODS

This single-center observational study included patients aged ≥ 70 years with at least one PIP that had been stopped during hospitalization (according to Screening Tool for Older Persons Prescriptions [STOPP] and Screening Tool to Alert doctors to Right Treatment [START] criteria, version 2) between May 2018 and October 2018. We collected sociodemographic data, medication reconciliation data, and descriptive data during a comprehensive geriatric assessment. Each patient's medication history after discharge was determined in collaboration with their usual community pharmacist.

RESULTS

A total of 125 patients (females 70%, mean age 87.1 years) were included. Data for the admission and discharge medication reconciliations were available for 44 patients (35%). On admission, 121 of the 125 patients (97%) were taking cardiovascular medication. Of the 336 treatments withdrawn, 61 (18.2%) had been re-prescribed at 6 months post-discharge-including half within the first month. The most frequent STOPP criterion was lack of indication (32%), and the overall PIP resumption rate was 22%. According to the anatomical therapeutic chemical (ATC) classification, the main organ system affected by PIPs was the cardiovascular system (47%, with a resumption rate of 17%).

CONCLUSION

Our results highlighted a low PIP resumption rate at 6 months and showed that a collaborative medication review is associated with persistent medium-term medication changes.

Appropriate polypharmacy: a barometer for integrated care

Purpose

Polypharmacy, the concurrent use of multiple medicines by one individual, is a common and growing challenge driven by an ageing population and the growing number of people living longer with chronic conditions. Up to 11% of unplanned hospital admissions in the UK are attributable to, mostly avoidable, harm from medicines. However, this topic is not yet central to integrated practice. This paper reviews the challenge that polypharmacy presents to the health and care system and offers lessons for integrated policy and practice.

Design/methodology/approach

Two commonly encountered scenarios illustrate the relevance of addressing inappropriate polypharmacy to integrated practice. An overview of the literature on polypharmacy and frailty, including two recent large studies of policy and practice in Europe, identifies lessons for practitioners, managers, policy makers and commissioners.

Findings

Comprehensive change strategies should extend beyond pharmacist led deprescribing initiatives. An inter-professional and systems thinking approach is required, so all members of the integrated team can play their part in realising the value of holistic prescribing, appropriate polypharmacy and shared decision making.

Practical implications

Awareness and education about polypharmacy should be embedded in inter-professional training for all practitioners who care for people with multimorbidity or frailty.

Originality/value

This paper will help policy makers, commissioners, managers and practitioners understand the value of addressing polypharmacy within their integrated services. Best practice national guidance developed in Scotland illustrates how to target resources so those at greatest risk of harm from polypharmacy can benefit from effective pharmaceutical care as part of holistic integrated care.

Medication and healthcare utilization variation among older adults with pain

BACKGROUND

While pain is very common in older adults, the associated impact on daily life, including usage of medication and healthcare, varies considerably and often pain remains inadequately treated. It is not clear what is associated with this variation.

METHODS

Latent class analysis (LCA) is a model-based approach to identifying underlying subgroups in a population. In this study LCA was used to examine biopsychosocial risk classes of adults aged 50 years and older, who were often troubled by pain, from The Irish Longitudinal Study on Ageing (TILDA), (n = 2,896), and the associations with future medication and healthcare use.

RESULTS

Four biopsychosocial risk classes (Low Biopsychosocial Risk, Physical Health Risk, Mental Health Risk, High Biopsychosocial Risk) were identified, with the 'High Biopsychosocial Risk' class accounting for 24% of older adults with pain. This class were much more likely to use medication and healthcare services when followed up across three waves of the TILDA study. In contrast, the Physical Health Risk and the Mental Health Risk classes reported lower usage of medication and healthcare at waves 2 and 3. Amongst the higher risk classes of older adults who are troubled by pain, there is considerable consumption of medication and healthcare services evident.

CONCLUSION

Given our ageing population and significant number of adults in this high risk class, there is a need to optimize current pain management approaches among older adults. Intensive non-pharmacological approaches to pain management in older adults, tailored to individual biopsychosocial risk indicators for each individual class, may be worth exploring.

SIGNIFICANCE

While pain is very common in older adults, the usage of medication and healthcare varies considerably and often pain remains inadequately treated. Given our ageing population and the significant number of older adults reporting high biopsychosocial risk (24%), there is a need to optimize current pain management approaches. Intensive non-pharmacological approaches to pain management in older adults, tailored to individual biopsychosocial risk indicators for each individual class, may be worth exploring.

Potentially Inappropriate Medications and Polypharmacy: A Study of Older People with Mild Cognitive Impairment and Mild Dementia

BACKGROUND

With multimorbidity increasing among older people, polypharmacy and the use of potentially inappropriate medications (PIMs) are assuming a prominent role in the life of the geriatric population.

OBJECTIVE

To investigate the association of polypharmacy and PIM use with a wide range of factors in older people with mild cognitive impairment (MCI) to mild dementia.

METHODS

The study population comprised 160 outpatients with a Clinical Dementia Rating of 0.5-1 and a Mini-Mental State Examination score of 20-30. Patients were classified as receiving polypharmacy when they took ≥5 different medications at the same time. PIMs were identified using the STOPP-J criteria. Cognitive, neuropsychological, nutritional, and physical function tests were performed and body measurements taken. Quality of life (QOL) was assessed using both components of the EQ-5D scale, the index score and the visual analogue scale (QOL VAS). A comorbidity index was calculated for all participants.

RESULTS

PIM use was significantly associated with lower scores on the verbal fluency (initial letters) test and QOL index. Participants receiving polypharmacy showed an increased likelihood of worse frailty status and lower QOL VAS score. The number of medications was significantly associated with a worse frailty status.

CONCLUSION

In a geriatric population with MCI to mild dementia, PIM use was associated with lower verbal fluency (initial letters) score and lower QOL, while the presence of polypharmacy was correlated with a worse frailty status and lower QOL. The number of medicines, instead, was correlated with a worse frailty status only.

Evidence of association between the use of drugs and community-dwelling older people frailty: a cross-sectional study

BACKGROUND

The scientific literature has shown that an association between polypharmacy and frailty exists. However, few studies have also considered drug interactions and the use of potentially inappropriate medications.

OBJECTIVE

To evaluate the association between the use of drugs and frailty among community-dwelling older people.

DESIGN AND SETTING

Cross-sectional study carried out among 580 older people in Uberaba (MG).

METHODS

Data were collected at these older people's homes using instruments validated in Brazil. Descriptive, bivariate and binary logistic regression analyses were performed (P < 0.05).

RESULTS

Most of these individuals were classified as pre-frail (55.7%), while 13.1% were frail. It was found that 31.7% of them presented polypharmacy, 41.7% had drug interactions and 43.8% were using potentially inappropriate medications. In the initial model, polypharmacy (odds ratio, OR = 1.91; confidence interval, CI = 1.27-2.86) and use of potentially inappropriate medications (OR = 2.45; CI = 1.68-3.57) increased the chance that these older people would be pre-frail or frail. In the final adjusted model, use of potentially inappropriate drugs remained associated with the outcome (OR = 2.26; CI = 1.43-3.57).

CONCLUSION

Use of potentially inappropriate medications was the independent variable that explained the occurrence of frailty in a representative sample of community-dwelling older adults.

The Double Burden of the COVID-19 Pandemic and Polypharmacy on Geriatric Population - Public Health Implications

COVID-19 pandemic is inducing acute respiratory distress syndrome, multi-organ failure, and eventual death. Respiratory failure is the leading cause of mortality in the elderly population with pre-existing medical conditions. This group is particularly vulnerable to infections due to a declined immune system, comorbidities, geriatric syndrome, and potentially inappropriate polypharmacy. These conditions make the elderly population more susceptible to the harmful effects of medications and the deleterious consequences of infections, including MERS-CoV, SARS-CoV, and SARS-CoV-2. Chronic diseases among elderlies, including respiratory diseases, hypertension, diabetes, and coronary heart diseases, present a significant challenge for healthcare professionals. To comply with the clinical guidelines, the practitioner may prescribe a complex medication regimen that adds up to the burden of pre-existing treatment, potentially inducing adverse drug reactions and leading to harmful side-effects. Consequently, the geriatric population is at increased risk of falls, frailty, and dependence that enhances their susceptibility to morbidity and mortality due to SARS-CoV-2 respiratory syndrome, particularly interstitial pneumonia. The major challenge resides in the detection of infection that may present as atypical manifestations in this age group. Healthy aging can be possible with adequate preventive measures and appropriate medication regimen and follow-up. Adherence to the guidelines and recommendations of WHO, CDC, and other national/regional/international agencies can reduce the risks of SARS-CoV-2 infection. Better training programs are needed to enhance the skill of health care professionals and patient’s caregivers. This review explains the public health implications associated with polypharmacy on the geriatric population with pre-existing co-morbidities during the COVID-19 pandemic.

Low Serum 3-Methylhistidine Levels Are Associated With First Hospitalization in Kidney Transplantation Recipients

BACKGROUND

Low protein intake and increased muscle breakdown are associated with increased mortality risk in patients with kidney transplantation (KT). 3-methylhistidine (3-MH), a nonproteinogenic amino acid residue, is an index of muscle breakdown. the present study investigated the association between serum 3-MH levels and subsequent first hospitalization events in patients with KT.

METHODS

A total of 64 KT patients were enrolled and 43 first hospitalization events occurred. Fasting blood samples were obtained and serum 3-MH level was performed with high-performance liquid chromatography and mass spectrometry. Associations between serum 3-MH levels and first hospitalization over a 5-year follow-up period were examined.

RESULTS

Compared with patients without hospitalization, the 64 patients with KT revealed higher diabetes (P = .012) and hypertension (P = .006) prevalence, higher body fat mass (P = .012) and systolic blood pressure (P = .002), higher serum blood urea nitrogen (BUN) levels (P = .003), and lower serum 3-MH levels (P = .001). Statistical analysis revealed that serum 3-MH (95% confidence interval [CI]: 0.902-0.986, P = .010) and serum BUN (95% CI: 1.003-1.040, P = .022) levels were independently associated with first hospitalization events in patients with KT. Kaplan-Meier analysis showed a greater cumulative incidence of first hospitalization events in the patients with lower 3-MH levels (≤5.91 ng/mL) than that in those with higher 3-MH levels (P = .014; log-rank test).

CONCLUSIONS

Low serum 3-MH levels are associated with increased first hospitalization risk in KT recipients.

Frailty and the Risk of Polypharmacy in the Older Person: Enabling and Preventative Approaches

Frail older people have an inherent risk of polypharmacy due to the need to treat multiple comorbidities, thus leading to various negative effects on their health due to the adverse actions from the drugs. This issue was discussed from a person-centered perspective, highlighting the category of frail older adults who are at a higher risk. Appropriate medication reconciliation in this population with useful prescribing tools (Beers and START/STOPP criteria) to minimize polypharmacy and to provide alternative prescriptive intervention could go alongside primary care to reduce the extent of frailty and polypharmacy. Reducing delayed referrals and extended hospitalization with electronic health record systems and using the signs of frailty from the Electronic Frailty Index (EFI) to predict polypharmacy for frail older persons are preventative approaches that proactively respond to frailty associated with the risk of polypharmacy.

Use of potentially inappropriate medications in institutionalized elderly: prevalence and associated factors

This study aimed to verify the prevalence of the use of Potentially Inappropriate Medications (PIM) for elderly living in Long-Term Care Institutions for the Elderly (LTCIE), as well as the types of medications and their associated factors. This is a cross-sectional study carried out in 10 LTCIEs in the city of Natal in the period October-December 2013. Potentially inappropriate medications were classified according to the 2015 American Geriatric Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults - 2015. Sociodemographic, LTCIE-related and health-related variables were considered. Univariate and multivariate analyses were performed between the primary variable (PIM use) and the independent variables using Poisson regression. The sample consisted of 321 older people, of whom 304 used medications. The prevalence of PIM use was 54.6% (95% CI: 48.9-60.2) and was associated with polypharmacy and dementia in the final model. The most common PIMs were antipsychotics and benzodiazepines. The study revealed a high prevalence of PIM use among the elderly of the LTCIEs, evidencing the need to adopt indicators on the use of these drugs and the implementation of strategies that make drug therapy safer and more adequate for older adults.

Frailty status and increased risk for falls: The role of anticholinergic burden

PURPOSE OF THE STUDY

Frailty leads to serious adverse outcomes including falls. The relationship between frailty and falls has not been evaluated in the context of the side effects of drugs with anticholinergic properties. The aim of this study was to examine the potential association of anticholinergic burden (ACB) with the risk of falls among frail older adults.

DESIGN AND METHODS

Community-dwelling older adults were consecutively selected from the geriatrics outpatient clinic. Based on a fall history in the last 12 months, the participants were grouped as fallers and non-fallers. Frailty status was assessed by Fried's phenotype method. Exposure to anticholinergic medications was estimated using the ACB scale, and the participants were classified into ACB_0 (none), ACB_1 (possible) and ACB_2+ (definite).

RESULTS

The study included 520 older adults (mean age 77.7 years, 62.7 % female), with a fall prevalence of 25.8 % 12 months past. The proportions of frailty and pre-frailty were 33.1 % and 57.4 %, respectively. After adjustment for study confounders, receiving at least 1 drug with either possible or definite anticholinergic properties was independently associated to falls in frail [OR = 3.84 (1.48-9.93), p = 0.006] and pre-frail participants [OR = 2.71 (1.25-5.89); p = 0.012], but not in robust subjects. Moreover, ACB was significantly associated with the frailty components on adjusted analysis (p's<0.05).

IMPLICATIONS

Current study showed that the use of any drugs with possible or definite anticholinergic properties was associated with an increased risk of falls in frail older adults. The results emphasize the importance of medication management with respect to fall prevention in these patients.

The Relationship between Polypharmacy and Physical Activity in Those with or at Risk of Knee Osteoarthritis

OBJECTIVES

Physical activity is associated with improved pain, functional status, and less disability in persons with knee osteoarthritis (KOA). Because polypharmacy is related to several adverse health outcomes in older persons, we hypothesized that it might also be associated with decreased physical activity in those with KOA. This study evaluates the relationship between the number of prescription medications and weekly moderate to vigorous physical activity (MVPA).

DESIGN

We used hierarchical median quantile regression analysis to examine the cross-sectional association between the number of prescription medications taken in the past 30 days and the median objectively measured MVPA minutes controlling for demographic and clinical variables.

SETTING

Four Osteoarthritis Initiative (OAI) recruitment centers in Providence, Rhode Island; Columbus, Ohio; Baltimore, Maryland; and Pittsburgh, Pennsylvania.

PARTICIPANTS

Accelerometer monitoring occurred in 2,127 OAI participants. Of these, 1,889 participants had 4 or more days of valid physical activity monitoring data and complete medication/covariate data. Data were collected at the 48-month OAI follow-up visit (2008-2010).

MEASUREMENTS

The outcome was weekly minutes of MVPA measured with an accelerometer. Number/type of prescribed medications and covariate data (age, sex, race/ethnicity, body mass index, presence of comorbidities, pain, depressive symptoms, and radiographic KOA severity) were taken from the public OAI database. Polypharmacy was defined as taking five or more prescribed medications.

RESULTS

The prevalence of polypharmacy in the study population was 28.2%. Each additional prescription medication was related to a decrease of 3.6 minutes (95% confidence interval [CI] = -4.8 to -2.1) in median weekly MVPA minutes. Participants meeting the polypharmacy criterion exhibited a decrease of 12.6 minutes (95% CI = -21.2 to -4.7) in median weekly MVPA minutes compared with those not meeting the criterion.

CONCLUSION

An increased number of prescription medications and polypharmacy are associated cross-sectionally with decreased MVPA in adults with KOA. Further study is necessary to establish the causal nature of this association.

Potentially Inappropriate Medication Use in Older Adults in the Preoperative Period: A Retrospective Study of a Noncardiac Surgery Cohort

Background

Few studies have evaluated the prevalence of potentially inappropriate medications (PIMs) and its association with postoperative outcomes in a geriatric population in the preoperative setting.

Objectives

The purpose of this study was to evaluate the prevalence of PIMs in an older elective surgery population and to explore associations between PIMs and postoperative length of stay (LOS) and emergency department (ED) visits in the 90 days post hospital discharge, depending on frailty status.

Methodology

We performed a retrospective cohort study of older adults awaiting major elective noncardiac surgery and undergoing an evaluation in the preoperative clinic at a tertiary academic center between 2017 and 2018. We identified PIMs using MedSafer, a software tool built to improve the safety of prescribing. Frailty status was assessed using the 7-point Clinical Frailty Scale. We estimated the association between PIMs and postoperative LOS and ED visits in the 90 days post hospital discharge.

Results

The MedSafer software generated 394 recommendations on PIMs in 1619 medications for 252 patients. In total, 197 (78%) patients had at least one PIM. The cohort included 138 (51%) robust, 87 (32.2%) vulnerable and 45 (16.7%) frail patients. The association between PIMs and LOS was not significant for the robust and frail subgroups. For the vulnerable patients, every additional PIM increased LOS by 20% (incidence rate ratio 1.20; 95% confidence interval 0.90–1.44; p = 0.089) without reaching statistical significance. No association was found between PIMs and ED visits.

Conclusion

PIMs identified by the MedSafer software were prevalent. Preoperative evaluation represents an opportunity to plan deprescribing of PIMs.

Electronic supplementary material

The online version of this article (10.1007/s40801-020-00190-y) contains supplementary material, which is available to authorized users.

Medication exposure and frailty in older community-dwelling patients: a cross-sectional study

Objective To investigate the association between the medication exposure, measured by the polypharmacy/excessive polypharmacy and the anticholinergic and/or sedative drug exposure, on frailty status among French older community-dwelling patients. Setting day-care unit in France (Lyon), with retrospective data from July, 2017 to March, 2018. Method This monocentric cross-sectional study included community-dwelling patients aged 65 years and over and admitted at the day-care unit for a geriatric evaluation. Frailty was assessed according to the frailty phenotype, described by Fried et al. Polypharmacy and excessive polypharmacy were defined as the concomitant use of 5-9 and 10 or more drugs, respectively. The cumulative anticholinergic and sedative exposure was measured using the drug burden index (DBI). The DBI score was presented in 4 differentiated scores: a null score (DBI = 0), a combined score (anticholinergic and sedative score), an anticholinergic score, and a sedative score. The association between medication and frailty was assessed by logistic regression models controlled for multiple potential confounders. Main outcome measure Association between medication exposure (polypharmacy, anticholinergic and sedative exposure) and frailty. Results In this study, 403 patients were included: 44.7% were frail and 40.7% were pre-frail. Polypharmacy and excessive polypharmacy affected 44.7% and 17.1% of the population respectively. The mean DBI was 0.33 ± 0.43, with 16.4% of patients with only sedative exposure, 9.7% with only anticholinergic exposure and 33.0% with both exposures. After adjustment, polypharmacy and excessive polypharmacy were associated with frailty with adjusted odds ratios (95% confidence interval) of 2.18 (1.03-4.22) and 2.72 (1.01-7.37) respectively. The cumulative exposure to anticholinergic and sedative drugs (combined score) was significantly associated to an increased risk for frailty with adjusted odds ratios (95% confidence interval) of 3.54 (1.47-8.57). Conclusion The study showed that polypharmacy and cumulative anticholinergic and sedative exposure are associated with frailty. Further research should address the potential benefit of collaborative medication review for preventing medication-associated frailty.