Polypharmacy in the elderly from the clinical toxicologist perspective

The effectiveness of walking exercise on the bowel preparation before colonoscopy: a single blind randomized clinical trial study

BACKGROUND AND AIM

Bowel preparation is a crucial factor affecting the diagnostic accuracy of colonoscopy, and few randomized control trials evaluated enhancement in bowel preparation. In this study, we aimed to evaluate the effectiveness of walking exercises on bowel preparation before a colonoscopy procedure.

METHODS

The present study is a single-blind randomized controlled trial involving 262 patients scheduled for colonoscopy procedures. These patients were randomly assigned to two groups: an intervention group (n = 131) and a control group (n = 131). In the intervention group, participants followed a predetermined plan that included the consumption of specific liquids and foods, bisacodyl pills, polyethylene glycol powder, and a regimen of walking exercises in preparation for their colonoscopy. Conversely, individuals in the control group followed the same regimen but were not instructed to engage in walking exercises. On the day of the colonoscopy, both groups were assessed for their level of physical activity using a foot counter. Additionally, an experienced gastroenterologist evaluated and compared the bowel preparation between the two groups using the Boston Bowel Preparation Scale (BBPS).

RESULTS

The number of footsteps recorded in the two groups exhibited a significant difference (P < 0.001). Although there was no statistically significant difference between the intervention and control groups in terms of mean BBPS scores (6.26 ± 1.9 vs. 6.29 ± 1.9, P = 0.416), individuals who took more than 6900 steps had significantly higher BBPS scores compared to those with fewer than 6900 footsteps (6.62 ± 1.8 vs. 5.92 ± 1.9, P = 0.003).In the univariate analysis, BBPS was found to be significantly associated with individuals under the age of 50 (OR: 2.45, 95% CI: 1.30-4.61, P = 0.006) and smoking status (OR: 0.41, 95% CI: 0.17-0.94, P = 0.043). In the multivariate analysis, the relationship between BBPS and age below 50 and smoking remained significant (OR: 2.50, 95% CI: 1.30-4.70, P = 0.005, and OR: 0.38, 95% CI: 0.16-0.93, P = 0.034, respectively).

CONCLUSION

A higher number of footsteps taken especially more than 6900 can significantly enhance bowel preparation; however, walking exercise as an intervention before colonoscopy is not significantly associated with BBPS. Also, older people and smokers seem to have fewer benefits from walking exercises for bowel preparation.

TRIAL REGISTRATION

ISRCTN32724024 (Registration date:22/08/2018).

Risk Factors for Inadequate Bowel Preparation During Colonoscopy in Nigerian Patients

Background The past few decades have witnessed the introduction of various innovative technologies into colon study by colonoscopy. A well-prepared bowel is crucial to their effective utilization. An inadequate bowel preparation during colonoscopy is associated with increased technical difficulties, enhanced risks of perforation, longer examination durations, reduced adenoma detection rates, and additional costs related to repeated colonoscopies. There is a paucity of literature from Africa on the multiple patient factors that affect the quality of bowel preparation; hence, the need to identify patients at risk for inadequate bowel preparation to allow for more diligence in this special group. Aim To study the risk factors of inadequate bowel preparation for colonoscopy and identify the group of patients who need intensified preparation in a Nigerian population. Methods A case-control study of consecutive patients undergoing colonoscopy in an open access/referral-based multi-disciplinary endoscopy facility in Port Harcourt metropolis, Nigeria from March 2014 to November 2020. Consecutive adult patients who underwent colonoscopy with inadequate bowel preparation irrespective of the indication were retrospectively identified. Each case of inadequate bowel preparation while using a particular bowel preparation agent was matched with the next colon study with adequate bowel preparation (control) for the same agent in a 1:1 ratio. The variables collated were age, gender, literacy level, colonoscopy indication, medical history, bowel preparation agent, timing of endoscopy, and outcome. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 25 (IBM Corp., Armonk, NY). Results There were 143 cases of inadequate bowel preparation during colonoscopy included in the study with an equal number of control (cases of adequate bowel preparation). The age of patients ranged from 24 years to 92 years. Bleeding per rectum - 122(42.7%), and screening for colorectal cancer - 67(23.4%), were the leading indications for colonoscopy in study patients. Bivariate analysis of cases and controls revealed significant difference in educational status, comorbidity of hypertension, and constipation (p < 0.01, p = 0.082, p = 0.143, respectively). In the multivariate analysis of risk factors, the odds ratio (OR) for secondary level of education and below was 2.54 (95% confidence interval CI 1.50-4.30; p = 0.001); hypertension - OR 1.64 (95% CI 0.98-2.73; p = 0.058); constipation - OR 1.27 (95% CI 0.52-3.10; p = 0.598). Conclusion The educational status of patients is a strong risk factor associated with inadequate bowel preparation for colonoscopy in this Nigerian population. There is a need for effective patient education especially for patients with a low literacy level.

[Outpatient care for the old and very old]

BACKGROUND

Outpatient treatment of elderly patients is the responsibility of the family doctor. In addition to general practitioner care, there are some regionally different models that are currently not established and evaluated in Germany. The investigation presented here aims to contribute to the profiling of outpatient geriatric care in the future.

METHOD

A full survey on the attitude and acceptance of general practitioners towards outpatient geriatrics and a geriatric focus practice was carried out. At the same time, referral and advisory events were systematically recorded and compared.

RESULTS AND CONCLUSION

A geriatric focus practice can complement primary care. It is well accepted by many family doctors if there is a transparent exchange, pilot function and basic family doctor activities remain with the family doctor and he is relieved of the burden on complex patients.

Predictors and colonoscopy outcomes of inadequate bowel cleansing: a 10-year experience in 28,725 patients

Background:

Inadequate bowel preparation is still the main obstacle to a complete colonoscopy in many patients and necessitates many repeated procedures. We aimed to identify risk factors associated with inadequate bowel preparation and to better characterize these patients.

Methods:

This was a retrospective study that reviewed electronic reports of colonoscopy procedures over a 10-year period. Patients were divided into 2 groups: adequate vs. non-adequate bowel preparation. A multivariate analysis was performed to identify variables associated with inadequate bowel preparation, including age, sex, setting (inpatient/outpatient), preparation regimen and procedures’ indications. We examined the effect of inadequate preparation on colonoscopy quality indicators.

Results:

Of the 28,725 patients included in the study, 6,702 (23.3%) had inadequate bowel preparation. In the multivariate analysis, advanced age (odds ratio [OR] 1.015, 95% confidence interval [CI] 1.013-1.017; P<0.01), male sex (OR 1.353, 95%CI 1.286-1.423; P<0.01) and a minority population (OR 1.635, 95%CI 1.531-1.746; P<0.01) were significantly associated with inadequate bowel preparation. The inpatient setting was among the most prominent factors associated with inadequate bowel preparation (OR 2.018, 95%CI 1.884-2.163; P<0.01). Adequate bowel preparation was associated with a higher polyp detection rate (26.8% vs. 23.6%; OR 1.22, 95%CI 1.109-1.347; P<0.01) and colorectal cancer (2.8% vs. 2.4%; OR 1.402, 95%CI 1.146-1.716; P<0.01), and higher frequencies of cecal (96.4% vs. 73.5%; OR 2.243, 95%CI 2.095-2.403; P<0.01) and terminal ileum intubation (8.1% vs. 5.4%; OR 1.243, 95%CI 1.088-1.434; P<0.01).

Conclusion:

We outlined various factors associated with inadequate bowel preparation and confirmed its adverse effect on colonoscopy quality indicators.

Survival of the elderly and exposition to polypharmacy in the city of São Paulo, Brazil: SABE Study

INTRODUCTION

The use of polypharmacy may be due to the concomitant presence of chronic conditions, medical care by several doctors simultaneously and self-medication. Combined with the vulnerability of the elderly to the effects of drugs due to pharmacokinetic and pharmacodynamic changes, polypharmacy makes this population more susceptible to adverse outcomes. In Brazil, studies show that polypharmacy is a common problem among elderly people. However, few information is available on the association between polypharmacy and mortality.

OBJECTIVE

It was assessed the survival of the elderly from São Paulo city exposed to the use of polypharmacy (five or more medications).

METHODS

That was a population-based cohort, the Health, Well-Being and Aging Study (SABE Study), conducted from 2006 to 2010. The sample was composed of 1,258 individuals aged 60 years or more. The Kaplan-Meier method and Cox proportional risks model were used to examine the association between polypharmacy and mortality.

RESULTS

The probability of survival after five years of the users of polypharmacy at baseline was 77.2%, while among the non-users was 85.5%. Polypharmacy remained as a risk factor for death even after adjustment in other conditions associated with mortality, such as age, gender, income, chronic diseases and hospitalization.

CONCLUSION

The results point polypharmacy as an indicator of mortality in elderly people. The use of multiple medications by the elderly should be carefully assessed to avoid or minimize the damage to this population.

Number of medications and adverse drug events by unintentional poisoning among older adults in consideration of inappropriate drug use: a Swedish population-based matched case-control study

PURPOSE

This national, population-based study aims to determine the association between the number of prescribed medications and adverse drug events (ADE) by unintentional poisoning and examine this risk when known indicators of inappropriate drug use (IDU) are accounted for.

METHODS

We employed a matched case-control design among people living in Sweden who were 50 years and older. Cases experiencing an ADE by unintentional poisoning resulting in hospitalization or death (n = 5336) were extracted from the National Health and Death Registers from January 2006 to December 2009. Four controls per case matched by age, sex and residential area were randomly selected among those without an ADE (n = 21,344). Prescribed medications dispensed during the 4-month period prior to the ADE were identified via the Swedish Prescribed Drug Register and coded according to the number of different dispensed medications (NDDM) (0 to 10 medications) and IDU indicators (one single-drug, and three drug-combinations). Conditional logistic regression was used.

RESULTS

Each of the IDU indicators was significantly associated with very high risks of ADE. For NDDM, we found a lower but graded positive association from two to ten or more medications (adjusted OR, 1.5; 95% CI, 1.2-1.8). Exclusion of IDU from the NDDM decreased the risk of ADE, but the effects remained significant for three or more medications (adjusted OR excl. IDU, 1.5; 95% CI, 1.2-2.0).

CONCLUSION

At population level, the number of different dispensed medications starting from three or more remains associated with ADE even after adjusting for known IDUs. Clinicians and patients need to be made aware of the increased likelihood of serious ADE, not only in case of documented inappropriate medications but also in the case of an increasing number of medications.

Relationship between sleep disturbances and multimorbidity among community-dwelling men and women aged 65-93 years: results from the KORA Age Study

BACKGROUND/OBJECTIVE

Although the association of disturbed sleep with specific chronic conditions is well known, the relationship between sleep disturbances and multiple diseases is less clear. Therefore, the objectives of this study were to examine the independent relationships of various sleep disturbances with 1) multimorbidity (≥2 chronic conditions) and 2) commonly co-occurring pairs of chronic conditions.

METHODS

Analyses were based on data from 4127 individuals aged ≥65 years participating in the population-based cross-sectional Cooperative Health Research in the Region of Augsburg (KORA) Age Study conducted from 2008 to 2009 in Germany. Sex-specific odds ratios (OR) and 95% confidence intervals (CI) were calculated from sequential logistic regression models.

RESULTS

Neither short nor long daily sleep duration was significantly associated with multimorbidity among men; a significant positive relationship was identified regarding short sleep duration among women (OR 2.16, 95% CI: 1.42-3.30). While insomnia and all unique symptoms of insomnia were connected to multimorbidity among women in the multivariable models, the relationship concerning trouble falling asleep no longer remained significant after adjustment for all covariables among men. Regarding commonly co-occurring pairs of conditions, the clearest associations were observed between insomnia and daytime tiredness with joint diseases/eye diseases in men and joint diseases/heart diseases in women.

CONCLUSIONS

There seems to be sex-specific particularities in the relationship between sleep disturbances and sleep duration with multimorbidity and commonly co-occurring pairs of chronic conditions in older adults from the general population.

Predictors of Inadequate Bowel Preparation and Salvage Options on Colonoscopy

Inadequate bowel preparation is observed in more than 25% of all colonoscopies. Identification of predictive factors for inadequate colon cleaning is helpful and more detailed preparation methods should be used for patients at high risk. Age, male sex, inpatient status, and comorbidities were identified as independent risk factors in several previous studies. In patients with insufficient colon preparation, colon irrigation with endoscopic pumps or next-day colonoscopy following further bowel cleaning should be performed. In order to improve the efficacy and safety of both bowel preparation and colonoscopy, the endoscopic team should identify the patient’s medical conditions and choose the optimal bowel preparation agent and regimen.

Optimizing polypharmacy among elderly hospital patients with chronic diseases--study protocol of the cluster randomized controlled POLITE-RCT trial

Background

Treatment of patients with multimorbidity is challenging. A rational reduction of long-term drugs can lead to decreased mortality, less acute hospital treatment, and a reduction of costs. Simplification of drug treatment schemes is also related to higher levels of patient satisfaction and adherence. The POLITE-RCT trial will test the effectiveness of an intervention aiming at reducing the number of prescribed long-term drugs among multimorbid and chronically ill patients. The intervention focuses on the interface between primary and secondary health care and includes a pharmacist-based, patient-centered medication review prior to the patient’s discharge from hospital.

Methods

The POLITE-RCT trial is a cluster randomized controlled trial. Two major secondary health care providers of Mecklenburg-Western Pomerania, Germany, take part in the study. Clusters are wards of both medical centers. All wards where patients with chronic diseases and multimorbidity are regularly treated will be included. Patients aged 65+ years who take five or more prescribed long-term drugs and who are likely to spend at least 5 days in the participating hospitals will be recruited and included consecutively. Cluster-randomization takes place after a six-month baseline data collection period. Patients of the control group receive care as usual. The independent two main primary outcomes are (1) health-related quality of life (EQ-5D) and (2) the difference in the number of prescribed long-term pharmaceutical agents between intervention and control group. The secondary outcomes are appropriateness of prescribed medication (PRISCUS list, Beers Criteria, MAI), patient satisfaction (TSQM), patient empowerment (PEF-FB-9), patient autonomy (IADL), falls, re-hospitalization, and death. The points of measurement are at admission to (T0) and discharge from hospital (T1) as well as 6 and 12 months after discharge from the hospital (T2 and T3). In 42 wards, 1,626 patients will be recruited.

Discussion

In case of positive evaluation, the proposed study will provide evidence for a sustainable reduction of polypharmacy by enhancing patient-centeredness and patient autonomy.

Trial registration

Current Controlled Trials ISRCTN42003273

Association between sleep disturbances and falls among the elderly: results from the German Cooperative Health Research in the Region of Augsburg-Age study

OBJECTIVE

We aimed to examine the association between various sleep disturbances and falls among older individuals from the general population while considering the influence of age and dizziness.

METHODS

Data were derived from the population-based cross-sectional KORA (Cooperative Health Research in the Region of Augsburg)-Age study, whereby information was conducted in standardized telephone interviews with 4127 men and women aged ⩾65years in 2008 and 2009. Unstratified and stratified (by age and dizziness) multivariable logistic regression model analyses were performed.

RESULTS

The multivariable analysis showed a marginally significant association between trouble staying asleep and ⩾1 fall in the previous year (odds ratio [OR], 1.23 [95% confidence interval (CI), 1.01-1.50]). This association was more pronounced in participants older than the age of 75years (OR, 1.58 [95% CI, 1.16-2.16]) and in individuals without dizziness (OR, 1.35 [95% CI, 1.04-1.76]). There was no association between daytime sleepiness and falls in the fully-adjusted models, but the odds of falls in the previous year in individuals older than the age of 75years were significantly higher for individuals with difficulty falling asleep. Although sleep duration was not associated with falls in multivariable analyses when stratified by dizziness, sleep duration of 9h daily was significantly associated with higher odds of experiencing at least one fall in the previous year.

CONCLUSIONS

Our study suggested that the positive relationship between a trend towards longer sleep duration, trouble falling and staying asleep, and falls is strongest in older individuals and in individuals who did not experience dizziness in the previous year.

The next therapeutic challenge in HIV: polypharmacy

With the adoption of combination antiretroviral therapy (ART), most HIV-infected individuals in care are on five or more medications and at risk of harm from polypharmacy, a risk that likely increases with number of medications, age, and physiologic frailty. Established harms of polypharmacy include decreased medication adherence and increased serious adverse drug events, including organ system injury, hospitalization, geriatric syndromes (falls, fractures, and cognitive decline) and mortality. The literature on polypharmacy among those with HIV infection is limited, and the literature on polypharmacy among non-HIV patients requires adaptation to the special issues facing those on chronic ART. First, those aging with HIV infection often initiate ART in their 3rd or 4th decade of life and are expected to remain on ART for the rest of their lives. Second, those with HIV may be at higher risk for age-associated comorbid disease, further increasing their risk of polypharmacy. Third, those with HIV may have an enhanced susceptibility to harm from polypharmacy due to decreased organ system reserve, chronic inflammation, and ongoing immune dysfunction. Finally, because ART is life-extending, nonadherence to ART is particularly concerning. After reviewing the relevant literature, we propose an adapted framework with which to address polypharmacy among those on lifelong ART and suggest areas for future work.

Factors influencing quality of bowel preparation for colonoscopy

Recent technological advances in colonoscopy have led to improvements in both image enhancement and procedural performance. However, the utility of these technological advancements remain dependent on the quality of bowel preparation during colonoscopy. Poor bowel preparation has been shown to be associated with lower quality indicators of colonoscopy performance, such as reduced cecal intubation rates, increased patient discomfort and lower adenoma detection. The most popular bowel preparation regimes currently used are based on either Polyethylene glycol-electrolyte, a non-absorbable solution, or aqueous sodium phosphate, a low-volume hyperosmotic solution. Statements from various international societies and several reviews have suggested that the efficacy of bowel preparation regimes based on both purgatives are similar, although patients’ compliance with these regimes may differ somewhat. Many studies have now shown that factors other than the type of bowel preparation regime used, can influence the quality of bowel preparation among adult patients undergoing colonoscopy. These factors can be broadly categorized as either patient-related or procedure-related. Studies from both Asia and the West have identified patient-related factors such as an increased age, male gender, presence of co-morbidity and socio-economic status of patients to be associated with poor bowel preparation among adults undergoing routine out-patient colonoscopy. Additionally, procedure-related factors such as adherence to bowel preparation instructions, timing of bowel purgative administration and appointment waiting times for colonoscopy are recognized to influence the quality of colon cleansing. Knowledge of these factors should aid clinicians in modifying bowel preparation regimes accordingly, such that the quality of colonoscopy performance and delivery of service to patients can be optimised.