The Association Between Polypharmacy and Physical Function in Older Adults: a Systematic Review

Pre-clinical Models for Geriatric Pharmacotherapy

With ageing of the population worldwide and discovery of new medications for prevention and management of age-related conditions, there is increasing use of medications by older adults. There are international efforts to increase the representativeness of participants in clinical trials to match the intended real-world users of the medications across a range of characteristics including age, multimorbidity, polypharmacy and frailty. Currently, much of the data on medication-related harm in older adults are from pharmacovigilance studies. New methods in pre-clinical models have allowed for measurement of exposures (such as chronic exposure, polypharmacy and deprescribing) and outcomes (such as health span functional measures and frailty) that are highly relevant to geriatric pharmacotherapy. Here we describe opportunities for design and implementation of pre-clinical models that can better predict drug effects in geriatric patients. This could improve the translation of new drugs from bench to bedside and improve outcomes of pharmacotherapy in older adults.

Predictors of basic and instrumental activities of daily living among older adults with multiple chronic conditions

BACKGROUND

Understanding the predictors of functional status can be useful for improving modifiable predictors or identifying at-risk populations. Researchers have examined the predictors of functional status in older adults, but there has not been sufficient study in this field in older adults with multiple chronic conditions, especially in Iran. Consequently, the results of this body of research may not be generalizable to Iran. Therefore, this study was conducted to determine the predictors of functional status in Iranian older adults with multiple chronic conditions.

METHODS

In this cross-sectional study, 118 Iranian older adults with multiple chronic conditions were recruited from December 2022 to September 2023. They were invited to respond to questionnaires inquiring about their demographic and health information, basic activities of daily living (BADL) and instrumental activities of daily living (IADL), depression and cognitive status. The predictors included age, gender, marital status, education, number of chronic conditions, and depression. Descriptive and analytical statistical tests (univariate and multiple regression analysis) were used to analyze the data.

RESULTS

The majority of participants were married (63.9%) and women (59.3%). Based on the results of the multiple regression analysis, age (B=-0.04, P = 0.04), depression (B=-0.12, P = 0.04), and IADL (B = 0.46, P < 0.001) were significant predictors for functional status in terms of BADL. Also, marital status (B=-0.51, P = 0.05), numbers of chronic conditions (B=-0.61, P = 0.002), and BADL (B = 0.46, P < 0.001) were significant predictors for functional status in terms of IADL.

CONCLUSION

The findings support the predictive ability of age, marital status, number of chronic diseases, and depression for the functional status. Older adults with multiple chronic conditions who are older, single, depressed and with more chronic conditions number are more likely to have limitations in functional status. Therefore, nurses and other health care providers can benefit from the results of this study and identify and pay more attention to the high risk older adult population.

Topic evolution before fall incidents in new fallers through natural language processing of general practitioners' clinical notes

BACKGROUND

Falls involve dynamic risk factors that change over time, but most studies on fall-risk factors are cross-sectional and do not capture this temporal aspect. The longitudinal clinical notes within electronic health records (EHR) provide an opportunity to analyse fall risk factor trajectories through Natural Language Processing techniques, specifically dynamic topic modelling (DTM). This study aims to uncover fall-related topics for new fallers and track their evolving trends leading up to falls.

METHODS

This case-cohort study utilised primary care EHR data covering information on older adults between 2016 and 2019. Cases were individuals who fell in 2019 but had no falls in the preceding three years (2016-18). The control group was randomly sampled individuals, with similar size to the cases group, who did not endure falls during the whole study follow-up period. We applied DTM on the clinical notes collected between 2016 and 2018. We compared the trend lines of the case and control groups using the slopes, which indicate direction and steepness of the change over time.

RESULTS

A total of 2,384 fallers (cases) and an equal number of controls were included. We identified 25 topics that showed significant differences in trends between the case and control groups. Topics such as medications, renal care, family caregivers, hospital admission/discharge and referral/streamlining diagnostic pathways exhibited a consistent increase in steepness over time within the cases group before the occurrence of falls.

CONCLUSIONS

Early recognition of health conditions demanding care is crucial for applying proactive and comprehensive multifactorial assessments that address underlying causes, ultimately reducing falls and fall-related injuries.

Polypharmacy and Healthcare Service Use Among Prescription Opioid Poisoning Cases Age 50

Objectives: To examine relationships between polypharmacy and level of healthcare service use among prescription opioid poisoning cases age 50 and older. Methods: Data came from the American Association of Poison Control Center's National Poison Data System, 2015-2020. We used multinomial logistic regression to examine the study questions. Results: Of the 77 946 cases with prescription opioid exposures, 64.5% were managed at a healthcare facility (HCF). Of HCF-managed cases, 41.2% were treated/evaluated and released and 21.3% and 37.5% were admitted for noncritical care and critical care, respectively. Medications for cardiovascular disease, benzodiazepines, other types of sedatives/hypnotics, antipsychotics, muscle relaxants, acetaminophen, and gabapentin were associated with increased risk of admission to both noncritical and critical care compared to treatment/evaluation and release. Acetaminophen use had the highest relative risk ratios (RRRs) for noncritical care (1.70, 95% CI = 1.51-1.91) and critical care (1.56, 95% CI = 1.39-1.76). Each additional medication/substance used was associated with 1.14 (95% CI = 1.11-1.17) and 1.19 (95% CI = 1.16-1.22) greater risk of noncritical and critical care admissions, respectively. Conclusions: Among older-adult poison control center cases for prescription opioid exposures, co-use of several commonly prescribed/used medicines was associated with increased risk of admissions to both noncritical and critical care units. Careful monitoring of medication use among older adults who use prescription opioids may reduce the risk of unintentional and intentional opioid poisoning.

Polypharmacy and pattern of medication use among patients with gastroesophageal reflux disease: results from Pars Cohort study

BACKGROUND

Gastroesophageal Reflux Disease (GERD) is a common chronic condition. Its chronic nature may affect the pattern of medication use. This study aimed to investigate the prevalence, associated factors, and patterns of polypharmacy and medication use among GERD patients in southwestern Iran.

METHODS

We used data from the Pars Cohort Study. We classified drugs using the Anatomical Therapeutic Chemical classification system. The Lexicomp® database was used to assess potential drug-drug interactions. Multivariable Poisson regression was applied. Adjusted prevalence ratio (PR) and its 95% confidence interval (CI) were estimated.

RESULTS

A total of 9262 participants were included. Among 2,325 patients with GERD, age-standardized prevalence of polypharmacy was 9.5% (95% CI: 7.5%, 11.6%) in males, and 19.3% (95% CI: 17.2%, 21.4%) in females. The PR of experiencing Polypharmacy by GERD patients compared to non-GERD patients was 1.82 (95% CI: 1.61, 2.05%). Multimorbidity (PR: 3.33; CI: 2.66, 4.15), gender (PR: 1.68; CI: 1.30, 2.18), and metabolic syndrome (PR: 1.77; CI: 1.45, 2.15) were associated with polypharmacy among GERD patients. Drugs for acid-related disorders were the most common used drugs among men, women and elders. We found that 13.9%, 4.2%, and 1.1% of GERD patients had type C, D and X drug interactions, respectively.

CONCLUSION

GERD is correlated with a higher prevalence of polypharmacy. Among GERD patients, females, those with multi-morbidities, and those with metabolic syndrome may be affected more by polypharmacy. Considering the fairly high rate of interactions identified, a review of the medication list is essential when approaching GERD patients, and physicians must check for medications that may worsen GERD.

How Would You Manage This Patient With Heart Failure With Preserved Ejection Fraction? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center

The proportion of patients with new-onset heart failure who have preserved rather than reduced left ventricular ejection fraction (HFpEF and HFrEF) has been increasing over recent decades. In fact, HFpEF now outweighs HFrEF as the predominant heart failure subtype and likely remains underdiagnosed in the community. This is due in part to an aging population and a rise in other risk factors for HFpEF, including obesity and associated cardiometabolic disease. Whereas the diagnosis of HFrEF is relatively straightforward, the diagnosis of HFpEF is often more challenging because there can be other causes for symptoms, including dyspnea and fatigue, and cardinal physical examination findings of elevated jugular venous pressure or pulmonary congestion may not be evident at rest. In 2022, the American College of Cardiology, the American Heart Association, and the Heart Failure Society of America published a comprehensive guideline on heart failure that included recommendations for the management of HFpEF. The use of diuretics for the management of congestion remained the only class 1 (strong) recommendation. New recommendations included broader use of sodium-glucose cotransporter-2 inhibitors (SGLT2i, class 2a), and angiotensin receptor-neprilysin inhibitors (class 2b). In 2023, the American College of Cardiology published an expert consensus decision pathway for the management of HFpEF that suggests treatment strategies based on sex assigned at birth, ejection fraction, clinical evidence of congestion, and candidacy for SGLT2i therapy. Here, 2 experts, a cardiologist and a geriatrician, discuss their approach to the diagnosis and management of HFpEF and how they would apply guidelines to an individual patient.

Reversing frailty in older adults: a scoping review

BACKGROUND

Individuals 65 years or older are presumably more susceptible to becoming frail, which increases their risk of multiple adverse health outcomes. Reversing frailty has received recent attention; however, little is understood about what it means and how to achieve it. Thus, the purpose of this scoping review is to synthesize the evidence regarding the impact of frail-related interventions on older adults living with frailty, identify what interventions resulted in frailty reversal and clarify the concept of reverse frailty.

METHODS

We followed Arksey and O'Malley's five-stage scoping review approach and conducted searches in CINAHL, EMBASE, PubMed, and Web of Science. We hand-searched the reference list of included studies and conducted a grey literature search. Two independent reviewers completed the title, abstract screenings, and full-text review using the eligibility criteria, and independently extracted approximately 10% of the studies. We critically appraised studies using Joanna Briggs critical appraisal checklist/tool, and we used a descriptive and narrative method to synthesize and analyze data.

RESULTS

Of 7499 articles, thirty met the criteria and three studies were identified in the references of included studies. Seventeen studies (56.7%) framed frailty as a reversible condition, with 11 studies (36.7%) selecting it as their primary outcome. Reversing frailty varied from either frail to pre-frail, frail to non-frail, and severe to mild frailty. We identified different types of single and multi-component interventions each targeting various domains of frailty. The physical domain was most frequently targeted (n = 32, 97%). Interventions also varied in their frequencies of delivery, intensities, and durations, and targeted participants from different settings, most commonly from community dwellings (n = 23; 69.7%).

CONCLUSION

Some studies indicated that it is possible to reverse frailty. However, this depended on how the researchers assessed or measured frailty. The current understanding of reverse frailty is a shift from a frail or severely frail state to at least a pre-frail or mildly frail state. To gain further insight into reversing frailty, we recommend a concept analysis. Furthermore, we recommend more primary studies considering the participant's lived experiences to guide intervention delivery.

Polypharmacy, physical activity, and sedentary time in older adults: A scoping review

OBJECTIVE

To map out the studies that have investigated the associations of polypharmacy and/or potentially inappropriate medication (PIM) use with physical activity and sedentary time in older adults.

METHODS

We conducted a literature search from inception to December 2022 in PubMed, Embase, Web of Science, and Scopus.

INCLUSION CRITERIA

observational studies including older adults (≥60 years); English, Portuguese, and Spanish languages; any definition of polypharmacy; implicit and explicit criteria of PIM use; physical activity and/or sedentary time data.

RESULTS

Fourteen cross-sectional studies were included; 11 defined polypharmacy as ≥5 medications (prevalence ranging from 9.5 % to 57 %). No study reported information on PIM use. Most studies included participants aged <80 years. Twelve studies included self-reported measures of physical activity, while two studies used accelerometer-measured physical activity. Ten studies included analyses adjusted for confounders, and nine considered polypharmacy as an outcome. All of them demonstrated an inverse association between physical activity and polypharmacy, irrespective of the definition of polypharmacy and the assessment method employed (self-reported or accelerometry). One study reported an inverse association between polypharmacy (as the exposure) and physical activity (as the outcome). None of the studies investigated the association between sedentary time and polypharmacy.

CONCLUSIONS

Limited evidence suggests an inverse association between physical activity and polypharmacy in older adults. However, the relationship between PIM use, physical activity, and sedentary time remains unknown. Longitudinal studies utilizing objectively-measured physical activity and sedentary time are needed to better clarify the relationship between these movement behaviors and polypharmacy and/or PIM use in older adults.

Medical Cannabis Is Not Associated with a Decrease in Activities of Daily Living in Older Adults

The proportion of older adults using medical cannabis is rising. Therefore, we aimed to assess the effects of herbal medical cannabis on the functional status of older adults. We conducted a prospective observational study of patients aged 65 years or older that initiated cannabis treatment for different indications, mostly chronic non-cancer pain, during 2018-2020 in a specialized geriatric clinic. The outcomes assessed were activities of daily living (ADL), instrumental activities of daily living (IADL), pain intensity, geriatric depression scale, chronic medication use, and adverse events at six months. A cohort of 119 patients began cannabis treatment: the mean age was 79.3 ± 8.5 and 74 (62.2%) were female. Of the cohort, 43 (36.1%) experienced adverse effects due to cannabis use and 2 (1.7%) required medical attention. The mean ADL scores before and after treatment were 4.4 ± 1.8 and 4.5 ± 1.8, respectively (p = 0.27), and the mean IADL scores before and after treatment were 4.1 ± 2.6 and 4.7 ± 3, respectively (p = 0.02). We concluded that medical cannabis in older adults has a number of serious adverse events, but was not associated with a decrease in functional status, as illustrated by ADL and IADL scores after six months of continuous treatment.

Multiparametric Evaluation of Geriatric Patients Admitted to Intermediate Care: Impact on Geriatric Rehabilitation

Optimizing the functional status of patients of any age is a major global public health goal. Rehabilitation is a process in which a person with disabilities is accompanied to achieve the best possible physical, functional, social, intellectual, and relational outcomes. The Intermediate Care Unit within the O.U. of Geriatrics and Gerontology of the San Martino Hospital in Genoa is focused on the treatment and motor reactivation of patients with geriatric pathologies. The objective of this study was to identify which factor, among the characteristics related to the patient and those identified by the geriatric evaluation, had the greatest impact on rehabilitation outcomes. Our findings revealed significant correlations between the Barthel Index delta, the 4AT Screening Test, and the number of drugs taken. This association highlights the potential benefits of medication management in enhancing the overall well-being and functional abilities of frail older adults, despite the literature suggesting that polypharmacotherapy is associated with a reduction in functional status and an increase in mortality. These findings underscore the significance of a multidimensional geriatric assessment. Refining and optimising these multidisciplinary approaches is the objective of a more effective geriatric rehabilitation strategy.

Life's Essential 8: Optimizing Health in Older Adults

The population worldwide is getting older as a result of advances in public health, medicine, and technology. Older individuals are living longer with a higher prevalence of subclinical and clinical cardiovascular disease (CVD). In 2010, the American Heart Association introduced a list of key prevention targets, known as "Life's Simple 7" to increase CVD-free survival, longevity, and quality of life. In 2022, sleep health was added to expand the recommendations to "Life's Essential 8" (eat better, be more active, stop smoking, get adequate sleep, manage weight, manage cholesterol, manage blood pressure, and manage diabetes). These prevention targets are intended to apply regardless of chronologic age. During this same time, the understanding of aging biology and goals of care for older adults further enhanced the relevance of prevention across the range of functions. From a biological perspective, aging is a complex cellular process characterized by genomic instability, telomere attrition, loss of proteostasis, inflammation, deregulated nutrient-sensing, mitochondrial dysfunction, cellular senescence, stem cell exhaustion, and altered intercellular communication. These aging hallmarks are triggered by and enhanced by traditional CVD risk factors leading to geriatric syndromes (eg, frailty, sarcopenia, functional limitation, and cognitive impairment) which complicate efforts toward prevention. Therefore, we review Life's Essential 8 through the lens of aging biology, geroscience, and geriatric precepts to guide clinicians taking care of older adults.

Association between deprescribing from polypharmacy and functional recovery and home discharge among older patients with sarcopenia after stroke

OBJECTIVE

Evidence regarding the association between deprescribing from polypharmacy and outcomes in the convalescent rehabilitation setting is rare. The aim of this study was to assess the association between deprescribing from polypharmacy and functional recovery and home discharge in older patients with sarcopenia after stroke.

METHODS

This retrospective cohort study was conducted at a convalescent rehabilitation hospital from January 2015 to December 2021. Among newly admitted patients in the convalescent rehabilitation ward who had experienced a stroke, patients aged ≥65 y with sarcopenia at admission and who were using at least five medications were included. Sarcopenia was diagnosed according to hand-grip strength and skeletal muscle mass index following the criteria of the Asian Working Group for Sarcopenia 2019. The primary outcome measures were functional independence-measured motor activity (FIM-motor) at discharge and home discharge. Multiple regression analysis was used to determine whether deprescribing from polypharmacy at admission was independently associated with rehabilitation outcomes.

RESULTS

Among the 264 patients with polypharmacy, 153 patients (mean age, 81.1 y; 46.4% males) were diagnosed with sarcopenia and included in the analysis. Of them, 56 (36.6%) were deprescribed from polypharmacy. Deprescribing from polypharmacy was independently associated with FIM-motor at discharge (β, 0.137; P = 0.017) and home discharge (odds ratio, 1.393; P = 0.002).

CONCLUSIONS

Because no effective pharmacotherapy for sarcopenia has been established, the novel findings of this study may be useful in the pharmacotherapy for older patients with sarcopenia after stroke. Deprescribing from polypharmacy on admission was positively associated with functional status at discharge and home discharge in older patients with sarcopenia after stroke.

Associations of Polypharmacy With Clinical Parameters, Function, and Health-Related Quality of Life in Psoriatic Arthritis

OBJECTIVE

The aim of this study was to assess predictors of polypharmacy and its effect on health-related quality of life in patients with psoriatic arthritis (PsA).

METHODS

This cross-sectional study was performed between February and December 2019. The number of medications was grouped into minor (2-4) and major (≥5) polypharmacy. Functional status and quality of life were assessed using the Health Assessment Questionnaire and Short-Form 36, respectively. Clinical and demographic characteristics, physical function, and quality of life of the polypharmacy group were compared. Predictive factors for major polypharmacy were evaluated using a logistic regression analysis.

RESULTS

The mean age of the 100 patients (70 females and 30 males) with PsA was 48.43 ± 12.94 years. The proportion of patients with major polypharmacy was 19%. The physical function subscale of Short-Form 36 was lower in the major polypharmacy group ( p = 0.009). Univariable analysis revealed that sex, body mass index, disease duration, disease activity, psoriasis severity, dactylitis, enthesitis, PsA subtypes, smoking, and Health Assessment Questionnaire were not associated with major polypharmacy ( p > 0.10). In the multivariable model, the number of comorbidities (odds ratio, 3.151; 95% confidence interval, 1.828-5.429; p < 0.001) and age ≥60 years (odds ratio, 4.864; 95% confidence interval, 1.159-20.418; p = 0.031) were significantly associated with major polypharmacy.

CONCLUSIONS

The number of comorbid diseases and age ≥60 years were the factors associated with major polypharmacy in patients with PsA. Although physical function was not associated with polypharmacy, patients with major polypharmacy had poorer quality of life.

Association of Plant Protein Intake with Change in Physical Performance in Chinese Community-Dwelling Older Adults

(1) Background: Dietary protein intake might be beneficial in optimizing physical performance, yet whether this is dependent on protein source and sex is unclear. We examined the association between dietary protein intake and change in physical performance among Chinese community-dwelling older adults. (2) Methods: This prospective study included older Chinese adults (≥65 years) in Hong Kong. Total, plant and animal protein intakes at baseline were assessed using a food frequency questionnaire. Physical performance at baseline and 4-year follow-up were assessed by the time to complete a 6-m walking test. Adjusted linear regression examined the association between total, plant and animal protein intakes (g/kg of body weight (BW)) and 4-year change in physical performance. (3) Results: 3133 participants (49.8% males) aged 71.8 ± 4.9 years were included. In males, total, plant and animal protein intakes were not associated with a change in physical performance. In females, higher plant protein intake was associated with less decline in physical performance (β 0.723, SE 0.288, p = 0.012). No associations were observed for total animal protein intakes. (4) Conclusion: In Chinese community-dwelling older adults, total and animal protein intakes were not associated with a 4-year change in physical performance. Higher plant protein intake was associated with less decline in physical performance in females.

Statins are associated with reduced likelihood of sarcopenia in a sample of heart failure outpatients: a cross-sectional study

BACKGROUND

Sarcopenia is prevalent in heart failure (HF) patients, contributing to its poor prognosis. Statin use is postulated as a probable risk for developing sarcopenia, but little is known regarding this association in HF patients. This work aims at classifying and characterising sarcopenia and at describing the association of statin use with sarcopenia in a sample of Portuguese HF outpatients.

METHODS

In this cross-sectional study, a sample of 136 HF patients (median age: 59 years, 33.8% women) was recruited from an HF outpatients' clinic of a University Hospital in Portugal. Sarcopenia was defined according to the European Working Group on Sarcopenia in Older People 2. Clinical, nutritional, and dietary data were collected.

RESULTS

A total of 25 (18.4%) individuals were categorised as sarcopenic, ranging from 12.2% in younger (< 65 years) participants vs. 30.4% in older ones and from 3.3% in men vs. 47.8% in women. Severe sarcopenia accounted for 7.4% of the sample and sarcopenic obesity was identified in 5.1% of the individuals. A total of 65.4% of the participants were statin users. In multivariable analysis (n = 132, 25 sarcopenic), the use of statins was inversely associated with sarcopenia (OR = 0.03; 95% CI = 0.01, 0.30). Each additional age year was associated with a 9% increase in the likelihood of being sarcopenic (OR = 1.09; 95% CI = 1.01, 1.17), and each Kg.m^-2 increment in body mass index was associated with a 21% decrease in the likelihood of sarcopenia (OR = 0.79; 95% CI = 0.65, 0.96). The daily use of five or more medicines was also directly associated with sarcopenia (OR = 26.87; 95% CI = 2.01, 359.26). On the other hand, being a man and being physically active were inversely associated with sarcopenia (OR = 0.01; 95% CI = 0.00, 0.07 and OR = 0.09; 95% CI = 0.01, 0.65, respectively).

CONCLUSIONS

Contrary to what was expected, patients medicated with statins were less likely to be sarcopenic. Although this finding deserves further research, we hypothesise that this might be related to the pleiotropic effects of statins on endothelial function, contributing to better neuromuscular fitness.

Uses and perceptions of medications among French older adults: results from the 2020 French Health Barometer survey

BACKGROUND

There are few studies reporting on self-medication, perceptions or difficulties older adults have with their medications. This study aimed to describe the uses and the perceptions of medications among older adults in France and to identify patient groups based on that information.

METHODS

We used data from the 2020 'French Health Barometer' - a nationally-representative cross-sectional survey. We assessed polypharmacy (five or more medications), self-medication, and patient perceptions of medications. Robust Poisson regression was used to investigate socio-demographic and health-related factors associated with the outcomes. Latent class analysis was used to identify patient groups classified by the use and the perceptions of medications. Factors associated with group assignment were investigated by multinomial logistic regression. All analyses were weighted.

RESULTS

The study sample comprised 1,623 respondents aged 70-85 years. Polypharmacy and self-medication were reported in 23.5 and 48.7% of the older population, respectively. Polypharmacy was associated with increasing age, low education, and impaired health status. Self-medication was associated with female sex and high education. Among individuals taking at least 1 medication, 8.2% reported not to understand all their medications, and 9.7% having difficulty taking medications as prescribed. Among individuals taking at least 2 medications, 23.2% thought that they took too many medications. Three patient groups were identified: 'Non-polypharmacy, positive perceptions' (62.5%), 'Polypharmacy, positive perceptions' (28.0%), and 'Negative perceptions' (9.5%).

CONCLUSIONS

Polypharmacy and self-medication are common in French older adults. One segment of people reported negative perceptions of their medications regardless of their polypharmacy status. This underlines the difference between the objective and perceived measures of polypharmacy.

The Prevalence of Low Handgrip Strength and Its Predictors among Outpatient Older Adults in a Tertiary Care Setting: A Cross-Sectional Study

Background: Low muscle strength is linked to several adverse health outcomes. However, there are limited data regarding its prevalence and associated factors in Thai older adults. This study aimed to fill that gap. Methods: This cross-sectional study was conducted with patients aged ≥ 60 years at the outpatient clinic of the internal medicine department of a tertiary care hospital from April 2020 to December 2021. Patient characteristics were collected, and a handgrip dynamometer was used to measure handgrip strength (HGS). Low HGS was defined according to the 2019 recommendations of the Asian Working Group for Sarcopenia. Results: In total, 198 patients were recruited. The prevalence of low HGS was 51%. Median HGS was 17.8 kg and 27.7 kg in women and men, respectively. Every age per year increase, greater number of medications of any type, and lower Montreal Cognitive Assessment (MoCA) score were independent factors associated with low HGS, with adjusted odds ratios of 1.1, 1.2, and 0.9, respectively. Conclusions: Low HGS was prevalent among older patients in this setting, indicating a high degree of possible sarcopenia. As there were some modifiable factors associated with low HGS, routine measurement, medication review, and cognitive evaluation are recommended for early diagnosis and management.

Over- and under-prescribing, and their association with functional disability in older patients at risk of further decline in Germany - a cross-sectional survey conducted as part of a randomised comparative effectiveness trial

Background

Older patients at risk of functional decline are frequently affected by polypharmacy. This is associated with a further loss of independence. However, a relationship between functional disability and medications, such as ‘Potentially Inappropriate Medications’ (PIMs) and ‘Potential Prescribing Omissions’ (PPOs), as itemised for (de) prescribing in practice-orientated medication lists, has yet to be established.

Methods

As part of a randomised comparative effectiveness trial, LoChro, we conducted a cross-sectional analysis of the association between PIMs and PPOs measured using the ‘Screening Tool of Older Persons’ Prescription Criteria / Screening Tool To Alert to Right Treatment’ (STOPP/START) Version 2, with functional disability assessed using the ‘World Health Organization Disability Assessment Schedule 2.0’ (WHODAS). Individuals aged 65 and older at risk of loss of independence were recruited from the inpatient and outpatient departments of the local university hospital. Multiple linear regression analysis was used to model the potential prediction of functional disability using the numbers of PIMs and PPOs, adjusted for confounders including multimorbidity.

Results

Out of 461 patients, both the number of PIMs and the number of PPOs were significantly associated with an increase in WHODAS-score (Regression coefficients B 2.7 [95% confidence interval: 1.5-3.8] and 1.5 [95% confidence interval: 0.2-2.7], respectively). In WHODAS-score prediction modelling the contribution of the number of PIMs exceeded the one of multimorbidity (standardised coefficients beta: PIM 0.20; multimorbidity 0.13; PPO 0.10), whereas no significant association between the WHODAS-score and the number of medications was seen. 73.5 % (339) of the participants presented with at least one PIM, and 95.2% (439) with at least one PPO. The most common PIMs were proton pump inhibitors and analgesic medication, with frequent PPOs being pneumococcal and influenza vaccinations, as well as osteoporosis prophylaxis.

Conclusions

The results indicate a relationship between inappropriate prescribing, both PIMs and PPOs, and functional disability, in older patients at risk of further decline. Long-term analysis may help clarify whether these patients benefit from interventions to reduce PIMs and PPOs.

Body composition and functional performance of older adults

Objectives

To determine if anthropometric variables, body composition, medication and gender are associated with functional performance and to compare these variables between octogenarians with high and low functional performance.

Methods

Observational, cross-sectional study. Weight, height, body mass index (BMI), waist circumference (WC), and waist-to-height ratio (WHtR) were evaluated. Handgrip strength (HGS) was assessed. Participants' body composition was assessed by dual-energy X-ray absorptiometry (DXA) and functional performance by Short Physical Performance Battery (SPPB). A binomial logistic regression was performed.

Results

One hundred and twenty-two octogenarians were included and separated into high and low function groups. The high function group showed lower values of WHtR (mean difference [MD] = 0.047, P = 0.025) and body fat (BF%) (MD = 3.54, P = 0.032) and higher values of apendicular skeletal muscle mass (ALM) (MD = 3.03, P = 0.001), HGS (MD = 6.11, P = 0.001) and SPPB score (MD = 4.20, P = 0.001). Women were more likely to be classified as low function (OR = 3.66, P = 0.002) and males showed 5.21 odds ratio (P = 0.021) of having high functional performance compared to females. Also, each decrease in age and medication use displayed 1.30 (P = 0.007) and 1.26 odds ratio increases (P = 0.008) in high functional performance.

Conclusions

Older males display better functional performance than women, and decrements in age and medications increase the high functional performance odds ratio. Octogenarians with high functional performance displayed lower BF measurements and higher values of muscle mass and strength.

Aging and the Prevalence of Polypharmacy and Hyper-Polypharmacy Among Older Adults in South Korea: A National Retrospective Study During 2010–2019

Background: Polypharmacy has become a global health problem and is associated with adverse health outcomes in the elderly. This study evaluated the prevalence of polypharmacy and hyper-polypharmacy in elderly patients in South Korea during 2010–2019.

Methods: We analyzed the outpatient care of persons aged ≥65 years covered by National Health Insurance (NHI) using NHI claims data from 2010 to 2019. Polypharmacy was defined as the use of ≥5 medications, and hyper-polypharmacy was defined as the use of ≥10 medications, and we examined them over periods of ≥90 days and ≥180 days. The average annual percent change (AAPC) was calculated using Joinpoint statistical software.

Results: The prevalence of polypharmacy among ≥90 days of medication use elderly decreased from 42.5% in 2010 to 41.8% in 2019, and the prevalence of hyper-polypharmacy for ≥90 days increased from 10.4% to 14.4%. The prevalence of polypharmacy for ≥180 days increased from 37.8% in 2010 to 38.1% in 2019, and the prevalence of hyper-polypharmacy for ≥180 days increased from 6.4% to 9.4%. The prevalence of polypharmacy for ≥90 days and ≥180 days steadily increased among elderly patients, with AAPCs of 3.7 and 4.5, respectively.

Conclusion: The prevalence of polypharmacy for ≥90 days and ≥180 days remained stably high, with rates of about 42 and 38%, respectively, and hyper-polypharmacy increased over the past 10 years in South Korea. Therefore, strategies to address polypharmacy need to be implemented. Further research is also required to identify the clinical outcomes (including mortality risks) associated with polypharmacy.

Diurnal effects of polypharmacy with high drug burden index on physical activities over 23 h differ with age and sex

Aging, polypharmacy (concurrent use of ≥ 5 medications), and functional impairment are global healthcare challenges. However, knowledge of the age/sex-specific effects of polypharmacy is limited, particularly on daily physical activities. Using continuous monitoring, we demonstrated how polypharmacy with high Drug Burden Index (DBI-cumulative anticholinergic/sedative exposure) affected behaviors over 23 h in male/female, young/old mice. For comparison, we also evaluated how different drug regimens (polypharmacy/monotherapy) influenced activities in young mice. We found that after 4 weeks of treatment, high DBI (HDBI) polypharmacy decreased exploration (reduced mean gait speed and climbing) during the habituation period, but increased it during other periods, particularly in old mice during the transition to inactivity. After HDBI polypharmacy, mean gait speed consistently decreased throughout the experiment. Some behavioral declines after HDBI were more marked in females than males, indicating treatment × sex interactions. Metoprolol and simvastatin monotherapies increased activities in young mice, compared to control/polypharmacy. These findings highlight that in mice, some polypharmacy-associated behavioral changes are greater in old age and females. The observed diurnal behavioral changes are analogous to drug-induced delirium and sundowning seen in older adults. Future mechanistic investigations are needed to further inform considerations of age, sex, and polypharmacy to optimize quality use of medicines.

Sarcopenia and polypharmacy among older adults: A scoping review of the literature

BACKGROUND

Sarcopenia and polypharmacy are both prevalent conditions in the geriatric population, leading to poor quality of life and adverse outcomes.

OBJECTIVE

To explore the evidence on the relationship between sarcopenia and polypharmacy and to summarize the findings and the gaps from the existing literature.

METHOD

A systematic scoping review was conducted between March and May 2021, with no restriction on publication date, using the Arksey and O'Malley framework and reported according to PRISMA-ScR. Four bibliographic databases, PubMed, Web of Science, Scopus, Proquest One Academic, and four sources of gray literature were searched for studies written in English or Greek. Data were extracted quantitatively and using thematic analysis.

RESULTS

Of the 397 initially retrieved records, 22 studies were finally included in this review, 20 published articles and 2 posters-presentations. Most of the studies used cross-sectional data. The relationship between sarcopenia and polypharmacy should be interpreted on the basis of the definition of polypharmacy, the diagnostic criteria of sarcopenia used, and the population setting. Sarcopenia or risk for sarcopenia are associated with polypharmacy or the number of medications in community-dwelling older adults, regardless of diagnostic criteria used for sarcopenia.

CONCLUSION

There is an association between sarcopenia or risk for sarcopenia and polypharmacy or the number of medications in community-dwelling older adults but not among residents of nursing homes or inpatients. Specific widely accepted definitions of polypharmacy and sarcopenia, a consensus on the method of sarcopenia assessment, and prospective studies are needed to identify polypharmacy as a potential risk factor for sarcopenia.

Functional Status among Polymedicated Geriatric Inpatients at Discharge: A Population-Based Hospital Register Analysis

This study explored and compared the functional status of polymedicated and non-polymedicated geriatric inpatients at hospital discharge. We used a cross-sectional registry of geriatric patients' hospital records from a multi-site public hospital center in Switzerland. The analysis included all inpatients aged 65 years old or more admitted between 1 January 2015 and 31 December 2017 (n = 53,690), of whom 67.5% were polymedicated at hospital discharge, 52.1% were women (n = 18,909), and 42.7% were 75-84 years old (n = 15,485). On average, the polymedicated patients' hospital lengths of stay were six days longer, they presented with more than three comorbidities, and they were prescribed more than nine medications at hospital discharge (p < 0.001). They showed more frequent general mobility decline (43.2% vs. 41.9%), gait disorders (46.2% vs. 43%), fatigue (48.6% vs. 43.4%) and dependence on lower-body care (49.7% vs. 47.6%), and presented a higher malnutrition risk (OR = 1.411; 95%CI 1.263-1.577; p < 0.001). However, the non-polymedicated inpatients had proportionally more physical and cognitive impairments. The comparison of the functional status of polymedicated and non-polymedicated geriatric inpatients at hospital discharge is important for clinicians trying to identify and monitor those who are most vulnerable to functional decline, and to design targeted strategies for the prevention of functional impairment and related adverse health outcomes.

Fat-Fit Patterns, Drug Consumption, and Polypharmacy in Older Adults: The EXERNET Multi-Center Study

Background: Physical fitness levels and the amount of accumulated adipose tissue (fatness) relate to current and future individuals’ heath status. Nevertheless, the interrelationships of their combined patterns with polypharmacy and the types of medications consumed have not been sufficiently investigated. Methods: This cross-sectional study was carried out in six Spanish regions between 2008 and 2009 with a sample of older community-dwelling adults (≥65 years old) without dementia or cancer. Fitness was measured with one-leg balance and senior fitness tests, as well as by measuring weight and fat mass with a bioelectrical impedance analyzer. Polypharmacy was defined as the use of five or more medications. An analysis of variance was performed for comparisons between the physical fitness and fatness patterns and the medication consumed. Results: A total of 1709 elders were included in the study (72.1 ± 5.2 years). The two unfit patterns were those with the highest drug consumption. The High-Fat–Unfit pattern was the one that had the most significant consumption and had the highest percentage of polymedicated subjects. The Low-Fat–Fit pattern had a significantly lower percentage of people that did not consume any medications. The highest percentages of drug consumption in 7 of the 10 groups that were included were concentrated in the two unfit patterns. Conclusions: This study highlights the importance of fitness in older adults, as it is at least as important as the avoidance of accumulation of excess fat with respect to the consumption of a smaller number of medicines.

Inappropriate medications and physical function: a systematic review

BACKGROUND AND AIMS

Inappropriate medication prescription is highly prevalent in older adults and is associated with adverse health outcomes. The aim of this study was to examine the associations between potentially inappropriate medications (PIMS) and potential prescribing omissions with physical function in older adults situated in diverse environments.

METHODS

A systematic search was completed using the following databases: MEDLINE, CINAHL, PsycINFO, EMBASE and COCHRANE. Results were extracted from the included studies.

RESULTS

In total, 55 studies reported on 2,767,594 participants with a mean age of 77.1 years (63.5% women). Study designs comprised 26 retrospective cohort studies, 21 prospective cohort studies and 8 cross-sectional studies. Inappropriate medications in community and hospital settings were significantly associated with higher risk of falls (21 out of 30 studies), higher risk of fractures (7 out of 9 studies), impaired activities of daily living (ADL; 8 out of 10 studies) and impaired instrumental ADL (IADL) score (4 out of 6 studies). Five out of seven studies also showed that PIMs were associated with poorer physical performance comprising the Timed Up and Go test, walking speed, grip strength, time to functional recovery, functional independence and scale of functioning. Many medication classes were implicated as PIMs in falls, fractures and impairment in physical performance including antipsychotic, sedative, anti-anxiety, anticholinergic, antidiabetic, opioid and antihypertensive medications. For patients not receiving musculoskeletal medications, such as calcium, vitamin D and bisphosphonates, older adults were found to be at risk of a hospital admission for a fall or fracture.

CONCLUSION

Inappropriate medication prescriptions are associated with impaired physical function across longitudinal and cross-sectional studies in older adults situated in diverse settings. It is important to support older people to reduce their use of inappropriate medications and prevent prescribing omissions.

PLAIN LANGUAGE SUMMARY

Inappropriate medications and physical function Background and aims: The use of inappropriate medications is very common in older adults and is associated with harmful health problems. The aim was to examine associations between potentially inappropriate medications and potential prescribing omissions with physical function in older adults situated in diverse environments. Methods: Library databases were examined for possible studies to include and a systematic search was completed. Relevant information was obtained from the included studies. Results: In total, 55 studies reported on 2,767,594 participants who were an average age of 77.1 years and about 6 out of 10 were women. A variety of different study designs were used. Inappropriate medication prescriptions in community and hospital settings were significantly associated with higher risk of falls (21 out of 30 studies), higher risk of fractures (7 out of 9 studies), problems with activities of daily living (ADL), such as eating, bathing, dressing, grooming, walking and toileting (8 out of 10 studies) and problems with instrumental ADL such as managing medications, house cleaning and shopping (4 out of 6 studies). Five out of seven studies also showed that inappropriate medications were associated with poorer physical performance involving the Timed Up and Go test, walking speed, grip strength, time to functional recovery, functional independence and scale of functioning. Many types of medication classes were shown to be associated with a risk of falls, fractures and problems with physical performance. Omitted medications were also associated with falls and fractures. Conclusion: Inappropriate medication prescriptions are associated with problems relating to physical function. It is important to support older people to reduce their use of inappropriate medications and prevent prescribing omissions.

Inappropriate medications and physical function: a systematic review

Background and aims:

Inappropriate medication prescription is highly prevalent in older adults and is associated with adverse health outcomes. The aim of this study was to examine the associations between potentially inappropriate medications (PIMS) and potential prescribing omissions with physical function in older adults situated in diverse environments.

Methods:

A systematic search was completed using the following databases: MEDLINE, CINAHL, PsycINFO, EMBASE and COCHRANE. Results were extracted from the included studies.

Results:

In total, 55 studies reported on 2,767,594 participants with a mean age of 77.1 years (63.5% women). Study designs comprised 26 retrospective cohort studies, 21 prospective cohort studies and 8 cross-sectional studies. Inappropriate medications in community and hospital settings were significantly associated with higher risk of falls (21 out of 30 studies), higher risk of fractures (7 out of 9 studies), impaired activities of daily living (ADL; 8 out of 10 studies) and impaired instrumental ADL (IADL) score (4 out of 6 studies). Five out of seven studies also showed that PIMs were associated with poorer physical performance comprising the Timed Up and Go test, walking speed, grip strength, time to functional recovery, functional independence and scale of functioning. Many medication classes were implicated as PIMs in falls, fractures and impairment in physical performance including antipsychotic, sedative, anti-anxiety, anticholinergic, antidiabetic, opioid and antihypertensive medications. For patients not receiving musculoskeletal medications, such as calcium, vitamin D and bisphosphonates, older adults were found to be at risk of a hospital admission for a fall or fracture.

Conclusion:

Inappropriate medication prescriptions are associated with impaired physical function across longitudinal and cross-sectional studies in older adults situated in diverse settings. It is important to support older people to reduce their use of inappropriate medications and prevent prescribing omissions.

Plain language summary

Inappropriate medications and physical function

Background and aims: The use of inappropriate medications is very common in older adults and is associated with harmful health problems. The aim was to examine associations between potentially inappropriate medications and potential prescribing omissions with physical function in older adults situated in diverse environments. Methods: Library databases were examined for possible studies to include and a systematic search was completed. Relevant information was obtained from the included studies. Results: In total, 55 studies reported on 2,767,594 participants who were an average age of 77.1 years and about 6 out of 10 were women. A variety of different study designs were used. Inappropriate medication prescriptions in community and hospital settings were significantly associated with higher risk of falls (21 out of 30 studies), higher risk of fractures (7 out of 9 studies), problems with activities of daily living (ADL), such as eating, bathing, dressing, grooming, walking and toileting (8 out of 10 studies) and problems with instrumental ADL such as managing medications, house cleaning and shopping (4 out of 6 studies). Five out of seven studies also showed that inappropriate medications were associated with poorer physical performance involving the Timed Up and Go test, walking speed, grip strength, time to functional recovery, functional independence and scale of functioning. Many types of medication classes were shown to be associated with a risk of falls, fractures and problems with physical performance. Omitted medications were also associated with falls and fractures. Conclusion: Inappropriate medication prescriptions are associated with problems relating to physical function. It is important to support older people to reduce their use of inappropriate medications and prevent prescribing omissions.

Rationally decreasing the number of drugs seems to be a useful therapeutic approach in older adults: 6-month follow-up study

AIMS

Older adults are at risk for polypharmacy, which has multidimensional safety, clinical and economic implications. Therefore, the optimization of drug therapy is one of the critical components of geriatrics clinical practice. This study is aimed to investigate the effect of drug rationalization on comprehensive geriatric assessment(CGA) parameters.

MATERIALS AND METHODS

The study was a retrospective and longitudinal study examining the effect of change in drug number on functionality and physical performance. A total of 515 patients were included in the study. Detailed medication history, laboratory findings, CGA parameters were recorded in the first admission. Polypharmacy was accepted as concurrent usage of five or more drugs. Medications of each patient were reviewed with the guidance of CGA and Beers Criteria.

RESULTS

The mean age of patients was 74.13 ± 7.29 years, and 68.7% were female. The baseline mean number of drugs was 5.11 ± 3.34. The polypharmacy group(269 patients) had a higher rate of geriatric syndromes and lower CGA scores in the first admission. After optimization of medications, the mean drug number decreased to 4.76 ± 2.72. Depression, mobility and nutritional scores improved at the end of six months in the patients whose total number of drugs decreased, while global cognition, activities of daily living scores, and gait speed were preserved. Increasing the number of drugs was associated with lower mobility and functionality.

CONCLUSION

Drug rationalization guided with CGA improves the nutritional, physical, and psychosocial status of geriatric patients. Thus, medication reviews have key importance in the management of older patients.

Polypharmacy is associated with functional decline in Alzheimer's disease and Lewy body dementia

BACKGROUND

In dementia, a number of factors may influence functional decline in addition to cognition. In this study, we aimed to study the potential association of the number of prescribed medications with functional decline trajectories over a five-year follow-up in people diagnosed with mild Alzheimer's disease (AD) or Lewy Body dementia (LBD).

METHODS

This is a longitudinal analysis of a Norwegian cohort study entitled "The Dementia Study of Western Norway". We included 196 patients newly diagnosed with AD (n=111) and LBD (n=85), followed annually for 5 years. We conducted linear mixed-effects models to analyse the association of the number of medications with functional decline measured by the Rapid Disability Rating Scale - 2.

RESULTS

The mean prescribed medications at baseline was 4.18∓2.60, for AD 3.92∓2.51 and LBD 4.52∓2.70. The number of medications increased during the follow-up; at year five the mean for AD was 7.28∓4.42 and for LBD 8.11∓5.16. Using more medications was associated with faster functional decline in AD (Est 0.04, SE 0.01, p-value 0.003) and LBD (Est 0.08, SE 0.03, p-value 0.008) after adjusting for age, sex, comorbidity, neuropsychiatric symptoms, and cognition. For each medication added during the follow-up, functional trajectories worsened by 1% for AD and 2% for LBD. The number of medications was not associated with cognitive decline.

CONCLUSION

We found that higher number of medications was related to a faster functional decline, both in AD and LBD. With disease progression, there was an increase in the number of medications. Prescription in dementia should be carefully assessed, possibly improving the functional prognosis.

Polypharmacy in older adults: a narrative review of definitions, epidemiology and consequences

BACKGROUND

The number of older adults has been constantly growing around the globe. Consequently, multimorbidity and related polypharmacy have become an increasing problem. In the absence of an accepted agreement on the definition of polypharmacy, data on its prevalence in various studies are not easily comparable. Besides, the evidence on the potential adverse clinical outcomes related to polypharmacy is limited though polypharmacy has been linked to numerous adverse clinical outcomes. This narrative review aims to find and summarize recent publications on definitions, epidemiology and clinical consequences of polypharmacy.

METHODS

The MEDLINE database was used to identify recent publications on the definition, prevalence and clinical consequences of polypharmacy using their respective common terms and their variations. Systematic reviews and original studies published between 2015 and 2020 were included.

RESULTS

One hundred and forty-three definitions of polypharmacy and associated terms were found. Most of them are numerical definitions. Its prevalence ranges from 4% among community-dwelling older people to over 96.5% in hospitalized patients. In addition, numerous adverse clinical outcomes were associated with polypharmacy.

CONCLUSION

The term polypharmacy is imprecise, and its definition is yet subject to an ongoing debate. The clinically oriented definitions of polypharmacy found in this review such as appropriate or necessary polypharmacy are more useful and relevant. Regardless of the definition, polypharmacy is highly prevalent in older adults, particularly in nursing home residents and hospitalized patients. Approaches to increase the appropriateness of polypharmacy can improve clinical outcomes in older adults.

[Less can be more-Examples on medication in older and geriatric patients from current studies]

Polypharmacy, i.e. the prescription of five or more different drugs for medicinal treatment, is a typical problem in older and geriatric patients. Polypharmacy predisposes to different negative health sequelae, such as undesired side effects, drug interactions, potentially inappropriate medication, reduced functional abilities, increased hospitalization and increased mortality. Various consensus groups and specialist societies have developed recommendations on how to handle polypharmacy in geriatric patients. Although concepts to reduce the number of drugs are considered necessary, in many areas there is a lack of evidence on how to limit polypharmacy in geriatric patients and to reduce and discontinue medication. This article presents examples of recent studies dealing with potentially inappropriate medication, vitamin D substitution and antipsychotic drugs, which show how to critically appraise a prescribed medication, to critically check the indications for drugs and to discontinue drug use.

Relationship between functional capacity, nutritional status and sociodemographic variables of institutionalized older adults

Abstract Objective To analyze the relationship between functional capacity, nutritional status, and sociodemographic variables of older adults living in long-term care facilities. Method This is a cross-sectional study conducted with 82 institutionalized older adults. For data collection, we used the Barthel Index to assess the degree of independence in the performance of basic activities of daily living and the Mini Nutritional Assessment (MNA) to assess the nutritional status of older adults. Data were collected in five geriatric long-term care facilities located in southern Brazil. Ordinal regression analyses were performed to identify associations between contextual social factors, and nutritional status with the functional capacity of institutionalized older adults. Results Most participants showed complete independence in performing activities of daily living (39.0%) and poor nutritional status (59.8%). The multivariate ordinal regression analysis showed that older adults with higher scores in the nutritional assessment are associated with better indicators of functional capacity (OR=1.33; 95% CI=1.15 to 1.54; p<0.001). We did not find an association between educational level, pressure injuries, body mass index, and functionality. Conclusion Nutritional status is a significant predictor for dependency in institutionalized older adults.

Relação entre capacidade funcional, estado nutricional e variáveis sociodemográficas de idosos institucionalizados

Resumo Objetivo Analisar a relação entre a capacidade funcional, o estado nutricional e as variáveis sociodemográficas de idosos residentes em instituições de longa permanência. Método Trata-se de um estudo transversal conduzido com 82 idosos institucionalizados. Para a coleta de dados foram aplicados o Índice de Barthel para avaliação do grau de independência no desempenho das atividades básicas de vida diária e a Mini Avaliação Nutricional (MNA) para a avaliação do estado nutricional dos idosos. Os dados foram coletados em cinco instituições de longa permanência situadas na região Sul do Brasil. Análises de regressão logística ordinal foram realizadas para verificar as associações dos fatores contextuais com a capacidade funcional dos idosos institucionalizados Resultados A maioria dos participantes apresentou independência total no desempenho das atividades de vida diária (39,0%) e estado nutricional deficiente (59,8%). A análise de regressão ordinal multivariada demonstrou que idosos institucionalizados com maiores escores na avaliação nutricional estão associados com melhores indicadores de capacidade funcional (RC=1,33; IC 95%=1,15 a 1,54; p<0,001). Não se encontrou associação entre escolaridade, lesões por pressão, índice de massa corpórea e a capacidade funcional. Conclusão O estado nutricional é um importante preditor para a dependência de idosos institucionalizados.

Deprescribing in nursing homes: Protocol for nested, randomised controlled hybrid trials of deprescribing interventions

INTRODUCTION

Polypharmacy and the use of potentially inappropriate medication (PIMs) are frequent among nursing home (NH) residents, and are associated with adverse health outcomes like falls, hospitalisation and death. Deprescribing has been proposed as a way to curtail both problems; however, the best way to implement deprescribing and its real impact are still unclear. This article describes nested trials of two consecutive deprescribing interventions, the first at the NH level, and the second at the resident level.

METHODS AND ANALYSIS

The first intervention (QC-DeMo) will be a deprescribing module to be carried out in existing interprofessional quality circles in NHs, with the goal to develop a NH-wide deprescribing consensus. Its effects will be evaluated on the use of PIMs and on patient safety outcomes such as death, hospitalisation and falls. All NHs in the cantons of Vaud and Fribourg with an integrated pharmacy service will be eligible. The second intervention (IDeI), at the resident level, will be a deprescribing-focused medication review, resulting in the implementation of a deprescribing plan. Its effects will be evaluated on the use of PIMs and chronic medications, and on quality of life. This second trial will take place in the NHs allocated to the intervention group of the first trial. All residents of these NHs over 65 years old, living in the NH for at least 4 months, and taking 5 or more medications will be eligible to participate. Both trials will be hybrid effectiveness and implementation trials, aiming to understand the implementation process for the interventions, and to identify barriers and facilitators.

ETHICS, REGISTRATION AND FUNDING

Both trials were approved by the relevant ethics committee, registered on ClinicalTrials.gov (QC-DeMo: NCT03688542; IDeI: NCT03655405), and funded by the Swiss National Fund for Scientific Research.