Analgesic use among community-dwelling people aged 75 years and older: A population-based interview study

Prescription opioids among older adults: ten years of data across five countries

BACKGROUND

Opioid use has increased globally in the recent decade. Although pain remains a significant problem among older adults, susceptibility to opioid-related harms highlights the importance of careful opioid therapy monitoring on individual and societal levels. We aimed to describe the trends of prescription opioid utilisation among residents aged ≥65 in all Nordic countries during 2009-2018.

METHODS

We conducted cross-sectional measurements of opioid utilisation in 2009-2018 from nationwide registers of dispensed drugs in Denmark, Finland, Iceland, Norway, and Sweden. The measures included annual opioid prevalence, defined daily doses (DDDs) per 1000 inhabitants per day (DIDs), and morphine milligram equivalents (MMEs) per user per day.

RESULTS

From 2009 to 2018, an average of 808,584 of adults aged ≥65 used opioids yearly in all five countries; an average annual prevalence of 17.0%. During this time period, the prevalence decreased in Denmark, Norway, and Sweden due to declining codeine and/or tramadol use. Iceland had the highest opioid prevalence in 2009 (30.2%), increasing to 31.7% in 2018. In the same period, DIDs decreased in all five countries, and ranged from 28.3 in Finland to 58.5 in Denmark in 2009, and from 23.0 in Finland to 54.6 in Iceland in 2018. MMEs/user/day ranged from 4.4 in Iceland to 19.6 in Denmark in 2009, and from 4.6 in Iceland to 18.8 in Denmark in 2018. In Finland, Norway, and Sweden, MMEs/user/day increased from 2009 to 2018, mainly due to increasing oxycodone utilisation.

CONCLUSIONS

The stable or decreasing opioid utilisation prevalence among a majority of older adults across the Nordic countries coincides with an increase in treatment intensity in 2009-2018. We found large cross-national differences despite similarities across the countries' cultures and healthcare systems. For the aged population, national efforts should be placed on improving pain management and monitoring future trends of especially oxycodone utilisation.

Prevalence and persistent use of analgesic drugs in older adults receiving domiciliary care at baseline-A longitudinal study

AIMS

To describe the prevalence and persistence of analgesic drug use (opioids and antipyretics [ie, paracetamol and acetylsalicylic acid]) in participants (≥70 years) with and without dementia receiving domiciliary care in the eastern part of Norway. In addition, to explore factors associated with persistent drug use and examine whether drug use has changed after admission to a nursing home.

METHODS

A longitudinal study with 1001 participants (mean [SD] age 83.4 [5.7] years) receiving domiciliary care. Medical information including analgesic drug use was collected at baseline (A1) between August 2008 and December 2010, follow-up assessments after 18 (A2) and 36 months (A3). Analgesic drugs prescribed for regular use were recorded from the participants' medical records. The participants' cognitive and physical health was evaluated at all assessments. Level of care (domiciliary care or nursing home care) was recorded at A2 and A3. Generalized linear mixed models were used to examine the prevalence and persistence of analgesic drug use.

RESULTS

The prevalence of prescribed use of antipyretics and opioids was 13.6% and 9.2%, respectively. Participants with dementia had more frequent use of antipyretics in all assessments and opioids in the last assessment than participants without dementia. Persistent use of both antipyretics and opioids was high between two consecutive assessments, both for participants with and without dementia. Persistent use of analgesics was associated with poorer physical functioning, but not by level of care. Overall, there was no difference between those admitted to a nursing home and those receiving domiciliary care at follow-up, with respect to change in analgesic drug use over time.

CONCLUSION

The prevalence and persistent use of analgesics were high in older adults receiving domiciliary care at baseline and especially in participants with dementia. A holistic approach and interdisciplinary collaboration are essential to effectively assess and treat pain in older adults.

Obesity and the Receipt of Prescription Pain Medications in the US

BACKGROUND

Little is known about disparities in pain treatment associated with weight status despite prior research on weight-based discrepancies in other realms of healthcare and stigma among clinicians.

OBJECTIVE

To investigate the association between weight status and the receipt of prescription analgesics in a nationally representative sample of adults with back pain, adjusting for the burden of pain.

DESIGN

Cross-sectional analyses using the Medical Expenditure Panel Survey (2010-2017).

PARTICIPANTS

Five thousand seven hundred ninety-one civilian adults age ≥ 18 with back pain.

MAIN MEASURES

We examine the odds of receiving prescription analgesics for back pain by weight status using logistic regression. We study the odds of receiving (1) any pain prescription, (2) three pain prescription categories (opioid only, non-opioid only, the combination of both), and (3) opioids conditional on having a pain prescription.

KEY RESULTS

The odds of receiving pain prescriptions increase monotonically across weight categories, when going from normal weight to obesity II/III, despite adjustments for the burden of pain. Relative to normal weight, higher odds of receiving any pain prescription is associated with obesity I (OR = 1.30 [95% CI = 1.04-1.63]) and obesity II/III (OR = 1.72 [95% CI = 1.36-2.18]). Obesity II/III is also associated with higher odds of receiving opioids only (OR = 1.53 [95% CI = 1.16-2.02]), non-opioids only (OR = 1.77 [95% CI = 1.21-2.60]), and a combination of both (OR = 2.48 [95% CI = 1.44-4.29]). Obesity I is associated with increased receipt of non-opioids only (OR = 1.55 [95% CI = 1.07-2.23]). Conditional on having a pain prescription, the odds of receiving opioids are comparable across weight categories.

CONCLUSIONS

This study suggests that, relative to those with normal weight, adults with obesity are more likely to receive prescription analgesics for back pain, despite adjustments of the burden of pain. Hence, the possibility of weight-based undertreatment is not supported. These findings are reassuring because individuals with obesity generally experience a higher prevalence of back pain. The possibility of over-treatment associated with obesity, however, may warrant further investigation.

PRN Medicines Management for Older People with Long-Term Mental Health Disorders in Home Care

Older people with long-term mental health conditions who receive care in their own home are vulnerable to the inappropriate use of medications and polypharmacy given their underlying health conditions and comorbidities. Inappropriate use of pro re nata (PRN) medications in these older people can enhance their suffering and have negative consequences for their quality of life and well-being, leading to readmission to healthcare settings and the increased cost of health care. This narrative review on published international literature aims at improving our understanding of medicines management in home care and how to improve PRN medication use among older people with long-term health conditions in their own home. Accordingly, the improvement of PRN medicines management for these older people requires the development of an individualised care plan considering ‘reduction of older people’s dependence on PRN medications’, ‘empowerment of family caregivers’, and ‘support by healthcare professionals.’ PRN medication use should be reduced through deprescription and discontinuation strategies. Also, older people and their family caregivers should be encouraged to prioritize the use of non-pharmacologic methods to relieve physical and psychological problems. Besides the empowerment of family caregivers through role development, education and training about PRN medications, and involvement in decision-making, they need support by the multidisciplinary network in terms of supervision, monitoring, and home visits.

Analgesic purchases among older adults - a population-based study

Background

Pain is a frequent and inevitable factor affecting the quality of life among older people. Several studies have highlighted the ineffectiveness of treating chronic pain among the aged population, and little is known about the prevalence of analgesics administration among community-dwelling older adults. The objective was to examine older adults’ prescription analgesic purchases in relation to SF-36 pain in a population-based setting.

Methods

One thousand four hundred twenty community-dwelling citizens aged 62–86 years self-reported SF-36 bodily pain (pain intensity and pain-related interference) scores for the previous 4 weeks. The Social Insurance Institution of Finland register data on analgesic purchases for 6 months prior to and 6 months after the questionnaire data collection were considered. Special interest was focused on factors related to opioid purchases.

Results

Of all participants, 84% had purchased prescription analgesics during 1 year. NSAIDs were most frequently purchased (77%), while 41% had purchased paracetamol, 32% opioids, 17% gabapentinoids, and 7% tricyclic antidepressants. Age made no marked difference in purchasing prevalence. The number of morbidities was independently associated with analgesic purchases in all subjects and metabolic syndrome also with opioid purchases in subjects who had not reported any pain.

Discussion

Substantial NSAID and opioid purchases emerged. The importance of proper pain assessment and individual deliberation in terms of analgesic contraindications and pain quality, as well as non-pharmacological pain management, need to be highlighted in order to optimize older adults’ pain management.

Use of pain relieving drugs in community-dwelling older people with and without type 2 diabetes

AIMS

To analyze the use of pain medication among community-dwelling people aged 65 years or older with and without type 2 diabetes in primary care.

METHODS

A total of 187 patients with and 176 patients without diabetes were randomly selected from a primary care sample of 389 patients with diabetes and 604 age- and gender-matched controls. Pain status was defined as no pain, nociceptive pain or neuropathic pain. Pain medication (paracetamol, NSAID, opioids, neuropathic pain medication) use was based on electronic patient records and checked by a physician during a health examination.

RESULTS

Some pain was present in 90 (51%) patients without and in 106 (57%) patients with diabetes (p = 0.55). Of the patients without diabetes, 109 (62%) and with diabetes 123 (66%) used some pain medication (p = 0.45). The respective proportions for the regular use were 13% and 11% and for the as needed use 56% and 61%. Diabetes was not associated with any of the pain medications used. The use of pain-relieving drugs was most common for neuropathic pain.

CONCLUSIONS

The present study indicated that community-dwelling people with and without diabetes used pain medication similarly. Pain medication was used mostly as needed instead of being regular.

Evaluation of prescription pattern of analgesic use among ambulatory elderly in South-Western Nigeria

Background:

Inappropriate prescribing of analgesics has a global impact on the health of elderly patients and the society. Empirical evidence on the prescription of analgesics among elderly Nigerians is scarce.

Objectives:

The objective of the study was to evaluate the prescription pattern of analgesics and describe the co-prescribing of gastroprotective agents with non-steroidal anti-inflammatory drugs (NSAIDs) among elderly patients at the geriatric center, University College Hospital, Ibadan.

Methods:

A retrospective cross-sectional, hospital-based study was carried out among elderly patients (≥60 years) who were prescribed analgesics. Using a data extraction sheet, information on demographic characteristics, drug utilization pattern, and morbidities was obtained from patients’ case files via electronic health records.

Results:

A total of 337 patients case files were reviewed, the mean age was 72 ± 8.8 years, and 210 (62.3%) were females. There were a total of 2074 medications prescribed, with 733 (35.3%) being analgesics. Majority of the elderly patients (259, 76.9%) were on nonopioids, with 252 (74.8%) on NSAIDs. Paracetamol was the most commonly prescribed analgesics (181, 24.6%), followed by diclofenac/misoprostol (177, 24.1%), opioid analgesic prescribed was 88 (12.0%), with paracetamol/codeine 58 (65.9%), and tramadol 16 (18.2%) being the most prescribed opioid. A significant proportion of the hypertensive elderly patients (160, 78.8%; P < 0.036) were on NSAIDs. The oral route of administration (302, 89.6%) was the most common route of administration. Majority (310, 92%) of elderly patients taking NSAIDs had a co-prescription for gastroprotective agents.

Conclusions:

Majority of hypertensive patients were on NSAIDs. This calls for prompt awareness of rational analgesic use among the elderly to improve management and their survival.

Purchases of medicines among community-dwelling older people: comparing people in the last 2 years of life and those who lived at least 2 years longer

While it is known that those who are living their last years are frequent users of social and health services, research about medicines at the end of life is scarce. We examined whether the proportions of purchasers and the types of prescription medicines purchased during a 2-year period differed between community-dwelling old people who died (decedents) in 2002, 2006 or 2011 and old people who lived at least 2 years longer (survivors) in Finland. We also examined how those differences changed over time. The study population was identified from nationwide registers and consisted of 174,097 community-dwelling people who were 70 years of age or older. Of these, 81,893 were decedents and 92,204 survivors. Data on purchases of medicines were gathered from the Finnish prescription database. Along with descriptive analyses, binary logistic regression analysis was used to find the association between decedent status and the purchase of medicines in general and different categories of medicines in particular. Almost all community-dwelling decedents and survivors purchased medicines at least once during the 2-year period. Over time, the proportion of purchasers increased in both groups but especially among survivors, thereby reducing the differences between the groups. However, the probability of purchasing medicines in general and different categories of medicine in particular remained significantly higher for decedents than for survivors after adjustments. This study shows that purchases of medication are concentrated at the end of life, as is the use of social and health services. However, the differences between decedents and survivors diminish over time.

Musculoskeletal Pain Medication Use in Middle Age and Older Adults in 15 European Countries and Israel

BACKGROUND

The experience of musculoskeletal pain is widespread among adults and entails high costs to both individuals and society. Few studies look at disparities in pain management.

AIMS

To examine factors associated with the presence of musculoskeletal pain and the use of pain medication use among individuals aged 50+.

DESIGN

Cross-sectional analysis of data from the SHARE.

PARTICIPANTS

64,281 community-dwelling individuals in 15 European countries and Israel.

METHODS

Bivariate analysis and logistic regression were used to identify factors associated with the presence of musculoskeletal pain and pain medication use.

RESULTS

Among our population, the prevalence of musculoskeletal pain at the time of the survey was 40.1%. Women had more pain than men (odds ratio [OR] = 1.477, confidence interval [CI] = 1.428-1.528), those who were 60-69 years old had less pain than younger individuals (OR = 0.927, CI = 0.883-0.973), whereas those who were 80+ years old had more pain than younger individuals (OR = 1.280, CI = 1.199-1.367). About 50% of those with musculoskeletal pain take no medication to manage it. Predictors of pain medication use include male sex (OR = 1.468, CI = 1.389-1.553), more education (OR = 1.034, CI = 1.023-1.041), and better ability to cope economically (OR = 1.446, CI = 1.368-1.527). Those over 70 are less likely than younger individuals to be taking medication to manage their pain (70-79: OR = 0.822, CI = 0.761-0.887), (80+: OR = 0.619, CI = 0.566-0.677).

CONCLUSIONS

Nurses should be aware of the association of education and income with pain-medication use, which suggests that pain medication use is less accessible to those with fewer resources. Pain is a significant public-health problem, and access to medicine deserves attention from nurses, healthcare workers and policymakers.

PRN Medicines Management for Psychotropic Medicines in Long-Term Care Settings: A Systematic Review

Many medications are prescribed and administered PRN (pro re nata, as needed). However, there are few integrative reviews to inform PRN psychotropic medication use in long-term care facilities and nursing or care homes. Accordingly, this integrative systematic review aimed to improve our understanding of PRN medicines management with a focus on psychotropic medications (antipsychotics, sedatives, anxiolytics, and hypnotics) in long-term care settings. Keywords relating to PRN in English, Norwegian, and Spanish were used, and articles published between 2009 and 2019 were retrieved. Based on the inclusion criteria, eight articles were used for data analysis and synthesis. This review offers a description of PRN prescription and administration of psychotropic medications in long-term care. Variations were observed in the management of PRN psychotropic medications based on residents’ underlying health conditions and needs, duration of use, and changes between medications and doses. Neither the reasons for PRN prescription and administration nor the steps taken to identify and manage any associated adverse reactions or adverse drug events were reported. Further initiatives are needed to improve PRN medicines management to explore factors that affect PRN prescription and administration and to develop appropriate PRN guidelines to prevent harm and improve the safety of people living in long-term care facilities.

Opioid Prescription Use in Nursing Home Residents with Advanced Dementia

Background

Although proper pain treatment may require opioids, discussion continues about possible undertreatment or overtreatment in persons with advanced dementia.

Objective

To investigate the prevalence of pain, frequency of opioid prescription use, and factors associated with strong opioid prescription use in nursing homes.

Design

Cross-sectional study.

Setting and Subjects

Eighteen Norwegian nursing homes; 327 persons with advanced dementia and behavioral disturbances participated.

Methods

Potential factors associated with strong opioid prescription use were assessed: demographics (age, gender), medical conditions (comorbidity, number of medications), pain (Mobilization-Observation-Behaviour-Intensity-Dementia-2 Pain Scale ≥ 3, pain-related diagnoses, analgesic prescription use), functioning (activities of daily living, Mini-Mental State Examination) and behavior (Neuropsychiatric Inventory-Nursing Home version, Cohen-Mansfield Agitation Inventory). Factors with P < 0.10, age, and gender were included in multivariate regression analysis.

Results

The prevalence of moderate to severe pain was 62.1%. Of all participants, 19.3% (N = 63) were prescribed opioids, and of these, 79.4% (N = 50) were still in pain; 66.7% of the opioid prescriptions were less than or equal to the lowest dosage of fentanyl patches (12 mcg/h) or buprenorphine (5 or 10 mcg/h). Pain (odds ratio [OR] = 1.26, 95% confidence interval [CI] = 1.12-1.42), total number of pain-related diagnoses (OR = 1.47, 95% CI = 1.14-1.90), and depression and anxiety (OR = 1.05, 95% CI = 1.01-1.11) were positively associated with an opioid prescription. Stroke was negatively associated (OR = 0.43, 95% CI = 0.19-0.99).

Conclusions

Strong opioid prescription use was mainly associated with pain. However, in this population, despite the relatively prevalent use of strong prescription opioids, pain was still prevalent. This emphasizes the challenge of proper pain treatment and need for regular evaluation of pain and pain management.

The silent epidemic of chronic pain in older adults

Chronic pain is highly prevalent among older adults where it is associated with significant suffering, disability, social isolation, and greater costs and burden to health care systems. Pharmaceutical treatment of chronic pain in older adults is usually only partially effective and is often limited by side effects including urinary retention, constipation, sedation, cognitive impairment, and increased risk of falls. Since older adults are underrepresented in clinical trials testing treatments for chronic pain, the potential impacts of polypharmacy and frailty on reported outcomes and side effect profiles are largely unknown. Thus, for current treatments, providers and patients must balance anticipated benefits of pain reduction with the known and unknown risks of treatment. Chronic pain is also a risk factor for premature death as well as accelerated cognitive decline, suggesting potential shared mechanisms between persistent pain (or its treatment) and dementia. Cognitive decline and dementia may also impact pain perception and the ability to report pain, complicating treatment decisions. Associations between persistent pain and the risks of premature death and accelerated cognitive decline make estimates for chronic pain in these populations particularly challenging. Future research is needed to improve estimates for chronic pain in older adults, to elucidate underlying mechanisms of pain with aging, and to develop and advance safer, more effective treatment options for chronic pain in older adults.

Pain assessment and pain treatment for community-dwelling people with dementia: A systematic review and narrative synthesis

OBJECTIVES

To describe the current literature on pain assessment and pain treatment for community-dwelling people with dementia.

METHOD

A comprehensive systematic search of the literature with narrative synthesis was conducted. Eight major bibliographic databases were searched in October 2018. Titles, abstracts, and full-text articles were sequentially screened. Standardised data extraction and quality appraisal exercises were conducted.

RESULTS

Thirty-two studies were included in the review, 11 reporting findings on pain assessment tools or methods and 27 reporting findings on treatments for pain. In regard to pain assessment, a large proportion of people with moderate to severe dementia were unable to complete a self-report pain instrument. Pain was more commonly reported by informal caregivers than the person with dementia themselves. Limited evidence was available for pain-focused behavioural observation assessment. In regard to pain treatment, paracetamol use was more common in community-dwelling people with dementia compared with people without dementia. However, non-steroidal anti-inflammatory drugs (NSAIDs) were used less. For stronger analgesics, community-dwelling people with dementia were more likely to receive strong opioids (eg, fentanyl) than people without dementia.

CONCLUSION

This review identifies a dearth of high-quality studies exploring pain assessment and/or treatment for community-dwelling people with dementia, not least into non-pharmacological interventions. The consequences of this lack of evidence, given the current and projected prevalence of the disease, are very serious and require urgent redress. In the meantime, clinicians should adopt a patient- and caregiver-centred, multi-dimensional, longitudinal approach to pain assessment and pain treatment for this population.

Factors Influencing Judgments to Consult Prescription Monitoring Programs: A Factorial Survey Experiment

BACKGROUND

Prescription monitoring programs (PMPs) can provide health care professionals with valuable information. However, few studies have explored providers' decision making for accessing PMPs.

AIMS

This study aimed to identify provider characteristics and situational factors most influencing perceived importance of consulting the PMP for patients in a simulated context.

DESIGN

The study used a cross-sectional factorial survey.

SETTINGS

The survey was administered electronically.

PARTICIPANTS/SUBJECTS

Community pharmacists, advanced practice registered nurses (APRNs), and physicians in Iowa.

METHODS

Participants were recruited by mail which included a link to the online survey. The survey consisted of demographic questions, eight randomly generated vignettes, and one ranked item. The vignettes described a hypothetical prescription using eight experimental variables whose levels were randomly varied. Respondents evaluated each vignette for importance to access the PMP. Analyses used linear mixed-effects models in R (Version 3.5.0).

RESULTS

A total of 138 responses were available for multilevel analysis. Women, physicians, and APRNs rated it more important to consult the PMP for a given prescription compared with men and pharmacists. Accessing a PMP was perceived as more important with cash payments, quantity dispensed, suspicion for misuse, hydromorphone and oxycodone prescriptions, and headache. Advancing age, postoperative pain, and anxiety or sleep indications were associated with less importance.

CONCLUSIONS

Age, indication for prescribing, misuse, and payment mode each independently had greater importance to providers in accessing the PMP. This was the first study to isolate the influence of different controlled substances on how important it was to consult the PMP.

Chronic Pain Management Among Older Adults: A Scoping Review

Chronic pain is a significant problem for older adults. The effect of chronic pain on older people's quality of life needs to be described and identified. For a decade, the Roy Adaptation Model has been used extensively to explain nursing phenomena and guide nursing research in several settings with several populations. The objective of this study was to use the Roy Adaptation Model to describe chronic pain and present a systematic scoping review of the literature about the middle-range theory of chronic pain among older adults. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses model guided a scoping review search method. A literature search was undertaken using MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Ovid, and ProQuest. The search terms were "chronic pain," "pain management," "older adult," "Roy Adaptation Model," and "a scope review." The search included articles written in English published for the period of 2004-2017. All articles were synthesized using concepts of Roy's Adaptation Model. Twenty-two studies were considered for the present review. Twenty-one articles were reports of quantitative studies, and one was a report of a qualitative study. Two outcome measures were found in this systematic scoping review. The primary outcomes reported in all articles were the reduction of pain due to interventions and an increase in coping with chronic pain. The secondary outcome measures reported in all studies were the improvement of physical function, quality of life, sleep disturbance, spiritual well-being, and psychological health related to pain management interventions among older adults. Many interventions of all studies reported improvement in chronic pain management among older adults. However, to improve chronic pain management, nurses need to understand about nursing theories, the context which instruments work, and develop empirical instruments based on the conceptual model.

Medication taking in people with hip and knee osteoarthritis: An analysis of the English Longitudinal Study of Ageing

OBJECTIVES

Osteoarthritis (OA) is a highly prevalent condition seen across primary care services. Although evidence-based guidelines have encouraged the prescription of medications, including analgesics, for this population, there remains uncertainty as to which types of individuals actually take prescribed or over-the-counter medications. The purpose of the present study was to determine whether there is a difference in characteristics between people who take medicines for OA compared with those who do not.

METHODS

A cross-sectional analysis of the English Longitudinal Study of Ageing (ELSA) cohort was undertaken. Individuals who reported hip and/or knee OA pain were included. Data on medication taking were self-reported and collected as part of the ELSA data collection programme. Logistic regression analyses were undertaken to determine the relationship between potential predictors (demographic, pathology-specific, psychological, social and functional) and whether individuals took medications for their OA symptoms.

RESULTS

A total of 654 participants reported OA: 543 medicine takers and 111 nontakers. Individuals who had access to a car (odds ratio [OR]: 56.2; 95% confidence interval [CI]: 3.35 to 941.36), those with a greater duration of hip pain (OR: 5.79; 95% CI: 1.40 to 24.0) and those who achieved 10 chair raises at greater speed (OR: 1.08; 95% CI: 1.03 to 1.14) were more likely to take OA medicines.

CONCLUSIONS

The study identified predictors for medication taking in individuals with hip and/or knee OA. Strategies are now warranted to provide better support to these individuals, to improve health and well-being for this long-term, disabling condition.

Age-Related Changes in Headache Days across the Cognitive Spectrum

Introduction

Prior studies demonstrating age-related declines in headache prevalence have not accounted for the potentially confounding effects of cognitive impairment. Our primary goal was to assess the relationship between aging and self-reported monthly headache days across the cognitive spectrum.

Methods

A detailed headache questionnaire was included prospectively as part of an annual mailing to participants in the Sanders-Brown Center on Aging longitudinal cohort.

Results

The overall survey response rate was 58.6%, yielding a cohort of 332 cognitively normal, 71 mild cognitive impairment (median Mini-Mental Status Examination [MMSE] score = 27, interquartile range [IQR] = 25-28), and 51 demented (median MMSE score = 24, IQR = 19-26) individuals. Current headaches were reported by 22.8%, 25%, and 27.1%, respectively, across normal, mild cognitive impairment, and dementia subgroups. A negative correlation was observed between age and average headache days in cognitively normal (ρ = -0.163, 95% confidence interval [CI] = -0.246 to -0.022, P = 0.004), mild cognitive impairment (ρ = -0.255, 95% CI = -0.274 to 0.229, P = 0.0475), and dementia groups (ρ = -0.295, 95% CI = -0.457 to 0.159, P = 0.068). Ordinary least-squares regression with backward selection identified age alone, but not gender or MMSE, as predicting headache days in the overall cohort.

Conclusions

Aging is associated with a decline in headache days in the absence of any confounding cognitive pathology and is weakly predictive of headache days across the cognitive spectrum. Whether this represents a reporting bias due to dementia or has neurobiological significance warrants further investigation.

The roles of gender and profession on gender role expectations of pain in health care professionals

Introduction

Gender-related stereotypes of pain may account for some assessment and treatment disparities among patients. Among health care providers, demographic factors including gender and profession may influence the use of gender cues in pain management decision-making. The Gender Role Expectations of Pain Questionnaire was developed to assess gender-related stereotypic attributions of pain regarding sensitivity, endurance, and willingness to report pain, and has not yet been used in a sample of health care providers. The purpose of this study was to examine the presence of gender role expectation of pain among health care providers. It was hypothesized that health care providers of both genders would endorse gender stereotypic views of pain and physicians would be more likely than dentists to endorse these views.

Methods

One-hundred and sixty-nine providers (89 dentists, 80 physicians; 40% women) were recruited as part of a larger study examining providers’ use of demographic cues in making pain management decisions. Participants completed the Gender Role Expectations of Pain Questionnaire to assess the participant’s views of gender differences in pain sensitivity, pain endurance, and willingness to report pain.

Results

Results of repeated measures analysis of variance revealed that health care providers of both genders endorsed stereotypic views of pain regarding willingness to report pain (F_(1,165)=34.241, P<0.001; d=0.479). Furthermore, female dentists rated men as having less endurance than women (F_(1,165)=4.654, P=0.032; d=0.333).

Conclusion

These findings affirm the presence of some gender-related stereotypic views among health care providers and suggest the presence of a view among health care providers that men are underreporting their pain in comparison to women. Future work can refine the effects of social learning history and other psychosocial factors that contribute to gender and provider differences in pain management decisions.

Preferences and attitudes of older adults of Bialystok, Poland toward the use of over-the-counter drugs

Purpose

The aim of the study was to assess preferences and attitudes toward the use of over-the-counter (OTC) drugs among residents of Bialystok aged 60 or older.

Patients and methods

The study included 170 people, inhabitants of Bialystok aged over 60: 85 students of the University of a Healthy Senior and the University of Psychogeriatric Prophylaxis, and 85 students of the University of the Third Age in Bialystok. The study made use of a diagnostic survey conducted via a questionnaire prepared by the authors.

Results

The vast majority of respondents bought OTC drugs for own use. About one-third of the respondents from each analyzed group bought OTC drugs less often than once every 3 months. Over half of the respondents bought OTC drugs due to a cold. A majority of the respondents were of the opinion that OTC drugs should be sold only in pharmacies. Over 40% of seniors took 1 OTC drug regularly. Most respondents also took vitamins and supplements. The main sources of information on OTC drugs for the studied seniors were their doctor and pharmacist. Respondents did not always consult the treatment method with a doctor or pharmacist. Over half of the respondents familiarized themselves with the contents of the OTC drug package leaflet. Over three-quarters of the respondents were familiar with drug disposal methods; however, despite declarations of being familiar with these principles, a significant percentage did not bring back medication to a pharmacy or clinic, or threw the drugs into the trash.

Conclusion

Our study found that in our sample there were many OTC drug consumers who did not always demonstrate responsible attitudes toward using this group of drugs. Thus, older people should be educated on the possible adverse effects of taking OTC drugs without consulting a doctor or pharmacist as well as basic drug disposal principles. Furthermore, legislation should be introduced that will limit the wide availability of OTC drugs, particularly to the elderly; and thus, lower the costs of hospitalization and outpatient treatment of this age group. Also, a wider-reaching study should be conducted. It should include a larger group of elderly people as well as information on intake of prescribed medications in order to be able to determine the frequency of drug consumption in this population, as well as seniors' preferences and attitudes in this regard.

Is self-rated health in adolescence a predictor of prescribed medication in adulthood? Findings from the Nord Trøndelag Health Study and the Norwegian Prescription Database

Self-rated health (SRH) is a commonly used health indicator predicting morbidity and mortality in a range of populations. However, the relationship between SRH and medication is not well established. The aim of this study was to examine adolescent SRH as a predictor for prescribed medication later in young adulthood. Eighteen years' prospective data from the Nord-Trøndelag Health Study (HUNT) and the Norwegian Prescription Database (NorPD) were analyzed. Baseline data, gathered from 8982 adolescents (mean age 16.0 years) in the Young-HUNT I survey (1995-1997), were linked to individual data from NorPD, including information on all medications prescribed in 2013-2014. Gender-stratified negative binomial regression models were used to investigate the association between SRH and medication, also adjusted for age, baseline self-reported medicine use, physical and mental disability, smoking, and physical activity. Based on the Anatomical Therapeutic Chemical (ATC) Classification System, total consumption and consumption related to various ATC groups were examined. The adjusted analyses showed a dose-response relationship for females, with poorer SRH predicting higher average medication for both total consumption and for the ATC groups "Musculoskeletal system" (M), "Nervous system" (N; Analgesics (N02), Opioids (N02A)) and "Respiratiory system" (R). The predictive power of SRH, as well as the role of the adjustment factors, varies by gender and drug groups. This knowledge is important in order to identify risks for later disease and to capture pathological changes before and beyond the disease diagnosis, potentially preventing morbidity in the adult population.

Pain severity and pharmacologic pain management among community-living older adults: the MOBILIZE Boston study

BACKGROUND

Concerns about polypharmacy and medication side effects contribute to undertreatment of geriatric pain. This study examines use and effects of pharmacologic treatment for persistent pain in older adults.

METHODS

The MOBILIZE Boston Study included 765 adults aged ≥70 years, living in the Boston area, recruited from 2005 to 2008. We studied 599 participants who reported chronic pain at baseline. Pain severity, measured using the Brief Pain Inventory (BPI) severity subscale, was grouped as very mild (BPI <2), mild (BPI 2-3.99), and moderate to severe (BPI 4-10). Medications taken in the previous 2 weeks were recorded from medication bottles in the home interview.

RESULTS

Half of participants reported using analgesic medications in the previous 2 weeks. Older adults with moderate to severe pain were more likely to use one or more analgesic medications daily than those with very mild pain (49 versus 11%, respectively). The most commonly used analgesic was acetaminophen (28%). Opioid analgesics were used daily by 5% of participants. Adjusted for health and demographic factors, pain severity was strongly associated with daily analgesic use (moderate-severe pain compared to very mild pain, adj. OR 7.19, 95% CI 4.02-12.9). Nearly one third of participants (30%) with moderate to severe pain felt they needed a stronger pain medication while 16% of this group were concerned they were using too much pain medication.

CONCLUSION

Serious gaps persist in pain management particularly for older adults with the most severe chronic pain. Greater efforts are needed to understand barriers to effective pain management and self-management in the older population.

Factors Associated to Medication Consumption Among the Immigrant Population Residing in Spain

We aimed to determine the prevalence of medication use by the immigrant population residing in Spain, and to identify the factors associated with this consumption. Descriptive cross-sectional study was performed using secondary data retrieved from the 2012 Spanish National Health Survey (SNHS). Using logistic multivariate regression analysis, three models were generated: one for immigrants from high income countries (HIC), another for immigrants from low income countries (LIC), and a third one for the native population. The prevalence of total consumption of medicinal products is greater in the native population (61.75%) than in the immigrant population (HIC: 56.22%; LIC: 48.55%). Analgesics are the most consumed drugs in all the groups. Greater medication consumption is associated with being female, being of an advanced age (immigrants from HIC: AOR 9.75, for older than 75 years), the presence of chronic disease, a perception of bad health (HIC: AOR 3.48) and the use of emergency services (LIC immigrants: AOR 1.68). Medicine consumption in the immigrant population living in Spain is lower than in the native population. The factors associated with this consumption are similar; however, LIC immigrants who needed healthcare services and did not receive them presented a greater probability of consuming medicinal products.

Move it or Lose it. Is it Reasonable for Older Adults with Osteoarthritis to Continue to Use Paracetamol in Order to Maintain Physical Activity?

Osteoarthritis is a common progressive disease in older adults, and those affected often have impaired physical function, co-existing disease states, and reduced quality of life. In patients with osteoarthritis, pain is reported as a primary cause of mobility limitation, and guidelines recommend a mix of pharmacologic and non-pharmacologic strategies for pain management. The benefits of exercise in the management of osteoarthritis are well established; however, pain appears to be the biggest barrier to patients engaging in, and adhering to, physical activity programs. Attitudes towards the use of pain medications differ widely, and lack of efficacy or fear of side effects may lead to sub-therapeutic dosing. Furthermore, a recent review suggesting that short-term paracetamol use is ineffective for osteoarthritis has added to the confusion. This narrative review investigates limitations of current medications, summarizes patient attitudes toward the use of analgesics for osteoarthritis pain (with a focus on paracetamol), and explores the uptake of physical activity for osteoarthritis management. Evidence suggests that, despite clear guidelines, symptoms of osteoarthritis generally remain poorly managed. More research is required to investigate clinical outcomes in patients with osteoarthritis through optimized medication plans to better understand whether longer-term analgesic use in conjunction with physical activity can assist patients to overcome mobility limitations.

Differences in analgesic use in community-dwelling persons with and without Alzheimer's disease

BACKGROUND

There are conflicting findings about analgesic use among persons with cognitive impairment compared to cognitively intact older persons. The objective of our study was to investigate the prevalence of analgesic use in community-dwelling persons with and without Alzheimer's disease (AD), within six months after AD diagnosis and to find out factors associated with the use of analgesics and specific analgesic groups.

METHOD

We utilized data from register based MEDALZ (Medication use and Alzheimer's disease) cohort consisting of all community-dwelling persons diagnosed with AD during 2005-2011 in Finland and their matched comparison persons without AD. Altogether, 67,215 persons with AD and one comparison person for each case were included. Drug use data were collected from the Prescription Register and comorbidities from Special Reimbursement and Hospital Discharge Registers.

RESULTS

Statistically significant (p < 0.001) yet mostly small differences were found for analgesics use: analgesics were used by 34.9% and 33.5% of persons with and without AD, respectively. Paracetamol was the most frequently used analgesic both among persons with (25.0%) and without AD (19.1%). Persons with AD used less frequently NSAIDs (Nonsteroidal Anti-inflammatory Drugs) (13.2% vs. 17.3%) and mild opioids (5.0% vs. 7.1%), while the use of strong opioids was more common in comparison to persons without AD (1.3% vs. 1.1%, respectively). Analgesic users were more likely women, aged ≥80 years, had asthma/COPD, cardiovascular disease, diabetes, cancer, hip fracture, osteoporosis, rheumatoid arthritis, and lower socioeconomic position.

CONCLUSION

Further studies are needed to evaluate the adequateness of pain relief in older persons with and without AD.

SIGNIFICANCE

Persons with Alzheimer's disease (AD) used more frequently paracetamol and less frequently NSAIDs and mild opioids. A decreasing trend of NSAID use was observed among persons with AD during the study period.

Exploring the prevalence of and factors associated with pain: a cross-sectional study of community-dwelling people with dementia

Few pain studies have made community-dwelling people with dementia (PWD) their focus. The aim of this study was to determine the prevalence of pain among this patient population and to explore medication use. Moreover, we sought to investigate patient and caregiver variables associated with the presence of pain. Community-dwelling PWD and their caregivers were recruited between May 2009 and July 2012 from outpatient memory clinics in Northern Ireland to take part in a face-to-face structured interview with a researcher. Patients' cognitive status and presence of depression were established. A full medication history was taken. Both patients and caregivers were asked to rate patients' pain, at the time of the interview and on an average day, using a 7-point verbal descriptor scale. From the 206 patients who were eligible to take part, 75 patient-caregiver dyads participated in the study (participation rate = 36.4%). The majority of patients (92.0%) had dementia classed as mild or moderate. Pain was commonly reported among the sample, with 57.3% of patients and 70.7% of caregivers reporting patient pain on an average day. Significant differences were found between patients' and caregivers' reports of pain. Two-fifths of patients (40.0%) were prescribed analgesia. Antipsychotic, hypnotic and anxiolytic drug use was low, whereas antidepressant drugs were prescribed more commonly. Presence of pain was unaffected by dementia severity; however, the use of prescribed analgesic medication was a significant predictor of the presence of pain in these patients, whether reported by the patient or their caregiver 'right now' or 'on an average day' (P < 0.001). Patient and caregiver recruitment was challenging, and remains a barrier to research in this area in the future.

Associations between falls and general health, nutrition, dental health and medication use in Swedish home-dwelling people aged 75 years and over

The vast majority of elderly people in Sweden live in private homes in their communities for as long as possible. Poor health and a high risk of falls are very common among this group. This cross-sectional study investigates the association between falls and general health, appetite, dental health, and the use of multiple medications among home-dwelling men and women aged ≥ 75 years. Data were collected between October 2008 and March 2009 using a postal questionnaire. A total of 1243 people participated in the questionnaire survey (74% response rate), of which 1193 were included in the analysis. The majority of participants were women (n = 738, 62%). Falls in the previous 12-month period were reported by 434 (36%) participants. Most fallers (n = 276, 64%) were women. The majority of the fallers lived in a flat (n = 250, 58%). Poor health (aOR: 1.61; CI: 1.34-1.95), poor dental health (aOR: 1.22; CI: 1.07-1.39) and the use of four or more types of medication daily (aOR: 1.13; CI: 1.03-1.25) were significantly associated with falls in all participants. Poor dental health was found irrespectively of living in a flat (aOR: 1.23; CI: 1.04-1.46) or living in a house (aOR: 1.28; CI: 1.02-1.61), and both were significantly associated with falls. The use of more than four different types of medication daily (aOR: 1.25; CI: 1.11-1.41) was associated with falls for those living in a flat. The results highlight that falls are associated with poor general health, poor dental health and the use of four or more types of medication daily. Health professionals should provide health promotion education and investigate dental health and risk factors for oral disease. Likewise, medical and clinical practices of physicians and community care nurses should include assessing the risk of falling, and treatment that predisposes falls.

Predicting falls in elderly patients with chronic pain and other chronic conditions

BACKGROUND

The aim was to identify fall predictors in elderly suffering from chronic pain (CP) and to test their applicability among patients with other chronic conditions.

METHODS

1,379 non-institutionalized patients aged 65 years and older who were suffering from CP (S.AGE CP sub-cohort) were monitored every 6 months for 1 year. Socio-demographic, clinical and pain data and medication use were assessed at baseline for the association with falls in the following year. Falls were assessed retrospectively at each study visit. Logistic regression analyses were performed to identify fall predictors. The derived model was applied to two additional S.AGE sub-cohorts: atrial fibrillation (AF) (n = 1,072) and type-2 diabetes mellitus (T2DM) (n = 983).

RESULTS

Four factors predicted falls in the CP sub-cohort: fall history (OR: 4.03, 95 % CI 2.79-5.82), dependency in daily activities (OR: 1.81, 95 % CI 1.27-2.59), age ≥75 (OR: 1.53, 95 % CI 1.04-2.25) and living alone (OR: 1.73, 95 % CI 1.24-2.41) (Area Under the Curve: AUC = 0.71, 95 % CI 0.67-0.75). These factors were relevant in AF (AUC = 0.71, 95 % CI 0.66-0.75) and T2DM (AUC = 0.67, 95 % CI 0.59-0.73) sub-cohorts. Fall predicted probability in CP, AF and T2DM sub-cohorts increased from 7, 7 and 6 % in patients with no risk factors to 59, 66 and 45 % respectively, in those with the four predictors. Fall history was the strongest predictor in the three sub-cohorts.

CONCLUSION

Fall history, dependency in daily activities, age ≥75 and living alone are independent fall predictors in CP, AF and T2DM patients.

Uso de anti-inflamatórios e analgésicos por uma população de idosos atendida na Estratégia Saúde da Família

ResumoEste estudo objetivou analisar a prevalência do uso de anti-inflamatórios e analgésicos em idosos da Estratégia Saúde da Família de Porto Alegre-RS, bem como investigar fatores associados: dados sociodemográficos e de saúde; uso contínuo ou se necessário da medicação; indicação médica ou automedicação. A coleta de dados ocorreu entre março de 2011 e dezembro de 2012. Os agentes de saúde comunitários aplicaram um questionário com dados sociodemográficos, de saúde e uso de medicamentos. Foram estudados os anti-inflamatórios não esteroidais, glicocorticoides, analgésicos não opioides e opioides de uso oral. Foram incluídos 758 idosos e o uso de anti-inflamatórios e analgésicos era feito por 28,8%. O paracetamol e o ibuprofeno foram os mais utilizados. No que diz respeito à autopercepção de saúde, quanto pior a saúde relatada, maior o uso da terapêutica (p<0,001). A doença hepática e artrose/artrite/reumatismo mostraram estar associadas ao uso de anti-inflamatórios e analgésicos (p<0,001). A prevalência de uso de anti-inflamatórios e analgésicos foi considerada moderada quando comparada a estudos prévios (28,8%). Além disso, a maioria dos idosos fazia uso desses medicamentos quando era preciso, provavelmente porque sentia dores leves a moderadas, não sendo necessário o uso contínuo da medicação ou também por sofrer com os efeitos adversos desses medicamentos, optando por usá-los esporadicamente.

Referrals and Treatment Completion for Prescription Opioid Admissions: Five Years of National Data

This study examines sources of referral for prescription opioid admission to substance use disorder treatment facilities and their relative completion success rates using secondary analysis of an existing data set (treatment episode datasets-discharge). Five years of data from public and private treatment facilities were extracted for client discharges with no prior treatment (N=2,909,884). Healthcare professionals account for very few referrals to treatment (<10%). Prescription opioid clients referred into treatment had lower treatment success compared to other substance clients and when referred by healthcare providers had lower success rates (OR=0.72, 95% CI 0.70-0.75) than clients from other referral sources. Fewer treatment referrals for prescription opioid misuse by healthcare providers and lower success rates are significant and timely findings due to the prevalence of prescription opioid misuse. Healthcare providers are well positioned to refer early for prescription opioid misuse and continue support of their patients during treatment.

Alternative methods of pain management for the older adult population: Review of topical pain medications

The older adult population is one of the fastest growing age groups in the United States. As this population continues to expand, determining the safest way to provide pain management has become increasingly important. More than 50% of community-dwelling older adults experience pain on a daily basis, and up to 83% of those in assisted living facilities experience persistent pain. Pain is exceedingly challenging to treat safely and effectively in the elderly because of the physiologic changes that occur as people age. In addition, many nonnarcotic medications with analgesic properties are listed in both the 2012 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults and the Pharmacy Quality Alliance high-risk medications lists. An approach to the growing challenge of managing pain in the elderly that is gaining popularity among community-dwelling patients is the use of topical pain medications. The goal of this article is to review some of the available literature regarding the use of various topical analgesics alone or in combination, and to discuss their known or theoretical mechanisms of peripheral pain modulation. Commercially available or compounded topical pain medications may be used to replace or augment doses of oral medications in an effort to decrease the risk of adverse drug events for older adult patients. When prescribing topical pain medications physicians should consider the nature of the pain targeted, the type of analgesia expected from each ingredient, the potential for systemic absorption, and related side effects.

Do male and female general practitioners differently prescribe chronic pain drugs to older patients?

OBJECTIVE

The aim of this study was to identify the relationship between general practitioner (GP) gender and prescribing practice of chronic pain drugs in older adults.

DESIGN

Cross-sectional observational study.

SETTING

GPs in private practice throughout France.

SUBJECTS

Two hundred and sixty GPs (80.8% male and 19.2% female) enrolled 1,379 (28.4% male and 71.6% female) noninstitutionalized patients over 65 years of age, suffering from chronic pain.

METHODS

A comparison of prescribing habits between male and female GPs was performed on baseline data with univariate analyses followed by multivariate analyses after taking several confounding factors into account.

RESULTS

No significant differences were found when comparing male and female GPs' prescriptions of World Health Organization step 1, step 2, and step 3 analgesics. Male GPs were more likely than female GPs to prescribe antineuropathic pain drugs (11.3% of patients with male GPs versus 4.8% of patients with female GPs, P = 0.004) and less likely to prescribe symptomatic slow-acting drugs for osteoarthritis (SySADOA) (10.2% of male GPs' patients versus 18.8% of female GPs' patients, P = 0.0003). After adjusting for several confounding factors, male GPs were still more likely to prescribe antineuropathic pain drugs (OR 2.43, 95% CI 1.15-5.14, P = 0.02) and less likely to prescribe symptomatic slow-acting drugs (OR 0.64, 95% CI 0.42-0.97, P = 0.03).

CONCLUSION

Male and female GPs prescribe analgesics in a similar manner. However, male GPs prescribe more antineuropathic pain drugs, but fewer SySADOA.

Physician practicing preferences for conventional or homeopathic medicines in elderly subjects with musculoskeletal disorders in the EPI3-MSD cohort

Background

Musculoskeletal pain is common in elderly persons. Analgesic use is high in the elderly and may involve unacceptable risk in individuals with chronic pain. Our aim was to compare the socio-demographic characteristics of elderly subjects with musculoskeletal disorders (MSD) and to assess medication use and clinical evolution of musculoskeletal pain according to physician prescribing preference: homeopathy (Ho) group, conventional medicine (CM) group, or mixed prescription (MX) group.

Methods

The EPI3 study was a 1 year observational survey carried out among general practitioners in France between March 2007 and July 2008. This sub-analysis was carried out on elderly subjects aged ≥70 years from the original EPI3 cohort. Socio-demographic data were collected at inclusion using a self-administered patient questionnaire and medical data were recorded for each patient. Quality of life was measured using the Short Form-12 questionnaire. Patients completed a structured telephone interview on their functional status (evaluated with the QuickDash questionnaire, EIFEL scale or Lequesne index) within 72 hours of inclusion. This telephone interview was repeated at 1, 3, and 12 months. Drug exposure was also assessed during these interviews.

Results

146 patients (mean age ± standard deviation: 75.8±4.8 years) were analyzed (80.1% female, 74.7% MSD of the spine or lower limbs, 64.4% chronic MSD). Patients in the CM and MX groups were 3.7 times or 2.5 times more likely (odds ratio [OR] =3.71, 95% confidence interval [CI]: 1.12–12.30; OR =2.52, 95% CI: 1.05–6.05; respectively) to have used non-steroidal anti-inflammatory drugs (NSAIDs) than those in the Ho group. In contrast, analgesic use was comparable in the three groups (OR =1.06 [CM versus Ho], 95% CI: 0.09–12.11; OR =0.34 [MX versus Ho], 95% CI: 0.07–1.57). Overall functional score evolution was similar in the three groups over time (P=0.16).

Conclusion

NSAID use was significantly higher in elderly MSD patients consulting a conventional practice general practitioner. In contrast, analgesic use and MSD evolution were similar in the three groups. Consulting a homeopathic physician for MSD management does not appear to represent a loss of therapeutic opportunity, and decreases the use of NSAIDs.

What analgesics do older people use prior to initiating oxycodone for non-cancer pain? A retrospective database study

BACKGROUND

Increased oxycodone use has been associated with adverse drug events, non-medical use and overdose deaths.

OBJECTIVES

To explore patterns of non-opioid, weak opioid and strong opioid use prior to initiation of oxycodone for non-cancer pain in a predominantly older Australian population.

METHODS

A retrospective study was conducted using the Australian Government Department of Veterans' Affairs administrative claims database. Analgesic use 12 months prior to incident dispensing of oxycodone was determined for people in the community and in residential aged-care facilities (RACFs). Log-binomial regression was used to compute adjusted rate ratios (RRs) and 95 % confidence intervals (95 % CIs) for the use of other analgesics prior to initiating oxycodone.

RESULTS

Of 10,791 people who initiated oxycodone in 2010, 26 % in community settings and 13 % in RACFs were not dispensed other analgesics in the 12 months prior to initiating oxycodone. Thirty-four percent and 20 % of those in community settings and RACFs, respectively, were not dispensed other analgesics in the previous 4 months. Co-morbidity had little impact on prior analgesic use. Each additional co-morbid condition was associated with a 1.4 % increased likelihood (RR 1.014, 95 % CI 1.012-1.016; p < 0.0001) and a 1.2 % increased likelihood (RR 1.012, 95 % CI 1.009-1.015; p < 0.0001) of being dispensed another analgesic prior to initiating oxycodone in community and RACF settings, respectively.

CONCLUSIONS

Oxycodone is frequently initiated for non-cancer pain without first trialing other analgesics. This highlights the need for prescribing practices to be reviewed in light of increasing concerns about adverse drugs events and death due to oxycodone, particularly in older people.

Pain characteristics associated with the onset of disability in older adults: the maintenance of balance, independent living, intellect, and zest in the Elderly Boston Study

OBJECTIVES

To determine the effects of chronic pain on the development of disability and decline in physical performance over time in older adults.

DESIGN

Longitudinal cohort study with 18 months of follow-up.

SETTING

Urban and suburban communities.

PARTICIPANTS

Community-dwelling older adults aged 65 and older (N = 634).

MEASUREMENTS

Chronic pain assessment consisted of musculoskeletal pain locations and pain severity and pain interference according to the subscales of the Brief Pain Inventory. Disability was self-reported as any difficulty in mobility and basic and instrumental activities of daily living (ADLs, IADLs). Mobility performance was measured using the Short Physical Performance Battery (SPPB). Relationships between baseline pain and incident disability in 18 months were determined using risk ratios (RRs) from multivariable Poisson regression models.

RESULTS

Almost 65% of participants reported chronic musculoskeletal pain at baseline. New onset of mobility difficulty at 18 months was strongly associated with baseline pain distribution: 7% (no sites), 18% (1 site), 24% (multisite), and 39% (widespread pain, P-value for trend < .001). Similar graded effects were found for other disability measures. Elderly adults with multisite or widespread pain had at a risk of onset of mobility difficulty at least three times as great as that of their peers without pain after adjusting for disability risk factors (multisite pain: risk ratio (RR) = 2.95, 95% confidence interval (CI) 1.58-5.50; widespread pain: RR = 3.57, 95% CI = 1.71-7.48). Widespread pain contributed to decline in mobility performance (1-point decline in SPPB, RR = 1.47, 95% CI = 1.08-2.01). Similar associations were found for baseline pain interference predicting subsequent mobility decline and ADL and IADL disability. Weaker and less-consistent associations were observed with pain severity.

CONCLUSION

Older community-dwelling adults living with chronic pain in multiple musculoskeletal locations have a substantially greater risk for developing disability over time and for clinically meaningful decline in mobility performance than those without pain.

Diagnoses indicating pain and analgesic drug prescription in patients with dementia: a comparison to age- and sex-matched controls

Background

The evidence of undertreatment of pain in patients with dementia is inconsistent. This may largely be due to methodological differences and shortcomings of studies. In a large cohort of patients with incident dementia and age- and sex-matched controls we examined (1) how often they receive diagnoses indicating pain, (2) how often they receive analgesics and (3) in which agents and formulations.

Methods

Using health insurance claims data we identified 1,848 patients with a first diagnosis of dementia aged ≥ 65 years and 7,385 age- and sex-matched controls. We analysed differences in diagnoses indicating pain and analgesic drugs prescribed between these two groups within the incidence year. We further fitted logistic regression models and stepwise adjusted for several covariates to study the relation between dementia and analgesics.

Results

On average, patients were 78.7 years old (48% female). The proportions receiving at least one diagnosis indicating pain were similar between the dementia and control group (74.4% vs. 72.5%; p = 0.11). The proportion who received analgesics was higher in patients with dementia in the crude analysis (47.5% vs. 44.7%; OR: 1.12; 95% CI: 1.01-1.24), but was significantly lower when adjusted for socio-demographic variables, care dependency, comorbidities and diagnoses indicating pain (OR: 0.78; 95% CI: 0.68-0.88). Analgesics in liquid form such as metamizole and tramadol were more often used in dementia.

Conclusions

Our findings show a comparable documentation of diagnoses indicating pain in persons with incident dementia compared to those without. However, there still seems to be an undertreatment of pain in patients with dementia. Irrespective of dementia, analgesics seem to be more often prescribed to sicker patients and to control pain in the context of mobility.

Persistent use of analgesic medications in mild-to-moderate Alzheimer's disease

BACKGROUND AND OBJECTIVES

Previous studies have reported a lower use of analgesics in patients with Alzheimer's disease (AD) than in non-AD elderly. To date, no study has focused on persistent analgesic use in patients with mild-to-moderate AD.

METHODS

The "Réseau sur la maladie d'Alzheimer Français" (REAL.FR) cohort study enrolled community-dwelling patients with mild-to-moderate AD. Persistent analgesic use was defined as the consumption of at least one analgesic drug during two consecutive visits (6 months). Associated factors were identified in a nested case-control study.

RESULTS

In REAL.FR, 595 patients were present during at least two consecutive visits [mean age = 77.5 ± 6.8 years, mini-mental state examination (MMSE) = 20.1 ± 4.2]. Prevalence of persistent analgesic use was 13.1 % (95 % CI = 10.4-15.9). The incidence of persistent analgesic use was 5.9/100 patient-years (95 % CI = 5.2-6.6). Women (adjusted odds ratio [OR] = 3.1, 95 % CI = 1.2-8.1), patients with musculoskeletal disorders (OR = 3.4, 95 % CI = 1.6-7.3) and patients treated with numerous medications (OR = 3.0, 95 % CI = 1.5-5.8) were more likely to use analgesics persistently. Statistically significant associations were found with disease duration and disease progression but not with AD severity at baseline.

CONCLUSIONS

Our results suggest a low use of analgesics in AD patients, which could vary with AD progression.

National observatory on the therapeutic management in ambulatory care patients aged 65 and over, with type 2 diabetes, chronic pain or atrial fibrillation

The primary objective of the S.AGES cohort is to describe the real-life therapeutic care of elderly patients. Patients and methods. This is a prospective observational cohort study of 3 700 non-institutionalized patients over the age of 65 years with either type 2 diabetes mellitus (T2DM), chronic pain or atrial fibrillation (AF) recruited by French general practitioners (GPs). Follow-up is planned for 3 years. Baseline characteristics. In the chronic pain sub-cohort, 33% of patients are treated with only grade 1 analgesics, 29% with grade 2 analgesics and 3% with grade 3 analgesics, and 22% have no pain treatment. In the T2DM sub-cohort, 61% of patients have well-controlled diabetes (Hb1c<7%) and 18% are treated with insulin. In the AF sub-cohort, 65% of patients have a CHADS2 score greater than 2, 77% are treated with oral anticoagulants, 17% with platelet inhibitors, 40% with antiarrhythmic drugs and 56% with rate slowing medications. Conclusion. The S.AGES cohort presents a unique opportunity to clarify the real-life therapeutic management of ambulatory elderly subjects and will help to identify the factors associated with the occurrence of major clinical events.

Polypharmacy meets polyherbacy: pharmaceutical, over-the-counter, and natural health product use among Canadian adults

OBJECTIVES

Natural health products (NHP) are increasingly being used to supplement prescription medications (PM) and over-the-counter (OTC) products. The objective of this study was to examine patterns of overall health product use and how these patterns are associated with social and health factors.

METHODS

We used direct health measures data from the Canada Health Measures Survey (CHMS) Cycle 1.0 (2007/2009) to examine recent product use among adults aged 18-79 years (n=3,721). Latent class analyses were used to detect use (propensity) and intensity of use among users of all three product types. Associations between social and health covariates and product patterns were examined using linear and multinomial logit regression procedures.

RESULTS

Three latent classes of health product use were identified. The largest (43%) was characterized by a high probability of PM and NHP but not OTC use. Class two (37%), in contrast, had a low probability of using any of the three health products. Class three (20%) had a high probability of PM and OTC but not NHP use. Age, gender, immigrant status, household size, co-morbidity, perceived health status, and having a regular doctor were associated with these patterns of use. Analyses of intensity of product use among users revealed seven distinct classes; these were differentiated by age, household size, co-morbidity and weight (BMI status).

CONCLUSION

If defining polypharmacy or polyherbacy is based simply on number of health products used, then for Canadians under age 80 neither practice appeared to be widespread. More work needs to be done to define the "poly" in polypharmacy and polyherbacy. This will inform the conversation on appropriate product use, particularly given that about one half of Canadians used medications and NHPs concurrently.

Management of persistent pain in older adults: the MOBILIZE Boston Study

OBJECTIVES

To describe the prevalence of pharmacological (PS) and nonpharmacological (NPS) pain management approaches used by older adults with persistent pain and to identify characteristics associated with use of these approaches.

DESIGN

Population-based cohort.

SETTING

Urban and suburban communities in the Boston, Massachusetts, area.

PARTICIPANTS

Seven hundred sixty-five adults aged 64 and older underwent a home interview and clinic examination. Those reporting any persistent pain were included in this analysis (N = 599).

MEASUREMENTS

All prescription and nonprescription medications were recorded during the home interview. NPS modalities for pain management were assessed using a modification of the Pain Management Inventory. The baseline assessment included extensive measures of pain, health, and functioning.

RESULTS

More than one-third (37.5%) of participants reported using both PS and NPS modalities. Thirty-one percent reported use of NPS modalities alone, and 11.5% used PS modalities alone. NPS modalities (68.4%) were reported more frequently than PS modalities (49%). Women (odds ratio (OR)= 2.2, 95% confidence interval (CI) = 1.26-3.82), individuals with knee osteoarthritis (OR = 3.07, 95% CI = 1.6-5.9), and individuals with moderate to severe pain (OR = 5.02, 95% CI = 2.23-11.28) were more likely to report combined use of PS and NPS modalities. Characteristics associated with individual NPS modalities varied greatly.

CONCLUSION

Only one-third of older adults with persistent pain reported pain management strategies consistent with current guidelines. Further research is required to understand reasons behind choices, barriers to adherence, and the benefits of multiple modalities that older adults with persistent pain use.

Musculoskeletal pain and its treatment among older home-dwelling people: ten-year changes in two Finnish birth cohorts

The purpose of this study is to evaluate the prevalence of musculoskeletal pain and the use of analgesics in two random cohorts of home-dwelling older people 10 years apart (1999 (N = 2044) and 2009 (N = 1610)) in Helsinki, Finland, and to explore which patients characteristics are associated with potential undertreatment or overtreatment of pain. In 1999, the prevalence of daily joint pain interfering with functioning was 16.4% and that of back pain 13.9% among 75-85-year-old people, the respective figures being 21.9% and 17.1% in 2009 (p < 0.001). The proportion of those patients suffering from joint pain and using prescribed analgesics for that was 35.5% in 1999 and 41.5% in 2009 (p < 0.001). The corresponding figures for patients suffering from back pain with analgesics were 38.2% and 48.2% (p < 0.001), respectively. In 2009, 66.1% suffered from any musculoskeletal pain and 28.7% of them were prescribed analgesics, the figures being more frequent among women than men. In addition to higher age, female gender, and painful conditions, also psychiatric symptoms and dizziness tended to be independently associated with analgesic prescriptions. Among persons not reporting pain (N = 545) psychiatric symptoms were overrepresented in the group using prescribed analgesics (22.4% vs. 8.1%, p < 0.05). In conclusion, musculoskeletal pain is still clearly undertreated, but the coverage has increased during 10 years. In addition to pain, several patient characteristics, functioning and psychiatric symptoms, especially, were associated with analgesic prescriptions.

Potentially inappropriate drug use among older persons in Finland: application of a new national categorization

PURPOSE

The Finnish Medicines Agency published a new consensus categorization for potentially inappropriate drug (PID) use among persons aged 75 years and older (A = suitable, B = limited evidence, C = suitable for use under certain conditions only, D = inappropriate) in 2010. We investigated factors associated with use of one or more Category D drugs.

METHOD

Cross-sectional analyses were conducted using baseline data from the Geriatric Multidisciplinary Strategy for the Good Care of the Elderly (GeMS) Study collected in Kuopio, Finland, in 2004. From a random sample of 1000 persons aged 75 years and older, 781 persons provided consent to participate. Logistic regression was used to compute unadjusted and adjusted odds ratios (ORs) and 95 % confidence intervals (95 % CIs) for factors associated with PID use.

RESULTS

PIDs were used by 30 % (n = 234) of all participants on a regular or as-needed basis. Among the 764 persons (98 %) who used prescription or non-prescription drugs, PID use was associated with the number of drugs in use (adjusted OR 1.20; 95 % CI 1.13-1.28) and moderate self-rated health compared to good self-rated health (adjusted OR 1.74; 95 % CI 1.19-2.55). PID use was associated with poor maximum walking speed (adjusted OR 1.64; 95 % CI 1.10-2.45), poor Timed Up and Go (TUG) test scores (adjusted OR 1.66; 95 % CI 1.11-2.47), impaired instrumental activities of daily living (adjusted OR 1.50; 95 % CI 1.06-2.12) and Mini Mental State Examination scores <18 (adjusted OR 2.27; 95 % CI 1.41-3.65).

CONCLUSION

PID use was highly prevalent and associated with impaired functional outcomes. This highlights the importance of clinicians conducting regular reviews of drug therapy.

Drug Burden Index associated with function in community-dwelling older people in Finland: a cross-sectional study

BACKGROUND

This cross-sectional study aimed to investigate the relationship between exposure to anticholinergic and sedative medications, measured with the Drug Burden Index (DBI), and functional outcomes in community-dwelling older people living in Finland.

METHODS

The study population consisted of community-dwelling older people (n = 700) enrolled in the Geriatric Multidisciplinary Strategy for the Good Care of the Elderly (GeMS) study. Outcomes included walking speed, chair stands test, grip strength, timed up and go (TUG) test, instrumental activities of daily living (IADL), and Barthel Index.

RESULTS

Exposure to DBI drugs was identified in 37% of participants: 24% had a DBI range between >0 <1, and 13% DBI ≥ 1. After adjusting for confounders, exposure to DBI drugs was associated with slower walking speed (P < 0.0001), poorer performance on chair stands (P = 0.0001) and TUG (P < 0.0001), difficulties in IADL (P < 0.0001), and Barthel Index (P < 0.0001). The mean adjusted walking speed, time to complete chair stands and TUG, IADL, and Barthel scores were significantly poorer among participants with higher DBI ranges.

CONCLUSION

In older adults living in Finland, DBI was associated with impaired function on previously tested and new outcomes. This finding supports the use of the DBI as tool, in combination with other assessments, to identify older people at risk of functional impairment. The findings highlight the need for revision of current guidelines to improve the quality of drug use in older people.

Adverse drug reactions in older patients: an Italian observational prospective hospital study

Background

In adults over 65 years of age, the frequency of adverse drug reaction (ADRs) related hospital admissions is higher than in younger adults, and the frequency of ADRs occurring during hospital stay highly ranges. The review was designed to evaluate the frequency of ADRs, both resulting in hospital admission and occurring during the hospital stay of older patients, while identifying the types of reactions and the associated drugs.

Methods

Age, sex, date, and diagnosis of admission of all patients aged 65 and over admitted in three geriatric wards of University Hospital of Verona, Italy, from February to July 2009 were registered by nurses on a special form. In the specific cases of admissions caused by an ADR as well as in the cases of an ADR occurring during the hospital stay, the type of reactions and the suspected drugs were also registered by nurses and physicians involved in the study.

Results

During the six months of the study, 1023 patients matched the inclusion criteria and were included in the study. One hundred fourteen hospital admissions (11.1%) were caused by ADRs, while 256 patients (25.0%) had an ADR during their hospital stay. The duration of hospital stay was significantly longer in patients who developed an ADR during their time in hospital, 18.7 (95% CI: 17.2–20.1) days versus 12.6 (95% CI: 11.9–13.3) days. Electrolyte disorders, gastrointestinal disorders, anemia, and International Normalized Ratio increase were the more frequent observed ADRs, with diuretics, antithrombotic agents, and antibacterials as the main involved drugs. Our study confirms that ADRs are an important cause of hospitalization in older patients. In addition, the frequency of ADRs occurring during hospital stay is high and causes prolonged hospitalization.

Sedative load among community-dwelling people aged 75 years and older: a population-based study

BACKGROUND

Drugs with sedative properties are among the most widely used drugs in community-dwelling older people. Use of sedative drugs has been associated with falls and fractures, cognitive and memory impairment and impaired physical function among older people. The sedative load model has been developed to quantify the cumulative effect of taking multiple drugs with sedative properties.

OBJECTIVE

The objective of the study was to investigate factors associated with sedative load among community-dwelling older people, using data collected as part of the Finnish Geriatric Multidisciplinary Strategy for the Good Care of the Elderly (GeMS) study.

METHODS

The GeMS study was a randomized, comparative study that evaluated a model for geriatric assessment, care and rehabilitation using a study sample of 1000 persons aged≥75 years who were living in Kuopio, Finland. Of these, 700 people consented to participate and were community-dwelling. Demographic, diagnostic and drug use data (both regular and when-required drugs) were elicited during nurse interviews. For the current analysis, sedative load was computed using a previously published model, in which drugs taken on a regular and when-required basis were classified into one of four groups according to their sedative potential. Group 1 included primary sedatives (sedative rating 2) and group 2 included drugs with sedation as a prominent side effect (sedative rating 1). Each participant's sedative load was calculated by summing the sedative ratings of group 1 and 2 drugs. Logistic regression models were used to investigate factors associated with sedative load.

RESULTS

Twenty-nine percent of participants (n=205) had a sedative load of ≥1 (i.e. used one or more drugs with sedative properties), and 22% (n=158) had a sedative load of ≥2 (i.e. used either one primary sedative or two drugs with sedation as a prominent adverse effect or preparations with a sedating component) when considering regularly used drugs. A sedative load of ≥2 that related to regularly used drugs was associated with female sex (odds ratio [OR] 1.65; 95% CI 1.02, 2.67), poor self-perceived health (OR 2.06; 95% CI 1.25, 3.38), impaired instrumental activities of daily living [IADL] (OR 1.89; 95% CI 1.18, 3.01) and often feeling lonely (OR 4.72; 95% CI 2.15, 10.40). The same factors remained significantly associated with a sedative load of ≥2 after drugs used on a when-required basis were included in the analyses.

CONCLUSIONS

The advantages of the sedative load model were that it included drugs with sedative properties prescribed for somatic diseases, described cumulative exposure to drugs that exert sedative effects through multiple mechanisms in the CNS, and incorporated a sedative rating for each drug. In an older population, female sex, impaired IADL, poor self-perceived health, and loneliness were associated with higher sedative load. Clinicians should remain cognizant of these factors when reviewing drug regimens and targeting interventions to optimize sedative use.

The metabolism of opioid agents and the clinical impact of their active metabolites

BACKGROUND

The metabolism of opioids is critical to consider for multiple reasons. The most commonly prescribed opioid agents often have metabolites that are active and are the source of both analgesic activity and an increased incidence of adverse events. Many opioids are metabolized by cytochrome P450 enzymes. Polymorphisms in cytochrome P450 genes and inhibition or induction of cytochrome P450 enzymes by coadministered drugs may significantly impact the systemic concentration of opioids and their metabolites and the associated efficacy or adverse events.

METHODS

This is a narrative review of the metabolism of various opioids that will highlight the impact of their active metabolites, and the potential impact of cytochrome P450 activity on analgesic activity.

RESULTS

An understanding of "opioid metabolic machinery," cytochrome P450 activity, and drug-drug interactions in the context of opioid selection may benefit clinicians and patients alike.

CONCLUSIONS

A greater appreciation of the metabolism of commonly prescribed opioid analgesics and the impact of their active metabolites on efficacy and safety may aid prescribers in tailoring care for optimal outcomes.