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Stanley ME, Ehsan A, Sodha NR, Sellke FW. History of Psychoactive Medication a Risk Factor for Neurocognitive Decline After Cardiac Surgery. J Surg Res 2024; 295:414-422. [PMID: 38070255 PMCID: PMC10922466 DOI: 10.1016/j.jss.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 09/24/2023] [Accepted: 11/08/2023] [Indexed: 12/29/2023]
Abstract
INTRODUCTION Neurocognitive decline (NCD) is a common complication after cardiac surgery with implications for outcomes and quality of life. Identifying risk factors can help surgeons implement preventative measures, optimize modifiable risk factors, and counsel patients about risk and prognosis. METHODS Prospective cohort study at a single academic center. 104 patients planned to undergo cardiac surgery were enrolled. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) was used to measure neurocognitive function preoperatively, on postoperative day four, and postoperative day 30. NCD is defined as a change in RBANS scaled score of < -8 from baseline to postoperative day 4. Patient charts were reviewed for medication history: beta-blockers, angiotensin-converting enzyme and angiotensin receptor blockers, calcium channel blockers, statins, oral hypoglycemic agents, and psychoactive medications. Charts were also reviewed to calculate postoperative opioid usage. RESULTS NCD was detected in 42.9% of patients. Incidence of NCD was significantly higher in patients taking a psychoactive medication (56.8%) than patients not (31.9%), P < 0.03. There was no relationship between historical use of beta-blocker, calcium-channel blocker, statin, or oral hypoglycemic medications and incidence of NCD. Simple linear regression showed no relationship between change in RBANS total scaled score and opioid usage. There was no difference in incidence of NCD at 1 mo. CONCLUSIONS Patients with a history of taking psychoactive medications prior to cardiac surgery have an increased risk of acute postoperative NCD.
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Affiliation(s)
- Madigan E Stanley
- Divison of Cardiothoracic Surgery, Warren Alpert Medical School at Brown University and Rhode Island Hospital, Providence, Rhode Island.
| | - Afshin Ehsan
- Divison of Cardiothoracic Surgery, Warren Alpert Medical School at Brown University and Rhode Island Hospital, Providence, Rhode Island
| | - Neel R Sodha
- Divison of Cardiothoracic Surgery, Warren Alpert Medical School at Brown University and Rhode Island Hospital, Providence, Rhode Island
| | - Frank W Sellke
- Divison of Cardiothoracic Surgery, Warren Alpert Medical School at Brown University and Rhode Island Hospital, Providence, Rhode Island
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van Poelgeest E, van der Velde N. A themed journal issue on (de)prescribing dilemmas in older, multimorbid adults with increased fall risk. Eur Geriatr Med 2023; 14:645-648. [PMID: 37542645 DOI: 10.1007/s41999-023-00845-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2023]
Affiliation(s)
- Eveline van Poelgeest
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Nathalie van der Velde
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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van Poelgeest EP, Seppala LJ, Lee JM, Bahat G, Ilhan B, Lavan AH, Mair A, van Marum RJ, Onder G, Ryg J, Fernandes MA, Garfinkel D, Guðmundsson A, Hartikainen S, Kotsani M, Montero-Errasquín B, Neumann-Podczaska A, Pazan F, Petrovic M, Soulis G, Vankova H, Wehling M, Wieczorowska-Tobis K, van der Velde N. Deprescribing practices, habits and attitudes of geriatricians and geriatricians-in-training across Europe: a large web-based survey. Eur Geriatr Med 2022; 13:1455-1466. [PMID: 36319837 PMCID: PMC9722796 DOI: 10.1007/s41999-022-00702-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 09/26/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE To provide an overview of the current deprescribing attitudes, practices, and approaches of geriatricians and geriatricians-in-training across Europe. METHODS An online survey was disseminated among European geriatricians and geriatricians-in-training. The survey comprised Likert scale and multiple-choice questions on deprescribing approaches and practices, deprescribing education and knowledge, and facilitators/barriers of deprescribing. Responses to the survey questions and participant characteristics were quantified and differences evaluated between geriatricians and geriatricians-in-training and between European regions. RESULTS The 964 respondents (median age 42 years old; 64% female; 21% geriatricians-in-training) were generally willing to deprescribe (98%) and felt confident about deprescribing (85%). Despite differences across European regions, the most commonly reported reasons for deprescribing were functional impairment and occurrence of adverse drug reactions. The most important barriers for deprescribing were patients' unwillingness, fear of negative consequences, lack of time, and poor communication between multiple prescribers. Perceived risk of adverse drug reactions was highest for psychotropic drugs, nonsteroidal anti-inflammatory drugs, cardiovascular drugs, and opioid analgesics. Only one in four respondents (23% of geriatricians and 37% of geriatricians-in-training) think education in medical school had sufficiently prepared them for deprescribing in clinical practice. They reported that their future deprescribing activities would probably increase with improved information sharing between various prescribers, deprescribing recommendations in guidelines, and increased education and training. Approximately 90% think that a paradigm shift is required for prescribers and patients, increasing focus on the possible benefits of deprescribing (potentially) inappropriate medications. CONCLUSIONS Based on the outcomes of this survey, we recommend investing in improved inter-professional communication, better education and evidence-based recommendations to improve future patient-centered deprescribing practices.
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Affiliation(s)
- Eveline P van Poelgeest
- Department of Internal Medicine Section of Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands.
| | - Lotta J Seppala
- Department of Internal Medicine Section of Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands
| | - Jihoo M Lee
- Graduate School of Communication Science, University of Amsterdam, Amsterdam, The Netherlands
| | - Gülistan Bahat
- Division of Geriatrics, Department of Internal Medicine, Istanbul Medical School, Istanbul University, Capa, Istanbul, Turkey
| | - Birkan Ilhan
- Division of Geriatrics, Department of Internal Medicine, Sisli Hamidiye Etfal Training and Research Hospital, University of Medical Sciences, Istanbul, Turkey
| | - Amanda H Lavan
- Mercers Institute of Successful Ageing, St James's Hospital, Dublin, Ireland
- Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
| | - Alpana Mair
- Effective Prescribing and Therapeutics, Health and Social Care Directorate, Scottish Government, Edinburgh, Scotland, UK
| | - Rob J van Marum
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands
- Department of Elderly Care Medicine, Amsterdam University Medical Centers, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands
| | - Graziano Onder
- Department of Cardiovascular, Endocrine-Metabolic Diseases and Aging, Istituto Superiore di Sanità, Rome, Italy
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Odense Deprescribing Initiative (ODIN), Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Marília Andreia Fernandes
- Department of Internal Medicine, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Doron Garfinkel
- Center for Appropriate Medication Use, Sheba Medical Center and Deputy Head, Homecare Hospice, Israel Cancer Association, 55 Ben Gurion Road, 5932210, Bat, Yam, Israel
| | - Aðalsteinn Guðmundsson
- Landspitali University Hospital, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | | | - Marina Kotsani
- Université de Lorraine, CHRU-Nancy, Pôle (Maladies du Vieillissement, Gérontologie et Soins Palliatifs), Nancy, France
| | | | | | - Farhad Pazan
- Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Mirko Petrovic
- Section of Geriatrics, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
| | - George Soulis
- Outpatient Geriatric Assessment Unit, Henry Dunant Hospital Center, Athens, Greece
- Hellenic Open University, Patras, Greece
| | - Hana Vankova
- Cooperatio 34 - Internal Disciplines, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Martin Wehling
- Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Nathalie van der Velde
- Department of Internal Medicine Section of Geriatrics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging and Later Life, Amsterdam, The Netherlands
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Chiam R, Saedon N, Khor HM, A/P Subramaniam S, Binti Mohmad Nasir SS, Binti Abu Hashim NFI, Tan MP. Potentially inappropriate prescribing in a falls clinic using the STOPP and START criteria. Int J Clin Pharm 2021; 44:163-171. [PMID: 34626298 DOI: 10.1007/s11096-021-01329-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 09/09/2021] [Indexed: 11/30/2022]
Abstract
Background Potentially inappropriate prescribing is increasingly common in older patients with falls. However, published indicators to assess inappropriate prescribing remains unestablished in many countries. Objective This study determined the burden and profile of potentially inappropriate prescribing among patients attending a falls clinic using the STOPP/START criteria and evaluated the factors for falls potentially associated to inappropriate prescribing. Setting University of Malaya Medical Centre Falls Clinic. Method Data of individuals aged ≥ 65 years referred to the falls and syncope clinic were extracted from the falls registry. Potentially inappropriate prescribing was determined with the STOPP/START version 2 criteria. The relationship between potentially inappropriate prescribing with polypharmacy (≥ 5 medications), comorbidities and clinical variables were determined using Pearson's chi-square and potential confounders adjusted for with multivariate regression. Main outcome measure Potentially inappropriate medicines and/or omitted medicines using STOPP/START criteria. Results Data from 421 individuals, aged 77.8 ± 6.7 years and 53.4% women, were included. Potentially inappropriate prescribing was present in 311 (73.9%). Potentially inappropriate medicines use accounted for 84.6% of the 325 prescriptions. 361/659 instances (54.8%) were falls-risk-increasing drugs, with vasodilators (49.3%) being the main potentially inappropriate medicine identified. Of the 177/421 with polypharmacy, 169/177 (95.5%) were exposed to ≥ one potentially inappropriate medicine. 129 instances of potentially omitted medicines were observed in 109 prescriptions (25.9%). Conclusion STOPP/START criteria are useful to identify potentially inappropriate prescribing at the falls and syncope clinic. This finding has important implications for medication review strategies at falls clinic. Future research should determine whether identifying potentially inappropriate prescribing may reduce adverse falls outcomes among patients in this setting.
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Affiliation(s)
- Rosalind Chiam
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Nor'izzati Saedon
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Hui Min Khor
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Sukanya A/P Subramaniam
- Falls and Syncope Service, Cardiorespiratory Laboratory, University of Malaya Medical Centre, 59100, Kuala Lumpur, Malaysia
| | | | | | - Maw Pin Tan
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia. .,Department of Medical Sciences, Faculty of Healthcare and Medical Sciences, Sunway University, Bandar Sunway, Malaysia.
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The Dilemma of Falls in Older Persons: Never Forget to Investigate the Syncope. ACTA ACUST UNITED AC 2021; 57:medicina57060623. [PMID: 34203693 PMCID: PMC8232203 DOI: 10.3390/medicina57060623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/07/2021] [Accepted: 06/11/2021] [Indexed: 11/16/2022]
Abstract
Background and objectives: Falls represent a major cause of morbidity, hospitalizations, and mortality in older persons. The identification of risk conditions for falling is crucial. This study investigated the presence of syncope as a possible cause of falls in older persons admitted to a Sub-Acute Care Unit (SACU) with a diagnosis of accidental fall after initial management in an emergency department and acute hospitalization. Materials and methods: A retrospective monocentric study of patients aged ≥65 years, consecutively admitted to a SACU with a diagnosis of fall-related trauma. All patients underwent a complete assessment of the index event and clinical status. Patients were categorized into three groups according to the identified cause of falls: (1) transient loss of consciousness (T-LOC), (2) unexplained fall (UF), and (3) definite accidental fall (AF). Results: A total of 100 patients were evaluated. T-LOC was present in 36 patients, UF in 37, and AF in 27. Of the 36 patients with T-LOC, a probable origin was identified in most cases (n = 33, 91%), 19 subjects (53%) had orthostatic hypotension, 9 (25%) a cardiac relevant disturbance, 2 (6%) a reproduced vaso-vagal syncope, 2 (6%) severe anemia, and 1 (3%) severe hypothyroidism. The T-LOC group was older and more clinically complex than the other groups. Conclusion: In older patients who recently experienced a fall event, the prevalence of syncope is relevant. In frail and clinically complex patients with falls, the identification of the underlying cause is pivotal and can be achieved through prolonged monitoring and a comprehensive assessment of the person.
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Levine AMP, Emonds EE, Smith MA, Rickles NM, Kuchel GA, Steffens DC, Ohlheiser A, Fortinsky RH. Pharmacist Identification of Medication Therapy Problems Involving Cognition Among Older Adults Followed by a Home-Based Care Team. Drugs Aging 2020; 38:157-168. [PMID: 33354755 DOI: 10.1007/s40266-020-00821-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dementia, depression, and delirium alone or in combination (3Ds) can threaten independence among older adults, and polypharmacy may further accelerate decline. Clinical pharmacists can play an important role on multidisciplinary home-based care teams by identifying medication therapy problems (MTPs) involving cognition. Within a larger ongoing clinical trial, this paper describes cognition-related MTPs and pharmacist recommendations among older adults with 3Ds followed by a home-based care team. METHODS We conducted a retrospective analysis of medication data among Medicare Advantage members aged ≥ 65 years living at home in Connecticut with International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes related to 3Ds; analyses include the first 105 subjects randomized to the home-based care team from March 2017 to January 2019. Advanced practice registered nurses conducted in-home medication reconciliations along with medical and cognitive assessments. Clinical pharmacists then conducted medication reviews centered on agents treating or exacerbating 3Ds. After review by the study advanced practice registered nurse, geriatrician, and psychiatrist, salient recommendations were forwarded to primary care providers for consideration. Medication therapy problems related to cognition were retrospectively abstracted and classified as: (1) indication: underuse or overuse; (2) effectiveness: ineffective agent or low dose (mainly for antidepressants); and (3) safety: undesirable effect (e.g., impaired cognition, dementia treatment side effects), unsafe medication (e.g., potentially inappropriate medications that can harm cognition), drug interaction, or high dose. RESULTS Pharmacists identified 166 cognitive MTPs, with a mean (standard deviation) of 1.58 (1.35) [range 0-6] MTPs per subject. Indication MTPs represented 34% of total MTPs, of which 79% involved underuse and 21% overuse; effectiveness represented 13% of total MTPs; and safety represented over half (52%) of all MTPs, with benzodiazepines and anticholinergics frequently implicated. Recommendations commonly included medication reduction (discontinuation 23% and dose reduction 19%). We found MTPs involving cognition among most (79%) patients. CONCLUSIONS Our study findings support the role of pharmacists on multidisciplinary teams to identify cognitively harmful medications, dementia treatment side effects, and untreated cognitive conditions. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT02945085.
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Affiliation(s)
- Allison M P Levine
- Center on Aging, UConn Health, 263 Farmington Avenue, Farmington, CT, 06030, USA.
| | - Erin E Emonds
- PGY1 Pharmacy Practice Residency Program, UConn Health, Farmington, CT, USA
| | - Marie A Smith
- Center on Aging, UConn Health, 263 Farmington Avenue, Farmington, CT, 06030, USA.,Department of Pharmacy Practice, School of Pharmacy, University of Connecticut, Storrs, CT, USA
| | - Nathaniel M Rickles
- Department of Pharmacy Practice, School of Pharmacy, University of Connecticut, Storrs, CT, USA
| | - George A Kuchel
- Center on Aging, UConn Health, 263 Farmington Avenue, Farmington, CT, 06030, USA
| | - David C Steffens
- Department of Psychiatry, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Alis Ohlheiser
- Center on Aging, UConn Health, 263 Farmington Avenue, Farmington, CT, 06030, USA
| | - Richard H Fortinsky
- Center on Aging, UConn Health, 263 Farmington Avenue, Farmington, CT, 06030, USA
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Farrell MC, Shibao CA. Morbidity and mortality in orthostatic hypotension. Auton Neurosci 2020; 229:102717. [PMID: 32896712 DOI: 10.1016/j.autneu.2020.102717] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/27/2020] [Accepted: 08/07/2020] [Indexed: 02/07/2023]
Abstract
This review summarizes the current literature on the epidemiology of orthostatic hypotension (OH) in the elderly and in patients with autonomic impairment also known as neurogenic OH (nOH); these two conditions have distinct pathophysiologies and affect different patient populations. The prevalence of OH in the elderly varies depending on the study population. In community dwellers, OH prevalence is estimated at 16%, whereas in institutionalized patients, it may be as high as 60%. The prevalence of OH increases exponentially with age, particularly in those 75 years and older. Multiple epidemiological studies have identified OH as a risk factor for all-cause mortality and cardiovascular disease including heart failure and stroke. Real-world data from administrative databases found polypharmacy, multiple co-morbid conditions, and high health-care utilization as common characteristics in OH patients. A comprehensive evaluation of medications associated with OH is discussed with particular emphasis on the use of anti-hypertensive therapy from two large clinical trials on high-intensive versus standard blood pressure management. Finally, we also review the epidemiology of nOH based on the underlying neurodegenerative disorder (either Parkinson's disease or multiple system atrophy), and the presence of co-morbid conditions such as hypertension and cognitive impairment.
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Affiliation(s)
- Maureen C Farrell
- Drexel University College of Medicine, Philadelphia, PA, United States of America
| | - Cyndya A Shibao
- Department of Medicine, Division of Clinical Pharmacology, Vanderbilt Autonomic Dysfunction Center, Vanderbilt University Medical Center, Nashville, TN, United States of America.
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