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Doody H, Ayre J, Livori A, Ilomäki J, Khalil V, Bell JS, Morton JI. The impact of frailty on initiation, continuation and discontinuation of secondary prevention medications following myocardial infarction. Arch Gerontol Geriatr 2024; 122:105370. [PMID: 38367524 DOI: 10.1016/j.archger.2024.105370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/02/2024] [Accepted: 02/12/2024] [Indexed: 02/19/2024]
Abstract
AIM To evaluate the association between frailty and initiating, continuing, or discontinuing secondary prevention medications following myocardial infarction (MI). METHODS We conducted a cohort study using linked health data, including all adults aged ≥65 years who discharged from hospital following MI from January 2013 to April 2018 in Victoria, Australia (N = 29,771). The Hospital Frailty Risk Score (HFRS) was used to assess frailty. Logistic regression was used to investigate associations of frailty with initiation, continuation, and discontinuation of secondary prevention medications (P2Y12 inhibitor antiplatelets, beta-blockers, renin-angiotensin-aldosterone system (RAAS) inhibitors, and lipid-lowering therapies) in the 90 days from discharge post-MI, by HFRS, adjusted for age, sex, and Charlson Comorbidity Index. RESULTS Increasing frailty was associated with lower probability of initiating and continuing P2Y12 inhibitors, RAAS inhibitors, and lipid-lowering therapies, but not beta-blockers. At at an HFRS of 0, the predicted probabiliy of having all four medications initiated or continued was 0.59 (95 %CI 0.57-0.62) for STEMI and 0.35 (0.34-0.36) for non-STEMI, compared to 0.38 (0.33-0.42) and 0.16 (0.14-0.18) at an HFRS of 15. Increasing frailty was associated with higher probability of discontinuing these medications post-MI. The predicted probability of discontinuing at least one secondary prevention medication post-MI at an HFRS of 0 was 0.10 (0.08-0.11) for STEMI and 0.14 (0.13-0.15) for non-STEMI, compared to 0.27 (0.22-0.32) and 0.34 (0.32-0.36) at an HFRS of 15. CONCLUSION People with higher levels of frailty were managed more conservatively following MI than people with lower levels of frailty. Whether this conservative treatment is justified warrants further study.
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Affiliation(s)
- Hannah Doody
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia; Pharmacy Department, Launceston General Hospital, Tasmania, Australia; Pharmacy Department, Monash Health - Victorian Heart Hospital, Melbourne, Australia
| | - Justine Ayre
- Pharmacy Department, Launceston General Hospital, Tasmania, Australia
| | - Adam Livori
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia; Grampians Health, Ballarat, Australia
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Viviane Khalil
- Pharmacy Department, Monash Health - Victorian Heart Hospital, Melbourne, Australia; Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Jedidiah I Morton
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia; Diabetes and Population Health, Baker Heart and Diabetes Institute, Melbourne, Australia.
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Doody H, Livori A, Ayre J, Ademi Z, Bell JS, Morton JI. Guideline concordant prescribing following myocardial infarction in people who are frail: A systematic review. Arch Gerontol Geriatr 2023; 114:105106. [PMID: 37356114 DOI: 10.1016/j.archger.2023.105106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 06/27/2023]
Abstract
AIMS The risk-to-benefit ratio of cardioprotective medications in frail older adults is uncertain. The objective was to systematically review prescribing of guideline-recommended cardioprotective medications following myocardial infarction (MI) in people who are frail. DATA SOURCES Ovid Medline, PubMed and Cochrane were searched from inception to October 2022 for studies that reported prescribing of one or more cardioprotective medication classes post-MI or acute coronary syndromes in people with frailty. STUDY SELECTION We included observational studies that reported prescribing of cardioprotective medications post-MI stratified by frailty status. RESULTS Overall, 16 cohort studies published from 2013 to 2022 that used seven different frailty scales were included. Prescribing of all cardioprotective medication classes following MI was lower in frail compared to non-frail people, with absolute rates of prescribing varying substantially across studies. Median prescribing in frail and non-frail people, respectively, was 88.9% (IQR 81.5-96.2) and 93.1% (IQR 92.0-98.9) for aspirin; 68.1% (IQR 61.9-91.2) and 86.7% (IQR 79.5-92.8) for P2Y12-inhibitors; 83.1% (IQR 76.9-91.3) and 94.0% (IQR 87.1-95.9) for lipid-lowering therapy; 67.9% (IQR 60.6-74.0) and 74.7% (IQR 71.3-84.5) for angiotensin-converting enzyme inhibitor/angiotensin II receptor blockers; and 74.1% (IQR 69.2-79) and 77.6% (IQR 71.8-85.9) for beta-blockers. CONCLUSION People who were frail were less likely to be prescribed guideline recommended medication classes post-MI than those who were non-frail. Further research is needed into treatment benefits and risks in frail people to avoid unnecessarily withholding treatment in this high-risk population, while also minimising potential for medication related harm.
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Affiliation(s)
- Hannah Doody
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Australia; Pharmacy Department, Launceston General Hospital, Tasmania, Australia
| | - Adam Livori
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Australia; Grampians Health, Ballarat, Victoria, Australia
| | - Justine Ayre
- Pharmacy Department, Launceston General Hospital, Tasmania, Australia
| | - Zanfina Ademi
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Australia; School of Public Health and Preventive Medicine, Monash University, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Australia
| | - Jedidiah I Morton
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Australia.
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Lee DS, Zullo AR, Lee Y, Daiello LA, Kim DH, Kiel DP, Berry SD. Discontinuation of beta-blockers among nursing home residents at end of life. J Am Geriatr Soc 2022; 70:200-207. [PMID: 34669190 PMCID: PMC8742763 DOI: 10.1111/jgs.17493] [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: 06/09/2021] [Revised: 09/01/2021] [Accepted: 09/04/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Given limited life expectancy of nursing home (NH) residents, harms of continuing beta-blockers (BBs) may outweigh clinical benefits. Our objective was to describe beta-blocker discontinuation for NH residents during the last year of life, and identify characteristics associated with earlier discontinuation. METHODS This was a retrospective cohort study that included all long-stay residents in fee-for-service Medicare who died in 2016 and were prescribed oral BBs 1 year before death. Beta-blocker discontinuation was defined as a gap in medication on hand for ≥45 days per Medicare Part D claims, measured from the last date drug was on hand. Comorbidities were obtained from Chronic Condition Warehouse, and other characteristics from the Minimum Data Set. Kaplan-Meier curves were used to describe time to first discontinuation. Findings were stratified by cardiac diagnoses, perceived life expectancy of <6 months, or elevated mortality index. RESULTS Eighty-eight thousand two hundred and eighty-four residents were prescribed ≥1 daily BB 12 months before death. Mean age was 84.1 years and 69.2% were female. Of these, 60,573 residents (68.6%) remained on a BB in the last 45 days of life, and 57,880 residents (65.6%) had ≥1 cardiac diagnosis. Only 5239 residents (5.9%) had elevated mortality index, whereas 16,798 residents (19.0%) had perceived poor prognosis. In the last year of life, there was no difference in beta-blocker discontinuation pattern between residents with and without cardiac diagnoses. Residents with perceived poor prognosis and elevated mortality index discontinued BBs earlier. For example, mean time until discontinuation among residents with poor perceived prognosis was 245 versus 279 days in residents without such prognosis (p < 0.0001). CONCLUSIONS BBs are commonly prescribed to NH residents in the final year of life. Overall, discontinuation occurs earlier in residents for whom clinicians perceive limited life expectancy, suggesting that improved prognostication may offer an important opportunity to reduce polypharmacy toward end of life.
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Affiliation(s)
| | | | - Yoojin Lee
- Brown University School of Public Health
| | | | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife,Beth Israel Deaconess Medical Center & Harvard Medical School
| | - Douglas P. Kiel
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife,Beth Israel Deaconess Medical Center & Harvard Medical School
| | - Sarah D. Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife,Beth Israel Deaconess Medical Center & Harvard Medical School
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Zullo AR, Riester MR, Erqou S, Wu WC, Rudolph JL, Steinman MA. Comparative Effectiveness of Angiotensin II Receptor Blockers and Angiotensin-Converting Enzyme Inhibitors in Older Nursing Home Residents After Myocardial Infarction: A Retrospective Cohort Study. Drugs Aging 2020; 37:755-766. [PMID: 32808250 PMCID: PMC7530043 DOI: 10.1007/s40266-020-00791-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Evidence regarding differences in outcomes between angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) among older nursing home (NH) residents after acute myocardial infarction (AMI) is limited. OBJECTIVES The purpose of our study was to estimate the post-AMI effects of ARBs versus ACEIs on mortality, rehospitalization, and functional decline outcomes in this important population. METHODS This retrospective cohort study used national Medicare claims linked to Minimum Data Set assessments. The study population included individuals aged ≥ 65 years who resided in a US NH ≥ 30 days, were hospitalized for AMI between May 2007 and March 2010, and returned to the NH. We compared 90-day mortality, rehospitalization, and functional decline outcomes between ARB and ACEI users with inverse-probability-of-treatment-weighted binomial and multinomial logistic regression models. RESULTS Of the 2765 NH residents, 270 (9.8%) used ARBs and 2495 (90.2%) used ACEIs. The mean age of ARB versus ACEI users was 82.3 versus 82.7 years, respectively. No marked differences existed between ARB and ACEI users for mortality [odds ratio (OR) 1.18; 95% confidence interval (CI) 0.78-1.79], rehospitalization (OR 1.22; 95% CI 0.90-1.65), or functional decline (OR 1.23; 95% CI 0.88-1.74). In subgroup analyses, ARBs were associated with increased mortality and rehospitalization in individuals with moderate to severe cognitive impairment and with increased rehospitalization in those aged < 85 years. CONCLUSIONS Our findings align with prior data and suggest that clinicians can prescribe either ARBs or ACEIs post-AMI for secondary prevention in NH residents, although the subgroup findings merit further scrutiny and replication. Providers should consider factors such as patient preferences, class-specific adverse events, and costs when prescribing.
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Affiliation(s)
- Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA. .,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA. .,Department of Pharmacy, Rhode Island Hospital, Providence, RI, USA.
| | | | - Sebhat Erqou
- Division of Cardiology, Department of Medicine, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Wen-Chih Wu
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA.,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Division of Cardiology, Department of Medicine, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - James L Rudolph
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA.,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Department of Medicine, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco and San Francisco VA Medical Center, San Francisco, CA, USA
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Zullo AR, Mogul A, Corsi K, Shah NR, Lee SJ, Rudolph JL, Wu WC, Dapaah-Afriyie R, Berard-Collins C, Steinman MA. Association Between Secondary Prevention Medication Use and Outcomes in Frail Older Adults After Acute Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2020; 12:e004942. [PMID: 31002274 DOI: 10.1161/circoutcomes.118.004942] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Secondary prevention medications are often not prescribed to frail, older adults following acute myocardial infarction, potentially because of the absence of data to support use, perceived lack of benefit, and concern over possible harms. We examined the effect of using more guideline-recommended medications after myocardial infarction on mortality, rehospitalization, and functional decline in the frailest and oldest segment of the US population-long-stay nursing home residents. Methods and Results We conducted a retrospective cohort study of nursing home residents aged ≥65 years using 2007 to 2010 national US Minimum Data Set clinical assessment data and Medicare claims. Exposure was the number of secondary prevention medications (antiplatelets, β-blockers, statins, and renin-angiotensin-aldosterone system inhibitors) initiated after myocardial infarction. Outcomes were 90-day death, rehospitalization, and functional decline. We compared outcomes for new users of 2 versus 1 and 3 or 4 versus 1 medications using the inverse probability of treatment-weighted odds ratios with 95% CI. The cohort comprised 4787 residents, with a total of 509 death, 820 functional decline, and 1226 rehospitalization events. Compared with individuals who initiated 1 medication, mortality odds ratios were 0.98 (95% CI, 0.79-1.22) and 0.74 (95% CI, 0.57-0.97) for users of 2 and 3 or 4 medications, respectively. Rehospitalization odds ratios were 1.00 (95% CI, 0.85-1.17) for 2 and 0.97 (95% CI, 0.8-1.17) for 3 or 4 medications. Functional decline odds ratios were 1.04 (95% CI, 0.85-1.28) for 2 and 1.12 (95% CI, 0.89-1.40) for 3 or 4 medications. In a stability analysis excluding antiplatelet drugs from the exposure definition, more medication use was associated with functional decline. Conclusions Use of more guideline-recommended medications after myocardial infarction was associated with decreased mortality in older, predominantly frail adults, but no difference in rehospitalization. Results for functional decline from the main and stability analyses were discordant and did not rule out an increased risk associated with more medication use.
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Affiliation(s)
- Andrew R Zullo
- Department of Health Services, Policy, and Practice (A.R.Z., N.R.S., J.L.R., W.- C.W.), Brown University School of Public Health, Providence, RI.,Department of Epidemiology (A.R.Z., W.-C.W.), Brown University School of Public Health, Providence, RI.,Department of Pharmacy, Rhode Island Hospital, Providence (A.R.Z., A.M., K.C., R.D.-A., C.B.-C.).,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI (A.R.Z., J.L.R.)
| | - Amanda Mogul
- Department of Pharmacy, Rhode Island Hospital, Providence (A.R.Z., A.M., K.C., R.D.-A., C.B.-C.).,Department of Pharmacy Practice, Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, NY (A.M.)
| | - Katherine Corsi
- Department of Pharmacy, Rhode Island Hospital, Providence (A.R.Z., A.M., K.C., R.D.-A., C.B.-C.).,Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston (K.C.)
| | - Nishant R Shah
- Department of Health Services, Policy, and Practice (A.R.Z., N.R.S., J.L.R., W.- C.W.), Brown University School of Public Health, Providence, RI.,Division of Cardiology, Department of Medicine, Brown University Warren Alpert Medical School, Providence, RI (N.R.S., W.-C.W.)
| | - Sei J Lee
- Division of Geriatrics, University of California, San Francisco and San Francisco VA Medical Center, San Francisco (M.A.S., S.J.L.)
| | - James L Rudolph
- Department of Health Services, Policy, and Practice (A.R.Z., N.R.S., J.L.R., W.- C.W.), Brown University School of Public Health, Providence, RI.,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI (A.R.Z., J.L.R.)
| | - Wen-Chih Wu
- Department of Health Services, Policy, and Practice (A.R.Z., N.R.S., J.L.R., W.- C.W.), Brown University School of Public Health, Providence, RI.,Department of Epidemiology (A.R.Z., W.-C.W.), Brown University School of Public Health, Providence, RI.,Division of Cardiology, Department of Medicine, Brown University Warren Alpert Medical School, Providence, RI (N.R.S., W.-C.W.)
| | - Ruth Dapaah-Afriyie
- Department of Pharmacy, Rhode Island Hospital, Providence (A.R.Z., A.M., K.C., R.D.-A., C.B.-C.)
| | - Christine Berard-Collins
- Department of Pharmacy, Rhode Island Hospital, Providence (A.R.Z., A.M., K.C., R.D.-A., C.B.-C.)
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco and San Francisco VA Medical Center, San Francisco (M.A.S., S.J.L.)
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Nanna MG, Hajduk AM, Krumholz HM, Murphy TE, Dreyer RP, Alexander KP, Geda M, Tsang S, Welty FK, Safdar B, Lakshminarayan DK, Chaudhry SI, Dodson JA. Sex-Based Differences in Presentation, Treatment, and Complications Among Older Adults Hospitalized for Acute Myocardial Infarction: The SILVER-AMI Study. Circ Cardiovasc Qual Outcomes 2019; 12:e005691. [PMID: 31607145 DOI: 10.1161/circoutcomes.119.005691] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Studies of sex-based differences in older adults with acute myocardial infarction (AMI) have yielded mixed results. We, therefore, sought to evaluate sex-based differences in presentation characteristics, treatments, functional impairments, and in-hospital complications in a large, well-characterized population of older adults (≥75 years) hospitalized with AMI. METHODS AND RESULTS We analyzed data from participants enrolled in SILVER-AMI (Comprehensive Evaluation of Risk Factors in Older Patients With Acute Myocardial Infarction)-a prospective observational study consisting of 3041 older patients (44% women) hospitalized for AMI. Participants were stratified by AMI subtype (ST-segment-elevation myocardial infarction [STEMI] and non-STEMI [NSTEMI]) and subsequently evaluated for sex-based differences in clinical presentation, functional impairments, management, and in-hospital complications. Among the study sample, women were slightly older than men (NSTEMI: 82.1 versus 81.3, P<0.001; STEMI: 82.2 versus 80.6, P<0.001) and had lower rates of prior coronary disease. Women in the NSTEMI subgroup presented less frequently with chest pain as their primary symptom. Age-associated functional impairments at baseline were more common in women in both AMI subgroups (cognitive impairment, NSTEMI: 20.6% versus 14.3%, P<0.001; STEMI: 20.6% versus 12.4%, P=0.001; activities of daily living disability, NSTEMI: 19.7% versus 11.4%, P<0.001; STEMI: 14.8% versus 6.4%, P<0.001; impaired functional mobility, NSTEMI: 44.5% versus 30.7%, P<0.001; STEMI: 39.4% versus 22.0%, P<0.001). Women with AMI had lower rates of obstructive coronary disease (NSTEMI: P<0.001; STEMI: P=0.02), driven by lower rates of 3-vessel or left main disease than men (STEMI: 38.8% versus 58.7%; STEMI: 24.3% versus 32.1%), and underwent revascularization less commonly (NSTEMI: 55.6% versus 63.6%, P<0.001; STEMI: 87.3% versus 93.3%, P=0.01). Rates of bleeding were higher among women with STEMI (26.2% versus 15.6%, P<0.001) but not NSTEMI (17.8% versus 15.7%, P=0.21). Women had a higher frequency of bleeding following percutaneous coronary intervention with both NSTEMI (11.0% versus 7.8%, P=0.04) and STEMI (22.6% versus 14.8%, P=0.02). CONCLUSIONS Among older adults hospitalized with AMI, women had a higher prevalence of age-related functional impairments and, among the STEMI subgroup, a higher incidence of overall bleeding events, which was driven by higher rates of nonmajor bleeding events and bleeding following percutaneous coronary intervention. These differences may have important implications for in-hospital and posthospitalization needs.
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Affiliation(s)
- Michael G Nanna
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.G.N., K.P.A.)
| | - Alexandra M Hajduk
- Department of Internal Medicine, Geriatrics Section, Program on Aging (A.H., T.E.M., M.G., S.T.), Yale School of Medicine, New Haven, CT
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine (H.M.K.), Yale School of Medicine, New Haven, CT.,National Clinician Scholars Program, Department of Internal Medicine (H.M.K., S.I.C.), Yale School of Medicine, New Haven, CT.,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.).,Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
| | - Terrence E Murphy
- Department of Internal Medicine, Geriatrics Section, Program on Aging (A.H., T.E.M., M.G., S.T.), Yale School of Medicine, New Haven, CT
| | - Rachel P Dreyer
- Department of Emergency Medicine, Center for Outcomes Research and Evaluation (R.P.D., B.S.), Yale School of Medicine, New Haven, CT
| | - Karen P Alexander
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.G.N., K.P.A.)
| | - Mary Geda
- Department of Internal Medicine, Geriatrics Section, Program on Aging (A.H., T.E.M., M.G., S.T.), Yale School of Medicine, New Haven, CT
| | - Sui Tsang
- Department of Internal Medicine, Geriatrics Section, Program on Aging (A.H., T.E.M., M.G., S.T.), Yale School of Medicine, New Haven, CT
| | - Francine K Welty
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (F.W., D.K.L.)
| | - Basmah Safdar
- Department of Emergency Medicine, Center for Outcomes Research and Evaluation (R.P.D., B.S.), Yale School of Medicine, New Haven, CT
| | - Dharshan K Lakshminarayan
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (F.W., D.K.L.)
| | - Sarwat I Chaudhry
- National Clinician Scholars Program, Department of Internal Medicine (H.M.K., S.I.C.), Yale School of Medicine, New Haven, CT.,Section of General Internal Medicine, Department of Internal Medicine (S.I.C.), Yale School of Medicine, New Haven, CT
| | - John A Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine (J.A.D.), New York University School of Medicine.,Department of Population Health (J.A.D.), New York University School of Medicine
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Morin L, Wastesson JW, Laroche ML, Fastbom J, Johnell K. How many older adults receive drugs of questionable clinical benefit near the end of life? A cohort study. Palliat Med 2019; 33:1080-1090. [PMID: 31172885 PMCID: PMC6691599 DOI: 10.1177/0269216319854013] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The high burden of disease-oriented drugs among older adults with limited life expectancy raises important questions about the potential futility of care. AIM To describe the use of drugs of questionable clinical benefit during the last 3 months of life of older adults who died from life-limiting conditions. DESIGN Longitudinal, retrospective cohort study of decedents. Death certificate data were linked to administrative and healthcare registries with national coverage in Sweden. SETTING Older adults (≥75 years) who died from conditions potentially amenable to palliative care between 1 January and 31 December 2015 in Sweden. We identified drugs of questionable clinical benefit from a set of consensus-based criteria. RESULTS A total of 58,415 decedents were included (mean age, 87.0 years). During their last 3 months of life, they received on average 8.9 different drugs. Overall, 32.0% of older adults continued and 14.0% initiated at least one drug of questionable clinical benefit (e.g. statins, calcium supplements, vitamin D, bisphosphonates, antidementia drugs). These proportions were highest among younger individuals (i.e. aged 75-84 years), among people who died from organ failure and among those with a large number of coexisting chronic conditions. Excluding people who died from acute and potentially unpredictable fatal events had little influence on the results. CONCLUSION A substantial share of older persons with life-limiting diseases receive drugs of questionable clinical benefit during their last months of life. Adequate training, guidance and resources are needed to rationalize and deprescribe drug treatments for older adults near the end of life.
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Affiliation(s)
- Lucas Morin
- 1 Aging Research Center, Karolinska Institutet, Stockholm, Sweden.,2 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jonas W Wastesson
- 1 Aging Research Center, Karolinska Institutet, Stockholm, Sweden.,2 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Marie-Laure Laroche
- 3 Centre de pharmacovigilance et de pharmaco-épidémiologie, Department of Pharmacology-Toxicology and Centre of Pharmacovigilance, CHU Limoges, Limoges, France.,4 INSERM 1248, University of Limoges, CHU Limoges, Limoges, France
| | - Johan Fastbom
- 1 Aging Research Center, Karolinska Institutet, Stockholm, Sweden
| | - Kristina Johnell
- 2 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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8
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Yum B, Archambault A, Levitan EB, Dharamdasani T, Kneifati-Hayek J, Hanlon JT, Diaz I, Maurer MS, Lachs MS, Safford MM, Goyal P. Indications for β-Blocker Prescriptions in Heart Failure with Preserved Ejection Fraction. J Am Geriatr Soc 2019; 67:1461-1466. [PMID: 31095736 DOI: 10.1111/jgs.15977] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 04/13/2019] [Accepted: 04/15/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To better understand indications for β-blocker (BB) prescriptions among older adults hospitalized with heart failure with preserved ejection fraction (HFpEF). DESIGN/SETTING Retrospective observational study of hospitalizations derived from the geographically diverse Reasons for Geographic and Racial Differences in Stroke cohort. PARTICIPANTS We examined Medicare beneficiaries aged 65 years or older with an expert-adjudicated hospitalization for HFpEF (left ventricular ejection fraction = 50% or greater). MEASUREMENTS Discharge medications and indications for BBs were abstracted from medical records. RESULTS Of 306 hospitalizations for HFpEF, BBs were prescribed at discharge in 68%. Among hospitalizations resulting in BB prescriptions, 60% had a compelling indication for BB-44% had arrhythmias, and 29% had myocardial infarction (MI) history. Among the 40% with neither indication, 57% had coronary artery disease (CAD) without MI and 38% had hypertension alone (without arrhythmia, MI, or CAD), both clinical scenarios with little supportive evidence of benefit of BBs. Among hospitalizations resulting in BB prescription at discharge, 69% had geriatric conditions (functional limitation, cognitive impairment, hypoalbuminemia, or history of falls). There were no significant differences in the prevalence of geriatric conditions between hospitalizations of individuals with compelling indications for BBs and hospitalizations of individuals with noncompelling indications. CONCLUSIONS BBs are commonly prescribed following a hospitalization for HFpEF, even in the absence of compelling indications. This occurs even for hospitalizations of individuals with geriatric conditions, a subpopulation who may be at elevated risk for experiencing harm from BBs.
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Affiliation(s)
- Brian Yum
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | | | - Emily B Levitan
- Department of Epidemiology, University of Alabama-Birmingham, Birmingham, Alabama
| | | | - Jerard Kneifati-Hayek
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Joseph T Hanlon
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ivan Diaz
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
| | - Mathew S Maurer
- Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Mark S Lachs
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Monika M Safford
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, New York
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9
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Abstract
There are important sex-related differences in elderly patients with acute coronary syndrome (ACS). Women are older, more frequently frail, and present more comorbidities than men. Atypical symptoms at presentation are also more common in female patients, they are leaded to a delayed diagnosis and treatment. Coronary angiography and subsequent revascularization are frequently underused in elderly women and they tend to receive less guidelines-recommended therapies. The prognosis in elderly frail women with ACS is poor, and it is with high mortality and readmissions rates. Bleeding is recurrent ischemic events in which it is more frequent in women than in men. Recovery time might be long, and a multidisciplinary approach is desirable to improve prognosis and quality of life. Further studies are needed in order to clarify the benefit of the different therapies in the group of frail women, and this is particularly true for revascularization, as scientific evidence in this group is very scarce.
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