Medication prescription among elderly patients admitted through an acute assessment unit

Regular Medications in the Emergency Department Short Stay Unit (ReMedIES): Can Prescribing be Improved Without Increasing Resources?

Background: Hospital medication errors are frequent and may result in adverse events. Data on non-prescription of regular medications to emergency department short stay unit patients is lacking. In response to local reports of regular medication omissions, a multi-disciplinary team was tasked to introduce corrective emergency department (ED) process changes, but with no additional financing or resources. Aim: To reduce the rate of non-prescription of regular medications for patients admitted to the ED Short Stay Unit (SSU), through process change within existing resource constraints. Methods: A pre- and post-intervention observational study compared regular medication omission rates for patients admitted to the ED SSU. Included patients were those who usually took regular home medications at 08:00 or 20:00. Omissions were classified as clinically significant medications (CSMs) or non-clinically significant medications (non-CSMs). The intervention included reinforcement that the initially treating acute ED doctor was responsible for prescription completion, formal checking of prescription presence at SSU handover rounds, double-checking of prescription completeness by the overnight SSU lead nurse and junior doctor, and ED pharmacist medication reconciliation for those still identified as having regular medication non-prescription at 07:30. Results: For the 110 and 106 patients in the pre- and post-intervention periods, there was a non-significant reduction in the CSM omission rate of -11% (95% CI: -23 to 2), from 41% (95% CI: 32-50) to 30% (95% CI: 21-39). Conclusion: Non-prescription of regular CSMs for SSU patients was not significantly reduced by institution of work practice changes within existing resource constraints.

Polypharmacy difference between older people with and without diabetes: Evidence from the English longitudinal study of ageing

AIM

To study the association between diabetes and the prevalence of and risk factors for polypharmacy among adults aged 50 and older in England.

METHODS

A cross-sectional study (2012-2013) of the English Longitudinal Study of Ageing. Polypharmacy was defined as taking 5-9 long-term medications a day and heightened polypharmacy as 10 or more. Diabetes included diagnosed and undiagnosed cases (glycated haemoglobin ≥ 6.5% (48 mmol/mol)).

RESULTS

Of 7729 participants, 1100 people had diabetes and showed higher prevalence rates of polypharmacy (41.1% vs 14.8%) and heightened polypharmacy (5.8% vs 1.7%) than those without diabetes, even when antihyperglycemic medications were excluded. Risk factors for polypharmacy also differed according to diabetes status. Among people with diabetes, risk factors for polypharmacy and heightened polypharmacy were having more long-term conditions (relative risk ratio (RRR) = 1.86; 3.51) and being obese (RRR = 1.68; 3.68), while females were less likely to show polypharmacy (RRR = 0.51) and heightened polypharmacy (RRR = 0.51) than males. Older age (RRR = 1.04) was only related to polypharmacy among people without diabetes.

CONCLUSIONS

Adults with diabetes had higher prevalence rates of polypharmacy and heightened polypharmacy than those without diabetes, regardless of including antihyperglycemic drugs. Early detection of polypharmacy among older people with diabetes needs to focus on co-morbidities and obesity.

Prevalence of drug interactions in hospitalised elderly patients: a systematic review

BACKGROUND

The prevalence of drug-drug interactions (DDIs) in hospital settings is variable, and elderly patients are considered a high risk population for DDIs. There are no systematic reviews describing the prevalence of DDIs in hospitalised elderly patients.

OBJECTIVES

To assess and summarise the available data on the prevalence of DDIs in hospitalised elderly patients and to describe which drugs, drug classes and drug combinations are most commonly involved in DDIs.

DATA SOURCE

A systematic electronic literature search was conducted on Medline/PubMed, Embase, Lilacs, SciElo, Web of Science, Cinahl, Scopus, Cochrane, OpenGrey, Capes Thesis Bank, OasisBR, OpenAire and abstracts from scientific events, without limitation on language or period of publication. Study selection was completed on 21 September 2018.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

Original observational studies that reported the prevalence of actual or potential DDIs during hospitalisation in patients aged 60 years or older were included. The main outcome measure was prevalence of DDIs and number of DDIs per patient. Subgroup analysis was performed in studies that reported the prevalence of DDIs in geriatric units.

STUDY APPRAISAL AND SYNTHESIS METHODS

Study quality was assessed using the Agency for Healthcare Research and Quality methodological checklist for cross sectional and prevalence studies.

RESULTS

34 studies were included, involving 9577 patients. The prevalence of DDIs ranged from 8.34% to 100%. In studies conducted in geriatric units, the prevalence ranged from 80.5% to 90.5%. The number of DDIs per patient ranged from 1.2 to 30.6. Single drugs most commonly involved in DDIs were furosemide, captopril, warfarin and dipyrone. Drug classes mostly involved were potassium sparing diuretics and angiotensin converting enzyme inhibitors.

LIMITATIONS

The main limitation is the heterogeneity between the included studies that precluded a meta-analysis. Several different methods were used to identify DDIs, majorly, and potential DDIs. Few studies have reported measures to control the quality of the collected data.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

The prevalence of DDIs ranged widely, and the variation may reflect differences in the conditions of the elderly patients and level of attention (or complexity of care), as well as methodological differences, especially the methods and/or software used to identify DDIs.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42018096720.

Evaluation of potentially inappropriate medication utilization in elderly patients with cancer at outpatient oncology unit

Background

The aim of the study was to evaluate potentially inappropriate medication use in elderly patients with cancer.

Method

This study was conducted at outpatient oncology clinic from December 2014 to March 2015 among elderly cancer patients. Screening Tool of Older Person's Prescriptions/Screening Tool to Alert doctors to Right Treatment criteria were used to identify potentially inappropriate medication in elderly patients.

Results

Among 114 cancer patients 55.26% of them were male and the mean age of them was 71.78 ± 5.50 (years). The most common concurrent diseases were hypertension in 45 (39.47%) and diabetes in 26 (22.81%) patients. Polypharmacy (≥5 medications) was seen in 94.73% of them. Eighteen patients (15.79%) utilized medications inappropriately according to Screening Tool of Older Person's Prescriptions criteria. Medication omissions were identified in 112 patients (98.25%) with Screening Tool to Alert doctors to Right Treatment criteria.

Conclusions

Clinical pharmacists could improve the current prescribing practices in elderly patients with cancer by assessing potentially inappropriate medications.

Effects of Renal Impairment on Steady-State Plasma Concentrations of Rivastigmine: A Population Pharmacokinetic Analysis of Capsule and Patch Formulations in Patients with Alzheimer's Disease

Introduction

The glomerular filtration rate (GFR), a measure of renal function, decreases by approximately 10 mL/min every 10 years after the age of 40 years, which could lead to the accumulation of drugs and/or renal toxicity. Pharmacokinetic studies of drugs excreted both renally and non-renally are desirable in patients with impaired renal function, defined by parameters including estimated GFR (eGFR) and creatinine clearance (CL_CR).

Objective

We describe here a population pharmacokinetic analysis of the possible effects of renal impairment on steady-state plasma concentrations of rivastigmine and its metabolite NAP226-90 after rivastigmine patch (5 cm² [4.6 mg/24 h], 10 cm² [9.5 mg/24 h], 15 cm² [13.3 mg/24 h], and 20 cm² [17.4 mg/24 h]) and capsule (1.5, 3, 4.5, and 6 mg/12 h) treatment in patients with Alzheimer’s disease.

Methods

The data used to conduct the current pharmacokinetic analysis were obtained from the pivotal phase III, 24-week, multicenter, randomized, double-blind, placebo- and active-controlled, parallel-group study (IDEAL). One blood sample was collected from each patient at steady-state to measure plasma concentrations of rivastigmine and NAP226-90 using a liquid chromatography–tandem mass spectrometry (LC–MS/MS) method. The steady-state plasma concentrations of rivastigmine and NAP226-90 were plotted against CL_CR and eGFR data, and boxplots were constructed after stratification by renal function.

Results

The two groups (mild/no renal impairment vs. moderate/severe/end-stage renal impairment) showed comparable demographic covariates for all patch sizes and capsule doses. No correlation was observed between CL_CR or eGFR and plasma concentrations of rivastigmine or NAP226-90. Boxplots of concentrations of rivastigmine or NAP226-90 for each dose largely overlapped for patch and capsule. Additionally, model-based estimates of plasma concentrations adjusted for body weight yielded similar results.

Conclusion

The results of this study show that renal function does not affect rivastigmine or NAP226-90 steady-state plasma concentrations, and no dose adjustment in patients with renal impairment is required.

ClinicalTrials.gov

NCT00099242.

Fatores associados aos incidentes de segurança entre idosos em terapia intensiva

Resumo Objetivo Verificar os fatores demográficos e clínicos associados aos incidentes de segurança entre idosos em terapia intensiva. Métodos Estudo retrospectivo em prontuários de 112 admissões de idosos internados na Unidade de Terapia Intensiva em 2015. Os dados foram coletados de janeiro a junho de 2016, utilizando: Formulário de caracterização da população, Simplified Acute Physiology Score II; índice de Charlson e a Classificação Internacional de Segurança do Paciente; analisados por regressão linear múltipla (p<0,05). Resultados O tempo de internação aumentou todos os tipos de incidentes sem dano (ISD), eventos adversos (EA) geral, processo/procedimento e infecção. O sexo masculino aumentou os ISD de dieta e, o feminino, EA de administração. O grupo etário de 60 a 79 anos aumentou ISD de medicação. A internação clínica aumentou os ISD de comportamento e, a cirúrgica, EA de infecção. Conclusão Tempo de internação; sexo, grupo etário e internação associaram-se ao aumento de ISD e EA.

Emotional function in dementia patients

Behavioural and psychological symptoms of dementia, which can be considered as hyperreactivity of the emotional functioning of dementia, can be alleviated or aggravated by the behavioural and psychological symptoms of the caregiver. Comfortable stimulations of emotional function through sensory stimulations are effective methods for alleviating behavioural and psychological symptoms of dementia. Although cognitive function deteriorates with age, emotional function is often retained even in advanced years. Thus, it is recommended that care in patients with dementia be focused mainly on the stimulation of emotional function (e.g. sympathy and empathy, which are human traits), rather than relying solely on the stimulation of cognitive function.

Potentially inappropriate medication related to weakness in older acute medical patients

BACKGROUND

The use of potentially inappropriate medications (PIMs) is common in the older population. Inappropriate medications as well as polypharmacy expose older people to a greater risk of adverse drug reactions and may result in hospitalizations.

OBJECTIVE

To evaluate the prevalence of PIMs among acutely hospitalized patients aged ≥65 years in an acute medical unit, and to investigate the relationship between use of PIMs and weakness.

SETTING

This longitudinal observational study was undertaken in the Acute Medical Unit, Hvidovre Hospital, University of Copenhagen, Denmark.

METHOD

Patients aged ≥65 years admitted to the acute medical unit during the period October to December 2011 were included. Patients were interviewed at admission and at a follow-up visit 30 days after discharge. Data included information about medications, social status, functional status, cognitive status, handgrip strength, health-related quality of life, visual acuity, days of hospitalization, and comorbidities, and was prospectively collected. Polypharmacy was defined as regular use of 5 or more drugs. The Charlson Comorbidity Index was used to categorize comorbidities.

MAIN OUTCOME MEASURE

The prevalence of PIMs and the association with PIMs and functional status handgrip strength, HRQOL, comorbidities, social demographic data and vision.

RESULTS

Seventy-one patients (55 % men) with a median age of 78.7 years participated. The median number of medications was eight per person. Eighty percent were exposed to polypharmacy. PIMs were used by 85 % of patients, and PIMs were associated with low functional status (p = 0.032), low handgrip strength (p = 0.006), and reduced health-related quality of life (p = 0.005), but not comorbidities (p = 0.63), age (p = 0.60), sex (p = 0.53), education (p = 0.94), cognition (p = 0.10), pain (p = 0.46), or visual acuity (p = 0.55).

CONCLUSIONS

Use of PIMs was very common among older people admitted to an acute medical unit. The use of PIMs is associated with low functional status, low handgrip strength, and reduced health-related quality of life.

Hepatotoxicity and drug interactions in liver transplant candidates and recipients

In this article the medications that have been shown to increase rates of drug-induced liver injury in patients with cirrhosis and the important drug-drug interactions in recipients of liver transplantation are reviewed. In general, the risk of drug-induced liver injury in patients with cirrhosis does not seem to be higher when compared with the noncirrhotic population. There are, however, 2 classes of agents that have been implicated-medications used to treat tuberculosis and medications used to treat human immunodeficiency virus infection. However, with careful monitoring, even significant interactions can be effectively managed.