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Foote DC, Miller JL, Skrepnek GH, Neely S, Bennett K, Boylan PM. Montelukast deprescribing in outpatient specialty clinics: A single center cross-sectional study. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2024; 16:100509. [PMID: 39351122 PMCID: PMC11439829 DOI: 10.1016/j.rcsop.2024.100509] [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: 08/02/2024] [Revised: 09/13/2024] [Accepted: 09/15/2024] [Indexed: 10/04/2024] Open
Abstract
Objective To identify and evaluate montelukast deprescribing in outpatient specialty clinics. Methods This was a single-center, retrospective, cross-sectional study conducted at an academic health system in the southern US including 21 specialty clinics. Subjects included adults ≥18 years with an active prescription for montelukast who attended at least one appointment in pulmonology, otolaryngology, or neurology outpatient specialty clinics between January 1, 2021 to December 31, 2022. Patients <18 years and those with diagnoses of uncontrolled asthma or allergic rhinitis were excluded. Outcomes assessed included the frequency and period prevalence of montelukast deprescribing, defined by a documented montelukast discontinuation within the medical record, and evaluation of reasoning for discontinuation mentioned in visit notes. Results There were 1152 patients who met inclusion criteria. Of these, 43 (3.7 %) experienced a montelukast deprescribing event: 18 (41.9 %) in neurology, 13 (30.2 %) in otolaryngology, and 12 (27.9 %) in pulmonology. Documented reasons for deprescribing were only available for 11 patients (25.6 %); reasons for deprescribing included patient-provider shared decision-making regarding the Black Box Warning [n = 5 (11.6 %)], inadequate treatment response [n = 3 (7.0 %)], suicidal thought development [n = 1 (2.3 %)], adverse drug event [n = 1 (2.3 %)], and pregnancy planning [n = 1 (2.3 %)]. Conclusion Montelukast deprescribing rates were less than 5 % in outpatient specialty clinics. Factors associated with montelukast deprescribing beget further investigation.
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Affiliation(s)
- David C Foote
- Department of Experiential Education, The University of Oklahoma Health Sciences College of Pharmacy, 1110 N Stonewall Ave, CPB 139, Oklahoma City, OK 73117, United States of America
| | - Jamie L Miller
- Department of Pharmacy: Clinical and Administrative Sciences, The University of Oklahoma Health Sciences College of Pharmacy, 1110 N Stonewall Ave, O'Donoghue Research Building #4417, Oklahoma City, OK 73117, United States of America
| | - Grant H Skrepnek
- Department of Pharmacy: Clinical and Administrative Sciences, The University of Oklahoma Health Sciences College of Pharmacy, 1110 N Stonewall Ave, CPB 207, Oklahoma City, OK 73117, United States of America
| | - Stephen Neely
- Office of Instruction, Assessment, and Faculty and Staff Development, The University of Oklahoma Health Sciences College of Pharmacy, 1110 N Stonewall Ave, CPB 222, Oklahoma City, OK 73117, United States of America
| | - Kiya Bennett
- Department of Pharmacy: Clinical and Administrative Sciences, The University of Oklahoma Health Sciences College of Pharmacy, 1110 N Stonewall Ave, CPB 219, Oklahoma City, OK 73117, United States of America
| | - Paul M Boylan
- Department of Pharmacy: Clinical and Administrative Sciences, The University of Oklahoma Health Sciences College of Pharmacy, 1110 N Stonewall Ave, CPB 239, Oklahoma City, OK 73117, United States of America
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2
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Oliveira MG, Moreira PM, Amorim WW, Boockvar K. Deprescribing Hypertension Medication in Older Adults: Can It Lower Drug Burden Without Causing Harm? Clin Geriatr Med 2024; 40:659-668. [PMID: 39349038 PMCID: PMC11443064 DOI: 10.1016/j.cger.2024.04.012] [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] [Indexed: 10/02/2024]
Abstract
Due to the high prevalence of older individuals with multiple morbidities, polypharmacy, and exposed to unnecessary or inappropriate treatments that can cause potentially serious adverse effects, better medication management should be an objective of all health professionals. This is particularly important in older patients with hypertension. Antihypertensive deprescribing and non-pharmacological strategies have been disseminated as viable and safe alternatives for improving the quality of care for hypertension in the older population.
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Affiliation(s)
- Marcio Galvão Oliveira
- Multidisciplinary Institute in Health, Federal University of Bahia, Brazil; Postgraduate Program in Pharmaceutical Services and Policies, Federal University of Bahia, Brazil.
| | - Pablo Maciel Moreira
- Postgraduate Program in Pharmaceutical Services and Policies, Federal University of Bahia, Brazil; Municipal Health Department of Vitória da Conquista, Vitória da Conquista, Bahia, Brazil
| | - Welma Wildes Amorim
- State University of Southwest Bahia, Department of Health Sciences, Brazil. Estrada do Bem Querer, km 4. Bairro Universitário, CEP.: 45083 -900. Vitória da Conquista - BA, Brazil
| | - Kenneth Boockvar
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama, 933 19th Street South, Birmingham, AL 35233, USA
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3
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Plasencia JT, Ashraf MS. Management of Bacteriuria and Urinary Tract Infections in the Older Adult. Urol Clin North Am 2024; 51:585-594. [PMID: 39349025 DOI: 10.1016/j.ucl.2024.07.002] [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] [Indexed: 10/02/2024]
Abstract
Urinary tract infection (UTI) is one of the most frequent bacterial infections diagnosed in older adults and the most common reason for antibiotic prescriptions in nursing homes. Distinguishing between asymptomatic bacteriuria and UTI in older adults can be challenging and implementing a systematic approach to diagnosis using standard toolkits or algorithms is recommended for patients residing in post-acute and long-term care settings. This article reviews the pathophysiology, microbiology, diagnostic approach, treatment, and approaches to prophylaxis in the older adult.
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Affiliation(s)
- Juan Teran Plasencia
- Division of Infectious Diseases, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198-5400, USA.
| | - Muhammad Salman Ashraf
- Division of Infectious Diseases, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198-5400, USA; Division of Public Health, Nebraska Department of Health and Human Services, 301 Centennial Mall South, PO Box 95026, Lincoln, NE 68509, USA
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4
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Supiano MA. Optimal Blood Pressure Targets with Age. Clin Geriatr Med 2024; 40:585-595. [PMID: 39349033 PMCID: PMC11443060 DOI: 10.1016/j.cger.2024.04.002] [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] [Indexed: 10/02/2024]
Abstract
The focus of antihypertensive therapy in older adults should be on lowering the systolic blood pressure (SBP) to the patient's "optimal" benefit-based target goal. Applying benefit-based therapy to the majority of adults aged 65 years or older who are at high cardiovascular disease or cognitive impairment risk favors an SBP goal of less than 130 mm Hg, and for some, a goal of 120 mm Hg may be considered.
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Affiliation(s)
- Mark A Supiano
- Division of Geriatrics, Spencer Fox Eccles School of Medicine, Center on Aging, University of Utah, 30 North Mario Capecchi Drive, 2nd Floor North, Salt Lake City, UT 84112, USA.
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5
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Umoh ME, Fitzgerald D, Vasunilashorn SM, Oh ES, Fong TG. The Relationship between Delirium and Dementia. Semin Neurol 2024. [PMID: 39393800 DOI: 10.1055/s-0044-1791543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2024]
Abstract
Delirium and dementia are common causes of cognitive impairment in older adults. They are distinct but interrelated. Delirium, an acute confusional state, has been linked to the chronic and progressive loss of cognitive ability seen in dementia. Individuals with dementia are at higher risk for delirium, and delirium itself is a risk factor for incident dementia. Additionally, delirium in individuals with dementia can hasten underlying cognitive decline. In this review, we summarize recent literature linking these conditions, including epidemiological, clinicopathological, neuroimaging, biomarker, and experimental evidence supporting the intersection between these conditions. Strategies for evaluation and diagnosis that focus on distinguishing delirium from dementia in clinical settings and recommendations for delirium prevention interventions for patients with dementia are presented. We also discuss studies that provide evidence that delirium may be a modifiable risk factor for dementia and consider the impact of delirium prevention interventions on long-term outcomes.
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Affiliation(s)
- Mfon E Umoh
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Dennis Fitzgerald
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sarinnapha M Vasunilashorn
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Esther S Oh
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Tamara G Fong
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
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6
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Fung CH, Huang AJ, Markland AD, Schembri M, Martin JL, Bliwise DL, Cheng J, Alessi CA, Johnson TM, Burgio KL, Muirhead L, Neymark A, Der-Mcleod E, Sergent T, Chang A, Bauer SR, Spencer C, Guzman A, Vaughan CP. A multisite feasibility study of integrated cognitive-behavioral treatment for co-existing nocturia and chronic insomnia. J Am Geriatr Soc 2024. [PMID: 39389800 DOI: 10.1111/jgs.19214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 08/13/2024] [Accepted: 09/14/2024] [Indexed: 10/12/2024]
Abstract
BACKGROUND Nocturia (waking from sleep at night to void) and chronic insomnia frequently co-exist in older adults, contributing synergistically to sleep disturbance. Treatments typically target either nocturia or insomnia rather than simultaneously addressing shared mechanisms for these disorders. METHODS We conducted a multisite feasibility study to: (1) test and refine a protocol for recruitment, randomization, and assessment of older adults with co-existing nocturia and insomnia; and (2) examine preliminary changes in outcome measures to inform a future larger, multisite clinical trial. Participants were men and women aged 60 years and older recruited from outpatient clinics, reporting an average of two or more nocturia episodes per night over the past 4 weeks and meeting diagnostic criteria for chronic insomnia disorder. Participants were randomized to receive either integrated cognitive-behavioral therapy for insomnia and nocturia or a health education control program involving five weekly visits with a trained nurse practitioner interventionist. Outcomes (e.g., nocturia episodes) were measured 1-week post-treatment and 4-month post-randomization. Descriptive statistics examined the feasibility of outcomes to guide preparations for a future efficacy trial. RESULTS Of 245 adults screened, 55% were ineligible and 25% declined to participate. Sixty-one percent of 49 participants who provided informed consent were randomized. Of the 30 participants randomized (mean age = 70.6 years, 60% White), 14 were assigned to integrated cognitive-behavioral treatment and 16 to the control group. All randomized participants provided 4-month follow-up data. At 4 months, mean nightly nocturia episodes decreased by 0.9 (SD 1.0) in the integrated treatment group and by 0.2 (SD 1.2) in the control group compared with baseline. DISCUSSION Findings demonstrate the feasibility of recruiting, randomizing, and collecting outcome data from older adults (predominantly male) assigned to an integrated cognitive-behavioral therapy for coexisting insomnia and nocturia or a health education control program.
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Affiliation(s)
- Constance H Fung
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Alison J Huang
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Alayne D Markland
- Birmingham/Atlanta Geriatric Research Education and Clinical Center, Birmingham, Alabama, USA
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michael Schembri
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Jennifer L Martin
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Donald L Bliwise
- Sleep Program, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jing Cheng
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Cathy A Alessi
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Theodore M Johnson
- Birmingham/Atlanta Geriatric Research Education and Clinical Center, Birmingham, Alabama, USA
- Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia, USA
- Department of Medicine, Division of General Internal Medicine, Emory University, Atlanta, Georgia, USA
| | - Kathryn L Burgio
- Birmingham/Atlanta Geriatric Research Education and Clinical Center, Birmingham, Alabama, USA
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Lisa Muirhead
- Birmingham/Atlanta Geriatric Research Education and Clinical Center, Birmingham, Alabama, USA
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Alison Neymark
- Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Erin Der-Mcleod
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Taressa Sergent
- Birmingham/Atlanta Geriatric Research Education and Clinical Center, Birmingham, Alabama, USA
- Department of Medicine, Division of Geriatrics & Gerontology, Emory University, Atlanta, Georgia, USA
| | - Ann Chang
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Scott R Bauer
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Department of Medicine, San Francisco VA Healthcare System, San Francisco, California, USA
| | - Colette Spencer
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Andrew Guzman
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Camille P Vaughan
- Birmingham/Atlanta Geriatric Research Education and Clinical Center, Birmingham, Alabama, USA
- Department of Medicine, Division of Geriatrics & Gerontology, Emory University, Atlanta, Georgia, USA
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Sohn BC, Tung EE, Takahashi PY, Verdoorn BP. Clinician's Guide to Geriatric Assessment. Mayo Clin Proc 2024:S0025-6196(24)00417-8. [PMID: 39387794 DOI: 10.1016/j.mayocp.2024.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 07/24/2024] [Accepted: 08/21/2024] [Indexed: 10/15/2024]
Abstract
The population of older adults is rapidly growing worldwide. Because of the substantial shortage of geriatricians, all clinicians need basic fluency in older adult care. In our approach to evaluating an older adult in the clinic or at the bedside, we apply the "Geriatric 5Ms" framework to manage the patient's care. The Geriatric 5Ms consist of the following key steps. First, consider the mind: the cognitive and psychological domains of a patient's health. Second, evaluate mobility and fall risk. Third, review and reconcile medications, particularly high-risk medications. Fourth, ask what matters most to the patient. Fifth, assess multicomplexity: how the intersection of multiple chronic conditions and social determinants of health influence the patient's health care management. Herein, we provide clinicians with practical suggestions and resources for quickly and effectively applying the Geriatric 5Ms to the care of older adults.
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Affiliation(s)
- Bonnie C Sohn
- Fellow in the Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science
| | - Ericka E Tung
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, MN
| | - Paul Y Takahashi
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, MN
| | - Brandon P Verdoorn
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, MN.
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8
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Wu PS, Chao CT, Hsiao CH, Yang CF, Lee YH, Lin HJ, Yeh CF, Lee LT, Huang KC, Lee MC, Huang CK, Lin YH, Chen MYC, Chan DC. Blood pressure targets, medication consideration and unique concerns in elderly hypertension IV: Focus on frailty, orthostatic hypotension, and resistant hypertension. J Formos Med Assoc 2024:S0929-6646(24)00442-X. [PMID: 39370367 DOI: 10.1016/j.jfma.2024.09.022] [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: 06/24/2024] [Accepted: 09/18/2024] [Indexed: 10/08/2024] Open
Abstract
Hypertension increases the risk of cardiovascular disease in the elderly. Although treating hypertension can reduce the risk of cardiovascular disease and its related mortality, it is also challenging because these patients could have frailty, orthostatic hypotension (OH) and resistant hypertension (RHTN), which makes them more susceptible to treatment-related adverse events. Identifying such patients and tailoring the choice of drugs and blood pressure targets is crucial to balance the harms and benefits. The Clinical Frailty Scale is recommended to assess elderly patients with hypertension and frailty. For very frail patients, unnecessary medications should be deprescribed to avoid adverse events. Hypertension and OH frequently co-occur in the elderly, and recognizing and managing OH is essential to prevent falls and adverse events. The management of blood pressure in elderly patients with frailty, OH, and RHTN is complex, requiring the patients, their family and caregivers to be involved in decision-making to ensure that treatment plans are well-informed and aligned with the patient's needs.
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Affiliation(s)
- Po-Sheng Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Ter Chao
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Division of Nephrology, Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; Division of Nephrology, Department of Internal Medicine, Min-Sheng General Hospital, Taoyuan City, Taiwan; Graduate Institute of Toxicology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chien-Hao Hsiao
- Division of Cardiology, Department of Internal Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - Chiu-Fen Yang
- Department of Cardiology, Cardiovascular Research Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Ying-Hsiang Lee
- Department of Medicine, Mackay Medical College, Cardiovascular Center, Department of Internal Medicine, MacKay Memorial Hospital, New Taipei City, Taiwan
| | - Hung-Ju Lin
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Fan Yeh
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Long-Teng Lee
- Department of Family Medicine, National Taiwan University Hospital & National Taiwan University, Taipei, Taiwan
| | - Kuo-Chin Huang
- Department of Family Medicine, National Taiwan University Hospital & National Taiwan University, Taipei, Taiwan
| | - Meng-Chih Lee
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; Department of Family Medicine, Taichung Hospital, Ministry of Health and Welfare, Taichung City, Taiwan; Institute of Population Health Sciences, National Health Research Institutes, Miaoli County, Taiwan; College of Management, Chaoyang University of Technology, Taichung, Taiwan; Study Group of Integrated Health and Social Care Project, Ministry of Health and Welfare, Taichung, Taiwan
| | - Cheng-Kuo Huang
- Taiwan Association of Family Medicine, Taipei, Taiwan; Dr. Cheng-Kuo Huang Clinic, Keelung, Taiwan
| | - Yen-Hung Lin
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Michael Yu-Chih Chen
- Division of Cardiology, Department of Internal Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Ding-Cheng Chan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan.
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Hall RK, Morton-Oswald S, Wilson J, Nair D, Colón-Emeric C, Pendergast J, Pieper C, Scialla JJ. Association of Coprescribing of Gabapentinoid and Other Psychoactive Medications With Altered Mental Status and Falls in Adults Receiving Dialysis. Am J Kidney Dis 2024:S0272-6386(24)00986-7. [PMID: 39368619 DOI: 10.1053/j.ajkd.2024.07.013] [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: 02/19/2024] [Revised: 06/14/2024] [Accepted: 07/01/2024] [Indexed: 10/07/2024]
Abstract
RATIONALE & OBJECTIVE Prescribing psychoactive medications for patients with kidney disease is common, but for patients receiving dialysis, some medications may be inappropriate. We evaluated the association of coprescribing gabapentinoids and other psychoactive potentially inappropriate medications (PPIMs) (e.g., sedatives, opioids) with altered mental status (AMS) and falls, and whether the associations are modified by frailty. STUDY DESIGN Observational cohort study. SETTING & Participants: Adults receiving dialysis represented in the United States Renal Data System who had an active gabapentinoid prescription and no other PPIM prescriptions in the prior 6 months. EXPOSURE PPIM coprescribing, or the presence of overlapping prescriptions of a gabapentinoid and ≥1 additional PPIM. OUTCOMES Acute care visits for AMS and injurious falls. ANALYTICAL APPROACH Prentice-Williams-Petersen Gap Time models estimated the association between PPIM coprescribing and each outcome, adjusting for demographics, comorbidities, and frailty (assessed by a validated frailty index (FI)). Each model tested for interaction between PPIM coprescribing and frailty. RESULTS Overall, PPIM coprescribing was associated with increased hazard of AMS (HR: 1.66 [95% CI 1.44, 1.92]) and falls (HR: 1.55 [95% CI 1.36, 1.77]). Frailty significantly modified the effect of PPIM coprescribing on the hazard of AMS (interaction p=0.01), but not falls. Among individuals with low frailty (FI=0.15), the hazard ratio for AMS with PPIM co-prescribing was 2.14 (95% CI: 1.69, 2.71); while for individuals with severe frailty (FI=0.34), the hazard ratio for AMS with PPIM coprescribing was 1.64 (95% CI: 1.42, 1.89). Individuals with PPIM coprescribing and severe frailty (FI =0.34) had the highest hazard of AMS [HR 4.04 (95% CI: 3.20, 5.10)] and falls [HR 2.77 (95% CI: 2.27, 3.38)] compared to non-frail individuals without PPIM coprescribing. LIMITATIONS Outcome ascertainment bias; residual confounding. CONCLUSIONS Compared to gabapentinoid prescriptions alone, PPIM coprescribing was associated with an increased risk of AMS and falls. Clinicians should consider these risks when coprescribing PPIMs to patients receiving dialysis.
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Affiliation(s)
- Rasheeda K Hall
- Department of Medicine, Duke University School of Medicine, Durham, NC; Durham Veterans Affairs Medical Center, Durham, NC.
| | - Sarah Morton-Oswald
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Jonathan Wilson
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Devika Nair
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cathleen Colón-Emeric
- Department of Medicine, Duke University School of Medicine, Durham, NC; Durham Veterans Affairs Medical Center, Durham, NC
| | - Jane Pendergast
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Carl Pieper
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Julia J Scialla
- Departments of Medicine and Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA
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Wagg A, Heckman G, Northwood M, Hirdes J. The clinical advantages of making our hospitals older adult friendly. Can J Cardiol 2024:S0828-282X(24)01008-0. [PMID: 39368705 DOI: 10.1016/j.cjca.2024.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 09/03/2024] [Accepted: 09/19/2024] [Indexed: 10/07/2024] Open
Abstract
Older adults (≥65 years old), now comprise half of the inpatient population. Catering for the needs of this group requires consideration of the processes of care, the inpatient environment and care practices operating in our hospitals. Older adults are often multimorbid, more likely than older adults in the community to be malnourished and have coexistent physical and cognitive impairments. These older adults are at great risk of suffering hospital associated harms or being designated as "bed blockers", partly due to inadequate understanding of their needs, a failure of recognition or an unwillingness to address them. The adoption of older adult friendly care presents considerable opportunity to transform the manner in which care is delivered in order to mitigate avoidable harms and optimize outcomes for older adults. This review explores the nature of our older adult inpatients, the implications of older adult friendly care, the requirement for true interprofessional care, the advantages of systematic assessment which spans pre-hospital to post-hospital care and highlights specific interventions to deal with in hospital problems which differentially impair health related outcomes for older adults. As such it raises awareness of the needs of older adults under cardiological to improve outcomes for hospitalized older adults.
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Affiliation(s)
- Adrian Wagg
- Professor, Department of Medicine, Division of Geriatric Medicine, University of Alberta, Edmonton, Alberta, Canada.
| | - George Heckman
- Schlegel Research Chair in Geriatric Medicine, Assistant Clinical Professor of Medicine, University of Waterloo, Waterloo, Ontario, Canada
| | - Melissa Northwood
- Assistant Professor, Nursing, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - John Hirdes
- Professor, School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
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11
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Érszegi A, Csupor D, Bodó G, Engi Z, Bahar MA, Matuz M, Benkő R, Pető Z, Viola R. High rate of potentially inappropriate medication use in older people: a case-control study. GeroScience 2024; 46:5217-5233. [PMID: 38980633 PMCID: PMC11335697 DOI: 10.1007/s11357-024-01274-1] [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: 05/10/2024] [Accepted: 06/27/2024] [Indexed: 07/10/2024] Open
Abstract
Annually, 172 million fall events cause temporary or permanent impairment in older adults, and this number is increasing. Contributing factors that increase the risk for falls include age, polypharmacy, and malnutrition. This study evaluated medications mainly included in the EU(7)-PIM (potentially inappropriate medication) list. From March 21, 2022, to July 6, 2022, 945 patients who experienced a fall and visited the Department of Emergency Medicine at the Albert Szent-Györgyi Health Centre of the University of Szeged in Hungary. Data from 886 patients were collected (study group). The control group included 1364 patient data collected from three general practice in Hungary. The use of ≥ 2 EU(7)-PIM drugs was found to be associated with increased risk for falls (adjusted odds ratio [AOR], 1.38; 95% confidence interval [CI] 1.01-1.88). Piracetam (AOR, 1.81; 95% CI, 1.28-2.57) and trimetazidine (AOR, 1.62; 95% CI, 1.17-2.24) were associated with increased risk for falls. Doxazosin was associated with a low risk for falls (AOR, 0.59; 95% CI, 0.41-0.86). Tiapride (AOR, 3.54; 95% CI, 1.75-7.17), gliclazide (AOR, 1.57; 95% CI, 1.02-2.43), and vinpocetine (AOR, 1.95; 95% CI, 1.29-2.95) are not included in the EU(7)-PIM list; however, they are associated with increased risk for falls. Long-acting benzodiazepines (AOR, 1.79; 95% CI, 1.20-2.68), antidepressants (AOR, 1.89; 95% 95% CI, 1.37-2.61), serotonin-norepinephrine reuptake inhibitor (AOR, 2.82; 95% CI, 1.41-5.67; p < 0.01), and selective serotonin reuptake inhibitor (AOR, 1.88; 95% CI, 1.24-2.85) were also associated with increased risk for falls. However, Z-drugs were associated with a low risk for falls (AOR, 0.57; 95% CI, 0.36-0.92). With the help of this tool, trimetazidine and piracetam are filtered as EU(7)-PIM drugs associated with increased risk for falls.
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Affiliation(s)
- András Érszegi
- Faculty of Pharmacy, Institute of Clinical Pharmacy, University of Szeged, Szeged, Hungary
- Albert Szent-Györgyi Health Center, Central Pharmacy, University of Szeged, Szeged, Hungary
| | - Dezső Csupor
- Faculty of Pharmacy, Institute of Clinical Pharmacy, University of Szeged, Szeged, Hungary
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Gabriella Bodó
- Borsod-Abaúj-Zemplén County Central Hospital and University Teaching Hospital, Miskolc, Hungary
| | - Zsófia Engi
- Faculty of Pharmacy, Institute of Clinical Pharmacy, University of Szeged, Szeged, Hungary
| | - Muh Akbar Bahar
- Faculty of Pharmacy, Institute of Clinical Pharmacy, University of Szeged, Szeged, Hungary
- Department of Pharmacy, Faculty of Pharmacy, Universitas Hasanuddin, Makassar, Indonesia
| | - Mária Matuz
- Faculty of Pharmacy, Institute of Clinical Pharmacy, University of Szeged, Szeged, Hungary
- Albert Szent-Györgyi Health Center, Central Pharmacy, University of Szeged, Szeged, Hungary
| | - Ria Benkő
- Faculty of Pharmacy, Institute of Clinical Pharmacy, University of Szeged, Szeged, Hungary
- Albert Szent-Györgyi Health Center, Central Pharmacy, University of Szeged, Szeged, Hungary
| | - Zoltán Pető
- Albert Szent-Györgyi Health Center, Department of Emergency Medicine, University of Szeged, Szeged, Hungary
| | - Réka Viola
- Faculty of Pharmacy, Institute of Clinical Pharmacy, University of Szeged, Szeged, Hungary.
- Albert Szent-Györgyi Health Center, Central Pharmacy, University of Szeged, Szeged, Hungary.
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12
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Warren S, McKee S, Yakiwchuk E. Geriatric Pharmacotherapy Case Series: Medications for Diabetes-A Focus on Secondary Stroke Prevention. Sr Care Pharm 2024; 39:350-359. [PMID: 39358879 DOI: 10.4140/tcp.n.2024.350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2024]
Abstract
This report addresses evidence for efficacy of diabetes medications with a focus on stroke risk reduction. The cardiovascular benefits of SGLT-2 inhibitors and GLP-1 receptor agonists have been well-established; however, clinical trials to date have examined composite cardiovascular endpoints that include, but do not specifically focus on, stroke. The purpose of this case review is to examine the evidence for the various diabetes medications in reducing the risk for stroke. This literature review was inspired by a patient seen in a geriatric day hospital program with diabetes and a history of multiple strokes. Our goal was to select a diabetes management regimen that would provide both glycemic control and stroke risk reduction. As diabetes and cerebrovascular disease commonly coexist and are important contributors to morbidity and mortality in older individuals, appropriate management must incorporate both current evidence as well as consideration for patient-specific factors that may influence the treatment plan. This patient case illustrates the importance of both.
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Affiliation(s)
- Sabrina Warren
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Shayla McKee
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Erin Yakiwchuk
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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13
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Chen A, Metzger E, Lee S, Osser D. A Proposed Algorithm for the Pharmacological Treatment of Generalized Anxiety Disorder in the Older Patient. J Geriatr Psychiatry Neurol 2024:8919887241289533. [PMID: 39352792 DOI: 10.1177/08919887241289533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2024]
Abstract
BACKGROUND This is a new algorithm from the Psychopharmacology Algorithm Project at the Harvard South Shore Program, focused on generalized anxiety disorder (GAD) in older adults. Pertinent articles were identified and reviewed. RESULTS Selective serotonin reuptake inhibitors (SSRIs) are considered to be first-line medications, with a preference for sertraline or escitalopram. If avoiding sexual side effects is a priority, buspirone is an option for the relatively healthy older adult. If response is inadequate, the second recommended trial is with a different SSRI or one of the serotonin-norepinephrine update inhibitors (SNRIs), venlafaxine or duloxetine. For a third medication trial, additional alternatives added to the previous options now include pregabalin/gabapentin, lavender oil, and agomelatine. If there is an unsatisfactory response to the third option chosen, quetiapine may be considered. We recommend caution with the following for acute treatment in this population: benzodiazepines and hydroxyzine. Other agents given low priority but having some supportive evidence were vilazodone, vortioxetine, mirtazapine, and cannabidiol. Acknowledging that the median age of onset of GAD is in early adulthood, many patients with GAD will have been started on benzodiazepines (or other medications that require caution in the elderly) for GAD at a younger age. These medications may be continued with regular observation to see if the potential harms are starting to exceed the benefits and a switch to other recommended agents may be justified.
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Affiliation(s)
- Anderson Chen
- Psychiatry Department, Massachusetts General Hospital, Boston, MA, USA
| | - Eran Metzger
- Psychiatry Department, Hebrew Senior Life, Boston, MA, USA
| | - Soyoung Lee
- Psychiatry Department, Brigham and Women's Hospital, Boston, MA, USA
| | - David Osser
- Psychiatry Department, VA Boston Healthcare System, Brockton, MA, USA
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14
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Basham CA, Edrees H, Huybrechts KF, Hwang CS, Bateman BT, Bykov K. Tramadol use in U.S. Adults With Commercial Health Insurance, 2005-2021. Am J Prev Med 2024; 67:558-567. [PMID: 38876295 DOI: 10.1016/j.amepre.2024.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 06/07/2024] [Accepted: 06/07/2024] [Indexed: 06/16/2024]
Abstract
INTRODUCTION Tramadol has been associated with chronic opioid use and emergency room (ER) visits. However, little is known about trends in prescription tramadol use in the U.S. METHODS Optum's de-identified Clinformatics® Data Mart Database was used to assess trends in monthly incident and prevalent tramadol use from 2005 to 2021, stratified by sex and age (18-64 vs. ≥65 years). State-specific trends following scheduling of tramadol as Class IV controlled substance in August 2014 were analyzed with random effects regression models. Demographics, comorbidities, initiation setting, dose, and co-dispensing with other opioids and central nervous system (CNS) agents were assessed in people initiating tramadol, stratified by age and initiation year (2005-2010, 2011-2015, 2016-2021). Analyses were performed in 2023 and 2024. RESULTS During 2005-2021, the mean percentage using tramadol in a given month was 0.88% of younger females, 0.55% of younger males, 1.97% of older females, and 1.14% of older males; 5,729,652 initiations were identified. Since 2014, estimated relative yearly decrease was 4% (95% CI 3%; 5%) in use and 5% (95% CI 4%; 5%) in initiation, with variation across states. Primary care percentage of tramadol initiations declined from 49.2% in 2005-2010 to 37.2% in 2016-2021. During 2016-2021, co-dispensing with other CNS agents occurred in 37.8% of younger and 32.1% of older adults initiating tramadol. CONCLUSIONS Tramadol use was higher in females and older adults, exhibited heterogeneous trends across states, and shifted from primary care to ER and specialist settings over time. Co-dispensing with other CNS agents was common and warrants further monitoring.
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Affiliation(s)
- Christopher Andrew Basham
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Heba Edrees
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Catherine S Hwang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brian T Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical School, San Francisco, California
| | - Katsiaryna Bykov
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.
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15
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Pogge E, Sibicky S. Heart Failure in Older People Part 2: Guideline-Directed Medical Therapy. Sr Care Pharm 2024; 39:360-372. [PMID: 39358876 DOI: 10.4140/tcp.n.2024.360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2024]
Abstract
Heart failure is a common cardiovascular disease that affects older people and has a high rate of mortality. Treatment for heart failure has evolved in the past 10 years to include novel evidence-based agents as well as changes in how medications are initiated and up-titrated. Despite evidence of the importance of using four guideline-directed medications, older people are often undertreated with these lifesaving therapies. Senior care pharmacists play an important role in heart failure management among older people by providing therapeutic recommendations; monitoring therapeutic interventions; and educating patients, caregivers, and/ or providers.
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Affiliation(s)
- Elizabeth Pogge
- 1 Midwestern University College of Pharmacy-Glendale, Glendale, Arizona
| | - Stephanie Sibicky
- 2 Northeastern University School of Pharmacy and Pharmaceutical Sciences, Boston, Massachusetts
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16
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Ramin T, Peter JU, Schneider M, Heinze M, Riedel O, Langbein SH, Haug U, Zolk O. Age and sex differences in outpatient antipsychotic prescriptions for schizophrenia: a claims data study. Eur Arch Psychiatry Clin Neurosci 2024:10.1007/s00406-024-01867-z. [PMID: 39347833 DOI: 10.1007/s00406-024-01867-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 07/15/2024] [Indexed: 10/01/2024]
Abstract
Most studies on antipsychotic efficacy and safety, including sex differences, focus on young schizophrenia patients. However, with an aging population, the number of older schizophrenia patients is increasing. This group faces challenges due to varying treatment responses and higher risks of adverse reactions, and guidelines often lack specific recommendations due to insufficient trials. Therefore, we investigated how age and sex influence antipsychotic prescribing practices in schizophrenia using the German Pharmacoepidemiological Research Database (GePaRD). We included patients diagnosed with schizophrenia (ICD-10 code F20.X) who had been prescribed at least one antipsychotic on an outpatient basis in at least two consecutive quarters in 2020, analyzing prescription data for 49,681 patients. Key findings include a notable preference for second-generation antipsychotics (SGAs) across all age groups, especially in younger patients, possibly due to their perceived better tolerability and efficacy. Treatment intensity with SGAs (expressed as the defined daily doses of SGAs per patient in 2020) initially increased with age, peaked among 35- to 44-year-olds, and then decreased, with the lowest treatment intensity in patients aged 65 years and older. The prescription patterns of specific SGAs and first-generation antipsychotics varied across age groups, highlighting the complexity of treatment decisions in schizophrenia management. Sex differences in prescription frequency and treatment intensity were also observed. The basic recommendation of the guideline to consider sex and age when prescribing antipsychotics therefore appears to be followed. Whether this prescribing practice is really optimal for older male and female schizophrenia patients, however, still needs to be proven in clinical trials.
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Affiliation(s)
- Tabea Ramin
- Institute for Clinical Pharmacology, Brandenburg Medical School, Immanuel Klinik Rüdersdorf, Seebad 82/83, 15562, Rüdersdorf, Germany
| | - Jens-Uwe Peter
- Institute for Clinical Pharmacology, Brandenburg Medical School, Immanuel Klinik Rüdersdorf, Seebad 82/83, 15562, Rüdersdorf, Germany
| | - Michael Schneider
- Faculty of Health Sciences, Joint Faculty of the University of Potsdam, The Brandenburg Medical School Theodor Fontane and the Brandenburg University of Technology Cottbus-Senftenberg, Karl-Liebknecht-Str. 24-25, 14476, Potsdam, Germany
| | - Martin Heinze
- Department for Psychiatry and Psychotherapy, Brandenburg Medical School, Immanuel Klinik Rüdersdorf, Seebad 82/83, 15562, Rüdersdorf, Germany
| | - Oliver Riedel
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany
| | - Sophie Hanna Langbein
- Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany
| | - Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany
- Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany
| | - Oliver Zolk
- Institute for Clinical Pharmacology, Brandenburg Medical School, Immanuel Klinik Rüdersdorf, Seebad 82/83, 15562, Rüdersdorf, Germany.
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17
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Puig T, Leache L, González-Senac NM, Carreras E, Gutiérrez-Valencia M, Losa L, Revuelta-Herrero JL, Marrero-Álvarez P, de Miguel M, Aguirrezabal Arredondo A, Aranguren A, Vilariño A, Ruiz VE, Fernández I, Bilbao J, González-Guerrero C, Del Pino B, Garin N. Prevalence of potentially inappropriate medications and prescription dynamics in elderly hospitalized patients in Spain. BMC Geriatr 2024; 24:798. [PMID: 39350081 PMCID: PMC11443693 DOI: 10.1186/s12877-024-05308-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 08/16/2024] [Indexed: 10/04/2024] Open
Abstract
PURPOSE In recent years, the need for a more appropriate prescription of medications in the older population has emerged as a significant public health concern. In this study, we aimed to evaluate the prevalence of potentially inappropriate medications (PIM) in hospitalized adults aged ≥ 75. PATIENTS AND METHODS This was a retrospective descriptive observational study of patients at 16 hospitals in Spain. The study population included inpatients aged ≥ 75 admitted during a 7-day period (May 10 to 16, 2021). Data were obtained from the pharmacy databases of the participating hospitals. The list of PIMs was based on the Beers, STOPP-START, EU-PIM and PRISCUS criteria. RESULTS A total of 4,183 patients were included. PIMs were detected in 23.5% (N = 1,126) of the cohort. The prevalence rates at the participating hospitals ranged from 10% to 42.5%. The PIM/patient ratio was 1.2. The most common PIMs were midazolam, dexketoprofen, diazepam, and doxazosin, all of which (except for doxazosin) were more common in women. Benzodiazepines accounted for 70% of all PIMs. In 35% of cases, the PIMs were initiated before hospital admission. Of the 818 PIMs initiated during hospitalization, the two most common were benzodiazepines (49%) and anti-inflammatory drugs (25%). At discharge, only 4.9% of the PIMs initiated during the hospital stay were still prescribed. CONCLUSION In this population of older hospitalized patients, the overall prevalence of PIMs was moderate. However, the prevalence rate at the participating hospitals was highly variable. In most cases, PIMs prescribed prior to hospitalization for chronic conditions were not withdrawn during the hospital stay. No significant increase in PIMs was observed from pre-admission to post-discharge. These findings underscore the need for multidisciplinary interventions to optimize the pharmaceutical treatment in older adults in the hospital setting to reduce the consequences of PIMs in patients.
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Affiliation(s)
- T Puig
- Epidemiology Department, Hospital de la Santa Creu i Sant Pau, IR Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
| | - L Leache
- Innovation and Organization Unit, Navarre Health Service (SNS-O), Pamplona, Navarre, Spain
- Navarra Institute for Health Research (IdiSNA), Pamplona, Navarre, Spain
| | - N M González-Senac
- Geriatric Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Health Research Institute Gregorio Marañón (IiSGM), Madrid, Spain
| | - E Carreras
- Epidemiology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - M Gutiérrez-Valencia
- Innovation and Organization Unit, Navarre Health Service (SNS-O), Pamplona, Navarre, Spain
- Navarra Institute for Health Research (IdiSNA), Pamplona, Navarre, Spain
| | - L Losa
- Pharmacy Department, Complex Hospitalari Universitari Moisès Broggi, Oriol Martorell, 12, Sant Joan Despí, Barcelona, 08970, Spain
| | - J L Revuelta-Herrero
- Health Research Institute Gregorio Marañón (IiSGM), Madrid, Spain
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - P Marrero-Álvarez
- Pharmacy Department, Vall d'Hebron Hospital Universitari, Barcelona, 08035, Spain
| | - M de Miguel
- Department of Hospital Pharmacy, Osakidetza Basque Health Service, Cruces University Hospital, Barakaldo, Spain
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
| | | | - A Aranguren
- Pharmacy Department, OSI Donostialdea- Hospital Universitario Donosti, Donostia, Spain
| | - A Vilariño
- Pharmacy Department, Hospital Universitari Germans Trias i Pujol, Badalona, 08916, Spain
| | - V E Ruiz
- Quality Department, Consorci Sanitari de Terrassa, Terrassa, Spain
| | - I Fernández
- Pharmacy Department, Osakidetza Basque Health Service, Zumárraga Hospital, Zumárraga, Spain
| | - J Bilbao
- Pharmacy Department, Hospital San Eloy, Integrated Health Care Organization Barakaldo-Sestao, Barakaldo, Spain
| | | | - B Del Pino
- Pharmacy Department, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain
| | - N Garin
- Pharmacy Department, Hospital de la Santa Creu i Sant Pau, IR Sant Pau, Barcelona, Spain
- Blanquerna School of Health Science, Universitat Ramon Llull, Barcelona, 08025, Spain
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18
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Naghavi M, Vollset SE, Ikuta KS, Swetschinski LR, Gray AP, Wool EE, Robles Aguilar G, Mestrovic T, Smith G, Han C, Hsu RL, Chalek J, Araki DT, Chung E, Raggi C, Gershberg Hayoon A, Davis Weaver N, Lindstedt PA, Smith AE, Altay U, Bhattacharjee NV, Giannakis K, Fell F, McManigal B, Ekapirat N, Mendes JA, Runghien T, Srimokla O, Abdelkader A, Abd-Elsalam S, Aboagye RG, Abolhassani H, Abualruz H, Abubakar U, Abukhadijah HJ, Aburuz S, Abu-Zaid A, Achalapong S, Addo IY, Adekanmbi V, Adeyeoluwa TE, Adnani QES, Adzigbli LA, Afzal MS, Afzal S, Agodi A, Ahlstrom AJ, Ahmad A, Ahmad S, Ahmad T, Ahmadi A, Ahmed A, Ahmed H, Ahmed I, Ahmed M, Ahmed S, Ahmed SA, Akkaif MA, Al Awaidy S, Al Thaher Y, Alalalmeh SO, AlBataineh MT, Aldhaleei WA, Al-Gheethi AAS, Alhaji NB, Ali A, Ali L, Ali SS, Ali W, Allel K, Al-Marwani S, Alrawashdeh A, Altaf A, Al-Tammemi AB, Al-Tawfiq JA, Alzoubi KH, Al-Zyoud WA, Amos B, Amuasi JH, Ancuceanu R, Andrews JR, Anil A, Anuoluwa IA, Anvari S, Anyasodor AE, Apostol GLC, Arabloo J, Arafat M, Aravkin AY, Areda D, Aremu A, Artamonov AA, Ashley EA, Asika MO, Athari SS, Atout MMW, Awoke T, Azadnajafabad S, Azam JM, Aziz S, Azzam AY, Babaei M, Babin FX, Badar M, Baig AA, Bajcetic M, Baker S, Bardhan M, Barqawi HJ, Basharat Z, Basiru A, Bastard M, Basu S, Bayleyegn NS, Belete MA, Bello OO, Beloukas A, Berkley JA, Bhagavathula AS, Bhaskar S, Bhuyan SS, Bielicki JA, Briko NI, Brown CS, Browne AJ, Buonsenso D, Bustanji Y, Carvalheiro CG, Castañeda-Orjuela CA, Cenderadewi M, Chadwick J, Chakraborty S, Chandika RM, Chandy S, Chansamouth V, Chattu VK, Chaudhary AA, Ching PR, Chopra H, Chowdhury FR, Chu DT, Chutiyami M, Cruz-Martins N, da Silva AG, Dadras O, Dai X, Darcho SD, Das S, De la Hoz FP, Dekker DM, Dhama K, Diaz D, Dickson BFR, Djorie SG, Dodangeh M, Dohare S, Dokova KG, Doshi OP, Dowou RK, Dsouza HL, Dunachie SJ, Dziedzic AM, Eckmanns T, Ed-Dra A, Eftekharimehrabad A, Ekundayo TC, El Sayed I, Elhadi M, El-Huneidi W, Elias C, Ellis SJ, Elsheikh R, Elsohaby I, Eltaha C, Eshrati B, Eslami M, Eyre DW, Fadaka AO, Fagbamigbe AF, Fahim A, Fakhri-Demeshghieh A, Fasina FO, Fasina MM, Fatehizadeh A, Feasey NA, Feizkhah A, Fekadu G, Fischer F, Fitriana I, Forrest KM, Fortuna Rodrigues C, Fuller JE, Gadanya MA, Gajdács M, Gandhi AP, Garcia-Gallo EE, Garrett DO, Gautam RK, Gebregergis MW, Gebrehiwot M, Gebremeskel TG, Geffers C, Georgalis L, Ghazy RM, Golechha M, Golinelli D, Gordon M, Gulati S, Gupta RD, Gupta S, Gupta VK, Habteyohannes AD, Haller S, Harapan H, Harrison ML, Hasaballah AI, Hasan I, Hasan RS, Hasani H, Haselbeck AH, Hasnain MS, Hassan II, Hassan S, Hassan Zadeh Tabatabaei MS, Hayat K, He J, Hegazi OE, Heidari M, Hezam K, Holla R, Holm M, Hopkins H, Hossain MM, Hosseinzadeh M, Hostiuc S, Hussein NR, Huy LD, Ibáñez-Prada ED, Ikiroma A, Ilic IM, Islam SMS, Ismail F, Ismail NE, Iwu CD, Iwu-Jaja CJ, Jafarzadeh A, Jaiteh F, Jalilzadeh Yengejeh R, Jamora RDG, Javidnia J, Jawaid T, Jenney AWJ, Jeon HJ, Jokar M, Jomehzadeh N, Joo T, Joseph N, Kamal Z, Kanmodi KK, Kantar RS, Kapisi JA, Karaye IM, Khader YS, Khajuria H, Khalid N, Khamesipour F, Khan A, Khan MJ, Khan MT, Khanal V, Khidri FF, Khubchandani J, Khusuwan S, Kim MS, Kisa A, Korshunov VA, Krapp F, Krumkamp R, Kuddus M, Kulimbet M, Kumar D, Kumaran EAP, Kuttikkattu A, Kyu HH, Landires I, Lawal BK, Le TTT, Lederer IM, Lee M, Lee SW, Lepape A, Lerango TL, Ligade VS, Lim C, Lim SS, Limenh LW, Liu C, Liu X, Liu X, Loftus MJ, M Amin HI, Maass KL, Maharaj SB, Mahmoud MA, Maikanti-Charalampous P, Makram OM, Malhotra K, Malik AA, Mandilara GD, Marks F, Martinez-Guerra BA, Martorell M, Masoumi-Asl H, Mathioudakis AG, May J, McHugh TA, Meiring J, Meles HN, Melese A, Melese EB, Minervini G, Mohamed NS, Mohammed S, Mohan S, Mokdad AH, Monasta L, Moodi Ghalibaf A, Moore CE, Moradi Y, Mossialos E, Mougin V, Mukoro GD, Mulita F, Muller-Pebody B, Murillo-Zamora E, Musa S, Musicha P, Musila LA, Muthupandian S, Nagarajan AJ, Naghavi P, Nainu F, Nair TS, Najmuldeen HHR, Natto ZS, Nauman J, Nayak BP, Nchanji GT, Ndishimye P, Negoi I, Negoi RI, Nejadghaderi SA, Nguyen QP, Noman EA, Nwakanma DC, O'Brien S, Ochoa TJ, Odetokun IA, Ogundijo OA, Ojo-Akosile TR, Okeke SR, Okonji OC, Olagunju AT, Olivas-Martinez A, Olorukooba AA, Olwoch P, Onyedibe KI, Ortiz-Brizuela E, Osuolale O, Ounchanum P, Oyeyemi OT, P A MP, Paredes JL, Parikh RR, Patel J, Patil S, Pawar S, Peleg AY, Peprah P, Perdigão J, Perrone C, Petcu IR, Phommasone K, Piracha ZZ, Poddighe D, Pollard AJ, Poluru R, Ponce-De-Leon A, Puvvula J, Qamar FN, Qasim NH, Rafai CD, Raghav P, Rahbarnia L, Rahim F, Rahimi-Movaghar V, Rahman M, Rahman MA, Ramadan H, Ramasamy SK, Ramesh PS, Ramteke PW, Rana RK, Rani U, Rashidi MM, Rathish D, Rattanavong S, Rawaf S, Redwan EMM, Reyes LF, Roberts T, Robotham JV, Rosenthal VD, Ross AG, Roy N, Rudd KE, Sabet CJ, Saddik BA, Saeb MR, Saeed U, Saeedi Moghaddam S, Saengchan W, Safaei M, Saghazadeh A, Saheb Sharif-Askari N, Sahebkar A, Sahoo SS, Sahu M, Saki M, Salam N, Saleem Z, Saleh MA, Samodra YL, Samy AM, Saravanan A, Satpathy M, Schumacher AE, Sedighi M, Seekaew S, Shafie M, Shah PA, Shahid S, Shahwan MJ, Shakoor S, Shalev N, Shamim MA, Shamshirgaran MA, Shamsi A, Sharifan A, Shastry RP, Shetty M, Shittu A, Shrestha S, Siddig EE, Sideroglou T, Sifuentes-Osornio J, Silva LMLR, Simões EAF, Simpson AJH, Singh A, Singh S, Sinto R, Soliman SSM, Soraneh S, Stoesser N, Stoeva TZ, Swain CK, Szarpak L, T Y SS, Tabatabai S, Tabche C, Taha ZMA, Tan KK, Tasak N, Tat NY, Thaiprakong A, Thangaraju P, Tigoi CC, Tiwari K, Tovani-Palone MR, Tran TH, Tumurkhuu M, Turner P, Udoakang AJ, Udoh A, Ullah N, Ullah S, Vaithinathan AG, Valenti M, Vos T, Vu HTL, Waheed Y, Walker AS, Walson JL, Wangrangsimakul T, Weerakoon KG, Wertheim HFL, Williams PCM, Wolde AA, Wozniak TM, Wu F, Wu Z, Yadav MKK, Yaghoubi S, Yahaya ZS, Yarahmadi A, Yezli S, Yismaw YE, Yon DK, Yuan CW, Yusuf H, Zakham F, Zamagni G, Zhang H, Zhang ZJ, Zielińska M, Zumla A, Zyoud SHH, Zyoud SH, Hay SI, Stergachis A, Sartorius B, Cooper BS, Dolecek C, Murray CJL. Global burden of bacterial antimicrobial resistance 1990-2021: a systematic analysis with forecasts to 2050. Lancet 2024; 404:1199-1226. [PMID: 39299261 DOI: 10.1016/s0140-6736(24)01867-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Revised: 08/20/2024] [Accepted: 09/03/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Antimicrobial resistance (AMR) poses an important global health challenge in the 21st century. A previous study has quantified the global and regional burden of AMR for 2019, followed with additional publications that provided more detailed estimates for several WHO regions by country. To date, there have been no studies that produce comprehensive estimates of AMR burden across locations that encompass historical trends and future forecasts. METHODS We estimated all-age and age-specific deaths and disability-adjusted life-years (DALYs) attributable to and associated with bacterial AMR for 22 pathogens, 84 pathogen-drug combinations, and 11 infectious syndromes in 204 countries and territories from 1990 to 2021. We collected and used multiple cause of death data, hospital discharge data, microbiology data, literature studies, single drug resistance profiles, pharmaceutical sales, antibiotic use surveys, mortality surveillance, linkage data, outpatient and inpatient insurance claims data, and previously published data, covering 520 million individual records or isolates and 19 513 study-location-years. We used statistical modelling to produce estimates of AMR burden for all locations, including those with no data. Our approach leverages the estimation of five broad component quantities: the number of deaths involving sepsis; the proportion of infectious deaths attributable to a given infectious syndrome; the proportion of infectious syndrome deaths attributable to a given pathogen; the percentage of a given pathogen resistant to an antibiotic of interest; and the excess risk of death or duration of an infection associated with this resistance. Using these components, we estimated disease burden attributable to and associated with AMR, which we define based on two counterfactuals; respectively, an alternative scenario in which all drug-resistant infections are replaced by drug-susceptible infections, and an alternative scenario in which all drug-resistant infections were replaced by no infection. Additionally, we produced global and regional forecasts of AMR burden until 2050 for three scenarios: a reference scenario that is a probabilistic forecast of the most likely future; a Gram-negative drug scenario that assumes future drug development that targets Gram-negative pathogens; and a better care scenario that assumes future improvements in health-care quality and access to appropriate antimicrobials. We present final estimates aggregated to the global, super-regional, and regional level. FINDINGS In 2021, we estimated 4·71 million (95% UI 4·23-5·19) deaths were associated with bacterial AMR, including 1·14 million (1·00-1·28) deaths attributable to bacterial AMR. Trends in AMR mortality over the past 31 years varied substantially by age and location. From 1990 to 2021, deaths from AMR decreased by more than 50% among children younger than 5 years yet increased by over 80% for adults 70 years and older. AMR mortality decreased for children younger than 5 years in all super-regions, whereas AMR mortality in people 5 years and older increased in all super-regions. For both deaths associated with and deaths attributable to AMR, meticillin-resistant Staphylococcus aureus increased the most globally (from 261 000 associated deaths [95% UI 150 000-372 000] and 57 200 attributable deaths [34 100-80 300] in 1990, to 550 000 associated deaths [500 000-600 000] and 130 000 attributable deaths [113 000-146 000] in 2021). Among Gram-negative bacteria, resistance to carbapenems increased more than any other antibiotic class, rising from 619 000 associated deaths (405 000-834 000) in 1990, to 1·03 million associated deaths (909 000-1·16 million) in 2021, and from 127 000 attributable deaths (82 100-171 000) in 1990, to 216 000 (168 000-264 000) attributable deaths in 2021. There was a notable decrease in non-COVID-related infectious disease in 2020 and 2021. Our forecasts show that an estimated 1·91 million (1·56-2·26) deaths attributable to AMR and 8·22 million (6·85-9·65) deaths associated with AMR could occur globally in 2050. Super-regions with the highest all-age AMR mortality rate in 2050 are forecasted to be south Asia and Latin America and the Caribbean. Increases in deaths attributable to AMR will be largest among those 70 years and older (65·9% [61·2-69·8] of all-age deaths attributable to AMR in 2050). In stark contrast to the strong increase in number of deaths due to AMR of 69·6% (51·5-89·2) from 2022 to 2050, the number of DALYs showed a much smaller increase of 9·4% (-6·9 to 29·0) to 46·5 million (37·7 to 57·3) in 2050. Under the better care scenario, across all age groups, 92·0 million deaths (82·8-102·0) could be cumulatively averted between 2025 and 2050, through better care of severe infections and improved access to antibiotics, and under the Gram-negative drug scenario, 11·1 million AMR deaths (9·08-13·2) could be averted through the development of a Gram-negative drug pipeline to prevent AMR deaths. INTERPRETATION This study presents the first comprehensive assessment of the global burden of AMR from 1990 to 2021, with results forecasted until 2050. Evaluating changing trends in AMR mortality across time and location is necessary to understand how this important global health threat is developing and prepares us to make informed decisions regarding interventions. Our findings show the importance of infection prevention, as shown by the reduction of AMR deaths in those younger than 5 years. Simultaneously, our results underscore the concerning trend of AMR burden among those older than 70 years, alongside a rapidly ageing global community. The opposing trends in the burden of AMR deaths between younger and older individuals explains the moderate future increase in global number of DALYs versus number of deaths. Given the high variability of AMR burden by location and age, it is important that interventions combine infection prevention, vaccination, minimisation of inappropriate antibiotic use in farming and humans, and research into new antibiotics to mitigate the number of AMR deaths that are forecasted for 2050. FUNDING UK Department of Health and Social Care's Fleming Fund using UK aid, and the Wellcome Trust.
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DeCesaris C, Bedell S, Kelley K, Gaffney D, Suneja G, Burt L, Jarboe E, Brower J. Use of Radiation Therapy in the Management of Vulvar Cancers-Identification and Management of Acute and Late Toxicities. Pract Radiat Oncol 2024:S1879-8500(24)00216-9. [PMID: 39303777 DOI: 10.1016/j.prro.2024.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Accepted: 08/08/2024] [Indexed: 09/22/2024]
Abstract
Radiation therapy plays a critical role in the management of locally advanced vulvar cancers but can lead to a unique spectrum of side effects, with >25% of patients experiencing high-grade toxicities. The treatment phase requires meticulous perineal skincare and may require pharmacologic management of dysuria and cystitis, diarrhea, nausea, and dermatitis/mucositis. The addition of chemotherapy warrants close laboratory monitoring for hematologic and metabolic derangements.
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Affiliation(s)
- Cristina DeCesaris
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah.
| | - Sabrina Bedell
- Department of Gynecologic Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Kristen Kelley
- Department of Internal Medicine, Division of Hematology and Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - David Gaffney
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Gita Suneja
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Lindsay Burt
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Elke Jarboe
- Department of Pathology, Division of Gynecologic Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
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Talwar A, Chatterjee S, Abughosh S, Johnson M, Sherer J, Aparasu RR. Delirium event and associated treatment modifications among older adults with Alzheimer's disease: An interrupted time-series analysis of Medicare data. Pharmacotherapy 2024. [PMID: 39287108 DOI: 10.1002/phar.4610] [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: 09/27/2023] [Revised: 08/15/2024] [Accepted: 08/16/2024] [Indexed: 09/19/2024]
Abstract
BACKGROUND Both Alzheimer's disease (AD) and deliriogenic medications increase the risk of delirium in older adults. This study examined the association between delirium and the subsequent monthly use of anticholinergic, sedative, and opioid medications in the 1 year after delirium in older adults with AD. METHODS This comparative interrupted time series analysis involved adults (aged 65 years and older) with a diagnosis of AD initiating on cholinesterase inhibitors (ChEIs) based on 2013-2017 Medicare data. Separate patient-level segmented regression models were used for each outcome to evaluate changes in the cumulative anticholinergic burden (CAB), sedative load, and opioid load after the delirium/index event using a 12-month baseline and follow-up period among patients who had a delirium event and those without delirium (control group). Propensity score-based stabilized weights were utilized to balance baseline factors in the delirium and control groups. RESULTS The study included 80,019 older adults with AD with incident ChEI use; 17.11% had delirium. There was an immediate decline in monthly CAB after the delirium event (mean estimate -0.86, p-value: 0.01) compared to the control group. A similar decline was observed when examining the sedative load (-0.06, p-value: 0.002) after the delirium event. However, there was no decline in opioid load (-0.50, p-value: 0.18). In the long term, CAB (0.13; p-value: <0.0001), sedative load (0.01; p-value: <0.001), and opioid load (0.07; p-value: 0.006) increased over the 1-year post-delirium period in the delirium group compared to those without delirium. CONCLUSION This study found the burden of deliriogenic medications over the 1-year follow-up showed increasing trends in older adults with AD, even though there was some level shift in CAB and sedative load after the delirium event.
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Affiliation(s)
- Ashna Talwar
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Satabdi Chatterjee
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Susan Abughosh
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Michael Johnson
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Jeffrey Sherer
- Department of Pharmacy Practice and Translational Research, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Rajender R Aparasu
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
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Parks AL, Frankel DS, Kim DH, Ko D, Kramer DB, Lydston M, Fang MC, Shah SJ. Management of atrial fibrillation in older adults. BMJ 2024; 386:e076246. [PMID: 39288952 DOI: 10.1136/bmj-2023-076246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2024]
Abstract
Most people with atrial fibrillation are older adults, in whom atrial fibrillation co-occurs with other chronic conditions, polypharmacy, and geriatric syndromes such as frailty. Yet most randomized controlled trials and expert guidelines use an age agnostic approach. Given the heterogeneity of aging, these data may not be universally applicable across the spectrum of older adults. This review synthesizes the available evidence and applies rigorous principles of aging science. After contextualizing the burden of comorbidities and geriatric syndromes in people with atrial fibrillation, it applies an aging focused approach to the pillars of atrial fibrillation management, describing screening for atrial fibrillation, lifestyle interventions, symptoms and complications, rate and rhythm control, coexisting heart failure, anticoagulation therapy, and left atrial appendage occlusion devices. Throughout, a framework is suggested that prioritizes patients' goals and applies existing evidence to all older adults, whether atrial fibrillation is their sole condition, one among many, or a bystander at the end of life.
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Affiliation(s)
- Anna L Parks
- University of Utah, Division of Hematology and Hematologic Malignancies, Salt Lake City, UT, USA
| | - David S Frankel
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Dae H Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
| | - Darae Ko
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
- Richard A and Susan F Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center; Boston Medical Center, Section of Cardiovascular Medicine, Boston, MA, USA
| | - Daniel B Kramer
- Richard A and Susan F Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Melis Lydston
- Massachusetts General Hospital, Treadwell Virtual Library, Boston, MA, USA
| | - Margaret C Fang
- University of California, San Francisco, Division of Hospital Medicine, San Francisco, CA, USA
| | - Sachin J Shah
- Massachusetts General Hospital, Division of General Internal Medicine, Center for Aging and Serious Illness, and Harvard Medical School, Boston, MA, USA
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Anderssen-Nordahl E, Fernández-Liz E, Sabaté Gallego M, Bosch Ferrer M, Sánchez-Arcilla Rosanas M, Cervera León M, Magrinyà JM, Barceló-Colomer ME. The impact of a multidisciplinary team intervention on medication prescription in nursing homes in Catalonia. Front Pharmacol 2024; 15:1445141. [PMID: 39346555 PMCID: PMC11427848 DOI: 10.3389/fphar.2024.1445141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 08/26/2024] [Indexed: 10/01/2024] Open
Abstract
Background In response to the rising population of nursing home residents with frailty and multimorbidity, optimizing medication safety through drug utilization review and addressing medication-related problems (MRPs) is imperative. Clinical decision support systems help reduce medication errors and detect potential MRPs, as well as medication reviews performed by a multidisciplinary team, but these combined assessments are not commonly performed. The objective of this study was to evaluate the impact on medication plans of a multidisciplinary team intervention in nursing homes, by analyzing the medication plan before and after the intervention and assessing whether the recommendations given had been implemented. Methods A multicenter before-after study, involving five nursing homes, assessed the impact of a multidisciplinary team intervention, to estimate effectiveness related to the review of the prescribed medications. The follow-up period for each patient was 12 months or until death if prior, from July 2020 to February 2022, and involved 483 patients. The clinical pharmacologist coordinated the intervention and reviewed all the prescribed medications to make recommendations, focused on the completion of absent data, withdrawal of a drug, verification of whether a drug was adequate, the substitution of a drug, and the addition of drugs. Since the intervention was performed during the COVID-19 pandemic, optimization of psychotropic drugs and absorbent pads were limited. Results The intervention had an impact with recommendations given for 398 (82.4%) of the patients and which were followed by 58.5% of them. At least one drug was withdrawn in 293 (60.7%) of the patients, with a mean of 2.3 (SD 1.7). As for the total of 1,097 recommendations given, 355 (32.4%) were followed. From the intervention, antipsychotics, antidepressants, benzodiazepines, statins, and diuretics were the most frequently withdrawn. Conclusion The findings underscore the impact of targeted interventions to reduce inappropriate medications and enhance medication safety in nursing homes. The proposed recommendations given and followed show the importance of a multidisciplinary team, coordinated by a clinical pharmacologist, for a patient-centered approach to make medication reviews regularly, with the help of clinical decision support systems, to help reduce potential MRPs and polypharmacy.
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Affiliation(s)
- Emilie Anderssen-Nordahl
- Clinical Pharmacology Service, Vall d’Hebron University Hospital, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Clinical Pharmacology Group, Vall d’Hebron Research Institute, Barcelona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eladio Fernández-Liz
- Primary Healthcare Barcelona, Management of Primary Care and the Community of Barcelona City, Catalan Institute of Health, Barcelona, Spain
- Foundation University Institute for Research in Primary Health Care Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Mònica Sabaté Gallego
- Clinical Pharmacology Service, Vall d’Hebron University Hospital, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Clinical Pharmacology Group, Vall d’Hebron Research Institute, Barcelona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Montserrat Bosch Ferrer
- Clinical Pharmacology Service, Vall d’Hebron University Hospital, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Clinical Pharmacology Group, Vall d’Hebron Research Institute, Barcelona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Margarita Sánchez-Arcilla Rosanas
- Geriatric Unit, Internal Medicine Service, Vall d’Hebron University Hospital, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Mercè Cervera León
- Primary Healthcare Barcelona, Management of Primary Care and the Community of Barcelona City, Catalan Institute of Health, Barcelona, Spain
| | - Joaquim Miquel Magrinyà
- Primary Healthcare Barcelona, Management of Primary Care and the Community of Barcelona City, Catalan Institute of Health, Barcelona, Spain
| | - Maria Estrella Barceló-Colomer
- Primary Healthcare Barcelona, Management of Primary Care and the Community of Barcelona City, Catalan Institute of Health, Barcelona, Spain
- Foundation University Institute for Research in Primary Health Care Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
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Casey MF, Hallmark J, Chang PP, Rodgers JE, Mehta A, Chari SV, Skersick P, Bohrmann T, Goyal P, Meyer ML. Emergency Department Use of Heart Failure-Exacerbating Medications in Patients with Chronic Heart Failure. Drug Saf 2024:10.1007/s40264-024-01479-5. [PMID: 39264483 DOI: 10.1007/s40264-024-01479-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2024] [Indexed: 09/13/2024]
Abstract
BACKGROUND Use of heart failure-exacerbating medications (HFEMs) may lead to preventable episodes of acute decompensated heart failure (HF). HFEMs use is common in patients with HF, and there may be opportunities to reduce their use from the emergency department (ED). METHODS We performed an observational study on patients with HF presenting to EDs within a healthcare system between 1 January 2016 and 31 December 2020. Patients with chronic HF were identified using diagnostic codes within the electronic health record. The cohort was restricted to ambulatory (i.e., discharged to home) ED encounters. Medications, either ordered in the ED or prescribed at ED discharge, were extracted from the medication administration record and identified as potential HFEMs based on the 2016 American Heart Association Scientific Statement. Descriptive statistics were used to summarize the prevalence of HFEM use during ambulatory ED encounters. Exploratory analyses to identify correlates of HFEM use were performed. RESULTS The study cohort included 23,907 ED encounters. ED administration or prescription of HFEMs occurred during 20% of ambulatory ED encounters. HFEM administration in the ED (17%) was more common than HFEM prescription at ED discharge (6%). The most common HFEMs administered in the ED included nonsteroidal anti-inflammatory drugs (11%) and albuterol (7%). CONCLUSION HFEM use is common in patients with HF seeking ED care, occurring in roughly one-fifth of ambulatory ED encounters. There may be opportunities to optimize medication use among patients with HF in the ED.
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Affiliation(s)
- Martin F Casey
- Department of Emergency Medicine, University of North Carolina School of Medicine, 170 Manning Dr, CB# 7594, Chapel Hill, NC, 27599-7594, USA.
| | - Joy Hallmark
- Department of Emergency Medicine, University of North Carolina School of Medicine, 170 Manning Dr, CB# 7594, Chapel Hill, NC, 27599-7594, USA
| | - Patricia P Chang
- Division of Cardiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Jo E Rodgers
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Aakash Mehta
- Department of Emergency Medicine, University of North Carolina School of Medicine, 170 Manning Dr, CB# 7594, Chapel Hill, NC, 27599-7594, USA
| | - Srihari V Chari
- Department of Emergency Medicine, University of North Carolina School of Medicine, 170 Manning Dr, CB# 7594, Chapel Hill, NC, 27599-7594, USA
| | - Preston Skersick
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | | | - Parag Goyal
- Division of Cardiology, Weill Cornell Medicine, New York, NY, USA
- Division of General Internal Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Michelle L Meyer
- Department of Emergency Medicine, University of North Carolina School of Medicine, 170 Manning Dr, CB# 7594, Chapel Hill, NC, 27599-7594, USA
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Cross AJ, Villani ER, Jadczak AD, Pitkälä K, Hamada S, Zhao M, Gutiérrez-Valencia M, Aalto U, Dowd LA, Li L, Liau SJ, Liperoti R, Martínez-Velilla N, Ooi CE, Onder G, Petrie K, Roitto HM, Roncal-Belzunce V, Saarela R, Sakata N, Visvanathan R, Zhang TG, Bell JS. Prevalence of strong anticholinergic use in residents with and without cognitive impairment and frailty: Analysis from 106 nursing homes in 12 Asia-Pacific and European countries. Arch Gerontol Geriatr 2024; 128:105636. [PMID: 39303422 DOI: 10.1016/j.archger.2024.105636] [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: 06/18/2024] [Revised: 08/29/2024] [Accepted: 09/10/2024] [Indexed: 09/22/2024]
Abstract
PURPOSE There is a need to balance the benefits and risks associated with strong anticholinergic medications in older adults, particularly among those with frailty and cognitive impairment. This study explored the international prevalence of strong anticholinergic medication use in residents of nursing homes with and without cognitive impairment and frailty. METHODS Secondary, cross-sectional analyses of data from 5,800 residents of 106 nursing homes in Australia, China, Czech Republic, England, Finland, France, Germany, Israel, Italy, Japan, Netherlands, and Spain were conducted. Strong anticholinergic medications were defined as medications with a score of 2 or 3 on the Anticholinergic Cognitive Burden scale. Dementia or cognitive impairment was defined as a documented diagnosis or using a validated scale. Frailty was defined using the FRAIL-NH scale as 0-2 (non-frail), 3-6 (frail) and 7-14 (most-frail). Data were analyzed using descriptive statistics. RESULTS Overall, 17.4 % (n = 1010) residents used ≥1 strong anticholinergic medication, ranging from 1.3 % (n = 2) in China to 27.1 % (n = 147) in Italy. The most prevalent strong anticholinergics were quetiapine (n = 290, 5.0 % of all residents), olanzapine (132, 2.3 %), carbamazepine (102, 1.8 %), paroxetine (88, 1.5 %) and amitriptyline (87, 1.5 %). Prevalence was higher among residents with cognitive impairment (n = 602, 17.9 %) compared to those without (n = 408, 16.8 %), and among residents who were most frail (n = 553, 17.9 %) compared to those who were frail (n = 286, 16.5 %) or non-frail (n = 171, 17.5 %). CONCLUSIONS One in six residents who were most frail and living with cognitive impairment used a strong anticholinergic. However, there was a 20-fold variation in prevalence across the 12 countries. Targeted deprescribing interventions may reduce potentially avoidable medication-harm.
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Affiliation(s)
- Amanda J Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.
| | - Emanuele R Villani
- Department of Geriatrics and Orthopedics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; UOC Geriatria, Disturbi Cognitivi e Demenze, Dipartimento di Cure Primarie, AUSL Modena, 41121 Modena, Italy
| | - Agathe D Jadczak
- Adelaide Geriatrics Training and Research with Aged Care (GTRAC) Centre, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia; The Basil Hetzel Institute, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Kaisu Pitkälä
- Department of General Practice, University of Helsinki Unit of Primary Health Care, Helsinki University Hospital, Helsinki, Finland
| | - Shota Hamada
- Research Department, Institute for Health Economics and Policy, Association for Health Economics Research and Social Insurance and Welfare, Tokyo, Japan; Department of Health Services Research, Institute of Medicine, University of Tsukuba, Tsukuba, Japan; Department of Home Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Meng Zhao
- School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Marta Gutiérrez-Valencia
- Unit of Innovation and Organization, Navarre Health Service, Pamplona, Navarre, Spain; Navarre Institute for Health Research (IdiSNA), Pamplona, Navarre, Spain
| | - Ulla Aalto
- Department of Geriatrics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Laura A Dowd
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Li Li
- School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Shin J Liau
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Rosa Liperoti
- Department of Geriatrics and Orthopedics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Nicolás Martínez-Velilla
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Choon Ean Ooi
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Graziano Onder
- Department of Geriatrics and Orthopedics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Kate Petrie
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Hanna M Roitto
- Department of Geriatrics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Victoria Roncal-Belzunce
- Navarre Institute for Health Research (IdiSNA), Pamplona, Navarre, Spain; Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Riitta Saarela
- Social Services, Health Care and Rescue Services Division, City of Helsinki, Finland
| | - Nobuo Sakata
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Tsukuba, Japan; Heisei Medical Welfare Group Research Institute, Tokyo, Japan
| | - Renuka Visvanathan
- Adelaide Geriatrics Training and Research with Aged Care (GTRAC) Centre, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia; Aged and Extended Care Services, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Tiange G Zhang
- School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
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Coe AB, Zhang T, Zullo AR, Gerlach LB, Daiello LA, Varma H, Lo D, Joshi R, Bynum JPW, Shireman TI. Association of nursing home antipsychotic reduction policies with antipsychotic use in community dwellers with dementia. J Am Geriatr Soc 2024. [PMID: 39242359 DOI: 10.1111/jgs.19184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 05/31/2024] [Accepted: 08/16/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND Antipsychotic and other psychotropic medication use is prevalent among community-dwelling older adults with dementia despite the potential for adverse effects. Two Centers for Medicare & Medicaid Services (CMS) initiatives, the National Partnership to Improve Dementia Care ("the Partnership") and the Five Star Quality Rating System for antipsychotic use reporting, have been successful in reducing antipsychotic use in nursing home residents. We assessed if these initiatives had a spillover effect in antipsychotic and other psychotropic medication use among community dwellers with dementia due to potential overlap in prescribers across settings. METHODS Among community-dwelling older adults with dementia, we examined psychotropic medication class use (i.e., antipsychotics, antidepressants, anxiolytics, anticonvulsants/mood stabilizers, antidementia) in 2010-2017 Medicare fee-for-service claims using interrupted time series analyses across three periods ("Pre-Partnership": July 1, 2010 to March 31, 2012; "Post-Partnership": April 1, 2012 to January 31, 2015; "Five Star Quality Rating": February 1, 2015 to December 31, 2017). RESULTS We included 1,289,401 community dwellers with dementia contributing 26,609,697 person-months. The mean age was 80 years, most were female (70%), approximately 80% were non-Hispanic Whites, 10% were non-Hispanic Blacks, and 5% were Hispanic ethnicity. Antipsychotic use was declining pre-Partnership (β = -0.06, 95% CI: -0.08, -0.05) and post-Partnership (β = -0.02, 95% CI: -0.02, -0.01). Post-Five Star Quality Rating, antipsychotic use remained stable with a nearly flat slope (β = -0.01, 95% CI: -0.01, 0.00). Anticonvulsant and antidepressant use increased and anxiolytic and antidementia medication use decreased among community-dwelling older adults with dementia. CONCLUSIONS These two CMS policies on antipsychotic use for nursing home residents were not associated with a spillover effect to community-dwelling older adults with dementia. Strategies to monitor the appropriateness of psychotropic medication use may be warranted for community-dwellers with dementia.
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Affiliation(s)
- Antoinette B Coe
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Tingting Zhang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Andrew R Zullo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Lauren B Gerlach
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Lori A Daiello
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Hiren Varma
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Derrick Lo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Richa Joshi
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Julie P W Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Theresa I Shireman
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
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Pham Nguyen TP, Thibault D, Hamedani AG, Willis AW. Attitudes and beliefs towards medication burden and deprescribing in Parkinson disease. BMC Neurol 2024; 24:325. [PMID: 39242502 PMCID: PMC11378437 DOI: 10.1186/s12883-024-03830-w] [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: 05/30/2024] [Accepted: 08/27/2024] [Indexed: 09/09/2024] Open
Abstract
BACKGROUND Deprescribing of potentially inappropriate medications is recommended for older adults and may improve health outcomes and quality of life in persons living with Parkinson disease (PD). Patient attitudes, beliefs, and preferences play a crucial role in the success of deprescribing interventions. We aimed to examine the attitudes and beliefs about medication burden and deprescribing among persons living with PD. METHODS We administered a survey to participants of Fox Insight, a prospective longitudinal study of persons living with PD. The survey included the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire and additional questions about adverse drug effects. We used logistic regression models to explore potential predictors of treatment dissatisfaction and willingness to deprescribe. RESULTS Of the 4945 rPATD respondents, 31.6% were dissatisfied with their current medications, and 87.1% would be willing to deprescribe medications. Male sex was associated with a greater willingness to deprescribe (adjusted odds ratio [aOR] 1.62, 95% confidence interval [CI] 1.37-1.93). A greater belief that the medication burden was high or that some medications were inappropriate was associated with treatment dissatisfaction (aORs 3.74, 95% CI 3.26-4.29 and 5.61, 95% CI 4.85-6.50), and more willingness to deprescribe (aORs 1.74, 95% CI 1.47-2.06 and 2.87, 95% CI 2.41-3.42). Cognitive impairment was the adverse drug effect participants were most concerned about when prescribed new medications to treat nonmotor symptoms. CONCLUSIONS Persons with PD are often dissatisfied with their overall medication load and are open to deprescribing. Medications that are associated with cognitive impairment might be prioritized targets for deprescribing interventions in this population.
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Affiliation(s)
- Thanh Phuong Pham Nguyen
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Department of Neurology Translational Center for Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Center for Real-World Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Dylan Thibault
- Department of Neurology Translational Center for Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ali G Hamedani
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Neurology Translational Center for Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Real-World Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Allison W Willis
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Neurology Translational Center for Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Real-World Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Division of Neurology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
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Huon JF, Sanyal C, Gagnon CL, Turner JP, Khuong NB, Bortolussi-Courval É, Lee TC, Silvius JL, Morgan SG, McDonald EG. The cost of potentially inappropriate medications for older adults in Canada: A comparative cross-sectional study. J Am Geriatr Soc 2024. [PMID: 39235969 DOI: 10.1111/jgs.19164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 07/22/2024] [Accepted: 07/30/2024] [Indexed: 09/07/2024]
Abstract
BACKGROUND Potentially inappropriate medications (PIMs) are medications whereby the harms may outweigh the benefits for a given individual. Although overprescribed to older adults, their direct costs on the healthcare system are poorly described. METHODS This was a cross-sectional study of the cost of PIMs for Canadians aged 65 and older, using adapted criteria from the American Geriatrics Society. We examined prescription claims information from the National Prescription Drug Utilization Information System in 2021 and compared these with 2013. The overall levels of inflation-adjusted total annual expenditure on PIMs, average cost per quarterly exposure, and average quarterly exposures to PIMs were calculated in CAD$. RESULTS Exposure to most categories of PIMs decreased, aside from gabapentinoids, proton pump inhibitors, and antipsychotics, all of which increased. Canadians spent $1 billion on PIMs in 2021, a 33.6% reduction compared with 2013 ($1.5 billion). In 2021, the largest annual expenditures were on proton pump inhibitors ($211 million) and gabapentinoids ($126 million). The quarterly amount spent on PIMs per person exposed decreased from $95 to $57. In terms of mean cost per person, opioids and antipsychotics were highest ($138 and $118 per exposure). Some cost savings may have occurred secondary to an observed decline of 16.4% in the quarterly rate of exposure to PIMs (from 7301 per 10,000 in 2013 to 6106 per 10,000 in 2021). CONCLUSIONS While expenditures on PIMs have declined in Canada, the overall cost remains high. Prescribing of some seriously harmful classes of PIMs has increased and so directed, scalable interventions are needed.
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Affiliation(s)
- Jean-François Huon
- Canadian Medication Appropriateness and Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, Quebec, Canada
- Nantes Université, CHU Nantes, Pharmacie, Nantes, France
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Chiranjeev Sanyal
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Camille L Gagnon
- Canadian Medication Appropriateness and Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, Quebec, Canada
| | - Justin P Turner
- Canadian Medication Appropriateness and Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, Quebec, Canada
- Faculty of Pharmacy and Pharmaceutical Sciences, Center for Medicine Use and Safety, Monash University, Clayton, Victoria, Australia
| | - Ninh B Khuong
- Canadian Medication Appropriateness and Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, Quebec, Canada
| | - Émilie Bortolussi-Courval
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Todd C Lee
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - James L Silvius
- Canadian Medication Appropriateness and Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, Quebec, Canada
- Alberta Health Services, Edmonton, Alberta, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Steven G Morgan
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Emily G McDonald
- Canadian Medication Appropriateness and Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, Quebec, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
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Barboza Zanetti MO, Dos Santos I, Durante JC, Varallo FR, Pereira LRL, Miasso AI. Consumption patterns and factors associated with inappropriate prescribing of benzodiazepines in Primary Health Care settings. PLoS One 2024; 19:e0309984. [PMID: 39231170 PMCID: PMC11373788 DOI: 10.1371/journal.pone.0309984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 08/05/2024] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND Benzodiazepines are frequently prescribed to treat anxiety and insomnia, but long-term use has been associated with the development of dependence, tolerance, and cognitive decline, especially among older adults. This study aimed to investigate the pattern of consumption and factors associated with inappropriate prescribing of benzodiazepines in primary health care. METHODS This is a cross-sectional analytical study, using dispensing records of diazepam, clonazepam, and nitrazepam from public pharmacies in a Brazilian municipality between 2018 and 2022. Metrics for benzodiazepine consumption were DDD (Defined Daily Dose) and DDD/1000PD (per 1000 population per day). Long-term/prolonged benzodiazepine use was defined as consuming at least 90 DDD and at least 2 dispensations per year. To ascertain associations between long-term use and predictor variables, a multivariate logistic regression model was utilized. FINDINGS A total of 40402 participants were included, with an average age of 55 years (SD = 0.30), 38.5% were older aged. Diazepam and nitrazepam exceeded the daily dose recommended. There was a reduction in diazepam consumption during the study period, as calculated by DDD/1.000PD, while the consumption of other benzodiazepines remained stable. However, a significant increase in diazepam consumption is noted when considering the last decade. Prolonged use was observed in 29.1% of participants, with a significant prevalence among the older people (34.8% of them were long-term users) and advancing age was identified as a risk factor for long-term use. Higher PDDs were also associated with long-term use and aging. Participants who used different benzodiazepines during the period had a higher risk of prolonged use. CONCLUSIONS These results provide insights into the prevalence of problematic utilization of benzodiazepines in primary health care. Authorities and health care providers must take steps to encourage gradual cessation of prolonged benzodiazepine prescriptions and the embrace of suitable strategies for addressing anxiety and insomnia within primary health care settings.
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Affiliation(s)
- Maria Olívia Barboza Zanetti
- Department of Psychiatric Nursing and Human Sciences, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | - Iara Dos Santos
- Department of Psychiatric Nursing and Human Sciences, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
| | - Júlia Casanova Durante
- Department of Pharmaceutical Sciences, University of São Paulo at School of Pharmaceutical Sciences of Ribeirao Preto, Ribeirão Preto, São Paulo, Brazil
| | - Fabiana Rossi Varallo
- Department of Pharmaceutical Sciences, University of São Paulo at School of Pharmaceutical Sciences of Ribeirao Preto, Ribeirão Preto, São Paulo, Brazil
| | - Leonardo Régis Leira Pereira
- Department of Pharmaceutical Sciences, University of São Paulo at School of Pharmaceutical Sciences of Ribeirao Preto, Ribeirão Preto, São Paulo, Brazil
| | - Adriana Inocenti Miasso
- Department of Psychiatric Nursing and Human Sciences, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil
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Gentile G, Del Casale A, De Luca O, Salerno G, Spirito S, Regiani M, Regiani M, Preissner S, Rocco M, Preissner R, Simmaco M, Borro M. Recognizing and preventing unacknowledged prescribing errors associated with polypharmacy. Arch Public Health 2024; 82:146. [PMID: 39232813 PMCID: PMC11373128 DOI: 10.1186/s13690-024-01381-7] [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: 01/22/2024] [Accepted: 08/23/2024] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND Prescribing errors put an enormous burden on health and the economy, claiming implementation of effective methods to prevent/reduce them. Polypharmacy regimens (five or more drugs) are highly prone to unacknowledged prescribing errors, since the complex network of drug-drug interactions, guidelines and contraindications is challenging to be adequately evaluated in the prescription phase, especially if different doctors are involved. Clinical decision support systems aimed at polypharmacy evaluation may be crucial to recognize and correct prescribing errors. METHODS A commercial clinical decision support system (Drug-PIN®) was applied to estimate the frequency of unrecognized prescribing errors in a group of 307 consecutive patients accessing the hospital pre-admission service of the Sant'Andrea Hospital of Rome, Italy, in the period April-June 2023. Drug-PIN® is a two-step system, first scoring the risk (low, moderate or high) associated with a certain therapy-patient pair, then allowing therapy optimization by medications exchanges. We defined prescribing errors as cases where therapy optimization could achieve consistent reduction of the Drug-PIN® calculated risk. RESULTS Polypharmacy was present in 205 patients, and moderate to high risk for medication harm was predicted by Drug-PIN® in 91 patients (29.6%). In 58 of them (63.7%), Drug-PIN® guided optimization of the therapy could be achieved, with a statistically significant reduction of the calculated therapy-associated risk score. Patients whose therapy cannot be improved have a statistically significant higher number of used drugs. Considering the overall study population, the rate of avoidable prescribing errors was 18.89%. CONCLUSIONS Results suggest that computer-aided evaluation of medication-associated harm could be a valuable and actionable tool to identify and prevent prescribing errors in polypharmacy. We conducted the study in a Hospital pre-admission setting, which is not representative of the general population but represents a hotspot to intercept fragile population, where a consistent fraction of potentially harmful polypharmacy regimens could be promptly identified and corrected by systematic use of adequate clinical decision support tools.
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Affiliation(s)
- Giovanna Gentile
- , Via di Grottarossa 1035/1039, Rome, 00189, Italy
- Laboratory of Clinical Biochemistry, Advanced Molecular Diagnostic Unit, Sant'Andrea University Hospital, Via di Grottarossa 1035/1039, Rome, 00189, Italy
| | - Antonio Del Casale
- Department of Dynamic and Clinical Psychology and Health Studies, Faculty of Medicine and Psychology, Sapienza University of Rome, Roma, 00189, Italy
- Unit of Psychiatry, Sant'Andrea University Hospital, Via di Grottarossa 1035/1039, Rome, 00189, Italy
| | - Ottavia De Luca
- Laboratory of Clinical Biochemistry, Advanced Molecular Diagnostic Unit, Sant'Andrea University Hospital, Via di Grottarossa 1035/1039, Rome, 00189, Italy
| | - Gerardo Salerno
- , Via di Grottarossa 1035/1039, Rome, 00189, Italy
- Laboratory of Clinical Biochemistry, Advanced Molecular Diagnostic Unit, Sant'Andrea University Hospital, Via di Grottarossa 1035/1039, Rome, 00189, Italy
| | - Sara Spirito
- , Via di Grottarossa 1035/1039, Rome, 00189, Italy
| | - Martina Regiani
- Faculty of Medicine and Psychology, Sapienza University of Rome, Roma, 00189, Italy
| | - Matteo Regiani
- Faculty of Medicine and Psychology, Sapienza University of Rome, Roma, 00189, Italy
| | - Saskia Preissner
- Department Oral and Maxillofacial Surgery, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Monica Rocco
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Rome, 00189, Italy
- Unit of Anaesthesia, Intensive Care and Pain Medicine, Sant'Andrea University Hospital, Via di Grottarossa 1035/1039, Rome, 00189, Italy
| | - Robert Preissner
- Structural Bioinformatics Group, Institute for Physiology, Charité-University Medicine Berlin, 10117, Berlin, Germany
| | - Maurizio Simmaco
- , Via di Grottarossa 1035/1039, Rome, 00189, Italy
- Laboratory of Clinical Biochemistry, Advanced Molecular Diagnostic Unit, Sant'Andrea University Hospital, Via di Grottarossa 1035/1039, Rome, 00189, Italy
| | - Marina Borro
- , Via di Grottarossa 1035/1039, Rome, 00189, Italy.
- Laboratory of Clinical Biochemistry, Advanced Molecular Diagnostic Unit, Sant'Andrea University Hospital, Via di Grottarossa 1035/1039, Rome, 00189, Italy.
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30
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Zdanys KF. "We Don't Really Do That in Geriatrics" Commentary on Long-Acting Injectable Antipsychotics in the Geriatric Population: A Longitudinal Study. Am J Geriatr Psychiatry 2024:S1064-7481(24)00439-1. [PMID: 39278796 DOI: 10.1016/j.jagp.2024.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2024] [Accepted: 08/23/2024] [Indexed: 09/18/2024]
Affiliation(s)
- Kristina F Zdanys
- Department of Psychiatry, University of Connecticut School of Medicine, 263 Farmington Ave. Farmington, CT 06030.
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Clark S, Johnson T, Runkel K, Wallace J. Update on Therapies in Older Adults. Med Clin North Am 2024; 108:895-910. [PMID: 39084840 DOI: 10.1016/j.mcna.2024.02.005] [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] [Indexed: 08/02/2024]
Abstract
Memory loss and dementia are among older adults' greatest health fears. This article provides insight into new developments to help delay the onset of dementia, to treat dementia in its earliest stages, and to manage behavioral problems that occur in persons with dementia. Urinary incontinence (UI) is another common problem in older adults that has a major impact on quality of life. This article evaluates newer medications for reducing urinary urge/UI and provides perspective in their role for managing UI.
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Affiliation(s)
- Sophie Clark
- Division of Geriatric Medicine, University of Colorado School of Medicine, 12631 East 17th Avenue, Box B179, Aurora, CO 80045, USA
| | - Thomas Johnson
- Division of Geriatric Medicine, University of Colorado School of Medicine, 12631 East 17th Avenue, Box B179, Aurora, CO 80045, USA. https://twitter.com/TMJohnsonMD
| | - Katherine Runkel
- Division of Geriatric Medicine, University of Colorado School of Medicine, 12631 East 17th Avenue, Box B179, Aurora, CO 80045, USA
| | - Jeffrey Wallace
- Division of Geriatric Medicine, University of Colorado School of Medicine, 12631 East 17th Avenue, Box B179, Aurora, CO 80045, USA.
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Skains RM, Koehl JL, Aldeen A, Carpenter CR, Gettel CJ, Goldberg EM, Hwang U, Kocher KE, Southerland LT, Goyal P, Berdahl CT, Venkatesh AK, Lin MP. Geriatric Emergency Medication Safety Recommendations (GEMS-Rx): Modified Delphi Development of a High-Risk Prescription List for Older Emergency Department Patients. Ann Emerg Med 2024; 84:274-284. [PMID: 38483427 PMCID: PMC11343681 DOI: 10.1016/j.annemergmed.2024.01.033] [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: 10/19/2023] [Revised: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 04/14/2024]
Abstract
STUDY OBJECTIVE Half of emergency department (ED) patients aged 65 years and older are discharged with new prescriptions. Potentially inappropriate prescriptions contribute to adverse drug events. Our objective was to develop an evidence- and consensus-based list of high-risk prescriptions to avoid among older ED patients. METHODS We performed a modified, 3-round Delphi process that included 10 ED physician experts in geriatrics or quality measurement and 1 pharmacist. Consensus members reviewed all 35 medication categories from the 2019 American Geriatrics Society Beers Criteria and ranked each on a 5-point Likert scale (5=highest) for overall priority for avoidance (Round 1), risk of short-term adverse events and avoidability (Round 2), and reasonable medical indications for high-risk medication use (Round 3). RESULTS For each round, questionnaire response rates were 91%, 82%, and 64%, respectively. After Round 1, benzodiazepines (mean, 4.60 [SD, 0.70]), skeletal muscle relaxants (4.60 [0.70]), barbiturates (4.30 [1.06]), first-generation antipsychotics (4.20 [0.63]) and first-generation antihistamines (3.70 [1.49]) were prioritized for avoidance. In Rounds 2 and 3, hypnotic "Z" drugs (4.29 [1.11]), metoclopramide (3.89 [0.93]), and sulfonylureas (4.14 [1.07]) were prioritized for avoidability, despite lower concern for short-term adverse events. All 8 medication classes were included in the final list. Reasonable indications for prescribing high-risk medications included seizure disorders, benzodiazepine/ethanol withdrawal, end of life, severe generalized anxiety, allergic reactions, gastroparesis, and prescription refill. CONCLUSION We present the first expert consensus-based list of high-risk prescriptions for older ED patients (GEMS-Rx) to improve safety among older ED patients.
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Affiliation(s)
- Rachel M Skains
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL; Geriatric Research, Education and Clinical Center, Birmingham VAMC, Birmingham, AL
| | - Jennifer L Koehl
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA
| | | | | | - Cameron J Gettel
- Department of Emergency Medicine, Yale University, New Haven, CT
| | | | - Ula Hwang
- Department of Emergency Medicine, Yale University, New Haven, CT; Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, NY
| | - Keith E Kocher
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | | | - Pawan Goyal
- Quality Division, American College of Emergency Physicians, Irving, TX
| | - Carl T Berdahl
- Department of Emergency Medicine, Cedars Sinai Medical Center, Los Angeles, CA
| | | | - Michelle P Lin
- Department of Emergency Medicine, Stanford University, Palo Alto, CA.
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Kransdorf LN, Wang AY, Files JA. Updates in the Care of Women in Menopause. J Womens Health (Larchmt) 2024; 33:1283-1287. [PMID: 38979624 DOI: 10.1089/jwh.2024.0644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024] Open
Affiliation(s)
- Lisa N Kransdorf
- Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Annie Y Wang
- Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Julia A Files
- Division of Women's Health Internal Medicine, Mayo Clinic, Scottsdale, Arizona, USA
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Ferrante LE, Han L, Andrews B, Cohen AB, Davis JL, Gritsenko D, Lee S, Pisani MA, Reed NS, Rouse G, Truebig J. Effect of a Three-Component Geriatrics Bundle on Incident Delirium among Critically Ill Older Adults: A Pilot Clinical Trial. Ann Am Thorac Soc 2024; 21:1333-1337. [PMID: 38785442 PMCID: PMC11376353 DOI: 10.1513/annalsats.202311-963rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 05/07/2024] [Indexed: 05/25/2024] Open
Affiliation(s)
| | - Ling Han
- Yale University New Haven, Connecticut
| | | | - Andrew B Cohen
- Yale University New Haven, Connecticut
- VA Connecticut Healthcare System West Haven, Connecticut
| | | | | | - Seohyuk Lee
- Beth Israel Deaconess Medical Center Boston, Massachusetts
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Watterson TL, Moon J, Stone JA, Gilson AM, Berbakov ME, Hoffins EL, Chladek JS, Lehnbom EC, Resendiz SM, Mai S, Walker KD, Gollhardt JD, Chui MA. Linking Inner Context and Innovation Factors: Examining a pharmacy-based intervention through the eyes of pharmacy staff. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2024; 15:100486. [PMID: 39205955 PMCID: PMC11350256 DOI: 10.1016/j.rcsop.2024.100486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 07/30/2024] [Accepted: 07/31/2024] [Indexed: 09/04/2024] Open
Abstract
INTRODUCTION Community pharmacies, as unique and accessible healthcare venues, are ideal locations to implement interventions aiming to improve patient care. However, these interventions may increase workload or disrupt workflow for community pharmacists, technicians, and other staff members, threatening long-term sustainment. There are growing calls from the field of implementation science to design for intervention sustainment and maintenance by maximizing innovation fit. Senior Safe™, an intervention to facilitate safer over-the-counter (OTC) product selection by older adults, serves as a case study to examine the congruence between Innovation Factors and community pharmacy Inner Context constructs and their implications for workload and sustainment. METHODS Using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, this qualitative study identified factors surrounding Senior Safe implementation. Semi-structured interviews were conducted with staff from pharmacies where Senior Safe was implemented. Two coders independently analyzed interview transcripts using deductive analysis based on EPIS constructs. Thematic analysis was used to generate three themes that encapsulated innovation fit. RESULTS Nineteen pharmacy staff members participated, with the majority reporting no significant change in their workload or workflow due to Senior Safe. Interview feedback supported a pre-existing culture of the healthcare system to engage patients, of leadership commitment to patient safety initiatives, and of an amplified role of pharmacy technicians. DISCUSSION AND CONCLUSION Pharmacy staff interviews revealed congruence between Innovation Factors and Inner Context that likely yielded intervention workload neutrality. This study highlighted the importance for researchers to consider maintenance and sustainability when designing and implementing an intervention and the critical influence of culture and leadership support during this process.
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Affiliation(s)
- Taylor L. Watterson
- Pharmacy Systems Outcomes and Policy, College of Pharmacy, University of Illinois Chicago, USA
| | - Jukrin Moon
- Department of Industrial and Systems Engineering, University of Iowa, USA
| | - Jamie A. Stone
- Social and Administrative Sciences, School of Pharmacy, University of Wisconsin-Madison, USA
- Sonderegger Research Center for Improved Medication Outcomes, University of Wisconsin-Madison, USA
| | - Aaron M. Gilson
- Social and Administrative Sciences, School of Pharmacy, University of Wisconsin-Madison, USA
- Sonderegger Research Center for Improved Medication Outcomes, University of Wisconsin-Madison, USA
| | - Maria E. Berbakov
- Social and Administrative Sciences, School of Pharmacy, University of Wisconsin-Madison, USA
- Sonderegger Research Center for Improved Medication Outcomes, University of Wisconsin-Madison, USA
| | - Emily L. Hoffins
- Social and Administrative Sciences, School of Pharmacy, University of Wisconsin-Madison, USA
| | - Jason S. Chladek
- Social and Administrative Sciences, School of Pharmacy, University of Wisconsin-Madison, USA
| | - Elin C. Lehnbom
- Social Pharmacy Group, Department of Pharmacy, Faculty of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Stephanie M. Resendiz
- Social and Administrative Sciences, School of Pharmacy, University of Wisconsin-Madison, USA
| | - Shiying Mai
- Social and Administrative Sciences, School of Pharmacy, University of Wisconsin-Madison, USA
| | | | | | - Michelle A. Chui
- Social and Administrative Sciences, School of Pharmacy, University of Wisconsin-Madison, USA
- Sonderegger Research Center for Improved Medication Outcomes, University of Wisconsin-Madison, USA
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Zhang J, Kanchi R, Conderino S, Levy NK, Adhikari S, Blecker S, Davis N, Divers J, Rabin C, Weiner M, Thorpe L, Dodson JA. Decline in use of high-risk agents for tight glucose control among older adults with diabetes in New York City: 2017-2022. J Am Geriatr Soc 2024; 72:2721-2729. [PMID: 38980267 PMCID: PMC11368607 DOI: 10.1111/jgs.19060] [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: 02/06/2024] [Revised: 05/25/2024] [Accepted: 05/31/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND This study aimed to examine the prevalence of inappropriate tight glycemic control in older adults with type 2 diabetes and other chronic conditions in New York City, and to identify factors associated with this practice. METHODS We conducted a retrospective cohort study using the INSIGHT Clinical Research Network. The study population included 11,728 and 15,196 older adults in New York City (age ≥ 75 years) with a diagnosis of type 2 diabetes, and at least one other chronic medical condition, in 2017 and 2022, respectively. The main outcome of interest was inappropriate tight glycemic control, defined as HbA1c <7.0% (<53 mmol/mol) with prescription of at least one high-risk agent (insulin or insulin secretagogue). RESULTS The proportion of older adults with inappropriate tight glycemic control decreased by nearly 19% over a five-year period (19.4% in 2017 to 15.8% in 2022). There was a significant decrease in insulin (27.8% in 2017; 24.3% in 2022) and sulfonylurea (29.4% in 2017; 21.7% in 2022) medication prescription, and increase in use of GLP-1 agonists (1.8% in 2017; 11.4% in 2022) and SGLT-2 inhibitors (5.8% in 2017; 25.1% in 2022), among the total population. Factors associated with inappropriate tight glycemic control in 2022 included history of heart failure (adjusted odds ratio [aOR] 1.38), chronic kidney disease ([aOR] 1.93), colorectal cancer ([aOR] 1.38), acute myocardial infarction ([aOR] 1.28), "other" ([aOR] 0.72) or "unknown" ([aOR] 0.72) race, and a point increase in BMI ([aOR] 0.98). CONCLUSIONS We found an encouraging trend toward less use of high-risk medication strategies for older adults with type 2 diabetes and multiple chronic conditions. However, one in six patients in 2022 still had inappropriate tight glycemic control, indicating a need for continued efforts to optimize diabetes management in this population.
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Affiliation(s)
- Jeff Zhang
- Department of Population Health, NYU Grossman School of Medicine
| | - Rania Kanchi
- Division of Epidemiology, Department of Population Health, NYU Grossman School of Medicine
| | - Sarah Conderino
- Division of Epidemiology, Department of Population Health, NYU Grossman School of Medicine
| | - Natalie K Levy
- Division of General Internal Medicine and Clinical Innovation, Department of Medicine, NYU Grossman School of Medicine
| | | | - Saul Blecker
- Department of Population Health, NYU Grossman School of Medicine
| | - Nichola Davis
- Department of Population Health, NYU Grossman School of Medicine
| | - Jasmin Divers
- Department of Foundations of Medicine, NYU Grossman Long Island School of Medicine
| | - Catherine Rabin
- INSIGHT Clinical Research Network, Department of Population Health Sciences, Weill Cornell Medicine
| | - Mark Weiner
- INSIGHT Clinical Research Network, Department of Population Health Sciences, Weill Cornell Medicine
| | - Lorna Thorpe
- Division of Epidemiology, Department of Population Health, NYU Grossman School of Medicine
| | - John A. Dodson
- Division of Healthcare Delivery Science, Department of Population Health, NYU Grossman School of Medicine
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine
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Borrelli EP. Assessing the prevalence of Beers medication utilization in the Medicare Part D population in 2020. J Am Geriatr Soc 2024; 72:2800-2806. [PMID: 38709112 DOI: 10.1111/jgs.18943] [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: 02/04/2024] [Revised: 04/05/2024] [Accepted: 04/15/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Medication utilization has been increasing in the U.S. year-over-year for several decades. As older adults take more medications, there is a higher risk of them being exposed to drug-drug or drug-disease interactions. The American Geriatrics Society in 2019 updated their Beers Criteria for Potentially Inappropriate Medication (PIM) Use in Older Adults. The objective of this study was to assess the prevalence of utilization of medications included in the 2019 Beers Criteria. METHODS An analysis was conducted using the Medicare Part D Provider Utilization and Payment Data Public Use File for calendar-year 2020. Medications identified in the 2019 Beers Criteria were applied to the analysis. Two categories of medications were assessed: (1) "Avoid" and (2) "Use With Caution." RESULTS In 2020, 56 million prescriptions were dispensed to Medicare patients 65 years and older that are recommended to be avoided without exception (4.7% of all prescriptions) totaling $957 million in medication costs. The most utilized medication classes in this category were benzodiazepines (25,949,994 prescriptions), "Z-drugs" (6,204,909 prescriptions), long-acting sulfonylureas (5,306,577 prescriptions), 1st-generation antihistamines (5,049,289 prescriptions), and tricyclic antidepressants (4,190,062 prescriptions). Additionally, 135 million prescriptions were dispensed to Medicare beneficiaries 65 years and older for medications which the Beers Criteria states to use caution (11.3% of all prescriptions) exceeding $2.85 billion in medication costs. The most utilized medications for this category were diuretics (74,599,126 prescriptions), selective serotonin reuptake inhibitors (30,033,121 prescriptions), serotonin and norepinephrine reuptake inhibitors (11,858,968 prescriptions), tramadol (11,450,878 prescriptions), and mirtazapine (5,737,304 prescriptions). CONCLUSION Even with the existence of the AGS Beers Criteria for PIM Use in Older Adults and its continued updated versions, 16% of medications dispensed to Medicare Part D were potentially inappropriate. Future studies are needed to assess if this has led to worsened outcomes among older adults who utilized these PIM.
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Affiliation(s)
- Eric P Borrelli
- University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, California, USA
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Wahler RG, Olbrich CL, McCarthy LM. Preventing Prescribing Cascades: Ensuring Medication Safety for Older Adults. J Gerontol Nurs 2024; 50:7-11. [PMID: 39194326 DOI: 10.3928/00989134-20240809-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
PURPOSE To define prescribing cascades (PCs) and provide tools to identify PCs, including the most common PCs described in the literature. PCs lead to the accumulation of medications prescribed to older adults, disproportionately affecting those who often have additional health care complexities, such as multiple chronic conditions and multiple transitions of care. METHOD Review of recent research efforts to identify and describe evolving clinical practice interventions to detect and reverse PCs. RESULTS Clinicians can contribute to mitigating PCs through better understanding of how PCs occur in practice. Armed with this knowledge, clinical team members can implement proposed strategies and techniques to engage in primary and secondary prevention of PCs. CONCLUSION Ultimately, PCs are a culprit of preventable medication harm. Several tools are presented, which are initiated through maintaining a high index of suspicion for PCs in the evaluation of a new symptom presentation by older patients. [Journal of Gerontological Nursing, 50(9), 7-11.].
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Christoffersen T, Kornholt J, Riis T, Sonne DP, Klarskov N. Effect of Single-Dose Imipramine on Anal Sphincter Tone in Healthy Women: A Randomized, Placebo-Controlled Study Using Anal Acoustic Reflectometry. Int Urogynecol J 2024; 35:1873-1879. [PMID: 39167201 PMCID: PMC11420375 DOI: 10.1007/s00192-024-05890-5] [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: 03/14/2024] [Accepted: 07/14/2024] [Indexed: 08/23/2024]
Abstract
INTRODUCTION AND HYPOTHESIS Despite the high prevalence of fecal incontinence, existing treatment options may be inadequate. Drugs that enhance the tone of the anal sphincter complex could potentially be an effective pharmacological approach. This study investigated the effect of the tricyclic antidepressant imipramine on anal sphincter tone in healthy women, employing anal acoustic reflectometry as the evaluating method. METHODS In a double-blind, randomized, placebo-controlled crossover study, 16 healthy female volunteers were randomized to one of two treatment sequences. The participants attended two study visits separated by at least 7 days' washout. At each visit, they received a single dose of 50 mg imipramine or matching placebo, in alternating order. We assessed the anal opening pressure under the resting state and during voluntary squeezing of the pelvic floor. Measurements were performed pre-dose and 1 h after drug administration, corresponding to the estimated time of peak plasma concentration of imipramine. RESULTS All participants completed the study. In total, 44% of the participants reported at least one adverse effect, primarily anticholinergic. Compared with placebo, imipramine increased anal opening pressure by 15.2 cmH2O (95% confidence interval [CI] 2.0-28.2 cmH2O, p = 0.03) in the resting state and 15.1 (95% CI 4.2-26.0 cmH2O, p = 0.01) cmH2O during squeezing. CONCLUSIONS The findings indicate that imipramine increases anal sphincter tone in healthy women. However, further research is required to evaluate its clinical impact on individuals with fecal incontinence. This research also demonstrates the effectiveness of using anal acoustic reflectometry for assessing pharmacological effects on anal sphincter function.
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Affiliation(s)
- Thea Christoffersen
- Department of Clinical Pharmacology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2nd Floor, 2400, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Jonatan Kornholt
- Department of Clinical Pharmacology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2nd Floor, 2400, Copenhagen, Denmark
- Novo Nordisk A/S, Bagsvaerd, Denmark
| | - Troels Riis
- Department of Clinical Pharmacology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2nd Floor, 2400, Copenhagen, Denmark
| | - David P Sonne
- Department of Clinical Pharmacology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2nd Floor, 2400, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Niels Klarskov
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Gynecology and Obstetrics, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
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Micheal J, Sothilingam N, Schwartz NJ, Guver A, D'Adamo CR, Lipkin S, Demos J, Felton J, Wolf JH. Comparison of Post-Hemorrhoid Surgery Pain Profiles in Older and Younger Adults. J Surg Res 2024; 301:572-577. [PMID: 39059125 DOI: 10.1016/j.jss.2024.07.005] [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: 03/03/2024] [Revised: 05/31/2024] [Accepted: 07/01/2024] [Indexed: 07/28/2024]
Abstract
INTRODUCTION Older and younger adults are offered similar analgesic options after hemorrhoid surgery (HS), but the differences in pain between the two populations are unknown. This study aims to compare postoperative pain outcomes after HS in older and younger individuals. METHODS This is a retrospective analysis of electronic medical records of patients who underwent HS between 2018 and 2023. Patients were excluded if additional anorectal procedures were performed at the time of HS. Data related to pain-related outcomes were compiled: (1) need for narcotic prescription refills; (2) documentation of a pain-related phone call within 30 d; (3) urgent postoperative office visit before regular scheduled follow-up; and (4) pain-related postoperative emergency department visits. Associations between age and pain-related outcomes were tested using Fisher's exact test, chi-square test, and covariate adjusted logistic regression modeling. RESULTS There were a total of 249 patients, 60 older adults, and 189 younger adults. Compared to younger patients, older adults demonstrated a reduced frequency of pain-related phone calls (10.3 versus 32.1%, P < 0.01) and opioid refills (0 versus 14.4%, P < 0.01). After adjusting for confounders, older age remained inversely associated with pain-related postoperative phone calls (odds ratio = 0.25, 95% confidence interval = [0.1-0.6], P = 0.003). CONCLUSIONS Older adults had better pain outcomes after HS in comparison to younger patients. These findings suggest that the postoperative analgesic needs of older patients after HS are lower than those of younger patients. Decisions regarding opioid prescription in older adults recovering from HS should be tailored to avoid narcotic-related complications.
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Affiliation(s)
- Joseph Micheal
- Department of Colorectal Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland; Xavier University School of Medicine, Oranjestad, Aruba
| | - Nishanthan Sothilingam
- Department of Colorectal Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland; Saba University School of Medicine, Saba, Netherlands Antilles
| | - Nathaniel J Schwartz
- Department of Colorectal Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland; Touro College of Osteopathic Medicine, Harlem, New York
| | - Alperen Guver
- Department of Colorectal Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Christopher R D'Adamo
- Department of Colorectal Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland; Department of Epidemiology and Public Health, Department of Family and Community Medicine, University of Maryland, Baltimore, Maryland
| | - Sloane Lipkin
- Department of Colorectal Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jasmine Demos
- Department of Colorectal Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jessica Felton
- Department of Colorectal Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland; George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Joshua H Wolf
- Department of Colorectal Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland; George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.
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King EM, Tkachuk S, Tseng A. Aging on antiretrovirals: reviewing the need for pharmacologic data in elderly people with HIV. AIDS 2024; 38:1609-1616. [PMID: 38953894 PMCID: PMC11296272 DOI: 10.1097/qad.0000000000003973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 06/19/2024] [Accepted: 06/24/2024] [Indexed: 07/04/2024]
Affiliation(s)
- Elizabeth Marie King
- Women's Health Research Institute, British Columbia (BC) Women's Hospital, Vancouver
- Simon Fraser University, Faculty of Health Sciences, Burnaby
- Oak Tree Clinic, BC Women's Hospital
| | - Stacey Tkachuk
- Oak Tree Clinic, BC Women's Hospital
- Faculty of Pharmaceutical Sciences, UBC, Vancouver
| | - Alice Tseng
- Immunodeficiency Clinic, Toronto General Hospital
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
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Clark CM, Guan J, Patel AR, Stoll J, Wahler RG, Feuerstein S, Singh R, Jacobs DM. Association between potentially inappropriate medications prescription and health-related quality of life among US older adults. J Am Geriatr Soc 2024; 72:2807-2815. [PMID: 38725422 DOI: 10.1111/jgs.18957] [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: 09/07/2023] [Revised: 03/22/2024] [Accepted: 04/15/2024] [Indexed: 09/03/2024]
Abstract
BACKGROUND Potentially inappropriate medications (PIMs) are associated with worse health outcomes among older adults. Our objective was to examine the association between PIM prescription and health-related quality of life (HRQoL) among older adults in the United States using nationally representative data. METHODS This was a retrospective study utilizing 2011-2015 Medical Expenditure Panel Survey (MEPS) data. Community dwelling US adults aged 65 years or older were included. A qualified definition operationalized from the 2019 American Geriatrics Society Beers Criteria® was used to define exposure to PIMs during the study period. The Physical Component Summary (PCS) and Mental Component Summary (MCS) of the Medical Outcomes Study 12-Item Short Form Health Survey (SF-12) were used to measure HRQoL. Survey-weighted linear regression models were constructed to investigate the association between PIM exposure and participants' PCS and MCS scores. Analyses were stratified across three age cohorts (65-74, 75-85, and ≥85 years). RESULTS Unadjusted analysis showed poorer scores in the PIM exposed group for both PCS and MCS (all p < 0.001). PIM exposure was associated with poorer PCS scores across all age groups with those aged 65-74 years (adjusted regression coefficient = -1.60 [95% CI = -2.27, -0.93; p < 0.001]), those 75-84 years (adjusted regression coefficient: -1.49 [95% CI = -2.45, -0.53; p = 0.003]), and those 85 years and older (adjusted regression coefficient = -1.65 [95% CI = -3.03, -0.27; p = 0.02]). PIM exposure was also associated with poorer MCS scores in participants aged 65-74 years (adjusted regression coefficient = -0.69 [95% CI = -1.16, -0.22; p = 0.004]) and 85 years and older (adjusted regression coefficient = -2.01 [95% CI = -3.25, -0.78; p = 0.002]). CONCLUSIONS Our results suggest that patients' exposure to PIMs is associated with poorer HRQoL. Further work is needed to assess whether interventions to deprescribe PIMs may help to improve patients' HRQoL.
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Affiliation(s)
- Collin M Clark
- Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York, USA
| | - Jiajie Guan
- Department of Pharmacy, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Aman R Patel
- Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York, USA
| | - Jennifer Stoll
- Department of Family Medicine, Primary Care Research Institute, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Robert G Wahler
- Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York, USA
| | - Steven Feuerstein
- Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York, USA
| | - Ranjit Singh
- Department of Family Medicine, Primary Care Research Institute, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - David M Jacobs
- Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York, USA
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Sultana J, Aquilina G, Lagaa MB, Micallef N, Mifsud J. The outcomes of goal-oriented medication reviews for the elderly: current research and future directions. Expert Rev Clin Pharmacol 2024; 17:767-769. [PMID: 39225169 DOI: 10.1080/17512433.2024.2400248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Accepted: 08/30/2024] [Indexed: 09/04/2024]
Affiliation(s)
- Janet Sultana
- Department of Clinical Pharmacology and Therapeutics, University of Malta, Msida, Malta
- Exeter College of Medicine and Health, University of Exeter, Exeter, UK
| | - Graziella Aquilina
- Department of Clinical Pharmacology and Therapeutics, University of Malta, Msida, Malta
| | - Malak Bashir Lagaa
- Department of Clinical Pharmacology and Therapeutics, University of Malta, Msida, Malta
| | - Nicole Micallef
- Department of Clinical Pharmacology and Therapeutics, University of Malta, Msida, Malta
| | - Janet Mifsud
- Department of Clinical Pharmacology and Therapeutics, University of Malta, Msida, Malta
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Chung CS, Park SE, Hsiao JL, Lee KH. A Review of Hidradenitis Suppurativa in Special Populations: Considerations in Children, Pregnant and Breastfeeding Women, and the Elderly. Dermatol Ther (Heidelb) 2024; 14:2407-2425. [PMID: 39230800 PMCID: PMC11393272 DOI: 10.1007/s13555-024-01249-2] [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: 05/28/2024] [Accepted: 07/30/2024] [Indexed: 09/05/2024] Open
Abstract
Hidradenitis suppurativa (HS) is a chronic skin condition that significantly impacts patients' quality of life. HS is often challenging to treat. In this review, we discuss the unique characteristics of HS in four special populations: children, the elderly, pregnant individuals, and breastfeeding mothers. In children, diagnosis may be delayed due to atypical and early HS disease presentations. HS management plans must take into consideration the lack of rigorous efficacy and safety data of HS treatments in this population. However, it is important to weigh the risk of treatments against the risk of untreated HS and the morbidity and mortality risk that having HS confers. Pregnancy poses unique challenges for women with HS, with their condition possibly worsening during pregnancy and increased risk of fetal death. Management strategies during pregnancy must consider both maternal and fetal safety. Similarly, breastfeeding mothers require thoughtful medication selection to balance symptom management with infant safety. In the elderly, HS may present more severely and is often complicated by comorbidities. Treating HS in this population should safely accommodate patients' additional health conditions. Furthermore, this review highlights the overall paucity of primary literature addressing management in these populations, underscoring the need for further research to optimize HS care across all stages of life.
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Affiliation(s)
- Claire S Chung
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Sarah E Park
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Jennifer L Hsiao
- Department of Dermatology, Keck School of Medicine, University of Southern California, 1441 Eastlake Ave, Ezralow Tower, Suite 5301, Los Angeles, CA, 90033-9174, USA
| | - Katrina H Lee
- Department of Dermatology, Keck School of Medicine, University of Southern California, 1441 Eastlake Ave, Ezralow Tower, Suite 5301, Los Angeles, CA, 90033-9174, USA.
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Hammond E, Zhan-Moodie S, Sapkalova V, Rivera D, Agrawal R, Thomas J, Fox E, Lawson A. Establishing Geriatric Opiate Use Patterns in Trauma. Am Surg 2024; 90:2228-2231. [PMID: 38782463 DOI: 10.1177/00031348241256063] [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] [Indexed: 05/25/2024]
Abstract
Introduction: There is evidence that providers often overprescribe opiates in the postoperative period. Despite an ever-growing geriatric population, there is little research detailing current opiate usage in older patients after trauma. This population presents a unique set of challenges for pain management and prescription drug dependence due to sensitivity, a narrow therapeutic window, and high rates of pre-existing polypharmacy.Objective: Assess the use of narcotics in geriatric trauma patients with various injury patterns to establish a reference point for future intervention for reduction in narcotic dependence.Methods: We created a database of trauma patients' age ≥65 years admitted to a single level 1 trauma center in the Southeastern United States during the 2019 calendar year. Information gathered included patient factors, injury patterns, operative intervention, pain medications prescribed during hospitalization and at discharge, total and average daily morphine milligram equivalents (MME) inpatient and outpatient, and requests/prescriptions for narcotics at follow-up.Results: In 2019, there were 475 patients aged ≥65 admitted to our level 1 trauma center for acute traumatic injuries. 219 of those patients required operative intervention. Average total inpatient MME for this cohort was 169.0 with average daily MME of 22.89. The average total prescribed MME upon discharge was 79.27. There were 29 patients documented to request narcotic prescription refill at time of clinic follow-up, 27 of whom were prescribed a narcotic medication at follow-up.Conclusion: This dataset establishes a reference point for opiate use in geriatric trauma patients to facilitate further research for mitigation of risk in this population.
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Affiliation(s)
- Emily Hammond
- Department of Surgery, Medical College of Georgiaat Augusta University, Augusta, GA, USA
| | - Samantha Zhan-Moodie
- Department of Surgery, Medical College of Georgiaat Augusta University, Augusta, GA, USA
| | - Viktoriya Sapkalova
- Department of Surgery, Medical College of Georgiaat Augusta University, Augusta, GA, USA
| | - Daniel Rivera
- Department of Surgery, Medical College of Georgiaat Augusta University, Augusta, GA, USA
| | - Rishabh Agrawal
- Department of Surgery, Medical College of Georgiaat Augusta University, Augusta, GA, USA
| | - Jason Thomas
- Department of Surgery, Medical College of Georgiaat Augusta University, Augusta, GA, USA
| | - Elizabeth Fox
- Department of Surgery, Medical College of Georgiaat Augusta University, Augusta, GA, USA
| | - Andrew Lawson
- Department of Surgery, Medical College of Georgiaat Augusta University, Augusta, GA, USA
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Walsh DJ, O'Driscoll M, Horgan AM, Tabb E, Hannan M, Morris C, Sahm LJ. Hospitalisation and adverse drug events in a geriatric oncology setting: A systematic review of the literature. Res Social Adm Pharm 2024; 20:820-827. [PMID: 38705819 DOI: 10.1016/j.sapharm.2024.04.018] [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: 11/30/2023] [Revised: 04/05/2024] [Accepted: 04/29/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Geriatric Oncology is a specialty where a multidisciplinary approach can address the unmet needs of older adults with cancer. Older adults are at increased risk of adverse drug events (ADE) due to age-related changes in pharmacokinetics and pharmacodynamics, increasing treatment complexity, and medication burden. OBJECTIVES To review the literature to determine the incidence of unplanned hospitalisation due to ADE for all medications, both systemic anticancer therapy (SACT) and non-SACT medications. METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The search included the following databases: PubMed, CINAHL, and Embase. A manual search of Scopus was then performed. Study quality was assessed using the Cochrane Handbook for Systematic Reviews of Interventions, Mixed Methods Appraisal Tool (MMAT) and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. RESULTS Overall, three studies were included. One observational study reported 19 % of unplanned hospital admissions due to ADE in patients aged ≥70 years with cancer. The first retrospective study reported 24 % of unplanned hospital admissions are due to ADE in patients aged ≥70 years with cancer, and the second retrospective study reported 26 % of patients with metastatic melanoma treated with immune checkpoint inhibitors had an unplanned hospital admission due to an ADE. CONCLUSION There is a paucity of studies assessing unplanned hospitalisation due to ADE in older adults with cancer. Future studies are needed and should account for the reporting of potential ADE relative to supportive care, ancillary medications, and indeed chronic medications used to treat long-standing comorbidities.
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Affiliation(s)
- Darren J Walsh
- University Hospital Waterford, Waterford, Ireland; Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland.
| | - Michelle O'Driscoll
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland
| | | | - Eoin Tabb
- University Hospital Waterford, Waterford, Ireland
| | | | | | - Laura J Sahm
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland; Department of Pharmacy, Mercy University Hospital, Grenville Place, Cork, Ireland
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Wang J, Shen JY, Conwell Y, Nathan K, Moskow MS, Brasch JD, Yu F, Simmons SF, Mixon AS, Caprio TV. Implementing Essential Components of Deprescribing in Post-Acute Home Health Care. J Am Med Dir Assoc 2024; 25:105125. [PMID: 38972332 DOI: 10.1016/j.jamda.2024.105125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 05/28/2024] [Accepted: 05/28/2024] [Indexed: 07/09/2024]
Affiliation(s)
- Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, University of Rochester, School of Nursing, Rochester, NY
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, NY
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY
| | - Kobi Nathan
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, NY; Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY
| | - Marian S Moskow
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, NY
| | - Judith D Brasch
- Harriet Kitzman Center for Research Support, University of Rochester School of Nursing, Rochester, NY
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ
| | - Sandra F Simmons
- Department of Medicine, Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN; Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN; Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Amanda S Mixon
- Department of Medicine, Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN; Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN; Department of Medicine, Division of General Internal Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Thomas V Caprio
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, NY; University of Rochester - Home Care, University of Rochester Medical Center, Rochester, NY; Finger Lakes Geriatric Education Center, University of Rochester Medical Center, Rochester, NY
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Mertz A, Fair C, Pol J. Geriatric Pharmacotherapy Case Series: Clotting and Gender-Affirming Care. Sr Care Pharm 2024; 39:319-324. [PMID: 39180181 DOI: 10.4140/tcp.n.2024.319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2024]
Abstract
Background A transfeminine patient is a 79-year-old with past medical history significant for type 2 diabetes mellitus, hypertension, gender dysphoria, chronic kidney disease, dyslipidemia, total left hip replacement, and recent provoked deep venous thromboembolism (DVT). She was seen by a pharmacist in a primary care clinic after her discharge from a skilled nursing facility. The patient was experiencing symptoms of gender dysphoria after discontinuation of her estradiol in setting of her DVT. Assessment Her renal function was calculated to ensure she was on appropriate dosing of her medications. Because her DVT was provoked, providers determined she would require only 3 months of anticoagulation. Her laboratory test results showed a subtherapeutic estradiol level and her estradiol was restarted. Additionally, aspirin was being prescribed for primary prevention of atherosclerotic cardiovascular disease and was discontinued. Outcome She has significant improvement in her gender dysphoria symptoms with resuming her estradiol and now has a therapeutic estradiol level. She is tolerating her direct oral coagulant well and reports good quality of life. Conclusion When reviewing medications for patients it is important to take several factors into account, including dose, appropriate indication, and patient preference. Pharmacists play a key role, through collaboration with providers, in assessing these medication-specific factors. Estradiol was stopped in this patient because of her DVT, but given her DVT was provoked after a recent surgery, it was unlikely that estradiol was the cause of her clot. Weighing the risks and benefits for any patient is important when determining what medications are appropriate to continue. Additionally, calculating renal function appropriately in a gender-non-conforming patients ensures appropriate and safe dosing.
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Affiliation(s)
- Amanda Mertz
- 1 Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio
| | - Collin Fair
- 1 Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio
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Parodi López N, Svensson SA, Lönnbro J, Hoffmann M, Wallerstedt SM. Reliability and validity of the Swedish indicator 'Drugs that should be avoided in older people'-an appraisal of a set of potentially inappropriate medications. Eur J Clin Pharmacol 2024; 80:1285-1293. [PMID: 38743072 PMCID: PMC11303435 DOI: 10.1007/s00228-024-03700-x] [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: 03/22/2024] [Accepted: 05/05/2024] [Indexed: 05/16/2024]
Abstract
PURPOSE To analyse the reliability and validity of the Swedish indicator 'Drugs that should be avoided in older people'. METHODS From a previous study that included consecutive primary care patients ≥ 65 years of age, all patients ≥ 75 years of age were analysed. Two physicians independently screened their medication lists and medical records, applying the Swedish indicator which includes potentially inappropriate medications (PIMs): long-acting benzodiazepines, drugs with anticholinergic action, tramadol, propiomazine, codeine, and glibenclamide. The clinical relevance of identified PIMs was independently assessed. Thereafter, the physicians determined in consensus whether some medical action related to the drug treatment was medically justified and prioritised before the next regular visit. If so, the drug treatment was considered inadequate, and if not, adequate. RESULTS A total of 1,146 drugs were assessed in 149 patients (75‒99 years, 62% female, 0‒20 drugs per patient). In 29 (19%) patients, at least one physician identified ≥ 1 PIM according to the indicator at issue; 24 (16%) patients were concordantly identified with ≥ 1 such PIM (kappa: 0.89). Of 26 PIMs concordantly identified, the physicians concordantly assessed four as clinically relevant and 12 as not clinically relevant (kappa: 0.17). After the consensus discussion, six (4%) patients had ≥ 1 PIM according to the studied indicator that merited action. Using the area under the receiver operating characteristic (ROC) curve, the indicator did not outperform chance in identifying inadequate drug treatment: 0.56 (95% confidence interval: 0.46 to 0.66). CONCLUSION The Swedish indicator has strong reliability regarding PIM detection but does not validly reflect the adequacy of drug treatment.
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Affiliation(s)
- Naldy Parodi López
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Clinical Pharmacology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Staffan A Svensson
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Nötkärnan Bergsjön Health Centre, Gothenburg, Sweden
| | - Johan Lönnbro
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mikael Hoffmann
- NEPI Foundation - Swedish Network for Pharmacoepidemiology, Linköping University, Linköping, Sweden
| | - Susanna M Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- HTA-Centrum, Sahlgrenska University Hospital, Gothenburg, Sweden
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Hatano M, Sogawa R, Shin K, Esumi S, Ishikawa A, Mizumura R, Araki H, Yamada S. Comprehensive signal detection of delirium-associated medication using the Food and Drug Administration Adverse Event Reporting System. Gen Hosp Psychiatry 2024; 90:50-55. [PMID: 38941744 DOI: 10.1016/j.genhosppsych.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 06/20/2024] [Accepted: 06/20/2024] [Indexed: 06/30/2024]
Abstract
OBJECTIVE Several medications are associated with delirium; however, studies with adequate statistical power are limited, and it is difficult to determine the effects of the various concomitant medications used in clinical practice. Therefore, in this study, we aimed to comprehensively evaluate the safety signals of delirium-associated drugs using a spontaneous adverse event reporting system. METHOD The JAPIC AERS (Food and Drug Administration Adverse Event Reporting System pre-processed by the Japan Pharmaceutical Information Center) was used for the analysis in this pharmacovigilance study. The reporting odds ratio (ROR) for delirium was adjusted for using multivariate logistic regression analysis with sex, age, indication, and melatonin receptor agonist use, and 22 drug categories were targeted as covariates. RESULTS After excluding patients with missing information, 7,527,568 patients were included in the study. Delirium signals were detected even after adjusting for covariates in 17 drug categories, including benzodiazepines (adjusted ROR, 1.76; 95% confidence interval [CI], 1.64-1.89), opioids (adjusted ROR, 4.42; 95% CI, 4.21-4.64), and tricyclic antidepressants (adjusted ROR, 2.44; 95% CI, 2.20-2.71). CONCLUSIONS These findings suggest that many drug classes, such as benzodiazepines, are independent risk factors for delirium and strengthen the evidence of an association between delirium and medications.
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Affiliation(s)
- Masakazu Hatano
- Department of Pharmacotherapeutics and Informatics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan.
| | - Rintaro Sogawa
- Department of Pharmacy, Saga University Hospital, Nabeshima, Saga, Japan.
| | - Kenji Shin
- Department of Pharmacy, Iizuka Hospital, Fukuoka, Japan.
| | - Satoru Esumi
- The Faculty of Pharmaceutical Sciences, Kobe Gakuin University, Kobe, Japan.
| | - Akira Ishikawa
- Department of Pharmacy, Saitama Medical University Hospital, Japan.
| | - Ryosuke Mizumura
- Department of Pharmacy, Saitama Medical University Hospital, Japan.
| | - Haruna Araki
- Department of Pharmacotherapeutics and Informatics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan.
| | - Shigeki Yamada
- Department of Pharmacotherapeutics and Informatics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan.
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