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Chen LJ, Sha S, Brenner H, Schöttker B. Longitudinal associations of polypharmacy and frailty with major cardiovascular events and mortality among more than half a million middle-aged participants of the UK Biobank. Maturitas 2024; 185:107998. [PMID: 38678818 DOI: 10.1016/j.maturitas.2024.107998] [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: 09/25/2023] [Revised: 03/04/2024] [Accepted: 04/11/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Studies of the associations of polypharmacy and frailty with adverse health outcomes in middle-aged adults are limited. Furthermore, a potentially stronger association of polypharmacy with adverse health outcomes in frail than in non-frail adults is of interest. OBJECTIVE To evaluate associations of frailty (assessed using a frailty index) and polypharmacy (defined as taking five or more drugs) with major cardiovascular events, cancer incidence, all-cause, cardiovascular disease-specific, and cancer-specific mortality. METHODS Cox proportional hazards regression models were used to analyze 501,548 participants of the UK Biobank cohort study aged 40-69 years who were followed up for an average of 12 years. RESULTS The prevalence of pre-frailty and frailty were 43.2 % and 2.3 %, respectively, and that of polypharmacy was 18.3 %. Although strongly associated with each other, frailty and polypharmacy were independently, statistically significantly associated with major cardiovascular events, cardiovascular disease-specific, and all-cause mortality. In addition, the hazard ratios of polypharmacy were stronger among (pre-)frail than non-frail study participants. No profound associations with cancer incidence and cancer mortality were observed. No sex and age differences were observed. CONCLUSIONS This large cohort study showed that polypharmacy and frailty are independent risk factors for major cardiovascular events, cardiovascular disease-specific and all-cause mortality in both middle-aged (40-64 years) and older people (≥ 65 years). In addition, the hazard ratios of polypharmacy were stronger among (pre-)frail than non-frail study participants. This underlines the need to avoid polypharmacy as far as possible not only in older but also in middle-aged subjects (40-64 years), especially if they are pre-frail or frail.
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Affiliation(s)
- Li-Ju Chen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 581, 69120 Heidelberg, Germany
| | - Sha Sha
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 581, 69120 Heidelberg, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 581, 69120 Heidelberg, Germany; Network Aging Research, Heidelberg University, Bergheimer Straße 20, 69115 Heidelberg, Germany; Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Im Neuenheimer Feld 581, 69120 Heidelberg, Germany; German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Ben Schöttker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 581, 69120 Heidelberg, Germany; Network Aging Research, Heidelberg University, Bergheimer Straße 20, 69115 Heidelberg, Germany.
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Rawle MJ, Lau WCY, Gonzalez-Izquierdo A, Patalay P, Richards M, Davis D. Associations Between Midlife Anticholinergic Medication Use and Subsequent Cognitive Decline: A British Birth Cohort Study. Drugs Aging 2024; 41:543-554. [PMID: 38740716 DOI: 10.1007/s40266-024-01116-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Anticholinergic medication use is associated with cognitive decline and incident dementia. Our study, a prospective birth cohort analysis, aimed to determine if repeated exposure to anticholinergic medications was associated with greater decline, and whether decline was reversed with medication reduction. METHODS From the Medical Research Council (MRC) National Survey of Health and Development, a British birth cohort with all participants born in a single week of March 1946, we quantified anticholinergic exposure between ages 53 and 69 years using the Anticholinergic Cognitive Burden Scale (ACBS). We used multinomial regression to estimate associations with global cognition, quantified by the Addenbrooke's Cognitive Examination, 3rd Edition (ACE-III). Longitudinal associations between ACBS and cognitive test results (Verbal memory quantified by the Word Learning Test [WLT], and processing speed quantified by the Timed Letter Search Task [TLST]) at three time points (age 53, 60-64 and 69) were assessed using mixed and fixed effects linear regression models. Analyses were adjusted for sex, childhood cognition, education, chronic disease count and severity, and mental health symptoms. RESULTS Anticholinergic exposure was associated cross-sectionally with lower ACE-III scores at age 69, with the greatest effects in those with high exposure at ages 60-64 (mean difference - 2.34, 95% confidence interval [CI] - 3.51 to - 1.17). Longitudinally, both mild-moderate and high ACBS scores were linked to lower WLT scores, again with high exposure showing larger effects (mean difference with contemporaneous exposure - 0.90, 95% CI - 1.63 to - 0.17; mean difference with lagged exposure - 1.53, 95% CI - 2.43 to - 0.64). Associations remained in fixed effects models (mean difference with contemporaneous exposure -1.78, 95% CI -2.85 to - 0.71; mean difference with lagged exposure - 2.23, 95% CI - 3.33 to - 1.13). Associations with TLST were noted only in isolated contemporaneous exposure (mean difference - 13.14, 95% CI - 19.04 to - 7.23; p < 0.01). CONCLUSIONS Anticholinergic exposure throughout mid and later life was associated with lower cognitive function. Reduced processing speed was associated only with contemporaneous anticholinergic medication use, and not historical use. Associations with lower verbal recall were evident with both historical and contemporaneous use of anticholinergic medication, and associations with historical use persisted in individuals even when their anticholinergic medication use decreased over the course of the study.
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Affiliation(s)
- Mark J Rawle
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK.
- Academic Centre for Healthy Ageing (ACHA) @ Whipps Cross University Hospital, Barts Health NHS Trust, Whipps Cross Road, London, E11 1NR, UK.
| | - Wallis C Y Lau
- Research Department of Practice and Policy, School of Pharmacy, UCL, London, UK
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Pak Shek Kok, Hong Kong
| | - Arturo Gonzalez-Izquierdo
- Institute of Health Informatics and Health Data Research UK, UCL, London, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | | | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
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Alhalaseh L, Makahleh H, Al-Saleem B, Al-Omran F, Schoenmakers B. Functional Status in Relation to Common Geriatric Syndromes and Sociodemographic Variables - A Step Forward Towards Healthy Aging. Clin Interv Aging 2024; 19:901-910. [PMID: 38779378 PMCID: PMC11110820 DOI: 10.2147/cia.s462347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 05/04/2024] [Indexed: 05/25/2024] Open
Abstract
Purpose Geriatric syndromes (GS) are prevalent in the older population, with an impact on morbidity and disability. This study aimed to investigate the prevalence of functional dependence and ten GS in community older adults and to examine the different associations between these syndromes and sociodemographic variables and their impact on functional dependence. Patients and Methods A cross-sectional study of 342 outpatients seen at the geriatric clinic in the period 2015-2023. Results The mean age was 75±7.4. One-third had functional dependence and 96.2% had at least one GS. The mean number of GS was 3.11±1.74, ranging from 2.56±1.67 in the 60s to 3.55±1.70 in octogenarians. The most common GS found were polypharmacy (79.5%), musculoskeletal pain (49.7%), and Major Neurocognitive Disorder (MND) (32.7%). Polypharmacy was significantly associated with female sex and chronic pain, whereas sensory impairment was associated with male sex. MND, dizziness, and urinary incontinence were the only GS that significantly predicted functional dependence and were typically associated with increasing age. Conclusion Functional dependence increases as individuals age, paralleled by increases in MND, urinary incontinence, dizziness, sensory impairment, and constipation. Notably, only MND, incontinence, depression, and dizziness were significant predictors of functional dependence. Consequently, it is imperative to screen older adults presenting with these syndromes for early signs of functional decline to optimize their function and avert subsequent dependence, morbidity, and mortality.
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Affiliation(s)
- Lana Alhalaseh
- Department of Family and Community Medicine, School of Medicine, The University of Jordan, Amman, Jordan
| | - Hala Makahleh
- Department of Family and Community Medicine, School of Medicine, The University of Jordan, Amman, Jordan
| | - Bashayer Al-Saleem
- Department of Family and Community Medicine, School of Medicine, The University of Jordan, Amman, Jordan
| | - Farah Al-Omran
- Department of Family and Community Medicine, School of Medicine, The University of Jordan, Amman, Jordan
| | - Birgitte Schoenmakers
- Department of Public Health and Primary Care, Katholieke Universiteit Leuven, Leuven, Belgium
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Mascarelo A, Alves ALS, Hahn SR, Doring M, Portella MR. Incidence and risk factors for polypharmacy among elderly people assisted by primary health care in Brazil. BMC Geriatr 2023; 23:470. [PMID: 37542225 PMCID: PMC10403929 DOI: 10.1186/s12877-023-04195-4] [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: 10/20/2022] [Accepted: 07/21/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND Polypharmacy is recognized as a global public health problem and one of the greatest challenges related to the aging population. Few studies have investigated the incidence and risk factors for polypharmacy among elderly individuals. These studies provided important information on the issue but were developed in high-income countries. This study investigates the incidence and risk factors for polypharmacy among elderly people assisted by primary health care over a period of 11 years. METHODS This was a census-based prospective longitudinal study that included people aged 60 years or older living in a small municipality in the state of Rio Grande do Sul, Brazil. The baseline occurred in 2010 and the second wave of the study occurred in 2021. The study population consisted of elderly individuals who did not use polypharmacy at baseline and were reinterviewed in 2021 (N = 128). Data collection in the first and second waves was performed through a household survey using a structured questionnaire. The dependent variable was polypharmacy, defined as the simultaneous use of 5 or more drugs. The independent variables included sociodemographic, health and functionality factors. For multivariate analyses, Poisson regression with robust variance was used, estimating the relative risk and 95% confidence intervals. RESULTS The incidence of polypharmacy was 46.1% in the 11-year period. The highest number of health problems was a risk factor for polypharmacy (RR = 1.177; 95% CI 1.093-1.267). CONCLUSIONS The incidence of polypharmacy among elderly people assisted in primary health care in Brazil is high. The number of diseases is a risk factor for polypharmacy. These results have implications for future primary health care practices and may support the development of policies, actions and services aimed at reducing polypharmacy and promoting the rational use of drugs in the population at higher risk.
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Affiliation(s)
- Andréia Mascarelo
- Postgraduate Program in Human Aging, University of Passo Fundo/UPF, BR 285 Km 292,7, Campus I, Bairro São José, Passo Fundo, RS, CEP 99052-900, Brazil.
| | - Ana Luisa Sant'Anna Alves
- Postgraduate Program in Human Aging, University of Passo Fundo/UPF, BR 285 Km 292,7, Campus I, Bairro São José, Passo Fundo, RS, CEP 99052-900, Brazil
| | - Siomara Regina Hahn
- Postgraduate Program in Human Aging, University of Passo Fundo/UPF, BR 285 Km 292,7, Campus I, Bairro São José, Passo Fundo, RS, CEP 99052-900, Brazil
| | - Marlene Doring
- Postgraduate Program in Human Aging, University of Passo Fundo/UPF, BR 285 Km 292,7, Campus I, Bairro São José, Passo Fundo, RS, CEP 99052-900, Brazil
| | - Marilene Rodrigues Portella
- Postgraduate Program in Human Aging, University of Passo Fundo/UPF, BR 285 Km 292,7, Campus I, Bairro São José, Passo Fundo, RS, CEP 99052-900, Brazil
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Wong HL, Weaver C, Marsh L, Mon KO, Dapito JM, Amin FR, Chauhan R, Mandal AKJ, Missouris CG. Polypharmacy and cumulative anticholinergic burden in older adults hospitalized with fall. Aging Med (Milton) 2023. [DOI: 10.1002/agm2.12250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Affiliation(s)
- Ho Lun Wong
- Wexham Park Hospital, Frimley Health NHS Trust Slough UK
| | - Claire Weaver
- Wexham Park Hospital, Frimley Health NHS Trust Slough UK
| | - Lauren Marsh
- Wexham Park Hospital, Frimley Health NHS Trust Slough UK
| | - Khine Oo Mon
- Wexham Park Hospital, Frimley Health NHS Trust Slough UK
| | - John M. Dapito
- Wexham Park Hospital, Frimley Health NHS Trust Slough UK
| | - Fouad R. Amin
- Wexham Park Hospital, Frimley Health NHS Trust Slough UK
- Al Azhar University Cairo Egypt
| | - Rahul Chauhan
- Wexham Park Hospital, Frimley Health NHS Trust Slough UK
| | | | - Constantinos G. Missouris
- Wexham Park Hospital, Frimley Health NHS Trust Slough UK
- University of Nicosia Medical School Nicosia Cyprus
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Iqbal A, Richardson C, Iqbal Z, O’Keefe H, Hanratty B, Matthews FE, Todd A. Are there socioeconomic inequalities in polypharmacy among older people? A systematic review and meta-analysis. BMC Geriatr 2023; 23:149. [PMID: 36934249 PMCID: PMC10024437 DOI: 10.1186/s12877-023-03835-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 02/20/2023] [Indexed: 03/20/2023] Open
Abstract
BACKGROUND Socioeconomic status (SES) may influence prescribing, concordance and adherence to medication regimens. This review set out to investigate the association between polypharmacy and an individual's socioeconomic status. METHODS A systematic review and meta-analyses of observational studies was conducted across four databases. Older people (≥ 55 years) from any healthcare setting and residing location were included. The search was conducted across four databases: Medline (OVID), Web of Science, Embase (OVID) and CINAHL. Observational studies from 1990 that reported polypharmacy according to SES were included. A random-effects model was undertaken comparing those with polypharmacy (≥ 5 medication usage) with no polypharmacy. Unadjusted odds ratios (ORs), 95% confidence intervals (CIs) and standard errors (SE) were calculated for each study. RESULTS Fifty-four articles from 13,412 hits screened met the inclusion criteria. The measure of SES used were education (50 studies), income (18 studies), wealth (6 studies), occupation (4 studies), employment (7 studies), social class (5 studies), SES categories (2 studies) and deprivation (1 study). Thirteen studies were excluded from the meta-analysis. Lower SES was associated with higher polypharmacy usage: individuals of lower educational backgrounds displayed 21% higher odds to be in receipt of polypharmacy when compared to those of higher education backgrounds. Similar findings were shown for occupation, income, social class, and socioeconomic categories. CONCLUSIONS There are socioeconomic inequalities in polypharmacy among older people, with people of lower SES significantly having higher odds of polypharmacy. Future work could examine the reasons for these inequalities and explore the interplay between polypharmacy and multimorbidity.
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Affiliation(s)
- Anum Iqbal
- grid.1006.70000 0001 0462 7212School of Pharmacy, Population Health Sciences Institute, Newcastle University, King George VI Building, King’s Road, Newcastle Upon Tyne, NE1 7RU England
| | - Charlotte Richardson
- grid.1006.70000 0001 0462 7212School of Pharmacy, Newcastle University, Newcastle Upon Tyne, England
| | - Zain Iqbal
- grid.419481.10000 0001 1515 9979Novartis International, Basel, Switzerland
| | - Hannah O’Keefe
- grid.1006.70000 0001 0462 7212Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, England
| | - Barbara Hanratty
- grid.1006.70000 0001 0462 7212Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, England
| | - Fiona E. Matthews
- grid.1006.70000 0001 0462 7212Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, England
| | - Adam Todd
- grid.1006.70000 0001 0462 7212School of Pharmacy, Newcastle University, Newcastle Upon Tyne, England
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Doheny M, Schön P, Orsini N, Fastbom J, Burström B, Agerholm J. Socio-demographic differences in polypharmacy and potentially inappropriate drug use among older people with different care needs and in care settings in Stockholm, Sweden. Scand J Public Health 2023; 51:11-20. [PMID: 34190622 PMCID: PMC9903244 DOI: 10.1177/14034948211018384] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIMS Polypharmacy and potentially inappropriate medications (PIM) are risk factors for negative health outcomes among older people. This study aimed to investigate socio-demographic differences in polypharmacy and PIM use among older people with different care needs in a standard versus an integrated care setting. METHODS Population-based register data on residents aged ⩾65 years in Stockholm County based on socio-demographic background and social care use in 2014 was linked to prescription drug use in 2015. A logistic regression analysis was used to estimate socio-demographic differences in polypharmacy and PIM, adjusting for education, age group, sex, country of birth, living alone, morbidity and dementia by care setting based on area and by care need (i.e. independent, home help or institutionalised). RESULTS The prevalence of polypharmacy and PIM was greater among home-help users (60.4% and 11.5% respectively) and institutional residents (74.4% and 11.9%, respectively). However, there were greater socio-demographic differences among the independent, with those with lower education, older age and females having higher odds of polypharmacy and PIM. Morbidity was a driver of polypharmacy (odds ratio (OR)=1.19, confidence interval (CI) 1.16-1.22) among home-help users. Dementia diagnosis was associated with reduced odds of polypharmacy and PIM among those in institutions (OR=0.78, CI 0.71-0.87 and OR 0.52, CI 0.45-0.59, respectively) and of PIM among home-help users (OR=0.53, 95% CI 0.42-0.67). CONCLUSIONS Polypharmacy and PIM were associated with care needs, most prevalent among home-help users and institutional residents, but socio-demographic differences were most prominent among those living independently, suggesting that municipal care might reduce differences between socio-demographic groups. Care setting had little effect on inappropriate drug use, indicating that national guidelines are followed.
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Affiliation(s)
- Megan Doheny
- Department of Global Public Health, Karolinska Institutet, Sweden,Megan Doheny, Department of Global Public Health, Karolinska Institutet, Widerströmska plan 3, Stockholm, 171 71, Sweden. E-mail:
| | - Pär Schön
- Aging Research Center, Karolinska Institutet – Stockholm University, Sweden
| | - Nicola Orsini
- Department of Global Public Health, Karolinska Institutet, Sweden
| | - Johan Fastbom
- Aging Research Center, Karolinska Institutet – Stockholm University, Sweden
| | - Bo Burström
- Department of Global Public Health, Karolinska Institutet, Sweden,Center for Epidemiology and Community Medicine, Stockholm County Council, Sweden
| | - Janne Agerholm
- Aging Research Center, Karolinska Institutet – Stockholm University, Sweden
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Okui T, Nakashima N. Regional difference in multi-psychotropic drug prescription in Japan and its associated factors: an ecological study using national health insurance claims data. RESEARCH IN HEALTH SERVICES & REGIONS 2023; 2:1. [PMID: 39177732 PMCID: PMC11281765 DOI: 10.1007/s43999-022-00018-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 12/21/2022] [Indexed: 08/24/2024]
Abstract
BACKGROUND In Japan, regulations preventing the prescriptions of various types of psychotropic drugs have become stricter in recent years. However, the areas where multi-psychotropic drug prescriptions are common and the geographic factors that contribute to the regional difference, have not been studied. In this study, we used data from all claims in Japan to examine regional differences in the prescription for multi-psychotropic drugs using an ecological study. METHODS The National Database of Health Insurance Claims and Specific Health Checkups of Japan Open data in 2019 were used. The outcome was the number of prescriptions for four or more different types of anxiolytics and hypnotics as well as for three or more of the same kind of psychotropic drugs (any one of anxiolytics, hypnotics, antipsychotics, antidepressants) for outpatients in each area. Among the 335 secondary medical areas in Japan, the data on 331 areas were used in the analysis. The standardized claim ratio (SCR), an indicator of the number of this multi-psychotropic drug prescription, correcting for regional differences in distribution of population by age and sex, was calculated for each of the secondary medical areas. The spatial cluster detection technique was used to locate a cluster of high-SCR areas. Furthermore, factors associated with regional differences in the SCRs were examined by a spatial statistics model. RESULTS North Japanese regions tend to have high SCRs, and 13 areas in Hokkaido were identified as the most likely cluster (cluster with the highest likelihood ratio) for multi-psychotropic drug prescription. Furthermore, a spatial regression analysis revealed that the proportion of people with lower educational levels, the total number of prescriptions per capita, and the number of physicians working in psychiatric departments per capita were statistically positively associated with the SCR for the prescription of multiple psychotropic drugs. CONCLUSIONS It was suggested that socioeconomic and medical characteristics of areas are related to the regional variation in the multi-psychotropic drug prescriptions, however, further research using individual-level data is required to confirm these results.
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Affiliation(s)
- Tasuku Okui
- Medical Information Center, Kyushu University Hospital, Maidashi3-1-1 Higashi-Ku, Fukuoka City Fukuoka Prefecture, 812-8582, Japan.
| | - Naoki Nakashima
- Medical Information Center, Kyushu University Hospital, Maidashi3-1-1 Higashi-Ku, Fukuoka City Fukuoka Prefecture, 812-8582, Japan
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Cho HJ, Chae J, Yoon S, Kim D. Factors related to polypharmacy and hyper-polypharmacy for the elderly: A nationwide cohort study using National Health Insurance data in South Korea. Clin Transl Sci 2022; 16:193-205. [PMID: 36401587 PMCID: PMC9926077 DOI: 10.1111/cts.13438] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 09/27/2022] [Accepted: 09/27/2022] [Indexed: 11/21/2022] Open
Abstract
Polypharmacy may cause adverse health outcomes in the elderly. This study examined the prevalence of continuous polypharmacy and hyper-polypharmacy, factors associated with polypharmacy, and the most frequently prescribed medications among older adults in South Korea. This was a retrospective observational study using National Health Insurance claims data. In total, 7,358,953 Korean elderly patients aged 65 years and older were included. Continuous polypharmacy and hyper-polypharmacy were defined as the use of ≥5 and ≥10 medications, respectively, for both ≥90 days and ≥180 days within 1 year. A multivariate logistic regression analysis was conducted with adjustment for general characteristics (sex, age, insurance type), comorbidities (12 diseases, number of comorbidities, and Elixhauser Comorbidity Index [ECI] classification), and healthcare service utilization. Among 7.36 million elderly patients, 47.8% and 36.9% had polypharmacy for ≥90 and ≥180 days, and 11.9% and 7.1% of patients exhibited hyper-polypharmacy for ≥90 and ≥180 days, respectively. Male sex, older age, insurance, comorbidities (cardio-cerebrovascular disease, diabetes mellitus, depressive disorder, dementia, an ECI score of ≥3), and healthcare service utilization were associated with an increased probability of polypharmacy. The therapeutic class with the most prescriptions was drugs for acid-related disorders (ATC A02). The number of outpatient visit days more strongly influenced polypharmacy than hospitalizations and ED visits. This study provides health policymakers with important evidence about the critical need to reduce polypharmacy among older adults.
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Affiliation(s)
- Ho Jin Cho
- Department of ResearchHealth Insurance Review and Assessment ServiceWonjuSouth Korea
| | - Jungmi Chae
- Department of ResearchHealth Insurance Review and Assessment ServiceWonjuSouth Korea
| | - Sang‐Heon Yoon
- Department of ResearchHealth Insurance Review and Assessment ServiceWonjuSouth Korea
| | - Dong‐Sook Kim
- Department of ResearchHealth Insurance Review and Assessment ServiceWonjuSouth Korea
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10
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Mohsenzadeh P, Ardekani A, Poustchi H, Mohammadi Z, Abdipour Mehrian SR, Bazrafshan Drissi H, Rahimian Z, Taherifard E, Nabavizadeh A, Kamalipour A, Mesgarpour B, Malekzadeh F, Molavi Vardanjani H. Population-based pattern of medication use and prevalence of polypharmacy among patients with cardiovascular diseases: results of the Pars cohort study from Iran. BMC Cardiovasc Disord 2022; 22:435. [PMID: 36203125 PMCID: PMC9536013 DOI: 10.1186/s12872-022-02872-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/26/2022] [Indexed: 11/10/2022] Open
Abstract
Background Polypharmacy in patients with cardiovascular diseases (CVDs) has been linked to several adverse outcomes. This study aimed to investigate the pattern of medication use and prevalence of polypharmacy among CVDs patients in Iran.
Method We used the baseline data of the Pars cohort study (PCS). The participants were asked to bring their medication bags; then, the medications were classified using the Anatomical Therapeutic Chemical classification. Polypharmacy was defined as using five or more medications concurrently. Poisson regression modeling was applied. The adjusted prevalence ratios (PR) and its 95% confidence interval (CI) were estimated. Results Totally, 9262 participants were enrolled in the PCS, of whom 961 had CVDs. The prevalence of polypharmacy in participants with and without CVDs was 38.9% and 7.1%, respectively. The highest prevalence of polypharmacy (51.5%) was among obese patients. Abnormal waist-hip ratio (PR: 2.79; 95% CI 1.57–4.94), high socioeconomic status (PR: 1.65; 95% CI 1.07–2.54), tobacco-smoking (PR: 1.35; 95% CI 1.00–1.81), patients with more than three co-morbidities (PR: 1.41; 95% CI 1.30–1.53), high physical activity (PR: 0.66; 95% CI 0.45–0.95), use of opiate ever (PR: 0.46; 95% CI 0.26–0.82), and healthy overweight subjects (PR: 0.22; 95% CI 0.12–0.39) were associated with polypharmacy. Cardiovascular drugs (76.1%), drugs acting on blood and blood-forming organs (50.4%), and alimentary tract and metabolism drugs (33.9%) were the most frequently used drugs. Agents acting on the renin-angiotensin system were the mostly used cardiovascular system drugs among men and those above 60 years old, while beta-blocking agents were mostly prevalent among cardiovascular system drugs in women with CVDs. Conclusion Given the high prevalence of polypharmacy among CVDs patients, and subsequent complications, programs to educate both physicians and patients to prevent this issue is crucial.
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Affiliation(s)
- Pooran Mohsenzadeh
- MPH Department, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Ardekani
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hossein Poustchi
- Liver and Pancreatobiliary Diseases Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Mohammadi
- Liver and Pancreatobiliary Diseases Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Reza Abdipour Mehrian
- MPH Department, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.,Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamed Bazrafshan Drissi
- Department of Cardiology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Rahimian
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Erfan Taherifard
- MPH Department, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Nabavizadeh
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Kamalipour
- Department of Ophthalmology, Hamilton Glaucoma Center, Shiley Eye Institute, University of California, San Diego, CA, USA
| | - Bita Mesgarpour
- Vice Chancellery for Research and Technology, National Institute for Medical Research and Development (NIMAD), Tehran, Iran
| | - Fatemeh Malekzadeh
- Digestive Diseases Research Center, Digestive Diseases Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Molavi Vardanjani
- MPH Department, School of Medicine, Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
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11
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Rubin LH, Neijna AG, Shi Q, Hoover DR, Tamraz B, Anastos K, Edmonds A, Fischl MA, Gustafson D, Maki PM, Merenstein D, Sheth AN, Springer G, Vance D, Weber KM, Sharma A. Degree of Polypharmacy and Cognitive Function in Older Women with HIV. AIDS Res Hum Retroviruses 2022; 38:571-579. [PMID: 35357949 PMCID: PMC9297323 DOI: 10.1089/aid.2021.0231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
The number of people with HIV (PWH) experiencing age-associated comorbidities including those treated with medications and cognitive impairment is increasing. We examined associations between polypharmacy and cognition in older women with HIV (WWH) given their vulnerability to this comorbidity. Cross-sectional analysis capitalizing on Women's Interagency HIV Study data collected between 2014 and 2017. WWH meeting the following criteria were analyzed: age ≥50 years; availability of self-reported non-antiretroviral therapy (ART) medications data; and neuropsychological data. The number of non-ART medications used regularly in the prior 6 months was summed. Polypharmacy was categorized as none/low (0-4), moderate (5-9), or severe (≥10). Multivariable linear regression analyses examined polypharmacy-cognition (T-score) associations in the total sample and among virally suppressed (VS; < 20 copies/mL)-WWH after covariate adjustment for enrollment site, income, depressive symptoms, substance use (smoking, heavy alcohol, marijuana, crack, cocaine, and/or heroin), the Veterans Aging Cohort Study index (indicators of HIV disease and organ system function, hepatitis C virus serostatus), ART use, nadir CD4 count, and specific ART drugs (efavirenz, integrase inhibitors). We included 637 women (median age = 55 years; 72% Black). Ninety-four percent reported ART use in the past 6 months and 75% had HIV RNA <20 copies/mL. Comorbidity prevalence was high (61% hypertension; 26% diabetes). Moderate and severe polypharmacy in WWH were 34% and 24%. In WWH, severe polypharmacy was associated with poorer executive function (p = .007) and processing speed (p = .01). The same pattern of findings remained among VS-WWH. Moderate polypharmacy was not associated with cognition. Moderate and severe polypharmacy were common and associated with poorer executive function and processing speed in WWH. Severe polypharmacy may be a major contributor to the persistence of domain-specific cognitive complications in older WWH above and beyond the conditions that these medications are used to treat.
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Affiliation(s)
- Leah H. Rubin
- Department of Neurology and Baltimore, Maryland, USA
- Department of Psychiatry and Behavioral Sciences Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ava G. Neijna
- Department of Neurology and Baltimore, Maryland, USA
| | - Qiuhu Shi
- New York Medical College, Valhalla, New York, USA
| | | | - Bani Tamraz
- Department of Clinical Pharmacy, University of California San Francisco School of Pharmacy, San Francisco, California, USA
| | | | - Andrew Edmonds
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Deborah Gustafson
- Department of Neurology, SUNY-Downstate Medical Center, Brooklyn, New York, USA
| | - Pauline M. Maki
- Department of Psychology and Psychiatry, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Daniel Merenstein
- Department of Family Medicine, Georgetown University Medical Center, Washington, District of Columbia, USA
| | | | - Gayle Springer
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - David Vance
- University of Alabama at Birmingham School of Nursing, Birmingham, Alabama, USA
| | - Kathleen M. Weber
- Cook County Health & Hospital System/Hektoen Institute of Medicine, Chicago, Illinois, USA
| | - Anjali Sharma
- Albert Einstein College of Medicine, Bronx, New York, USA
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12
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Downing J, Taylor R, Mountain R, Barr B, Daras K, Comerford T, Marson AG, Pirmohamed M, Dondelinger F, Alfirevic A. Socioeconomic and health factors related to polypharmacy and medication management: analysis of a Household Health Survey in North West Coast England. BMJ Open 2022; 12:e054584. [PMID: 35613765 PMCID: PMC9131085 DOI: 10.1136/bmjopen-2021-054584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To examine the socioeconomic and demographic drivers associated with polypharmacy (5-9 medicines), extreme polypharmacy (9-20 medicines) and increased medication count. DESIGN, SETTING AND PARTICIPANTS A total of 5509 participants, from two waves of the English North West Coast, Household Health Survey were analysed OUTCOME MEASURES: Logistic regression modelling was used to find associations with polypharmacy and extreme polypharmacy. A negative binomial regression identified associations with increased medication count. Descriptive statistics explored associations with medication management. RESULTS Age and number of health conditions account for the greatest odds of polypharmacy. ORs (95% CI) were greatest for those aged 65+ (3.87, 2.45 to 6.13) and for those with ≥5 health conditions (10.87, 5.94 to 19.88). Smaller odds were seen, for example, in those prescribed cardiovascular medications (3.08, 2.36 to 4.03), or reporting >3 emergency attendances (1.97, 1.23 to 3.17). Extreme polypharmacy was associated with living in a deprived neighbourhood (1.54, 1.06 to 2.26). The greatest risk of increased medication count was associated with age, number of health conditions and use of primary care services. Relative risks (95% CI) were greatest for those aged 65+ (2.51, 2.23 to 2.82), those with ≥5 conditions (10.26, 8.86 to 11.88) or those reporting >18 primary care visits (2.53, 2.18 to 2.93). Smaller risks were seen in, for example, respondents with higher levels of income deprivation (1.35, 1.03 to 1.77). Polypharmic respondents were more likely to report medication management difficulties associated with taking more than one medicine at a time (p<0.001). Furthermore, individuals reporting a mental health condition, were significantly more likely to consistently report difficulties managing their medication (p<0.001). CONCLUSION Age and number of health conditions are most associated with polypharmacy. Thus, delaying or preventing the onset of long-term conditions may help to reduce polypharmacy. Interventions to reduce income inequalities and health inequalities generally could support a reduction in polypharmacy, however, more research is needed in this area. Furthermore, increased prevention and support, particularly with medication management, for those with mental health conditions may reduce adverse medication effects.
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Affiliation(s)
- Jennifer Downing
- Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Rebecca Taylor
- Lancaster Medical School, Lancaster University, Lancaster, UK
| | | | - Ben Barr
- Public Health and Policy, University of Liverpool, Liverpool, UK
| | | | - Terence Comerford
- National Institute for Health and Care Research, Applied Research Collaboration North West Coast (NIHR ARC NWC), University of Liverpool, Liverpool, UK
| | | | - Munir Pirmohamed
- Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | | | - Ana Alfirevic
- Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
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13
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Aljeaidi MS, Haaksma ML, Tan ECK. Polypharmacy and trajectories of health-related quality of life in older adults: an Australian cohort study. Qual Life Res 2022; 31:2663-2671. [PMID: 35476171 PMCID: PMC9356923 DOI: 10.1007/s11136-022-03136-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2022] [Indexed: 11/30/2022]
Abstract
Background Health-related quality of life (HRQoL) is an important outcome measure when considering medical treatment; however, the impact of polypharmacy on trajectories of HRQoL over time is unknown. This study aimed to investigate the association between polypharmacy status and trajectories of HRQoL in older adults. Methods A longitudinal cohort study of 2181 community-dwelling adults, 65 years and older, who participated in the 2013 to 2017 waves of the Household Income and Labour Dynamics in Australia (HILDA) Survey. Polypharmacy was defined as the regular use of ≥ 5 prescription medications. Polypharmacy status was categorised into no polypharmacy, in 2013 only (baseline only polypharmacy), in 2017 only (incident polypharmacy) or at both time points (persistent polypharmacy). HRQoL was assessed through the SF-36 questionnaire generating two summary scores: physical component summary (PCS) and mental component summary (MCS). Linear mixed-effects models stratified according to polypharmacy status and change in comorbidities were used to assess trajectories of HRQoL. Results Older adults with persistent polypharmacy had lowest scores for HRQoL measures from 2013 to 2017. After adjusting for all covariates, those with incident polypharmacy had the steepest annual decline in both the PCS and MCS: − 0.86 in PCS and − 0.76 in MCS for those with decreasing or stable comorbidities, and − 1.20 in PCS and − 0.75 in MCS for those with increasing comorbidities. Conclusions Polypharmacy was associated with poorer HRQoL, even after adjusting for confounders. Incident polypharmacy was found to be associated with a clinically important decline in HRQoL and this should be considered when prescribing additional medication to older adults. Supplementary Information The online version contains supplementary material available at 10.1007/s11136-022-03136-9.
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Affiliation(s)
- Muhamad S Aljeaidi
- Medical School, The University of Western Australia, Perth, WA, Australia
| | - Miriam L Haaksma
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Edwin C K Tan
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Pharmacy Building A15, Science Road, Camperdown, Sydney, NSW, 2006, Australia.
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14
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Polypharmacy in Polish Older Adult Population-A Cross-Sectional Study: Results of the PolSenior Project. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031030. [PMID: 35162054 PMCID: PMC8834400 DOI: 10.3390/ijerph19031030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/13/2022] [Accepted: 01/15/2022] [Indexed: 11/24/2022]
Abstract
Polypharmacy is a challenging issue in geriatrics. The aim of the study was to characterize correlates of polypharmacy in the PolSenior project. The PolSenior project, was a comprehensive survey in a large and longitudinal representative sample of thePolish older population. The project was conducted by the International Institute of Molecular and Cell Biology in Warsaw between 2008 and 2011. All medications consumed during the week preceding the survey were evaluated for each participant (n = 4793, including 2314 females (48.3%)). Thereafter, the percentage of those with polypharmacy (at least 5 medications) and excessive polypharmacy (at least 10 medications) was calculated, and their correlates were determined. The average number of medications used by participants was 5.1 ± 3.6, and was higher in females than in males (5.5 ± 3.5 vs. 4.8 ± 3.5; p < 0.001). Polypharmacy characterized 2650 participants (55.3%) and excessive polypharmacy—532 of them (11.1%). The independent correlates associated withpolypharmacy were: age over 70 years, female sex, higher than primary education, living in an urban area, comorbidities, any hospitalization during past five years, and visiting general practicioners at least yearly. As for correlates with excessive polypharmacy, they were: age 80–84 years, female sex, living in an urban area, diagnosis of at least four chronic diseases, and at least two hospitalizations in the last five years. This study serves as a starting place to understand patient characteristics associated with polypharmacy, excessive polypharmacy, and identify targeted interventions.
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15
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McCarthy C, Clyne B, Boland F, Moriarty F, Flood M, Wallace E, Smith SM. GP-delivered medication review of polypharmacy, deprescribing, and patient priorities in older people with multimorbidity in Irish primary care (SPPiRE Study): A cluster randomised controlled trial. PLoS Med 2022; 19:e1003862. [PMID: 34986166 PMCID: PMC8730438 DOI: 10.1371/journal.pmed.1003862] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 11/05/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND There is a rising prevalence of multimorbidity, particularly in older patients, and a need for evidence-based medicines management interventions for this population. The Supporting Prescribing in Older Adults with Multimorbidity in Irish Primary Care (SPPiRE) trial aimed to investigate the effect of a general practitioner (GP)-delivered, individualised medication review in reducing polypharmacy and potentially inappropriate prescriptions (PIPs) in community-dwelling older patients with multimorbidity in primary care. METHODS AND FINDINGS We conducted a cluster randomised controlled trial (RCT) set in 51 GP practices throughout the Republic of Ireland. A total of 404 patients, aged ≥65 years with complex multimorbidity, defined as being prescribed ≥15 regular medicines, were recruited from April 2017 and followed up until October 2020. Furthermore, 26 intervention GP practices received access to the SPPiRE website where they completed an educational module and used a template for an individualised patient medication review that identified PIP, opportunities for deprescribing, and patient priorities for care. A total of 25 control GP practices delivered usual care. An independent blinded pharmacist assessed primary outcome measures that were the number of medicines and the proportion of patients with any PIP (from a predefined list of 34 indicators based predominantly on the STOPP/START version 2 criteria). We performed an intention-to-treat analysis using multilevel modelling. Recruited participants had substantial disease and treatment burden at baseline with a mean of 17.37 (standard deviation [SD] 3.50) medicines. At 6-month follow-up, both intervention and control groups had reductions in the numbers of medicines with a small but significantly greater reduction in the intervention group (incidence rate ratio [IRR] 0.95, 95% confidence interval [CI]: 0.899 to 0.999, p = 0.045). There was no significant effect on the odds of having at least 1 PIP in the intervention versus control group (odds ratio [OR] 0.39, 95% CI: 0.140 to 1.064, p = 0.066). Adverse events recorded included mortality, emergency department (ED) presentations, and adverse drug withdrawal events (ADWEs), and there was no evidence of harm. Less than 2% of drug withdrawals in the intervention group led to a reported ADWE. Due to the inability to electronically extract data, primary outcomes were measured at just 2 time points, and this is the main limitation of this work. CONCLUSIONS The SPPiRE intervention resulted in a small but significant reduction in the number of medicines but no evidence of a clear effect on PIP. This reduction in significant polypharmacy may have more of an impact at a population rather than individual patient level. TRIAL REGISTRATION ISRCTN Registry ISRCTN12752680.
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Affiliation(s)
- Caroline McCarthy
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Barbara Clyne
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Fiona Boland
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
- Data Science Centre, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Frank Moriarty
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Michelle Flood
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Emma Wallace
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Susan M. Smith
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
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16
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Chen LJ, Trares K, Laetsch DC, Nguyen TNM, Brenner H, Schöttker B. Systematic Review and Meta-Analysis on the Associations of Polypharmacy and Potentially Inappropriate Medication With Adverse Outcomes in Older Cancer Patients. J Gerontol A Biol Sci Med Sci 2021; 76:1044-1052. [PMID: 32459845 DOI: 10.1093/gerona/glaa128] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Both polypharmacy and potentially inappropriate medication (PIM) intake are highly prevailing in older cancer patients. However, only studies on the association of polypharmacy and postoperative complications have been meta-analyzed previously. METHODS A systematic review and a meta-analysis of prospective/retrospective observational studies reporting associations of polypharmacy or PIM with at least one out of five predefined adverse health outcomes in a population of older cancer patients (≥60 years) were carried out. PubMed and Web of Science were used to search for relevant studies published between January 1991 and March 2020. Data were pooled by adopting a random-effects model. RESULTS Overall, 42 publications were included in the systematic review. Meta-analyses could be performed on 39 studies about polypharmacy and 13 studies about PIM. Polypharmacy was found to be statistically significantly associated with all-cause mortality (risk ratio [95% confidence interval]: 1.37 [1.25-1.50]), hospitalization (1.53 [1.37-1.71]), treatment-related toxicity (1.22 [1.01-1.47]), and postoperative complications (1.73 [1.36-2.20]). The association of polypharmacy with prolongation of hospitalization was not statistically significant at the p < .05 significance level (1.62 [0.98-2.66]). With respect to PIM, a statistically significant association with all-cause mortality (1.43 [1.08-1.88]) was observed but not with other adverse outcomes. CONCLUSIONS Polypharmacy was found to be associated with several adverse outcomes and PIM use with all-cause mortality in older cancer patients. However, these results should be interpreted with caution because about three-quarters of the studies identified did not adjust for comorbidity and are prone to confounding by indication.
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Affiliation(s)
- Li-Ju Chen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Network Aging Research, University of Heidelberg, Germany
| | - Kira Trares
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Network Aging Research, University of Heidelberg, Germany
| | - Dana Clarissa Laetsch
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Thi Ngoc Mai Nguyen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Network Aging Research, University of Heidelberg, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Network Aging Research, University of Heidelberg, Germany
| | - Ben Schöttker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Network Aging Research, University of Heidelberg, Germany
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17
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Stewart S, Robertson C, Kennedy S, Kavanagh K, Haahr L, Manoukian S, Mason H, Dancer S, Cook B, Reilly J. Personalized infection prevention and control: identifying patients at risk of healthcare-associated infection. J Hosp Infect 2021; 114:32-42. [PMID: 34301394 DOI: 10.1016/j.jhin.2021.03.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 02/22/2021] [Accepted: 03/25/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Few healthcare-associated infection (HAI) studies focus on risk of HAI at the point of admission. Understanding this will enable planning and management of care with infection prevention at the heart of the patient journey from the point of admission. AIM To determine intrinsic characteristics of patients at hospital admission and extrinsic events, during the two years preceding admission, that increase risk of developing HAI. METHODS An incidence survey of adults within two hospitals in NHS Scotland was undertaken for one year in 2018/19 as part of the Evaluation of Cost of Nosocomial Infection (ECONI) study. The primary outcome measure was developing any HAI using recognized case definitions. The cohort was derived from routine hospital episode data and linkage to community dispensed prescribing data. FINDINGS The risk factors present on admission observed as being the most significant for the acquisition of HAI were: being treated in a teaching hospital, increasing age, comorbidities of cancer, cardiovascular disease, chronic renal failure and diabetes; and emergency admission. Relative risk of developing HAI increased with intensive care unit, high-dependency unit, and surgical specialties, and surgery <30 days before admission and a total length of stay of >30 days in the two years to admission. CONCLUSION Targeting patients at risk of HAI from the point of admission maximizes the potential for prevention, especially when extrinsic risk factors are known and managed. This study proposes a new approach to infection prevention and control (IPC), identifying those patients at greatest risk of developing a particular type of HAI who might be potential candidates for personalized IPC interventions.
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Affiliation(s)
- S Stewart
- Safeguarding Health through Infection Prevention Research Group, Research Centre for Health (ReaCH), Glasgow Caledonian University, Glasgow, UK.
| | - C Robertson
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
| | | | - K Kavanagh
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
| | - L Haahr
- Safeguarding Health through Infection Prevention Research Group, Research Centre for Health (ReaCH), Glasgow Caledonian University, Glasgow, UK
| | - S Manoukian
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - H Mason
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - S Dancer
- Department of Microbiology, Hairmyres Hospital, NHS Lanarkshire, UK; School of Applied Science, Edinburgh Napier University, Edinburgh, UK
| | - B Cook
- Departments of Anaesthesia and Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - J Reilly
- Safeguarding Health through Infection Prevention Research Group, Research Centre for Health (ReaCH), Glasgow Caledonian University, Glasgow, UK; National Services Scotland (NSS), UK
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18
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Huang YT, Steptoe A, Wei L, Zaninotto P. Polypharmacy difference between older people with and without diabetes: Evidence from the English longitudinal study of ageing. Diabetes Res Clin Pract 2021; 176:108842. [PMID: 33933497 DOI: 10.1016/j.diabres.2021.108842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 03/25/2021] [Accepted: 04/27/2021] [Indexed: 11/15/2022]
Abstract
AIM To study the association between diabetes and the prevalence of and risk factors for polypharmacy among adults aged 50 and older in England. METHODS A cross-sectional study (2012-2013) of the English Longitudinal Study of Ageing. Polypharmacy was defined as taking 5-9 long-term medications a day and heightened polypharmacy as 10 or more. Diabetes included diagnosed and undiagnosed cases (glycated haemoglobin ≥ 6.5% (48 mmol/mol)). RESULTS Of 7729 participants, 1100 people had diabetes and showed higher prevalence rates of polypharmacy (41.1% vs 14.8%) and heightened polypharmacy (5.8% vs 1.7%) than those without diabetes, even when antihyperglycemic medications were excluded. Risk factors for polypharmacy also differed according to diabetes status. Among people with diabetes, risk factors for polypharmacy and heightened polypharmacy were having more long-term conditions (relative risk ratio (RRR) = 1.86; 3.51) and being obese (RRR = 1.68; 3.68), while females were less likely to show polypharmacy (RRR = 0.51) and heightened polypharmacy (RRR = 0.51) than males. Older age (RRR = 1.04) was only related to polypharmacy among people without diabetes. CONCLUSIONS Adults with diabetes had higher prevalence rates of polypharmacy and heightened polypharmacy than those without diabetes, regardless of including antihyperglycemic drugs. Early detection of polypharmacy among older people with diabetes needs to focus on co-morbidities and obesity.
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Affiliation(s)
- Yun-Ting Huang
- Department of Epidemiology and Public Health, University College London, London, UK.
| | - Andrew Steptoe
- Department of Behavioural Science and Health, University College London, London, UK
| | - Li Wei
- School of Pharmacy, University College London, London, UK
| | - Paola Zaninotto
- Department of Epidemiology and Public Health, University College London, London, UK
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19
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Carr E, Federman A, Dzahini O, Dobson RJ, Bendayan R. A multidimensional measure of polypharmacy for older adults using the Health and Retirement Study. Sci Rep 2021; 11:8783. [PMID: 33888728 PMCID: PMC8062687 DOI: 10.1038/s41598-021-86331-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 01/07/2021] [Indexed: 02/05/2023] Open
Abstract
Polypharmacy is commonly defined based on the number of medications taken concurrently using standard cut-offs, but several studies have highlighted the need for a multidimensional assessment. We developed a multidimensional measure of polypharmacy and compared with standard cut-offs. Data were extracted for 2141 respondents of the 2007 Prescription Drug Survey, a sub-study of the Health Retirement Study. Latent classes were identified based on multiple indicators of polypharmacy, including quantity, temporality and risk profile. A four-class model was selected based on fit statistics and clinical interpretability: 'High risk, long-term' (Class 1), 'Low risk, long-term' (Class 2), 'High risk, short-term' (Class 3), and 'High risk for drug interactions, medium-term, regular' (Class 4). Classes differed regarding sex, cohabitation, disability and multimorbidity. Participants in the 'low risk' class tended to be male, cohabitating, and reported fewer health conditions, compared to 'high risk' classes. Polypharmacy classes were compared to standard cut-offs (5+ or 9+ medications) in terms of overlap and mortality risk. The three 'high risk' classes overlapped with the groups concurrently taking 5+ and 9+ medications per month. However, the multidimensional measure further differentiated individuals in terms of risk profile and temporality of medication taking, thus offering a richer assessment of polypharmacy.
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Affiliation(s)
- Ewan Carr
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Alex Federman
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Olubanke Dzahini
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science, King's College London, London, UK
| | - Richard J Dobson
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK
- Institute of Health Informatics, University College London, 222 Euston Road, London, UK
- Health Data Research UK London, University College London, 222 Euston Road, London, UK
| | - Rebecca Bendayan
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
- NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK.
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20
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Kabra M, Margotto L, Manuguid F. Real-world treatment patterns and healthcare resource use in patients with acute myeloid leukemia in Western Europe. Future Oncol 2021; 17:2769-2784. [PMID: 33881356 DOI: 10.2217/fon-2021-0179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Assess treatment patterns and healthcare resource utilization (HRU) in patients with treatment-naive (TN) or relapsed/refractory (R/R) acute myeloid leukemia (AML) in Europe. Patients & methods: Cross-sectional, retrospective, web-based survey of AML-treating healthcare professionals (HCPs) in 12 European countries. Results: 320 HCPs provided information on 1280 TN or R/R patients. Patients ineligible versus eligible for intensive induction therapy required more general practitioner visits (4.1 vs 2.4), more uses of healthcare-related transport (6.9 vs 4.5), but less hospitalization (11.4 vs 27.5 days). Differences were observed in HRU and treatment patterns across countries. Conclusions: This analysis of 'real-world' patients with TN or R/R AML in Europe demonstrates substantial healthcare use, including higher use of resources in patients ineligible for intensive induction therapy.
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Hellemans L, Nuyts S, Hias J, van den Akker M, Van Pottelbergh G, Rygaert X, Spriet I, Vaes B, Tournoy J, Van der Linden L. Polypharmacy and excessive polypharmacy in community-dwelling middle aged and aged adults between 2011 and 2015. Int J Clin Pract 2021; 75:e13942. [PMID: 33340210 DOI: 10.1111/ijcp.13942] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 12/14/2020] [Indexed: 01/03/2023] Open
Abstract
AIMS We aimed to assess the prevalence, components and evolution of polypharmacy and to evaluate risk factors associated with polypharmacy. METHODS A retrospective dynamic cohort study was performed, using a primary healthcare database comprising Flemish community-dwelling adults aged ≥40 years between 2011 and 2015. Polypharmacy and excessive polypharmacy were defined as the use of 5-9 or minimum 10 different medications during 1 year, respectively. Temporal changes were analysed using an autoregressive error model. Risk factors for polypharmacy were evaluated using logistic regression. RESULTS In total, 68 426 patients were included in the analysis. The prevalence of polypharmacy was 29.5% and 16.1% for excessive polypharmacy in 2015. The age-standardised prevalence rate of patients using minimum five medications increased with 1.3% per year (95% confidence interval (CI): 0.1968-2.4279). The mean number of unplanned hospital admissions was 0.07 (standard deviation (SD) 0.33) for polypharmacy patients and 0.19 (SD 0.53) for excessive polypharmacy patients. Four risk factors were found to be significantly correlated with polypharmacy: age (odds ratio (OR) 1.015; 95% CI: 1.013-1.017), female gender (OR 1.161; 95% CI: 1.108-1.216), number of chronic diseases (OR 1.126; 95% CI: 1.114-1.139) and number of general practitioner contacts (OR 1.283; 95% CI: 1.274-1.292). CONCLUSION The prevalence of polypharmacy increased between 2011 and 2015. Polypharmacy and excessive polypharmacy patients appeared to differ based on our observations of characteristics, drug therapy and outcomes. Age, female gender, number of chronic diseases and number of general practitioner contacts were associated with polypharmacy.
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Affiliation(s)
- Laura Hellemans
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Shauni Nuyts
- Academic Centre of General Practice/Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- L-BioStat, KU Leuven, Leuven, Belgium
| | - Julie Hias
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Marjan van den Akker
- Academic Centre of General Practice/Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
- Department of Family Medicine, School CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - Gijs Van Pottelbergh
- Academic Centre of General Practice/Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | | | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Bert Vaes
- Academic Centre of General Practice/Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Jos Tournoy
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Lorenz Van der Linden
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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22
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Davies LE, Kingston A, Todd A, Hanratty B. Characterising polypharmacy in the very old: Findings from the Newcastle 85+ Study. PLoS One 2021; 16:e0245648. [PMID: 33465141 PMCID: PMC7815158 DOI: 10.1371/journal.pone.0245648] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 01/05/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Polypharmacy is potentially harmful and under-researched amongst the fastest growing subpopulation, the very old (aged ≥85). We aimed to characterise polypharmacy using data from the Newcastle 85+ Study-a prospective cohort of people born in 1921 who turned 85 in 2006 (n = 845). METHODS The prevalence of polypharmacy at baseline (mean age 85.5) was examined using cut-points of 0, 1, 2-4, 5-9 and ≥10 medicines-so-called 'no polypharmacy', 'monotherapy', 'minor polypharmacy', 'polypharmacy' and 'hyperpolypharmacy.' Cross-tabulations and upset plots identified the most frequently prescribed medicines and medication combinations within these categories. Mixed-effects models assessed whether gender and socioeconomic position were associated with prescribing changes over time (mean age 85.5-90.5). Participant characteristics were examined through descriptive statistics. RESULTS Complex multimorbidity (44.4%, 344/775) was widespread but hyperpolypharmacy was not (16.0%, 135/845). The median medication count was six (interquartile range 4-8). Preventative medicines were common to all polypharmacy categories, and prescribing regimens were diverse. Nitrates and oral anticoagulants were more frequently prescribed for men, whereas bisphosphonates, non-opioid analgesics and antidepressants were more common in women. Cardiovascular medicines, including loop diuretics, tended to be more frequently prescribed for socioeconomically disadvantaged people (<25th centile Index of Multiple Deprivation (IMD)), despite no difference in the prevalence of cardiovascular disease (p = 0.56) and diabetes (p = 0.92) by IMD. CONCLUSION Considering their complex medical conditions, prescribing is relatively conservative amongst 85-year-olds living in North East England. Prescribing shows significant gender and selected socioeconomic differences. More support for managing preventative medicines, of uncertain benefit, might be helpful in this population.
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Affiliation(s)
- Laurie E. Davies
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Andrew Kingston
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Adam Todd
- School of Pharmacy, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Barbara Hanratty
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
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Magro L, Arzenton E, Leone R, Stano MG, Vezzaro M, Rudolph A, Castagna I, Moretti U. Identifying and Characterizing Serious Adverse Drug Reactions Associated With Drug-Drug Interactions in a Spontaneous Reporting Database. Front Pharmacol 2021; 11:622862. [PMID: 33536925 PMCID: PMC7848121 DOI: 10.3389/fphar.2020.622862] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/14/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Drug-drug interactions (DDIs) are an important cause of adverse drug reactions (ADRs). In literature most of studies focus only on potential DDIs, while detailed data on serious ADRs associated with DDIs are limited. Our aim is to identify and characterize serious ADRs caused by DDIs using a spontaneous reporting database. Methods: All serious ADR reports, not related to vaccines and with a “definite”, “probable” or “possible” causality assessment, inserted into the National Pharmacovigilance database from Veneto Region (January 1, 2015 to May 31, 2020) were analyzed. A list of drug pairs was created by selecting the reports containing at least two suspected or concomitant drugs. We verified which drug pairs potentially interacted according to the online version of DRUGDEX® system. For each potential DDI we controlled whether the ADR description in the report corresponded to the interaction effect as described in Micromedex. A detailed characterization of all serious reports containing an occurring DDI was performed. Results: In the study period a total of 31,604 reports of suspected ADRs from the Veneto Region were identified, of which 2,195 serious reports (6.9% of all ADR reports) containing at least two suspected or concomitant drugs were analyzed. We identified 1,208 ADR reports with at least one potential DDI (55.0% of 2,195) and 381 reports (17.4% of 2,195 reports) with an occurring ADR associated with a DDI. The median age of patients and the number of contraindicated or major DDIs were significantly higher in reports with an occurring DDI. Warfarin was the most frequently reported interacting drug and the most common ADRs were gastrointestinal or cerebral hemorrhagic events. The proton pump inhibitors/warfarin, followed by platelet aggregation inhibitors/warfarin were the drug-drug combinations most frequently involved in ADRs caused by DDIs. The highest proportion of fatal reports was observed with platelet aggregation inhibitors/warfarin and antidepressants/warfarin. Conclusion: Our findings showed that about one-third of patients exposed to a potential DDI actually experienced a serious ADR. Furthermore, our study confirms that a spontaneous reporting database could be a valuable resource for identifying and characterizing ADRs caused by DDIs and the drugs leading to serious ADRs and deaths.
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Affiliation(s)
- Lara Magro
- Section of Pharmacology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Elena Arzenton
- Section of Pharmacology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Roberto Leone
- Section of Pharmacology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Marilisa Giustina Stano
- Section of Pharmacology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Michele Vezzaro
- Section of Pharmacology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Annette Rudolph
- Section of Pharmacology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Irene Castagna
- Section of Pharmacology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Ugo Moretti
- Section of Pharmacology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
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Ishibashi Y, Nishitani R, Kato T, Chiba S, Ashidate K, Ishiwata N, Ichijo T, Sasabe M. Association of drugs with special caution in the guidelines with falls: A case-control and case-crossover study in Japan. Geriatr Gerontol Int 2021; 21:285-290. [PMID: 33442943 DOI: 10.1111/ggi.14127] [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: 03/12/2020] [Revised: 11/20/2020] [Accepted: 12/12/2020] [Indexed: 11/27/2022]
Abstract
AIM To determine the relationship between multiple medications and falls. METHODS This case-control and case-crossover study was carried out at Kudanzaka Hospital in Chiyoda, Tokyo, Japan. A total of 325 patients who experienced their first falls when hospitalized between January 2016 and November 2018, and 1285 controls matched by sex, age and clinical departments were included in this study. Hospitalization duration and fall risk score were adjusted for in the analyses. RESULTS In the case-control study, multivariable logistic regression showed that increasing the intake of oral medications was not significantly associated with the incidence of falls (odds ratio 1.02, 95% confidence interval 0.998-1.049). In contrast, drugs prescribed with special caution in accordance with the Elderly Oral Medication Guidelines were significantly associated with falls (odds ratio 1.17, 95% confidence interval 1.09-1.26). A similar pattern was observed in the case-crossover analysis. Among the drugs to be prescribed with special caution according to the guidelines, atypical antipsychotics, non-benzodiazepine hypnotics and magnesium oxide were significantly associated with the risk of falls. CONCLUSION The drugs to be prescribed with special caution according to the guidelines were associated with an increased fall risk. The risk of falls in hospitalized older people due to multiple medications varies among medications. Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2021; ••: ••-••.
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Affiliation(s)
- Yoshiki Ishibashi
- Department of Internal Medicine, Kudanzaka Hospital, Company Overview of Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan.,Department of Preventive Medicine and Public Health, School of Medicine, Keio University, Tokyo, Japan
| | - Rie Nishitani
- Department of Internal Medicine, Kudanzaka Hospital, Company Overview of Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan
| | - Takashi Kato
- Department of Pharmacy, Kudanzaka Hospital, Company Overview of Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan
| | - Sahoko Chiba
- Department of Internal Medicine, Kudanzaka Hospital, Company Overview of Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan
| | - Keiko Ashidate
- Department of Internal Medicine, Kudanzaka Hospital, Company Overview of Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan
| | - Nobuo Ishiwata
- Department of Internal Medicine, Kudanzaka Hospital, Company Overview of Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan
| | - Tomoyasu Ichijo
- Department of Internal Medicine, Kudanzaka Hospital, Company Overview of Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan
| | - Masataka Sasabe
- Department of Internal Medicine, Kudanzaka Hospital, Company Overview of Federation of National Public Service Personnel Mutual Aid Associations, Tokyo, Japan
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25
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Winchester RL, Martyn K. Could Early Identification of Changes in Olfactory Function Be an Indicator of Preclinical Neurodegenerative Disease? A Systematic Review. Neurol Ther 2020; 9:243-263. [PMID: 32529479 PMCID: PMC7606376 DOI: 10.1007/s40120-020-00199-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Alzheimer's disease (AD) is a debilitating neurodegenerative disease that currently affects 850,000 individuals in the UK with estimates continuing to rise. Diagnosis is only available in the presence of significant neuronal pathology and apparent cognitive decline, meaning that treatment avenues are often limited and carry little to no effect on prognosis. Olfactory function has been shown to have a direct correlation with cognitive function and therefore may serve as a potential diagnostic tool for the detection of preclinical disease. The objective was to examine the current literature to establish the accuracy of olfactory function testing in determining current and future cognitive function. METHODS A systematic review was performed via Medline on 17 October 2019 using the search terms and Boolean operators 'Dementia OR Alzheimer's AND olfaction AND cognitive impairment' yielding 111 results. These were then screened using inclusion/exclusion criteria alongside a PICO strategy. After titles, abstracts and full text were screened, nine articles were included in the review and critically appraised using the AXIS and CASP tools. RESULTS Significant correlations are demonstrated between olfactory impairment (OI) and cognitive decline. However, there were limitations of many of the studies in that confounders such as head trauma, upper respiratory infection (URTI) and smoking history were not considered. The majority of the studies also used an olfactory screening tool that was not designed for the population being examined. CONCLUSION Despite improvements in olfactory testing needing to be implemented, OI is clearly impaired in neurodegenerative disease across a multitude of ages and cultures, offering an early marker of future cognitive decline. As a result of the heterogenous nature of the included studies, there is a further need for future research to ensure the sensitivity, validity and reliability of implementing olfactory testing as an early marker of future cognitive decline.
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Affiliation(s)
- Rikki L Winchester
- Brighton and Sussex Medical School, University of Sussex, Brighton, England.
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26
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McMahon M, Hatton C, Bowring DL. Polypharmacy and psychotropic polypharmacy in adults with intellectual disability: a cross-sectional total population study. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2020; 64:834-851. [PMID: 32902029 DOI: 10.1111/jir.12775] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 08/25/2020] [Accepted: 08/25/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Adults with intellectual disability (ID) are prescribed high levels of medication, with polypharmacy and psychotropic polypharmacy common. However, reported rates vary between studies, and there has been an over-reliance on obtaining data from convenience samples. The objective of this study was to determine the prevalence of medication use and polypharmacy in a population-level sample of adults with IDs. Factors associated with polypharmacy and psychotropic polypharmacy are explored. METHODS We used a total population sample of 217 adults with IDs known to services in Jersey (sampling frame n = 285). The Anatomical Therapeutic Chemical classification system was used to categorise medications that participants were currently taking on a regular basis. We examined associations of polypharmacy and psychotropic polypharmacy with socio-economic status, health and demographic variables using univariate and multivariate analyses. RESULTS A total of 83.4% of participants were prescribed medication, with high doses common. Of the participants, 38.2% were exposed to polypharmacy while 23% of participants were exposed to psychotropic polypharmacy. After controlling for demographic, health and socio-economic characteristics, polypharmacy was significantly associated with older age, increased severity of ID, living in a residential setting and having increased comorbidities. Psychotropic polypharmacy was associated with being male, being aged 50+ years and having had a psychiatric diagnosis over the life course. Being prescribed psychotropic drugs above the defined daily dose was not associated with having had a psychiatric diagnosis over the life course, suggesting the possibility of 'off label' prescribing. CONCLUSIONS Our results indicate that medication use, in high doses, alongside polypharmacy and psychotropic polypharmacy are highly prevalent in adults with ID. The exposure to multiple medications increases the risk of developing adverse drug events, drug-drug interactions and medication-related problems. Future population-level, prospective cohort studies should examine the prevalence of polypharmacy and psychotropic polypharmacy using standardised definitions and consider the potential impact of adverse drug events, drug-drug interactions and medication-related problems in this population.
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Affiliation(s)
- M McMahon
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
- Health and Community Services, Government of Jersey, Saint Helier, Jersey
| | - C Hatton
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - D L Bowring
- CEDAR, University of Warwick, Coventry, UK
- Health and Community Services, Government of Jersey, Saint Helier, Jersey
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Varley A, Cullinan J. Are payment methods for prescription drugs associated with polypharmacy in older adults in Ireland? Evidence from the TILDA cohort study. BMJ Open 2020; 10:e036591. [PMID: 33004388 PMCID: PMC7534701 DOI: 10.1136/bmjopen-2019-036591] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Polypharmacy is commonly defined as the use of five or more medications, is associated with a range of adverse outcomes and is particularly common in older adults. We sought to examine the relationship between polypharmacy and payment methods for prescription drugs among older adults in Ireland. METHODS This is a cross-sectional analysis of data from wave 3 of The Irish Longitudinal Study on Aging, a nationally representative cohort study sample of community-living adults aged 50 years and older in Ireland. We used multivariable logistic regression to model the independent relationship between polypharmacy and drug payment methods. We controlled for a wide range of demographic, socioeconomic and health-related variables. RESULTS Enrolment in publicly funded schemes which entitle participants to subsidised or free prescription medications was independently associated with increased odds of reporting polypharmacy. Relative to out-of-pocket payment, we found polypharmacy was independently associated with payment via medical card (OR 2.65; 95% CI 2.13 to 3.28), drugs payment scheme (OR 3.83; 95% CI 2.96 to 4.95), long-term illness scheme (OR 4.24; 95% CI 3.06 to 5.87), but not private health insurance (OR 0.82; 95% CI 0.42 to 1.62). CONCLUSIONS Given multiple payment methods available for funding prescription charges in Ireland, there is a significant differential in the upfront costs faced by patients. One implication of our results is that the quantity of medications consumed by an individual may be influenced by payment methods for prescription fees. This could lead to overconsumption of medicines by those who are covered, or underconsumption by those who are not. However, our study was limited by an inability to discriminate between appropriate and inappropriate polypharmacy or to account for differential levels of multimorbidity, suggesting further research on this topic is warranted.
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Affiliation(s)
- Aine Varley
- Department of Pharmacology and Therapeutics, Trinity College Dublin, Dublin, Ireland
| | - John Cullinan
- Discipline of Economics, National University of Ireland Galway, Galway, Ireland
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Tefera YG, Alemayehu M, Mekonnen GB. Prevalence and determinants of polypharmacy in cardiovascular patients attending outpatient clinic in Ethiopia University Hospital. PLoS One 2020; 15:e0234000. [PMID: 32479516 PMCID: PMC7263581 DOI: 10.1371/journal.pone.0234000] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 05/15/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND While there are advances in medicine and pharmaceutical care, the burden of medication use has also grown with polypharmacy. In this regard, cardiovascular patients are subjected to polypharmacy for a longer period. OBJECTIVE The present study aimed to assess the prevalence and predictors of polypharmacy in cardiovascular outpatients attending the University of Gondar Comprehensive specialized hospital, northwest Ethiopia. METHODS A hospital-based cross-sectional study was employed at the University of Gondar Comprehensive Specialized Hospital from March 30 -May 30, 2019. The unique medical registration number of 424 patients was selected by using systematic random sampling to trace the medical chart and followed with an interview to explore the factors related to polypharmacy. All the Statistical analysis was carried out using Statistical Package for Social Sciences (SPSS) version 22. Bivariable and multivariable logistic regressions were used to identify the predictors of polypharmacy in cardiovascular patients. RESULT The mean age of the respondents was 56.83 ± 15.27 years. The mean number of medications per patient was 3.3±1.6. The prevalence of polypharmacy was 24.8% in cardiovascular outpatients while cardiovascular specific polypharmacy was 9.2%. Elderly (aged ≥ 65 years and above) patients were nearly two times more likely to had polypharmacy prescriptions with AOR: 1.97; 95% CI: 1.08-3.61; p = 0.027. Patients with abnormal weight (underweight AOR: 4.51; 95% CI: 1.42-14.30; p = 0.010, overweight AOR: 3.78; 95% CI: 1.83-7.83; p<0.001 and obese AOR: 5.1; 95% CI: 2.04-12.75 p<0.001) are more likely to have polypharmacy. Having a family history of CVD increase the likelihood of polypharmacy more than double; AOR: 2.40; 95% CI: 1.17-4.93; p = 0.017. A unit increase in Charlson comorbidity index score resulted in a nearly threefold likelihood of polypharmacy with AOR: 2.83; 95% CI 1.91-3.89; p<0.001. CONCLUSION One out of four cardiovascular patients attending the outpatient clinic was on polypharmacy. The elderly age, abnormal body mass index (non-normal weight), family history of cardiovascular diseases and increasing Charlson morbidity index were the predictors of polypharmacy in cardiovascular patients. Clinicians should ensure the relevance of all prescribed medications and pharmaceutical care targeting at the prevention of inappropriate polypharmacy would be pivotal to reduce polypharmacy associated burdens.
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Affiliation(s)
- Yonas Getaye Tefera
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- * E-mail:
| | - Mekuriaw Alemayehu
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Gashaw Binega Mekonnen
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Gbeasor-Komlanvi FA, Zida-Compaore WIC, Dare IH, Diallo A, Darre TP, Potchoo Y, Belo M, Ekouevi DK. Medication Consumption Patterns and Polypharmacy among Community-Dwelling Elderly in Lomé (Togo) in 2017. Curr Gerontol Geriatr Res 2020; 2020:4346035. [PMID: 32351556 PMCID: PMC7178761 DOI: 10.1155/2020/4346035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 08/05/2019] [Accepted: 09/17/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND In the sub-Saharan African, region of the world with a fast growing aging population and where the use of herbal products is very common, there is a paucity of data on medication consumption patterns among elderly people. The objective of this study was to assess the prevalence of polypharmacy and its associated factors among community-dwelling elderly in Lomé, Togo, in 2017. METHODS A cross-sectional study was conducted from March to June 2017 in Lomé, Togo among people aged 60 years and older. The Respondent Driven Sampling method was used to recruit participants. Data on socio-demographic characteristics and medication consumption patterns, including the use of medicinal plants and dietary supplements, were collected using a standardized questionnaire during a face-to-face interview at participants' home. Descriptive and binary logistic regression analyses were performed. RESULTS A total of 370 participants with median age 65 years, (IQR: 62-71) were enrolled in the study. Almost three elderly in five (57.6%) were multimorbid (had two or more chronic diseases). Conventional drugs (78.4%), medicinal plants (14.3%) and other dietary supplements (9.5%) were used by participants. The prevalence of polypharmacy was 22.7% (95% CI: 18.5-27.3%). Concurrent use of conventional drugs and medicinal plants or other dietary supplements was observed among 17.0% of participants and 67.3% reported self-medication. Multimorbidity (aOR = 4.55; 95% CI: [2.42-8.54]) and female sex (aOR = 1.86; 95% CI: [1.00-3.47]) were associated with polypharmacy. CONCLUSION One elderly in five uses five or more medications in Togo. Further studies are needed to assess drug-drug interactions and herb-drug interactions among this population.
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Affiliation(s)
- Fifonsi A. Gbeasor-Komlanvi
- Faculté des Sciences de la Santé, Université de Lomé, Lomé, BP 1515, Togo
- Centre Africain de Recherche en Epidémiologie et en Santé Publique, Lomé, BP 4089, Togo
| | | | - Ikpindi H. Dare
- Faculté des Sciences de la Santé, Université de Lomé, Lomé, BP 1515, Togo
| | | | - Tchin P. Darre
- Faculté des Sciences de la Santé, Université de Lomé, Lomé, BP 1515, Togo
| | - Yao Potchoo
- Faculté des Sciences de la Santé, Université de Lomé, Lomé, BP 1515, Togo
| | - Mofou Belo
- Faculté des Sciences de la Santé, Université de Lomé, Lomé, BP 1515, Togo
| | - Didier K. Ekouevi
- Faculté des Sciences de la Santé, Université de Lomé, Lomé, BP 1515, Togo
- Centre Africain de Recherche en Epidémiologie et en Santé Publique, Lomé, BP 4089, Togo
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Jungo KT, Rozsnyai Z, Mantelli S, Floriani C, Löwe AL, Lindemann F, Schwab N, Meier R, Elloumi L, Huibers CJA, Sallevelt BTGM, Meulendijk MC, Reeve E, Feller M, Schneider C, Bhend H, Bürki PM, Trelle S, Spruit M, Schwenkglenks M, Rodondi N, Streit S. 'Optimising PharmacoTherapy In the multimorbid elderly in primary CAre' (OPTICA) to improve medication appropriateness: study protocol of a cluster randomised controlled trial. BMJ Open 2019; 9:e031080. [PMID: 31481568 PMCID: PMC6731954 DOI: 10.1136/bmjopen-2019-031080] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/26/2019] [Accepted: 08/09/2019] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Multimorbidity and polypharmacy are major risk factors for potentially inappropriate prescribing (eg, overprescribing and underprescribing), and systematic medication reviews are complex and time consuming. In this trial, the investigators aim to determine if a systematic software-based medication review improves medication appropriateness more than standard care in older, multimorbid patients with polypharmacy. METHODS AND ANALYSIS Optimising PharmacoTherapy In the multimorbid elderly in primary CAre is a cluster randomised controlled trial that will include outpatients from the Swiss primary care setting, aged ≥65 years with ≥three chronic medical conditions and concurrent use of ≥five chronic medications. Patients treated by the same general practitioner (GP) constitute a cluster, and clusters are randomised 1:1 to either a standard care sham intervention, in which the GP discusses with the patient if the medication list is complete, or a systematic medication review intervention based on the use of the 'Systematic Tool to Reduce Inappropriate Prescribing'-Assistant (STRIPA). STRIPA is a web-based clinical decision support system that helps customise medication reviews. It is based on the validated 'Screening Tool of Older Person's Prescriptions' (STOPP) and 'Screening Tool to Alert doctors to Right Treatment' (START) criteria to detect potentially inappropriate prescribing. The trial's follow-up period is 12 months. Outcomes will be assessed at baseline, 6 and 12 months. The primary endpoint is medication appropriateness, as measured jointly by the change in the Medication Appropriateness Index (MAI) and Assessment of Underutilisation (AOU). Secondary endpoints include the degree of polypharmacy, overprescribing and underprescribing, the number of falls and fractures, quality of life, the amount of formal and informal care received by patients, survival, patients' quality adjusted life years, patients' medical costs, cost-effectiveness of the intervention, percentage of recommendations accepted by GPs, percentage of recommendation rejected by GPs and patients' willingness to have medications deprescribed. ETHICS AND DISSEMINATION The ethics committee of the canton of Bern in Switzerland approved the trial protocol. The results of this trial will be published in a peer-reviewed journal. MAIN FUNDING Swiss National Science Foundation, National Research Programme (NRP 74) 'Smarter Healthcare'. TRIAL REGISTRATION NUMBERS Clinicaltrials.gov (NCT03724539), KOFAM (Swiss national portal) (SNCTP000003060), Universal Trial Number (U1111-1226-8013).
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Affiliation(s)
| | - Zsofia Rozsnyai
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Sophie Mantelli
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Carmen Floriani
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Axel Lennart Löwe
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fanny Lindemann
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Nathalie Schwab
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Rahel Meier
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Lamia Elloumi
- Department of Information and Computing Sciences, Utrecht University, Utrecht, The Netherlands
- Department of Communication and Cognition, Tilburg University, Tilburg, The Netherlands
| | | | | | - Michiel C Meulendijk
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Division of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
- Geriatric Medicine Research, Faculty of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Canada College of Pharmacy, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Martin Feller
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Claudio Schneider
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Heinz Bhend
- Hausarzt Praxis Städtli Aarburg, Aarburg, Switzerland
| | - Pius M Bürki
- Berufsverband der Haus- und Kinderärztinnen Schweiz, Bern, Switzerland
| | - S Trelle
- CTU Bern, University of Bern, Bern, Switzerland
| | - Marco Spruit
- Department of Information and Computing Sciences, Utrecht University, Utrecht, The Netherlands
| | - Matthias Schwenkglenks
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sven Streit
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
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Affiliation(s)
- José Joaquín Mira
- a Health Psychology Department , Universidad Miguel Hernández , Sant Joan , Spain.,b Alicante-Sant Joan Health District , Alicante , Spain.,c Prometeo173 Research Group , FISABIO , Sant Joan , Spain
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Smaje A, Weston‐Clark M, Raj R, Orlu M, Davis D, Rawle M. Factors associated with medication adherence in older patients: A systematic review. Aging Med (Milton) 2018; 1:254-266. [PMID: 31410389 PMCID: PMC6692164 DOI: 10.1002/agm2.12045] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 10/24/2018] [Accepted: 10/28/2018] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE Medication adherence is a major challenge in the treatment of older patients; however, they are under-represented in research. We undertook a systematic review focused on older patients to assess the reasons underlying non-adherence in this population. METHODS We searched multiple electronic databases for studies reporting reasons for non-adherence to medication regimens in patients aged 75 years and over. Our results were not limited to specific diseases, health-care settings, or geographical locations. The quality of eligible studies was assessed using the Newcastle-Ottawa Scale. A narrative synthesis of findings was performed. RESULTS A total of 25 publications were included, all of which were in community settings. Frequent medication review and knowledge regarding the purpose of the medication were positively associated with adherence. Factors associated with poor adherence were multimorbidity, cognitive impairment, complex regimens with multiple prescribing physicians, and problems with drug storage or formulation. CONCLUSION These findings suggest that interventions to improve adherence could focus on medication review aimed at simplifying regimens and educating patients about their treatment. Groups with poor adherence that may benefit most from such a model include patients with multiple comorbidities and cognitive impairment.
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Affiliation(s)
- Ashley Smaje
- University College London Hospital NHS TrustLondonUK
- MRC Unit for Lifelong Health and Ageing at University College LondonLondonUK
| | - Maryse Weston‐Clark
- MRC Unit for Lifelong Health and Ageing at University College LondonLondonUK
| | | | - Mine Orlu
- University College London School of PharmacyLondonUK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at University College LondonLondonUK
| | - Mark Rawle
- MRC Unit for Lifelong Health and Ageing at University College LondonLondonUK
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