Prevalence and factors associated with polypharmacy: a systematic review and Meta-analysis

Integrated approach to reducing polypharmacy in older people: exploring the role of oxidative stress and antioxidant potential therapy

Increased life expectancy, attributed to improved access to healthcare and drug development, has led to an increase in multimorbidity, a key contributor to polypharmacy. Polypharmacy is characterised by its association with a variety of adverse events in the older persons. The mechanisms involved in the development of age-related chronic diseases are largely unknown; however, altered redox homeostasis due to ageing is one of the main theories. In this context, the present review explores the development and interaction between different age-related diseases, mainly linked by oxidative stress. In addition, drug interactions in the treatment of various diseases are described, emphasising that the holistic management of older people and their pathologies should prevail over the individual treatment of each condition.

Global and regional prevalence of polypharmacy and related factors, 1997-2022: An umbrella review

OBJECTIVE

Limited comprehensive evidence exists on the global prevalence of polypharmacy. This knowledge gap contributes to increased healthcare system costs and related public health concerns. Thus, we aimed to synthesize the current evidence on polypharmacy prevalence and associated factors in the general and older populations using an umbrella review.

METHODS

Our primary outcomes were global prevalence and related indicators of polypharmacy. We systematically searched Google Scholar, PubMed/MEDLINE, Embase, and CINAHL for studies published between the inception of each database until April 30, 2023.

RESULTS

Eleven meta-analyses incorporating 295 studies and 59,552,762 participants from 41 countries across six continents were identified. The global prevalence of polypharmacy in the general population is 37 %, with higher rates in older individuals (45 %), outpatients (48 %), and inpatients (52 %). North America showed a higher prevalence (52 %) than Asia (36 %) and Europe (36 %). Among frail elderly individuals, the prevalence of polypharmacy is 59 %, with the highest rates in Europe (68 %) and hospital settings (71 %).

CONCLUSION

The global prevalence of polypharmacy and its associated factors in older adults present a complex, multifaceted, and conflicting picture. Understanding the prevalence of polypharmacy and its associated factors may help reduce the number of multidrug prescriptions.

Association between continuity of care and inappropriate prescribing in outpatient care in Germany: a cross-sectional analysis conducted as part of the LoChro trial

OBJECTIVES

Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) are common in multimorbid patients. This study aims to describe PIMs and PPOs in an open-access outpatient setting and to investigate any association between continuity of care (CoC) and PIMs and PPOs in multimorbid older patients.

DESIGN

Cross-sectional study using patient-confirmed outpatient medication plans to describe PIMs and PPOs using the 'Screening Tool of Older Person's Prescription/Screening Tool to Alert to Right Treatment' version 2. Four Poisson regressions modelled the number of PIMs and PPOs using context-adapted versions of the Usual Provider of Care (UPC) and the Modified Modified Continuity Index (MMCI) as measures for CoC.

SETTING

Southern Germany, outpatient setting.

PARTICIPANTS

321 participants of the LoChro-trial at 12-month follow-up (both arms). The LoChro-trial compared healthcare involving an additional care manager with usual care. Inclusion criteria were age over 64, local residence and scoring over one in the Identification of Older patients at Risk Screening Tool.

PRIMARY OUTCOMES

Numbers of PIMs and PPOs.

RESULTS

The mean number of PIMs was 1.5 (SD 1.5), lower than the average number of PPOs at 2.9 (SD 1.7). CoC showed similar results for both indices with a mean of 0.548 (SD 0.279) for MMCI and 0.514 (SD 0.262) for UPC. Both models predicting PPOs indicated more PPOs with higher CoC; statistical significance was only demonstrated for MMCI (MMCI~PPO: Exp(B)=1.42, 95% CI (1.11; 1.81), p=0.004; UPC~PPO: Exp(B)=1.29, 95% CI (0.99; 1.67), p=0.056). No significant association between PIMs and CoC was found (MMCI~PIM: Exp(B)=0.72, 95% CI (0.50; 1.03), p=0.072; UPC~PIM: Exp(B)=0.83, 95% CI (0.57; 1.21), p=0.337).

CONCLUSION

The results did not show a significant association between higher CoC and lesser PIMs. Remarkably, an association between increased CoC, represented through MMCI, and more PPOs was found. Consultation of different care providers in open-access healthcare systems could possibly ameliorate under-prescribing in multimorbid older patients.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS): DRKS00013904.

Longitudinal cohort study of discrepancies between prescribed and administered polypharmacy rates: implications for National Aged Care Quality Indicator Programs

BACKGROUND

Polypharmacy is frequently used as a quality indicator for older adults in Residential Aged Care Facilities (RACFs) and is measured using a range of definitions. The impact of data source choice on polypharmacy rates and the implications for monitoring and benchmarking remain unclear. We aimed to determine polypharmacy rates (≥9 concurrent medicines) by using prescribed and administered data under various scenarios, leveraging electronic data from 30 RACFs.

METHOD

A longitudinal cohort study of 5662 residents in New South Wales, Australia. Both prescribed and administered polypharmacy rates were calculated biweekly from January 2019 to September 2022, providing 156 assessment times. 12 different polypharmacy rates were computed separately using prescribing and administration data and incorporating different combinations of items: medicines and non-medicinal products, any medicines and regular medicines across four scenarios: no, 1-week, 2-week and 4-week look-back periods. Generalised estimating equation models were employed to identify predictors of discrepancies between prescribed and administered polypharmacy.

RESULTS

Polypharmacy rates among residents ranged from 33.9% using data on administered regular medicines with no look-back period to 63.5% using prescribed medicines and non-medicinal products with a 4-week look-back period. At each assessment time, the differences between prescribed and administered polypharmacy rates were consistently more than 10.0%, 4.5%, 3.5% and 3.0%, respectively, with no, 1-week, 2-week and 4-week look-back periods. Diabetic residents faced over two times the likelihood of polypharmacy discrepancies compared with counterparts, while dementia residents consistently showed reduced likelihood across all analyses.

CONCLUSION

We found notable discrepancies between polypharmacy rates for prescribed and administered medicines. We recommend a review of the guidance for calculating and interpreting polypharmacy for national quality indicator programmes to ensure consistent measurement and meaningful reporting.

Optipharm: Enhancing pharmacological management skills in healthcare students for geriatric care through gamified e-learning

BACKGROUND

Complexities in older patient care and frequent polypharmacy requires tailored tools, specific skills and interdisciplinary collaborations. Traditional disease-centered education often overlooks these issues. Despite digital gamification's relevance in health education, limited exploration exists for gamified platforms addressing polypharmacy, especially within comprehensive geriatric assessment (CGA).

OBJECTIVE

This study outlines Optipharm's design, a gamified e-learning tool designed to enhance health students' education in managing polypharmacy among older adults. It also assesses its usability using a validated scale.

METHODS

Optipharm development utilized gamification techniques guided by pedagogical principles. Learning objectives addressed clinical and educational gaps in older adult care. Hosted on a Moodle system, the platform housed a structured clinical case as a SCORM file, a usability scale, a certificate of achievement, and a literature library. Optipharm was assessed by 304 medical students from the University of Navarre, Spain, using the SUS-G-Sp scale.

RESULTS

An immersive gamified e-learning tool simulating clinical practice settings was developed, requiring users to assume the role of healthcare professionals in multidisciplinary outpatient consultations. The interface, with a 2D cartoon-style aesthetic, aligns with learning objectives, integrating engaging storytelling and clear instructions for CGA in Phase 1 and pharmacological optimization in Phase 2. The evaluation of Optipharm's usability revealed very positive perceptions among users, with high agreement rates on usability items.

CONCLUSION

Optipharm represents a pioneering gamified tool designed to simulate clinical scenarios, allowing users to engage as healthcare professionals within multidisciplinary teams and address medication-related challenges in older patients with polypharmacy. It provides a secure, interactive learning environment with clear educational objectives and seamless integration of gamification elements, enhancing users' knowledge and skills in managing complex medication regimens. As a platform for experiential learning and knowledge exchange, Optipharm contributes to shaping the future of health education and fostering a culture of patient-centred care among future healthcare professionals.

Sex differences in patterns of potentially inappropriate prescribing and adverse drug reactions in hospitalized older people: Findings from the SENATOR trial

BACKGROUND

Older women experience more adverse drug reactions (ADRs) than older men. However, the underlying basis for this sex difference is unclear. Sex (biological status) and/or gender (sociocultural constructs) influences on patterns of inappropriate prescribing in multimorbid older adults may be one reason for this ADR sex difference. In this secondary analysis, we examined whether incident ADR sex differences could be related to concurrent sex differences in potentially inappropriate prescribing.

DESIGN AND SETTING

A retrospective secondary analysis of sex differences in the prevalence of potentially inappropriate medications (PIMs), potential prescribing omissions (PPOs), and ADRs among the 1537 participants (47.2% female, median [IQR] age 78 [72-84] years) was undertaken in the SENATOR clinical trial database, conducted in six large European medical centers.

PARTICIPANTS AND METHODS

We looked specifically for male/female differences relating to PIMs and PPOs (defined by STOPP/START version 2 criteria) identified within 48 h of acute hospitalization. We also assessed sex differences for ADRs identified at 14 days from admission or discharge, whichever came first. ADRs were assessed by blinded endpoint adjudication panel consensus.

RESULTS

During hospitalization, significantly more females experienced ≥1 ADR compared to males (28% and 21%, respectively; odds ratio 1.40, 95% CI 1.10-1.78, p < 0.005). Nine of the 11 STOPP-criteria PIMs showing a significant sex difference occurred more often in females. Of the four START-criteria PPOs showing a significant sex difference, all occurred more often in females. Some sex-associated PIMs reflect higher prevalence of related conditions in older women.

CONCLUSION

We conclude that specific STOPP-criteria PIMs and START-criteria PPOs were identified more frequently in older women than older men during acute hospitalization, possibly contributing to higher ADR incidence in older women. Prescribers should appreciate sex differences in exposure to potentially inappropriate prescribing and ADR risk, given the preponderance of older women over older men in most clinical settings.

Barriers to therapy adherence in narcolepsy

BACKGROUND

Treatment adherence (TA) in narcolepsy is a complex phenomenon influenced by various factors beyond patient-related aspects. The management of narcolepsy involves non-pharmacological and symptomatic pharmacological treatment. Factors such as chronic daytime sleepiness, cognitive deficits, psychiatric comorbidities and adverse effects of pharmacological treatment are aspects of narcolepsy that could undermine TA, impacting patients' ability or willingness to consistently follow treatment plans. The aim of this study was to identify the factors influencing TA in narcolepsy and to determine the most significant barriers to adherence.

METHODS

An online survey was conducted during the pandemic, assessing demographic and clinical data, medication usage, and adverse effects of treatment. Various questionnaires, such as the Adherence Barriers Questionnaire (ABQ) and Epworth Sleepiness Scale (ESS), were utilized. The ABQ identified patient-specific barriers to medication adherence, while the Patient Health Questionnaire (PHQ-9) assessed depressive symptoms.

RESULTS

We analyzed 243 narcolepsy patients (77 % female, mean age 35.7 ± 12.3 years) with 71 % having narcolepsy type 1 (NT1). The average ESS score was 16.4 (SD ± 3.7). Adherence barriers (AB) were identified in 89 % of patients (216/243) based on ABQ score. The most common barriers reported were "Forgetfulness" (77 %), "Depression" (57 %), and "Side effect-driven medication reduction/stopping behavior" (49 %). Approximately 72 % of patients reported side effects from their narcolepsy medication, leading to discontinuation in 78 % of cases. A moderate correlation was found between the severity of adherence barriers (ABQ score) and levels of depression (PHQ-9 score; rs = 0.412, p = 00.000), as well as ESS score (p = . 048). The results of this study may have been influenced by the pandemic situation.

CONCLUSION

Adherence barriers are common (89 %) and diverse among people with narcolepsy. Many barriers are related to excessive daytime sleepiness (EDS), cognitive deficits or depressive symptoms, highlighting the importance of recognizing and addressing them for optimal TA. Medication side effects, especially occurring when polypharmacology is utilized, also significantly contribute to adherence challenges. Effective communication regarding therapy adherence and improved detection and management of EDS and depression are crucial for enhancing TA in narcolepsy patients.

Trends in Number and Appropriateness of Prescription Medication Utilization Among Community-Dwelling Older Adults in the United States: 2011-2020

BACKGROUND

Contemporary data on the quantity and quality of medication use among older adults are lacking. This study examined recent trends in the number and appropriateness of prescription medication use among older adults in the United States.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES) between 2011 and March 2020 were used, and 6 336 adult participants aged 65 and older were included. We examined the number of prescription medication, prevalence of polypharmacy (≥5 prescription drugs), use of potentially inappropriate medication (PIM), and use of recommended medications (angiotensin-converting enzyme inhibitor [ACEI]/angiotensin receptor blockers [ARBs] plus beta-blockers among patients with heart failure and ACEI/ARBs among patients with albuminuria).

RESULTS

There has been a slight increase in the prevalence of polypharmacy (39.3% in 2011-2012 to 43.8% in 2017-2020, p for trend = .32). Antihypertensive, antihyperlipidemic, antidiabetic medications, and antidepressants are the most commonly used medications. There was no substantial change in the use of PIM (17.0% to 14.7%). Less than 50% of older adults with heart failure received ACEI/ARBs plus beta-blockers (44.3% in 2017-2020) and approximately 50% of patients with albuminuria received ACEI/ARBs (54.0% in 2017-2020), with no improvement over the study period. Polypharmacy, older age, female, and lower socioeconomic status were generally associated with greater use of PIM but lower use of recommended medications.

CONCLUSIONS

The medication burden remained high among older adults in the United States and the appropriate utilization of medications did not improve in the recent decade. Our results underscore the need for greater attentions and interventions to the quality of medication use among older adults.

The Drug Burden Index Is Associated With Measures of Cognitive Function Among Older Adults in the Health, Aging, and Body Composition Study

BACKGROUND

Anticholinergic and sedative medications affect cognition among older adults. The Drug Burden Index (DBI) is a validated measure of exposure to these medications, with higher DBI scores indicating higher drug burden. This ancillary analysis investigated the association between DBI and cognition assessed by the Modified Mini-Mental State Examination (3MS) and the Digit Symbol Substitution Test (DSST).

METHODS

The Health, Aging, and Body Composition Study was a prospective study of community-dwelling adults aged 70-79 years at enrollment. Using data from years 1, 5, and 10, DBI was calculated using medication data per participant. Linear mixed modeling was used to assess cross-sectional and longitudinal effects of DBI on 3MS and DSST. Adjusted models included biological sex, race, education level, APOE status, and death. Sensitivity analyses included testing the strength of the associations for each year and testing attrition due to death as a possible confounding factor via Cox-Proportional Hazard models.

RESULTS

After adjustment, DBI was inversely associated with 3MS and DSST scores. These associations became stronger in each subsequent year. Neither DBI at year 1 nor within-person change in DBI were predictive of longitudinal declines in either cognitive measure. Sensitivity analyses indicated that DBI, 3MS, and DSST were associated with a greater risk of attrition due to death.

CONCLUSIONS

Results suggest that in years when older adults had a higher DBI scores, they had significantly lower global cognition and slower processing speed. These findings further substantiate the DBI as a useful pharmacological tool for assessing the effect of medication exposure.

Frequency, Characteristics, and Preventability of Adverse Drug Reactions in Perioperative Neurosurgery: Analysis Over 11 Years

OBJECTIVE

Despite the importance of adverse drug reactions (ADRs), little is known about their role in perioperative neurosurgery. This study aimed to determine the prevalence of ADRs in perioperative neurosurgery and clarify the characteristics, severity, preventability, and risk factors of ADRs.

METHODS

Data for all patients who underwent neurosurgical procedures over an 11-year period were analyzed. During the study period, 3648 surgical procedures were performed for 2695 patients. Demographic and clinical information documented included medical history, allergic history, diagnosis, surgical method, suspected drugs, concomitant medications, and drug details. Multivariate logistic regression analyses were performed to identify independent parameters that were correlated with ADRs.

RESULTS

In total, 467 ADRs (18.3% ADRs/all neurosurgical procedures) were experienced by 401 patients. Anticonvulsants were associated with the highest number of ADRs (16.0%), followed by antibiotics (14.7%). Patients with ADRs were older than patients without ADRs (P < 0.01). The total number of drugs in patients with ADRs was 8.8 ± 3.6, compared to 5.2 ± 2.4 for patients without ADRs (P < 0.01). There were no significant differences in sex, allergic history, severe renal dysfunction (estimated glomerular filtration rate < 30 ml/min/1.73 m2), hypertension, diabetes, urgency of surgery, and type of surgery. Multivariate analysis showed that a high total number of drugs (odds ratio=3.2; 95% confidence interval 1.9-5.1) and older age (odds ratio=2.1; 95% confidence interval 1.3-3.8) were independent risk factors for ADRs.

CONCLUSIONS

The frequency of suspected and severe ADRs was higher than expected. Polypharmacy and older age were independent risk factors for ADRs in perioperative neurosurgery. To decrease ADRs during perioperative neurosurgery, polypharmacy must be discouraged, especially among older adult patients.

Deprescribing in older adults in a French community: a questionnaire study on patients' beliefs and attitudes

BACKGROUND

General practitioners (GPs) have a central role to play on reduction of polypharmacy and deprescribing. This study aimed to assess beliefs and attitudes towards deprescribing in patients, aged 65 years or older in primary care, and to identify factors associated with deprescribing and their willingness to stop medication.

METHODS

A questionnaire study was performed between 23 May and 29 July 2022 on patients aged 65 years or older attending a GP's surgery in a French area. We used the French version of the revised Patients' Attitudes Towards Deprescribing self-report questionnaire (rPATD), which measures four subscales ("Burden", "Appropriateness", "Concerns about stopping" and, "Involvement"), patients' willingness to stop one of their regular medicines, and patients' satisfaction with their current medicines.

RESULTS

The study enrolled 200 patients. Median age was 76 years old (IQR 71-81), 55% were women, and 42.5% took 5 or more medications per day. Although most patients (92.5%) were satisfied with their current medicines, 35% were reluctant to stop medications they had been taking for a long time, and 89.5% were willing to stop medication if asked to by their GP. Patients aged less than 75 years old reported more concerns about stopping. Women and patients with higher educational attainment showed significantly higher involvement in medication management.

CONCLUSIONS

The majority of older adults were willing to stop one or more of their regular medicines if asked to do so by their GP. GPs should address deprescribing into their current practice.

Comprehensive signal detection of delirium-associated medication using the Food and Drug Administration Adverse Event Reporting System

OBJECTIVE

Several medications are associated with delirium; however, studies with adequate statistical power are limited, and it is difficult to determine the effects of the various concomitant medications used in clinical practice. Therefore, in this study, we aimed to comprehensively evaluate the safety signals of delirium-associated drugs using a spontaneous adverse event reporting system.

METHOD

The JAPIC AERS (Food and Drug Administration Adverse Event Reporting System pre-processed by the Japan Pharmaceutical Information Center) was used for the analysis in this pharmacovigilance study. The reporting odds ratio (ROR) for delirium was adjusted for using multivariate logistic regression analysis with sex, age, indication, and melatonin receptor agonist use, and 22 drug categories were targeted as covariates.

RESULTS

After excluding patients with missing information, 7,527,568 patients were included in the study. Delirium signals were detected even after adjusting for covariates in 17 drug categories, including benzodiazepines (adjusted ROR, 1.76; 95% confidence interval [CI], 1.64-1.89), opioids (adjusted ROR, 4.42; 95% CI, 4.21-4.64), and tricyclic antidepressants (adjusted ROR, 2.44; 95% CI, 2.20-2.71).

CONCLUSIONS

These findings suggest that many drug classes, such as benzodiazepines, are independent risk factors for delirium and strengthen the evidence of an association between delirium and medications.

Polypharmacy Management in Chronic Conditions: A Systematic Literature Review of Italian Interventions

Background: Potentially inappropriate polypharmacy (PIP) is among the major factors leading to adverse drug reactions, increased healthcare costs, reduced medication adherence, and worsened patient conditions. This study aims to identify existing interventions implemented to monitor and manage polypharmacy in the Italian setting. Methods: A systematic literature review (PROSPERO: CRD42023457049) was carried out according to the PRISMA statement guidelines. PubMed, Embase, ProQuest, and Web of Science were queried without temporal constraints, encompassing all published papers until October 2023. Inclusion criteria followed the PICO model: patients with polypharmacy; interventions to monitor/manage polypharmacy regimen versus no/any intervention; outcomes in terms of intervention effectiveness and cost variation. Results: After duplicate deletion, 153 potentially relevant publications were extracted. Following abstract and full-text screenings, nine articles met the inclusion criteria. Overall, 78% (n = 7) were observational studies, 11% (n = 1) were experimental studies, and 11% (n = 1) were two-phase studies. A total of 44% (n = 4) of the studies involved patients aged ≥ 65 years, while 56% (n = 5) were disease-specific. Monitoring was the most prevalent choice of intervention (67%; n = 6). Outcomes were mainly related to levels of polypharmacy (29%; n = 6) and comorbidities (29%; n = 6), effectiveness rates (14%; n = 3), and avoidable costs (9%; n = 2). Conclusions: This review outlines that Italy is still lacking in interventions to monitor/manage PIP, addressing an unmet need in developing patient-tailored strategies for reducing health-system burden.

Polypharmacy and medication regimen complexity in transfusion-dependent thalassaemia patients: a cross- sectional study

BACKGROUND

Medication burden and complexity have been longstanding problems in chronically ill patients. However, more data are needed on the extent and impact of medication burden and complexity in the transfusion-dependent thalassaemia population.

AIM

The aim of this study was to determine the characteristics of medication complexity and polypharmacy and determine their relationship with drug-related problems (DRP) and control of iron overload in transfusion-dependent thalassaemia patients.

METHOD

Data were derived from a cross-sectional observational study on characteristics of DRPs conducted at a Malaysian tertiary hospital. The medication regimen complexity index (MRCI) was determined using a validated tool, and polypharmacy was defined as the chronic use of five or more medications. The receiver operating characteristic curve analysis was used to determine the optimal cut-off value for MRCI, and logistic regression analysis was conducted.

RESULTS

The study enrolled 200 adult patients. The MRCI cut-off point was proposed to be 17.5 (Area Under Curve  =  0.722; sensitivity of 73.3% and specificity of 62.0%). Approximately 73% and 64.5% of the patients had polypharmacy and high MRCI, respectively. Findings indicated that DRP was a full mediator in the association between MRCI and iron overload.

CONCLUSION

Transfusion-dependent thalassaemia patients have high MRCI and suboptimal control of iron overload conditions in the presence of DRPs. Thus, future interventions should consider MRCI and DRP as factors in serum iron control.

Oral anticoagulant therapy in older adults

Patients aged ≥65 years not only account for the majority of patients with atrial fibrillation (AF) and venous thromboembolism (VTE), they are also at a higher risk of morbidity, mortality, and undertreatment than younger patients. Several age-related physiological changes with effects on drug pharmacokinetics/-dynamics and blood vessel fragility as well as the higher prevalence of geriatric conditions such as frailty, multimorbidity, polypharmacy, fall risk, dementia, and malnutrition make older persons more vulnerable to disease- and anticoagulation-related complications. Moreover, because older patients with AF/VTE are underrepresented in oral anticoagulation (OAC) trials, evidence on OAC in older adults with AF/VTE is mainly based on subgroup analyses from clinical trials and observational studies. A growing body of such limited evidence suggests that direct oral anticoagulants (DOACs) may be superior in terms of efficacy and safety compared to vitamin K antagonists in older persons with AF/VTE and that specific DOACs may have a differing risk-benefit profile. In this narrative review, we summarize the evidence on epidemiology of AF/VTE, impact of age-related physiological changes, efficacy/safety of OAC, specifically considering individuals with common geriatric conditions, and review OAC guideline recommendations for older adults with AF/VTE. We also propose a research agenda to improve the evidence basis on OAC older individuals with AF/VTE, including the conduct of advanced age-specific and pragmatic studies using less restrictive eligibility criteria and patient-reported health outcomes, in order to compare the effectiveness and safety of different DOACs, and investigate lower-dose regimens and optimal OAC durations in older patients.

[Deprescribing in DGPPN S3 guidelines-a systematic analysis]

BACKGROUND

Deprescribing of medication or psychotherapy represents a critical phase in treatment. The aim of the work is to systematically analyze recommendations for deprescribing medication and discontinuation of psychotherapy in the evidence- and consensus-based S3 guidelines of the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) to identify potential research gaps.

METHODS

A systematic analysis of the DGPPN S3 guidelines to investigate and compare information and recommendations on deprescribing.

RESULTS

Regarding deprescribing of medication, our analysis showed that eight of the 20 included S3 guidelines contain information both in the form of recommendations and background information. Regarding psychotherapy, only two guidelines provided information on deprescribing.

CONCLUSION

Our results highlight the need to expand guidelines to include evidence-based recommendations for deprescribing medication or discontinuation of psychotherapy. Future research should focus on the development of specific, generic, and evidence-based guidelines that support both medical staff and patients during these critical phases of therapy.

Deprescribing in older adults with polypharmacy

Polypharmacy is common in older adults and is associated with adverse drug events, cognitive and functional impairment, increased healthcare costs, and increased risk of frailty, falls, hospitalizations, and mortality. Many barriers exist to deprescribing, but increased efforts have been made to develop and implement deprescribing interventions that overcome them. This narrative review describes intervention components and summarizes findings from published randomized controlled trials that have tested deprescribing interventions in older adults with polypharmacy, as well as reports on ongoing trials, guidelines, and resources that can be used to facilitate deprescribing. Most interventions were medication reviews in primary care settings, and many contained components such as shared decision making and/or a focus on patient care priorities, training for healthcare professionals, patient facing education materials, and involvement of family members, representing great heterogeneity in interventions addressing polypharmacy in older adults. Just over half of study interventions were found to perform better than usual care in at least one of their primary outcomes, and most study interventions were assessed over 12 months or less.

Inappropriate Polypharmacy and the Need for Comprehensive Medication Management Service

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Rosacea in Older Adults and Pharmacologic Treatments

Rosacea is a chronic inflammatory skin condition that is often more severe in older patients. The main clinical features are erythema, telangiectasia, and inflammatory lesions of the face. The pathogenesis of this condition is not fully understood but certainly multifaceted. Immune and inflammatory dysregulation, genetics, neurogenic dysregulation, microbiome dysbiosis, and systemic disease have all been implicated in rosacea pathogenesis. As we better understand the various pathways that lead to rosacea, we acknowledge that the different symptoms may have unique underlying triggers and mechanisms. Aging also impacts rosacea diagnosis and treatment. Older adults have more severe rosacea symptoms while also having more sensitive and fragile skin than younger patients; therefore, rosacea treatments for older patients require a balance between delivering adequate potency while also minimizing skin irritation and other adverse effects. Until recently, rosacea diagnoses were based on concrete subtypes that did not necessarily capture each patient's manifestation of rosacea. There is now an emphasis on more personalized phenotype-based diagnoses and treatments, which allows for more emphasis on treating individual symptoms and accounting for the unique characteristics of older patients. Centrofacial erythema is best treated with brimonidine and oxymetazoline, while phymatous change and telangiectasia are best treated with surgery and laser ablation. Treatment for rosacea papules and pustules ranges from topicals, such as azelaic acid, ivermectin, metronidazole, minocycline, and encapsulated benzoyl peroxide, to systemics, such as doxycycline and isotretinoin. It is important to understand these treatments in relation to adverse effects and drug interactions that may specifically arise in older populations to provide optimal care. As we advance in understanding rosacea's pathogenesis and adopt personalized phenotype-based approaches, optimizing care for older patients becomes crucial. Continued research into novel treatments is essential to address their unique needs.

Cefepime-induced encephalopathy in an older patient with polypharmacy and renal insufficiency: a case report

The world population is rapidly aging. Societal aging poses many challenges for individuals, families, nations, and the global healthcare system. Therefore, geriatric care is a crucial issue that demands our attention. In this case report, we describe a woman in her early 70s with multiple comorbidities, polypharmacy, and renal insufficiency who developed cefepime-induced encephalopathy with moderate to severe cerebral dysfunction during treatment of a urinary tract infection. The patient's consciousness level gradually improved, and no further seizures were observed following the discontinuation of cefepime for several days. This case report underscores the fact that polypharmacy and medication safety are significant concerns that are often overlooked when caring for older patients. The report also highlights the increased susceptibility of older individuals to antibiotic-associated adverse reactions during the management of infectious diseases. Therefore, optimization of antibiotic therapy for older patients is a critical issue that requires thorough investigation and consideration in geriatric care.

Investigating the association of anticholinergic burden with depression in older adults: a cross-sectional study

BACKGROUND

Although depression and anticholinergic drug use are common comorbidities that impair health status in later life, there are insufficient data on their relationship. This study aimed to investigate the relationship between depressive symptoms and anticholinergic use in older individuals.

METHODS

Community-dwelling older adults (≥65 years) admitted to the tertiary referral geriatric outpatient clinic were included. Participants were evaluated for depressive symptoms using the Geriatric Depression Scale (GDS) with a cut-off score of ≥6 for depression. Exposure to anticholinergic drugs was assessed using the anticholinergic cognitive burden (ACB) scale and three subgroups were created: ACB = 0, ACB = 1, and ACB ≥ 2. The relationship between these two parameters was assessed using multivariate logistic regression analysis considering other potential variables.

RESULTS

The study included 1232 participants (mean age 78.4 ± 7.2 years and 65.2% female) and the prevalence of depression was 24%. After adjusting for potential confounders, compared to ACB = 0, having ACB ≥ 2 was related to depression symptoms (odds ratio (OR): 1.56, 95% CI: 1.04-2.35, P = 0.034), whereas having ACB = 1 did not increase the risk (OR: 1.27, 95% CI: 0.88-1.83, P = 0.205).

CONCLUSION

Our findings indicate that special attention should be paid to drug therapy in preventing depression in older adults, as exposure to a high anticholinergic load is negatively associated with psychological status.

Digital Medication Management in Polypharmacy

BACKGROUND

Inappropriate drug prescriptions for patients with polypharmacy can have avoidable adverse consequences. We studied the effects of a clinical decision-support system (CDSS) for medication management on hospitalizations and mortality.

METHODS

This stepped-wedge, cluster-randomized, controlled trial involved an open cohort of adult patients with polypharmacy in primary care practices (=clusters) in Westphalia-Lippe, Germany. During the period of the intervention, their medication lists were checked annually using the CDSS. The CDSS warns against inappropriate prescriptions on the basis of patient-related health insurance data. The combined primary endpoint consisted of overall mortality and hospitalization for any reason. The secondary endpoints were mortality, hospitalizations, and high-risk prescription. We analyzed the quarterly health insurance data of the intention- to-treat population with a mixed logistic model taking account of clustering and repeated measurements. Sensitivity analyses addressed effects of the COVID-19 pandemic and other effects.

RESULTS

688 primary care practices were randomized, and data were obtained on 42 700 patients over 391 994 quarter years. No significant reduction was found in either the primary endpoint (odds ratio [OR] 1.00; 95% confidence interval [0.95; 1.04]; p = 0.8716) or the secondary endpoints (hospitalizations: OR 1.00 [0.95; 1.05]; mortality: OR 1.04 [0.92; 1.17]; high-risk prescription: OR 0.98 [0.92; 1.04]).

CONCLUSION

The planned analyses did not reveal any significant effect of the intervention. Pandemicadjusted analyses yielded evidence that the mortality of adult patients with polypharmacy might potentially be lowered by the CDSS. Controlled trials with appropriate follow-up are needed to prove that a CDSS has significant effects on mortality in patients with polypharmacy.

Influence of chronic medical conditions on older patients' willingness to deprescribe medications: a cross-sectional study

BACKGROUND

Aging correlates with a heightened prevalence of chronic diseases, resulting in multimorbidity affecting 60% of those aged 65 or older. Multimorbidity often leads to polypharmacy, elevating the risk of potentially inappropriate medication (PIM) use and adverse health outcomes. To address these issues, deprescribing has emerged as a patient-centered approach that considers patients' beliefs and attitudes toward medication and reduces inappropriate polypharmacy in older adults. Our study aims to investigate whether certain chronic medical conditions are associated with older patients' willingness to deprescribe medications.

METHODS

A cross-sectional study enrolled 192 community-dwelling individuals aged 65 or older taking at least one regular medication. Data included demographics, clinical characteristics, and responses to the Portuguese revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. Descriptive statistics characterized participants, while multiple binary logistic regression identified associations between chronic medical conditions and willingness to deprescribe.

RESULTS

Among the participants (median age: 72 years, 65.6% female), 91.6% had multimorbidity. The analysis revealed that willingness to deprescribe significantly increased with the presence of gastric disease (adjusted odds ratio [aOR] = 4.123; 95% CI 1.221, 13.915) and age (aOR = 1.121; 95% CI 1.009, 1.246). Conversely, prostatic pathology (aOR = 0.266; 95% CI 0.077, 0.916), higher scores in the rPATD appropriateness factor (aOR = 0.384; 95% CI 0.190, 0.773), and rPATD concerns about stopping factor (aOR = 0.450; 95% CI 0.229, 0.883) diminished patients' willingness to deprescribe.

CONCLUSIONS

This study highlights the intricate relationship between older patients' attitudes toward deprescribing and chronic medical conditions. We found that gastric disease was associated with an increased willingness to deprescribe medications, while prostate disease was associated with the opposite effect. Future research should explore how patients with specific diseases or groups of diseases perceive deprescribing of medications general and for specific medications, aiding in the development of targeted interventions.

Prevalence of multimorbidity and polypharmacy among adults and older adults: a systematic review

Multimorbidity (multiple conditions) and polypharmacy (multiple medications) are increasingly common, yet there is a need to better understand the prevalence of co-occurrence. In this systematic review, we examined the prevalence of multimorbidity and polypharmacy among adults (≥18 years) and older adults (≥65 years) in clinical and community settings. Six electronic databases were searched, and 87 studies were retained after two levels of screening. Most studies focused on adults 65 years and older and were done in population-based community settings. Although the operational definitions of multimorbidity and polypharmacy varied across studies, consistent cut-points (two or more conditions and five or more medications) were used across most studies. In older adult samples, the prevalence of multimorbidity ranged from 4·8% to 93·1%, while the prevalence of polypharmacy ranged from 2·6% to 86·6%. High heterogeneity between studies indicates the need for more consistent reporting of specific lists of conditions and medications used in operational definitions.

Comparing AGS Beers 2019, STOPP version 2, and EU(7)-PIM list in Portuguese older adults in primary health care

PURPOSE

This study aims to identify PIM prevalence in older adults according to the 2019 Beers criteria, Screening Tool of Older Person's Prescriptions version 2 (STOPP v2) criteria, and the Portuguese EU(7)-PIM list and also to analyze the concordance between these criteria.

METHODS

A retrospective study was conducted among 1200 Portuguese older adults (≥ 65 years old), users of primary health care. Demographic, clinical, and pharmacological data were collected concerning the period between April 2021 and August 2022. A comparative analysis was performed between the three PIM identification criteria, and the concordance was determined according to the Lin concordance correlation coefficient.

RESULTS

The mean age was 76.3 (SD 7.7) years old and 57.6% of the older adults were females. Our findings indicate varying prevalence rates among these criteria with 63.8% (95% CI 61.0-66.6%), 66.8% (95% CI 64.1-69.5%), and 50.1% (95% CI 47.2-53.0%) of the older adults take at least one PIM according to the EU(7)-PIM list, Beers 2019, and STOPP v2 criteria, respectively. The highest prevalence observed was for proton pump inhibitors according to EU(7)-PIM list (30.1%, 95% CI 27.6-32.9) and Beers criteria (30.1%, 95% CI 27.6-32.9) and alprazolam according to STOPP v2 criteria (10.1%, 95% CI 8.4-11.9%). A poor concordance between criteria was observed (< 0.834). The highest concordance coefficient was found between the EU(7)-PIM list and the Beers criteria (0.833), and the lowest between the EU(7)-PIM list and STOPP criteria (0.735).

CONCLUSION

This study reveals varying prevalence rates of PIM in older adults, as assessed by different criteria, and highlights the need for targeted interventions and improved prescribing practices. In the future, studies should focus on the occurrence of negative outcomes in older adults associated with PIM consumption.

The association of degree of polypharmacy before and after among hospitalised internal medicine patients and clinical outcomes: a retrospective, population-based cohort study

OBJECTIVES

To determine the prevalence and incidence of polypharmacy/hyperpolypharmacy and which medications are most prescribed to patients with varying burden of polypharmacy.

DESIGN

Retrospective, population-based cohort study.

SETTING

Iceland.

PARTICIPANTS

Including patients (≥18 years) admitted to internal medicine services at Landspitali - The National University Hospital of Iceland, between 1 January 2010 with a follow-up of clinical outcomes through 17 March 2022.

MAIN OUTCOMES MEASURES

Participants were categorised into medication use categories of non-polypharmacy (<5), polypharmacy (5-10) and hyperpolypharmacy (>10) based on the number of medications filled in the year predischarge and postdischarge. The primary outcome was prevalence and incidence of new polypharmacy. Secondary outcomes were mortality, length of hospital stay and re-admission.

RESULTS

Among 85 942 admissions (51% male), the median (IQR) age was 73 (60-83) years. The prevalence of preadmission non-polypharmacy was 15.1% (95% CI 14.9 to 15.3), polypharmacy was 22.9% (95% CI 22.6 to 23.2) and hyperpolypharmacy was 62.5% (95% CI 62.2 to 62.9). The incidence of new postdischarge polypharmacy was 33.4% (95% CI 32.9 to 33.9), and for hyperpolypharmacy was 28.9% (95% CI 28.3 to 29.5) for patients with preadmission polypharmacy. Patients with a higher level of medication use were more likely to use multidose drug dispensing and have a diagnosis of adverse drug reaction. Other comorbidities, including responsible subspeciality and estimates of comorbidity and frailty burden, were identical between groups of varying polypharmacy. There was no difference in length of stay, re-admission rate and mortality.

CONCLUSIONS

Preadmission polypharmacy/hyperpolypharmacy and postdischarge new polypharmacy/hyperpolypharmacy is common amongst patients admitted to internal medicine. A higher level of medication use category was not found to be associated with demographic, comorbidity and clinical outcomes. Medications that are frequently inappropriately prescribed were among the most prescribed medications in the group. An increased focus on optimising medication usage is needed after hospital admission.

TRIAL REGISTRATION NUMBER

NCT05756400.

Smartphone-delivered approach bias modification for reducing harmful drinking amongst middle-older age adults: Secondary analyses of a single-arm pilot study

INTRODUCTION

Novel, scalable, low-cost interventions are needed to reduce harmful drinking amongst middle-older adults. Approach bias modification (ApBM) is a promising form of cognitive training for preventing/reducing alcohol use that can be delivered via smartphone. This study explored the acceptability and preliminary effectiveness of smartphone delivered and personalised ApBM amongst Australians ≥55 years, an age cohort at risk of alcohol-related harms.

METHODS

Secondary analyses in a middle-older adult subsample (≥55 years, n = 289) of an open-label pilot study using a retrospective, repeated measures design. We explored acceptability (adherence, user mobile acceptability ratings, free-text responses) and preliminary effectiveness (changes in drinking quantity and frequency, craving, dependence and proportion drinking within government-recommended guidelines) of two sessions/week over 4 weeks of evidence-based ApBM training, adapted to include personalisation and smartphone delivery amongst Australians ≥55 years.

RESULTS

Although minor adaptations to training were suggested, the intervention was acceptable amongst survey completers, with 72% training adherence. Relative to baseline, there was a significant increase in the proportion of drinking within recommended single-session and weekly guidelines post-training (from 25% to 41% and 6% to 28%, respectively, p < 0.001), with past-week standard drinks significantly decreasing by 18% (p < 0.001) and significant reductions in drinking days, mean craving and dependence scores (p < 0.001).

DISCUSSION AND CONCLUSIONS

Findings suggest smartphone ApBM is acceptable amongst middle-to-older aged Australians and may support this 'at risk' cohort to remain within government-recommended alcohol consumption guidelines to optimise healthy aging, although, in the context of a single-arm study, preliminary results should be interpreted cautiously.

Is there a role for earlier use of combination therapy?

As the global population ages and cardiovascular risk factors rise, we can expect a continued increase in atherosclerotic disease. Low-density lipoprotein cholesterol (LDL-C) reduction is a cornerstone of cardiovascular risk reduction with strong, causal evidence indicating that the greatest benefit is derived from early and large decreases in LDL-C. Despite the adoption of statins as the backbone of lipid-therapy regimens, numerous studies and registry analyses reveal our collective inability to achieve LDL-C goals in high-risk patients. Combination therapy with ezetimibe has been shown to result in statistically significant decreases in LDL-C level, atheroma volume, and cardiovascular adverse event rates. A major barrier to implementing an upfront combination therapy approach is the perceived side effects from therapeutic agents although multiple studies show that a therapeutic patient-physician relationship could overcome this issue. Novel agents such as PCSK-9 inhibitors, bempedoic acid, and inclisiran have the potential to achieve similar outcomes although additional research is needed regarding the cost effectiveness of these approaches. Despite these hurdles, there is a role for the newer agents early in the disease course of high-risk patients such as those with markedly elevated LDL-C >190 mg/dL and FH. The implementation of upfront combination therapy, especially in high-risk patients, will decrease clinical inertia while allowing for earlier consideration of newer, effective agents to decrease cardiovascular burden.

Potentially inappropriate medication use among older adults with lower-limb loss

OBJECTIVE

The aim of this study was to evaluate the prevalence of, and explore factors related to, prescription of potentially inappropriate medications (PIMs) among older adults with lower-limb loss (LLL).

METHODS

This was a secondary analysis of a cross-sectional dataset collected through an interdisciplinary limb loss clinic between September 2013 and November 2022. Self-report medication lists were reviewed during in-clinic face-to-face interviews and compared to the American Geriatrics Society Beers Criteria corresponding to the patient's evaluation year.

RESULTS

Of 82 participants (72.9 ± 6.6 years-old; 78.0 % male), n = 41 (50.0 %) reported using one or more PIM. PIM prescription was significantly associated with presence of phantom limb pain, history of upper gastrointestinal issues, and a greater number of medications.

DISCUSSION

Polypharmacy and PIM use are common among older adults with LLL. Greater attention should be paid to medications post-amputation, especially pain management medications, to minimize potential adverse side-effects.

Chronic diseases spectrum and multimorbidity in elderly inpatients based on a 12-year epidemiological survey in China

BACKGROUND

The number and proportion of the elderly population have been continuously increasing in China, leading to the elevated prevalence of chronic diseases and multimorbidity, which ultimately brings heavy burden to society and families. Meanwhile, the status of multimorbidity tends to be more complex in elderly inpatients than community population. In view of the above concerns, this study was designed to investigate the health status of elderly inpatients by analyzing clinical data in Chinese People's Liberation Army (PLA) General Hospital from 2008 to 2019, including the constitution of common diseases, comorbidities, the status of multimorbidity, in-hospital death and polypharmacy among elderly inpatients, so as to better understand the diseases spectrum and multimorbidity of elderly inpatients and also to provide supporting evidence for targeted management of chronic diseases in the elderly.

METHODS

A clinical inpatients database was set up by collecting medical records of elderly inpatients from 2008 to 2019 in Chinese PLA General Hospital, focusing on diseases spectrum and characteristics of elderly inpatients. In this study, we collected data of inpatients aged ≥ 65 years old, and further analyzed the constitution of diseases, multimorbidity rates and mortality causes in the past decade. In addition, the prescriptions were also analyzed to investigate the status of polypharmacy in elderly inpatients.

RESULTS

A total of 210,169 elderly patients were hospitalized from January 1st, 2008 to December 31st, 2019. The corresponding number of hospitalizations was 290,833. The average age of the study population was 72.67 years old. Of the total population, 73,493 elderly patients were re-admitted within one year, with the re-hospitalization rate of 25.27%. Malignant tumor, hypertension, ischemic heart disease, diabetes mellitus and cerebrovascular disease were the top 5 diseases. Among the study population, the number of patients with two or more long-term health conditions was 267,259, accounting for 91.89%, with an average of 4.68 diseases. In addition, the average number of medications taken by the study population was 5.4, among which, the proportion of patients taking more than 5 types of medications accounted for 55.42%.

CONCLUSIONS

By analyzing the constitution of diseases and multimorbidity, we found that multimorbidity has turned out to be a prominent problem in elderly inpatients, greatly affecting the process of healthy aging and increasing the burden on families and society. Therefore, multidisciplinary treatment should be strengthened to make reasonable preventive and therapeutic strategies to improve the life quality of the elderly. Meanwhile, more attention should be paid to reasonable medications for elderly patients with multimorbidity to avoid preventable side effects caused by irrational medication therapy.

Underuse of heart failure medications and poor long-term prognosis in chronic heart failure patients with polypharmacy - A report from the CHART-2 study

Background

In patients with chronic heart failure (CHF), comorbidities are often managed with multiple medications, characterized by polypharmacy, leading to increased risk of potentially inappropriate medication and adverse effects.

Methods

We studied 4,876 consecutive patients with CHF (Stage C/D, age 69.0 ± 12.3 years) in the CHART-2 study to evaluate the association among polypharmacy, underuse of HF medications, and all-cause death. Polypharmacy was defined as the daily use of ≥ 8 medications for the survival classification and regression tree analysis.

Results

The average number of medications was 10 in the polypharmacy group and 5 in the non-polypharmacy group, respectively. Over a median of 8.3 (4.1-11.7) years, the incidence rate of all-cause death was significantly higher in the polypharmacy group (n = 2,108) than in the non-polypharmacy group (57.3 % vs. 40.6 %; adjusted hazard ratio [aHR] 1.34 (95 %CI, 1.22-1.48), P < 0.001), even in age < 55 years (26.6 % vs. 14.3 %; adjusted hazard ratio [aHR] 1.61 (95 %CI, 1.04-2.50), P = 0.033). In patients with polypharmacy, those without renin-angiotensin system inhibitors (RAS-I) and/or beta-blockers (N = 1,023) were associated with increased incidence of all-cause death as compared with those with both medications (aHR 1.18; 95 %CI 1.04-1.35, P = 0.012).

Conclusions

Polypharmacy was associated with poor long-term prognosis, even in younger patients with CHF. Among 4,876 patients with CHF, 1023 (20.9%) with polypharmacy and underuse of RAS-I and/or beta-blocker were associated with increased risk of all-cause death.

[Palliative Care Needs in Primary Health Care: Characteristics of Patients with Advanced Cancer and Dementia]

INTRODUCTION

The increase in life expectancy brought a higher prevalence of chronic diseases, with an emphasis on those who reached advanced stages and required palliative care. We aimed to characterize patients diagnosed with advanced neoplasms and/or dementia accompanied in primary health care and to test the sensitivity of two tools for identifying patients with palliative needs.

METHODS

We recruited three voluntary family physicians who provided data relative to 623 patients with active codification for neoplasm and/or dementia on the MIM@UF platform. We defined 'patient with palliative needs' as any patient with this codification in advanced stadium and made their clinical and sociodemographic characterization. Assuming the existence of advanced-stage disease as the gold standard, we calculated and compared the sensitivities of each of the tools under study: the surprise question, the question 'do you think this patient has palliative needs?' and an instrument that corresponded to identification by at least one of the questions.

RESULTS

Among the analyzed data, there were 559 (89.7%) active codifications of neoplasm and 64 (10.3%) of dementia; the prevalence of advanced neoplasm and dementia was 1.0% in the studied sample. The subgroup of patients with advanced dementia showed female sex predominance, an older age, and less access to health care. In both subgroups there was a scarcity of data related to education and income, and we observed polypharmacotherapy and multimorbidity. The sensitivity of the surprise question was 33.3% for neoplasia and 69.3% for dementia; of the new tool 50.0% for neoplasia and 92.3% for dementia; and, when used together, 55.6% for neoplasia and 92.3% for dementia.

CONCLUSION

Our results help characterize two subpopulations of patients in need of palliative care and advance with a possible tool for their identification, to be confirmed in a representative sample.

Older adults' attitudes towards deprescribing and medication changes: a longitudinal sub-study of a cluster randomised controlled trial

OBJECTIVE

To investigate the association between older patients' willingness to have one or more medications deprescribed and: (1) change in medications, (2) change in the appropriateness of medications and (3) implementation of prescribing recommendations generated by the electronic decision support system tested in the 'Optimising PharmacoTherapy In the Multimorbid Elderly in Primary CAre' (OPTICA) trial.

DESIGN

A longitudinal sub-study of the OPTICA trial, a cluster randomised controlled trial.

SETTING

Swiss primary care settings.

PARTICIPANTS

Participants were aged ≥65 years, with ≥3 chronic conditions and ≥5 regular medications recruited from 43 general practitioner (GP) practices.

EXPOSURES

Patients' willingness to have medications deprescribed was assessed using three questions from the 'revised Patient Attitudes Towards Deprescribing' (rPATD) questionnaire and its concerns about stopping score.

MEASURES/ANALYSES

Medication-related outcomes were collected at 1 year follow-up. Aim 1 outcome: change in the number of long-term medications between baseline and 12 month follow-up. Aim 2 outcome: change in medication appropriateness (Medication Appropriateness Index). Aim 3 outcome: binary variable on whether any prescribing recommendation generated during the OPTICA medication review was implemented. We used multilevel linear regression analyses (aim 1 and aim 2) and multilevel logistic regression analyses (aim 3). Models were adjusted for sociodemographic variables and the clustering effect at GP level.

RESULTS

298 patients completed the rPATD, 45% were women and 78 years was the median age. A statistically significant association was found between the concerns about stopping score and the change in the number of medications over time (per 1-unit increase in the score the average number of medications use was 0.65 higher; 95% CI: 0.08 to 1.22). Other than that we did not find evidence for statistically significant associations between patients' agreement with deprescribing and medication-related outcomes.

CONCLUSIONS

We did not find evidence for an association between most measures of patient agreement with deprescribing and medication-related outcomes over 1 year.

TRIAL REGISTRATION NUMBER

NCT03724539.

Polypharmacy and Associated Health Outcomes in the PARI-HD Study

Background

A growing body of evidence points to potential risks associated with polypharmacy (using ≥5 medications) in older adults, but most evidence is derived from studies where racial and ethnic minorities remain underrepresented among research participants.

Objective

Investigate the association between polypharmacy and cognitive function, subjective health state, frailty, and falls in Hispanic older adults.

Methods

Panama Aging Research Initiative-Health Disparities (PARI-HD) is a community-based cohort study of older adults free of dementia at baseline. Cognitive function was measured with a neuropsychological test battery. Frailty assessment was based on the Fried criteria. Subjective health state and falls were self-reported. Linear and multinomial logistic regression analyses were used to examine association.

Results

Baseline evaluations of 468 individuals with a mean age of 69.9 years (SD = 6.8) were included. The median number of medications was 2 (IQR: 1-4); the rate of polypharmacy was 19.7% (95% confidence interval [CI] = 16.1-23.3). Polypharmacy was inversely associated with self-rated overall health (b =-5.89, p < 0.01). Polypharmacy users had 2.3 times higher odds of reporting two or more falls in the previous 12 months (odds ratio [OR] = 2.31, 95% CI = 1.06-5.04). Polypharmacy was independently associated with Fried's criteria for pre-frailty (OR = 2.90, 95% CI = 1.36-5.96) and frailty (OR = 5.14, 95% CI = 1.83-14.42). Polypharmacy was not associated with cognitive impairment.

Conclusions

These findings illustrate the potential risks associated with polypharmacy among older adults in Panama and may inform interventions to improve health outcomes in this population.

Polypharmacy in patients with multiple sclerosis and the impact on levels of care and therapy units

Background

The aim of this study was to examine the societal costs of polypharmacy in patients with multiple sclerosis (MS). We therefore focused on the association between the number of medications on the level of care (LOC), the German classification of the need for care, and the number of therapy sessions (TTU).

Methods

In addition to demographic information and medication, 101 MS patients performed the Multiple Sclerosis Health Resource Utilization Survey (MS-HRS). Medications were subdivided into a total number of medications (TD), MS-related medication [MSD, i.e., disease-modifying drugs (DMDs) and symptomatic treatment (SD)], and medication for comorbidities (CDs). Multivariate linear regression models were performed to estimate if the amount of each medication type affects LOC or TTU.

Results

Polypharmacy appeared in 54 patients at the time of the survey. The relative risk (RR) of LOC 1 increased significantly by 2.46 (p = 0.001) per TD and by 2.55 (p = 0.004) per MSD, but not per CD (RR 1.44; p = 0.092). The effect of RR on MSD was driven by SD (RR 2.2; p = 0.013) but not DMD (RR 2.6; p = 0.4). RR of MSD remained significant for LOC 2 (1.77; p = 0.009) and LOC 3/4 (1.91; p = 0.015), with a strong trend in RR of SD, but not DMD. TTU increased significantly per MSD (p = 0.012), but not per TD (p = 0.081) and CD (p = 0.724).

Conclusion

The number of MSDs is related to the likelihood of a higher level of care and the number of therapy sessions and is therefore a good indication of the extent of the societal costs.

Drug-Related Problems in Elderly Patients Attended to by Emergency Services

The progressive aging and comorbidities of the population have led to an increase in the number of patients with polypharmacy attended to in the emergency department. Drug-related problems (DRPs) have become a major cause of admission to these units, as well as a high rate of short-term readmissions. Anticoagulants, antibiotics, antidiabetics, and opioids have been shown to be the most common drugs involved in this issue. Inappropriate polypharmacy has been pointed out as one of the major causes of these emergency visits. Different ways of conducting chronic medication reviews at discharge, primary care coordination, and phone contact with patients at discharge have been shown to reduce new hospitalizations and new emergency room visits due to DRPs, and they are key elements for improving the quality of care provided by emergency services.

Prevalence of polypharmacy in heart failure patients: A retrospective cross-sectional study in a tertiary hospital in Saudi Arabia

Background

Cardiovascular disease is the leading cause of death and disability worldwide. It is a general term used to describe a group of disorders that affect the heart or blood vessels. This study aimed to evaluate the prevalence and predictors of polypharmacy in patients with heart failure.

Methods

We conducted a cross-sectional study in a tertiary hospital in Saudi Arabia. Data was extracted from an electronic database between January 2019, and December 2022. The study included all adult patients with heart failure who visited outpatient clinics; individuals with cancer were excluded. The outcome variable in our study was "polypharmacy" which was defined as the use of eight or more medications. Descriptive analysis was performed using frequencies and percentages for categorical variables. In addition, Multivariate logistic regression was used to assess the covariates associated with polypharmacy.

Results

A total of 331 patients with heart failure were included in this study. The prevalence of polypharmacy among our HF population was 39.88 %. Most participants were male (60.73 %), and 60 years or older (68 %). The most frequently used medications were beta-blockers (67.98 %) and diuretics (58.31 %), whereas the least frequently used medications were hydralazine and histamine H2 blockers (5.74, and 3.02 %, respectively). Polypharmacy was likely to be a non-significantly higher in individuals aged between 60 and 69 years (adjusted odds ratio (AOR) = 1.52; 95 % confidence interval (CI) 0.78-2.98) and suffering from hypertension (AOR = 1.48; 95 % CI 0.83-2.64). However, patients with heart failure and diabetes mellitus had a significant six-fold higher of polypharmacy than those without diabetes mellitus (AOR = 6.55; 95 % CI 3.71-11.56).

Conclusion

Patients with heart failure often use multiple medications. Patients with heart failure together with diabetes have a higher risk of polypharmacy. Therefore, healthcare professionals should manage polypharmacy to improve the outcomes in patients with heart failure.

Polypharmacy in the Cardiovascular Geriatric Critical Care Population: Improving Outcomes

The cardiovascular geriatric population requiring intensive or critical care is a group vulnerable to adverse outcomes because of age, the critical care environment, geriatric syndromes, and multiple chronic conditions. Polypharmacy increases the risk of adverse events in this group. Several tools and aids are available to guide the clinical practice of appropriate prescribing and deprescribing. To optimize the care of the cardiovascular geriatric population, evidence-based prescribing, and deprescribing tools can be implemented by the interprofessional team consisting of the patient, their support system, critical care nurses, advanced practice clinicians, physicians, and allied health professionals.

Drivers of calcium oxalate stone formation in the octogenarian population

INTRODUCTION

American Urological Association (AUA) guidelines suggest metabolic testing via 24-h urine studies in high-risk, interested first-time stone formers, and recurrent stone formers. If metabolic testing is not available or otherwise not feasible, clinicians may need to utilize empiric therapy. Debility and social barriers, particularly in the elderly population, may limit the practicality of metabolic testing, and therefore, empiric therapy is of particular importance. The aim of this study is to identify whether unique urinary metabolic abnormality profiles exist for octogenarians with calcium oxalate kidney stones, as this may guide empiric stone prevention therapy more precisely in this population.

MATERIALS AND METHODS

Patients with calcium oxalate stones from a single academic kidney stone center in New York, NY, were retrospectively identified in our prospectively managed database. Patient data, including demographic, clinical information, and baseline 24-h urine studies, were collected before initiating any treatment. Subjects were stratified by age (≤ 40, 41-59, 60-79, and ≥ 80 years) to compare the metabolic urinary abnormality profiles between octogenarians and other age groups. Subgroup analyses were also performed to compare results by gender and by the presence of underlying kidney dysfunction. Comparative statistical analysis was carried out using Chi-square tests, Mann-Whitney U tests, and t-tests where appropriate.

RESULTS

Hypocitraturia, low urine pH, and low urine volume were most common in older patients, particularly in octogenarians. Hypercalciuria, hypernatriuria, and hyperuricosuria were more apparent in younger groups.

CONCLUSION

With increasing age, hypocitraturia, low urine pH, and low urine volume were more prevalent on 24-h urine metabolic testing. We hypothesize increased comorbidity, including medical renal disease, polypharmacy, and dehydration are possible factors contributing to this unique profile. We suggest that empiric therapy targeted towards this profile is important in very elderly stone formers in whom 24-h urine testing may not be possible. Increased hydration, increased fruit and vegetable intake, and low-dose alkali therapy are easy measures to accomplish this.

Differences in healthcare service utilization in patients with polypharmacy according to their risk level by adjusted morbidity groups: a population-based cross-sectional study

BACKGROUND

Patients with polypharmacy suffer from complex medical conditions involving a large healthcare burden. This study aimed to describe the characteristics and utilization of primary care (PC) and hospital care (HC) and factors associated in chronic patients with polypharmacy, stratifying by adjusted morbidity groups (AMG) risk level, sex and age, and comparing with non-polypharmacy.

METHODS

Cross-sectional study conducted in a Spanish basic healthcare area. Studied patients were those over 18 years with chronic diseases identified by the AMG tool from Madrid electronic clinical record, which was the data source. Sociodemographic, sociofunctional, clinical and healthcare utilization variables were described and compared by risk level, sex, age and having or not polypharmacy. Factors associated with healthcare utilization in polypharmacy patients were determined by a negative binomial regression model.

RESULTS

In the area studied, 61.3% patients had chronic diseases, of which 16.9% had polypharmacy vs. 83.1% without polypharmacy. Patients with polypharmacy (vs. non-polypharmacy) mean age was 82.7 (vs. 52.7), 68.9% (vs. 60.7%) were women, and 22.0% (vs. 1.2%) high risk. Their average number of chronic diseases was 4.8 (vs. 2.2), and 95.6% (vs. 56.9%) had multimorbidity. Their mean number of annual healthcare contacts was 30.3 (vs. 10.5), 25.9 (vs. 8.8) with PC and 4.4 (vs. 1.7) with HC. Factors associated with a greater PC utilization in patients with polypharmacy were elevated complexity, high risk level and dysrhythmia. Variables associated with a higher HC utilization were also increased complexity and high risk, in addition to male sex, being in palliative care, having a primary caregiver, suffering from neoplasia (specifically lymphoma or leukaemia) and arthritis, whereas older age and immobilization were negatively associated.

CONCLUSIONS

Polypharmacy population compared to non-polypharmacy was characterized by a more advanced age, predominance of women, high-risk, complexity, numerous comorbidities, dependency and remarkable healthcare utilization. These findings could help healthcare policy makers to optimize the distribution of resources and professionals within PC and HC systems, aiming for the improvement of polypharmacy management and rational use of medicines while reducing costs attributed to healthcare utilization by these patients.

Polypharmacy, physical activity, and sedentary time in older adults: A scoping review

OBJECTIVE

To map out the studies that have investigated the associations of polypharmacy and/or potentially inappropriate medication (PIM) use with physical activity and sedentary time in older adults.

METHODS

We conducted a literature search from inception to December 2022 in PubMed, Embase, Web of Science, and Scopus.

INCLUSION CRITERIA

observational studies including older adults (≥60 years); English, Portuguese, and Spanish languages; any definition of polypharmacy; implicit and explicit criteria of PIM use; physical activity and/or sedentary time data.

RESULTS

Fourteen cross-sectional studies were included; 11 defined polypharmacy as ≥5 medications (prevalence ranging from 9.5 % to 57 %). No study reported information on PIM use. Most studies included participants aged <80 years. Twelve studies included self-reported measures of physical activity, while two studies used accelerometer-measured physical activity. Ten studies included analyses adjusted for confounders, and nine considered polypharmacy as an outcome. All of them demonstrated an inverse association between physical activity and polypharmacy, irrespective of the definition of polypharmacy and the assessment method employed (self-reported or accelerometry). One study reported an inverse association between polypharmacy (as the exposure) and physical activity (as the outcome). None of the studies investigated the association between sedentary time and polypharmacy.

CONCLUSIONS

Limited evidence suggests an inverse association between physical activity and polypharmacy in older adults. However, the relationship between PIM use, physical activity, and sedentary time remains unknown. Longitudinal studies utilizing objectively-measured physical activity and sedentary time are needed to better clarify the relationship between these movement behaviors and polypharmacy and/or PIM use in older adults.

A Study of Drug Utilization Pattern and Pharmacoeconomic Analysis of Immunosuppressant Drugs in Patients With Skin Disorders in a Tertiary Care Hospital in Bihar

Aims The cost-effective therapy of immunosuppressant drugs in dermatological conditions will not only lead to adherence to rational prescribing but will also increase patient compliance with fewer dropouts due to cost factor. Thus, this study was done to determine and compare the drug utilization pattern, prescribed daily dose/defined daily dose (PDD/DDD) defined by WHO, and the cost-effectiveness ratio of different immunosuppressants.  Methods and material Prescriptions for patients with skin disorders prescribed with any one systematic or topical immunosuppressant were collected. The utilization of drugs in different skin disorders was expressed as frequency and percentage. PDD was compared with DDD as per the WHOCC-Anatomical Therapeutic Chemical (ATC)/DDD index. The pharmacoeconomic analysis was done using a cost-effectiveness ratio. Statistical analysis Descriptive statistics were used to calculate percentages, frequency, and 95% CI. The cost-effectiveness ratio in terms of SFDs (symptom-free days) was defined as the total cost of the initial antibiotic during the study period divided by the number of SFDs (cost/ SFD) and was expressed as mean±standard deviation, and the Kruskal-Wallis test was used to determine statistical significance of difference. Results Immunosuppressants were prescribed in 117 (19.12%) prescriptions out of a total of 612 prescriptions. Deflazacort was the most utilized systemic immunosuppressant prescribed in 27.18% of cases and was commonly prescribed for irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD) followed by prednisolone and betamethasone. Tacrolimus was the most utilized topical immunosuppressant prescribed in 15.90% of patients and was commonly used for ICD and vitiligo followed by clobetasol and mometasone. Betamethasone, prednisolone, clobetasol, and mometasone had better cost-effectiveness. PDD/DDD of all immunosuppressants was less than one except prednisolone, which had a PDD/DDD ratio of 3.52. Conclusions The cost-effectiveness of steroids has the advantage of providing better patients' adherence to pharmacotherapy, but over-prescribing could also lead to long-term adverse effects of steroids. Pharmacovigilance research should also incorporate pharmacoeconomic analysis to determine the relation between these two aspects.

Development of a Malaysian potentially inappropriate prescribing screening tool in older adults (MALPIP): a Delphi study

INTRODUCTION

Polypharmacy and potentially inappropriate medications (PIM) are common among older adults. To guide appropriate prescribing, healthcare professionals often rely on explicit criteria to identify and deprescribe inappropriate medications, or to start medications due to prescribing omission. However, most explicit PIM criteria were developed with inadequate guidance from quality metrics or integrating real-world data, which are rich and valuable data source.

AIM

To develop a list of medications to facilitate appropriate prescribing among older adults.

METHODS

A preliminary list of PIM and potential prescribing omission (PPO) were generated from systematic review, supplemented with local pharmacovigilance data of adverse reaction incidents among older people. Twenty-one experts from nine specialties participated in two Delphi to determine the list of PIM and PPO in February and March 2023. Items that did not reach consensus after the second Delphi round were adjudicated by six geriatricians.

RESULTS

The preliminary list included 406 potential candidates, categorised into three sections: PIM independent of diseases, disease dependent PIM and omitted drugs that could be restarted. At the end of Delphi, 92 items were decided as PIM, including medication classes, such as antacids, laxatives, antithrombotics, antihypertensives, hormones, analgesics, antipsychotics, antidepressants, and antihistamines. Forty-two disease-specific PIM criteria were included, covering circulatory system, nervous system, gastrointestinal system, genitourinary system, and respiratory system. Consensus to start potentially omitted treatment was achieved in 35 statements across nine domains.

CONCLUSIONS

The newly developed PIM criteria can serve as a useful tool to guide clinicians and pharmacists in identifying PIMs and PPOs during medication review and facilitating informed decision-making for appropriate prescribing.

Association between medication-induced xerostomia and orofacial pain: a systematic review

OBJECTIVE

Xerostomia (or oral dryness) is most commonly caused by medications that affect saliva secretion, and is often accompanied by symptoms of orofacial pain. Medication-induced xerostomia may or may not be associated with objectively demonstrable hyposalivation. The present study attempted to systematically identify an association between medication-induced xerostomia and orofacial pain.

METHOD AND MATERIALS

A systematic search was conducted using the following databases: WoS, PubMed, SCOPUS, and MEDLINE. The search terms used were: xerostomia OR "dry mouth" AND medication AND ("oral pain" OR "orofacial pain" OR "craniofacial pain" OR "burning mouth" OR "glossodynia") NOT Sjögren's NOT cancer. Inclusion criteria were medication-induced xerostomia and reported symptoms of orofacial pain. Four researchers performed the selection process and quality assessment and two researchers conducted data extraction.

RESULTS

Seven studies with a total of 1,029 patients were included. These studies were conducted between 2009 and 2022 and consisted of cross-sectional studies, case-control studies, and one randomized crossover trial. The studies consisted of a total of 1,029 participants. All studies included male and female participants whose mean ages ranged from 43 to 100 years.

CONCLUSIONS

A positive association was found between medication-induced xerostomia and orofacial pain. No associations were found between salivary flow measurements (hyposalivation) and medication use. Future research should focus on saliva flow measurements, standardized assessment of medication-induced xerostomia, as well as the inclusion of accompanying orofacial pain diagnosis in the medical history to allow for higher level of evidence in establishing reliable predictors of medication-induced oral health damage to facilitate clinical prevention and management.