Medication burden attributable to chronic co-morbid conditions in the very old and vulnerable

Characterizing the treatment patterns, medication burden, and patient demographics of older adults with major depressive disorder treated with antidepressants with or without selected comorbidities

OBJECTIVE

Evaluate clinical characteristics, comorbidity burden, major depressive disorder (MDD)-related healthcare resource utilization (HCRU), medication burden, and antidepressant treatment (ADT) patterns among older adults with MDD with and without selected comorbidities.

METHODS

Using Komodo's Healthcare Map claims data (1/1/2016-9/30/2022), patients with MDD (≥65 years) treated with ADTs were assessed 24 months preceding (baseline) and 12 months following (follow-up) first observed ADT prescription fill (index). Patients were separated into cohorts of those with ≥1 of 5 selected comorbidities and those without. Clinical characteristics, comorbidities, and MDD-related HCRU were assessed during baseline; treatment patterns were assessed during follow-up. Baseline and follow-up all-cause and comorbidity-specific medication burdens (mean prescription claims/month) were determined.

RESULTS

Among the total cohort (N = 417,643), 97.1% had ≥1 of 5 selected comorbidities: hypertension (80.3%), hyperlipidemia (75.4%), diabetes (54.2%), anxiety disorder (39.0%), and chronic obstructive pulmonary disorder (19.5%). Baseline and follow-up all-cause medication burdens per month were 3.8 and 4.5 for patients with selected comorbidities and 1.7 and 2.3 for those without. During baseline, most patients (96.0% with selected comorbidities, 96.2% without) had ≥1 outpatient visit, and a numerically higher percentage of those with vs. without selected comorbidities had MDD-related emergency room (13.9% vs. 6.0%) and inpatient (13.5% vs. 4.1%) visits. The majority of both cohorts (61.0% with selected comorbidities, 59.5% without) underwent treatment pattern changes.

CONCLUSION

This study highlights the medication burden and ADT patterns in older adults with MDD, assessing these outcomes among patients with and without comorbidities. Numerically higher medication burdens among those with selected comorbidities suggests future studies could investigate the impact of comorbidities on MDD-related care.

Human Immunodeficiency Virus in Older Adults

As people with HIV live longer, they can experience increased incidence and earlier onset of chronic conditions and geriatric syndromes. Older people are also at substantially increased risk of delayed diagnosis and treatment for HIV. Increasing provider awareness of this is pivotal in ensuring adequate consideration of HIV testing and earlier screening for chronic conditions. In addition, evaluating patients for common geriatric syndromes such as polypharmacy, frailty, falls, and cognitive impairment should be contextualized based on how they present.

Health Outcomes for Older Patients with Chronic Diseases During the First Pandemic Year

Background

Worldwide, chronic diseases are prevalent among the older adults, significantly affecting their health and healthcare system. The COVID-19 pandemic exacerbated these challenges, disrupting healthcare services. Our study assesses the impact on older individuals with chronic diseases who were not infected with COVID-19, analyzing comorbidities, medication use, mortality rates, and resource utilization using real data from Aragon, Spain.

Methods

A retrospective observational study, conducted in Aragon, Spain, focused on individuals aged 75 and older with at least one chronic disease, who were not infected of COVID-19. The research used actual data collected during three distinct periods: the first covered the six months prior to the pandemic, the second the six months after the lockdown, and the third the period between six and twelve months. Key variables included socio-demographics, comorbidities, clinical parameters, medication use, and health services utilization.

Results

We included 128.130 older adults. Mean age was 82.88 years, with 60.3% being women. The most common chronic diseases were hypertension (73.2%), dyslipidemia (52.5%), and dorsopathies (31.5%). More than 90% had more than 2 conditions. A notable decline in new chronic disease diagnoses was observed, particularly pronounced in the six to twelve months period after lockdown. Although statistically significant differences were observed in all clinical variables analyzed, they were considered clinically irrelevant. Furthermore, a decrease in healthcare services utilization and medication prescriptions was reported.

Conclusion

Our study highlights a decrease in new chronic disease diagnoses, ongoing reductions in healthcare utilization, and medication prescriptions for older adults with pre-existing chronic conditions, unaffected by COVID-19.

Deprescribing Strategies: A Prospective Study on Proton Pump Inhibitors

Proton pump inhibitors (PPIs) are among the most controversially prescribed drugs in polypharmacy. This observational prospective study assessed the PPI prescriptive trend during hospitalization before and after implementation of a prescribing/deprescribing algorithm in a real-life hospital setting and the related clinical-economic benefit at discharge. PPI prescriptive trends were compared between three quarters of 2019 (9 months) and the same period of 2018 by a chi-square test with a Yate's correction. The proportions of treated patients in the two years (1120 discharged patients in 2018 and 1107 in 2019) were compared by the Cochran-Armitage trend test. DDDs (defined daily doses) were compared between 2018 and 2019 by the non-parametric Mann-Whitney test and normalizing DDD/DOT (days of therapy) and DDD/100 bd (bed days) for each patient. Multivariate logistic regression was performed on PPI prescriptions at discharge. The distribution of patients with PPIs at discharge was significantly different in the two years (p = 0.0121). There was a downward trend in the number of PPI prescriptions (29.9%) in the third trimester of 2019 compared to the others of the same year (first trimester: 34.1%, second trimester: 36.0%) and by contrast with the same periods of 2018 (29.4, 36.0, and 34.7%) (p = 0.0124). DDDs/patient did not differ between 2018 and 2019 nor across the three trimesters. However, both DDD/DOT and DDD/100 bd showed a decrease in the third trimester of 2019, with a marked difference for DDD/DOT (p = 0.0107). The reduction in consumption detected in the last phase of 2019 in terms of DDD/DOT was 0.09 with a consequent containment of pharmaceutical spending. The development and implementation of multidisciplinary prescribing/deprescribing protocols in both hospital and community settings could lead to a reduction in the misuse of PPIs, with significant savings in healthcare resources.

Comparative Effectiveness and Safety of Seizure Prophylaxis Among Adults After Acute Ischemic Stroke

BACKGROUND

Older adults occasionally receive seizure prophylaxis in an acute ischemic stroke (AIS) setting, despite safety concerns. There are no trial data available about the net impact of early seizure prophylaxis on post-AIS survival.

METHODS

Using a stroke registry (American Heart Association's Get With The Guidelines) individually linked to electronic health records, we examined the effect of initiating seizure prophylaxis (ie, epilepsy-specific antiseizure drugs) within 7 days of an AIS admission versus not initiating in patients ≥65 years admitted for a new, nonsevere AIS (National Institutes of Health Stroke Severity score ≤20) between 2014 and 2021 with no recorded use of epilepsy-specific antiseizure drugs in the previous 3 months. We addressed confounding by using inverse-probability weights. We performed standardization accounting for pertinent clinical and health care factors (eg, National Institutes of Health Stroke Severity scale, prescription counts, seizure-like events).

RESULTS

The study sample included 151 patients who received antiseizure drugs and 3020 who did not. The crude 30-day mortality risks were 219 deaths per 1000 patients among epilepsy-specific antiseizure drugs initiators and 120 deaths per 1000 among noninitiators. After standardization, the estimated mortality was 251 (95% CI, 190-307) deaths per 1000 among initiators and 120 (95% CI, 86-144) deaths per 1000 among noninitiators, corresponding to a risk difference of 131 (95% CI, 65-200) excess deaths per 1000 patients. In the prespecified subgroup analyses, the risk difference was 52 (95% CI, 11-72) among patients with minor AIS and 138 (95% CI, 52-222) among moderate-to-severe AIS patients. Similarly, the risk differences were 86 (95% CI, 18-118) and 157 (95% CI, 57-219) among patients aged 65 to 74 years and ≥75 years, respectively.

CONCLUSIONS

There was a higher risk of 30-day mortality associated with initiating versus not initiating seizure prophylaxis within 7 days post-AIS. This study does not support the role of seizure prophylaxis in reducing 30-day poststroke mortality.

Predictors of Mortality in 433 Nonagenarians Inside the Mugello Study: A 10 Years Follow-Up Study

OBJECTIVE

to identify the predictors of mortality in a cohort of nonagenarians inside the "Mugello study" after 10 years follow-up.

METHODS

Information on sociodemographic data, cognitive and functional status, lifestyle, medical history, and drug use was collected from 433 non-selected participants aged 90-99 years, living in the Mugello area (Italy). Participants were followed over 10 years and their dates of death were retrieved from the municipal registers. Cox regression analysis was used to determine significant potential prognostic factors.

RESULTS

The mortality rate was 96.5%. Cox proportional hazards analysis showed that a lower cognitive status was significantly associated with higher mortality as well as a poorer functional status, a higher comorbidity, and a higher number of drugs consumption.

DISCUSSION

Impaired cognitive function, loss of functional independence, higher comorbidity, and higher drugs intake were the stronger predictors of mortality.

Polypharmacy occurrence and the related risk of premature death among older adults in Denmark: A nationwide register-based cohort study

Background

Polypharmacy, defined as the concurrent use of ≥5 medications, increases the risk of drug-drug and drug-disease interactions as well as non-adherence to drug therapy. This may have negative health consequences particularly among older adults due to age-related pharmacokinetic and pharmacodynamic changes. This study aims to uncover the occurrence of polypharmacy among older adults in Denmark and investigate how polypharmacy relates to mortality.

Method

This nationwide register-based study included 1,338,058 adults aged 65+ years between January 2013 and December 2017 in Denmark. Polypharmacy prevalence was measured at time of inclusion while incidence and the association between polypharmacy and mortality were measured over the five-year follow-up using Cox regression. In an attempt to adjust for confounding by indication, propensity scores with overlap weighting were introduced to the regression model.

Results

At time of inclusion, polypharmacy prevalence was 29% and over the five years follow-up, 47% of the remaining adults transitioned into polypharmacy. Identified risk factors included multimorbidity (2+ morbidities: HR = 3.51; 95% CI = 3.48–3.53), age (95+ years: HR = 2.85; 95% CI = 2.74–2.96), socioeconomic factors (Highest income quartile: HR = 0.81; 95% CI = 0.80–0.81), region of birth region (Non-western migrants: HR = 0.77; 95% CI = 0.75–0.79), marital status (Divorced: HR = 1.10; 95% CI = 1.10–1.12) and year of inclusion (2017: HR = 1.19; 95% CI = 1.19–1.22). Further analyses showed that polypharmacy involves many different drug cocktails with medication for the cardiovascular system (95%), blood and blood-forming organs (69%), alimentary tract and metabolism (61%) and nervous system (54%) contributing the most. After adjustment for propensity scores with OW, both polypharmacy (HR = 3.48, CI95% = 3.41–3.54) and excessive polypharmacy (HR = 3.48, CI95% = 3.43–3.53) increased the risk of death substantially.

Conclusion

A considerable proportion of older adults in Denmark were exposed to polypharmacy dependent on health status, socio-economic status, and societal factors. The associated three- to four-fold mortality risk indicate a need for further exploration of the appropriateness of polypharmacy among older adults.

Clinical Trial Diversity: An Opportunity for Improved Insight into the Determinants of Variability in Drug Response

Although the number of countries participating in pivotal trials submitted to enable drug registration has nearly doubled over the past 25 years, there has not been a substantial increase in the diversity of clinical trial populations. In parallel, our understanding of factors that influence medicine response and variability has continued to evolve. The notion of intrinsic and extrinsic sources of variability has been embedded into different regulatory guidelines, including the recent guideline on the importance of enhancing the diversity of clinical trial populations.

In addition to presenting the clinical and scientific reasons for ensuring that clinical trial populations represent the demographics of patient populations, this overview outlines the efforts of regulatory agencies, patient advocacy groups and clinical researchers to attain this goal through strategies to meet representation in recruitment targets and broaden eligibility criteria. Despite these efforts, challenges to participation in clinical trials remain, and certain groups continue to be underrepresented in development programmes. These challenges are amplified when the representativeness of specific groups may vary across countries and regions in a global clinical programme.

Whilst enhanced trial diversity is a critical step towards ensuring that results will be representative of patient populations, a concerted effort is required to characterise further the factors influencing interindividual and regional differences in response for global populations. Quantitative clinical pharmacology principles should be applied to allow extrapolation of data across groups or regions as well as provide insight into the effect of patient‐specific characteristics on a medicine's dose rationale and efficacy and safety profiles.

Impact of gastrointestinal tract variability on oral drug absorption and pharmacokinetics: An UNGAP review

The absorption of oral drugs is frequently plagued by significant variability with potentially serious therapeutic consequences. The source of variability can be traced back to interindividual variability in physiology, differences in special populations (age- and disease-dependent), drug and formulation properties, or food-drug interactions. Clinical evidence for the impact of some of these factors on drug pharmacokinetic variability is mounting: e.g. gastric pH and emptying time, small intestinal fluid properties, differences in pediatrics and the elderly, and surgical changes in gastrointestinal anatomy. However, the link of colonic factors variability (transit time, fluid composition, microbiome), sex differences (male vs. female) and gut-related diseases (chronic constipation, anorexia and cachexia) to drug absorption variability has not been firmly established yet. At the same time, a way to decrease oral drug pharmacokinetic variability is provided by the pharmaceutical industry: clinical evidence suggests that formulation approaches employed during drug development can decrease the variability in oral exposure. This review outlines the main drivers of oral drug exposure variability and potential approaches to overcome them, while highlighting existing knowledge gaps and guiding future studies in this area.

Prevalence and Associated Factors of Polypharmacy in Nursing Home Residents: A Cross-Sectional Study

In Spain, there has been a progressive increase in aging. Specifically, Leon has been one of the Spanish provinces with the highest aging index. Polypharmacy is highly prevalent among the elderly, with significant consequences for safety. The aim of this study was to assess the consumption of drugs in a nursing home in the province of Leon and establish the relationship between polypharmacy and the most common comorbid diseases. A descriptive, observational, and cross-sectional study design was used. Residents' information and treatments were collected by reviewing on medical charts, completed with clinical information obtained from the physician of the nursing home. The mean age of residents was 86.8 years, and 63.8% were female. Mean medical consumption amounted to 7.02 prescriptions. Polypharmacy was observed in 54.9% of residents, and excessive polypharmacy in 22.1%. The most commonly used medications (ATC classification) were those acting on the cardiovascular system (84.4%) and the nervous system (82.8%). A high-level of drug consumption was observed in the nursing home. Interventions should focus on those residents hospitalized the last year and with recent contact with a general practitioner. There is a need to develop a comprehensive monitoring system to assess the quality of prescriptions for nursing home residents.

Self-transcendence among adults 65 years and older: A meta-analysis

INTRODUCTION

Self-transcendence is a human capacity for wellbeing by expanding one's personal boundaries and may act as a health-promoting resource among adults ≥65 years. Therefore, the objectives of this meta-analysis were to determine the mean score of self-transcendence based on place of residence and gender, and to evaluate the correlations of self-transcendence with meaning, sense of coherence, resilience and depression.

METHODS

Based on inclusion criteria, 13 studies were included. Orwin Safe N and Egger's test assessed publication bias. The mean score of self-transcendence and the correlation coefficients of the selected variables were estimated by random effects models.

RESULTS

The self-transcendence mean score (n = 1634) was low (M = 43.6) and a bit lower among those staying in care facilities (M = 42.8), but did not vary significantly across gender. The correlation coefficients were self-transcendence_depression (r = -0.40), self-transcendence_meaning-in-life (r = 0.53), self-transcendence_resilience (r = 0.50) and self-transcendence_sense of coherence (r = 0.28). The correlation coefficients, except for meaning-in-life, were homogeneous.

CONCLUSION

In a health-promoting perspective, the concept of self-transcendence can help to better understand wellbeing among older individuals and provide guidance for health professionals in facilitating wellbeing and health. The concept and theory of self-transcendence can inspire health professionals in realising new health-promoting approaches to support older individuals in maintaining health, wellbeing and independency.

Alterations in drug disposition in older adults: a focus on geriatric syndromes

INTRODUCTION

Age-associated physiological changes can alter the disposition of drugs, however, pathophysiological changes associated with geriatric syndromes in older adults may lead to even greater heterogeneity in pharmacokinetics. Geriatric syndromes are common health problems in older adults which have multifactorial causes and do not fit into distinct organ-based disease categories. With older adults being the greatest users of medications, understanding both age- and geriatric syndrome-related changes is important clinically to ensure safe and effective medication use.

AREAS COVERED

This review provides an overview of current evidence regarding pharmacokinetic alterations that occur with aging and in common geriatric syndromes, including frailty, sarcopenia, dementia, polypharmacy and enteral feeding. The evidence is presented according to the four primary pharmacokinetic processes (Absorption, Distribution, Metabolism and Excretion).

EXPERT OPINION

There is some evidence to inform our understanding of the impact of chronological aging and various geriatric syndromes on drug disposition. However, many areas require more research, including drug induced inhibition and induction of cytochrome P450 enzymes and the clinical utility of emerging methods for estimating renal function. There is a need to develop tools to predict alterations in drug disposition in subgroups of older adults, particularly where the currently available clinical information is sparse.

Relationships of diabetes self-care behaviours to glycaemic control in adults with type 2 diabetes and comorbid heart failure

Aim

To describe the relationship between diabetes self-care behaviours and glycaemic control in patients with type 2 diabetes and comorbid heart failure.

Design

A cross-sectional, correlational study.

Method

A secondary analysis of 180 participants' baseline data from a clinical trial that tested a 6-month integrated self-care intervention was performed. Correlational and hierarchical linear regression analysis was used to assess the relationships between diabetes self-care behaviours and glycaemic control.

Result

The Summary of Diabetes Self-Care Activities general diet and Summary of Diabetes Self-Care Activities exercise were negatively associated with glycated haemoglobin (HbA1c), while Summary of Diabetes Self-Care Activities specific diet was positively associated. Diabetic end-organ failure, taking insulin only and taking both oral antiglycaemic and insulin, predicted higher HbA1c and fasting blood glucose. African American race and dyslipidaemia predicted higher HbA1c while taking higher total daily medication predicted higher fasting blood glucose. Longer years lived with heart failure, lower ventricular ejection fraction and exposure to chemotherapy predicted lower fasting blood glucose.

Revisiting the Role of Physicians in Assisted Living and Residential Care Settings

As the United States population ages, a higher share of adults is likely to use long-term services and supports. This change increases physicians' need for information about assisted living and residential care (AL/RC) settings, which provide supportive care and housing to older adults. Unlike skilled nursing facilities, states regulate AL/RC settings through varying licensure requirements enforced by state agencies, resulting in differences in the availability of medical and nursing services. Where some settings provide limited skilled nursing care, in others, residents rely on resident care coordinators, or their own physicians to oversee chronic conditions, medications, and treatments. The following narrative review describes key processes of care where physicians may interact with AL/RC operators, staff, and residents, including care planning, managing Alzheimer's disease and related conditions, medication management, and end-of-life planning. Communication and collaboration between physicians and AL/RC operators are a crucial component of care management.

Measuring Adherence: A Proof of Concept Study for Multiple Medications for Chronic Conditions in Alternative Payment Models

Adherence to renin angiotensin system antagonists (RASA), non-insulin diabetes medications (NIDM) and statins has been included in the Medicare Star Ratings program since 2012. The long-term use of these measures emphasizes adherence to a limited number of chronic medications and may present opportunities for Part D plan sponsors to misuse the measures to influence their Medicare Part D Star Rating. It also does not capture the adherence needs of high-risk patients with multiple chronic conditions. The objective of this study was to describe the development of a new measure to capture adherence to multiple medications for chronic conditions (MMCC). The MMCC measure captures adherence to 71 different therapeutic categories of medication and was constructed using North Carolina Medicaid prescription claims data from 2015 to 2017. This measure was validated against the existing RASA, NIDM and statin adherence measures. This new measure was highly correlated with Star Rating measures, captured a greater number of eligible patients than these existing measures and had a lower proportion of patients meet the adherence threshold than the existing Star Ratings adherence measures. There is an opportunity to develop new measures, which include adherence to multiple medications in populations with multiple chronic conditions.

Independent Functioning in Nonagenarians Living in a Rural Italian Community: The Mugello Study

Nonagenarians are a fast-growing population deserving specific research. We explored the prevalence and characteristics of functionally independent nonagenarians from a rural community-dwelling Italian population. Data were collected in the Mugello Study; 475 persons aged ≥90 years (median age, 92) underwent a home-based clinical and functional assessment, including psychosocial, clinical, functional, and lifestyle history and status and physical and instrumental examinations. Sixty-eight (15%) persons reported no need for help in basic and instrumental daily living activities. Among variables significantly associated with independent functionality after age- and gender-adjusted cross-sectional analysis, lower body mass index (BMI; p = .034) and depressive symptoms (p = .028), higher current physical activity (p < .001), better cognitive status (p = .033), and lower medication intake (p = .048) were associated with reporting no disability in the logistic regression analysis. Disability was mainly associated with current lifestyle-related potentially modifiable factors. Thus, lifestyle-oriented multidimensional interventions, should be developed and evaluated for their potential effects on functionality, even in the oldest old.

Opioids, Pain Management, and Palliative Care in a Norwegian Nursing Home From 2013 to 2018

In Norway, approximately 50% of older people die in nursing homes (NH). Holistic care and pharmacological management are key factors in quality at the end of life. The purpose of this longitudinal study was to describe the use of opioids in an NH during a 5-year period. We focused on palliative care, symptoms, and suffering during the last 3 days before death. Data were collected from spring 2013 to spring 2018. We used the interRAI assessment instrument annually and when the resident died. We conducted a semi-structured interview with nurses on duty at the deathbed. At the time of death, the residents had an average age of 88.9 years and an average stay of 2.9 years (N = 100). At the first assessment, 19% of the residents used 1 or more type of opioids. On the day of death, 55% had an active prescription for opioids, mainly as subcutaneous injections. The results illustrate the different uses of opioids, including managing pain, dyspnoea, sedation, for comfort, as a prophylaxis, or a combination of reasons. Cancer- and cardiovascular diagnoses were the strongest predictor for using morphine (P < 0.05). Identification of the residents' needs for opioids is a challenge for palliative care nurses, both ethically and legally.

Under-representation of elderly in clinical trials: An analysis of the initial approval documents in the Food and Drug Administration database

Aims

To evaluate the availability of pharmacokinetic, safety and efficacy analyses specifically targeted at elderly, prior to the authorization of drugs.

Methods

A cross‐sectional, structured review of publicly available initial approval documents of Food and Drug Administration‐approved drugs was performed. The 10 most frequently on‐label prescribed drug classes, drugs with known pharmacokinetic differences in the elderly or drugs that are relatively contraindicated in elderly (e.g. anticholinergics or benzodiazepines) were included in the analyses.

Results

In total, 1129 unique active pharmaceutical ingredients were found eligible for the analyses, of these, 506 were found in the Food and Drug Administration database (45%). The initial approval documents were available for 182 drugs. For the majority of the drugs, the initial approval documents in the database showed information on pharmacokinetics in elderly (n = 113; 62%). Furthermore, over time, the availability of information with regard to elderly increased statistically significantly from 0% in the period 1970–1979 to 76% for the period 2010–2018. Information on safety and efficacy was less frequently present, i.e. 42% and 45%, respectively and, moreover, the availability of information did not improve over time.

Conclusion

The under‐representation of elderly in clinical trials thereby challenging the external validity of benefit/risk assessments of launched drugs was confirmed. Priority should be given to a study population that is representative for the target population.