Prescribing for frail older people

Frailty and Medication Appropriateness in Rural Adults: Proposing Interventions through Pharmacist-Physician Collaborative Efforts

Background: Frailty and polymedication are closely interrelated. Addressing these concurrent conditions in primary care settings relies on the utilization of potentially inappropriate medication (PIM) lists and medication reviews (MRs), particularly in rural areas, where healthcare professionals serve as the sole point of access to the medical system. The aim of this study was to examine the relationship between medication appropriateness and variables related to frailty in a rural municipality in order to propose potential strategies for therapy optimization. Methods: This cross-sectional study included all adult community dwellers aged 50 and above officially registered in the municipality of Tiriez (Albacete, Spain) in 2023 (n = 241). The primary outcome variable was frailty (assessed using the fatigue, resistance, ambulation, illness, and loss of weight (FRAIL) scale). The independent variables were age, gender, medication regimen, history of falls, comorbidities, PIMs (evaluated using the screening tool of older persons' prescriptions (STOPP) 2023 criteria), fall-risk-increasing drugs (FRID), and anticholinergic burden (ACB). Results: The prevalence of frailty was approximately 20%. FRID and ACB scores were statistically associated (p-value < 0.001) with frailty, 1.1 ± 1.3 vs. 2.5 ± 1.7, and 1.0 ± 1.3 vs. 2.8 ± 2.5, respectively. Regardless of age, frailty was observed to be more prevalent among females (odds ratio (OR) [95% confidence interval (CI)]: 3.5 [1.5, 9.0]). On average, 2.1 ± 1.6 STOPP criteria were fulfilled, with the prolonged use of anxiolytics and anti-peptic-ulcer agents being the most frequent. Priority interventions (PIs) included opioid dose reduction, benzodiazepine withdrawal, and the assessment of antidepressant and antiplatelet treatment plans. Conclusions: The optimization of medication in primary care is of paramount importance for frail patients. Interventional measures should focus on ensuring the correct dosage and combination of drugs for each therapeutic regimen.

Investigating drug-induced urinary retention: a pharmacovigilance analysis of FDA adverse event reports from 2004 to 2024

BACKGROUND

Drug-induced urinary retention (DIUR) can severely impact patient quality of life and complicate treatment. This study investigates the incidence and characteristics of DIUR using data from the FDA Adverse Event Reporting System (FAERS) over 20 years.

METHODS

FAERS reports related to urinary retention (UR) from Q1 2004 to Q1 2024 were analyzed. Potential causative drugs were identified, and the top 30 drugs with the most UR reports were ranked. Statistical disproportionality analyses, including Proportional Reporting Ratio (PRR) and Reporting Odds Ratio (ROR), were conducted to detect significant safety signals.

RESULTS

Out of 17,703,515 reports in the FAERS database 28,423 cases of UR were identified. Anticholinergics, antidepressants, and opioids were the most frequently implicated drug classes. The highest ROR and PRR values were observed for drugs like ezogabine. Additionally, less commonly associated drugs, such as adalimumab and others, were implicated, suggesting potential under-recognition of this adverse effect. However, these associations should be interpreted with caution, as they do not confirm a direct causal relationship.

CONCLUSION

This study underscores the importance of pharmacovigilance in identifying and understanding DIUR. Further research is needed to confirm these findings and develop strategies to manage and reduce the risk, improving patient outcomes.

Antihypertensive deprescribing in frail long-term care residents (OptimizeBP): protocol for a prospective, randomised, open-label pragmatic trial

INTRODUCTION

Although antihypertensive medication use is common among frail older adults, observational studies in this population suggest blood pressure (BP) lowering may convey limited benefit and perhaps even harm. This protocol describes an antihypertensive deprescribing trial in frail older adults powered for mortality and morbidity outcomes.

METHODS AND ANALYSIS

Design: Prospective, parallel, randomised, open-label pragmatic trial.Participants: Long-term care (LTC) residents ≥70 years of age, diagnosed with hypertension, with mean systolic BP <135 mm Hg, ≥1 daily antihypertensive medication and no history of congestive heart failure.Setting: 18 LTC facilities in Alberta, Canada, with eligible residents identified using electronic health services data.Intervention: All non-opted-out eligible residents are randomised centrally by a provincial health data steward to either usual care, or continually reducing antihypertensives provided an upper systolic threshold of 145 mm Hg is not exceeded. Deprescribing is carried out by pharmacists/nurse practitioners, using an investigator-developed algorithm.Follow-up: Provincial healthcare databases tracking hospital, continuing care and community medical services.Primary outcome: All-cause mortality.Secondary outcome: Composite of all-cause mortality or all-cause unplanned hospitalisation/emergency department visit.Tertiary outcomes: All-cause unplanned hospitalisation/emergency department visit, non-vertebral fracture, renal insufficiency and cost of care. Also, as assessed roughly 135-days postrandomisation, fall in the last 30 days, worsening cognition, worsening activities of daily living and skin ulceration.Process outcomes: Number of daily antihypertensive medications (broken down by antihypertensive class) and average systolic and diastolic BP over study duration.Primary outcome analysis: Cox proportional hazards survival analysis.Sample size: The trial will continue until observation of 247 primary outcome events has occurred.Current status: Enrolment is ongoing with ~400 randomisations to date (70% female, mean age 86 years).

ETHICS AND DISSEMINATION

Ethics approval was obtained from the University of Alberta Health Ethics Review Board (Pro00097312) and results will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT05047731.

The adverse inpatient medication event and frailty (AIME-frail) risk prediction model

BACKGROUND

Medication harm affects between 5 and 15% of hospitalised patients, with approximately half of the harm events considered preventable through timely intervention. The Adverse Inpatient Medication Event (AIME) risk prediction model was previously developed to guide a systematic approach to patient prioritisation for targeted clinician review, but frailty was not tested as a candidate predictor variable.

AIM

To evaluate the predictive performance of an updated AIME model, incorporating a measure of frailty, when applied to a new multisite cohort of hospitalised adult inpatients.

METHODS

A retrospective cohort study was conducted at two tertiary Australian hospitals on patients discharged between 1st January and April 31, 2020. Data were extracted from electronic medical records (EMRs) and clinical coding databases. Medication harm was identified using ICD-10 Y-codes and confirmed by senior pharmacist review of medical records. The Hospital Frailty Risk Score (HFRS) was calculated for each patient. Logistic regression analysis was used to construct a modified AIME model. Candidate variables of the original AIME model, together with new variables including HFRS were tested. Performance of the final model was reported using area under the curve (AUC) and decision curve analysis (DCA).

RESULTS

A total of 4089 patient admissions were included, with a mean age ± standard deviation (SD) of 64 years (±19 years), 2050 patients (50%) were males, and mean HFRS was 6.2 (±5.9). 184 patients (4.5%) experienced one or more medication harm events during hospitalisation. The new AIME-Frail risk model incorporated 5 of the original variables: length of stay (LOS), anti-psychotics, antiarrhythmics, immunosuppressants, and INR greater than 3, as well as 5 new variables: HFRS, anticoagulants, antibiotics, insulin, and opioid use. The AUC was 0.79 (95% CI: 0.76-0.83) which was superior to the original model (AUC = 0.70, 95% CI: 0.65-0.74) with a sensitivity of 69%, specificity of 81%, positive predictive value of 0.14 (95% CI: 0.10-0.17) and negative predictive value of 0.98 (95% CI: 0.97-0.99). The DCA identified the model as having potential clinical utility between the probability thresholds of 0.05-0.4.

CONCLUSION

The inclusion of a frailty measure improved the predictive performance of the AIME model. Screening inpatients using the AIME-Frail tool could identify more patients at high-risk of medication harm who warrant timely clinician review.

Cross-sectional study to evaluate patients' medication management with a new model of care: incorporating a pharmacist into a community specialist palliative care telehealth service

BACKGROUND

Patients receiving palliative care are often on complex medication regimes to manage their symptoms and comorbidities and at high risk of medication-related problems. The aim of this cross-sectional study was to evaluate the involvement of a pharmacist to an existing community specialist palliative care telehealth service on patients' medication management.

METHOD

The specialist palliative care pharmacist attended two palliative care telehealth sessions per week over a six-month period (October 2020 to March 2021). Attendance was allocated based on funding received. Data collected from the medication management reviews included prevalence of polypharmacy, number of inappropriate medication according to the Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy criteria (STOPP/FRAIL) and recommendations on deprescribing, symptom control and medication management.

RESULTS

In total 95 patients participated in the pharmaceutical telehealth service with a mean age of 75.2 years (SD 10.67). Whilst 81 (85.3%) patients had a cancer diagnosis, 14 (14.7%) had a non-cancer diagnosis. At referral, 84 (88.4%, SD 4.57) patients were taking ≥ 5 medications with 51 (53.7%, SD 5.03) taking ≥ 10 medications. According to STOPP/FRAIL criteria, 142 potentially inappropriate medications were taken by 54 (56.8%) patients, with a mean of 2.6 (SD 1.16) inappropriate medications per person. Overall, 142 recommendations were accepted from the pharmaceutical medication management review including 49 (34.5%) related to deprescribing, 20 (14.0%) to medication-related problems, 35 (24.7%) to symptom management and 38 (26.8%) to medication administration.

CONCLUSION

This study provided evidence regarding the value of including a pharmacist in palliative care telehealth services. Input from the pharmacist resulted in improved symptom management of community palliative care patients and their overall medication management.

The impact of frailty on initiation, continuation and discontinuation of secondary prevention medications following myocardial infarction

AIM

To evaluate the association between frailty and initiating, continuing, or discontinuing secondary prevention medications following myocardial infarction (MI).

METHODS

We conducted a cohort study using linked health data, including all adults aged ≥65 years who discharged from hospital following MI from January 2013 to April 2018 in Victoria, Australia (N = 29,771). The Hospital Frailty Risk Score (HFRS) was used to assess frailty. Logistic regression was used to investigate associations of frailty with initiation, continuation, and discontinuation of secondary prevention medications (P2Y12 inhibitor antiplatelets, beta-blockers, renin-angiotensin-aldosterone system (RAAS) inhibitors, and lipid-lowering therapies) in the 90 days from discharge post-MI, by HFRS, adjusted for age, sex, and Charlson Comorbidity Index.

RESULTS

Increasing frailty was associated with lower probability of initiating and continuing P2Y12 inhibitors, RAAS inhibitors, and lipid-lowering therapies, but not beta-blockers. At at an HFRS of 0, the predicted probabiliy of having all four medications initiated or continued was 0.59 (95 %CI 0.57-0.62) for STEMI and 0.35 (0.34-0.36) for non-STEMI, compared to 0.38 (0.33-0.42) and 0.16 (0.14-0.18) at an HFRS of 15. Increasing frailty was associated with higher probability of discontinuing these medications post-MI. The predicted probability of discontinuing at least one secondary prevention medication post-MI at an HFRS of 0 was 0.10 (0.08-0.11) for STEMI and 0.14 (0.13-0.15) for non-STEMI, compared to 0.27 (0.22-0.32) and 0.34 (0.32-0.36) at an HFRS of 15.

CONCLUSION

People with higher levels of frailty were managed more conservatively following MI than people with lower levels of frailty. Whether this conservative treatment is justified warrants further study.

Deprescribing antihypertensive drugs in frail older adults

Antihypertensive drugs are commonly used by older adults because of the high prevalence of cardiovascular disease and its risk factors, and the increased absolute benefit of blood pressure reduction with increasing age. Clinical trials of blood pressure reduction in older adults have generally excluded older adults with multimorbidity, frailty and limited life expectancy. In this population, the benefit-harm ratio of aggressive blood pressure lowering may become unfavourable; a more relaxed blood pressure target may be appropriate; and deprescribing (cessation or dose reduction) of one or more antihypertensive drugs can be considered. Before deprescribing an antihypertensive drug, it is important to consider other indications for which it may have been prescribed (e.g. heart failure with reduced ejection fraction, diabetic nephropathy, atrial fibrillation). Evidence from randomised controlled deprescribing trials indicates that it is possible to deprescribe antihypertensives in frail older people. However, some patients may experience an increase in blood pressure that warrants restarting the drug. There are limited data on long-term outcomes (follow-up in deprescribing trials ranged from 4 to 56 weeks). The risk of adverse outcomes associated with deprescribing, such as withdrawal effects, can be minimised through appropriate planning, patient engagement, dose tapering and monitoring.

'I think we could probably do more': an interview study to explore community pharmacists' experiences and perspectives of frailty and optimising medicines use in frail older adults

BACKGROUND

Community pharmacists potentially have an important role to play in identification of frailty and delivery of interventions to optimise medicines use for frail older adults. However, little is known about their knowledge or views about this role.

AIM

To explore community pharmacists' knowledge of frailty and assessment, experiences and contact with frail older adults, and perceptions of their role in optimising medicines use for this population.

METHODS

Semi-structured interviews conducted between March and December 2020 with 15 community pharmacists in Northern Ireland. Interviews were transcribed verbatim and analysed thematically.

RESULTS

Three broad themes were generated from the data. The first, 'awareness and understanding of frailty', highlighted gaps in community pharmacists' knowledge regarding presentation and identification of frailty and their reluctance to broach potentially challenging conversations with frail older patients. Within the second theme, 'problem-solving and supporting medication use', community pharmacists felt a large part of their role was to resolve medicines-related issues for frail older adults through collaboration with other primary healthcare professionals but feedback on the outcome was often not provided upon issue resolution. The third theme, 'seizing opportunities in primary care to enhance pharmaceutical care provision for frail older adults', identified areas for further development of the community pharmacist role.

CONCLUSIONS

This study has provided an understanding of the views and experiences of community pharmacists about frailty. Community pharmacists' knowledge deficits about frailty must be addressed and their communication skills enhanced so they may confidently initiate conversations about frailty and medicines use with older adults.

Pharmacological treatments and medication-related problems in nursing homes in Catalonia: a multidisciplinary approach

Background: Aging correlates with increased frailty, multi-morbidity, and chronic diseases. Furthermore, treating the aged often entails polypharmacy to achieve optimal disease management, augmenting medication-related problems (MRPs). Few guidelines and tools address the problem of polypharmacy and MRPs, mainly within the institutionalized elderly population. Routine pharmacological review is needed among institutionalized patients. This pharmacological review may improve with a multidisciplinary approach of a collaboration of multiple health professionals. This study aimed to describe institutionalized patients, systematically review their medication plans, and then give recommendations and identify MRPs. Methods: A cross-sectional study was performed using data obtained from patients living in five nursing homes in the northern area of Barcelona, Spain. The inclusion criteria comprised institutionalized patients with public health coverage provided by the Health Department of Catalonia. A detailed description of the clinical characteristics, chronic diseases, pharmacological treatments, recommendations, incomplete data, and MRPs, such as potential drug-drug interactions, therapeutic duplications, contraindications, and drugs deemed inappropriate or of doubtful efficacy, was made. The clinical pharmacologist was the medical doctor specialist who acted as the coordinator of the multidisciplinary team and actively reviewed all the prescribed medications to make recommendations and detect MRPs. Results: A total of 483 patients were included. Patients had a mean age of 86.3 (SD 8.8) years, and 72.0% were female individuals. All patients had at least three health-related problems, with a mean of 17.4 (SD 5.6). All patients, except one, had a minimum of one prescription, with a mean of 8.22 drugs prescribed (SD 3.5) per patient. Recommendations were made for 82.4% of the patients. Of these recommendations, verification of adequate use was made for 69.3% and withdrawal of a drug for 49.5%. Conclusion: This study demonstrates a high prevalence of health-related problems and several prescribed drugs in nursing homes in Catalonia. Many recommendations were made, confirming the increased proportion of polypharmacy, MRPs, and the need for standardized interventions. A multidisciplinary team approach, including general practitioners, geriatric assessments, a clinical pharmacist, and a clinical pharmacologist, should address this problem.

Efficacy and Safety of Dapagliflozin in Patients With Chronic Kidney Disease Across the Spectrum of Frailty

BACKGROUND

A sizeable proportion of patients with chronic kidney disease (CKD) are reported to be frail. Here we examined the safety and efficacy of dapagliflozin in patients with CKD by frailty level.

METHODS

Adults with CKD, with/without type 2 diabetes, with an estimated glomerular filtration rate (eGFR) of 25-75 mL/min/1.73 m2, and urinary albumin-to-creatinine ratio 200-5 000 mg/g were randomized to dapagliflozin (10 mg/day) or placebo. The primary endpoint was a composite of sustained ≥50% eGFR decline, end-stage kidney disease (ESKD), or death from kidney or cardiovascular (CV) causes.

RESULTS

Frailty index (FI), assessed by Rockwood cumulative deficit approach, was calculable in 4 303/4 304 (99.9%) patients: 1 162 (27.0%) in not-to-mildly frail (FI ≤0.210), 1 642 (38.2%) in moderately frail (FI 0.211-0.310), and 1 499 (34.8%) in severely frail categories (FI >0.311). Dapagliflozin reduced the risk of the primary composite endpoint across all FI categories (hazard ratios [95% confidence interval {CI}]: 0.50 [0.33-0.76], 0.62 [0.45-0.85], and 0.64 [0.49--0.83], respectively; p-interaction = 0.67). Results were similar for secondary outcomes including kidney composite outcome (sustained ≥50% eGFR decline, ESKD or death from kidney cause; p-interaction = 0.44), CV endpoint (heart failure hospitalization or CV death; p-interaction = 0.63), and all-cause mortality (p-interaction p = .42). Results were consistent when using FI as a continuous variable. Occurrence of serious adverse events was numerically lower in patients receiving dapagliflozin versus placebo in all FI categories (16.9% vs 20.1%, 26.3% vs 30.7%, and 42.9% vs 47.8%, in not-to-mildly, moderately, and severely frail categories, respectively).

CONCLUSIONS

The relative benefit of dapagliflozin for all outcomes was consistent across all frailty categories, with no difference in associated safety.

Guideline concordant prescribing following myocardial infarction in people who are frail: A systematic review

AIMS

The risk-to-benefit ratio of cardioprotective medications in frail older adults is uncertain. The objective was to systematically review prescribing of guideline-recommended cardioprotective medications following myocardial infarction (MI) in people who are frail.

DATA SOURCES

Ovid Medline, PubMed and Cochrane were searched from inception to October 2022 for studies that reported prescribing of one or more cardioprotective medication classes post-MI or acute coronary syndromes in people with frailty.

STUDY SELECTION

We included observational studies that reported prescribing of cardioprotective medications post-MI stratified by frailty status.

RESULTS

Overall, 16 cohort studies published from 2013 to 2022 that used seven different frailty scales were included. Prescribing of all cardioprotective medication classes following MI was lower in frail compared to non-frail people, with absolute rates of prescribing varying substantially across studies. Median prescribing in frail and non-frail people, respectively, was 88.9% (IQR 81.5-96.2) and 93.1% (IQR 92.0-98.9) for aspirin; 68.1% (IQR 61.9-91.2) and 86.7% (IQR 79.5-92.8) for P2Y12-inhibitors; 83.1% (IQR 76.9-91.3) and 94.0% (IQR 87.1-95.9) for lipid-lowering therapy; 67.9% (IQR 60.6-74.0) and 74.7% (IQR 71.3-84.5) for angiotensin-converting enzyme inhibitor/angiotensin II receptor blockers; and 74.1% (IQR 69.2-79) and 77.6% (IQR 71.8-85.9) for beta-blockers.

CONCLUSION

People who were frail were less likely to be prescribed guideline recommended medication classes post-MI than those who were non-frail. Further research is needed into treatment benefits and risks in frail people to avoid unnecessarily withholding treatment in this high-risk population, while also minimising potential for medication related harm.

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.

A nurse-led comprehensive geriatric assessment intervention in primary care: A feasibility cluster randomized controlled trial

AIM

To determine the feasibility of a nurse-led, primary care-based comprehensive geriatric assessment (CGA) intervention.

DESIGN

A feasibility cluster randomized controlled trial.

METHODS

The trial was conducted in six general practices in the United Kingdom from May 2018 to April 2020. Participants were moderately/severely frail people aged 65 years and older living at home. Clusters were randomly assigned to the intervention arm control arms. A CGA was delivered to the intervention participants, with control participants receiving usual care. Study outcomes related to feasibility of the intervention and of conducting the trial including recruitment and retention. A range of outcome measures of quality of life, function, loneliness, self-determination, mortality, hospital admission/readmission and number of prescribed medications were evaluated.

RESULTS

All pre-specified feasibility criteria relating to recruitment and retention were met with 56 participants recruited in total (30 intervention and 26 control). Retention was high with 94.6% of participants completing 13-week follow-up and 87.5% (n = 49) completing 26-week follow-up. All outcome measures instruments met feasibility criteria relating to completeness and responsiveness over time. Quality of life was recommended as the primary outcome for a definitive trial with numbers of prescribed medications as a secondary outcome measure.

CONCLUSION

It is feasible to implement and conduct a randomized controlled trial of a nurse-led, primary care-based CGA intervention.

IMPACT

The study provided evidence on the feasibility of a CGA intervention for older people delivered in primary care. It provides information to maximize the success of a definitive trial of the clinical effectiveness of the intervention.

PATIENT OR PUBLIC CONTRIBUTION

Patient and public representatives were involved in the study design including intervention development and production of participant-facing documentation. Representatives served on the trial management and steering committees and, as part of this role, interpreted feasibility data. ISRCTN Number: 74345449.

Deprescribing Anticholinergic and Sedative Drugs to Reduce Polypharmacy in Frail Older Adults Living in the Community: A Randomized Controlled Trial

BACKGROUND

Polypharmacy is associated with poor outcomes in older adults. Targeted deprescribing of anticholinergic and sedative medications may improve health outcomes for frail older adults. Our pharmacist-led deprescribing intervention was a pragmatic 2-arm randomized controlled trial stratified by frailty. We compared usual care (control) with the intervention of pharmacists providing deprescribing recommendations to general practitioners.

METHODS

Community-based older adults (≥65 years) from 2 New Zealand district health boards were recruited following a standardized interRAI needs assessment. The Drug Burden Index (DBI) was used to quantify the use of sedative and anticholinergic medications for each participant. The trial was stratified into low, medium, and high-frailty. We hypothesized that the intervention would increase the proportion of participants with a reduction in DBI ≥ 0.5 within 6 months.

RESULTS

Of 363 participants, 21 (12.7%) in the control group and 21 (12.2%) in the intervention group had a reduction in DBI ≥ 0.5. The difference in the proportion of -0.4% (95% confidence interval [CI]: -7.9% to 7.0%) provided no evidence of efficacy for the intervention. Similarly, there was no evidence to suggest the effectiveness of this intervention for participants of any frailty level.

CONCLUSION

Our pharmacist-led medication review of frail older participants did not reduce the anticholinergic/sedative load within 6 months. Coronavirus disease 2019 (COVID-19) lockdown measures required modification of the intervention. Subgroup analyses pre- and post-lockdown showed no impact on outcomes. Reviewing this and other deprescribing trials through the lens of implementation science may aid an understanding of the contextual determinants preventing or enabling successful deprescribing implementation strategies.

The extent of anticholinergic burden across an older Welsh population living with frailty: cross-sectional analysis of general practice records

BACKGROUND

Anticholinergic medicines are associated with adverse outcomes for older people. However, little is known about their use in frailty. The objectives were to (i) investigate the prevalence of anticholinergic prescribing for older patients, and (ii) examine anticholinergic burden according to frailty status.

METHODS

Cross-sectional analysis of Welsh primary care data from the Secure Anonymised Information Linkage databank including patients aged ≥65 at their first GP consultation between 1 January and 31 December 2018. Frailty was identified using the electronic Frailty Index and anticholinergic burden using the Anticholinergic Cognitive Burden (ACB) scale. Descriptive analysis and logistic regression were conducted to (i) describe the type and frequency of anticholinergics prescribed; and (ii) to estimate the association between frailty and cumulative ACB score (ACB-Sum).

RESULTS

In this study of 529,095 patients, 47.4% of patients receiving any prescription medications were prescribed at least one anticholinergic medicine. Adjusted regression analysis showed that patients with increasing frailty had higher odds of having an ACB-Sum of >3 compared with patients who were fit (mild frailty, adj OR 1.062 (95%CI 1.061-1.064), moderate frailty, adj OR 1.134 (95%CI 1.131-1.136), severe frailty, adj OR 1.208 (95%CI 1.203-1.213)).

CONCLUSIONS

Anticholinergic prescribing was high in this older population. Older people with advancing frailty are exposed to the highest anticholinergic burden despite being the most vulnerable to the associated adverse effects. Older people with advancing frailty should be considered for medicines review to prevent overaccumulation of anticholinergic medications, given the risks of functional and cognitive decline that frailty presents.

Weighing the necessities and concerns of deprescribing among older ambulatory patients and primary care trainees: a qualitative study

BACKGROUND

Deprescribing can be a challenging and complex process, particularly for early career doctors such as primary care trainees. To date, there is limited data from patients' and doctors' perspectives regarding the deprescribing of medications in older persons, particularly from developing countries. This study aimed to explore the necessities and concerns of deprescribing in older persons among older ambulatory patients and primary care trainees.

METHODS

A qualitative study was conducted among patients and primary care trainees (known henceforth as doctors). Patients aged ≥ 60 years, having ≥ 1 chronic disease and prescribed ≥ 5 medications and could communicate in either English or Malay were recruited. Doctors and patients were purposively sampled based on their stage of training as family medicine specialists and ethnicity, respectively. All interviews were audio-recorded and transcribed verbatim. A thematic approach was used to analyse data.

RESULTS

Twenty-four in-depth interviews (IDIs) with patients and four focus group discussions (FGDs) with 23 doctors were conducted. Four themes emerged: understanding the concept of deprescribing, the necessity to perform deprescribing, concerns regarding deprescribing and factors influencing deprescribing. Patients were receptive to the idea of deprescribing when the term was explained to them, whilst doctors had a good understanding of deprescribing. Both patients and doctors would deprescribe when the necessity outweighed their concerns. Factors that influenced deprescribing were doctor-patient rapport, health literacy among patients, external influences from carers and social media, and system challenges.

CONCLUSION

Deprescribing was deemed necessary by both patients and doctors when there was a reason to do so. However, both doctors and patients were afraid to deprescribe as they 'didn't want to rock the boat'. Early-career doctors were reluctant to deprescribe as they felt compelled to continue medications that were initiated by another specialist. Doctors requested more training on how to deprescribe medications.

Medication Assessment in an Older Population during Acute Care Hospitalization and Its Effect on the Anticholinergic Burden: A Prospective Cohort Study

(1) Background: Anticholinergic and sedative drugs (ASDs) contribute to negative health outcomes, especially in the frail population. In this study, we aimed to assess whether frailty increases with anticholinergic burden and to evaluate the effects of medication reviews (MRs) on ASD regimens among patients attending an acute care for the elderly (ACE) unit. (2) Methods: A cohort study was conducted between June 2019 and October 2020 with 150 consecutive patients admitted to our ACE unit. Demographic, clinical, and pharmacological data were assessed. Frailty score was determined using the Frail-VIG index (FI-VIG), and ASD burden was quantified using the drug burden index (DBI). In addition, the MR was performed using the patient-centered prescription (PCP) model. We used a paired T-test to compare the DBI pre- and post-MR and univariate and multivariate regression to identify the factors associated with frailty. (3) Results: Overall, 85.6% (n = 128) of participants showed some degree of frailty (FI-VIG > 0.20) and 84% (n = 126) of patients received treatment with ASDs upon admission (pre-MR). As the degree of frailty increased, so did the DBI (p < 0.001). After the implementation of the MR through the application of the PCP model, a reduction in the DBI was noted (1.06 ± 0.8 versus 0.95 ± 0.7) (p < 0.001). After adjusting for covariates, the association between frailty and the DBI was apparent (OR: 11.42, 95% (CI: 2.77-47.15)). (4) Conclusions: A higher DBI was positively associated with frailty. The DBI decreased significantly in frail patients after a personalized MR. Thus, MRs focusing on ASDs are crucial for frail older patients.

Attitude towards deprescribing and its association with frailty and complexity of medication regimen: A survey of older inpatients in a district health board in New Zealand

BACKGROUND

Older inpatients, particularly those with frailty, have increased exposure to complex medication regimens. It is not known whether frailty and complexity of medication regimens influence attitudes toward deprescribing. This study aimed to investigate (1) older inpatients' attitudes toward deprescribing; (2) if frailty and complexity of medication regimen influence attitudes and willingness to deprescribe - a relationship that has not been investigated in previous studies.

METHODS

In this cross-sectional study, older adults (≥ 65 years) recruited from general medicine and geriatric services in a New Zealand hospital completed the revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire. Hospital frailty risk score (HFRS) was calculated using diagnostic codes and other relevant information present at the time of index hospital admission; higher scores indicate higher frailty risk. Medication regimen complexity was quantified using the medication regimen complexity index (MRCI); higher scores indicate greater complexity. Logistic regression analysis was used to identify predictors of attitudes and willingness to deprescribe.

RESULTS

A total of 222 patients were included in the study, the median age was 83 years and 63% were female. One in two patients reported feeling they were taking too many medications, and 1 in 5 considered their medications burdensome. Almost 3 in 4 (73%) wanted to be involved in decision-making about their medications, and 4 in 5 (84%) were willing to stop one or more of their medications if their prescriber said it was possible. Patients with higher MRCI had increased self-reported medication burden (adjusted odds ratio (AOR) 2.6, 95% CI 1.29, 5.29) and were more interested in being involved in decision-making about their medications (AOR 1.8, CI 0.99, 3.42) than those with lower MRCI. Patients with moderate HFRS had lower odds of willingness to deprescribe (AOR 0.45, CI 0.22,0.92) compared to the low-risk group. Female patients had a lower desire to be involved in decision-making. The oldest old age group( > 80 years) had lower self-reported medication burden and were less likely to want to try stopping their medications.

CONCLUSION

Most older inpatients wanted to be involved in decision-making about their medications and were willing to stop one or more medications if proposed by their prescriber. Medication complexity and frailty status influence patients' attitudes toward deprescribing and thus should be taken into consideration when making deprescribing decisions. Further research is needed to investigate the relationship between frailty and the complexity of medication regimens.

A rapid review of interventions to improve medicine self-management for older people living at home

BACKGROUND

As people age, they are more likely to develop multiple long-term conditions that require complicated medicine regimens. Safely self-managing multiple medicines at home is challenging and how older people can be better supported to do so has not been fully explored.

AIM

This study aimed to identify interventions to improve medicine self-management for older people living at home and the aspects of medicine self-management that they address.

DESIGN

A rapid review was undertaken of publications up to April 2022. Eight databases were searched. Inclusion criteria were as follows: interventions aimed at people 65 years of age or older and their informal carers, living at home. Interventions needed to include at least one component of medicine self-management. Study protocols, conference papers, literature reviews and articles not in the English language were not included. The results from the review were reported through narrative synthesis, underpinned by the Resilient Healthcare theory.

RESULTS

Database searches returned 14,353 results. One hundred and sixty-seven articles were individually appraised (full-text screening) and 33 were included in the review. The majority of interventions identified were educational. In most cases, they aimed to improve older people's adherence and increase their knowledge of medicines. Only very few interventions addressed potential issues with medicine supply. Only a minority of interventions specifically targeted older people with either polypharmacy, multimorbidities or frailty.

CONCLUSION

To date, the emphasis in supporting older people to manage their medicines has been on the ability to adhere to medicine regimens. Most interventions identify and target deficiencies within the patient, rather than preparing patients for problems inherent in the medicine management system. Medicine self-management requires a much wider range of skills than taking medicines as prescribed. Interventions supporting older people to anticipate and respond to problems with their medicines may reduce the risk of harm associated with polypharmacy and may contribute to increased resilience in the system.

PATIENT OR PUBLIC CONTRIBUTION

A patient with lived experience of medicine self-management in older age contributed towards shaping the research question as well as the inclusion and exclusion criteria for this review. She is also the coauthor of this article. A patient advisory group oversaw the study.

Sodium-Glucose Cotransporter 2 Inhibitors in Frail Patients with Heart Failure: Clinical Experience of a Heart Failure Unit

OBJECTIVE

The objective of this study was to determine the difference in tolerance for sodium glucose cotransporter 2 inhibitors between patients with heart failure classified as frail according to the FRAIL questionnaire, compared to those with heart failure without frailty.

METHODS

A prospective cohort study was performed between 2021 and 2022 that included patients with heart failure at a heart failure unit in Bogotá who were being treated with a sodium glucose cotransporter 2 inhibitor. Clinical and laboratory data were collected during an initial visit and 12-48 weeks after that. The FRAIL questionnaire was applied to all participants through a phone call or during the follow-up visit. The primary outcome was the adverse effect rate and as a secondary outcome we compared the estimated glomerular filtration rate change between frail and non-frail patients.

RESULTS

One hundred and twelve patients were included in the final analysis. Frail patients had a more than twice increased risk of having adverse effects (95% confidence interval 1.5-3.9). Age was also a risk factor for the appearance of these.  The estimated glomerular filtration rate decrease was inversely correlated with the age, left ventricular ejection fraction, and renal function before the use of sodium glucose cotransporter 2 inhibitors.

CONCLUSIONS

When prescribing in heart failure, it is important to remember that frail patients are more likely to have adverse effects with the use of sodium glucose cotransporter 2 inhibitors, of which the most common are those related to osmotic diuresis. Nonetheless, these do not appear to increase the risk of discontinuation or abandonment of therapy in this population.

Prevalence and health outcomes of polypharmacy and hyperpolypharmacy in older adults with frailty: A systematic review and meta-analysis

Polypharmacy is a prevalent issue in older adults, associated with a wide range of adverse health outcomes, amplified in those with frailty. This review aims to synthesize current literature on the prevalence and health outcomes of polypharmacy and hyperpolypharmacy in older adults with frailty. A systematic search was carried out within ten databases till December 2021. Data was extracted using a piloted data extraction form, and methodological quality was assessed using JBI critical appraisal checklists. Meta-analyses were conducted for prevalence, and narrative synthesis was conducted for the health outcomes of polypharmacy and hyperpolypharmacy in older adults with frailty. Heterogeneity was assessed using Chi² and I² statistics, with sensitivity and subgroup analyses performed to explore sources of heterogeneity. Sixty-six studies were included for this review. The overall pooled prevalence of polypharmacy and hyperpolypharmacy was 59% and 22% respectively. When stratifying the studies by setting, WHO regions, in eighteen frailty assessment instruments, and by its year of publication, subgroup analysis found the highest rates of prevalence in the hospital setting (71%), in the European region (68%), when Reported Edmonton Frail Scale was used (96%), and in studies published in 2015 (86%). Additionally, frail older adults with polypharmacy were less likely to experience an improvement in frailty states, had higher risks of mortality, were more likely to suffer adverse hospital-related outcomes, and required additional assistance compared to those without polypharmacy. Therefore, the high prevalence and poorer health outcomes urges the healthcare providers and health policymakers to develop and implement preventative and restorative measures targeted at the adverse outcomes associated with polypharmacy and hyperpolypharmacy in older adults with frailty.

Co-designing an intervention to improve the process of deprescribing for older people living with frailty in the United Kingdom

BACKGROUND

In older people living with frailty, polypharmacy can lead to preventable harm like adverse drug reactions and hospitalization. Deprescribing is a strategy to reduce problematic polypharmacy. All stakeholders should be actively involved in developing a person-centred deprescribing process that involves shared decision-making.

OBJECTIVE

To co-design an intervention, supported by a logic model, to increase the engagement of older people living with frailty in the process of deprescribing.

DESIGN

Experience-based co-design is an approach to service improvement, which uses service users and providers to identify problems and design solutions. This was used to create a person-centred intervention with the potential to improve the quality and outcomes of the deprescribing process. A 'trigger film' showing older people talking about their healthcare experiences was created and facilitated discussions about current problems in the deprescribing process. Problems were then prioritized and appropriate solutions were developed. The review located the solutions in the context of current processes and procedures. An ideal care pathway and a complex intervention to deliver better care were developed.

SETTING AND PARTICIPANTS

Older people living with frailty, their informal carers and professionals living and/or working in West Yorkshire, England, UK. Deprescribing was considered in the context of primary care.

RESULTS

The current deprescribing process differed from an ideal pathway. A complex intervention containing seven elements was required to move towards the ideal pathway. Three of these elements were prototyped and four still need development. The complex intervention responded to priorities about (a) clarity for older people about what was happening at all stages in the deprescribing process and (b) the quality of one-to-one consultations.

CONCLUSIONS

Priorities for improving the current deprescribing process were successfully identified. Solutions were developed and structured as a complex intervention. Further work is underway to (a) complete the prototyping of the intervention and (b) conduct feasibility testing.

PATIENT OR PUBLIC CONTRIBUTION

Older people living with frailty (and their informal carers) have made a central contribution, as collaborators, to ensure that a complex intervention has the greatest possible potential to enhance the experience of deprescribing medicines.

An Atypical Case of Extreme Polypharmacy

A commonly reported definition of polypharmacy is the numerical definition of 5 or more medications daily, and definitions have ranged from 2 or more to 11 or more medications. In this case report, an extreme case of polypharmacy is presented, highlighted by the inordinate number of drugs used over time throughout the patient’s care. A 48-year-old African American female with multiple comorbidities experienced a serious adverse drug event (ADE) prompting reporting to MedWatch, the US Food and Drug Administration’s adverse drug event reporting system. The patient’s concomitant medications included 146 drug entities, across 82 therapeutic drug categories. It is apparent that the greatest influence on the occurrence of polypharmacy was the presence of multiple comorbidities, and treatment centered around addressing each morbidity with drug therapy. This case illustrates the insidious nature of polypharmacy and raises questions as to the appropriate progression and limits on the use of multiple medications.

Individualized Medication Review in Older People with Multimorbidity: A Comparative Analysis between Patients Living at Home and in a Nursing Home

(1) Background: aging is associated with complex and dynamic changes leading to multimorbidity and, therefore, polypharmacy. A periodic medication review (MR) in frail older people leads to optimizing medication use. The aims of the study were to perform a comparative analysis of the impact of place of residence (own home versus nursing home) in a cohort of older patients on the characteristics of the baseline therapeutic plan and characteristics of the therapeutic plan after an MR; (2) Methods: Study with paired pre- and post-MR data based on person-centred prescription, with a follow-up assessment at three months. Patients who lived either in their own home or in a nursing home were recruited. We selected patients of 65 years or more with multimorbidity whose General Practitioner identified difficulties with the prescription management and the need for an MR. Each patient’s treatment was analysed by applying the Patient-Centred Prescription (PCP) model; (3) Results: 428 patients. 90% presented at least one inappropriate prescription (IP) in both settings. In nursing homes, a higher number of implemented optimization proposals was detected (81.6% versus 65.7% (p < 0.001)). After the MR, nursing-home patients had a greater decrease in their mean number of medications, polypharmacy prevalence, therapeutic complexity, and monthly drug expenditure (p < 0.001); (4) Conclusions: PCP model detected a high number of IP in both settings. However, after an individualized MR, nursing-home patients presented a greater decrease in some pharmacological parameters related to adverse events, such as polypharmacy and therapeutic complexity, compared to those living at home. Nursing homes may be regarded as a highly suitable scenario to carry out a periodic MR, due to its high prevalence of frail people and its feasibility to apply the recommendations of an MR. Prospective studies with a robust design should be performed to demonstrate this quasi-experimental study along with a longitudinal follow-up on clinical outcomes.

Factors associated to potentially inappropriate prescribing in older patients according to STOPP/START criteria: MoPIM multicentre cohort study

OBJECTIVES

The objectives of the present analyses are to estimate the frequency of potentially inappropriate prescribing (PIP) at admission according to STOPP/START criteria version 2 in older patients hospitalised due to chronic disease exacerbation as well as to identify risk factors associated to the most frequent active principles as potentially inappropriate medications (PIMs).

METHODS

A multicentre, prospective cohort study including older patients (≥65) hospitalized due to chronic disease exacerbation at the internal medicine or geriatric services of 5 hospitals in Spain between September 2016 and December 2018 was conducted. Demographic and clinical data was collected, and a medication review process using STOPP/START criteria version 2 was performed, considering both PIMs and potential prescribing omissions (PPOs). Primary outcome was defined as the presence of any most frequent principles as PIMs, and secondary outcomes were the frequency of any PIM and PPO. Descriptive and bivariate analyses were conducted on all outcomes and multilevel logistic regression analysis, stratified by participating centre, was performed on the primary outcome.

RESULTS

A total of 740 patients were included (mean age 84.1, 53.2% females), 93.8% of them presenting polypharmacy, with a median of 10 chronic prescriptions. Among all, 603 (81.5%) patients presented at least one PIP, 542 (73.2%) any PIM and 263 (35.5%) any PPO. Drugs prescribed without an evidence-based clinical indication were the most frequent PIM (33.8% of patients); vitamin D supplement in older people who are housebound or experiencing falls or with osteopenia was the most frequent PPO (10.3%). The most frequent active principles as PIMs were proton pump inhibitors (PPIs) and benzodiazepines (BZDs), present in 345 (46.6%) patients. This outcome was found significantly associated with age, polypharmacy and essential tremor in an explanatory model with 71% AUC.

CONCLUSIONS

PIMs at admission are highly prevalent in these patients, especially those involving PPIs or BZDs, which affected almost half of the patients. Therefore, these drugs may be considered as the starting point for medication review and deprescription.

TRIAL REGISTRATION NUMBER

NCT02830425.

Is polypharmacy associated with mortality in the very old: findings from the Newcastle 85+ Study

Polypharmacy is common in the very old (≥85 years), where little is known about its association with mortality. We aimed to investigate the association between polypharmacy and all-cause mortality in the very old, over an 11-year time period. Data were drawn from the Newcastle 85+ Study (741), a cohort of people who were born in 1921 and turned 85 in 2006. Survival analysis was performed using Cox proportional hazards models with time-varying covariates, wherein polypharmacy was operationalised continuously. Each additional medication prescribed was associated with a 3% increased risk of mortality (HR: 1.03, 95% CI: 1.00-1.06). Amongst the very old, the risks and benefits of each additional medication prescribed should be carefully considered.

Association of Oral Health with Multimorbidity among Older Adults: Findings from the Longitudinal Ageing Study in India, Wave-1, 2017-2019

India is witnessing an increase in the prevalence of multimorbidity. Oral health is related to overall health but is seldom included in the assessment of multimorbidity. Hence, this study aimed to estimate the prevalence of oral morbidity and explore its association with physical multimorbidity using data from Longitudinal Ageing Study in India (LASI). LASI is a nationwide survey amongst adults aged ≥ 45 years conducted in 2018. Descriptive analysis was performed on included participants (n = 59,764) to determine the prevalence of oral morbidity. Multivariable logistic regression assessed the association between oral morbidity and physical multimorbidity. Self-rated health was compared between multimorbid participants with and without oral morbidity. Oral morbidity was prevalent in 48.56% of participants and physical multimorbidity in 50.36%. Those with multimorbidity were at a higher risk of having any oral morbidity (AOR: 1.60 (1.48–1.73)) than those without multimorbidity. Participants who had only oral morbidity rated their health to be good more often than those who had physical multimorbidity and oral morbidity (40.84% vs. 32.98%). Oral morbidity is significantly associated with physical multimorbidity. Multimorbid participants perceived their health to be inferior to those with only oral morbidity. The findings suggest multidisciplinary health teams in primary care should include the management of oral morbidity and physical multimorbidity.

Interventions to improve medicines optimisation in frail older patients in secondary and acute care settings: a systematic review of randomised controlled trials and non-randomised studies

Background: Frailty is a geriatric syndrome in which physiological systems have decreased reserve and resistance against stressors. Frailty is associated with polypharmacy, inappropriate prescribing and unfavourable clinical outcomes. Aim: To identify and evaluate randomised controlled trials (RCTs) and non-randomised studies of interventions designed to optimise the medications of frail older patients, aged 65 years and over, in secondary or acute care settings. Method: Literature searches were conducted across seven electronic databases and three trial registries from the date of inception to October 2021. All types of interventional studies were included. Study selection, data extraction, risk of bias and quality assessment were conducted by two independent reviewers. Results: Three RCTs were eligible for inclusion; two employed deprescribing as the intervention, and one used comprehensive geriatric assessment. All reported significant improvements in prescribing appropriateness. One study investigated the effect of the intervention on clinical outcomes including hospital presentations, falls, fracture, quality of life and mortality, and reported no significant differences in these outcomes, but did report a significant reduction in monthly medication cost. Two of the included studies were assessed as having ‘some concerns’ of bias, and one was judged to be at ‘high risk’ of bias. Conclusion: This systematic review demonstrates that medicines optimisation interventions may improve medication appropriateness in frail older inpatients. However, it highlights the paucity of high-quality evidence that examines the impact of medicines optimisation on quality of prescribing and clinical outcomes for frail older inpatients. High-quality studies are needed to address this gap.

Optimising oral health in frail older people

There is a link between oral health and systemic health. Conditions such as dementia and pneumonia are associated with poor oral health.

Frail older people receive regular care from medical and nursing staff but tend not to see dentists regularly or only seek treatment when there is a dental problem. Collaboration between dentists and other health professionals is therefore increasingly important.

Oral health should be assessed regularly. This enables early referral to a dentist.

Anticholinergic drugs, particularly in polypharmacy, can have a profound deleterious effect on salivary function and oral health. A medication review may enable the anticholinergic burden to be reduced.

In addition to regular brushing, oral preventive products may be appropriate in frail older people.

Factors Associated with the Detection of Inappropriate Prescriptions in Older People: A Prospective Cohort

(1) Background: Ageing is associated with complex and dynamic changes leading to multimorbidity and, therefore, polypharmacy. The main objectives were to study an older community-dwelling cohort, to detect inappropriate prescriptions (IP) applying the Patient-Centred Prescription model, and to evaluate the most associated factors. (2) Methods: This was a prospective, descriptive, and observational study conducted from June 2019 to October 2020 on patients ≥ 65 years with multimorbidity who lived in the community. Demographic, clinical and pharmacological data were assessed. Variables assessed were: degree of frailty, using the Frail-VIG index; therapeutical complexity and anticholinergic and sedative burden; and the number of chronic drugs to determine polypharmacy or excessive polypharmacy. Finally, a medication review was carried out through the application of the Patient-Centred Prescription model. We used univariate and multivariate regression to identify the factors associated with IP. (3) Results: We recruited 428 patients (66.6% women; mean age 85.5, SD 7.67). A total of 50.9% of them lived in a nursing home; the mean Barthel Index was 49.93 (SD 32.14), and 73.8% of patients suffered some degree of cognitive impairment. The prevalence of frailty was 92.5%. Up to 90% of patients had at least one IP. An increase in IP prevalence was detected when the Frail-VIG index increased (p < 0.05). With the multivariate model, the relationship of polypharmacy with IP detection stands out above all. (4) Conclusions: 90% of patients presented one IP or more, and this situation can be detected through the PCP model. Factors with higher association with IP were frailty and polypharmacy.

Home Medicines Review and frailty among community-dwelling older women

OBJECTIVES

Home Medicines Reviews (HMRs) can optimize medications for frail older adults. This study aimed to determine the use of HMRs according to frailty status and the association between frailty and use of HMRs.

METHODS

The study included 9139 female participants enrolled in the Australian Longitudinal Study on Women's Health from 2003 (aged 77-82 years) to 2017 (aged 91-96 years). Generalized estimating equations (GEEs) using log-binomial regressions were used to determine associations using repeated measures on individuals over time.

KEY FINDINGS

The majority of participants in the study remained non-frail and did not receive HMRs from 2003 [7116 (77.86%)] to 2017 [1240 (71.31%)]. The use of HMRs was low in both groups with 33 (1.68%; 95% CI, 1.16 to 2.36) frail and 64 (0.89%; 95% CI, 0.69 to 1.14) non-frail participants receiving HMRs in 2003; by 2017, 19 (4.19%; 95% CI, 2.54 to 6.46) frail and 45 (3.50%; 95% CI, 2.57 to 4.66) non-frail participants received HMRs. Frailty was not associated with receiving a HMR (RR 1.06; 95% CI, 0.95 to 1.20), although for every 1-year increase, participants were 10% more likely to receive a HMR (RR 1.10; 95% CI, 1.09 to 1.11). Participants with continuous polypharmacy, ≥4 chronic diseases, >4 general practitioner visits and Department of Veterans Affairs coverage were more likely to receive a HMR.

CONCLUSIONS

Despite the proven value of HMRs for frail older people, HMRs were not used for most frail and non-frail community-dwelling women in this study. Reasons for low use of the service should be explored, with interventions to raise awareness of the benefits of the service.

New Horizons in the impact of frailty on pharmacokinetics: latest developments

Frail older people have a high prevalence of drug use and are susceptible to adverse drug reactions. The physiological changes of frailty are likely to affect pharmacokinetics and pharmacodynamics. We reviewed the methods and findings of published studies of pharmacokinetics in frailty. Nine studies describing pharmacokinetics and an additional three of pharmacokinetic pathways in frail older people were identified. Most pharmacokinetic studies investigated a single administration of a medication, dose or formulation, in small populations, often with limited representation of males or females, and applied variable definitions of frailty. Pharmacokinetic sampling designs generally utilised saturated sampling followed by analysis based on the trapezoidal rule for area under the curve, with more recent studies using sparser sampling and more sophisticated modelling to obtain individual and population values of all pharmacokinetic parameters. Overall, the pharmacokinetic studies reported only small changes in some parameters for some drugs with frailty, with the most consistent change reduced hepatic clearance in frail older people. Recommendations for future studies of pharmacokinetics in frailty include (i) standard objective definitions of frailty; (ii) larger studies including people with mild, moderate and severe frailty; (iii) population pharmacokinetic modelling to allow sparser sampling and consideration of multiple influences on pharmacokinetics; (iv) physiologically based modelling as the physiology of frailty emerges and (v) longitudinal pharmacokinetic studies of chronic drug therapy from middle to old age and from robust to pre-frail to frail, including pre-clinical studies. These data, accompanied by pharmacodynamics data in frailty, will inform safe, effective prescribing for frail older people.

Population pharmacokinetic model of subcutaneous fentanyl in older acute care patients

PURPOSE

Subcutaneous fentanyl injection is commonly prescribed to manage acute pain in older patients; however, there is a gap in the literature describing the pharmacokinetic parameters for this route of administration in this population. The aim of this study was to develop and evaluate a population pharmacokinetic model for subcutaneous fentanyl injection in older patients.

METHODS

Twenty-one patients who received subcutaneous fentanyl injections (50 to 75 μg) were recruited. Fentanyl concentrations were determined using a validated liquid chromatography/tandem mass spectrometry method. A population pharmacokinetic model was developed using non-linear mixed-effects modelling. A base model was selected based on the Akaike information criterion. Age, sex, body weight, number of previous fentanyl doses, number of prescribed medications, creatinine clearance, Charlson Comorbidity Index, Identification of Seniors at Risk score and concurrent use of CYP3A4 inhibitors were covariates considered for inclusion. A p value of < 0.05 was considered statistically significant for inclusion of covariates in the final model by stepwise addition. The simulation performance of the model was assessed by visual predictive check.

RESULTS

A one-compartment, first-order absorption with lag time and linear elimination model was the best to fit to the fentanyl concentration data. The absorption rate constant was 0.136 h^-1 (between subject variability (BSV), 46%), lag time 0.66 h (BSV 51%), apparent volume of distribution 6.28 L (BSV 30%), and apparent clearance 16.3 L.h^-1 (BSV 54%). The Charlson Comorbidity Index was the only covariate included in the final model, where a higher value of the index increased fentanyl exposure and C_max.

CONCLUSION

This is the first report of subcutaneous fentanyl population pharmacokinetic model to evaluate fentanyl pharmacokinetic in older patients. The between subject variability in clearance and subcutaneous absorption rate was relatively high, and some patients recorded high fentanyl concentrations in the context of their titration to effect.

The associations of the number of medications and the use of anticholinergics with recovery from tubal feeding: a longitudinal hospital-based study

Background

Several medications, such as anticholinergics, are considered to affect the swallowing function adversely; however, whether or not anticholinergics or polypharmacy should be avoided to prevent eating dysfunction in elderly populations remains unclear. We therefore examined whether or not the number of medications or the use of anticholinergics was associated with recovery from tubal feeding in elderly inpatients.

Methods

We conducted a retrospective 1-year observation study in 95 Japanese hospitalized patients (83.3 ± 9.7 years old) receiving nutrition through a feeding tube. The anticholinergic cognitive burden scale (ACBs) was used as an index for quantifying the anticholinergic action.

Results

Thirty-six (37.9%) subjects recovered from tubal to oral feeding during the observation period. The logistic regression models showed that an increased number of prescribed medications and an increase in ACBs decreased the incidence of recovery from tubal feeding (odds ratio [95% confidence interval]: 0.66 [0.50–0.87], P = 0.003 and 0.52 [0.29–0.92], P = 0.024, respectively). Furthermore, the cumulative incidence of recovery from tubal feeding was significantly lower in the subjects who were given an additional ≥3 medications during the observation period than in those who were not (hazard ratio [95% confidence interval]: 0.08 [0.01–0.59], P = 0.014).

Conclusions

The findings of this study suggest that an increased exposure to medications, especially anticholinergics, may be an important factor interfering with recovery from tubal feeding in hospitalized elderly patients.

Association between Statins Prescribed for Primary and Secondary Prevention and Major Adverse Cardiac Events among Older Adults with Frailty: A Systematic Review

BACKGROUND

Statins reduce the risk of major adverse cardiovascular events (MACE), however their clinical benefit for primary and secondary prevention among older adults with frailty is uncertain. This systematic review investigates whether statins prescribed for primary and secondary prevention are associated with reduced MACE among adults aged ≥ 65 years with frailty.

METHODS

We conducted a systematic review of studies published between 1 January 1952 and 1 January 2019 in the MEDLINE, EMBASE, Scopus, Web of Science, Cochrane Library and International Pharmaceutical Abstracts databases. Studies that investigated the effect of statins on MACE among adults ≥ 65 years of age with a validated frailty assessment were included. Data were extracted from the papers as per a prepublished protocol, PROSPERO: CRD42019127486. Risk of bias was assessed using the Cochrane Risk of Bias in Non-Randomised Studies of Interventions tool.

RESULTS

Six cohort studies fulfilled the inclusion criteria; there were no randomised clinical trials. Among studies evaluating the association between statins for primary and secondary prevention and mortality, one study found statins were associated with reduced mortality (hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.37-0.93), while another study found they were not (HR 0.81, 95% CI 0.61-1.08). Furthermore, one study of statins used for secondary prevention found they were associated with reduced mortality (HR 0.28, 95% CI 0.21-0.39). No studies investigated the effect of statins for primary prevention or the effect of statins on the frequency of MACE.

CONCLUSION

This review identified only observational evidence that among older people with frailty, statins are associated with reduced mortality when prescribed for secondary prevention, and an absence of evidence evaluating statin therapy for primary prevention. Randomised trial data are needed to better inform the use of statins among older adults living with frailty.

Medication Management in Frail Older People: Consensus Principles for Clinical Practice, Research, and Education

Frailty is a geriatric condition associated with increased vulnerability to adverse drug events and medication-related harm. Existing clinical practice guidelines rarely provide medication management recommendations specific to frail older people. This report presents international consensus principles, generated by the Optimizing Geriatric Pharmacotherapy through Pharmacoepidemiology Network, related to medication management in frail older people. This consensus comprises 7 principles for clinical practice, 6 principles for research, and 4 principles for education. Principles for clinical practice include (1) perform medication reconciliation and maintain an up-to-date medication list; (2) assess and plan based on individual's capacity to self-manage medications; (3) ensure appropriate prescribing and deprescribing; (4) simplify medication regimens when appropriate to reduce unnecessary burden; (5) be alert to the contribution of medications to geriatric syndromes; (6) regularly review medication regimens to align with changing goals of care; and (7) facilitate multidisciplinary communication among patients, caregivers, and healthcare teams. Principles for research include (1) include frail older people in randomized controlled trials; (2) consider frailty status as an effect modifier; (3) ensure collection and reporting of outcome measures important in frailty; (4) assess impact of frailty on pharmacokinetics and pharmacodynamics; (5) encourage frailty research in under-researched settings; and (6) utilize routinely collected linked health data. Principles for education include (1) provide undergraduate and postgraduate education on frailty; (2) minimize low-value care related to medication management; (3) improve health and medication literacy; and (4) incorporate evidence in relation to frailty into clinical practice guidelines. These principles for clinical practice, research and education highlight different considerations for optimizing medication management in frail older people. These principles can be used in conjunction with existing best practice guidelines to help achieve optimal health outcomes for this vulnerable population. Implementation of the principles will require multidisciplinary collaboration between healthcare professionals, researchers, educators, organizational leaders, and policymakers.

Safinamide as an adjunct therapy in older patients with Parkinson's disease: a retrospective study

BACKGROUND

Safinamide, as a levodopa adjunct, is effective in reducing motor fluctuations in Parkinson's disease (PD) patients; however, scarce evidence is available regarding its use in older PD patients.

AIM

To evaluate the safety and tolerability of safinamide as an adjunct therapy in patients aged ≥ 60 years with advanced PD.

METHODS

A retrospective study including 203 PD patients admitted to a geriatric day hospital, who were evaluated following an extensive clinical protocol. Safinamide use was categorized as never used, ongoing, and withdrawn. Potential correlations of Safinamide withdrawal were investigated in stepwise backward logistic regression models.

RESULTS

A total of 44 out of 203 participants were current or former users of Safinamide. Overall, 14 (32%) patients discontinued due to treatment-emergent adverse events (TEAEs). Withdrawal was not associated with older age.

CONCLUSIONS

Safinamide as an adjunct therapy in patients aged ≥ 60 years with advanced PD was found to be safe and well-tolerated in older patients. There were no specific demographic or clinical characteristics associated with suspension.

Incidência e fatores de risco para hospitalização em pessoas idosas institucionalizadas

Resumo Objetivo Avaliar a incidência de hospitalização e seus fatores de risco em pessoas idosas institucionalizadas no follow-up de 12 meses na cidade de Natal, RN, Brasil. Método Estudo de coorte concorrente composto por idosos com 60 anos ou mais e que residiam nas 10 Instituições de Longa Permanência para Idosos (ILPI) participantes do estudo. Nos 320 participantes foram aferidas informações sobre condições sociodemográficas (idade, estado civil, filhos, plano de saúde, tipo de instituição, tempo de institucionalização e se foi por motivo de doença, relação do número de idosos por cuidador e, condições de saúde), estado nutricional (MAN), capacidade funcional (Índice de KATZ), estado cognitivo (teste de Pfeiffer), fraqueza muscular (Dinamômetro). Considerou-se um nível de significância de 5% (p < 0,05) e intervalo de confiança (IC) de 95% na análise bivariada e multivariada. Resultados 20,6% (IC 95%: 16,5-25,4), do total de participantes, foram hospitalizados, com a permanência média de 16,1 dias (dp: 17,1) ao final dos 12 meses. A principal causa da hospitalização foram as doenças pulmonares (30,3%). A presença de desnutrição ou risco de desnutrição (p=0,016; IC95%: 1,17-4,96) e fazer uso de medicamentos para o sistema cardiovascular (p=0,003; IC95%: 1,43-5,77) foram fatores de risco para a hospitalização, após ajustes das variáveis sociodemográficas e clínicas. Conclusão A hospitalização teve uma alta incidência entre os idosos. Além disto, a desnutrição ou risco de desnutrição e o uso de medicamentos cardiovasculares foram considerados fatores de risco para a hospitalização no período de 12 meses.

Biology of frailty: Implications for clinical pharmacology and drug therapy in frail older people

Polypharmacy is very common in frail older people, although medications are rarely evaluated in this population. We conducted a narrative review of the effects of the biology of frailty on clinical pharmacology to inform the extrapolation of the results from clinical trials in robust people to the treatment of frail older people. Biological changes of frailty, such as changes in body composition, organ function and vulnerability to external stressors, are likely to impact on the pharmacokinetics and pharmacodynamics of drugs when used in frail older people. We considered whether these theoretical impacts were observed in the limited empirical data on pharmacokinetics in frail and robust older people. We applied what is known about the biology of frailty to interpret results of clinical trials that have conducted subgroup analyses of drug response by frailty status; and results of observational data on the safety of medications when used in frail older people. Synthesising the effects of the biology of frailty on clinical pharmacology is complicated by the use of different definitions of frailty, including a range of validated scales (that identify different people as frail), clinical judgement and residence in a nursing home.

Challenges and innovations of delivering medicines to older adults

Older adults with multimorbidity, polypharmacy, and complex health needs are the major consumer of health care. Ensuring that medicines are used safely, effectively, and delivered efficiently in this population is challenging. In this context, the approach to medicines delivery should seek to overcome some of the difficulties of delivering medicines to older people, and ensure each medication is delivered by the optimal and most convenient route for the patient in question. However, this poses significant obstacles, as the development of medicines suitable for use in older populations does not often account for complex health needs, potential challenges in relation to drug disposition, safety of excipients and limitations with practical usability of dosage forms. The objective of this review is to summarise and discuss current challenges and novel approaches to delivering medications to older adults.

The relationship between frailty and polypharmacy in older people: A systematic review

AIMS

Frailty is a complex geriatric syndrome resulting in decreased physiological reserves. Frailty and polypharmacy are common in older adults and the focus of extensive studies, although little is known about the impact they may have on each other. This is the first systematic review analysing the available evidence on the relationship between frailty and polypharmacy in older adults.

METHODS

Systematic review of quantitative studies. A comprehensive literature search for publications in English or Spanish was performed on MEDLINE, CINAHL, the Cochrane Database and PsycINFO in September 2017 without applying restrictions on the date of publication. Studies reporting any relationship between frailty and polypharmacy in older adults were considered.

RESULTS

A total of 25 publications were included, all of them observational studies. Evaluation of Fried's frailty criteria was the most common approach, followed by the Edmonton Frail Scale and FRAIL scale. Sixteen of 18 cross-sectional analyses and five of seven longitudinal analyses demonstrated a significant association between an increased number of medications and frailty. The causal relationship is unclear and appears to be bidirectional. Our analysis of published data suggests that polypharmacy could be a major contributor to the development of frailty.

CONCLUSIONS

A reduction of polypharmacy could be a cautious strategy to prevent and manage frailty. Further research is needed to confirm the possible benefits of reducing polypharmacy in the development, reversion or delay of frailty.